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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

  • Quick Run-through
  • Step 1 & 2

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

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

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

Literature review guide

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

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

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

Download Word doc Download Google doc

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

For each publication, ask yourself:

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

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

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

Take notes and cite your sources

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

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

As you write, you can follow these tips:

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

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

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

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

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

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

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

 Statistics

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

Research bias

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

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

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

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

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

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

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

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

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

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 “A substantive, thorough, sophisticated literature review is a precondition for doing substantive, thorough, sophisticated research”. Boote and Baile 2005

Authors of manuscripts treat writing a literature review as a routine work or a mere formality. But a seasoned one knows the purpose and importance of a well-written literature review.  Since it is one of the basic needs for researches at any level, they have to be done vigilantly. Only then the reader will know that the basics of research have not been neglected.

Importance of Literature Review In Research

The aim of any literature review is to summarize and synthesize the arguments and ideas of existing knowledge in a particular field without adding any new contributions.   Being built on existing knowledge they help the researcher to even turn the wheels of the topic of research.  It is possible only with profound knowledge of what is wrong in the existing findings in detail to overpower them.  For other researches, the literature review gives the direction to be headed for its success. 

The common perception of literature review and reality:

As per the common belief, literature reviews are only a summary of the sources related to the research. And many authors of scientific manuscripts believe that they are only surveys of what are the researches are done on the chosen topic.  But on the contrary, it uses published information from pertinent and relevant sources like

  • Scholarly books
  • Scientific papers
  • Latest studies in the field
  • Established school of thoughts
  • Relevant articles from renowned scientific journals

and many more for a field of study or theory or a particular problem to do the following:

  • Summarize into a brief account of all information
  • Synthesize the information by restructuring and reorganizing
  • Critical evaluation of a concept or a school of thought or ideas
  • Familiarize the authors to the extent of knowledge in the particular field
  • Encapsulate
  • Compare & contrast

By doing the above on the relevant information, it provides the reader of the scientific manuscript with the following for a better understanding of it:

  • It establishes the authors’  in-depth understanding and knowledge of their field subject
  • It gives the background of the research
  • Portrays the scientific manuscript plan of examining the research result
  • Illuminates on how the knowledge has changed within the field
  • Highlights what has already been done in a particular field
  • Information of the generally accepted facts, emerging and current state of the topic of research
  • Identifies the research gap that is still unexplored or under-researched fields
  • Demonstrates how the research fits within a larger field of study
  • Provides an overview of the sources explored during the research of a particular topic

Importance of literature review in research:

The importance of literature review in scientific manuscripts can be condensed into an analytical feature to enable the multifold reach of its significance.  It adds value to the legitimacy of the research in many ways:

  • Provides the interpretation of existing literature in light of updated developments in the field to help in establishing the consistency in knowledge and relevancy of existing materials
  • It helps in calculating the impact of the latest information in the field by mapping their progress of knowledge.
  • It brings out the dialects of contradictions between various thoughts within the field to establish facts
  • The research gaps scrutinized initially are further explored to establish the latest facts of theories to add value to the field
  • Indicates the current research place in the schema of a particular field
  • Provides information for relevancy and coherency to check the research
  • Apart from elucidating the continuance of knowledge, it also points out areas that require further investigation and thus aid as a starting point of any future research
  • Justifies the research and sets up the research question
  • Sets up a theoretical framework comprising the concepts and theories of the research upon which its success can be judged
  • Helps to adopt a more appropriate methodology for the research by examining the strengths and weaknesses of existing research in the same field
  • Increases the significance of the results by comparing it with the existing literature
  • Provides a point of reference by writing the findings in the scientific manuscript
  • Helps to get the due credit from the audience for having done the fact-finding and fact-checking mission in the scientific manuscripts
  • The more the reference of relevant sources of it could increase more of its trustworthiness with the readers
  • Helps to prevent plagiarism by tailoring and uniquely tweaking the scientific manuscript not to repeat other’s original idea
  • By preventing plagiarism , it saves the scientific manuscript from rejection and thus also saves a lot of time and money
  • Helps to evaluate, condense and synthesize gist in the author’s own words to sharpen the research focus
  • Helps to compare and contrast to  show the originality and uniqueness of the research than that of the existing other researches
  • Rationalizes the need for conducting the particular research in a specified field
  • Helps to collect data accurately for allowing any new methodology of research than the existing ones
  • Enables the readers of the manuscript to answer the following questions of its readers for its better chances for publication
  • What do the researchers know?
  • What do they not know?
  • Is the scientific manuscript reliable and trustworthy?
  • What are the knowledge gaps of the researcher?

22. It helps the readers to identify the following for further reading of the scientific manuscript:

  • What has been already established, discredited and accepted in the particular field of research
  • Areas of controversy and conflicts among different schools of thought
  • Unsolved problems and issues in the connected field of research
  • The emerging trends and approaches
  • How the research extends, builds upon and leaves behind from the previous research

A profound literature review with many relevant sources of reference will enhance the chances of the scientific manuscript publication in renowned and reputed scientific journals .

References:

http://www.math.montana.edu/jobo/phdprep/documents/phd6.pdf

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Conducting a literature review: why do a literature review, why do a literature review.

  • How To Find "The Literature"
  • Found it -- Now What?

Besides the obvious reason for students -- because it is assigned! -- a literature review helps you explore the research that has come before you, to see how your research question has (or has not) already been addressed.

You identify:

  • core research in the field
  • experts in the subject area
  • methodology you may want to use (or avoid)
  • gaps in knowledge -- or where your research would fit in

It Also Helps You:

  • Publish and share your findings
  • Justify requests for grants and other funding
  • Identify best practices to inform practice
  • Set wider context for a program evaluation
  • Compile information to support community organizing

Great brief overview, from NCSU

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What is the Purpose of a Literature Review?

What is the Purpose of a Literature Review?

4-minute read

  • 23rd October 2023

If you’re writing a research paper or dissertation , then you’ll most likely need to include a comprehensive literature review . In this post, we’ll review the purpose of literature reviews, why they are so significant, and the specific elements to include in one. Literature reviews can:

1. Provide a foundation for current research.

2. Define key concepts and theories.

3. Demonstrate critical evaluation.

4. Show how research and methodologies have evolved.

5. Identify gaps in existing research.

6. Support your argument.

Keep reading to enter the exciting world of literature reviews!

What is a Literature Review?

A literature review is a critical summary and evaluation of the existing research (e.g., academic journal articles and books) on a specific topic. It is typically included as a separate section or chapter of a research paper or dissertation, serving as a contextual framework for a study. Literature reviews can vary in length depending on the subject and nature of the study, with most being about equal length to other sections or chapters included in the paper. Essentially, the literature review highlights previous studies in the context of your research and summarizes your insights in a structured, organized format. Next, let’s look at the overall purpose of a literature review.

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Literature reviews are considered an integral part of research across most academic subjects and fields. The primary purpose of a literature review in your study is to:

Provide a Foundation for Current Research

Since the literature review provides a comprehensive evaluation of the existing research, it serves as a solid foundation for your current study. It’s a way to contextualize your work and show how your research fits into the broader landscape of your specific area of study.  

Define Key Concepts and Theories

The literature review highlights the central theories and concepts that have arisen from previous research on your chosen topic. It gives your readers a more thorough understanding of the background of your study and why your research is particularly significant .

Demonstrate Critical Evaluation 

A comprehensive literature review shows your ability to critically analyze and evaluate a broad range of source material. And since you’re considering and acknowledging the contribution of key scholars alongside your own, it establishes your own credibility and knowledge.

Show How Research and Methodologies Have Evolved

Another purpose of literature reviews is to provide a historical perspective and demonstrate how research and methodologies have changed over time, especially as data collection methods and technology have advanced. And studying past methodologies allows you, as the researcher, to understand what did and did not work and apply that knowledge to your own research.  

Identify Gaps in Existing Research

Besides discussing current research and methodologies, the literature review should also address areas that are lacking in the existing literature. This helps further demonstrate the relevance of your own research by explaining why your study is necessary to fill the gaps.

Support Your Argument

A good literature review should provide evidence that supports your research questions and hypothesis. For example, your study may show that your research supports existing theories or builds on them in some way. Referencing previous related studies shows your work is grounded in established research and will ultimately be a contribution to the field.  

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Ensure your literature review is polished and ready for submission by having it professionally proofread and edited by our expert team. Our literature review editing services will help your research stand out and make an impact. Not convinced yet? Send in your free sample today and see for yourself! 

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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.

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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.

Literature review guide

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

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

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

Download Word doc Download Google doc

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

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

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

For each publication, ask yourself:

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

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

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

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

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

Take notes and cite your sources

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

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

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

Prevent plagiarism, run a free check.

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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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.

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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.

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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.

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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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Research on research? If you find this idea rather peculiar, know that nowadays, with the huge amount of information produced daily all around the world, it is becoming more and more difficult to keep up to date with all of it. In addition to the sheer amount of research, there is also its origin. We are witnessing the economic and intellectual emergence of countries like China, Brazil, Turkey, and United Arab Emirates, for example, that are producing scholarly literature in their own languages. So, apart from the effort of gathering information, there must also be translators prepared to unify all of it in a single language to be the object of the literature survey. At Elsevier, our team of translators is ready to support researchers by delivering high-quality scientific translations , in several languages, to serve their research – no matter the topic.

What is a literature review?

A literature review is a study – or, more accurately, a survey – involving scholarly material, with the aim to discuss published information about a specific topic or research question. Therefore, to write a literature review, it is compulsory that you are a real expert in the object of study. The results and findings will be published and made available to the public, namely scientists working in the same area of research.

How to Write a Literature Review

First of all, don’t forget that writing a literature review is a great responsibility. It’s a document that is expected to be highly reliable, especially concerning its sources and findings. You have to feel intellectually comfortable in the area of study and highly proficient in the target language; misconceptions and errors do not have a place in a document as important as a literature review. In fact, you might want to consider text editing services, like those offered at Elsevier, to make sure your literature is following the highest standards of text quality. You want to make sure your literature review is memorable by its novelty and quality rather than language errors.

Writing a literature review requires expertise but also organization. We cannot teach you about your topic of research, but we can provide a few steps to guide you through conducting a literature review:

  • Choose your topic or research question: It should not be too comprehensive or too limited. You have to complete your task within a feasible time frame.
  • Set the scope: Define boundaries concerning the number of sources, time frame to be covered, geographical area, etc.
  • Decide which databases you will use for your searches: In order to search the best viable sources for your literature review, use highly regarded, comprehensive databases to get a big picture of the literature related to your topic.
  • Search, search, and search: Now you’ll start to investigate the research on your topic. It’s critical that you keep track of all the sources. Start by looking at research abstracts in detail to see if their respective studies relate to or are useful for your own work. Next, search for bibliographies and references that can help you broaden your list of resources. Choose the most relevant literature and remember to keep notes of their bibliographic references to be used later on.
  • Review all the literature, appraising carefully it’s content: After reading the study’s abstract, pay attention to the rest of the content of the articles you deem the “most relevant.” Identify methodologies, the most important questions they address, if they are well-designed and executed, and if they are cited enough, etc.

If it’s the first time you’ve published a literature review, note that it is important to follow a special structure. Just like in a thesis, for example, it is expected that you have an introduction – giving the general idea of the central topic and organizational pattern – a body – which contains the actual discussion of the sources – and finally the conclusion or recommendations – where you bring forward whatever you have drawn from the reviewed literature. The conclusion may even suggest there are no agreeable findings and that the discussion should be continued.

Why are literature reviews important?

Literature reviews constantly feed new research, that constantly feeds literature reviews…and we could go on and on. The fact is, one acts like a force over the other and this is what makes science, as a global discipline, constantly develop and evolve. As a scientist, writing a literature review can be very beneficial to your career, and set you apart from the expert elite in your field of interest. But it also can be an overwhelming task, so don’t hesitate in contacting Elsevier for text editing services, either for profound edition or just a last revision. We guarantee the very highest standards. You can also save time by letting us suggest and make the necessary amendments to your manuscript, so that it fits the structural pattern of a literature review. Who knows how many worldwide researchers you will impact with your next perfectly written literature review.

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  • 1. Define your research question
  • 2. Plan your search
  • 3. Search the literature
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Definition: A literature review is a systematic examination and synthesis of existing scholarly research on a specific topic or subject.

Purpose: It serves to provide a comprehensive overview of the current state of knowledge within a particular field.

Analysis: Involves critically evaluating and summarizing key findings, methodologies, and debates found in academic literature.

Identifying Gaps: Aims to pinpoint areas where there is a lack of research or unresolved questions, highlighting opportunities for further investigation.

Contextualization: Enables researchers to understand how their work fits into the broader academic conversation and contributes to the existing body of knowledge.

literature review relevance of

tl;dr  A literature review critically examines and synthesizes existing scholarly research and publications on a specific topic to provide a comprehensive understanding of the current state of knowledge in the field.

What is a literature review NOT?

❌ An annotated bibliography

❌ Original research

❌ A summary

❌ Something to be conducted at the end of your research

❌ An opinion piece

❌ A chronological compilation of studies

The reason for conducting a literature review is to:

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

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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. 

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Conducting a Literature Review

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  • Steps in Conducting a Literature Review
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  • Literature Review Tutorial by American University Library
  • The Literature Review: A Few Tips On Conducting It by University of Toronto
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While there might be many reasons for conducting a literature review, following are four key outcomes of doing the review.

Assessment of the current state of research on a topic . This is probably the most obvious value of the literature review. Once a researcher has determined an area to work with for a research project, a search of relevant information sources will help determine what is already known about the topic and how extensively the topic has already been researched.

Identification of the experts on a particular topic . One of the additional benefits derived from doing the literature review is that it will quickly reveal which researchers have written the most on a particular topic and are, therefore, probably the experts on the topic. Someone who has written twenty articles on a topic or on related topics is more than likely more knowledgeable than someone who has written a single article. This same writer will likely turn up as a reference in most of the other articles written on the same topic. From the number of articles written by the author and the number of times the writer has been cited by other authors, a researcher will be able to assume that the particular author is an expert in the area and, thus, a key resource for consultation in the current research to be undertaken.

Identification of key questions about a topic that need further research . In many cases a researcher may discover new angles that need further exploration by reviewing what has already been written on a topic. For example, research may suggest that listening to music while studying might lead to better retention of ideas, but the research might not have assessed whether a particular style of music is more beneficial than another. A researcher who is interested in pursuing this topic would then do well to follow up existing studies with a new study, based on previous research, that tries to identify which styles of music are most beneficial to retention.

Determination of methodologies used in past studies of the same or similar topics.  It is often useful to review the types of studies that previous researchers have launched as a means of determining what approaches might be of most benefit in further developing a topic. By the same token, a review of previously conducted studies might lend itself to researchers determining a new angle for approaching research.

Upon completion of the literature review, a researcher should have a solid foundation of knowledge in the area and a good feel for the direction any new research should take. Should any additional questions arise during the course of the research, the researcher will know which experts to consult in order to quickly clear up those questions.

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Understanding the importance of a literature review in research

  • March 29, 2023

literature review relevance of

Gerald Naepi

When conducting research, a literature review plays a crucial role as it provides an overview of the existing literature related to a specific topic. Its main objective is to identify the gaps in the current knowledge and provide direction for future research. This article delves into the purpose and structure of a literature review, along with the various types of literature reviews typically employed in research. By familiarising themselves with the different types of literature reviews and their unique features, researchers can determine which review type would best suit their research question and help them achieve their desired results.

Purpose of a literature review in research

The primary goal of a literature review in research is to offer a comprehensive overview of the relevant research within a given area. A well-executed literature review should provide readers with a clear understanding of the theoretical and empirical contributions made in the field, while also highlighting areas that require further exploration or investigation. Additionally, literature reviews help researchers identify gaps in existing knowledge that can lead to new hypotheses or questions for future study.

When conducting a literature review, researchers should pay close attention to key themes and topics covered by previous studies, including the approaches used to answer specific questions or address particular issues. This ensures that any conclusions drawn by the researcher are supported by established evidence and build on prior work in the field. Moreover, when synthesising information from multiple studies, researchers should aim to identify conflicting opinions or discrepancies in the literature and draw implications for further study. Through this process, a comprehensive literature review can provide invaluable insights into the current state of research and inform future studies.

literature review relevance of

Literature review format

The format of a literature review in research typically consists of the following elements:

Introduction: The introduction is an important part of a literature review, as it gives the reader a sense of what to expect. It should start with a clear statement of the research question or objective, so that the reader understands what the review is trying to achieve. It’s also important to explain why the topic is important, so that the reader understands the relevance of the review. Finally, the introduction should give the reader an overview of the structure and organisation of the review, so that they can easily navigate through the rest of the content.

Search Strategy: The search strategy should be comprehensive, focused, and systematic. It involves selecting appropriate databases, developing effective search terms, and utilizing other sources to collect information. To begin, the researcher needs to determine the most relevant databases to search. Depending on the topic, discipline, and research question, different databases may be more suitable. Some commonly used databases are PubMed, Scopus, Web of Science, and Google Scholar. Once the databases are selected, the researcher can develop a set of search terms that accurately reflect the topic and research question. These search terms can be a combination of keywords and subject headings. Other sources of information may include reference lists, grey literature, conference proceedings, and experts in the field. These sources can provide additional insights and help to ensure a comprehensive search.

The search strategy should be documented in detail to enable replication and transparency. This documentation should include the databases searched, search terms used, search dates, and any filters or limits applied. By having a clear and systematic search strategy, the researcher can ensure that they have identified all relevant literature and that the research findings are reliable and valid.

Inclusion and Exclusion Criteria: Inclusion criteria refer to the characteristics that a study must have to be included in the review, while exclusion criteria refer to the characteristics that disqualify a study from being included. The inclusion and exclusion criteria may vary depending on the research question, but generally, they should be clearly defined and stated in the methods section of the review. Common criteria include study design, population, intervention or exposure, and outcome measures. For example, a systematic review on the effectiveness of a particular drug for a specific condition may include only randomized controlled trials (RCTs) with a minimum sample size of 50 participants, and exclude non-randomized studies or studies with a high risk of bias.

Defining clear inclusion and exclusion criteria is crucial in ensuring that the studies included in the review are relevant, appropriate, and of high quality. It also helps to minimize bias and enhance the validity of the review’s findings. Additionally, transparent reporting of inclusion and exclusion criteria allows readers to assess the rigor of the review process and the generalizability of the findings to their own context.

Methodology: The methodology section typically involves outlining the procedures and techniques employed to collect relevant data and information, including any data extraction forms that were used. Additionally, this section may also include information about the process of data extraction, such as how the data was collected, coded, and analysed. Furthermore, it is essential to include a description of the quality assessment process used to ensure that the extracted data was reliable and valid. This may involve explaining the criteria used to evaluate the quality of the studies, as well as any potential biases or limitations that were taken into consideration. By providing a thorough description of the methodology, readers will be able to assess the rigor of the research and better understand the context and implications of the findings.

