literature review matrix for qualitative research

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Common Assignments: Literature Review Matrix

Literature review matrix.

As you read and evaluate your literature there are several different ways to organize your research. Courtesy of Dr. Gary Burkholder in the School of Psychology, these sample matrices are one option to help organize your articles. These documents allow you to compile details about your sources, such as the foundational theories, methodologies, and conclusions; begin to note similarities among the authors; and retrieve citation information for easy insertion within a document.

You can review the sample matrixes to see a completed form or download the blank matrix for your own use.

• Literature Review Matrix 1 This PDF file provides a sample literature review matrix.
• Literature Review Matrix 2 This PDF file provides a sample literature review matrix.
• Literature Review Matrix Template (Word)
• Literature Review Matrix Template (Excel)

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Writing Resources

The matrix method for literature reviews.

This handout is available for download in DOCX format and PDF format .

What is the Matrix Method, and why should I use it?

Using a review matrix enables you to quickly compare and contrast articles in order to determine the scope of research across time. A review matrix can help you more easily spot differences and similarities between journal articles about a research topic. While they may be helpful in any discipline, review matrices are especially helpful for health sciences literature reviews covering the complete scope of a research topic over time. This guide focuses on the review matrix step in the literature review process and offers tips on how to use it effectively.

Organize your sources

Once you complete your research, organize your source by date in order to make it easier to see changes in research over time.

Begin by creating the blank matrix. The matrices can be easily constructed using table-making software such as Microsoft Excel, Word or OneNote, Google Sheets, or Numbers. Every review matrix should have the same first three column headings: (1) authors, title, and journal, (2) publication year, and (3) purpose.

Be aware that it may be difficult to determine purpose from just a cursory review of the article. In some cases, it may be necessary to first read the paper fully to identify its purpose.

Choose your remaining column topics

Next, carefully read all your articles. Note any important issues you identify. The following broad categories provide some suggestions for determining your own subject headings:

Methodological

Methodology is often an important question. For example, if you are looking at tests of an Ebola vaccine beyond human subjects, it will be important to note what type of animal the test was carried out on, i.e. macaques or mice.

Content-specific

Consider noting what was actually studied. For example, when looking at the effectiveness of traditional Chinese medicine in the treatment of illnesses, it would be important to note what illness was being studied.

Geographical

It may be important to note where the research was completed. For example, if you want to compare the effects of the AIDS epidemic in different countries, you would use country as a column heading.

There are many ways to choose your column headings, and these are just a few suggestions. As you create your own matrix, choose column headings that support your research question and goals.

• Do not include column headings that are explicit in your research question. For example, if you are looking at drug use in adolescents, do not include a column heading for age of study participants. If the answer will be the same for every study, it's generally a bad choice for a column heading.
• Do not try to fully complete a review matrix before reading the articles. Reading the articles is an important way to discern the nuances between studies.

Credit: Adapted from David Nolfi, “Matrix Method for Literature Review: The Review Matrix,” Duquesne University, https://guides.library.duq.edu/matrix , 2020.

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Chapter 9. Reviewing the Literature

What is a “literature review”.

No researcher ever comes up with a research question that is wholly novel. Someone, somewhere, has asked the same thing. Academic research is part of a larger community of researchers, and it is your responsibility, as a member of this community, to acknowledge others who have asked similar questions and to put your particular research into this greater context. It is not simply a convention or custom to begin your study with a review of previous literature (the “ lit review ”) but an important responsibility you owe the scholarly community.

Too often, new researchers pursue a topic to study and then write something like, “No one has ever studied this before” or “This area is underresearched.” It may be that no one has studied this particular group or setting, but it is highly unlikely no one has studied the foundational phenomenon of interest. And that comment about an area being underresearched? Be careful. The statement may simply signal to others that you haven’t done your homework. Rubin ( 2021 ) refers to this as “free soloing,” and it is not appreciated in academic work:

The truth of the matter is, academics don’t really like when people free solo. It’s really bad form to omit talking about the other people who are doing or have done research in your area. Partly, I mean we need to cite their work, but I also mean we need to respond to it—agree or disagree, clarify for extend. It’s also really bad form to talk about your research in a way that does not make it understandable to other academics.…You have to explain to your readers what your story is really about in terms they care about . This means using certain terminology, referencing debates in the literature, and citing relevant works—that is, in connecting your work to something else. ( 51–52 )

A literature review is a comprehensive summary of previous research on a topic. It includes both articles and books—and in some cases reports—relevant to a particular area of research. Ideally, one’s research question follows from the reading of what has already been produced. For example, you are interested in studying sports injuries related to female gymnasts. You read everything you can find on sports injuries related to female gymnasts, and you begin to get a sense of what questions remain open. You find that there is a lot of research on how coaches manage sports injuries and much about cultures of silence around treating injuries, but you don’t know what the gymnasts themselves are thinking about these issues. You look specifically for studies about this and find several, which then pushes you to narrow the question further. Your literature review then provides the road map of how you came to your very specific question, and it puts your study in the context of studies of sports injuries. What you eventually find can “speak to” all the related questions as well as your particular one.

In practice, the process is often a bit messier. Many researchers, and not simply those starting out, begin with a particular question and have a clear idea of who they want to study and where they want to conduct their study but don’t really know much about other studies at all. Although backward, we need to recognize this is pretty common. Telling students to “find literature” after the fact can seem like a purposeless task or just another hurdle for completing a thesis or dissertation. It is not! Even if you were not motivated by the literature in the first place, acknowledging similar studies and connecting your own research to those studies are important parts of building knowledge. Acknowledgment of past research is a responsibility you owe the discipline to which you belong.

Literature reviews can also signal theoretical approaches and particular concepts that you will incorporate into your own study. For example, let us say you are doing a study of how people find their first jobs after college, and you want to use the concept of social capital . There are competing definitions of social capital out there (e.g., Bourdieu vs. Burt vs. Putnam). Bourdieu’s notion is of one form of capital, or durable asset, of a “network of more or less institutionalized relationships of mutual acquaintance or recognition” ( 1984:248 ). Burt emphasizes the “brokerage opportunities” in a social network as social capital ( 1997:355 ). Putnam’s social capital is all about “facilitating coordination and cooperation for mutual benefit” ( 2001:67 ). Your literature review can adjudicate among these three approaches, or it can simply refer to the one that is animating your own research. If you include Bourdieu in your literature review, readers will know “what kind” of social capital you are talking about as well as what kind of social scientist you yourself are. They will likely understand that you are interested more in how some people are advantaged by their social capital relative to others rather than being interested in the mechanics of how social networks operate.

The literature review thus does two important things for you: firstly, it allows you to acknowledge previous research in your area of interest, thereby situating you within a discipline or body of scholars, and, secondly, it demonstrates that you know what you are talking about. If you present the findings of your research study without including a literature review, it can be like singing into the wind. It sounds nice, but no one really hears it, or if they do catch snippets, they don’t know where it is coming from.

Examples of Literature Reviews

To help you get a grasp of what a good literature review looks like and how it can advance your study, let’s take a look at a few examples.

Reader-Friendly Example: The Power of Peers

The first is by Janice McCabe ( 2016 ) and is from an article on peer networks in the journal Contexts . Contexts presents articles in a relatively reader-friendly format, with the goal of reaching a large audience for interesting sociological research. Read this example carefully and note how easily McCabe is able to convey the relevance of her own work by situating it in the context of previous studies:

Scholars who study education have long acknowledged the importance of peers for students’ well-being and academic achievement. For example, in 1961, James Coleman argued that peer culture within high schools shapes students’ social and academic aspirations and successes. More recently, Judith Rich Harris has drawn on research in a range of areas—from sociological studies of preschool children to primatologists’ studies of chimpanzees and criminologists’ studies of neighborhoods—to argue that peers matter much more than parents in how children “turn out.” Researchers have explored students’ social lives in rich detail, as in Murray Milner’s book about high school students, Freaks, Geeks, and Cool Kids , and Elizabeth Armstrong and Laura Hamilton’s look at college students, Paying for the Party . These works consistently show that peers play a very important role in most students’ lives. They tend, however, to prioritize social over academic influence and to use a fuzzy conception of peers rather than focusing directly on friends—the relationships that should matter most for student success. Social scientists have also studied the power of peers through network analysis, which is based on uncovering the web of connections between people. Network analysis involves visually mapping networks and mathematically comparing their structures (such as the density of ties) and the positions of individuals within them (such as how central a given person is within the network). As Nicholas Christakis and James Fowler point out in their book Connected , network structure influences a range of outcomes, including health, happiness, wealth, weight, and emotions. Given that sociologists have long considered network explanations for social phenomena, it’s surprising that we know little about how college students’ friends impact their experiences. In line with this network tradition, I focus on the structure of friendship networks, constructing network maps so that the differences we see across participants are due to the underlying structure, including each participant’s centrality in their friendship group and the density of ties among their friends. ( 23 )

What did you notice? In her very second sentence, McCabe uses “for example” to introduce a study by Coleman, thereby indicating that she is not going to tell you every single study in this area but is going to tell you that (1) there is a lot of research in this area, (2) it has been going on since at least 1961, and (3) it is still relevant (i.e., recent studies are still being done now). She ends her first paragraph by summarizing the body of literature in this area (after giving you a few examples) and then telling you what may have been (so far) left out of this research. In the second paragraph, she shifts to a separate interesting focus that is related to the first but is also quite distinct. Lit reviews very often include two (or three) distinct strands of literature, the combination of which nicely backgrounds this particular study . In the case of our female gymnast study (above), those two strands might be (1) cultures of silence around sports injuries and (2) the importance of coaches. McCabe concludes her short and sweet literature review with one sentence explaining how she is drawing from both strands of the literature she has succinctly presented for her particular study. This example should show you that literature reviews can be readable, helpful, and powerful additions to your final presentation.

Authoritative Academic Journal Example: Working Class Students’ College Expectations

The second example is more typical of academic journal writing. It is an article published in the British Journal of Sociology of Education by Wolfgang Lehmann ( 2009 ):

Although this increase in post-secondary enrolment and the push for university is evident across gender, race, ethnicity, and social class categories, access to university in Canada continues to be significantly constrained for those from lower socio-economic backgrounds (Finnie, Lascelles, and Sweetman 2005). Rising tuition fees coupled with an overestimation of the cost and an underestimation of the benefits of higher education has put university out of reach for many young people from low-income families (Usher 2005). Financial constraints aside, empirical studies in Canada have shown that the most important predictor of university access is parental educational attainment. Having at least one parent with a university degree significantly increases the likelihood of a young person to attend academic-track courses in high school, have high educational and career aspirations, and ultimately attend university (Andres et al. 1999, 2000; Lehmann 2007a). Drawing on Bourdieu’s various writing on habitus and class-based dispositions (see, for example, Bourdieu 1977, 1990), Hodkinson and Sparkes (1997) explain career decisions as neither determined nor completely rational. Instead, they are based on personal experiences (e.g., through employment or other exposure to occupations) and advice from others. Furthermore, they argue that we have to understand these decisions as pragmatic, rather than rational. They are pragmatic in that they are based on incomplete and filtered information, because of the social context in which the information is obtained and processed. New experiences and information can, however, also be allowed into one’s world, where they gradually or radically transform habitus, which in turn creates the possibility for the formation of new and different dispositions. Encountering a supportive teacher in elementary or secondary school, having ambitious friends, or chance encounters can spark such transformations. Transformations can be confirming or contradictory, they can be evolutionary or dislocating. Working-class students who enter university most certainly encounter such potentially transformative situations. Granfield (1991) has shown how initially dislocating feelings of inadequacy and inferiority of working-class students at an elite US law school were eventually replaced by an evolutionary transformation, in which the students came to dress, speak and act more like their middle-class and upper-class peers. In contrast, Lehmann (2007b) showed how persistent habitus dislocation led working-class university students to drop out of university. Foskett and Hemsley-Brown (1999) argue that young people’s perceptions of careers are a complex mix of their own experiences, images conveyed through adults, and derived images conveyed by the media. Media images of careers, perhaps, are even more important for working-class youth with high ambitions as they offer (generally distorted) windows into a world of professional employment to which they have few other sources of access. It has also been argued that working-class youth who do continue to university still face unique, class-specific challenges, evident in higher levels of uncertainty (Baxter and Britton 2001; Lehmann 2004, 2007a; Quinn 2004), their higher education choices (Ball et al. 2002; Brooks 2003; Reay et al. 2001) and fears of inadequacy because of their cultural outsider status (Aries and Seider 2005; Granfield 1991). Although the number of working-class university students in Canada has slowly increased, that of middle-class students at university has risen far more steeply (Knighton and Mizra 2002). These different enrolment trajectories have actually widened the participation gap, which in tum explains our continued concerns with the potential outsider status Indeed, in a study comparing first-generation working-class and traditional students who left university without graduating, Lehmann (2007b) found that first-generation working-class students were more likely to leave university very early in some cases within the first two months of enrollment. They were also more likely to leave university despite solid academic performance. Not “fitting in,” not “feeling university,” and not being able to “relate to these people” were key reasons for eventually withdrawing from university. From the preceding review of the literature, a number of key research questions arise: How do working-class university students frame their decision to attend university? How do they defy the considerable odds documented in the literature to attend university? What are the sources of information and various images that create dispositions to study at university? What role does their social-class background- or habitus play in their transition dispositions and how does this translate into expectations for university? ( 139 )

What did you notice here? How is this different from (and similar to) the first example? Note that rather than provide you with one or two illustrative examples of similar types of research, Lehmann provides abundant source citations throughout. He includes theory and concepts too. Like McCabe, Lehmann is weaving through multiple literature strands: the class gap in higher education participation in Canada, class-based dispositions, and obstacles facing working-class college students. Note how he concludes the literature review by placing his research questions in context.