Results: The results section summarises the main outcomes and findings of the review process, including the key themes, concepts, and trends identified in the literature. The results section provides a clear and concise description of the analysed data and should be presented in a logical and organized manner to make it easy for readers to understand. The results section of a literature review provides an overview of the evidence and information obtained from the analysed sources and explains how the findings support or challenge the research question or hypothesis. It is essential to ensure that the results are presented accurately, and any limitations or weaknesses of the study are acknowledged to provide a transparent and objective review of the literature.

Discussion: The discussion section of a literature review in research is an important component that provides a critical analysis of the literature reviewed in the study. This section allows the researcher to present their findings and interpretations of the literature, as well as to draw conclusions about the research question or problem being investigated. In the discussion section, the researcher will typically summarise the key findings of the literature review and then discuss these findings in relation to the research question or problem. The discussion section may also identify gaps in the literature and suggest areas for further research, as well as discuss the implications of the findings for theory, practice, or policy. Ultimately, the discussion section of a literature review should provide a comprehensive and insightful analysis of the literature reviewed, which contributes to the overall understanding of the research question or problem at hand.

Conclusion: The conclusion section in a literature review summarises the key findings and implications of the reviewed studies. It is the final part of the literature review that brings together all the main points and themes discussed in the previous sections. In this section, the researcher should provide a critical evaluation of the reviewed literature, highlighting the strengths and limitations of the studies, and how they relate to the research question or problem. The conclusion section should also address any gaps or inconsistencies in the existing literature and suggest future research directions. Furthermore, it should provide a clear and concise summary of the main findings and their significance for the field of study.

References: The reference section provides a comprehensive list of all the sources that have been cited in the literature review, including books, journal articles, reports, and other relevant materials. The purpose of the reference section is to give credit to the authors whose work has been used to support the arguments and ideas presented in the paper. Additionally, the reference section allows readers to locate and retrieve the sources that have been cited, which can help them further explore the topic or verify the accuracy of the information presented. The reference section is typically organized in alphabetical order by the last name of the first author of each source, and it includes all of the necessary bibliographic information such as the title of the work, the name of the journal or book, the date of publication, and the page numbers

Download our literature review template

literature review relevance of

Types of literature review in research

Literature reviews in research can be conducted for a variety of reasons, including to gain a comprehensive understanding of a topic, to identify research gaps, or to support the development of research proposals.

Here are the different types of literature reviews in research:

  • Narrative Literature Review: A narrative literature review is an overview of the literature on a specific topic or research question that does not follow a structured or systematic approach. It is a qualitative review that summarizes and synthesizes the findings from different studies.
  • Systematic Literature Review: A systematic literature review is a rigorous and structured approach to reviewing literature that involves a comprehensive search strategy, inclusion/exclusion criteria, and critical appraisal of the quality of evidence. It involves a meta-analysis and quantitative synthesis of data from multiple studies.
  • Meta-analysis: A meta-analysis is a quantitative review of the literature that involves statistical analysis of the data from multiple studies. It combines the results of different studies to produce an overall estimate of the effect size of a particular intervention or treatment.
  • Scoping Review: A scoping review is a type of literature review that aims to map the existing literature on a topic, identify research gaps, and provide an overview of the evidence. It is useful when the research question is broad or unclear.
  • Rapid Review: A rapid review is a type of systematic review that uses streamlined methods to quickly and efficiently review the literature. It is useful when there is a time constraint or when there is a need to update a previous review.
  • Umbrella Review: An umbrella review is a type of systematic review that synthesizes the findings of multiple systematic reviews on a particular topic. It provides a higher level of evidence by combining the findings from multiple studies.
  • Critical Review: A critical review involves the evaluation and analysis of the strengths and weaknesses of the literature on a particular topic. It assesses the quality, credibility, and relevance of the literature and identifies research gaps.

Literature review example:

A literature review can play a crucial role in connecting with qualitative talanoa research. Talanoa is a research approach that emphasises collaboration, dialogue, and relationships within Pacific communities. Conducting a thorough literature review can help researchers to identify existing knowledge and gaps in ta specific field. This can inform the design of Talanoa research that centers on community engagement and dialogue. By reviewing literature that focuses on Pacific cultures, histories, and knowledge systems, researchers can develop a deeper understanding of the context and values of the community they are working with. This can help to build trust and establish meaningful relationships between researchers and community members.

An example of a literature review is our social research on Pacific peoples’ concerns about COVID-19, titled “The $7 cabbage dilemma: Pacific peoples’ experiences and New Zealand’s COVID-19 response.pdf” The objective of our study was to investigate how the COVID-19 pandemic impacted the wellbeing of Pacific peoples in New Zealand. To accomplish this, we conducted a comprehensive literature review of existing research on Pacific peoples’ urban climate change, health, economy, and housing in New Zealand. Through our talanoa-based research, we discovered that many Pacific peoples were worried about the cost of living, access to healthcare, support for parents, and affordable healthy food options, which were all connected to the broader themes of urban climate change, health, economy, and housing that we had identified in our literature review.

In conclusion, a literature review is an essential component of research as it helps to identify gaps in existing knowledge, provide direction for future research and support or challenge research questions or hypotheses. The purpose of a literature review is to offer a comprehensive overview of the relevant research within a given area, identify key themes and topics, and synthesize information from multiple studies. Researchers need to pay attention to the different types of literature reviews and their unique features when conducting literature reviews to determine which review type would best suit their research question and help them achieve their desired results. A well-structured literature review should include an introduction, search strategy, inclusion and exclusion criteria, methodology and results sections. A well-executed literature review ensures that the research findings are reliable and valid and provides invaluable insights into the current state of research to inform future studies.

           

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literature review relevance of

Literature Reviews

  • Getting Started
  • Choosing a Type of Review
  • Developing a Research Question
  • Searching the Literature
  • Searching Tips
  • ChatGPT [beta]
  • Documenting your Search
  • Using Citation Managers
  • Concept Mapping
  • Concept Map Definition

MindMeister

  • Writing the Review
  • Further Resources

Additional Tools

Google slides.

GSlides can create concept maps using their Diagram feature. Insert > Diagram > Hierarchy will give you some editable templates to use.

Tutorial on diagrams in GSlides .

MICROSOFT WORD

MS Word can create concept maps using Insert > SmartArt Graphic. Select Process, Cycle, Hierarchy, or Relationship to see templates.

NVivo  is software for qualitative analysis that has a concept map feature. Zotero libraries can be uploaded using ris files. NVivo Concept Map information.

A concept map or mind map is a visual representation of knowledge that illustrates relationships between concepts or ideas. It is a tool for organizing and representing information in a hierarchical and interconnected manner. At its core, a concept map consists of nodes, which represent individual concepts or ideas, and links, which depict the relationships between these concepts .

Below is a non-exhaustive list of tools that can facilitate the creation of concept maps.

literature review relevance of

www.canva.com

Canva is a user-friendly graphic design platform that enables individuals to create visual content quickly and easily. It offers a diverse array of customizable templates, design elements, and tools, making it accessible to users with varying levels of design experience. 

Pros: comes with many pre-made concept map templates to get you started

Cons : not all features are available in the free version

Explore Canva concept map templates here .

Note: Although Canva advertises an "education" option, this is for K-12 only and does not apply to university users.

literature review relevance of

www.lucidchart.com

Lucid has two tools that can create mind maps (what they're called inside Lucid): Lucidchart is the place to build, document, and diagram, and Lucidspark is the place to ideate, connect, and plan.

Lucidchart is a collaborative online diagramming and visualization tool that allows users to create a wide range of diagrams, including flowcharts, org charts, wireframes, and mind maps. Its mind-mapping feature provides a structured framework for brainstorming ideas, organizing thoughts, and visualizing relationships between concepts. 

Lucidspark , works as a virtual whiteboard. Here, you can add sticky notes, develop ideas through freehand drawing, and collaborate with your teammates. Has only one template for mind mapping.

Explore Lucid mind map creation here .

How to create mind maps using LucidSpark: 

Note: U-M students have access to Lucid through ITS. [ info here ] Choose the "Login w Google" option, use your @umich.edu account, and access should happen automatically.

literature review relevance of

www.figma.com

Figma is a cloud-based design tool that enables collaborative interface design and prototyping. It's widely used by UI/UX designers to create, prototype, and iterate on digital designs. Figma is the main design tool, and FigJam is their virtual whiteboard:

Figma  is a comprehensive design tool that enables designers to create and prototype high-fidelity designs

FigJam focuses on collaboration and brainstorming, providing a virtual whiteboard-like experience, best for concept maps

Explore FigJam concept maps here .

literature review relevance of

Note: There is a " Figma for Education " version for students that will provide access. Choose the "Login w Google" option, use your @umich.edu account, and access should happen automatically.

literature review relevance of

www.mindmeister.com

MindMeister  is an online mind mapping tool that allows users to visually organize their thoughts, ideas, and information in a structured and hierarchical format. It provides a digital canvas where users can create and manipulate nodes representing concepts or topics, and connect them with lines to show relationships and associations.

Features : collaborative, permits multiple co-authors, and multiple export formats. The free version allows up to 3 mind maps.

Explore  MindMeister templates here .

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  • Last Updated: Feb 15, 2024 1:47 PM
  • URL: https://guides.lib.umich.edu/litreview
  • Open access
  • Published: 13 February 2024

Factors of success, barriers, and the role of frontline workers in Indigenous maternal-child health programs: a scoping review

  • Charlene Thompson 1 ,
  • Tara Million 2 ,
  • Devan Tchir 3 ,
  • Angela Bowen 1 &
  • Michael Szafron 4  

International Journal for Equity in Health volume  23 , Article number:  28 ( 2024 ) Cite this article

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Despite considerable investment in maternal-child programs in Canada, there has been little positive impact on the health of Indigenous mothers and their children. The reasons for this are unclear and there is a need to identify how such programs can be successfully implemented. Community input is essential for successful programs; however, it is unclear what the contributions of frontline workers have been in the health program process, i.e., program development, delivery, and evaluation. Based on these identified gaps, this scoping review aimed to: (1) identify factors of success and barriers to successful Indigenous maternal-child community health programs for mothers and their children aged 0–6 years; and (2) explore how frontline workers are included in the program process.

This scoping review was completed using the Arksey and O’Malley framework, informed by Levac et al. Four data bases (Medline, CINAHL, Embase, and Scopus), grey literature, and reference lists were searched for relevant materials from 1990–2019. Data was extracted from included articles and analysed using descriptive statistics, thematic analysis with the Braun and Clarke framework, and a Principal Component Analysis.

Forty-five peer-reviewed and grey articles were included in the review. Factors of program success included: relationship building; cultural inclusion; knowledge transmission styles; community collaboration; client-centred approaches; Indigenous staff; and operational considerations. Barriers included: impacts of colonization; power structure and governance; client and community barriers to program access; physical and geographical challenges; lack of staff; and operational deficits. Frontline workers were found to have a role in program delivery ( n  = 45) and development ( n  = 25). Few ( n  = 6) had a role in program evaluation.

Although a better understanding of the frontline worker role in maternal-child health programs was obtained from the review, in a large proportion of literature the authors could not determine if the role went beyond program delivery. In addition, no direct input from frontline workers and their perspectives on program success or barriers were identified, suggesting areas to explore in future research. This review's findings have been applied to inform a community-based participatory research project and may also help improve the development, delivery, and evaluation of Indigenous maternal-child health programs.

Health inequity is one of the key challenges to Indigenous maternal-child health [ 1 , 2 ]. Indigenous mothers and children experience a greater proportion of negative health outcomesand reduced access to care when compared to non-Indigenous mothers and children [ 2 , 3 , 4 ]. The increased burden resulting from health inequities negatively impacts mothers' health statuses and is a significant barrier to the growth and development of children [ 3 , 5 ].

Indigenous maternal-child health programs

Maternal-child health programs have an essential role in improving the health of Indigenous mothers and children and reducing health inequity [ 4 , 6 , 7 ]. In this context, Indigenous maternal-child health programs are an action or approach in the community setting aimed at mothers and their children to create a positive health impact [ 4 , 6 , 8 ]. Although there are a large number and variety of available maternal-child health programs, there has been little positive impact on the health status of Indigenous mothers and their children [ 4 , 9 ].Indigenous mothers continue to experience higher rates of gestational diabetes, postpartum diabetes, obesity, anxiety, and depression [ 10 ]. Indigenous children experience higher rates of preterm births, sudden infant death syndrome, and higher overall mortality rates [ 2 ]. With maternal-child health programs having little effect, there is a need to identify elements that can assist or hinder program success and, potentially, inform current practice [ 4 , 7 , 11 ].

Health programs have been successful when the community is included in the health program process, i.e., the development, delivery, and evaluation of a program [ 7 , 12 , 13 ].. Frontline workers are one aspect of community input that can contribute to program success [ 4 , 14 , 15 ],but it is unclear what their contributions have been in the health program process. Examining the available literature may provide insight into the role of frontline workers in the health program process and ways health program planning and evaluation may be improved. Hence this scoping review aimed to: (1) identify factors of success and barriers to successful Indigenous maternal-child community health programs for Indigenous mothers and their children aged 0–6 years; and (2) explore how frontline workers are included in the Indigenous maternal-child community health program process.

Scoping review rationale

One key challenge in Indigenous health program literature is evaluating research based on a western standard that does not fit the community or community definition of success [ 16 , 17 , 18 ]. This challenge has created a body of program evidence that has been criticized as weak [ 7 , 18 , 19 ].) Excluding literature based on quality alone from a review could result in the loss of valuable research that reflects the community and limit the usefulness of the review [ 16 , 20 ]. A scoping review eliminates a quality assessment from the review process, thus broadening the scope of literature beyond the western standard of evidence and generating relevant results [ 16 , 20 , 21 ] to inform Indigenous maternal-child health programs. Unlike other types of literature reviews, a scoping review is more likely to include a variety of study methods and designs [ 21 ]. The scoping review framework is an iterative process, where the team may revisit and refine the stages to ensure comprehensive and pertinent answers to the research questions [ 20 , 21 ]. Consequently, a scoping review fits the context of a review of literature pertaining to Indigenous maternal-child health where multiple methods, such as randomized control trials, community-based participatory research, and descriptive studies, have been used in health program research [ 13 , 15 , 22 ].

Scoping review process

This scoping review followed the framework that was developed by Arksey and O’Malley [ 21 ] and modified by Levac et al. [ 20 ] because Levac et al. [ 20 ] enhanced the Arksey and O’Malley framework [ 21 ] to include greater guidance to the methodology and build on the consistency of its application in the review process. Six stages make up the framework and include: Stage 1: identifying the research question; Stage 2: identifying relevant studies; Stage 3: study selection; Stage 4: charting the data; Stage 5: collating, summarizing, and reporting the results; and Stage 6: consultation. In an effort to strengthen the rigour of the scoping review, we followed the recommendation of Levac et al. [ 20 ] and formed a multi-disciplinary team, CT (team lead), TM, DT, AB, and MS, from public health, nursing, and Indigenous Studies to complete the review.

Implementation of the process

Stage 1: research questions.

Based on the aims of our scoping review, the team collaboratively generated two research questions to guide our review:

For Indigenous mothers and their children aged 0–6 years, what are the factors of success and barriers to successful Indigenous maternal-child community health programs?

How are frontline workers included in the Indigenous maternal-child community health program process?

Concepts of interest

The team discussed and determined three concepts underlying the research questions needed to be defined: Indigenous Peoples, Indigenous maternal-child community health programs and frontline workers. The team developed the conceptual definitions below using multiple literature sources.

  • Indigenous peoples

In the context of this study, Indigenous Peoples identifies the ‘First Peoples’ or those that inhabited countries such as Canada, Australia, New Zealand, and the United States before colonization [ 23 ]. Indigenous Peoples have distinct languages, cultures, and beliefs with strong connections to lands, territories, and resources [ 24 ].

Indigenous maternal-child community health program

An Indigenous maternal-child community health program was considered to be an action or approach aimed at one or more levels, i.e., the individual, family, whole community, policy, to reduce the mortality rates of women and children and improve their health and well-being [ 2 , 6 , 14 , 25 , 26 , 27 ].

  • Frontline workers

Frontline workers are individuals involved in some aspect of the health program process [ 4 , 12 , 14 , 15 ]. Examples of frontline workers include nurses, Indigenous Health and Community Workers, midwives, counsellors, peer support workers, and family support workers [ 3 , 13 , 28 , 29 , 30 , 31 , 32 , 33 ].

Stage 2: identifying relevant studies

Search strategy.

The scoping review team consulted with a health sciences librarian to obtain advice on the search parameters and search strategy. We included both peer-reviewed and grey literature in our search. For this review, unless preceded by “peer-reviewed” or “grey”, the terms “articles” and “literature” refer to the combined peer-reviewed and grey literature. Articles were restricted to those written in English.

The literature was limited to Australia, Canada, New Zealand, and the United States based on these countries:

Similar histories of colonization [ 19 , 34 ]

Significant populations of Indigenous peoples with similar health status [ 34 , 35 , 36 ]

scoring near the top of the good health and living standards in the United Nations Development Programme Human Development Index [ 35 ]; and

the program was implemented in the country.

Articles were narrowed to the timeframe of 1990 to 2019 to capture the developments in health promotion occurring after the introduction of the Ottawa Charter (1986) that defined the components and strategies of health promotion still being applied in current health programs and public health practice [ 37 , 38 ]. From the Ottawa Charter: health promotion was defined as a process that places the control with people to take a participatory role in improving their health; health is considered a state of physical, social, and mental well-being; health is influenced by external determinants such as education, income, and equity; and health promotion actions were established, such as building health policy, creating supportive environments, and developing personal skills [ 37 , 38 ].

Search terms

Search terms were developed in consultation with a health sciences librarian. The medical subject headings (MeSH) found in search sources, i.e., scholarly databases, and keywords specific to Indigenous Peoples and Indigenous maternal-child health community health programs informed the development of the search term strategy. The following search terms were applied in the search strategy: (Indigenous Peoples of Canada filters [ 39 , 40 ] OR Oceanic Ancestry Group OR Indigenous OR American Indian OR Indians, North American OR Aboriginal OR Native American) AND (Maternal-Child Health Services OR Child Health OR Child Health Services OR prenatal care OR perinatal care OR postnatal care OR prenatal education OR maternal child AND Health Promotion OR Program OR Health Education OR Primary Prevention OR Immunization) AND (community health services OR community health nursing OR home care services OR community).

Search sources

The literature search was completed between May 2019 and July 2019. Table 1 illustrates the search sources for the peer-reviewed and grey literature for the review. Grey literature consisted of materials related to the review aims, such as reports and websites, not published from commercial organizations that typically produce peer-reviewed literature [ 41 ]. Based on the librarian’s advice, we completed a focused grey literature search of targeted sources [ 41 ]. Grey literature sources were determined through consultation with the librarian and reference lists from included articles, as suggested in other literature reviews [ 4 , 42 ]. See Additional file 1 for a search example.

Stage 3: study selection

Inclusion and exclusion criteria.

Following the process in Arksey and O’Malley [ 21 ], the review team established the inclusion and exclusion criteria to be applied to all citations identified in Stage 2. Inclusion criteria consisted of articles specific to Indigenous peoples; maternal-child health programs; children aged 0–6 years of age; prenatal mothers; postnatal mothers; primary prevention; located within the community; all types of studies and methods; English language; timeframe 1990-April 2019; programs implemented in the countries, Australia, Canada, New Zealand, and the United States. Exclusion criteria consisted of articles, not Indigenous-specific; children > 6 years of age; acute care-based (i.e., hospital); outside designated timeframe; focused on a specific program element (i.e., the development of a survey for the evaluation of a health program); epidemiological focused (i.e., incidence, prevalence); disease-based.

Screening process

In August 2019, two of the three (CT, TM, and DT) reviewers independently screened each Title and abstract against the inclusion and exclusion criteria using the Rayyan software developed by Ouzzani et al. [ 43 ] Once title and abstract screening were complete, the full text articles were screened against the inclusion and exclusion criteria. As suggested by Levac et al. [ 20 ], a fourth reviewer (MS) was consulted to settle any disagreements between reviewers surrounding potential inclusions. Once the screening process was complete, 45 articles remained for inclusion in the scoping review including 36 peer-reviewed articles and 9 documents from grey literature. The screening process of selected articles can be found in Fig.  1 .

figure 1

Screening process of selected articles

Stage 4: charting the data

Data extraction from included literature.

Following the Levac et al. [ 20 ] process, information was extracted from the 45 articles and summarized in a table. The data extraction table included: author, year, and title; Indigenous first author; country and population; methodology; aims/purpose; program description; reported factors of program success; reported program barriers; frontline worker role in health program process; and program outcomes. From August 2019 to October 2019, two reviewers (CT, TM, or DT) independently extracted data from each article and recorded it in a data extraction table. As suggested in Levac et al. [ 20 ], results were compared to determine consistency between reviewers. The data extraction tables can be found in Additional file 2 .

Stage 5: collating, summarizing, and reporting the results

Data analysis methods.

Analysis of the extracted data included descriptive statistics, a thematic analysis, and a Principal Component Analysis [PCA]. Descriptive statistics were compiled using the Social Sciences Statistical Package [SPSS] 25.0 from IBM Corp [ 44 ] to describe study characteristics and the role of frontline workers in the health program process.

Thematic analysis

For the thematic analysis portion of the scoping review, Levac et al. [ 20 ] recommend using a qualitative analysis technique. The review team chose the Braun and Clarke [ 45 ] thematic analysis framework to guide our analysis as this framework has been used extensively in the health field, including previous scoping reviews on health topics affecting Indigenous peoples [ 42 , 46 ].

From November 2019 to January 2020, the Braun and Clarke [ 45 ] thematic analysis framework was applied by two authors (CT and TM) to the extracted data to generate codes and develop themes. The themes and corresponding codes and definitions supporting the themes were then distributed to all scoping review team members for review and refinement. No changes to the themes were requested by the team.

Principal component analysis

In an effort to address potential reviewer bias in identifying the themes in the extracted data (i.e., codes), a PCA using SPSS 25.0 [ 44 ] was completed by an independent reviewer (MS) to identify the themes (factors) underlying program success and barriers. The PCA was conducted with Promax oblique rotations applied to the codes from the thematic analysis. To identify the number of factors related to program success and barriers, a Parallel Analysis was performed (with 1000 Monte Carlo simulation repetitions). Codes that were moderately to strongly correlated to a factor (i.e., loadings –1.0 to –0.4 and 0.4 to 1.0) were used to name the themes.

Characteristics of included literature

Reviewers (CT, TM, and DT) searched publicly available online biographies in an attempt to determine the self-situation or positionality [ 47 ] discussed by Kovach [ 48 ] of first authors of Indigenous related literature. For most articles the reviewers were unable to determine whether or not the first author self-identified as Indigenous. ( n  = 28). A self-identified Indigenous first author was determined for a small portion of articles only ( n  = 4). The majority of study designs ( n  = 16) within the literature were qualitative; followed by mixed methods ( n  = 12); quantitative ( n  = 8); program descriptions ( n  = 5); and literature reviews ( n  = 4). The majority of articles originated in Canada ( n  = 18) and Australia ( n  = 17); with the United States ( n  = 8); New Zealand ( n  = 1); and a combination of these countries ( n  = 1) rounding out the remaining articles.

Factors of program success

From the thematic analysis using the Braun and Clarke [ 45 ] framework, seven themes were identified as contributing to program success for Indigenous maternal-child community health programs: relationship building; cultural; knowledge transmission styles; community collaboration; program approaches; staff; and operational considerations. Table 2 summarizes descriptions of the identified themes.

Program barriers

The thematic analysis using the Braun and Clarke [ 44 , 45 ] framework identified six themes contributing to program barriers: impacts of colonization; power and governance; client and community barriers to accessing the program; physical and geographical challenges; staff; and operational deficits. Summary descriptions of the themes are found in Table  3 .

The PCA yielded three key factors underlying program success: relationship; program implementation; and operational delivery. The PCA identified five overarching factors relating to program barriers: colonization and its impact; interpersonal staffing issues (issues amongst the staff); staff issues resulting from lack of cultural sensitivity and a lack of resources; challenges with how programs are being implemented; and access to programs. Although the thematic analysis and PCA were completed independently, the results of the PCA illustrate themes similar to those identified through the thematic analysis.

Role of frontline workers

A large portion of the reviewed literature ( n  = 29) did not explicitly state the role of frontline workers outside of program delivery. Program descriptions provided an alternative means for the reviewers to possibly identify the role of frontline workers. Within the reviewed articles ( n  = 45), frontline workers all had a role in program delivery. For a majority of the articles ( n  = 25), we could not determine if frontline workers had been involved in program development; less than half of frontline workers ( n  = 19) had a role in program development; and one article ( n  = 1) stated no involvement of frontline workers in program development. For the largest portion of the articles ( n  = 38), we could not determine if frontline workers were involved in developing the program evaluations, i.e., determining the evaluation design, methods, and measures of success; very few frontline workers ( n  = 6) had a role in developing program evaluations; and one article ( n  = 1) reported no involvement of frontline workers in developing the program evaluation. In most of the literature ( n  = 20), we could not determine if frontline workers participated in the program evaluations; in approximately half of the reviewed literature ( n  = 22), frontline workers participated in program evaluation; and a small portion of articles ( n  = 3) reported no frontline workers participating in the evaluations.

The importance of authorship

Self-situation or positionality conveys who the author is and how the author's perspective shapes the research [ 17 , 47 , 48 ]. The lack of positionality of authors, makes it challenging to identify the voices that are communicating research in Indigenous maternal-child health. The voices sharing the findings of Indigenous maternal-child health program research are important to research consumers because they can influence how data is analyzed, interpreted, and communicated to inform practice [ 17 , 47 , 48 , 80 ].

In a large portion of articles ( n  = 28) included in this scoping review, the reviewers were unable to determine the self-situation or positionality [ 47 , 48 ] of first authors. Currently, publication guidelines and length limitations may not permit researchers to describe their background and motivation for the project [ 35 , 48 , 81 ]. One way to strengthen the literature and research for consumers is to include authors’ positionality in the literature when communicating Indigenous health research [ 48 ]. Including positionality could help decolonize the peer-reviewed literature by creating space for an Indigenous perspective and potentially influencing what research is translated into practice [ 48 , 82 ]. Changing the peer-reviewed literature may help discontinue the cycle of knowledge used in decision-making that perpetuates colonial health policy and practices that have done little to reduce Indigenous health inequity [ 79 , 82 , 83 ].

Factors of program success and barriers

Connection between the factors of success and program barriers.

There appears to be a connection between the themes or those factors important for program success and ones acting as barriers; efforts to include elements for success may also help to address a program barrier. The connectivity between themes could be used as levers to strengthen programs. For example, the inclusion of extended families within the program approach has been identified as contributing to program success [ 1 , 4 , 15 , 49 , 77 ]. Incorporating extended families into a maternal-child health program may help address an identified barrier to accessing the program, such as the exclusion of fathers [ 5 , 8 , 66 , 77 ]. The thematic results reveal linkages between factors of program success and barriers that provide insight into areas and strategies that could be used to improve the health program process, i.e., program development and evaluation, and quality improvement. Application of these findings may positively impact Indigenous maternal-child health programs to increase program success.

Culture and maternal-child health programs

Our scoping review results highlight that culture does not stand alone as an identified factor of maternal-child health program success, but is interwoven throughout the themes, from the inclusion of local culture to knowledge transmission styles [ 14 , 50 , 52 , 53 , 65 , 73 ]. Although woven through the themes, in the reviewed literature there is a lack of acknowledgement or discussion of culture’s importance as an intervention that is emphasized by Sasakamoose et al. [ 84 ]. The discourse surrounding culture in the literature focuses on the inclusion of culture within programs, such as Indigenous artwork, story, kinship systems, or cultural terms to describe the program, such as culturally-based, culturally-appropriate, and culturally-safe care [ 3 , 5 , 15 , 28 , 53 , 68 ]. Cultural inclusion within the programs is intended to create an acceptable program for participants and a good fit for the community [ 15 , 55 , 65 ].

The lack of discussion surrounding Indigenous culture as an intervention may suggest that the full benefit and impact of culture as a tool for wellness [ 84 ] are not being realized within Indigenous maternal-child health programs. A knowledge gap within health program literature exists; it is not well understood that Indigenous culture brings strengths and protective health benefits to the program itself to foster positive health outcomes and reduce health inequity [ 4 , 84 ]. Omitting the acknowledgement and discussion of culture as an intervention creates a missed opportunity to engage in reconciliation and decolonization of programs [ 84 ].

Essential role of program staff in Indigenous maternal-child health programs

The literature included in this review identified the impact of staff on the program as either positive or negative [ 1 , 5 , 52 , 53 , 61 , 62 , 72 ], demonstrating a large part of program success and challenges are dependent on the people within the program. For example, successful relationships with program participants can contribute to program success and are primarily dependent on individual staff [ 5 , 8 , 52 ]. The Indigenous program staff was identified in half of the reviewed literature ( n  = 23) as essential to providing culturally competent and culturally safe care for program participants and contributing to program success [ 15 , 52 , 62 , 67 ]. The literature discusses staff characteristics, such as valuing relationships, displaying genuine empathy, and being respectful, as important for creating successful Indigenous maternal health programs [ 8 , 29 , 77 ]. Conversely, staff who lack cultural competence and are resistant to programs can create significant program challenges and may result in clients not accessing a program or not receiving the full benefit of the program [ 29 , 61 , 64 , 65 ].

The literature identifies that staff have an important role in Indigenous maternal-child health programs [ 5 , 52 , 60 ]. Hence staffing and hiring practices are areas that may impact program success and failures. Union-based work environments can create challenges to hiring practices that support the employment of Indigenous staff and individuals who possess characteristics that make them a good fit for maternal-child health programs [ 25 , 77 , 85 ]. For example, hiring may only be available to existing staff through internal union opportunities where seniority is a primary factor in awarding positions and determining successful candidates [ 86 , 87 ]. These limitations on hiring processes can create significant challenges to implementing best practices in recruiting providers for Indigenous maternal-child health programs. To bring best practice recommendations surrounding staffing forward requires employers and unions to work together and further develop hiring practices [ 88 ] that facilitate program success.

Frontline worker role in Indigenous maternal-child health programs

With the essential role of staff in maternal-child health programs [ 4 , 5 , 15 ], there is great potential for frontline workers to take an extended role in the health program process, beyond their primary role in program delivery. Although almost half of the reviewed articles reported frontline workers participating in program development, frontline workers can offer more to health program development than the current practice found in our review that frames their contributions exclusively on providing input on methods of program delivery and adapting program resources [ 5 , 15 , 67 ].

Frontline workers have local community knowledge and relationships within the community [ 4 , 8 , 77 ]. They provide an exclusive perspective that can be used to identify community-specific needs, set health program priorities, and assume a role in program evaluation [ 4 , 5 , 8 , 77 ]. Frontline workers are part of the community in which programs are delivered and can provide valuable contributions to all aspects of the health program process, i.e., development, planning, delivery, and evaluation [ 4 , 12 , 15 ]. Providing frontline workers with the opportunity of inclusion to share their knowledge and skills can: increase the likelihood of programs that align with local community values and practices; increase program relevance to the community; and, potentially, contribute to program success and create a positive impact on health outcomes [ 4 , 8 , 52 ].

Stage 6: consultation

Consultation with stakeholders is part of the scoping review process as discussed by Arksey and O’Malley [ 21 ] and Levac et al. [ 20 ]. The inclusion of stakeholders and their input may help to inform the review, strengthen the review’s findings, and provide direction for future research [ 20 , 21 ]. In addition, the inclusion of stakeholders is an essential and ethical responsibility in research that may impact practice in Indigenous health [ 20 , 89 ]. Central to a completed community-based participatory research project was accessing the perspective of our community partner to explore the scoping review research questions from the perspectives of stakeholders such as maternal-child health program families, frontline workers, and administrators. The findings from the scoping literature review were applied to inform the methodology and discussion of the community-based research project and identify convergences or divergences between the stakeholder perspective and reviewed literature.

Limitations

Some articles and programs may have been missed due to the search strategy employed. The data extraction relied on program descriptions from the included articles and there is potential that relevant data may have been missed as it was not included in the article [ 4 ]. Determining the self-situation of first authors depended on the retrieved literature and seeking out the authors’ publicly available biographies. These methods may not have been adequate to determine the published first author’s self-situation resulting in some authors being misidentified or missed.

Although the authors attempted to reduce bias by including (1) two reviewers in the study selection and data extraction and (2) a PCA in addition to the Braun and Clarke [ 45 ] thematic analysis, the potential for bias within the review remains. The review was limited to four countries: Australia, Canada, New Zealand, and the United States, based on similar histories of colonization and large Indigenous populations [ 34 , 35 ] therefore, the applicability of the results outside of these countries is unknown. Even within the countries of inclusion, Indigenous peoples, communities, and cultures are all distinct with local values, practices, and protocols [ 7 ]. The scoping review results may not apply to all Indigenous maternal-child health programs within the included countries.

This scoping review provided an overview of the literature about factors of Indigenous maternal-child health program success, barriers, and the role of frontline workers. Although a better understanding of the frontline worker role in maternal-child health programs was obtained from the review, there was a large proportion of literature where the authors could not determine if the role went beyond program delivery. In addition, no direct input from frontline workers and their perspectives on program success or barriers were identified, suggesting areas to explore in future research. Although the researchers hypothesized the strong connection between frontline workers and maternal-child health programs, one unanticipated finding from the review was the “loud” nature of the literature supporting the importance of staff in health programs. The findings from this scoping review have informed the methodology and analysis of a community-based participatory research project. Outside of the study, the review’s findings may help improve the development, delivery, and evaluation of Indigenous maternal-child health programs.

Availability of data and materials

The datasets supporting the conclusions of this article are included within the article and in Additional file 1 .

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Acknowledgements

The authors would like to acknowledge the support and advice of Vicky Duncan, Librarian, Health Sciences, University of Saskatchewan, Saskatoon, SK, Canada.

Funding for the scoping review was provided by: Canadian Institutes of Health Research (CIHR) Doctoral Research Award – Priority Announcement: Aboriginal Research Methodologies CIHR 201610DAR-383834–283432.

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CT, TM, and DT collected the data from the retrieved articles. CT and TM completed the data analysis and interpretation of the data regarding the factors of success, barriers, and the role of frontline workers in Indigenous maternal-child health programs. CT was the main contributor in writing the manuscript, with all authors contributing feedback, reading, and approving the final manuscript. MS, AB, and DR supported the team and provided input in all aspects of the review and manuscript preparation.

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CT is a non-Indigenous woman who lives and works on Treaty 6 Territory and the Homeland of the Métis. As Assistant Professor with the College of Nursing, University of Saskatchewan, Saskatoon, SK, Canada, her research has centered around public health, working with Indigenous mothers, children, and families to reduce the burden of health inequity. TM is a member of Saddle Lake Cree Nation in Treaty 6 Territory. As Assistant Professor in the Department of Indigenous Studies at the University of Lethbridge, Lethbridge, AB, Canada, her research has centered around identifying how Cree legal traditions can be applied to develop OH&S polices that address lateral violence in the workplace. DT works for Alberta Health Services, Edmonton, AB, Canada. MS is an Associate Professor in the School of Public Health University of Saskatchewan, Saskatoon, SK, Canada. AB is an Emeritus Professor in the College of Nursing University of Saskatchewan, Saskatoon, SK, Canada.

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Thompson, C., Million, T., Tchir, D. et al. Factors of success, barriers, and the role of frontline workers in Indigenous maternal-child health programs: a scoping review. Int J Equity Health 23 , 28 (2024). https://doi.org/10.1186/s12939-024-02118-2

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Received : 23 August 2023

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DOI : https://doi.org/10.1186/s12939-024-02118-2

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  • Maternal-child health
  • Health program planning and evaluation
  • Scoping review

International Journal for Equity in Health

ISSN: 1475-9276

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  • Open access
  • Published: 14 February 2024

Exploring challenges and perceptions in the learning environment: an online qualitative study of medical students

  • Mohammed Almansour 1 &
  • Fatmah Almoayad 2  

BMC Medical Education volume  24 , Article number:  147 ( 2024 ) Cite this article

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The teaching and learning environment (TLE) in medical schools is critical for shaping the outcomes and competencies of graduates. Research on TLE has highlighted its influence on student learning approaches and outcomes, yet gaps remain, particularly in qualitative insights, especially in Saudi Arabian contexts. This study aims to explore the students’ experiences and perceptions of the TLE in a new medical college.

This qualitative study consisted of a total of five focus group discussions (3consequtive sessions for male group and two for female group) conducted virtually using the Zoom videoconferencing application. All the discussion sessions took place during a lockdown because of the COVID-19 pandemic between December 2020 and February 2021. Each session lasted for 45–60 min. Each group was formed of 4–5 students from different academic levels in the Majmaah medical school, which was established 10 years ago and is located in a small city. After “ verbatim transcription” of the sessions was made, a framework thematic analysis of the data was performed using the NVivo software.

The study results revealed that various elements, such as educational content, faculty roles, and personal factors, collectively influenced the students’ educational experiences. The students valued educational relevance and autonomous decision-making. The multifunctional role of faculty as mentors, evaluators, and resource providers was considered essential in enhancing academic experiences. Additionally, there was an evident need to improve the physical learning environment and facilities to adapt to emerging educational needs. These results align with existing literature, emphasizing the integration of theory and practice and the significant impact of faculty roles in academic experiences.

The findings suggest that medical colleges should involve students more in decision-making related to their education and ensure the practical relevance of the educational content. Establishing open communication channels between students and faculty who act as mentors and evaluators is also essential. Furthermore, enhancing supportive infrastructures, such as mental health and financial services, and promoting extracurricular activities are crucial for fostering a more effective and nurturing learning environment.

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Introduction

Teaching and learning environment (TLE) in medical schools as attracted growing attention in the academic community, reflecting its central role in shaping the educational outcomes and professional competency of graduates [ 1 ]. Understanding the TLE in medical schools involves exploring several factors, such as administrative arrangements, curriculum design, assessment methods, student–teacher interaction, resources, facilities, and psychosocial elements [ 2 , 3 , 4 ].