Find other articles of interest and read their literature reviews carefully. I’ve included two more for you at the end of this chapter . As you learned how to diagram a sentence in elementary school (hopefully!), try diagramming the literature reviews. What are the “different strands” of research being discussed? How does the author connect these strands to their own research questions? Where is theory in the lit review, and how is it incorporated (e.g., Is it a separate strand of its own or is it inextricably linked with previous research in this area)?

One model of how to structure your literature review can be found in table 9.1. More tips, hints, and practices will be discussed later in the chapter.

Table 9.1. Model of Literature Review, Adopted from Calarco (2020:166)

Embracing Theory

A good research study will, in some form or another, use theory. Depending on your particular study (and possibly the preferences of the members of your committee), theory may be built into your literature review. Or it may form its own section in your research proposal/design (e.g., “literature review” followed by “theoretical framework”). In my own experience, I see a lot of graduate students grappling with the requirement to “include theory” in their research proposals. Things get a little squiggly here because there are different ways of incorporating theory into a study (Are you testing a theory? Are you generating a theory?), and based on these differences, your literature review proper may include works that describe, explain, and otherwise set forth theories, concepts, or frameworks you are interested in, or it may not do this at all. Sometimes a literature review sets forth what we know about a particular group or culture totally independent of what kinds of theoretical framework or particular concepts you want to explore. Indeed, the big point of your study might be to bring together a body of work with a theory that has never been applied to it previously. All this is to say that there is no one correct way to approach the use of theory and the writing about theory in your research proposal.

Students are often scared of embracing theory because they do not exactly understand what it is. Sometimes, it seems like an arbitrary requirement. You’re interested in a topic; maybe you’ve even done some research in the area and you have findings you want to report. And then a committee member reads over what you have and asks, “So what?” This question is a good clue that you are missing theory, the part that connects what you have done to what other researchers have done and are doing. You might stumble upon this rather accidentally and not know you are embracing theory, as in a case where you seek to replicate a prior study under new circumstances and end up finding that a particular correlation between behaviors only happens when mediated by something else. There’s theory in there, if you can pull it out and articulate it. Or it might be that you are motivated to do more research on racial microaggressions because you want to document their frequency in a particular setting, taking for granted the kind of critical race theoretical framework that has done the hard work of defining and conceptualizing “microaggressions” in the first place. In that case, your literature review could be a review of Critical Race Theory, specifically related to this one important concept. That’s the way to bring your study into a broader conversation while also acknowledging (and honoring) the hard work that has preceded you.

Rubin ( 2021 ) classifies ways of incorporating theory into case study research into four categories, each of which might be discussed somewhat differently in a literature review or theoretical framework section. The first, the least theoretical, is where you set out to study a “configurative idiographic case” ( 70 ) This is where you set out to describe a particular case, leaving yourself pretty much open to whatever you find. You are not expecting anything based on previous literature. This is actually pretty weak as far as research design goes, but it is probably the default for novice researchers. Your committee members should probably help you situate this in previous literature in some way or another. If they cannot, and it really does appear you are looking at something fairly new that no one else has bothered to research before, and you really are completely open to discovery, you might try using a Grounded Theory approach, which is a methodological approach that foregrounds the generation of theory. In that case, your “theory” section can be a discussion of “Grounded Theory” methodology (confusing, yes, but if you take some time to ponder, you will see how this works). You will still need a literature review, though. Ideally one that describes other studies that have ever looked at anything remotely like what you are looking at—parallel cases that have been researched.

The second approach is the “disciplined configurative case,” in which theory is applied to explain a particular case or topic. You are not trying to test the theory but rather assuming the theory is correct, as in the case of exploring microaggressions in a particular setting. In this case, you really do need to have a separate theory section in addition to the literature review, one in which you clearly define the theoretical framework, including any of its important concepts. You can use this section to discuss how other researchers have used the concepts and note any discrepancies in definitions or operationalization of those concepts. This way you will be sure to design your study so that it speaks to and with other researchers. If everyone who is writing about microaggressions has a different definition of them, it is hard for others to compare findings or make any judgments about their prevalence (or any number of other important characteristics). Your literature review section may then stand alone and describe previous research in the particular area or setting, irrespective of the kinds of theory underlying those studies.

The third approach is “heuristic,” one in which you seek to identify new variables, hypotheses, mechanisms, or paths not yet explained by a theory or theoretical framework. In a way, you are generating new theory, but it is probably more accurate to say that you are extending or deepening preexisting theory. In this case, having a single literature review that is focused on the theory and the ways the theory has been applied and understood (with all its various mechanisms and pathways) is probably your best option. The focus of the literature reviewed is less on the case and more on the theory you are seeking to extend.

The final approach is “theory testing,” which is much rarer in qualitative studies than in quantitative, where this is the default approach. Theory-testing cases are those where a particular case is used to see if an existing theory is accurate or accurate under particular circumstances. As with the heuristic approach, your literature review will probably draw heavily on previous uses of the theory, but you may end up having a special section specifically about cases very close to your own . In other words, the more your study approaches theory testing, the more likely there is to be a set of similar studies to draw on or even one important key study that you are setting your own study up in parallel to in order to find out if the theory generated there operates here.

If we wanted to get very technical, it might be useful to distinguish theoretical frameworks properly from conceptual frameworks. The latter are a bit looser and, given the nature of qualitative research, often fit exploratory studies. Theoretical frameworks rely on specific theories and are essential for theory-testing studies. Conceptual frameworks can pull in specific concepts or ideas that may or may not be linked to particular theories. Think about it this way: A theory is a story of how the world works. Concepts don’t presume to explain the whole world but instead are ways to approach phenomena to help make sense of them. Microaggressions are concepts that are linked to Critical Race Theory. One could contextualize one’s study within Critical Race Theory and then draw various concepts, such as that of microaggressions from the overall theoretical framework. Or one could bracket out the master theory or framework and employ the concept of microaggression more opportunistically as a phenomenon of interest. If you are unsure of what theory you are using, you might want to frame a more practical conceptual framework in your review of the literature.

Helpful Tips

How to maintain good notes for what your read.

Over the years, I have developed various ways of organizing notes on what I read. At first, I used a single sheet of full-size paper with a preprinted list of questions and points clearly addressed on the front side, leaving the second side for more reflective comments and free-form musings about what I read, why it mattered, and how it might be useful for my research. Later, I developed a system in which I use a single 4″ × 6″ note card for each book I read. I try only to use the front side (and write very small), leaving the back for comments that are about not just this reading but things to do or examine or consider based on the reading. These notes often mean nothing to anyone else picking up the card, but they make sense to me. I encourage you to find an organizing system that works for you. Then when you set out to compose a literature review, instead of staring at five to ten books or a dozen articles, you will have ten neatly printed pages or notecards or files that have distilled what is important to know about your reading.

It is also a good idea to store this data digitally, perhaps through a reference manager. I use RefWorks, but I also recommend EndNote or any other system that allows you to search institutional databases. Your campus library will probably provide access to one of these or another system. Most systems will allow you to export references from another manager if and when you decide to move to another system. Reference managers allow you to sort through all your literature by descriptor, author, year, and so on. Even so, I personally like to have the ability to manually sort through my index cards, recategorizing things I have read as I go. I use RefWorks to keep a record of what I have read, with proper citations, so I can create bibliographies more easily, and I do add in a few “notes” there, but the bulk of my notes are kept in longhand.

What kinds of information should you include from your reading? Here are some bulleted suggestions from Calarco ( 2020:113–114 ), with my own emendations:

• Citation . If you are using a reference manager, you can import the citation and then, when you are ready to create a bibliography, you can use a provided menu of citation styles, which saves a lot of time. If you’ve originally formatted in Chicago Style but the journal you are writing for wants APA style, you can change your entire bibliography in less than a minute. When using a notecard for a book, I include author, title, date as well as the library call number (since most of what I read I pull from the library). This is something RefWorks is not able to do, and it helps when I categorize.

I begin each notecard with an “intro” section, where I record the aims, goals, and general point of the book/article as explained in the introductory sections (which might be the preface, the acknowledgments, or the first two chapters). I then draw a bold line underneath this part of the notecard. Everything after that should be chapter specific. Included in this intro section are things such as the following, recommended by Calarco ( 2020 ):

• Key background . “Two to three short bullet points identifying the theory/prior research on which the authors are building and defining key terms.”
• Data/methods . “One or two short bullet points with information about the source of the data and the method of analysis, with a note if this is a novel or particularly effective example of that method.” I use [M] to signal methodology on my notecard, which might read, “[M] Int[erview]s (n-35), B[lack]/W[hite] voters” (I need shorthand to fit on my notecard!).
• Research question . “Stated as briefly as possible.” I always provide page numbers so I can go back and see exactly how this was stated (sometimes, in qualitative research, there are multiple research questions, and they cannot be stated simply).
• Argument/contributions . “Two to three short bullet points briefly describing the authors’ answer to the central research question and its implication for research, theory, and practice.” I use [ARG] for argument to signify the argument, and I make sure this is prominently visible on my notecard. I also provide page numbers here.

For me, all of this fits in the “intro” section, which, if this is a theoretically rich, methodologically sound book, might take up a third or even half of the front page of my notecard. Beneath the bold underline, I report specific findings or particulars of the book as they emerge chapter by chapter. Calarco’s ( 2020 ) next step is the following:

• Key findings . “Three to four short bullet points identifying key patterns in the data that support the authors’ argument.”

All that remains is writing down thoughts that occur upon finishing the article/book. I use the back of the notecard for these kinds of notes. Often, they reach out to other things I have read (e.g., “Robinson reminds me of Crusoe here in that both are looking at the effects of social isolation, but I think Robinson makes a stronger argument”). Calarco ( 2020 ) concludes similarly with the following:

• Unanswered questions . “Two to three short bullet points that identify key limitations of the research and/or questions the research did not answer that could be answered in future research.”

As I mentioned, when I first began taking notes like this, I preprinted pages with prompts for “research question,” “argument,” and so on. This was a great way to remind myself to look for these things in particular. You can do the same, adding whatever preprinted sections make sense to you, given what you are studying and the important aspects of your discipline. The other nice thing about the preprinted forms is that it keeps your writing to a minimum—you cannot write more than the allotted space, even if you might want to, preventing your notes from spiraling out of control. This can be helpful when we are new to a subject and everything seems worth recording!

After years of discipline, I have finally settled on my notecard approach. I have thousands of notecards, organized in several index card filing boxes stacked in my office. On the top right of each card is a note of the month/day I finished reading the item. I can remind myself what I read in the summer of 2010 if the need or desire ever arose to do so…those invaluable notecards are like a memento of what my brain has been up to!

Where to Start Looking for Literature

Your university library should provide access to one of several searchable databases for academic books and articles. My own preference is JSTOR, a service of ITHAKA, a not-for-profit organization that works to advance and preserve knowledge and to improve teaching and learning through the use of digital technologies. JSTOR allows you to search by several keywords and to narrow your search by type of material (articles or books). For many disciplines, the “literature” of the literature review is expected to be peer-reviewed “articles,” but some disciplines will also value books and book chapters. JSTOR is particularly useful for article searching. You can submit several keywords and see what is returned, and you can also narrow your search by a particular journal or discipline. If your discipline has one or two key journals (e.g., the American Journal of Sociology and the American Sociological Review are key for sociology), you might want to go directly to those journals’ websites and search for your topic area. There is an art to when to cast your net widely and when to refine your search, and you may have to tack back and forth to ensure that you are getting all that is relevant but not getting bogged down in all studies that might have some marginal relevance.

Some articles will carry more weight than others, and you can use applications like Google Scholar to see which articles have made and are continuing to make larger impacts on your discipline. Find these articles and read them carefully; use their literature review and the sources cited in those articles to make sure you are capturing what is relevant. This is actually a really good way of finding relevant books—only the most impactful will make it into the citations of journals. Over time, you will notice that a handful of articles (or books) are cited so often that when you see, say, Armstrong and Hamilton ( 2015 ), you know exactly what book this is without looking at the full cite. This is when you know you are in the conversation.

You might also approach a professor whose work is broadly in the area of your interest and ask them to recommend one or two “important” foundational articles or books. You can then use the references cited in those recommendations to build up your literature. Just be careful: some older professors’ knowledge of the literature (and I reluctantly add myself here) may be a bit outdated! It is best that the article or book whose references and sources you use to build your body of literature be relatively current.

Keep a List of Your Keywords

When using searchable databases, it is a good idea to keep a list of all the keywords you use as you go along so that (1) you do not needlessly duplicate your efforts and (2) you can more easily adjust your search as you get a better sense of what you are looking for. I suggest you keep a separate file or even a small notebook for this and you date your search efforts.

Here’s an example:

Table 9.2. Keep a List of Your Keywords

Think Laterally

How to find the various strands of literature to combine? Don’t get stuck on finding the exact same research topic you think you are interested in. In the female gymnast example, I recommended that my student consider looking for studies of ballerinas, who also suffer sports injuries and around whom there is a similar culture of silence. It turned out that there was in fact research about my student’s particular questions, just not about the subjects she was interested in. You might do something similar. Don’t get stuck looking for too direct literature but think about the broader phenomenon of interest or analogous cases.

Read Outside the Canon

Some scholars’ work gets cited by everyone all the time. To some extent, this is a very good thing, as it helps establish the discipline. For example, there are a lot of “Bourdieu scholars” out there (myself included) who draw ideas, concepts, and quoted passages from Bourdieu. This makes us recognizable to one another and is a way of sharing a common language (e.g., where “cultural capital” has a particular meaning to those versed in Bourdieusian theory). There are empirical studies that get cited over and over again because they are excellent studies but also because there is an “echo chamber effect” going on, where knowing to cite this study marks you as part of the club, in the know, and so on. But here’s the problem with this: there are hundreds if not thousands of excellent studies out there that fail to get appreciated because they are crowded out by the canon. Sometimes this happens because they are published in “lower-ranked” journals and are never read by a lot of scholars who don’t have time to read anything other than the “big three” in their field. Other times this happens because the author falls outside of the dominant social networks in the field and thus is unmentored and fails to get noticed by those who publish a lot in those highly ranked and visible spaces. Scholars who fall outside the dominant social networks and who publish outside of the top-ranked journals are in no way less insightful than their peers, and their studies may be just as rigorous and relevant to your work, so it is important for you to take some time to read outside the canon. Due to how a person’s race, gender, and class operate in the academy, there is also a matter of social justice and ethical responsibility involved here: “When you focus on the most-cited research, you’re more likely to miss relevant research by women and especially women of color, whose research tends to be under-cited in most fields. You’re also more likely to miss new research, research by junior scholars, and research in other disciplines that could inform your work. Essentially, it is important to read and cite responsibly, which means checking that you’re not just reading and citing the same white men and the same old studies that everyone has cited before you” ( Calarco 2020:112 ).

Consider Multiple Uses for Literature

Throughout this chapter, I’ve referred to the literature of interest in a rather abstract way, as what is relevant to your study. But there are many different ways previous research can be relevant to your study. The most basic use of the literature is the “findings”—for example, “So-and-so found that Canadian working-class students were concerned about ‘fitting in’ to the culture of college, and I am going to look at a similar question here in the US.” But the literature may be of interest not for its findings but theoretically—for example, employing concepts that you want to employ in your own study. Bourdieu’s definition of social capital may have emerged in a study of French professors, but it can still be relevant in a study of, say, how parents make choices about what preschools to send their kids to (also a good example of lateral thinking!).

If you are engaged in some novel methodological form of data collection or analysis, you might look for previous literature that has attempted that. I would not recommend this for undergraduate research projects, but for graduate students who are considering “breaking the mold,” find out if anyone has been there before you. Even if their study has absolutely nothing else in common with yours, it is important to acknowledge that previous work.

Describing Gaps in the Literature

First, be careful! Although it is common to explain how your research adds to, builds upon, and fills in gaps in the previous research (see all four literature review examples in this chapter for this), there is a fine line between describing the gaps and misrepresenting previous literature by failing to conduct a thorough review of the literature. A little humility can make a big difference in your presentation. Instead of “This is the first study that has looked at how firefighters juggle childcare during forest fire season,” say, “I use the previous literature on how working parents juggling childcare and the previous ethnographic studies of firefighters to explore how firefighters juggle childcare during forest fire season.” You can even add, “To my knowledge, no one has conducted an ethnographic study in this specific area, although what we have learned from X about childcare and from Y about firefighters would lead us to expect Z here.” Read more literature review sections to see how others have described the “gaps” they are filling.

Use Concept Mapping

Concept mapping is a helpful tool for getting your thoughts in order and is particularly helpful when thinking about the “literature” foundational to your particular study. Concept maps are also known as mind maps, which is a delightful way to think about them. Your brain is probably abuzz with competing ideas in the early stages of your research design. Write/draw them on paper, and then try to categorize and move the pieces around into “clusters” that make sense to you. Going back to the gymnasts example, my student might have begun by jotting down random words of interest: gymnasts * sports * coaches * female gymnasts * stress * injury * don’t complain * women in sports * bad coaching * anxiety/stress * careers in sports * pain. She could then have begun clustering these into relational categories (bad coaching, don’t complain culture) and simple “event” categories (injury, stress). This might have led her to think about reviewing literature in these two separate aspects and then literature that put them together. There is no correct way to draw a concept map, as they are wonderfully specific to your mind. There are many examples you can find online.

Ask Yourself, “How Is This Sociology (or Political Science or Public Policy, Etc.)?”

Rubin ( 2021:82 ) offers this suggestion instead of asking yourself the “So what?” question to get you thinking about what bridges there are between your study and the body of research in your particular discipline. This is particularly helpful for thinking about theory. Rubin further suggests that if you are really stumped, ask yourself, “What is the really big question that all [fill in your discipline here] care about?” For sociology, it might be “inequality,” which would then help you think about theories of inequality that might be helpful in framing your study on whatever it is you are studying—OnlyFans? Childcare during COVID? Aging in America? I can think of some interesting ways to frame questions about inequality for any of those topics. You can further narrow it by focusing on particular aspects of inequality (Gender oppression? Racial exclusion? Heteronormativity?). If your discipline is public policy, the big questions there might be, How does policy get enacted, and what makes a policy effective? You can then take whatever your particular policy interest is—tax reform, student debt relief, cap-and-trade regulations—and apply those big questions. Doing so would give you a handle on what is otherwise an intolerably vague subject (e.g., What about student debt relief?).

Sometimes finding you are in new territory means you’ve hit the jackpot, and sometimes it means you’ve traveled out of bounds for your discipline. The jackpot scenario is wonderful. You are doing truly innovative research that is combining multiple literatures or is addressing a new or under-examined phenomenon of interest, and your research has the potential to be groundbreaking. Congrats! But that’s really hard to do, and it might be more likely that you’ve traveled out of bounds, by which I mean, you are no longer in your discipline . It might be that no one has written about this thing—at least within your field— because no one in your field actually cares about this topic . ( Rubin 2021:83 ; emphases added)

Don’t Treat This as a Chore

Don’t treat the literature review as a chore that has to be completed, but see it for what it really is—you are building connections to other researchers out there. You want to represent your discipline or area of study fairly and adequately. Demonstrate humility and your knowledge of previous research. Be part of the conversation.

Supplement: Two More Literature Review Examples

Elites by harvey ( 2011 ).

In the last two decades, there has been a small but growing literature on elites. In part, this has been a result of the resurgence of ethnographic research such as interviews, focus groups, case studies, and participant observation but also because scholars have become increasingly interested in understanding the perspectives and behaviors of leaders in business, politics, and society as a whole. Yet until recently, our understanding of some of the methodological challenges of researching elites has lagged behind our rush to interview them.

There is no clear-cut definition of the term elite, and given its broad understanding across the social sciences, scholars have tended to adopt different approaches. Zuckerman (1972) uses the term ultraelites to describe individuals who hold a significant amount of power within a group that is already considered elite. She argues, for example, that US senators constitute part of the country’s political elite but that among them are the ultraelites: a “subset of particularly powerful or prestigious influentials” (160). She suggests that there is a hierarchy of status within elite groups. McDowell (1998) analyses a broader group of “professional elites” who are employees working at different levels for merchant and investment banks in London. She classifies this group as elite because they are “highly skilled, professionally competent, and class-specific” (2135). Parry (1998:2148) uses the term hybrid elites in the context of the international trade of genetic material because she argues that critical knowledge exists not in traditional institutions “but rather as increasingly informal, hybridised, spatially fragmented, and hence largely ‘invisible,’ networks of elite actors.” Given the undertheorization of the term elite, Smith (2006) recognizes why scholars have shaped their definitions to match their respondents . However, she is rightly critical of the underlying assumption that those who hold professional positions necessarily exert as much influence as initially perceived. Indeed, job titles can entirely misrepresent the role of workers and therefore are by no means an indicator of elite status (Harvey 2010).

Many scholars have used the term elite in a relational sense, defining them either in terms of their social position compared to the researcher or compared to the average person in society (Stephens 2007). The problem with this definition is there is no guarantee that an elite subject will necessarily translate this power and authority in an interview setting. Indeed, Smith (2006) found that on the few occasions she experienced respondents wanting to exert their authority over her, it was not from elites but from relatively less senior workers. Furthermore, although business and political elites often receive extensive media training, they are often scrutinized by television and radio journalists and therefore can also feel threatened in an interview, particularly in contexts that are less straightforward to prepare for such as academic interviews. On several occasions, for instance, I have been asked by elite respondents or their personal assistants what they need to prepare for before the interview, which suggests that they consider the interview as some form of challenge or justification for what they do.

In many cases, it is not necessarily the figureheads or leaders of organizations and institutions who have the greatest claim to elite status but those who hold important social networks, social capital, and strategic positions within social structures because they are better able to exert influence (Burt 1992; Parry 1998; Smith 2005; Woods 1998). An elite status can also change, with people both gaining and losing theirs over time. In addition, it is geographically specific, with people holding elite status in some but not all locations. In short, it is clear that the term elite can mean many things in different contexts, which explains the range of definitions. The purpose here is not to critique these other definitions but rather to highlight the variety of perspectives.

When referring to my research, I define elites as those who occupy senior-management- and board-level positions within organizations. This is a similar scope of definition to Zuckerman’s (1972) but focuses on a level immediately below her ultraelite subjects. My definition is narrower than McDowell’s (1998) because it is clear in the context of my research that these people have significant decision-making influence within and outside of the firm and therefore present a unique challenge to interview. I deliberately use the term elite more broadly when drawing on examples from the theoretical literature in order to compare my experiences with those who have researched similar groups.