Since the late 1970s, the study of the impact of the TLE on medical students has grown. Initially focusing on deep and surface learning approaches, the research has expanded. It now encompasses diverse learning strategies and styles, highlighting the influence of the TLE on student outcomes [ 5 ]. Ramsden and Entwistle [ 6 ] laid the groundwork for studying the relationship between approaches to learning which refers to the various ways in which students engage with their educational experiences and perceptions of the learning environment students’ views and opinions about the various aspects of their educational setting. In their study, they identified three main factors in approaches to studying: orientations toward personal meaning, reproducing, and achieving.

Despite advancements in TLE research, some contradictory evidence exists regarding the relationship between TLE characteristics and students’ learning approaches [ 7 ]. Additionally, there are indications of cultural differences in student learning approaches [ 8 ], which further the understanding of these dynamics.

Faculty play a crucial role in cultivating a positive TLE by encouraging peer collaboration, stimulating discussions, and fostering positive perceptions [ 9 ]. These aspects are vital for both learning and academic well-being, as indicated by major educational bodies [ 10 , 11 , 12 ].

A supportive TLE has been associated with the overall success of an educational program and the development of competent graduates, influencing aspects such as feelings, mood, and the prevention of burnout [ 13 , 14 , 15 , 16 ]. Several studies have demonstrated the significance of monitoring students’ perceptions as an effective method for evaluating and improving the TLE [ 12 , 17 , 18 , 19 ]. For example, learning communities in medical schools have been linked with positive perceptions of the learning environment [ 20 ], while factors such as quality teaching, faculty support, and self-directed learning spaces are influential in shaping these perceptions [ 19 , 20 , 21 ]. The ongoing evaluation and adaptation of TLEs in collaboration with teachers and students is crucial for improving medical education.

Student surveys have been widely used by institutions across the world as an evaluation tool to assess teaching quality and learning experiences [ 22 ]. In Saudi Arabia, multiple studies have employed the Dundee Ready Education Environment Measure (DREEM) to understand students’ perceptions of their educational environment. Recent regional studies have provided new insights into undergraduate medical students’ learning styles and perceptions [ 23 , 24 ]. However, these studies have also revealed varied perceptions in Saudi institutions. Some have reported positive changes after moving to new campuses. Others expressed concerns about teaching methods, student–teacher relations, and stress [ 25 , 26 , 27 ].

While global research offers a rich array of qualitative studies that intricately explore the TLE [ 7 , 28 , 29 ], there is a noticeable gap in the local literature, with Saudi Arabian studies predominantly relying on quantitative data. An emphasis on quantitative methodologies provides a broad overview but often lacks the in-depth insights that qualitative methods can bring, particularly in understanding the lived experiences of students [ 30 ].

Research conducted at the College of Medicine at Majmaah University has shed light on generally favorable perceptions of students toward the TLE. The study by Almansour, AlMehmadi [ 31 ] identified challenges in acquiring knowledge and developing subject-specific skills, particularly during the basic science years. Specific areas identified as needing improvement included organized studying, communicating knowledge, and effort management. Notably, differences in satisfaction levels between clinical and basic science students, as well as gender-specific perceptions, noted in the research.

Building on the insights provided by the prior mentioned study by Almansour AlMehmadi [ 31 ], the current study aimed to comprehensively explore the experience of students about teaching and learning environment at the College of Medicine at Majmaah University. By exploring into their lived experiences and perceptions, this research seeks to fill the gap in the local literature by providing qualitative data on the TLE. The insights gained will contribute to tailoring the learning environment more effectively to meet the diverse needs of the student population. This will ultimately contribute to the creation of an optimally supportive educational environment.

Study design and participants

This observational study involved medical students at the College of Medicine, Majmaah University, Al-Majmaah, Riyadh Region. A focus group discussion method was employed to deeply explore the impact of the teaching and learning environment on the student’s learning experiences.

Setting and curricular framework

Majmaah University is an evolving educational institution in the region. It was established in 2009. Its college of medicine has adopted an outcome-based hybrid curriculum. Students must complete a six-year medical school program before they enroll in a one-year mandatory internship to obtain their bachelor of medicine/bachelor of surgery (MBBS) degree. The first year (phase 1) in medical school is preparatory, during which the students study chemistry, physics, and the English language. The following two and a half years start (phase 2) with system-oriented basic medical science modules and are followed by two and a half years (phase 3) of clinical clerkship in which students rotate between a major and sub-specialties with a main focus on practical clinical sessions. During all phases, evaluation includes theoretical and practical exams held after each module. This is followed by a mandatory internship year (phase 4) comprised of clinical rotations in medicine, surgery, obstetrics and gynecology, pediatrics, and emergency medicine. in addition to two elective clinical rotations. The interns are evaluated by their direct supervisors at the end of each rotation on a pass/fail basis, and they are eligible for the Saudi Medical Licensing Exam (SMLE), which is held twice a year.

Sampling and recruitment

The participants were recruited for two focus group discussions during the last three months of the 2020/2021 academic year. The total combined number of male and female students in the college at the time of the study was 324. Each group comprised 4–5 participants who had previously participated in quantitative research conducted earlier in their college experience by the same researcher and his team. Both groups consisted of heterogenous type of participants from all academic levels as shown in Table  1 . Following the local cultural norms in Saudi Arabia, the male and female focus groups were kept separate during their participation. A student affairs employee was asked by the researcher to recruit five students from the previous participants to join the two focus group discussions.

Data collection

Data were collected between December 2020 and February 2021. General demographic information sheets were completed by the participants upon recruitment. The focus group discussions were led by the principal investigator. The researcher conducted the focus group discussions virtually through the Zoom videoconferencing application. The recording of all sessions was done through ZOOM videoconferencing features of recording. All focus group discussion sessions took place during a lockdown because of the COVID-19 pandemic, which mandated the use of technology to conduct the sessions. The main researcher, an observer from the research team (two sessions only), and the participants were the only individuals in the Zoom meeting. The discussions were audio-visually recorded and lasted between 45 and 60 min.

The participants were given the choice of speaking Arabic (the native language of all the participants) or English. The discussions were led by a topic guide that was developed based on the aims of the study, which was a deep exploration of our previous questionnaire-based study with the same population (See Additional file 1.) Flexibility was observed by following the structured topic guide to allow the emergence of new themes and in consideration of the interactive nature of the focus group.

The discussion started with a general question, “What is your experience of the teaching and learning as a medical student in the College of Medicine at Majmaah University?” This was followed by a discussion involving some of the learning environment issues identified in the previous study.

Data analysis

The focus group recordings were transcribed professionally by external individuals. To preserve the meaning, the transcripts were analyzed in their original language, and only quotes (as presented in this article) were translated into English. Two individuals (the main researcher and an independent research assistant) were involved in coding the data. The data analysis process was based on the thematic analysis approach [ 32 ], which involves a six-step process: (1) familiarizing yourself with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. Themes were developed based on the identified patterns of the codes. Coding was completed using emergent themes, which were investigated until saturation was achieved. The themes were derived from the collected data and the topic guide, which was partially developed from the previous study. The NVivo software version 11.4.2 was used for data analysis. Using the software increases the efficiency of data organization and retrieval. Familiarization, descriptive coding, basic analysis, and interpretation are the steps followed in data analysis and quotes from the discussions were used to support the themes.

Five focus group discussions were conducted during the course of the study. Three discussion sessions involved the male student group (same participants complete the three sessions), and two sessions were held with the female student group (same participants complete the two sessions). Five male students and four female students voluntarily participated in each group, and they all continued to the conclusion of the study. The participant demographic data are shown in Table  1 . This shows that they were well distributed in regard to educational level. Both the preclinical and clinical phases of the MBBS program were well represented.

The discussion sessions raised many issues about the learning environment in the local context of the college of medicine. The approach the groups used in handling the discussions was generally analytical problem-solving, and in some situations, it was more oriented toward generating recommendations, such as practical steps, to improve the learning environment. Three major themes emerged from the discussion sessions: (1) educational factors, (2) faculty-related factors, and (3) social and personal factors. Each theme contained a number of sub-themes (as shown in Table  2 ).

Educational factors

Decisions about the importance and relevance of their learning.

The students valued teaching methods that bridged the gap between theory and practice, which made their learning more relevant to real situations and practice. For example, the participants made the following comments:

‘Roleplaying is simulating the things that we studied theoretically, and this information won’t stick in our heads until we see it in reality… such as rare conditions, it is almost impossible, and we may never see some of them during practice, and that can be beneficial. Generally, I love simulating, and personally, I always make sure I participate in them.’ [P1M]. ‘The Case Discussions (CDs), which in general have helped me and made me think, especially in differential diagnosis. I wish it was in all the years, not just from the fifth year.’ [P1F].

They also emphasized their interest in deciding about their learning, such as which important topics are needed by the students to ensure their autonomy in the learning environment. This point was in the context of being able to make recommendations rather than changes in actual practice. For example, one participant (P4M) stated,

Not just the doctor can decide roleplay topics, the students themselves can choose as well.

Relevance of the curriculum structure to students’ learning

The feeling of being stressed by the compact courses and the required learning material in the curriculum was shared by many students. Although some students expressed views similar to P3F:

I really like the college’s plan…. It is an excellent point, and instead of studying the diseases all at once and getting me lost, it has been divided into two sections. Even though in the sixth year, there is huge pressure on me.

Some students thought that the distribution of courses, materials, and skills had a rationale behind it. However, some courses seemed less relevant to other students, as shown in the following examples:

‘In one module, I felt that it was not that important’ . [P4F] ‘Last year was the worst with the pressure of the modules and some doctors… sometimes, they don’t accept that we take modules for two weeks, and I have midterms every week. We face huge psychological pressure’ [P3F].

Role of self-reflection

Reflections on learning were expressed by some students. They often related it to their phase or level of clinical exposure. For example, the following comments were made:

‘I think I touched on this in the clinical phase more than basic science phase. I reflected on my learning about 30% in the basic phase and 70% in the clinical phase… when I knew things and I could relate to them, and I had the ability to answer questions from family and friends.’ [P4M]. ‘It depends on our exposure. If there is an exposure and I saw cases or a certain situation or such, I think about it, and sometimes it doesn’t have to be me who’s in the situation but someone else. I think about it and what they are thinking about. But not always because I would be overthinking.’ [PF3].

Some students took their reflections out of the college context to other real-life situations, as in the following examples:

‘It has happened to me in real life. I related what I studied with a situation—I mean the clinical relation of the lecture. It was kind of a fracture, and my diagnosis was right. We had the lecture the day before the incident or a day earlier.’ [P3M].

In contrast, some students focused their reflections on their study issues and mainly on the solutions to those difficulties, for example, the following:

‘For me, any problem facing me related to time management or difficulties or any studying issue, I preferred to talk with seniors because they have been through the exact same experience as mine, at the same college, and they have been taught by the same doctors as me, and this benefits me 200%.’ [P2F]. ‘If I find it difficult to concentrate, I will look for solutions such as reading from a book, reading from a website, and watching videos.’ [P1F]. ‘Block arrangements and the correlation of the information between blocks.’ [P5M]. ‘I remember that case very well, because we linked what we studied with what we saw.’ [P3M]. ‘We had a field visit. They have connected my knowledge with reality, especially with topics related to contamination and vaccines. It was years ago, but I remember it because it cleared up the picture.’ [P4M]. ‘The CDs which in general have helped me and made me think especially in differential diagnosis. I wish it is in all years, not just from fifth year.’ [P1F]. ‘We don’t have a university hospital, so the university should do something alternative to have clinical exposure and see patients in the earlier years.’ [P1F]. ‘It was patient history and clinical examination. Yes, I learned about them in basic science, but when I practiced them, they were different. I think if the university took advantage of the students, instead of us studying how to take a history and do a clinical examination theoretically, they could the students go to summer training, and we would benefit 100%.’ [P1F].

Extracurricular activities

The students described an issue of poor awareness of extracurricular activities early in their learning journeys. A lack of these activities and support was also mentioned as an issue, as described in the following:

‘As seniors, we didn’t know about them, and it is a requirement to participate in a student club for our CV. We didn’t know till this year.’ [P5M]. ‘So, I feel we lack this in our college, and we focus on studying. We don’t have student activities to motivate us and entertain us. Everything is under academic pressure, and the students will burn out, and they will not have the ability or passion to participate or represent the college of medicine in other forums. It is such a waste of excellent potential.’ [P3F]. ‘I wanted to establish a student club similar to the KSU [King Saud University] student club…. I didn’t get the university support and had a financial issue.’ [P3F].

Academic atmosphere and resources

In regards to facilities, there were some issues raised contrasting the old and new building, some were related to the separation of the male and female student campuses, and others related to the management of facilities:

In the old building, we had a public library. The atmosphere was actually encouraging you to study during your free time. Now we understand that the building is new, and this is the third year since we moved in. But, we hope that the future is better regarding this point. [P4M] We were moving constantly between the old college building, theater building, and the new college building. This was in regard to labs. We didn’t get the full advantage of them, and the lack of labs, especially for female students, and we were unsettled in one place. We have moved constantly. [P3F] We don’t have a garden in our building. We can’t sit outdoor. We’re always indoors from 8:00 AM to 2:00–3:00 PM, and we are forbidden to go out and do anything. We don’t have a place where we can breathe fresh air. [P4F] ‘If I compare it with another library in a different place, there is a difference. We have shortages in our resources, but what I see is, it is enough, and I don’t know. Additionally, nowadays, everybody is headed for software and soft copies. Honestly, now is different than three years ago; everyone has an iPad, which contains uncountable resources.’

The clinical posting in the local hospital had an impact mainly on the female students, with comments regarding the perceptions of inequality in the opportunities to learn due to gender:

‘I mean in terms of cases in King Khalid Hospital are so limited, and some of the doctors were not cooperative with us. The training at King Khalid Hospital was not the best. But there wasn’t inequality regarding our gender.’ [P1F].

As medical students, their focus was more on the clinical teaching-related factors that hindered their learning, such as limited clinical exposure. For most of their issues, they tried to link them to the setting (where they had limited clinical exposure in a small city hospital), gender difficulties due to cultural barriers, time management, and the number of students:

‘In terms of clinical exposure, we suffer. Some modules, for instance, are also practical, but we see the patient just once or twice during the module. This is due to several reasons, such as the hospital here, patients are few in number, and we don’t have a university hospital’ [P1M]. ‘Sometimes, it is a time matter and wondering how to study clinical skills in the college, then go to the hospital to see what we studied.’ [P4M]. ‘When I asked to go to a different hospital… unfortunately, in the female department, it was so hard to the extent that I went to the male department to transfer. I really wish it gets easier in the coming years.’ [P1F].

In contrast, some students acknowledged the effort that the college was making to overcome the limited clinical experience and appreciated the environment and resources, but with some critiques regarding certain facilities. This was shown in the maturity of the approach of some senior students as they advanced in their learning:

‘Clinical exposure… this matter is not only the students’ responsibility but also the responsibility of the college and the students at the same time. The college is trying to expose us and allow the students to do the examination once, twice, or more than that. However, some students are not interested. On the other hand, there are interested students, but the opportunity is not available for them.’ [P5M]. ‘The place, in my view… it is excellent in terms of theater and practicing places, except the library. It has limited resources.’ [P5M].

One issue appraised by most of the students was the safe environment and friendly atmosphere. The students, faculty, and administrative staff exhibit great cooperation, but that can be strained as the number of students increases:

‘The thing that we are doing is having a friendly meeting with doctors, and that depends on people’s free time. This will assist education more, and the general atmosphere would be more comfortable.’ [P4M]. ‘If the number of students is large and they don’t interact with each other, they won’t know each other. So, if there is group division, after a period of time, the group division changes.’ [P5M]. ‘There is huge cooperation between us and the doctors, and there is assistance and explanation when we ask for it, and they give their time off for us more than it is required from them, which is great.’ [P2F]. ‘The environment in general is good, to an extent. Some of the things were better than what we expected…. There is cooperation from the administration generally. For example, simple issues we faced, they have solved for us quickly.’ [P2F].

Faculty-related factors

Role as resource person.

The presence of a faculty member has a direct impact on the students: as a role model, a source of applied knowledge and skills that would be hard for the students themselves to perceive abstractly, and an accessible person in the institute with whom the students can easily interact. These various aspects are shown in the following examples:

‘Some doctors… the knowledge that they gave it to us… I cannot find it in any book or in any video, and the time I spend with them is precious.’ [P3F]. ‘The doctors are cooperative with us. We had good references, and everything was clear as a result. The outcome was very good, but in contrast, the other block was not.’ [P1F]. ‘They really provided a good explanation, especially for the clinical examination. It is impossible to forget how some lecturers explained clinical examination to us in a great and excellent way.’ [P1F]. ‘For example, during the breaks, I might find a certain doctor, and I’m free for half an hour. I sit with him and share ideas, or he explains something for me that will strengthen our relationship.’ [P4M]. ‘For clinical exposure, the faculty members have played their role and tried. There is a lot of bedside teaching in all the modules, and they have offered us a lot.’ [P4M].

Although the flip side of the potential positive impact of these various contributions is that some individual faculty members may not have the skills to guide the students or are failing to do so:

‘The problem is in some subjects the doctors are not fully knowledgeable or it’s not their subject. So, the doctor has difficulty in delivering the information to the students and that will cause a decrease of student knowledge.’ [P3F]. ‘I must present in a perfect way. On the other hand, the doctors who are teaching and giving us information are not presenting to us in a perfect way. They read from the iPad. They slide, open the book, and read from it .’ [P1F]. ‘The office hours of the faculty are a very important point that I want to mention. During the Directed Self Learning DSL, you weather have a meeting with doctors during their office hours, or you search about the topic. We have done it before, and we had time out of the lectures and office hours frame where we went to the doctor, so he clarified some points and explained them to us.’ [P1M]. ‘There is someone called a year coordinator, and he can play a major role, but for us as students, we didn’t feel that.’ [P4M]. ‘Some faculty members, if they knew that you are not interested in their subject (specialty), they won’t answer your questions.’ [P3F].

Role as evaluator (feedback provider)

The students appreciated the role of the feedback provided by the faculty on their performance and the impact of this practice on their development. However, they did address the feedback they received and the challenges in seeking feedback and how it was provided by the faculty:

‘Some of them, they give you feedback privately and explain weaknesses are strengths and what I need to change and to pay attention to some points that will come at residency.’ [P3F]. ‘When I present in their seminar and at the end, they give me feedback, so I develop myself. In reference to their feedback, I see an improvement in the next seminar, but other doctors, they don’t give feedback to their students, and that will lead to lack of improvement.’ [P4M]. ‘If we had better communication, it would be fantastic, and I think it is students’ responsibility…and if you know your seminar’s doctor, you search for him and show him your work.…and give you feedback. He will tell you what you need to add and what to remove.’ [P2M].