”Changing Dispositions among the Upwardly Mobile” by Curl, Lareau, and Wu ( 2018 )

There is growing interest in the role of cultural practices in undergirding the social stratification system. For example, Lamont et al. (2014) critically assess the preoccupation with economic dimensions of social stratification and call for more developed cultural models of the transmission of inequality. The importance of cultural factors in the maintenance of social inequality has also received empirical attention from some younger scholars, including Calarco (2011, 2014) and Streib (2015). Yet questions remain regarding the degree to which economic position is tied to cultural sensibilities and the ways in which these cultural sensibilities are imprinted on the self or are subject to change. Although habitus is a core concept in Bourdieu’s theory of social reproduction, there is limited empirical attention to the precise areas of the habitus that can be subject to change during upward mobility as well as the ramifications of these changes for family life.

In Bourdieu’s (1984) highly influential work on the importance of class-based cultural dispositions, habitus is defined as a “durable system of dispositions” created in childhood. The habitus provides a “matrix of perceptions” that seems natural while also structuring future actions and pathways. In many of his writings, Bourdieu emphasized the durability of cultural tastes and dispositions and did not consider empirically whether these dispositions might be changed or altered throughout one’s life (Swartz 1997). His theoretical work does permit the possibility of upward mobility and transformation, however, through the ability of the habitus to “improvise” or “change” due to “new experiences” (Friedman 2016:131). Researchers have differed in opinion on the durability of the habitus and its ability to change (King 2000). Based on marital conflict in cross-class marriages, for instance, Streib (2015) argues that cultural dispositions of individuals raised in working-class families are deeply embedded and largely unchanging. In a somewhat different vein, Horvat and Davis (2011:152) argue that young adults enrolled in an alternative educational program undergo important shifts in their self-perception, such as “self-esteem” and their “ability to accomplish something of value.” Others argue there is variability in the degree to which habitus changes dependent on life experience and personality (Christodoulou and Spyridakis 2016). Recently, additional studies have investigated the habitus as it intersects with lifestyle through the lens of meaning making (Ambrasat et al. 2016). There is, therefore, ample discussion of class-based cultural practices in self-perception (Horvat and Davis 2011), lifestyle (Ambrasat et al. 2016), and other forms of taste (Andrews 2012; Bourdieu 1984), yet researchers have not sufficiently delineated which aspects of the habitus might change through upward mobility or which specific dimensions of life prompt moments of class-based conflict.

Bourdieu (1999:511; 2004) acknowledged simmering tensions between the durable aspects of habitus and those aspects that have been transformed—that is, a “fractured” or “cleft” habitus. Others have explored these tensions as a “divided” or “fragmented” habitus (Baxter and Britton 2001; Lee and Kramer 2013). Each of these conceptions of the habitus implies that changes in cultural dispositions are possible but come with costs. Exploration of the specific aspects of one’s habitus that can change and generate conflict contributes to this literature.

Scholars have also studied the costs associated with academic success for working-class undergraduates (Hurst 2010; Lee and Kramer 2013; London 1989; Reay 2017; Rondini 2016; Stuber 2011), but we know little about the lasting effects on adults. For instance, Lee and Kramer (2013) point to cross-class tensions as family and friends criticize upwardly mobile individuals for their newly acquired cultural dispositions. Documenting the tension many working-class students experience with their friends and families of origin, they find that the source of their pain or struggle is “shaped not only by their interactions with non-mobile family and friends but also within their own minds, by their own assessments of their social positions, and by how those positions are interpreted by others” (Lee and Kramer 2013:29). Hurst (2010) also explores the experiences of undergraduates who have been academically successful and the costs associated with that success. She finds that decisions about “class allegiance and identity” are required aspects of what it means to “becom[e] educated” (4) and that working-class students deal with these cultural changes differently. Jack (2014, 2016) also argues that there is diversity among lower-income students, which yields varied college experiences. Naming two groups, the “doubly disadvantaged” and the “privileged poor,” he argues that previous experience with “elite environments” (2014:456) prior to college informs students’ ability to take on dominant cultural practices, particularly around engagement, such as help seeking or meeting with professors (2016). These studies shed light on the role college might play as a “lever for mobility” (2016:15) and discuss the pain and difficulty associated with upward mobility among undergraduates, but the studies do not illuminate how these tensions unfold in adulthood. Neither have they sufficiently addressed potential enduring tensions with extended family members as well as the specific nature of the difficulties.

Some scholars point to the positive outcomes upwardly mobile youth (Lehmann 2009) and adults (Stuber 2005) experience when they maintain a different habitus than their newly acquired class position, although, as Jack (2014, 2016) shows, those experiences may vary depending on one’s experience with elite environments in their youth. Researchers have not sufficiently explored the specific aspects of the habitus that upwardly mobile adults change or the conflicts that emerge with family and childhood friends as they reach adulthood and experience colliding social worlds. We contribute to this scholarship with clear examples of self-reported changes to one’s cultural dispositions in three specific areas: “horizons,” food and health, and communication. We link these changes to enduring tension with family members, friends, and colleagues and explore varied responses to this tension based on race.

Further Readings

Bloomberg, Linda Dale, and Marie F. Volpe. 2012. Completing Your Qualitative Dissertation: A Road Map from Beginning to End . 2nd ed. Thousand Oaks, CA: SAGE. In keeping with its general approach to qualitative research, includes a “road map” for conducting a literature review.

Hart, Chris. 1998. Doing a Literature Review: Releasing the Social Science Research Imagination . London: SAGE. A how-to book dedicated entirely to conducting a literature review from a British perspective. Useful for both undergraduate and graduate students.

Machi, Lawrence A., and Brenda T. McEvoy. 2022. The Literature Review: Six Steps to Success . 4th ed. Newbury Park, CA: Corwin. A well-organized guidebook complete with reflection sections to prompt successful thinking about your literature review.

Ridley, Diana. 2008. The Literature Review: A Step-by-Step Guide for Students . London: SAGE. A highly recommended companion to conducting a literature review for doctoral-level students.

The process of systematically searching through pre-existing studies (“literature”) on the subject of research; also, the section of a presentation in which the pre-existing literature is discussed.

Follow-up questions used in a semi-structured interview  to elicit further elaboration.  Suggested prompts can be included in the interview guide  to be used/deployed depending on how the initial question was answered or if the topic of the prompt does not emerge spontaneously.

A tool for identifying relationships among ideas by visually representing them on paper.  Most concept maps depict ideas as boxes or circles (also called nodes), which are structured hierarchically and connected with lines or arrows (also called arcs). These lines are labeled with linking words and phrases to help explain the connections between concepts.  Also known as mind mapping.

The people who are the subjects of an interview-based qualitative study. In general, they are also known as the participants, and for purposes of IRBs they are often referred to as the human subjects of the research.

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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

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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

• Quick Run-through
• Step 1 & 2

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

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

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

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See an example

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

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

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

Download Word doc Download Google doc

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

For each publication, ask yourself:

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

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

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

Take notes and cite your sources

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

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

As you write, you can follow these tips:

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

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

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

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

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

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

 Statistics

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

Research bias

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

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

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

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

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

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

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

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

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

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Communication Sciences & Disorders: Researching the Literature

• 1. Terms to Know: The Basics
• Practice: Identifying Information Sources (Opens Word Doc) This link opens in a new window
• 3: Browsing Key Journals
• 4: Author Searching
• 5: Reference Mining & Citation Searching
• 6. PICO: To Refine the Research Question
• 7: Database Searching
• 8. Finding Full Text Articles
• Sample Annotation
• Sample Annotation 2

Literature Review Matrices and Organizers

• 11. APA Style Citation

A literature review matrix is a tool used by researchers to analyze and synthesize information from various sources relevant to their research topic. It typically takes the form of a table or chart, where rows represent different studies or articles, and columns display key information such as research methodologies, findings, and key themes.

The primary purpose of a literature review matrix is to help you analyze and compare existing literature, to identify patterns, gaps, and contradictions in the body of knowledge related to your research question. 

• Literature Rewiew Matrix Template (example) You will be prompted to make a copy in your Google Drive. You are the sole owner, viewer and editor of the template until you choose to share it.
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• Last Updated: Jul 2, 2024 9:46 AM
• URL: https://libguides.uww.edu/comdis-lit-review

Archer Library

Qualitative research: literature review .

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Exploring the literature review 

Literature review model: 6 steps.

Adapted from The Literature Review , Machi & McEvoy (2009, p. 13).

Your Literature Review

Step 2: search, boolean search strategies, search limiters, ★ ebsco & google drive.

1. Select a Topic

"All research begins with curiosity" (Machi & McEvoy, 2009, p. 14)

Selection of a topic, and fully defined research interest and question, is supervised (and approved) by your professor. Tips for crafting your topic include:

• Be specific. Take time to define your interest.
• Topic Focus. Fully describe and sufficiently narrow the focus for research.
• Academic Discipline. Learn more about your area of research & refine the scope.
• Avoid Bias. Be aware of bias that you (as a researcher) may have.
• Document your research. Use Google Docs to track your research process.
• Research apps. Consider using Evernote or Zotero to track your research.

Consider Purpose

What will your topic and research address?

In The Literature Review: A Step-by-Step Guide for Students , Ridley presents that literature reviews serve several purposes (2008, p. 16-17).  Included are the following points:

• Historical background for the research;
• Overview of current field provided by "contemporary debates, issues, and questions;"
• Theories and concepts related to your research;
• Introduce "relevant terminology" - or academic language - being used it the field;
• Connect to existing research - does your work "extend or challenge [this] or address a gap;" 
• Provide "supporting evidence for a practical problem or issue" that your research addresses.

★ Schedule a research appointment

At this point in your literature review, take time to meet with a librarian. Why? Understanding the subject terminology used in databases can be challenging. Archer Librarians can help you structure a search, preparing you for step two. How? Contact a librarian directly or use the online form to schedule an appointment. Details are provided in the adjacent Schedule an Appointment box.

2. Search the Literature

Collect & Select Data: Preview, select, and organize

AU Library is your go-to resource for this step in your literature review process. The literature search will include books and ebooks, scholarly and practitioner journals, theses and dissertations, and indexes. You may also choose to include web sites, blogs, open access resources, and newspapers. This library guide provides access to resources needed to complete a literature review.

Books & eBooks: Archer Library & OhioLINK

Databases: Scholarly & Practitioner Journals

Review the Library Databases tab on this library guide, it provides links to recommended databases for Education & Psychology, Business, and General & Social Sciences.

Expand your journal search; a complete listing of available AU Library and OhioLINK databases is available on the Databases  A to Z list . Search the database by subject, type, name, or do use the search box for a general title search. The A to Z list also includes open access resources and select internet sites.

Databases: Theses & Dissertations

Review the Library Databases tab on this guide, it includes Theses & Dissertation resources. AU library also has AU student authored theses and dissertations available in print, search the library catalog for these titles.

Did you know? If you are looking for particular chapters within a dissertation that is not fully available online, it is possible to submit an ILL article request . Do this instead of requesting the entire dissertation.

Newspapers:  Databases & Internet

Consider current literature in your academic field. AU Library's database collection includes The Chronicle of Higher Education and The Wall Street Journal .  The Internet Resources tab in this guide provides links to newspapers and online journals such as Inside Higher Ed , COABE Journal , and Education Week .

The Chronicle of Higher Education has the nation’s largest newsroom dedicated to covering colleges and universities.  Source of news, information, and jobs for college and university faculty members and administrators

The Chronicle features complete contents of the latest print issue; daily news and advice columns; current job listings; archive of previously published content; discussion forums; and career-building tools such as online CV management and salary databases. Dates covered: 1970-present.

Search Strategies & Boolean Operators

There are three basic boolean operators:  AND, OR, and NOT.

Used with your search terms, boolean operators will either expand or limit results. What purpose do they serve? They help to define the relationship between your search terms. For example, using the operator AND will combine the terms expanding the search. When searching some databases, and Google, the operator AND may be implied.

Overview of boolean terms

About the example: Boolean searches were conducted on November 4, 2019; result numbers may vary at a later date. No additional database limiters were set to further narrow search returns.

Database Search Limiters

Database strategies for targeted search results.

Most databases include limiters, or additional parameters, you may use to strategically focus search results.  EBSCO databases, such as Education Research Complete & Academic Search Complete provide options to:

• Limit results to full text;
• Limit results to scholarly journals, and reference available;
• Select results source type to journals, magazines, conference papers, reviews, and newspapers
• Publication date

Keep in mind that these tools are defined as limiters for a reason; adding them to a search will limit the number of results returned.  This can be a double-edged sword.  How? 

• If limiting results to full-text only, you may miss an important piece of research that could change the direction of your research. Interlibrary loan is available to students, free of charge. Request articles that are not available in full-text; they will be sent to you via email.
• If narrowing publication date, you may eliminate significant historical - or recent - research conducted on your topic.
• Limiting resource type to a specific type of material may cause bias in the research results.

Use limiters with care. When starting a search, consider opting out of limiters until the initial literature screening is complete. The second or third time through your research may be the ideal time to focus on specific time periods or material (scholarly vs newspaper).

★ Truncating Search Terms

Expanding your search term at the root.

Truncating is often referred to as 'wildcard' searching. Databases may have their own specific wildcard elements however, the most commonly used are the asterisk (*) or question mark (?).  When used within your search. they will expand returned results.

Asterisk (*) Wildcard

Using the asterisk wildcard will return varied spellings of the truncated word. In the following example, the search term education was truncated after the letter "t."

Explore these database help pages for additional information on crafting search terms.

• EBSCO Connect: Searching with Wildcards and Truncation Symbols
• EBSCO Connect: Searching with Boolean Operators
• EBSCO Connect: EBSCOhost Search Tips
• EBSCO Connect: Basic Searching with EBSCO
• ProQuest Help: Search Tips
• ERIC: How does ERIC search work?

★ EBSCO Databases & Google Drive

Tips for saving research directly to Google drive.

Researching in an EBSCO database?

It is possible to save articles (PDF and HTML) and abstracts in EBSCOhost databases directly to Google drive. Select the Google Drive icon, authenticate using a Google account, and an EBSCO folder will be created in your account. This is a great option for managing your research. If documenting your research in a Google Doc, consider linking the information to actual articles saved in drive.

EBSCO Databases & Google Drive

EBSCOHost Databases & Google Drive: Managing your Research

This video features an overview of how to use Google Drive with EBSCO databases to help manage your research. It presents information for connecting an active Google account to EBSCO and steps needed to provide permission for EBSCO to manage a folder in Drive.

About the Video:  Closed captioning is available, select CC from the video menu.  If you need to review a specific area on the video, view on YouTube and expand the video description for access to topic time stamps.  A video transcript is provided below.

• EBSCOhost Databases & Google Scholar

Defining Literature Review

What is a literature review.

A definition from the Online Dictionary for Library and Information Sciences .

A literature review is "a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works" (Reitz, 2014). 

A systemic review is "a literature review focused on a specific research question, which uses explicit methods to minimize bias in the identification, appraisal, selection, and synthesis of all the high-quality evidence pertinent to the question" (Reitz, 2014).

Recommended Reading

About this page

EBSCO Connect [Discovery and Search]. (2022). Searching with boolean operators. Retrieved May, 3, 2022 from https://connect.ebsco.com/s/?language=en_US

EBSCO Connect [Discover and Search]. (2022). Searching with wildcards and truncation symbols. Retrieved May 3, 2022; https://connect.ebsco.com/s/?language=en_US

Machi, L.A. & McEvoy, B.T. (2009). The literature review . Thousand Oaks, CA: Corwin Press: 

Reitz, J.M. (2014). Online dictionary for library and information science. ABC-CLIO, Libraries Unlimited . Retrieved from https://www.abc-clio.com/ODLIS/odlis_A.aspx

Ridley, D. (2008). The literature review: A step-by-step guide for students . Thousand Oaks, CA: Sage Publications, Inc.

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East Carolina University: RN to BSN Library Research Guide: Literature Review Matrix

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Nursing Literature Reviews

What is a Literature (Lit) Review? 

A Literature Review is Not: 

• a quick summary of sources
• a grouping of broad, unrelated sources
• a compilation of everything that has ever been written on a topic
• a literature criticism or book review

So, what is it then?

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

Adapted from:  https://libguides.uwf.edu/c.php?g=215270&p=4439026  by Hillary Fox, University of West Florida,  hfox @uwf.edu.

Creating a Literature Review using the Matrix Method: 

A matrix review allows you to quickly compare and contrast articles in an easy to read format. It can help you to easily spot differences and similarities between journal articles and your nursing research topic. Review matrices are especially helpful for health sciences literature reviews that cover the scope of research over a given amount of time. 

Most literature reviews are set up in this format: 

Chart adapted from the book below: 

• Check out the e-book above for more help in creating a literature review matrix. 

Steps for Conducting a Literature Review

1. Choose Your Topic

• Review your PICO question and think about your central research question. To review the PICO process, please see Kerry Sewell's LibGuide on this subject. 

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? 

3. Select the databases you want to use to conduct your searches (See the Databases Tab Above!)

4. Conduct your searches and find the literature. (Keep track of your searches, try using the Search Strategy Lab Notebook!)

• Review the abstracts and conclusions carefully. This will help you decide which articles actually fit the criteria you are looking for. 
• Write down the keywords you used and where you found them. 
• You can also use RefWorks to keep track of your citations. 

5. Review the Literature (This will probably be the most time consuming part)

• What was the research question of the study you are reviewing?  What were the authors trying to discover? 
• Was the research funded by a company or source that could influence the findings? (Such as Colgate® sponsoring a toothpaste study?)
• What were the research methodologies? Analyze the paper's literature review, the samples and variables used, the results and conclusions. Does the research seem to be complete? Could it have been conducted more soundly? What questions does it raise? 
• If there are conflicting studies, why do you think that is? 
• How are the authors of the paper viewed in the field? Has this study been cited by other publications? 

Literature Review Examples

Remember, a lit review provides an intelligent overview of the topic. There may or may not be a method for how studies are collected or interpreted. Lit reviews aren't always labeled specifically as "literature reviews," they may often be embedded with other sections such as an introduction or background. 

• Mentes, J.C., Salem, N., & Phillips, L.R. (2017). Ethnocultural gerontological nursing. An integrative literature review. Journal of Transcultural Nursing, 28(1), 79-97.  https://journals.sagepub.com/doi/pdf/10.1177/1043659615601483
• Rosa, D.F., Carvalho, M.V., & Pereira, N.R, et al. (2019). Nursing care for the transgender population: genders from the perspective of professional practice. Revista Brasilerira de Enfermagem, 72 (Suppl 1), 299-306.  http://www.scielo.br/pdf/reben/v72s1/0034-7167-reben-72-s1-0299.pdf
• Dahlke, S.A., Hunter, K.F., Negrin, K. (2019). Nursing practice with hospitalized older people: Safety and harm. International Journal of Older People Nursing, 14 (1), Article e1220.  https://onlinelibrary.wiley.com/doi/full/10.1111/opn.12220

Adapted from:  https://libguides.uwf.edu/c.php?g=215270&p=4439026  by Hillary Fox, University of West Florida, [email protected].

Carrie Forbes, MLS

• << Previous: Identifying Research Articles
• Next: Research Databases to Use >>
• Last Updated: Jul 26, 2022 6:15 PM
• URL: https://libguides.ecu.edu/RN2BSNResearch

Module 4: Strategic Reading

Organize your Readings with a Literature Review Matrix

The next step after reading and evaluating your sources is to organize them in a way that will help you start the writing process.

Review Matrix

One way to organize your literature is with a review matrix. The review matrix is a chart that sorts and categorizes the different arguments presented per topic or issue. Using a matrix enables you to quickly compare and contrast your sources in order to determine the scope of research across time. This will allow you  to spot similarities and differences between sources. It is particularly useful in the synthesis and analysis stages of a review (See Module 1 Conducting a Literature Review with the SALSA Framework ).

Example of a Review Matrix

My research question:

How can we use machine learning to analyze social media data related to HIV?

Writing a Literature Review Modified from The WI+RE Team,  UCLA. Creative Commons CC-BY-NA-SA

Create a Review Matrix

Start with a charting tool you are most familiar with (for example MS Word, MS Excel, Google Sheets, Numbers etc).

• Organize your sources from oldest to most recent. This way you can see how the research on your topic has changed over time.
• First Column: citation (i.e., author, title, source, publication year)
• Second Column: purpose or summary (1-2 sentences)
• methodology
• intervention

Key Takeaways

Here are some examples of different review matrices and templates:

• Evidence Synthesis Matrix Template, Jane Schmidt, Toronto Metropolitan University (Google Sheets)
• The Matrix Method for Literature Reviews, Brandeis University, Writing Resources.
• Literature Review Synthesis Matrix , Concordia University (MS Word)
• Write a Literature Review: Synthesize . Johns Hopkins University, Sheridan Libraries

Advanced Research Skills: Conducting Literature and Systematic Reviews (2nd Edition) Copyright © 2021 by Kelly Dermody; Cecile Farnum; Daniel Jakubek; Jo-Anne Petropoulos; Jane Schmidt; and Reece Steinberg is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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• Volume 24, Issue 2
• Five tips for developing useful literature summary tables for writing review articles
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• http://orcid.org/0000-0003-0157-5319 Ahtisham Younas 1 , 2 ,
• http://orcid.org/0000-0002-7839-8130 Parveen Ali 3 , 4
• 1 Memorial University of Newfoundland , St John's , Newfoundland , Canada
• 2 Swat College of Nursing , Pakistan
• 3 School of Nursing and Midwifery , University of Sheffield , Sheffield , South Yorkshire , UK
• 4 Sheffield University Interpersonal Violence Research Group , Sheffield University , Sheffield , UK
• Correspondence to Ahtisham Younas, Memorial University of Newfoundland, St John's, NL A1C 5C4, Canada; ay6133{at}mun.ca

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

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Introduction

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

Tip 1: provide detailed information about frameworks and methods

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

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

Tip 2: include strengths and limitations for each article

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

Tip 3: write conceptual contribution of each reviewed article

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

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

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

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

Tip 5: create your personalised template for literature summaries

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

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

• Aromataris E ,
• Rasheed SP ,

Twitter @Ahtisham04, @parveenazamali

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

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

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Literature Review

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A literature review is a discussion of the literature (aka. the "research" or "scholarship") surrounding a certain topic. A good literature review doesn't simply summarize the existing material, but provides thoughtful synthesis and analysis. The purpose of a literature review is to orient your own work within an existing body of knowledge. A literature review may be written as a standalone piece or be included in a larger body of work.

You can read more about literature reviews, what they entail, and how to write one, using the resources below. 

Am I the only one struggling to write a literature review?

Dr. Zina O'Leary explains the misconceptions and struggles students often have with writing a literature review. She also provides step-by-step guidance on writing a persuasive literature review.

An Introduction to Literature Reviews

Dr. Eric Jensen, Professor of Sociology at the University of Warwick, and Dr. Charles Laurie, Director of Research at Verisk Maplecroft, explain how to write a literature review, and why researchers need to do so. Literature reviews can be stand-alone research or part of a larger project. They communicate the state of academic knowledge on a given topic, specifically detailing what is still unknown.

This is the first video in a whole series about literature reviews. You can find the rest of the series in our SAGE database, Research Methods:

Videos covering research methods and statistics

Identify Themes and Gaps in Literature (with real examples) | Scribbr

Finding connections between sources is key to organizing the arguments and structure of a good literature review. In this video, you'll learn how to identify themes, debates, and gaps between sources, using examples from real papers.

4 Tips for Writing a Literature Review's Intro, Body, and Conclusion | Scribbr

While each review will be unique in its structure--based on both the existing body of both literature and the overall goals of your own paper, dissertation, or research--this video from Scribbr does a good job simplifying the goals of writing a literature review for those who are new to the process. In this video, you’ll learn what to include in each section, as well as 4 tips for the main body illustrated with an example.

• Literature Review This chapter in SAGE's Encyclopedia of Research Design describes the types of literature reviews and scientific standards for conducting literature reviews.
• UNC Writing Center: Literature Reviews This handout from the Writing Center at UNC will explain what literature reviews are and offer insights into the form and construction of literature reviews in the humanities, social sciences, and sciences.
• Purdue OWL: Writing a Literature Review The overview of literature reviews comes from Purdue's Online Writing Lab. It explains the basic why, what, and how of writing a literature review.

Organizational Tools for Literature Reviews

One of the most daunting aspects of writing a literature review is organizing your research. There are a variety of strategies that you can use to help you in this task. We've highlighted just a few ways writers keep track of all that information! You can use a combination of these tools or come up with your own organizational process. The key is choosing something that works with your own learning style.