Role as mentor

Having a mentor is highly appreciated by students, and they admire the effort of the faculty to make it happen, both formally and informally. There is still the challenge of keeping it effective and appropriate for each level of student:

‘Having mentors is so great, but it needs more commitment because this situation is new to the students…. Honestly, the faculty were committed, and they tried to do so many things, such as, if you want to know your grade, go to your mentor, but I feel we need more sessions with our mentors .’ [P4M]. ‘Started the semester correctly, regular meetings with our mentors… then it decreased gradually, and it became a routine, just filling out papers or signing papers. Mentors are fundamental.’ [P1M]. ‘Before the pandemic, we organized with two doctors to meet in a coffee shop in the evening, and it was an informal meeting. It was so beneficial in terms of life experiences.’ [P1M]. ‘Also, the mentor has a role in impacting our experience. Doesn’t he? [two students verbally agreed with this after it was said.’ [P1M]. ‘We didn’t have a guide to show us what to do. There are so many things we were missing in the basic years.’ [P1F].

Social and personal factors

Educational challenges.

The students illustrated that their ability to cope with stressors of having a variety of educational activities that needed good preparation and often more time was challenging. Some students related those stressors to external factors affecting them, such as the short time frame of the courses, number of classes, nature of activities, and demands of the learning materials.

‘The experience so far is good from some students’ point of view. One of the problems that we face is the number of classes. Some days, we have five or six classes in one day that will reduce students’ understanding, and there’s no equal distribution for the lectures during that is one of the major problems we face .’ [P1M]. ‘There is no proportioning with the time. We have, for example, some modules; we will only have eight weeks, and the curriculum needs more time than that. Even in the exam, the quantity of the information is not proportional to the time, and I have been struggling with this issue myself.’ [P1M]. ‘The time of Problem Based Learning (PBLs) and CDs and these sorts of things. Honestly, they are putting us under psychological pressure during this time .’ [P2F].

Students’ interactions

The students’ interactions with each other have an important impact (positively and negatively) on the learning environments, as stated in the following examples:

‘For me, the thing that impacted me was the students. There is motivation and assistance between us. In addition, the faculty did a lot .’ [P3M]. ‘We notice that there is always a group of studious students, a group of average students, and so on. We need to promote the culture of strong people help weak people. Some students who are advanced academically shouldn’t be enclosed with each other and neglecting other students.’ [P5M]. ‘This phenomenon causes problems between students. For example, one group has a clarification of something or a particular source, and they don’t share it with other groups .’ [P1M]. ‘Comparing us with the female side, they always tell us that female students got higher marks then you and your level is less than female students’ level, and we struggle with this.’ [P1M]. ‘The second point that I feel helps is the relationships between the students. If the batch is connected and gathered, and they are helping each other, it is different than if they are doing silly actions or hiding information from each other. This will affect them. If there is group work and the students are helping each other constantly, it is different than if they are fighting each other.’ [P5M].

Psychological and financial support

Having a supportive context in the matter of psychological or financial support was also addressed as an issue impacting the learning environment:

‘Secondly, we lack psychological consultations and a clinic in the university, or at least, they could provide consultations and access to them .’ [P3F]. ‘Not just a program discount, but in general, some universities provide this to their students for free. They contract with shops, for example. Shops provide medical tools or scrubs .’ [P1F].

This study was conducted to explore the teaching and learning environment at the College of Medicine at Majmaah University. Insights from focus groups shed light on students’ experiences and perspectives within the educational context, revealing key themes in education, faculty interactions, and social as well as personal factors.

In the context of education, the importance of relevance in teaching methods cannot be overemphasized. Students in the current study valued teaching methods that effectively bridged theoretical concepts with practical application, enhancing the relevance of their learning. This finding was consistent with those from other contexts in which studies examined the dichotomy between perceived educational value and task engagement, as reported by various researchers [ 33 , 34 , 35 , 36 ]. Learners perceiving a separation between learning and practical work tend to engage selectively with tasks, influenced by their perceived educational value.

This aspect from educators’ was found in earlier literature where educators were required to make frequent decisions regarding what information to incorporate based on its relevance to the curriculum and school policies [ 37 ]. This prescriptive nature of relevance aligns with the desire of students for learning that resonates with reality.

In addition, the findings revealed that students want an active role in decision-making regarding their learning, which hints at anticipated relevance, as mentioned by Diekema and Olsen [ 37 ]. Thus, the relevance of content and the perceived educational value of tasks are central to the learner’s experience. While the current study focused on the students’ perspectives, the literature suggests that both educators and students have unique insights to offer in this respect, and the bridge between theory and practice can only be truly constructed when these insights are aligned.

The results of our study highlight the diverse ways in which students engage in self-reflection. Some contextualized their reflections within the specific phase of their medical training or the extent of their clinical exposure. Others extrapolated their learning to real-life scenarios, which is relevant to the previous point of perceiving the value of learning, while another group focused exclusively on academic difficulties and their potential solutions.

Schei, Fuks and Boudreau [ 34 ] illustrate this concept of reflection well, noting its potential in addressing medical education complexities, though acknowledging challenges posed by human cognition. Schei and colleagues argued for a form of reflection in medical education that results in wise practice, encompassing both self-awareness and self-correcting behaviors, which aligns with our findings in which the students reflected on solutions to their academic challenges.

Hargreaves [ 38 ] offers an interesting perspective, suggesting that reflective competence can be developed progressively throughout an undergraduate program. This concept provides a plausible explanation for the variations observed in student reflections. As students move through different stages of their education, the nature and depth of their reflections evolve.

Griggs [ 39 ] explored the challenges associated with assessing reflective practices in medical education. Our study’s findings resonate with this, as during the focus group, the reflections leaned toward discussing personal experiences. Griggs’ emphasis on storytelling as a catalyst for deeper reflection also aligns with our observations. When students relate their learning to real-life situations, they are, in essence, crafting a narrative that might foster more profound reflection.

Students reported a noticeable lack of information and encouragement regarding participation in extracurricular activities, which the literature has indicated as important in fostering various essential practical and analytical skills and attitudes, such as leadership, commitment, responsibility [ 40 ], problem-solving, and essay-writing abilities [ 41 ].

Extracurricular activities has been reported foster student-community interactions, thereby enhancing learning experiences [ 40 ]. However, in the current study, the students felt that there was inadequate support for extracurricular activities, both financial and organizational, from the university, echoing the barriers identified by Fuji [ 40 ], such as a lack of support, limited positions, and poor availability of physical and financial resources. Students’ feelings of burnout and academic pressure find echoes in existing literature on the subject. which mentions poor time management and the risk of lowered academic performance as potential barriers to participation in extracurricular activities [ 42 ].

The findings from the current study and the literature collectively advocate for a more supportive environment for extracurricular activities in medical education.

The results illustrate various issues and positive aspects related to the educational facilities and environment experienced by students. A noticeable concern is the inadequacy of certain facilities amenities, such as a public library and outdoor spaces. Female students, in particular, highlighted issues like insufficient lab facilities and a perception of unequal distribution of resources during clinical postings at local hospitals. Similar results were identified by other studies that emphasized the importance of well-equipped educational environments with necessary facilities and resources for students’ motivation, participation, and self-regulation in learning processes [ 43 , 44 ].

However, a new educational setting has also been credited for fostering a safe and cooperative environment where students, faculty, and administrative staff effectively collaborate, enhancing the educational experience. The adaptability to technological advancements is evident, with a shift toward digital resources like software and iPads, which seem to partly mitigate the limitations of physical resources. This resonates with the literature’s emphasis on the necessity of up-to-date resources for effective learning [ 44 ].

It is thus clear that while there are areas for improvement, particularly concerning facility provisions and gender-related challenges, various elements of the new environment were conducive to fostering a positive and adaptive learning experience.

The students expressed their concerns with the limited clinical exposure and constraints faced due to limited patient availability and the absence of a university hospital. This resonates with the concerns documented in the existing literature. The literature has shown that students exhibit a strong inclination toward hands-on clinical practice [ 45 ]. In the current study, gender difficulties, coupled with cultural barriers, further complicated this scenario.

Notably, the educational institution’s role, including that of faculties, has been addressed in literature. For example, there is an emphasis on the indispensability of authentic learning experiences [ 46 ]. The students’ reflections highlighted an appreciation for the college’s concerted efforts to improve the deficits in clinical exposure, underlining the institutional responsibility of enhancing the students’ practical learning experience.

Furthermore, the students’ aspirations for enriched clinical encounters were similarly found in Saigal, Takemura [ 47 ], emphasizing the influential role of preclinical and clinical experiences in shaping medical students’ specialty preferences and overarching professional paths.

The multifaceted roles that faculty members play—as resource persons, evaluators, and mentors—are instrumental in molding students’ academic experience was evident in the study results.

Ingraham, Davidson and Yonge [ 48 ] emphasized this dimension of the faculty–student relationship, where themes of support and care are paramount. A key aspect of this is the knowledge-sharing that happens outside of structured teaching sessions. This was evident in the results from students’ appreciation for informal meetings with faculty members, where they discussed life experiences in a casual setting like a coffee shop. Such interactions emphasize the importance of faculty as a well-spring of real-world experiences, not just academic knowledge.

As reported by Shim and Walczak [ 49 ], the efficacy of pedagogical methods often rests on the quality of the feedback provided. The feedback received from faculty helps students identify their strengths, understand their areas of improvement, and map out future learning pathways. Smith [ 50 ] indicated that the relationship between faculty members as mentors and students as mentees is significant in shaping perceptions and satisfaction levels in academic settings. For students, having a mentor is more than just an academic advantage; it is an avenue for holistic growth. Students praised the faculty’s efforts in establishing mentorship and guidance through uncertainties, albeit suggesting the need for more consistent interactions. They also raised concerns about the changing dynamics of mentorship, where initial enthusiasm can sometimes wane, and the interaction can devolve into accomplishing routine paperwork.

Naturally, the students expressed that they encountered stressors during their educational journeys. The results revealed that students found managing multiple educational activities within limited timeframes to be particularly challenging. This aligns with the findings of Weber, Skodda [ 51 ], who identified organizational factors, such as inadequate information flow and exam-related issues, as significant contributors to students’ stress levels.

The students highlighted specific external factors exacerbating their stress levels, such as the unequal distribution of lectures, short course durations, and an overwhelming volume of information relative to the time until each exam. These findings align with several studies in Saudi Arabia [ 52 , 53 ] emphasizing heightened stress levels in medical students due to the intensity of the curriculum and academic achievement. Similarly, Hill, Goicochea and Merlo [ 54 ] highlighted system-level concerns, such as administrative and assessment-related pressures, corroborating our findings regarding the impact of external and organizational factors on student stress.

As suggested by Hill, Goicochea and Merlo [ 54 ], our study highlights the necessity for structural consideration in medical education to create a more balanced and less stressful academic environment, thereby enhancing students’ ability to cope with the demands of their education.

The students highlighted the role of peer interactions in the learning process. Similarly, Akinla, Hagan and Atiomo [ 55 ] emphasized the value of near-peer mentoring in fostering professional and personal development. The students’ revealed that these interactions encompassed collaboration, as well as competition and comparison, and were helpful with their stressors and mental health challenges [ 54 , 56 ]. In particular, the gender-based comparisons and the withholding of information among groups revealed a competitive environment that can exacerbate stress and hinder collective academic progress.

Students emphasized the essential role of psychological and financial support in enhancing the medical students’ learning environment. This finding is consistent with the broader educational literature that emphasizes the crucial role of financial and mental health services in supporting students’ well-being and academic success [ 53 , 56 ].

The literature and student feedback collectively emphasize the importance of enhancing the supportive infrastructure within educational environments. Such improvements, including mental health services and financial assistance, are essential for creating a more supportive and conducive learning environment [ 52 ].

This study has highlighted the critical interaction of educational content, faculty involvement, and social and personal elements in shaping students’ educational experiences. A key finding is the students’ strong appreciation for educational relevance and their autonomy in decision-making. Faculty roles, encompassing resources, evaluators, and mentors, are central to shaping both the academic experience and supporting students’ development. Additionally, the necessity to enhance physical learning environments and facilities to meet evolving educational needs is underscored. This study contributes to existing literature by pinpointing specific improvement areas, emphasizing the importance of student involvement and faculty roles in the educational process.

Recommendations

Based on our study’s findings, we recommend several enhancements to the educational experience in medical colleges. Emphasizing practical applications in the curriculum is crucial to bridge the gap between theory and practice, making learning more relevant and engaging for students.

Student involvement in decision-making processes is essential for fostering a sense of ownership in their educational journey. Implementing structured reflection activities tailored to different curriculum stages can deepen students’ engagement and understanding.

Incorporating practical case studies and scenarios will enable students to relate their learning to real-life situations, enhancing practical knowledge application. Equally important is encouraging student participation in extracurricular activities, which aids in developing essential life skills.

Addressing facility inadequacies, such as enhancing library resources and outdoor spaces, is necessary to create a conducive learning environment. Ensuring equal clinical opportunities for all students, irrespective of gender, and addressing cultural barriers in clinical practice, will promote a more inclusive educational setting.

Strengthening mentorship programs is vital for providing ongoing support to students. Adjusting structural elements of the curriculum, like lecture distribution and course durations, can alleviate student stress, contributing to a more balanced academic environment.

Promoting collaboration over competition among students will foster a supportive educational atmosphere. Finally, enhancing psychological and financial support services, including counseling and financial aid, is crucial for students’ overall well-being and success.

These targeted recommendations aim to improve various aspects of medical education, ensuring a higher quality of learning and student satisfaction.

Data availability

The qualitative data used in the current study are not publicly available as the related quotes are shared in the results section, however they can be available from the corresponding author on reasonable request.

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Acknowledgements

We deeply appreciate Shams Khalid Almutawa from University of Strathclyde for her contribution in coding and analysis.

This research is funded by Princess Nourah bint Abdulrahman University, Researches Supporting Project number (PNURSP2024R353) Princess Nourah bint Abdulrahman University Saudi Arabia.

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  • Learning environment
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Effect of Osteoporosis Treatments on Osteoarthritis Progression in Postmenopausal Women: A Review of the Literature

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  • Wang-Chun Ho 1   na1 ,
  • Chung-Chih Chang 1   na1 ,
  • Wen-Tien Wu 1 , 2 , 3 ,
  • Ru-Ping Lee 3 ,
  • Ting-Kuo Yao 2 ,
  • Cheng-Huan Peng 2 &
  • Kuang-Ting Yeh 1 , 2 , 4  

Purpose of Review

The purpose of this literature review was to determine if medications used to treat osteoporosis are also effective for treating osteoarthritis (OA).

Recent Findings

A total of 40 relevant articles were identified. Studies were categorized into those (1) discussing estrogen and selective estrogen receptor modulators (SERMs), (2) bisphosphonates, (3) parathyroid hormone (PTH) analogs, and (4) denosumab, and (5) prior review articles. A large amount of evidence suggests that estrogen and SERMs are effective at reducing OA symptoms and disease progression. Evidence suggests that bisphosphonates, the most common medications used to treat osteoporosis, can reduce OA symptoms and disease progression. In vivo studies suggest that PTH analogs may improve the cartilage destruction associated with OA; however, few human trials have examined its use for OA. Denosumab is approved to treat osteoporosis, bone metastases, and certain types of breast cancer, but little study has been done with respect to its effect on OA.

The current evidence indicates that medications used to treat osteoporosis are also effective for treating OA. Estrogen, SERMs, and bisphosphonates have the most potential as OA therapies. Less is known regarding the effectiveness of PTH analogs and denosumab in OA, and more research is needed.

Avoid common mistakes on your manuscript.

Introduction

Osteoporosis (OP) and osteoarthritis (OA) are two important skeletal disorders primarily associated with aging [ 1 , 2 , 3 •, 4 ]. OP is a condition characterized by a loss of bone mineral density (BMD), resulting in bones with decreased structural integrity making them more prone to fractures [ 1 , 2 , 3 •, 4 ]. On the other hand, OA is a complex inflammatory disease affecting various joint tissues [ 5 , 6 ]. While cartilage degeneration is a hallmark feature of end-stage disease, OA disrupts joint homeostasis through chronic inflammation, impacting the synovium, subchondral bone, ligaments, and periarticular structures. In advanced stages, loss of cartilage quality and quantity leads to bone-on-bone contact, reducing joint mobility and function, causing severe pain [ 5 , 6 ]. Interestingly, some studies have reported that higher BMD was associated with a reduced risk of OA in the knee [ 3 •, 7 ]. Thus, OP and OA may be intersecting in terms of BMD.

The primary medications used to treat OP include bisphosphonates, estrogen, and selective estrogen receptor modulators (SERMs) [ 3 •]. Bisphosphonates bind with high affinity to the mineral matrix of bone and inhibit osteoclast resorption of the bone, leading to a decrease in bone turnover and a net gain in bone mass [ 1 , 3 •, 4 ]. Estrogen affects bone through via a number of mechanisms [ 1 , 3 •, 4 ]. Estrogen can (1) lower the sensitivity of bone to the effects of parathyroid hormone (PTH), and thus reduce bone resorption; (2) increase the production of calcitonin, and thus inhibit bone resorption; (3) accelerate calcium resorption by the intestine, and thus increase serum calcium concentration which promotes increase of bone mass; (4) reduce calcium excretion from the kidneys, and subsequently increases serum concentration; and (5) directly affect bone turnover due to the presence of estrogen receptors in bone. Other less common osteoporosis treatments, such as testosterone, calcitonin, and PTH analogs, operate through mechanisms distinct from bisphosphonates [ 3 •, 8 ]. Testosterone stimulates osteoblast-dependent bone formation more than osteoclast-dependent bone resorption, contributing to a positive skeletal balance. Calcitonin regulates calcium levels and inhibits osteoclast activity, impacting bone remodeling. PTH analogs, like teriparatide, directly stimulate osteoblastic formation, offering an anabolic approach to enhance bone density [ 8 ].

The purpose of this report is to review the literature and examine the effect of commonly used anti-osteoporotic medications on the development and progression of OA in postmenopausal women. The findings of this review may assist clinicians in treating aging women with concomitant osteoporosis and OA.

Search Strategy and Inclusion Criteria

A systematic search was conducted using the PubMed database that included the year 2013 through May 2023. The design and development of this study, and the database search and reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines ( http://www.prisma-statement.org/ ).

For the database search, the following keyword combinations were used: “postmenopausal AND osteoarthritis OR OA” and “ postmenopausal AND osteoporosis treatment OR anti-resorptive medication”; “estrogen OR hormone replacement therapy OR estrogen-related medication”; “selective estrogen-receptor modulators OR SERMs OR raloxifene OR tamoxifen OR levormeloxifene”; “ bisphosphonate OR alendronate OR zoledronic acid OR risedronate OR tiludronate OR pamidronate OR ibandronate OR Zometa OR Reclast OR Fosamax OR Actonel OR Boniva”; “parathyroid hormone OR PTH-related peptide OR Tymlos OR teriparatide OR abaloparatide OR Forteo”; and “osteoarthritis AND denosumab OR Prolia OR Romosozumab.”

Reference lists of all included articles were also screened for other potentially relevant articles that should be included in this review. Studies eligible for inclusion were those published in English and focused on postmenopausal women. Each article identified was independently reviewed and included in this review if it was a human or animal study investigating the effect of osteoporosis medications on OA. In addition, prior literature reviews and systematic review and meta-analyses relevant to the effect of medications used to treat osteoporosis on OA were also included.