Citation Managers

Citation managers are great tools, in general, for organizing research, but can be especially helpful when writing a literature review. You can keep all of your research in one place, take notes, and organize your materials into different folders or categories. Read more about citations managers here:

• Manage Citations & Sources

Concept Mapping

Some writers use concept mapping (sometimes called flow or bubble charts or "mind maps") to help them visualize the ways in which the research they found connects.

There is no right or wrong way to make a concept map. There are a variety of online tools that can help you create a concept map or you can simply put pen to paper. To read more about concept mapping, take a look at the following help guides:

• Using Concept Maps From Williams College's guide, Literature Review: A Self-guided Tutorial

Synthesis Matrix

A synthesis matrix is is a chart you can use to help you organize your research into thematic categories. By organizing your research into a matrix, like the examples below, can help you visualize the ways in which your sources connect. 

• Walden University Writing Center: Literature Review Matrix Find a variety of literature review matrix examples and templates from Walden University.
• Writing A Literature Review and Using a Synthesis Matrix An example synthesis matrix created by NC State University Writing and Speaking Tutorial Service Tutors. If you would like a copy of this synthesis matrix in a different format, like a Word document, please ask a librarian. CC-BY-SA 3.0
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• Next: Quantitative Research Methods >>
• Last Updated: May 7, 2024 9:51 AM

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Matrix Method for Literature Review

• The Review Matrix
• Organize Your Sources
• Choose Your Remaining Column Topics
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Sample Matrix and Templates

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• Review Matrix Example-Ebola Vaccine Clinical Studies This document includes a review matrix of two Ebola vaccine clinical reviews done on humans published by the National Institute of Health.
• Review Matrix Word Template A review matrix template in Microsoft Word.
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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

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Approaching literature review for academic purposes: The Literature Review Checklist

Debora f.b. leite.

I Departamento de Ginecologia e Obstetricia, Faculdade de Ciencias Medicas, Universidade Estadual de Campinas, Campinas, SP, BR

II Universidade Federal de Pernambuco, Pernambuco, PE, BR

III Hospital das Clinicas, Universidade Federal de Pernambuco, Pernambuco, PE, BR

Maria Auxiliadora Soares Padilha

Jose g. cecatti.

A sophisticated literature review (LR) can result in a robust dissertation/thesis by scrutinizing the main problem examined by the academic study; anticipating research hypotheses, methods and results; and maintaining the interest of the audience in how the dissertation/thesis will provide solutions for the current gaps in a particular field. Unfortunately, little guidance is available on elaborating LRs, and writing an LR chapter is not a linear process. An LR translates students’ abilities in information literacy, the language domain, and critical writing. Students in postgraduate programs should be systematically trained in these skills. Therefore, this paper discusses the purposes of LRs in dissertations and theses. Second, the paper considers five steps for developing a review: defining the main topic, searching the literature, analyzing the results, writing the review and reflecting on the writing. Ultimately, this study proposes a twelve-item LR checklist. By clearly stating the desired achievements, this checklist allows Masters and Ph.D. students to continuously assess their own progress in elaborating an LR. Institutions aiming to strengthen students’ necessary skills in critical academic writing should also use this tool.

INTRODUCTION

Writing the literature review (LR) is often viewed as a difficult task that can be a point of writer’s block and procrastination ( 1 ) in postgraduate life. Disagreements on the definitions or classifications of LRs ( 2 ) may confuse students about their purpose and scope, as well as how to perform an LR. Interestingly, at many universities, the LR is still an important element in any academic work, despite the more recent trend of producing scientific articles rather than classical theses.

The LR is not an isolated section of the thesis/dissertation or a copy of the background section of a research proposal. It identifies the state-of-the-art knowledge in a particular field, clarifies information that is already known, elucidates implications of the problem being analyzed, links theory and practice ( 3 - 5 ), highlights gaps in the current literature, and places the dissertation/thesis within the research agenda of that field. Additionally, by writing the LR, postgraduate students will comprehend the structure of the subject and elaborate on their cognitive connections ( 3 ) while analyzing and synthesizing data with increasing maturity.

At the same time, the LR transforms the student and hints at the contents of other chapters for the reader. First, the LR explains the research question; second, it supports the hypothesis, objectives, and methods of the research project; and finally, it facilitates a description of the student’s interpretation of the results and his/her conclusions. For scholars, the LR is an introductory chapter ( 6 ). If it is well written, it demonstrates the student’s understanding of and maturity in a particular topic. A sound and sophisticated LR can indicate a robust dissertation/thesis.

A consensus on the best method to elaborate a dissertation/thesis has not been achieved. The LR can be a distinct chapter or included in different sections; it can be part of the introduction chapter, part of each research topic, or part of each published paper ( 7 ). However, scholars view the LR as an integral part of the main body of an academic work because it is intrinsically connected to other sections ( Figure 1 ) and is frequently present. The structure of the LR depends on the conventions of a particular discipline, the rules of the department, and the student’s and supervisor’s areas of expertise, needs and interests.

Interestingly, many postgraduate students choose to submit their LR to peer-reviewed journals. As LRs are critical evaluations of current knowledge, they are indeed publishable material, even in the form of narrative or systematic reviews. However, systematic reviews have specific patterns 1 ( 8 ) that may not entirely fit with the questions posed in the dissertation/thesis. Additionally, the scope of a systematic review may be too narrow, and the strict criteria for study inclusion may omit important information from the dissertation/thesis. Therefore, this essay discusses the definition of an LR is and methods to develop an LR in the context of an academic dissertation/thesis. Finally, we suggest a checklist to evaluate an LR.

WHAT IS A LITERATURE REVIEW IN A THESIS?

Conducting research and writing a dissertation/thesis translates rational thinking and enthusiasm ( 9 ). While a strong body of literature that instructs students on research methodology, data analysis and writing scientific papers exists, little guidance on performing LRs is available. The LR is a unique opportunity to assess and contrast various arguments and theories, not just summarize them. The research results should not be discussed within the LR, but the postgraduate student tends to write a comprehensive LR while reflecting on his or her own findings ( 10 ).

Many people believe that writing an LR is a lonely and linear process. Supervisors or the institutions assume that the Ph.D. student has mastered the relevant techniques and vocabulary associated with his/her subject and conducts a self-reflection about previously published findings. Indeed, while elaborating the LR, the student should aggregate diverse skills, which mainly rely on his/her own commitment to mastering them. Thus, less supervision should be required ( 11 ). However, the parameters described above might not currently be the case for many students ( 11 , 12 ), and the lack of formal and systematic training on writing LRs is an important concern ( 11 ).

An institutional environment devoted to active learning will provide students the opportunity to continuously reflect on LRs, which will form a dialogue between the postgraduate student and the current literature in a particular field ( 13 ). Postgraduate students will be interpreting studies by other researchers, and, according to Hart (1998) ( 3 ), the outcomes of the LR in a dissertation/thesis include the following:

• To identify what research has been performed and what topics require further investigation in a particular field of knowledge;
• To determine the context of the problem;
• To recognize the main methodologies and techniques that have been used in the past;
• To place the current research project within the historical, methodological and theoretical context of a particular field;
• To identify significant aspects of the topic;
• To elucidate the implications of the topic;
• To offer an alternative perspective;
• To discern how the studied subject is structured;
• To improve the student’s subject vocabulary in a particular field; and
• To characterize the links between theory and practice.

A sound LR translates the postgraduate student’s expertise in academic and scientific writing: it expresses his/her level of comfort with synthesizing ideas ( 11 ). The LR reveals how well the postgraduate student has proceeded in three domains: an effective literature search, the language domain, and critical writing.

Effective literature search

All students should be trained in gathering appropriate data for specific purposes, and information literacy skills are a cornerstone. These skills are defined as “an individual’s ability to know when they need information, to identify information that can help them address the issue or problem at hand, and to locate, evaluate, and use that information effectively” ( 14 ). Librarian support is of vital importance in coaching the appropriate use of Boolean logic (AND, OR, NOT) and other tools for highly efficient literature searches (e.g., quotation marks and truncation), as is the appropriate management of electronic databases.

Language domain

Academic writing must be concise and precise: unnecessary words distract the reader from the essential content ( 15 ). In this context, reading about issues distant from the research topic ( 16 ) may increase students’ general vocabulary and familiarity with grammar. Ultimately, reading diverse materials facilitates and encourages the writing process itself.

Critical writing

Critical judgment includes critical reading, thinking and writing. It supposes a student’s analytical reflection about what he/she has read. The student should delineate the basic elements of the topic, characterize the most relevant claims, identify relationships, and finally contrast those relationships ( 17 ). Each scientific document highlights the perspective of the author, and students will become more confident in judging the supporting evidence and underlying premises of a study and constructing their own counterargument as they read more articles. A paucity of integration or contradictory perspectives indicates lower levels of cognitive complexity ( 12 ).

Thus, while elaborating an LR, the postgraduate student should achieve the highest category of Bloom’s cognitive skills: evaluation ( 12 ). The writer should not only summarize data and understand each topic but also be able to make judgments based on objective criteria, compare resources and findings, identify discrepancies due to methodology, and construct his/her own argument ( 12 ). As a result, the student will be sufficiently confident to show his/her own voice .

Writing a consistent LR is an intense and complex activity that reveals the training and long-lasting academic skills of a writer. It is not a lonely or linear process. However, students are unlikely to be prepared to write an LR if they have not mastered the aforementioned domains ( 10 ). An institutional environment that supports student learning is crucial.

Different institutions employ distinct methods to promote students’ learning processes. First, many universities propose modules to develop behind the scenes activities that enhance self-reflection about general skills (e.g., the skills we have mastered and the skills we need to develop further), behaviors that should be incorporated (e.g., self-criticism about one’s own thoughts), and each student’s role in the advancement of his/her field. Lectures or workshops about LRs themselves are useful because they describe the purposes of the LR and how it fits into the whole picture of a student’s work. These activities may explain what type of discussion an LR must involve, the importance of defining the correct scope, the reasons to include a particular resource, and the main role of critical reading.

Some pedagogic services that promote a continuous improvement in study and academic skills are equally important. Examples include workshops about time management, the accomplishment of personal objectives, active learning, and foreign languages for nonnative speakers. Additionally, opportunities to converse with other students promotes an awareness of others’ experiences and difficulties. Ultimately, the supervisor’s role in providing feedback and setting deadlines is crucial in developing students’ abilities and in strengthening students’ writing quality ( 12 ).

HOW SHOULD A LITERATURE REVIEW BE DEVELOPED?

A consensus on the appropriate method for elaborating an LR is not available, but four main steps are generally accepted: defining the main topic, searching the literature, analyzing the results, and writing ( 6 ). We suggest a fifth step: reflecting on the information that has been written in previous publications ( Figure 2 ).

First step: Defining the main topic

Planning an LR is directly linked to the research main question of the thesis and occurs in parallel to students’ training in the three domains discussed above. The planning stage helps organize ideas, delimit the scope of the LR ( 11 ), and avoid the wasting of time in the process. Planning includes the following steps:

• Reflecting on the scope of the LR: postgraduate students will have assumptions about what material must be addressed and what information is not essential to an LR ( 13 , 18 ). Cooper’s Taxonomy of Literature Reviews 2 systematizes the writing process through six characteristics and nonmutually exclusive categories. The focus refers to the reviewer’s most important points of interest, while the goals concern what students want to achieve with the LR. The perspective assumes answers to the student’s own view of the LR and how he/she presents a particular issue. The coverage defines how comprehensive the student is in presenting the literature, and the organization determines the sequence of arguments. The audience is defined as the group for whom the LR is written.
• Designating sections and subsections: Headings and subheadings should be specific, explanatory and have a coherent sequence throughout the text ( 4 ). They simulate an inverted pyramid, with an increasing level of reflection and depth of argument.
• Identifying keywords: The relevant keywords for each LR section should be listed to guide the literature search. This list should mirror what Hart (1998) ( 3 ) advocates as subject vocabulary . The keywords will also be useful when the student is writing the LR since they guide the reader through the text.
• Delineating the time interval and language of documents to be retrieved in the second step. The most recently published documents should be considered, but relevant texts published before a predefined cutoff year can be included if they are classic documents in that field. Extra care should be employed when translating documents.