Data Extraction

Each included study was read closely, and data/information extracted included (1) whether it was an animal or human study; (2) what animal model was used (for animal studies); (3) basic patient information (age and sex) and the number of patients (for human studies); (4) study design (e.g., prospective, retrospective, literature review/analysis (for human studies)); (5) the joint(s) studied; (6) the cell type studied; (7) the drug studied; (8) drug route of administration, dosage, frequency, and treatment length; (9) methods of outcome assessment before and after treatment; (10) results/outcomes; and (11) association between treatment and results/outcomes.

The literature search using the abovementioned criteria identified 40 articles relevant to the topic. The studies included in this article have been categorized into those discussing (1) estrogen and SERMs, (2) bisphosphonates, (3) parathyroid hormone, (4) denosumab, and (5) prior reviews.

Estrogen and Selective Estrogen Receptor Modulators (SERMs)

In postmenopausal women, the decrease of estrogen level is a causative factor in loss of BMD and is associated with a subsequent increased risk of fractures [ 1 , 3 •, 4 ]. Hormone therapy is now a standard treatment for osteoporosis. Hormones, especially estrogen and SERMs, are used for preventing osteoporosis.

Estrogen: Human Studies

Cheng et al. [ 9 •] provided an overview of osteoporosis due to hormone imbalance. While use of estrogen by postmenopausal women can increase the risk of endometrial cancer, it is effective in treating estrogen-deficiency osteoporosis [ 9 •]. While detailed discussion of the mechanisms of action of estrogen with respect to osteoporosis treatment is beyond the scope of this review, estrogen binds to estrogen receptors and subsequently inhibits osteoclast formation and bone resorptive activity.

In a very recent study, Yang et al. [ 10 ] performed a meta-analysis to examine the effects of estrogen on OA. The analysis included 11 studies with approximately 12,000 participants, with about half receiving estrogen to treat OA and the other half receiving treatments other than estrogen. Notably, patients treated with estrogen had a significantly lower collagen cross-linked C-telopeptide type 1 (CTX-I) level and a significantly higher bone Gla protein (BGP) level. Importantly, there were fewer patients treated with estrogen with joint pain than those treated with other medications, and those treated with estrogen with joint pain had lower subjective pain scores than patients treated with other therapies. However, the interpretation of outcomes of that meta-analysis might be limited due to a lack of strict criteria for inclusion, particularly in not explicitly incorporating studies utilizing the gold standard OA definition.

Estrogen: Animal Studies

Studies using animal models of a postmenopausal state and decreased estrogen level have indicated that maintaining a normal physiologic estrogen level can reduce OA symptoms [ 11 , 12 , 13 ]. Xu et el. [ 12 ] used a murine model of a postmenopausal state (ovariectomy mice) to study the effects of estrogen deficiency on cartilage and subchondral bone remodeling. The overall findings were that estrogen deficiency resulted in resorption of subchondral bone and degeneration of articular cartilage.

Corciulo et al. [ 11 ] also used a murine model of a postmenopausal state (ovariectomy mice) and found that treatment with estrogen prevented damage and thickening of the synovium, protected against loss of subchondral trabecular bone, and improved motor activity and reduced pain sensitivity. Psoralen is an estrogen analog that is derived from plants. Huang et al. [ 13 ] studied the effects of psoralen in a rabbit OA model that was created by transection of the anterior cruciate ligament. The results showed that psoralen decreased the destruction of cartilage tissue reflected by Osteoarthritis Research Society International (OARSI) score and increased subchondral BMD, trabecular thickness and number.

Selective estrogen receptor modulators (SERMs), also referred to estrogen receptor agonist/antagonists (ERAAs), are a class of drugs that act on estrogen receptors (ERs) [ 14 •]. Unlike pure ER agonists and antagonists, the effects of SERMs are different in different tissues, and thus can inhibit or stimulate ERs in different tissues [ 14 •, 15 ]. SERMs are used to treat a wide variety of conditions, including ovulatory dysfunction in the management of infertility, treatment and prevention of postmenopausal osteoporosis, treatment and reduction in risk of breast cancer, and treatment of dyspareunia and other symptoms of menopause [ 15 ].

A number of studies and review articles have examined the effect of different SERMs on OA [ 15 , 16 , 17 , 18 , 19 ]. Raloxifene is a second-generation SERM that has an estrogen-agonistic effect on bone; it increases BMD and bone mass by decreasing bone resorption [ 14 •]. It is indicated in the treatment and prevention of postmenopausal osteoporosis and for risk reduction of invasive breast cancer in postmenopausal women [ 14 •].

Xiao et al. [ 19 ] reviewed the use of “estrogen-related” drugs for the treatment of OA and concluded that although there are some inconsistencies in the literature, SERMs (and estrogen) may be particularly effective in lowering OA incidence and providing relief from OA-related pain, especially for individuals with early-stage OA or those with OA related to osteoporosis (reduced BMD related to high remodeling in subchondral bone). In a prior review of the literature (2014), Lugo et al. [ 15 ] also concluded that SERMs may be particularly effective in postmenopausal women with osteoporotic OA (reduced BMD related to high remodeling in subchondral bone).

Bei et al. [ 17 ] showed that raloxifene slows cartilage degradation and improves subchondral bone micro-architecture in a rat postmenopausal model (ovariectomized) with patellofemoral joint OA. An in vitro model study showed that raloxifene reversed OA-like alterations in rat chondrocytes [ 18 ]. Specifically, that study sheds light on the potential of raloxifene to influence and mitigate OA-related molecular alterations, presenting a multi-faceted perspective on its impact at the genetic, epigenetic, and proteomic levels.

Studies reporting effects of estrogen and SERMs in OA are summarized in Table  1 .

Bisphosphonates

Bisphosphonates prevent the loss of bone density and are the most commonly used drugs to treat osteoporosis [ 20 ]. Bone tissue is always undergoing remodeling, and the balance of bone tissue is maintained by osteoblasts creating bone and osteoclasts catalyzing bone [ 20 ]. Bisphosphonates work by causing osteoclasts to undergo apoptosis, and thus slow bone loss [ 20 ].

A large body of evidence shows that bisphosphonates reduce the risk of fracture in postmenopausal women with osteoporosis [ 20 ]. Bisphosphonates are also used to treat other conditions such as Paget’s disease, bone metastasis, multiple myeloma, and primary hyperparathyroidism [ 20 ]. Alendronate was the first bisphosphonate approved by the United States Food and Drug Administration (US FDA) as a treatment of osteoporosis in 1995, and many others have been approved and found wide use since then.

Although bisphosphonates are not generally used for the treatment of OA, a number of studies have indicated that they can reduce cartilage damage and symptoms of OA [ 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 ].

Prior Reviews

Our review of the literature identified 4 prior reviews examining the use of bisphosphonates with respect to OA published from 2013 to 2021 [ 22 , 26 , 27 , 28 ]. An in-depth analysis of each review is beyond the scope of this article; rather, the primary findings are summarized. The earliest review was published in 2013 by Davis et al. [ 27 ]. The systematic review and meta-analysis included 13 studies with 3832 participants. The authors concluded that there was limited evidence that bisphosphonates are effective for treating OA pain. However, they acknowledged there was marked heterogeneity in the included studies and a lack of long-term follow-up data.

Vaysbrot et al. [ 28 ] performed a systematic review and meta-analysis of randomized controlled trials to examine if bisphosphonates are effective in treating knee OA. The analysis included 7 trials with approximately 3000 patients. Most patients were treated with oral risedronate (about 2800). Overall there were no significant differences in pain, functional outcomes, or radiographic progression between patients who received a drug treatment and those that received placebo. However, based on the analysis, the authors concluded that bisphosphonates may be useful in subsets of patients who have a high rate of subchondral bone turnover.

Two reviews were published in 2021. The first by Fernández-Martín et al. [ 26 ] focused on preclinical animal studies published from 2000 to 2020. Overall, the authors concluded that bisphosphonates appeared to reduce osteoarthritic changes in a dose dependent manner, and that earlier initiation of treatment may produce better results. However, the authors indicated the heterogeneity of the studies and lack of long-term follow-up prevented definitive conclusions. The second review published in 2021 by Eriksen et al. [ 22 ] included animal and human studies and concluded that although in vitro and animal studies suggest that bisphosphonates may be of value in the treatment of OA, evidence from human studies is lacking and this may be due to study heterogeneity and lack of long-term follow-up.

Animal Studies

Our review identified 1 animal study meeting the search criteria. She et al. [ 21 ] studied the effect of zoledronic acid, a third-generation bisphosphonate, using a rabbit model of knee OA. The results showed that zoledronic acid increased subchondral bone density, reduced the degeneration of articular cartilage, and exerted a chondroprotective effect in a dose-dependent manner.

Human Studies

Three human studies published from 2017 to 2022 examining bisphosphonates and OA were identified in our review. Fu et al. [ 23 ] performed a national cohort study in Taiwan of persons with osteoporosis and newly diagnosed OA, and the risk of undergoing total knee arthroplasty (TKA). The study included about 16,000 bisphosphonate users and 124,000 persons not treated with any anti-osteoporosis drug seen from 2009 to 2012. The results showed that patients treated with a bisphosphonate had a significantly reduced risk of undergoing TKA (adjusted hazard ratio [HR] = 0.76, 95% confidence interval [CI]: 0.69 to 0.83, p  < 0.001). Adherence to treatment and longer treatment duration were also associated with reduced risk, and bisphosphonate users used significantly less pain medication than nonusers.

Hayes et al. [ 24 ] used data from the Osteoarthritis Initiative (OAI) to determine if bisphosphonate use protected against 2-year radiographic progression of knee OA. The study focused on women aged 50 and older with varying degrees of baseline radiographic knee OA, excluding individuals with severe OA, knee prosthetics, or self-reported exposure to non-bisphosphonate osteoporosis medications. While the sample size was relatively small (approximately 2000 women of whom 346 used bisphosphonates), the authors concluded that there may be a protective effect in patients with early-stage OA. The effect was specifically notable in patients who were not overweight, and the medications were less effective in patients with more advanced disease and those with more weight-bearing joint stress.

In an interesting, recent study, Kawai et al. [ 25 ] retrospectively reviewed the records and standing whole leg radiographs of patients ( N  = 398) who received a TKA. The authors measured the joint space narrowing in the non-arthritic hip and found that the rate of narrowing was significantly less in patients who were taking bisphosphonates than those who were not. Despite these evidences, there are currently no available human data on the relative efficacy for the prevention or against the progression of OA between specific bisphosphonates.

Studies reporting effects of bisphosphonates in OA are summarized in Table  2 .

Parathyroid Hormone (PTH)

PTH is a peptide hormone secreted by parathyroid gland and is associated with the regulation of serum calcium concentration; thus, it affects the remodeling of bone [ 29 , 30 ••]. Thus, treatment with PTH analogs have the potential to treat osteoporosis and/or OA [ 29 , 30 ••].

An early study of the use of PTH to treat osteoporosis showed that when given intermittently, bone formation exceeded bone resorption in the first 6–18 months of the treatment [ 29 ].

The PTH analog teriparatide (PTH (1–34)) has been studied extensively in in vitro experiments and animal models. A recent systematic review identified 22 in vivo studies for which the overall conclusions were that PTH (1–34) slowed the progression of OA by alleviating cartilage degeneration and aberrant modeling of subchondral bone and had analgesic and anti-inflammatory effects [ 30 ••]. Eleven in vitro studies were included in the review which concluded that PTH (1–34) increased the proliferation and matrix synthesis of chondrocytes. The authors of the review concluded that PTH (1–34) has potential for the treatment of OA in humans.

Our review identified 5 in vivo studies and 2 Mendelian randomization studies relevant to this article.

In Vivo Studies

Published in 2017, Zhang et al. [ 31 ] used a murine model to study the relevance of rapamycin complex 1 (mTORC1) in the initiation of OA. Prior to the study, it was known that disruption of the mTORC1 target promotes chondrocyte autophagy and survival, and thus decreases the severity of OA (experimental). The authors reported that mTORC1 activation downregulates PTH and PTH receptors in articular chondrocytes resulting in initiation of OA. Another studied published in 2017 by Ma et al. [ 32 ] used a rat model to study the effect of PTH (1–34) on cartilage degeneration. Overall, the results showed that administration of PTH (1–34) reduced histopathologic Mankin scores in the anterior cruciate ligament and medial meniscectomy-induced OA rat model. Subsequent studies have shown that PTH attenuates OA pain by remodeling subchondral bone in mice [ 33 ], that intra-articular PTH improves articular cartilage quality and a guinea pig knee OA model [ 34 ], and that PTH (1–34) attenuates cartilage degradation in a rat patellofemoral joint OA model [ 35 ].

Mendelian Randomization Studies

Mendelian randomization is a method of using measured variations in genes of known function to examine the causal effect of a modifiable exposure. Two Mendelian randomization studies were identified in our review, and both found a causative relation between decreased circulating PTH level and increased risk of hip and knee OA [ 36 , 37 ].

Denosumab is a human monoclonal antibody that targets the key bone resorption mediator RANKL [ 38 , 39 •]. Denosumab inhibits RANKL (receptor activator of nuclear factor kappa-Β ligand), and thus decreases the development of osteoclasts, which are cells that break down bone [ 38 , 39 •]. The drug is approved for the treatment of a number of conditions including osteoporosis, metastases to bone, and certain types of breast cancer [ 38 , 39 •].

Studies specifically centered on denosumab’s role in OA treatment were limited until a recent trial honed in on its application specifically for managing erosive hand OA[ 40 ]; however, some studies suggest that it can affect bone and cartilage positively and negatively. An analysis of secondary outcomes of an RCT found that administration of denosumab 1–3 days after surgery and 6 months after surgery prevented acetabular bone loss around an uncemented cup placed during total hip arthroplasty [ 41 ].

Conclusions

Based on the evidence in the current medical literature, medications for used for the treatment of osteoporosis can also be effective for the treatment of OA. Of current medications, estrogen, SERMs, and bisphosphonates are the most studied and have the most promise as effective treatments for OA. Less is known regarding the effectiveness of PTH and denosumab, and more research is needed to determine their usefulness in the treatment of OA.

Data Availability

All the data have been included in this published article.

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Wang-Chun Ho and Chung-Chih Chang contributed equally.

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School of Medicine, Tzu Chi University, Hualien, Taiwan

Wang-Chun Ho, Chung-Chih Chang, Wen-Tien Wu & Kuang-Ting Yeh

Department of Orthopedics, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan

Wen-Tien Wu, Ting-Kuo Yao, Cheng-Huan Peng & Kuang-Ting Yeh

Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan

Wen-Tien Wu & Ru-Ping Lee

Graduate Institute of Clinical Pharmacy, Tzu Chi University, Hualien, Taiwan

Kuang-Ting Yeh

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Conception and design: Kuang-Ting Yeh. Acquisition of data: Chung-Chih Chang. Analysis and interpretation of data: Ru-Ping Lee, Cheng-Huan Peng. Drafting of the manuscript: Wang-Chun Ho. Critical revision of the manuscript: Ting-Kuo Yao. Final approval of the manuscript: Wen-Tien Wu. All authors reviewed the manuscript.

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Ho, WC., Chang, CC., Wu, WT. et al. Effect of Osteoporosis Treatments on Osteoarthritis Progression in Postmenopausal Women: A Review of the Literature. Curr Rheumatol Rep (2024). https://doi.org/10.1007/s11926-024-01139-8

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  • Osteoporosis
  • Osteoarthritis (OA)
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  • Selective estrogen receptor modulators (SERMs)
  • Parathyroid hormone (PTH)

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Benefits and barriers associated with the use of smart home health technologies in the care of older persons: a systematic review

  • Yi Jiao (Angelina) Tian 1 ,
  • Nadine Andrea Felber 1 ,
  • Félix Pageau 2 , 3 ,
  • Delphine Roulet Schwab 4 &
  • Tenzin Wangmo 1  

BMC Geriatrics volume  24 , Article number:  152 ( 2024 ) Cite this article

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Smart home health technologies (SHHTs) have been discussed in the frame of caregiving to enable aging-in-place and independence. A systematic review was conducted in accordance with the PRISMA guidelines to gather the up-to-date knowledge on the benefits and barriers of using SHHTs in the care of older persons from the perspective of older persons and their caregivers.

Ten electronic databases were reviewed for empirical peer-reviewed literature published from 01.01.2000 to 31.12.2021 in English, German, and French reporting on experimental, qualitative, quantitative, and other empirical study designs were included. Included studies contained user-feedback from older persons over 65 years of age or their caregivers (formal and informal). We used an extraction document to collect relevant data from all included studies and applied narrative synthesis to analyze data related to benefits and barriers of SHHTs.

163 empirical peer-reviewed articles were included, the majority of those published between 2014 and 2021. Five first-order categories of benefits and five of barriers were found with individual sub-themes. SHHTs could be useful in the care context where continuous monitoring is needed. They improve self-management and independent living of older persons. Barriers currently exist with respect to ease of usability, social acceptance, and cost.

Conclusions

SHHTs could be useful in the care context but are not without concerns. Researchers and policy makers can use the information as a starting point to better understand how the roles and outcomes of SHHTs could be improved for the care of older persons, while caregivers of older adults could use our findings to comprehend the scope of SHHTs and to decide when and where such technology could best address their individual family needs. Limitations lie in the possible exclusion of relevant articles published outside the inclusion criteria as well as the fact that due to digital divide, our review represents opinions of those who could and wanted to participate in the included 163 studies.

Trial registration

This review has been registered as PROSPERO CRD42021248543. A protocol was completed in March 2021 with the PRISMA-P guidance. We have extended the review period from 2000 to 2020 since the registration of the protocol to 2000–2021.

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Introduction

Recent developments in medicine, public health, and medical technologies have led to an increase in life expectancy and an upwards trend in the global aging population [ 1 ]. At the same time, these trends are coupled with the rising likelihood for older adults to have increased risks of frailty, falls, disease and a reduced or loss of independence in completing instrumental activities of daily living (IADLs) (running errands, managing finances, using a computer and phone, etc.), and other ADLs (bathing, getting dressed, feeding oneself, etc.) [ 2 ]. To support and manage these declining abilities to independently undertake IADLs and ADLs, both informal and formal caregivers must provide extensive care and supervision, or alternatively consider a move towards institutionalization. Nevertheless, previous studies indicate that most older persons express negative feelings towards uprooting their lives from their homes, which may call for a solution that allows older persons to age-in-place while illness-appropriate and timely care could also be provided [ 3 , 4 ].

With recent technological advances in the field of connected devices and the Internet-of Things (IoTs), homes could be rendered “smart” by being fitted with unobtrusive, non-invasive, and wearable or stand-alone assistive health devices that communicate with each other, other systems, and end-users [ 5 , 6 ]. The definition of the “smart home” used in this paper is from Demiris and Hensel (2008), which is: “a residence wired with technology features that monitor the well-being and activities of their residents to improve overall quality of life, increase independence and prevent emergencies” [ 7 ]. To take this definition into more modern contexts with current advancements in wireless computing and application, this paper focuses on the empirical studies investigating all technologies available from 2000 to 2021 for health-related care and support in a home or residence context. These smart home health technologies (SHHTs) are categorized into 6 types: (a) physiological monitoring, pertaining to the collection and analysis of physiological measurements like heart rate, blood oxygen levels, blood pressure, respiration, temperature, or weight, etc.; (b) functional monitoring of data, including movements and activity levels while walking, sleeping, and eating, along with detecting abnormal movements or postures; (c) safety monitoring and assistance in the home environment for wandering behaviors, reduction of risks of falls or trips through automatic light switches in bathrooms during nighttime etc.; (d) security monitoring and assistance for the detection and responses towards intruders or threats; (e) social interaction monitoring and assistance with additional communication channels for health and well-being information or virtual participation in social events; and (f) cognitive and sensory assistance, including reminder systems for medication or cognitive aid functions for locating objects or practical instructions to aid forgetfulness [ 7 ]. The aspects of interoperability and automation in smart home technologies allow various different devices fulfilling the array of these health-related functions to communicate with one another [ 5 , 8 , 9 ]. Therefore, each health-related device in a residence is not a stand-alone entity but is compatible to be controlled and configured as connected ecosystem of technologies. For example, rather than measuring blood pressure, sleep time, and falls using individual devices at home, then operating and inputting the results onto another interface for a health-visit, the remote and continuous health monitoring function made possible with the installation of interoperable sensors enable any abnormalities in the older persons’ daily habits, postures, meals, and vital signs to be congregated and reported in real-time via another user interface or voice assistants to formal and informal caregivers, where they could continue to provide remote support while aging-in-place.

On a macro level, the concept of “smart homes” has been received positively and its global markets are predicted to grow [ 10 ]. Nevertheless, we agree with Wilson et al [ 11 ] that without evaluation and adoption by their actual end-users into the context of normal lives, their overall effectiveness as a solution for caregiving purposes would stay as theoretical potentials and assumed benefits. Most of the literature reviews and research are “pushed” by technology developers and still lack the feedback of end-users [ 11 , 12 ]. More research is needed to empirically investigate SHHTs from the end-users’ perspective, drawing in the issue of acceptance and adoption in the context of the personal environment that these technologies are used in [ 13 ].

Different from previous reviews of literature on smart home technology and caregiving, we narrowed the focus from reviewing all smart home devices similar to the work of Wilson, Hargreaves and Hauxwell-Baldwin [ 11 ] to SHHTs by adding the limit of the use of health technologies. We believe that this focus on health technologies, rather than those geared towards comfort, convenience, and entertainment could more directly address a few of the major concerns in the aging process, such as frailty, cognitive impairment, age-related disabilities, and risks of mortality [ 14 ]. The systematic review by Majumder and colleagues [ 5 ] focused on specific types of SHHTs used for older persons, such as wearable sensors, or another recent review by Pirzada and colleagues [ 15 ] that did not include assistive robots, whereas our more comprehensive review allows an aggregate overview of devices that fulfill a more diverse portfolio of interactive health needs and personal preferences. Namely, the installation of home sensors also involves the monitoring of health and signs of diseases, but could resolve the issue of forgetfulness common in the adoption of wearable sensors, concerns of waterproofing when the older person is in the shower, or the preferences against wearing devices on the body. The companion robots could address the angle of social isolation, while service robots could allow us to look futuristically towards the new features for hands-on, rather than monitoring functions that technologies could provide. Also different from those that focused on a specific topic in relation to SHHTs, such as loneliness and social isolation from Latikka et al. [ 16 ] and Choi and Lee [ 17 ], our systematic review provides an overview of benefits and barriers while presenting individual issues within a broader perspective of well-being, health, and an improvement of the quality of life of both the older persons and their caregivers. Therefore, we not only heed the calls from existing reviews to empirically examine from an end-user’s perspective, this review also differs from and adds to the works of our colleagues by focusing not only on, but all those, SHHTs used for caregiving purposes with sampling of older persons or those directly involved in their care.

Our systematic review aims to capture the existing knowledge including barriers and opportunities in the uptake of SHHTs in the care of older persons. Specific research questions include (1) What are the benefits and opportunities that SHHTs bring to the caregiving context in the existing empirical literature? (2) What are the barriers to acceptance or areas of improvement in SHHTs when they are used to care for older persons in the existing empirical literature?

Search Strategy

To capture the relevant intersection between older persons, caregivers, and SHHTs, we used a search algorithm (see Table  1 ) organized into four PICO (Population, Intervention, Context, Outcome) categories covering facets of interest: Population 1 (Older adults), Population 2 (Caregivers), Intervention (Smart home technologies), and Context (Home). By “home”, we mean an individual’s place of residence. This would include not only one’s home or apartment in the case of those older persons living in the community but also establishments providing residence and care such as retirement homes, nursing homes, aged care facilities, and assisted living that allows some level of independence for older persons. Each category included synonyms and varying spelling of each term, while also accommodating for possible definition and structure variabilities. The search strategy was also developed by the research team with the help of an information specialist. This algorithm was then adapted to use in ten digital databases: EMBASE, Medline, PsycINFO, CINAHL, SocIndex, SCOPUS, IEEE, Web of Science, Philpapers, and Philosophers Index (See Fig.  1 ). All terms were coupled with database-specific thesaurus terms where available. The search was limited to English, French, and German peer-reviewed papers published between 1 January 2000 and 31 December 2021. This date range was chosen to obtain a comprehensive review of existing studies, while taking into account the time of emergence and development trajectory of SHHTs, such as the advancement of wired to wireless devices or the increase in the number of interoperable multi-functional devices in the home. Although some reviews may purposively forgo searching for publications prior to 2010 (i.e. Liu, Stroulia [ 3 ]’s studied SHHTs’ technological readiness and their evidence to support older adults at home between 2010 and 2014), we believe that as the definitions and empirical work pertinent to early developments of smart homes began emerging as early as 2003 and all throughout the 2000s, there was ample need to include possible research outputs during these years [ 7 , 18 , 19 ].

Eligibility criteria

The inclusion criteria were: (1) The included study must be empirical and peer-reviewed. That is, an article was only included if it gathered the opinions of relevant end-users, such as caregivers and older persons, on the use of SHHTs in caregiving for older persons. (2) The studied population includes older persons over 65 years of age requiring care and support at their place of dwelling (home or nursing home) and/or professional and /or informal caregivers who provide care to older persons. Informal caregivers refer to family members or friends who provide support without monetary benefits. Professional or formal caregivers are those who are paid to help older persons receive medical treatment or perform tasks in their homes. (3) The empirical study concerns the use of SHHTs in the older persons’ place of dwelling. Specifically, these smart home technologies should be integrated into the older person’s place of dwelling, providing an interoperable system of devices that serves caregiving purposes. For example, studies were included if the health monitoring technologies such as cameras, motion detectors, or wearable sensors etc., mentioned were capable of interacting with each other and automatically alert end-users via either smartphones, tablets, or alarm services operated by formal caregivers.

We excluded studies that were (1) non-empirical and /or those published as book chapters, conference proceedings, newspaper articles, commentary, dissertations, and theses. Also excluded were systematic reviews. (2) Studies that did not report on the views of our population of interest or only included the views of researchers; and (3) technologies that are used for caregiving but is not interoperable or communicable with each other over an integration platform, such as stand-alone health devices such as those measuring blood pressure or weight, or the use of the video calling technologies to enable telehealth visits. Technologies that did not fulfill caregiving purposes for the promotion of health, such as single-purpose devices for cooking, cleaning, and comfort, were also excluded.

Selection process

After conducting a systematic search with the algorithm (see Table  1 ), results across all ten databases were consolidated and uploaded to a referencing software, where duplicates were removed automatically. From this point, all screening processes for format, content, and exclusion of additional duplicates were done manually. All titles were first screened manually by the third author. Thereafter, the abstracts of remaining articles were assessed independently by the first and third authors. Disagreements and uncertainties were resolved by the second author, who also proceeded to combine all included articles from the first and third authors and removed any duplicates generated during the abstract screening.

Data collection process

Upon screening both titles and abstracts, full electronically-available copies of remaining articles were retrieved and carefully studied by the first, second, and last authors for data extraction. At this stage, many papers were further deemed ineligible and were excluded with documented reasons. In order to identify appropriate data for extraction, the team developed a customized extraction document detailing information relevant to study demographics, technology specificities, benefits, and barriers, which was tested and adapted using several publications fulfilling the inclusion criteria. For relevant data to be extracted, it was not necessary for the article to use the exact wording of a theme already present on the extraction document. For example, though we were interested broadly in the concerns for the user-friendliness of a device, the researcher would extract data that also mentioned terms such as “slow, required directions, or anxious for making mistakes” which were not limited to whether the device was explicitly evaluated as “easy or difficult to use.” Nevertheless, articles that evaluated user-friendliness or design of a device without the collection of end-user opinions and experiences of a SHHT was not sufficient for extraction.

Ensuring quality of collected data

All data was extracted and coded first using the extraction document by the first, second, or last author, who were each responsible for a portion of articles. During the data extraction process, they discussed any challenges that they were facing in data interpretation and how to consolidate differences, where existed. To avoid bias between the primary coders, two external researchers (the third and fourth authors with backgrounds in geriatrics and psychology) additionally analyzed 10% of all articles, and achieved 80% in consistency in content. For the quality assessment, we used the Critical Appraisal Skills Programme (CASP) Checklists (e.g. CASP qualitative research, CASP case control, CASP cohort studies).

Data synthesis

The final extraction documents were combined across the three primary coders and data were analyzed first according to benefits or barriers to uptake of the SHHTs. Data synthesis was carried out by the first and last authors using narrative synthesis as it is most suited to combine different research designs and thus comprehensively inform policy [ 20 ]. During the data synthesis process, the two authors decided to reorganize similar columns and present them as sub-themes within several first-order categories by virtue of preserving precision while increasing comprehensiveness. Though the data extraction document with pre-existing themes was prepared in advance, the organization of final themes was dynamic, where we continuously discussed among authors on the best way to understand and subsequently portray the data as objectively and comprehensively as possible. A table containing basic information for all included articles can be found in the supplementary files.

Prior to implementing the search, the authors completed a protocol in accordance with PRISMA-P and registered the systematic review on PROSPERO (CRD42021248543) [ 21 ]. The review is designed and implemented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 22 , 23 ]. We have extended the review period from 2000 to 2020 since the registration of the protocol to 2000–2021.

Study selection

The search algorithm revealed 12,895 articles across ten databases for the 22 years of study time period. After removing duplicates and independently reviewing titles and abstracts, 403 articles were included at this stage. We sought to retrieve the full-text of all these articles and 21 full-texts were not found. Hence, 382 full-texts were further assessed for eligibility and data extracted where appropriate. During this process, 219 articles were excluded with reasons (see Fig.  1 ). This systematic review finally included 163 empirical articles for data analysis and the results are reported below.

To meet our eligibility criteria, many articles that fulfill some but not all of the required facets were not included in the final review. For example, a study on sleep disturbance in persons with dementia by Harris and Grando [ 24 ] that tested non-interoperable devices such as actigraphs as the sole technology component was also excluded, albeit on nursing home residents over 65 years old and its overall relevance for caregiving.

figure 1

PRISMA 2020 flowchart

Study characteristics

Of the 163 articles included for this review, 117 articles (72%) were published between 2014 and 2021, 37 (23%) between 2007 and 2013, and only 9 articles (5%) between 2000 and 2006. Almost all, with the exception of 3 articles, were published in English. The included studies encompassed a variety of empirical methodologies (see supplementary file). Furthermore, we also categorized the articles by functions of SHHTs tested or studied (Table  2 ), whereby the most studied function included physiological and functioning monitoring technologies (30 articles, 18.40%) followed by those solely promoting social interactions (28 articles, 17.18%). A significant portion of the locations of the included studies were in the U.S. (34 articles, 20.86%), with others in Japan, U.K., Germany, and Canada (Table  3 ).

Types of technology reviewed

Often the articles also involved technologies that fulfilled one or more of the functions noted in Table  2 . We also categorized all 163 articles into the specific types of emerging technologies (Abdi, de Witte & Hawley, 2020) and found that the two often mentioned technologies were intelligent homes (77 articles; 47.24%) and assistive autonomous robots (57 articles; 34.97%). Articles that fall under (1) intelligent homes investigated a collection of real-time monitoring sensors, such as cameras, infrared motion sensors, environmental sensors installed in the bed-mattress, contact sensors on doors, or pressure sensors detecting movements on the floors. (2) Autonomous robots include companion robots such as Pepper and Zora for entertainment and social interactions, or those combined with assistive functions like Care O Bot. In addition, we also included devices that could monitor for the frequency of social interactions of older persons and their families, as well as the inclusion of wearable devices monitoring for vital signs and activity levels within the wider package of smart home technologies under (3) AI-enabled health smart apps and wearables (5 articles; 3.07%). Due to the inclusion criteria of SHHTs needing to be home-based, we did not include articles that only investigated the uses of smart watches and fitness trackers that could be used outside of the home, namely for their GPS locating functions. (4) Voice-activated devices (3 articles; 1.84%) are those already on the market, such as Amazon Echo or Google Home, which articles are only included if they are tested on older persons for caregiving purposes. (5) Drug release mechanisms (2 articles; 1.23%) included smart pill dispensers that ejected specific numbers and types of medication in the homes of older persons, provided reminders when medications are not taken, which was all synced with interfaces accessible by caregivers.

Benefits mentioned in the included studies

From the 163 articles reviewed, we categorized benefits associated with the use of SHHTs into five main categories (see Table  4 ), which are described below.

Enables continuous monitoring of the older person : This category is mentioned in 115 articles, which represented more than two-third of all articles. Within this category, included studies mentioned technologies that could detect abnormality in postures, movements including falls, signs of agitation, and lights turning on at abnormal times (e.g. [ 25 , 26 , 27 , 28 ]). Such monitoring information were deemed as relevant information about the older persons’ health and habits that could be recorded and provided to the caregiver, which makes caregiving simpler, more efficient, holistic, or of higher quality (e.g. [ 29 , 30 , 31 , 32 ]). Furthermore, technologies could also be used to detect declines in the older persons’ cognitive or physical functioning through data related to periodic forgetfulness, vital signs, or mental health state (e.g. [ 33 , 34 , 35 , 36 , 37 ]). Technologies with a monitoring function also works to ensure the older persons’ safety in the home environment, in both aspects of home security and emergency situations (e.g. [ 38 , 39 , 40 , 41 , 42 , 43 ]). Technologies could also give confidence and assurance to the older persons that they are watched over and their knowledge about their own habits are valid (e.g. [ 44 , 45 , 46 ]). At the same time, older persons are also happy that technologies could provide peace-of-mind to their caregivers (e.g. [ 47 ]). Lastly, caregivers anticipate the possible usefulness of this function by enabling the prediction of fall risks from the older persons’ performance on mobility tasks [ 48 ].

Encourages social interactions : 74 articles mentioned benefits associated with promoting relationships, social exposure, and decreasing loneliness. Technology was cited to improve relationships between older persons and their caregivers, both in terms of quality and quantity (e.g. [ 43 , 49 , 50 , 51 , 52 ]). Specifically, technology facilitated communication with others through additional means, such as video calls, social media, or simply through a virtual interface (e.g. [ 53 , 54 , 55 , 56 , 57 ]). Technologies could improve older persons’ mental state by decreasing negative emotional states, such as loneliness and symptoms of apathy (e.g. [ 58 , 59 , 60 , 61 ])., enhancing social bonds by reminiscing about their past, and forming new social bonds (e.g. [ 62 , 63 , 64 , 65 ]). One article cited an older participant becoming more relaxed and positive, as well as more accepting of other people from interacting with the Paro robot [ 66 ].

Promotes independence or independent living for older persons : This category was discussed across 67 articles. Mobile assistive robots helped the older person with basic ADLs, such as walking, showering, and picking up objects from the floor (e.g. [ 67 , 68 , 69 , 70 ]). Such support was reported to allow older adults become less dependent on care from formal and informal caregivers, thereby making them less reliant on children and more independent (e.g. [ 71 , 72 ]). Digital medication dispensers, social robots, and pervasive sensor-equipped home systems could give older persons a sense of independence, self-determination, and empowerment in the home environment by giving them confidence to function well and be in control of their own health at home instead of asking for a human caregiver to come by to attend to their every need (e.g. [ 73 , 74 , 75 , 76 ]).

Reminds older persons to promote self-care and self-management : This category is mentioned across 49 articles. These strategies included the ability of SHHTs to support medication management, thus requiring less support from caregivers (e.g. [ 75 , 77 , 78 , 79 ]). Some enable older persons to analyze their health conditions and making medical information available to them (e.g. [ 80 , 81 , 82 ]). Others provided recommendations and feedback pertinent to diet, physical or cognitive exercises, as a way to encourage older persons to become more motivated to live healthier and happier lifestyles (e.g. [ 38 , 83 , 84 , 85 , 86 ]). Lastly, older persons could also be provided with memory aids for tasks other than medication, such as reminders for keeping appointments, guidance for completing tasks, and the reorientation to time and place (e.g. [ 87 , 88 , 89 , 90 ]).

Other purposes : 75 studies included all the remaining benefits raised, which were comparatively more scattered in definition than the preceding categories. For example, studied technologies were cited to reduce caregiving burden through decreased visits, time, and money combined with increased freedom, peace of mind, and support in caregiving tasks (e.g. [ 66 , 91 , 92 , 93 , 94 , 95 ]). Such technologies could improve older persons’ well-being, specifically in regard to memory, emotional and physical health, sleep, and communication (e.g. [ 57 , 96 , 97 , 98 , 99 , 100 ]). More broadly, they could support caregivers and healthcare systems, improving satisfaction and confidence with work, morale, and healthcare delivery cost and quality (e.g. [ 101 , 102 ]). Lastly, studies found that technologies could entertain older people with games, jokes, music, and humor (e.g. [ 103 , 104 , 105 ]).

Barriers mentioned in the included articles

From the 163 articles reviewed, we categorized barriers to the use to SHHTs into five main categories (see Table  5 ), which are described below.

Usability : In 110 studies, users thought the tested technology was not easy to use, intuitive, or conducive for use and was too bulky and ugly (e.g. [ 39 , 53 , 80 , 106 ]). Fear of a robotic device due to the unfamiliar and humanoid appearances could also lessen the frequency of interactions of older residents [ 107 ]. Technologies’ use was found to result in anxiety or destabilization of the end-user or complaints with the alert system, wearable, and sensors (e.g. [ 96 , 108 , 109 , 110 ]). Technical problems pertinent to battery life, internet connectivity, incompatibility with existing home systems, and password entry were also mentioned (e.g. [ 111 , 112 , 113 , 114 ]). Users were also unsatisfied with the technical limitations such as short screen time and long starting time or the inability to identify wrong postures, for instance, in fitness classes (e.g. [ 35 , 78 , 115 , 116 ]). There were suggestions for more interactive feedback from the devices to guide users, such as those to indicate the completion of a task or a physiological reading. Some complained that the technology was simply too disruptive and intrusive (e.g. [ 87 , 117 , 118 ]). On the other hand, articles also suggested possible improvements such as accounting for the visual, auditory, language barriers, cognitive declines and other limitations and wishes of older persons (e.g. [ 34 , 62 , 101 , 107 , 119 , 120 ]). For example, robotic assistants should be able to speak the language of the users, or devices requiring older participants’ engagement should be split into smaller, sporadic checks to account for cognitive declines in persons with dementia [ 107 , 121 ]. Reliability should be improved with less malfunctions and more accurate alerts and warnings (e.g. [ 27 , 69 , 122 , 123 ]. Lastly, technologies should be adaptive and customizable, that allows end-users with a variety of capabilities, needs, and preferences to maximize their benefits for caregiving [ 60 , 120 , 124 ].