Second step: Searching the literature

The ability to gather adequate information from the literature must be addressed in postgraduate programs. Librarian support is important, particularly for accessing difficult texts. This step comprises the following components:

• Searching the literature itself: This process consists of defining which databases (electronic or dissertation/thesis repositories), official documents, and books will be searched and then actively conducting the search. Information literacy skills have a central role in this stage. While searching electronic databases, controlled vocabulary (e.g., Medical Subject Headings, or MeSH, for the PubMed database) or specific standardized syntax rules may need to be applied.

In addition, two other approaches are suggested. First, a review of the reference list of each document might be useful for identifying relevant publications to be included and important opinions to be assessed. This step is also relevant for referencing the original studies and leading authors in that field. Moreover, students can directly contact the experts on a particular topic to consult with them regarding their experience or use them as a source of additional unpublished documents.

Before submitting a dissertation/thesis, the electronic search strategy should be repeated. This process will ensure that the most recently published papers will be considered in the LR.

• Selecting documents for inclusion: Generally, the most recent literature will be included in the form of published peer-reviewed papers. Assess books and unpublished material, such as conference abstracts, academic texts and government reports, are also important to assess since the gray literature also offers valuable information. However, since these materials are not peer-reviewed, we recommend that they are carefully added to the LR.

This task is an important exercise in time management. First, students should read the title and abstract to understand whether that document suits their purposes, addresses the research question, and helps develop the topic of interest. Then, they should scan the full text, determine how it is structured, group it with similar documents, and verify whether other arguments might be considered ( 5 ).

Third step: Analyzing the results

Critical reading and thinking skills are important in this step. This step consists of the following components:

• Reading documents: The student may read various texts in depth according to LR sections and subsections ( defining the main topic ), which is not a passive activity ( 1 ). Some questions should be asked to practice critical analysis skills, as listed below. Is the research question evident and articulated with previous knowledge? What are the authors’ research goals and theoretical orientations, and how do they interact? Are the authors’ claims related to other scholars’ research? Do the authors consider different perspectives? Was the research project designed and conducted properly? Are the results and discussion plausible, and are they consistent with the research objectives and methodology? What are the strengths and limitations of this work? How do the authors support their findings? How does this work contribute to the current research topic? ( 1 , 19 )
• Taking notes: Students who systematically take notes on each document are more readily able to establish similarities or differences with other documents and to highlight personal observations. This approach reinforces the student’s ideas about the next step and helps develop his/her own academic voice ( 1 , 13 ). Voice recognition software ( 16 ), mind maps ( 5 ), flowcharts, tables, spreadsheets, personal comments on the referenced texts, and note-taking apps are all available tools for managing these observations, and the student him/herself should use the tool that best improves his/her learning. Additionally, when a student is considering submitting an LR to a peer-reviewed journal, notes should be taken on the activities performed in all five steps to ensure that they are able to be replicated.

Fourth step: Writing

The recognition of when a student is able and ready to write after a sufficient period of reading and thinking is likely a difficult task. Some students can produce a review in a single long work session. However, as discussed above, writing is not a linear process, and students do not need to write LRs according to a specific sequence of sections. Writing an LR is a time-consuming task, and some scholars believe that a period of at least six months is sufficient ( 6 ). An LR, and academic writing in general, expresses the writer’s proper thoughts, conclusions about others’ work ( 6 , 10 , 13 , 16 ), and decisions about methods to progress in the chosen field of knowledge. Thus, each student is expected to present a different learning and writing trajectory.

In this step, writing methods should be considered; then, editing, citing and correct referencing should complete this stage, at least temporarily. Freewriting techniques may be a good starting point for brainstorming ideas and improving the understanding of the information that has been read ( 1 ). Students should consider the following parameters when creating an agenda for writing the LR: two-hour writing blocks (at minimum), with prespecified tasks that are possible to complete in one section; short (minutes) and long breaks (days or weeks) to allow sufficient time for mental rest and reflection; and short- and long-term goals to motivate the writing itself ( 20 ). With increasing experience, this scheme can vary widely, and it is not a straightforward rule. Importantly, each discipline has a different way of writing ( 1 ), and each department has its own preferred styles for citations and references.

Fifth step: Reflecting on the writing

In this step, the postgraduate student should ask him/herself the same questions as in the analyzing the results step, which can take more time than anticipated. Ambiguities, repeated ideas, and a lack of coherence may not be noted when the student is immersed in the writing task for long periods. The whole effort will likely be a work in progress, and continuous refinements in the written material will occur once the writing process has begun.

LITERATURE REVIEW CHECKLIST

In contrast to review papers, the LR of a dissertation/thesis should not be a standalone piece or work. Instead, it should present the student as a scholar and should maintain the interest of the audience in how that dissertation/thesis will provide solutions for the current gaps in a particular field.

A checklist for evaluating an LR is convenient for students’ continuous academic development and research transparency: it clearly states the desired achievements for the LR of a dissertation/thesis. Here, we present an LR checklist developed from an LR scoring rubric ( 11 ). For a critical analysis of an LR, we maintain the five categories but offer twelve criteria that are not scaled ( Figure 3 ). The criteria all have the same importance and are not mutually exclusive.

First category: Coverage

1. justified criteria exist for the inclusion and exclusion of literature in the review.

This criterion builds on the main topic and areas covered by the LR ( 18 ). While experts may be confident in retrieving and selecting literature, postgraduate students must convince their audience about the adequacy of their search strategy and their reasons for intentionally selecting what material to cover ( 11 ). References from different fields of knowledge provide distinct perspective, but narrowing the scope of coverage may be important in areas with a large body of existing knowledge.

Second category: Synthesis

2. a critical examination of the state of the field exists.

A critical examination is an assessment of distinct aspects in the field ( 1 ) along with a constructive argument. It is not a negative critique but an expression of the student’s understanding of how other scholars have added to the topic ( 1 ), and the student should analyze and contextualize contradictory statements. A writer’s personal bias (beliefs or political involvement) have been shown to influence the structure and writing of a document; therefore, the cultural and paradigmatic background guide how the theories are revised and presented ( 13 ). However, an honest judgment is important when considering different perspectives.

3. The topic or problem is clearly placed in the context of the broader scholarly literature

The broader scholarly literature should be related to the chosen main topic for the LR ( how to develop the literature review section). The LR can cover the literature from one or more disciplines, depending on its scope, but it should always offer a new perspective. In addition, students should be careful in citing and referencing previous publications. As a rule, original studies and primary references should generally be included. Systematic and narrative reviews present summarized data, and it may be important to cite them, particularly for issues that should be understood but do not require a detailed description. Similarly, quotations highlight the exact statement from another publication. However, excessive referencing may disclose lower levels of analysis and synthesis by the student.

4. The LR is critically placed in the historical context of the field

Situating the LR in its historical context shows the level of comfort of the student in addressing a particular topic. Instead of only presenting statements and theories in a temporal approach, which occasionally follows a linear timeline, the LR should authentically characterize the student’s academic work in the state-of-art techniques in their particular field of knowledge. Thus, the LR should reinforce why the dissertation/thesis represents original work in the chosen research field.

5. Ambiguities in definitions are considered and resolved

Distinct theories on the same topic may exist in different disciplines, and one discipline may consider multiple concepts to explain one topic. These misunderstandings should be addressed and contemplated. The LR should not synthesize all theories or concepts at the same time. Although this approach might demonstrate in-depth reading on a particular topic, it can reveal a student’s inability to comprehend and synthesize his/her research problem.

6. Important variables and phenomena relevant to the topic are articulated

The LR is a unique opportunity to articulate ideas and arguments and to purpose new relationships between them ( 10 , 11 ). More importantly, a sound LR will outline to the audience how these important variables and phenomena will be addressed in the current academic work. Indeed, the LR should build a bidirectional link with the remaining sections and ground the connections between all of the sections ( Figure 1 ).

7. A synthesized new perspective on the literature has been established

The LR is a ‘creative inquiry’ ( 13 ) in which the student elaborates his/her own discourse, builds on previous knowledge in the field, and describes his/her own perspective while interpreting others’ work ( 13 , 17 ). Thus, students should articulate the current knowledge, not accept the results at face value ( 11 , 13 , 17 ), and improve their own cognitive abilities ( 12 ).

Third category: Methodology

8. the main methodologies and research techniques that have been used in the field are identified and their advantages and disadvantages are discussed.

The LR is expected to distinguish the research that has been completed from investigations that remain to be performed, address the benefits and limitations of the main methods applied to date, and consider the strategies for addressing the expected limitations described above. While placing his/her research within the methodological context of a particular topic, the LR will justify the methodology of the study and substantiate the student’s interpretations.

9. Ideas and theories in the field are related to research methodologies

The audience expects the writer to analyze and synthesize methodological approaches in the field. The findings should be explained according to the strengths and limitations of previous research methods, and students must avoid interpretations that are not supported by the analyzed literature. This criterion translates to the student’s comprehension of the applicability and types of answers provided by different research methodologies, even those using a quantitative or qualitative research approach.

Fourth category: Significance

10. the scholarly significance of the research problem is rationalized.

The LR is an introductory section of a dissertation/thesis and will present the postgraduate student as a scholar in a particular field ( 11 ). Therefore, the LR should discuss how the research problem is currently addressed in the discipline being investigated or in different disciplines, depending on the scope of the LR. The LR explains the academic paradigms in the topic of interest ( 13 ) and methods to advance the field from these starting points. However, an excess number of personal citations—whether referencing the student’s research or studies by his/her research team—may reflect a narrow literature search and a lack of comprehensive synthesis of ideas and arguments.

11. The practical significance of the research problem is rationalized

The practical significance indicates a student’s comprehensive understanding of research terminology (e.g., risk versus associated factor), methodology (e.g., efficacy versus effectiveness) and plausible interpretations in the context of the field. Notably, the academic argument about a topic may not always reflect the debate in real life terms. For example, using a quantitative approach in epidemiology, statistically significant differences between groups do not explain all of the factors involved in a particular problem ( 21 ). Therefore, excessive faith in p -values may reflect lower levels of critical evaluation of the context and implications of a research problem by the student.

Fifth category: Rhetoric

12. the lr was written with a coherent, clear structure that supported the review.

This category strictly relates to the language domain: the text should be coherent and presented in a logical sequence, regardless of which organizational ( 18 ) approach is chosen. The beginning of each section/subsection should state what themes will be addressed, paragraphs should be carefully linked to each other ( 10 ), and the first sentence of each paragraph should generally summarize the content. Additionally, the student’s statements are clear, sound, and linked to other scholars’ works, and precise and concise language that follows standardized writing conventions (e.g., in terms of active/passive voice and verb tenses) is used. Attention to grammar, such as orthography and punctuation, indicates prudence and supports a robust dissertation/thesis. Ultimately, all of these strategies provide fluency and consistency for the text.

Although the scoring rubric was initially proposed for postgraduate programs in education research, we are convinced that this checklist is a valuable tool for all academic areas. It enables the monitoring of students’ learning curves and a concentrated effort on any criteria that are not yet achieved. For institutions, the checklist is a guide to support supervisors’ feedback, improve students’ writing skills, and highlight the learning goals of each program. These criteria do not form a linear sequence, but ideally, all twelve achievements should be perceived in the LR.

CONCLUSIONS

A single correct method to classify, evaluate and guide the elaboration of an LR has not been established. In this essay, we have suggested directions for planning, structuring and critically evaluating an LR. The planning of the scope of an LR and approaches to complete it is a valuable effort, and the five steps represent a rational starting point. An institutional environment devoted to active learning will support students in continuously reflecting on LRs, which will form a dialogue between the writer and the current literature in a particular field ( 13 ).

The completion of an LR is a challenging and necessary process for understanding one’s own field of expertise. Knowledge is always transitory, but our responsibility as scholars is to provide a critical contribution to our field, allowing others to think through our work. Good researchers are grounded in sophisticated LRs, which reveal a writer’s training and long-lasting academic skills. We recommend using the LR checklist as a tool for strengthening the skills necessary for critical academic writing.

AUTHOR CONTRIBUTIONS

Leite DFB has initially conceived the idea and has written the first draft of this review. Padilha MAS and Cecatti JG have supervised data interpretation and critically reviewed the manuscript. All authors have read the draft and agreed with this submission. Authors are responsible for all aspects of this academic piece.