Social acceptance : 69 articles elicited the factors affecting end-users’ decisions for technology adoption. Some end-users found the technology valuable and saw its utility in the future with increasing age and needs (e.g. [ 46 , 83 , 86 , 104 , 125 ]. In addition, the technology would be accepted when it addresses an actual need of an older person, thereby making it a necessity (e.g. [ 125 , 126 , 127 ]). Formal caregivers would accept the technology given its positive benefits for the workplace and the older patients (e.g. [ 62 , 112 ]). A few articles also recorded hesitancy to use technologies. For example, some users believed that the tested SHHTs are too difficult for older persons to use, citing too old to learn and keep up with changing technology (e.g. [ 51 , 114 , 117 , 128 ]). Older persons also worried that family members or the public may not approve, and the device may generate unwanted attention or gossip (e.g. [ 48 , 62 , 102 , 129 ]. In addition, not only did the perception of family member interfere with the older persons’ preferences or uptake of technologies, the relatives of older persons also preferred to be involved in the approval or opinion-gathering processes of the planned usage of technologies [ 130 , 131 ]. Lastly, technology itself could be deemed annoying due to the frequency or presence of alerts (e.g. [ 132 ].

Cost/Affordability : 44 studies questioned the cost-effectiveness and affordability of the tested technologies, noting to both their initial purchase and continued maintenance (e.g. [ 35 , 95 , 104 , 113 , 133 ])., though there was anticipatory comments that sensor usage could reduce healthcare costs and become an effective solution for caregivers and older persons [ 37 ]. However, the technology could be used if it was financed or reimbursed (e.g. [ 119 , 134 , 135 ]). This financial reimbursement extended beyond technologies, but their counselling services from healthcare providers, as this also affected the accessibility issue for many end-users [ 131 ]. While informal caregivers are less sensitive to the cost compared to older persons and buys the technology, it does not give them the right to disrupt the life-style choices of older persons [ 54 , 68 ]. Finally, a few papers pointed out that the high cost of technology risks to create a difference between the haves and the have-nots, such as those with in rural areas with no internet connection, and hence a better option would be when technology are made available to everyone (e.g. [ 37 , 46 , 71 , 92 ]).

Loss of relationships or increase of loneliness : Within the potential loss of relationships, two opposite issues were highlighted across 22 included studies. Firstly, there were concern and regret at the potential loss of social connectedness that older persons cannot enjoy as technology was supposed to provide for the care time that a loved one would have provided (e.g. [ 37 , 48 , 50 , 71 , 76 , 136 ]. On the contrary, family caregivers did not believe that technology would weaken their commitment towards the older persons (e.g. [ 136 ]. Specifically for the use of robots, caregivers also felt that they must supervise those interactions with older persons (e.g. [ 99 ]. Moreover, there were mentions that the robot would decrease loneliness since it is waiting for the older person at home and making the home environment friendlier (e.g. [ 38 , 72 , 88 ].

O ther concerns : The last category cites all other remaining concerns from 25 articles. For example, there were worries especially among formal caregivers that introducing technology would increase workload by requiring ample training and time before their introduction to older persons (e.g. [ 62 , 116 , 117 , 125 ]). This was echoed in an outlier set of articles that cited concerns with workload increases from translating conversations when the robotic agents did not speak the language of the older persons, as well as the necessity to process and react to the alerts generated by the monitoring devices [ 37 , 86 , 107 ]. There were also general complaints that the device is unnecessary, some of the components generated useful information, and procedural uncertainty with the generated data (e.g. [ 34 , 132 , 137 ]).

Considering the context of population aging and resource preparedness needed to support aging at home, it is necessary to consider the scope of viable solutions that could address caregiving to older persons. As a way to support caregivers by continuously providing information and monitoring abnormal health statuses of older persons, technological solutions such as SHHTs have been brought forth to improve well-being for older persons while reducing caregiving burdens. Our systematic review unearths important existing knowledge on SHHTs by studying their benefits and barriers in the care for older persons across the 163 empirical peer-reviewed publications. To supplement this review on the practical benefits and barriers to SHHTs’ adoption, we have published another article on the ethical concerns in the use of SHHTs from empirical and theoretical articles, where the issues of informational privacy in terms of data protection and security, and the impact on autonomy from the gain or loss in independence and control, as well as stigma and responsibility have been elaborated in further detail [ 138 ].

In regard to the existing benefits, most articles cited the capacity of SHHTs to allow continuous monitoring of the older person. This is not surprising as it is the one of the central challenges that many SHHTs aim to enable independently at home [ 10 , 11 , 139 ]. Importantly, monitoring technologies could relieve caregivers of the need to be constantly present to, for example, ensure safety by being able to find older persons who have wandered off [ 140 , 141 ]. As devices within the household communicate with each other via the concept of IoT, they not only allow continuous control and monitoring, but also regulation of the residents’ movement, routines as well as habits, and of the home itself [ 10 , 18 ]. As a critical extended function, older adults could choose to customize the SHHTs to alert any desired party if there are deviations from normal routines and postures. Stated in the results, end-users appreciated the ability of data from sensors to alert caregivers about any declines in cognitive or physical functioning. Having such knowledge could help in planning for increasing future caregiving needs. Furthermore, the function of medical alerts not only enables the provision of relevant emergency information to caregivers, but also provides a better understanding of the older person’s habits. Such information may provide greater insight into the patient and the circumstances of the medical visit.

Potential of SHHTs in supporting older persons with medication management and self-care were evident in our findings. The technologies thus could improve the independence and well-being of older persons [ 142 , 143 , 144 ]. On a larger scale of population aging and the increase in older persons living with chronic diseases, this independence and reduced caregiving supervision also parallels with a call for self-management of one’s own health at home while adapting to “social, physical, and emotional challenges” [ 145 ]. Nonetheless, the individual differences to prefer independence or self-manage conditions, rather than to receive care from another family or professional caregiver, should also be taken into consideration. Peek and colleagues [ 146 ] presented these differences between older participants’ reactions to use computers or mobile phones for ordering groceries. Whereas some self-identified as being “stubborn, proud, [and] handle a lot of things by [them]selves” and would not want to rely on any assistance from caregivers or technology, other older participants selectively relied on certain types of technologies or simply on their children to complete these tasks digitally [ 146 ]. In the context of SHHTs, we also found similar differences that drove participants to prefer reduced human intrusion into the home and the use of reminder technologies for taking medications, while others preferred shared decision-making and in-person visits for these tasks [ 47 , 78 , 105 , 130 ]. Whether an older person prefers to and would have greater confidence from independently accessing health information via technology, or would have greater trust in healthcare providers through in-person visits should also be considered.

Despite the potentials of SHHTs, it is more significant to highlight the several barriers which stand to hinder them from becoming viable solution for providing care for the older population [ 11 , 147 ]. The most cited barrier was usability, which included issues such as difficult to use, obtrusive, intrusive, low in interoperability with existing household automation systems, and also technical limitations that needed to be overcome by developers themselves. As underlined by other studies, [ 147 , 148 ], our systematic review further highlights that end-users had challenges in understanding the technology to the extent of avoidance and in particular, formal caregivers worried that the introduction of technologies could affect their work by requiring training and time for familiarization before allowing the older persons to use it independently. These practical challenges require critical thought and solutions from the part of technology developers. Improvement to user-friendliness could also improve access to the technologies and prevent the exacerbation of the digital divide. The articles reviewed revealed a wide range of knowledge and comfort levels of the designated end-users of SHHTs, where many of whom would likely be deterred by a technology that required lengthy training, frequent troubleshooting, and constant supervision. Conversely, a technology easily accessible and adoptable by more users could improve inequities amongst users of all backgrounds and technical expertise.

Though new developments of SHHTs were able to overcome and realize functional capabilities previously unseen, there were many technical malfunctions that caused frustration in end-users. Namely, there were challenges with the battery life, unstable or low wireless connectivity, incompatibility with existing house automation technologies, or that the technology was spatially inconvenient and could not fit comfortably in the home. Although these barriers seem simple and easy-to-overcome, they could be significantly troublesome for end-users to realistically implement in their home environment where familiarity is greatly valued. On the aspect of an incompatibility with existing home, there is call for adequate consideration towards the integration with existing home layouts while minimizing any modifications and interference to the older person [ 149 ]. As the aging process is dynamic and requires continuous adaptations from both caregivers and older persons, it is important that SHHTs are designed to interoperate with the end-users’ existing routines and home environment. Whilst the ability to access healthcare and constant remote monitoring could allow for a greater participation of the population living at a distance to healthcare resources or their caregivers, the extensive need for internet or cellular connection could again exclude older persons who are living in rural areas. This also plays into the need to incorporate large, bulky devices in the homes of older persons, begging the question of the characteristic or users whose home could meet these spatial requirements [ 150 ].

The aging process involves life transitions with higher risks of stressors, such as grief, bereavement, and a drop in socioeconomic statuses, which may in turn lead to an increased likelihood of loneliness and isolation for older adults [ 151 , 152 ]. The technologies with a social function could allow older people to engage positively in group dynamics, reminiscence, or develop new ways to communicate with others. Confirming the findings from Latikka et al. [ 16 ], we discovered that SHHTs’ overall contribution to the reduction of loneliness was positive, albeit without complete elimination. Our search also contributed a nuanced perspective, whereby end-users felt that while SHHTs could improve the relationships and communication between caregivers and older persons, both in terms of quality and quantity, older persons still worried that these new functions may eventually replace the social connectedness that they enjoyed during in-person visits. To complement this ambivalence, it is helpful to look towards an alternative view (Zhu et al., 2021), where researchers recommended that technologies should act as a collaborator in human caregiving, instead of a substitute for care from children. The question whether technologies would or could or should replace human care is one that has been raised intensively [ 153 , 154 , 155 , 156 ], and necessitates critical and clear discussion among various stakeholders as to what the purpose of their technology is and how it fits the overall societal goals.

The dynamic and complex interactions of cultural values in the adoption of smart technologies may also extend the conversation beyond the technologies themselves. Though there are many mentions of a reduction in caregiving burden, it is interesting to examine the nuance in this argument from a cultural angle towards the presence of a smaller portion of articles with concerns for an increase in workload with the use of technology in caregiving. One study investigating the attitudes of low-income U.S. immigrant older persons towards remote monitoring systems cited high discontinuation of Korean and Chinese American residents, for fear of frequent false alerts or the increase of workload for their children [ 132 ]. Albeit also cited by other studies, a lack of cultural awareness and significant language barriers combined with false alerts from a passive monitoring system could leave “unforgettable negative experience[s]”, where an older user is found be left with embarrassment after a door is broken down by the emergency medical services. Although previous reviews have noted these already [ 18 , 157 ], it is unfortunate that these recommendations have not been picked up and there still requires more development to improve the obtrusiveness and reliability of monitoring systems to reduce high rates of false alerts and malfunctions. Reducing feelings of embarrassment and maybe even stigma that follows are values that require serious attention.

Cost concerns has been raised by previous systematic reviews as a major barrier to adopting SHHTs [ 11 ]. While a stand-alone unit or an individual sensor may cost very little, to enable and maintain the continuous functioning of a complete and pervasive smart home environment could be more complicated than expected [ 5 , 147 ]. Also included in this cost is the hiring of specialized individuals at a service center or in the hospitals, who would also need to invest more time and cost to understand, analyze, and effectively make use of the health data collected. In an article on the “Hidden Work” of implementing GPS tracking devices with emergency contact functions for persons with cognitive impairment, the authors report the human resources necessary for the continuous maintenance of a sustainable program, which include the coordinators, commissioners, occupational therapists, call operators and managers in monitoring centers to receive the calls, and technology suppliers [ 158 ]. On a larger scale, to implement the use of monitoring technologies on a system level requires greater costs for training staff, and interventions to shift habits towards using these new care tools [ 159 ]. Justice issues also come into play with the levels of accessibility of different older persons and their families, depending on their abilities to shoulder one-off and maintenance costs, comfort and knowledge in using technical tools for caregiving, and the friendliness of the local policies towards introducing SHHTs in their populations. These all influence and could exacerbate the digital divide that technologies are already bringing forth now.

The COVID-19 pandemic has forced many older persons around the world into isolation and quarantine at least during early months, which expectedly may lead to a different perspective and necessity to employ the technologies reviewed in this article [ 15 , 160 , 161 ]. Specifically, with the ability for remote monitoring, technologies could allow continuation of care across physical barriers and detection of rapid health declines, countering the effects of social isolation and feelings of reassurance. Due to the nature of reviewing empirical articles published on end-user feedback, those articles that were empirical and contextualized on COVID-19 concentrated on delivering telehealth services, reasonably answering to the demands of providing healthcare remotely, rather than elaborate SHHTs studied in this review. Nonetheless, despite not yet gathering empirical feedback from end-users, an abundance of smart technologies for caregiving of older persons has been developed during COVID-19 that are worthy of mention and shows promise for expediting the diversity of applicable scenarios for a diverse set of users [ 162 , 163 ].

Customization and policy-implications

Whilst customization was a theme that arose in the early studies, the ability for a more personalized approach to the design and implementation of SHHT systems that, if not increased in frequency, but at least persisted in recently published studies in greater detail [ 43 , 53 , 60 , 86 ]. Users expressed that a heightened ability for technologies to “learn” and adapt its configurations, methods of data visualization, frequency of alerts, and complexity in its training programs could satisfy a more diverse array of user needs. This may be due to the improved technical capabilities and the shift towards personalized medicine in recent years. As a way to resolve individual preferences, comfort levels, or cultural norms, studies have cited the benefits of having technologies that were able to learn and adapt to the user [ 48 ]. For varying cost-bearing preferences and to accommodate the different national reimbursement programs, technologies should be offered in incremental stages with greater freedom for trial-periods before purchase. Directions of policy would greatly benefit the adoption or reduction of their barriers if it addresses the individual needs of older persons that are person-centric and situation-specific. Albeit smart homes are gradually making their way into policy decisions, there is a risk and uncertainty in their implementation to households that are of older persons or in rural areas with unstable wireless connectivity [ 164 ]. This would also heed calls for more personalization and tolerance in policy to adhere to the current array of needs and preferences.

Limitations

This systematic review has limitations. Firstly, despite having searched in 10 electronic databases with a 22-year time-period limit to reasonably incorporate the span of technological development of SHHTs, some papers could have still been excluded from our search, for example, those archived in databases outside the ones we included. We stopped our search in December 2021, and thus were not able to include any publications from January 2022. In addition, as we opted to include only peer-review empirical articles, there could have been valuable insight in other forms of data output relevant to our topic that were published as, for example, theoretical papers, book chapters, thesis or have been published as grey literature. Related to this limitation is also the fact that since our work includes end users who were able to participate in studies. In lieu of existing digital divide, it also means that our review was unable to capture the view of those who could not access the technologies or were not interested to participate in these studies. Due to resource limitations (i.e. personnel time, limited funding period) as well as the high number of papers that were included in the full text evaluation, it was not possible to carry out independent double assessment of (a) each included paper as well as (b) complete the risk of bias of included studies. From the positive outcome that we reached by randomly checking 10% of the data for risks of content biases, as well as 10% of articles whose quality we assessed, we are cautiously confident about the quality of the included studies and the data extracted.

Through functions of continuous monitoring, generating health-related reminders, providing additional channels for communication, SHHTs to-date could support caregivers in ways such as detecting falls and declines in functioning, provide assistance for basic activities for daily living, and the promotion and maintenance of a healthier lifestyle. However, our review found critical barriers to uptake that include issues with obtrusiveness and usability (such as technical problems and their limitations), social acceptance, costs, and the concern for loss of relationships. It becomes prudent to find ways to address these barriers as we move forward with technological development to ensure that the benefits generated does not come at higher costs. The data produced in this user-centric attempt to organize the current knowledge on SHHTs will prove informative to inform policy, improve user-acceptance, and serve as an additional resource for those who care for older persons. Finally, to take the call from Marikyan et al. [ 13 ] for further forwarding user-centric research, we encourage future researchers to focus on eliciting end-users’ conditions for acceptability in regards to different SHHTs. It would be interesting to also add independent variables in the equation, such as cultural background, generational gaps, technology readiness, living situation, financial comfort, and the nature of their social environment.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. A supplementary table of the basic information from all articles analyzed for this review and an example of the search string is nevertheless included.

Abbreviations

Activities of daily living

Instrumental activities of daily living

  • Smart home health technologies

Internet of Things

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Acknowledgements

We thank the information specialist who have given valuable guidance in the review’s initial stages, namely for search strategy and database support. We also immensely appreciate and are indebted to the two anonymous reviewers for their careful considerations and meaningful comments. The last author is in the editorial board of this journal and had no role in the peer-review or acceptance of this manuscript.

Open access funding provided by University of Basel. This systematic review was support financially by the Swiss National Science Foundation (SNF NRP-77 Digital Transformation, Grant Number 407740_187464/1) as part of the SmaRt homES, Older adUlts, and caRegivers: Facilitating social aCceptance and negotiating rEsponsibilities [RESOURCE] project. The funder neither took part in the writing process, nor does any part of the views expressed in the review belong to the funder.

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Yi Jiao (Angelina) Tian, Nadine Andrea Felber & Tenzin Wangmo

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Félix Pageau

Division of Geriatrics, Department of Medicine, Laval University, Quebec City, QC, Canada

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Contributions

Yi Jiao (Angelina) Tian: Formal analysis, Investigation, Writing– Original Draft, Visualization Nadine Andrea Felber: Conceptualization, Formal analysis, Investigation, Writing– Review & Editing Felix Pageau: Validation, Formal analysis, Writing– Review & Editing Delphine Roulet Schwab: Validation, Writing– Review & Editing Tenzin Wangmo: Conceptualization, Methodology, Formal analysis, Investigation, Resources, Writing– Review & Editing, Supervision.

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Correspondence to Yi Jiao (Angelina) Tian .

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Tian, Y.J.(., Felber, N.A., Pageau, F. et al. Benefits and barriers associated with the use of smart home health technologies in the care of older persons: a systematic review. BMC Geriatr 24 , 152 (2024). https://doi.org/10.1186/s12877-024-04702-1

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Ten Simple Rules for Writing a Literature Review

Marco pautasso.

1 Centre for Functional and Evolutionary Ecology (CEFE), CNRS, Montpellier, France

2 Centre for Biodiversity Synthesis and Analysis (CESAB), FRB, Aix-en-Provence, France

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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Object name is pcbi.1003149.g001.jpg

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] .

  • 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.

Funding Statement

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.

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