ACKNOWLEDGMENTS

We are grateful to all of the professors of the ‘Getting Started with Graduate Research and Generic Skills’ module at University College Cork, Cork, Ireland, for suggesting and supporting this article. Funding: DFBL has granted scholarship from Brazilian Federal Agency for Support and Evaluation of Graduate Education (CAPES) to take part of her Ph.D. studies in Ireland (process number 88881.134512/2016-01). There is no participation from sponsors on authors’ decision to write or to submit this manuscript.

No potential conflict of interest was reported.

1 The questions posed in systematic reviews usually follow the ‘PICOS’ acronym: Population, Intervention, Comparison, Outcomes, Study design.

2 In 1988, Cooper proposed a taxonomy that aims to facilitate students’ and institutions’ understanding of literature reviews. Six characteristics with specific categories are briefly described: Focus: research outcomes, research methodologies, theories, or practices and applications; Goals: integration (generalization, conflict resolution, and linguistic bridge-building), criticism, or identification of central issues; Perspective: neutral representation or espousal of a position; Coverage: exhaustive, exhaustive with selective citations, representative, central or pivotal; Organization: historical, conceptual, or methodological; and Audience: specialized scholars, general scholars, practitioners or policymakers, or the general public.

Literature Reviews

• What is a Literature Review?
• Six Steps to Writing a Literature Review
• Finding Articles
• Try A Citation Manager
• Avoiding Plagiarism

Selecting a Research Topic 

The first step in the process involves exploring and selecting a topic. You may revise the topic/scope of your research as you learn more from the literature. Be sure to select a topic that you are willing to work with for a considerable amount of time.

When thinking about a topic, it is important to consider the following: 

Does the topic interest you?

Working on something that doesn’t excite you will make the process tedious. The research content should reflect your passion for research so it is essential to research in your area of interest rather than choosing a topic that interests someone else. While developing your research topic, broaden your thinking and creativity to determine what works best for you. Consider an area of high importance to your profession, or identify a gap in the research. It may take some time to narrow down on a topic and get started, but it’s worth the effort.

Is the Topic Relevant?

Be sure your subject meets the assignment/research requirements. When in doubt, review the guidelines and seek clarification from your professor. 

What is the Scope and Purpose?

Sometimes your chosen topic may be too broad. To find direction, try limiting the scope and purpose of the research by identifying the concepts you wish to explore. Once this is accomplished, you can fine-tune your topic by experimenting with keyword searches our  A-Z Databases  until you are satisfied with your retrieval results.

Are there Enough Resources to Support Your Research? 

If the topic is too narrow, you may not be able to provide the depth of results needed. When selecting a topic make sure you have adequate material to help with the research. Explore a variety of resources: journals, books, and online information. 

Adapted from https://jgateplus.com/home/2018/10/11/the-dos-of-choosing-a-research-topic-part-1/

Why use keywords to search? 

• Library databases work differently than Google. Library databases work best when you search for concepts and keywords.
• For your research, you will want to brainstorm keywords related to your research question. These keywords can lead you to relevant sources that you can use to start your research project.
• Identify those terms relevant to your research and add 2-3 in the search box. 

Now its time to decide whether or not to incorporate what you have found into your literature review.  E valuate  your resources to make sure they contain information that is authoritative, reliable, relevant and the most useful in supporting your research.

Remember to be:

• Objective : keep an open mind
• Unbiased : Consider all viewpoints, and include all sides of an argument,  even ones that don't support your own

Criteria for Evaluating Research Publications

Significance and Contribution to the Field

• What is the author’s aim?

• To what extent has this aim been achieved?

• What does this text add to the body of knowledge? (theory, data and/or practical application)

• What relationship does it bear to other works in the field?

• What is missing/not stated?

• Is this a problem?

Methodology or Approach (Formal, research-based texts)

• What approach was used for the research? (eg; quantitative or qualitative, analysis/review of theory or current practice, comparative, case study, personal reflection etc…)

• How objective/biased is the approach?

• Are the results valid and reliable?

• What analytical framework is used to discuss the results?

Argument and Use of Evidence

• Is there a clear problem, statement or hypothesis?

• What claims are made?

• Is the argument consistent?

• What kinds of evidence does the text rely on?

• How valid and reliable is the evidence?

• How effective is the evidence in supporting the argument?

• What conclusions are drawn?

• Are these conclusions justified?

Writing Style and Text Structure

• Does the writing style suit the intended audience? (eg; expert/non-expert, academic/non- academic)

• What is the organizing principle of the text?

• Could it be better organized?

Prepared by Pam Mort, Lyn Hallion and Tracey Lee Downey, The Learning Centre © April 2005 The University of New South Wales. 

Analysis: the Starting Point for Further Analysis & Inquiry

After evaluating your retrieved sources you will be ready to explore both what has been  found  and what is  missing . Analysis involves breaking the study into parts,  understanding  each part, assessing the  strength  of evidence, and drawing  conclusions  about its relationship to your topic. 

Read through the information sources you have selected and try to analyze, understand and critique what you read.  Critically  review each source's methods, procedures, data validity/reliability, and other themes of interest.  Consider  how each source approaches your topic in addition to their collective points of  intersection  and  separation .  Offer an appraisal of past and current thinking, ideas, policies, and practices, identify gaps within the research, and place your current work and research within this wider discussion by considering how your research supports, contradicts, or departs from other scholars’ research and offer recommendations for future research.

Top 10 Tips for Analyzing the Research

• Define key terms
• Note key statistics 
• Determine emphasis, strengths & weaknesses
• Critique research methodologies used in the studies
• Distinguish between author opinion and actual results
• Identify major trends, patterns, categories, relationships, and inconsistencies
• Recognize specific aspects in the study that relate to your topic
• Disclose any gaps in the literature
• Stay focused on your topic
• Excluding landmark studies, use current, up-to-date sources

Prepared by the fine librarians at California State University Sacramento. 

Synthesis vs Summary

Your literature review should not simply be a summary of the articles, books, and other scholarly writings you find on your topic. It should synthesize the various ideas from your sources with your own observations to create a map of the scholarly conversation taking place about your research topics along with gaps or areas for further research.

Bringing together your review results is called synthesis. Synthesis relies heavily on pattern recognition and relationships or similarities between different phenomena. Recognizing these patterns and relatedness helps you make  creative connections  between previously unrelated research and identify any gaps.

As you read, you'll encounter various ideas, disagreements, methods, and perspectives which can be hard to organize in a meaningful way.  A  synthesis matrix  also known as a Literature Review Matrix is an effective and efficient method to organize your literature by recording the main points of each source and documenting how sources relate to each other. If you know how to make an Excel spreadsheet, you can create your own synthesis matrix, or use one of the templates below. 

Because a literature review is NOT a summary of these different sources, it can be very difficult to keep your research organized. It is especially difficult to organize the information in a way that makes the writing process simpler. One way that seems particularly helpful in organizing literature reviews is the synthesis matrix. Click on the link below for a short tutorial and synthesis matrix spreadsheet.

• Literature Review and Synthesis
• Lit Review Synthesis Matrix
• Synthesis Matrix Example

A literature review must include a thesis statement, which is your perception of the information found in the literature. 

A literature review: 

• Demonstrates your thorough  investigation  of and acquaintance with sources related to your topic
• Is not a simple listing, but a  critical discussion
• Must  compare  and  contrast  opinions
• Must  relate  your study to previous studies
• Must show  gaps  in research
• Can  focus  on a research question or a thesis
• Includes a  compilation  of the primary questions and subject areas involved
• Identifies  sources

https://custom-writing.org/blog/best-literature-review

Organizing Your Literature Review

The structure of the review is divided into three main parts—an introduction, body, and the conclusion.

Introduction

Discuss what is already known about your topic and what readers need to know in order to understand your literature review. 

• Scope, Method, Framework: ​ Explain your selection criteria and similarities between your sources. Be sure to mention any consistent methods, theoretical frameworks, or approaches.  
• Research Question or Problem Statement:  State the problem you are addressing and why it is important. Try to write your research question as a statement. 
• Thesis : Address the connections between your sources, current state of knowledge in the field, and consistent approaches to your topic. 
• Format:  Describe your literature review’s organization and adhere to it throughout.   

​ Body 

The discussion of your research and its importance to the literature should be presented in a logical structure.

• Chronological: Structure your discussion by the literature’s publication date moving from the oldest to the newest research. Discuss how your research relates to the literature and highlight any breakthroughs and any gaps in the research.
• Historical: Similar to the chronological structure, the historical structure allows for a discussion of concepts or themes and how they have evolved over time.
• Thematic: Identify and discuss the different themes present within the research. Make sure that you relate the themes to each other and to your research.
• Methodological: This type of structure is used to discuss not so much what is found but how. For example, an methodological approach could provide an analysis of research approaches, data collection or and analysis techniques.

Provide a concise summary of your review and provide suggestions for future research.

Writing for Your Audience 

Writing within your discipline means learning:

• the  specialized vocabulary  your discipline uses
• the rhetorical conventions and  discourse  of your discipline
• the research  methodologies  which are employed

Learn how to write in your discipline by  familiarizing  yourself with the journals and trade publications professionals, researchers, and scholars use. 

Use our Databases by Title  to access:

• The best journals
• The most widely circulated trade publications
• The additional ways professionals and researchers communicate, such as conferences, newsletters, or symposiums.
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Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

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Open Access

Peer-reviewed

Research Article

Identifying stigmatizing language in clinical documentation: A scoping review of emerging literature

Roles Conceptualization, Funding acquisition, Supervision, Writing – original draft

* E-mail: [email protected]

Affiliation Columbia University School of Nursing, New York, New York, United States of America

Roles Data curation, Formal analysis, Writing – review & editing

Roles Data curation, Writing – review & editing

Affiliation Department of Biomedical Informatics, Columbia University, New York, New York, United States of America

Roles Conceptualization, Writing – review & editing

Affiliation Department of Computer Science, Aalto University, Aalto, Finland

Affiliation University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, United States of America

Roles Conceptualization, Supervision, Writing – review & editing

• Veronica Barcelona, 
• Danielle Scharp, 
• Betina R. Idnay, 
• Hans Moen, 
• Kenrick Cato, 
• Maxim Topaz

• Published: June 28, 2024
• https://doi.org/10.1371/journal.pone.0303653
• Reader Comments

Racism and implicit bias underlie disparities in health care access, treatment, and outcomes. An emerging area of study in examining health disparities is the use of stigmatizing language in the electronic health record (EHR).

We sought to summarize the existing literature related to stigmatizing language documented in the EHR. To this end, we conducted a scoping review to identify, describe, and evaluate the current body of literature related to stigmatizing language and clinician notes.

We searched PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Embase databases in May 2022, and also conducted a hand search of IEEE to identify studies investigating stigmatizing language in clinical documentation. We included all studies published through April 2022. The results for each search were uploaded into EndNote X9 software, de-duplicated using the Bramer method, and then exported to Covidence software for title and abstract screening.

Studies (N = 9) used cross-sectional (n = 3), qualitative (n = 3), mixed methods (n = 2), and retrospective cohort (n = 1) designs. Stigmatizing language was defined via content analysis of clinical documentation (n = 4), literature review (n = 2), interviews with clinicians (n = 3) and patients (n = 1), expert panel consultation, and task force guidelines (n = 1). Natural language processing was used in four studies to identify and extract stigmatizing words from clinical notes. All of the studies reviewed concluded that negative clinician attitudes and the use of stigmatizing language in documentation could negatively impact patient perception of care or health outcomes.

The current literature indicates that NLP is an emerging approach to identifying stigmatizing language documented in the EHR. NLP-based solutions can be developed and integrated into routine documentation systems to screen for stigmatizing language and alert clinicians or their supervisors. Potential interventions resulting from this research could generate awareness about how implicit biases affect communication patterns and work to achieve equitable health care for diverse populations.

Citation: Barcelona V, Scharp D, Idnay BR, Moen H, Cato K, Topaz M (2024) Identifying stigmatizing language in clinical documentation: A scoping review of emerging literature. PLoS ONE 19(6): e0303653. https://doi.org/10.1371/journal.pone.0303653

Editor: Guanghui Liu, State University of New York at Oswego, UNITED STATES

Received: April 13, 2023; Accepted: April 30, 2024; Published: June 28, 2024

Copyright: © 2024 Barcelona et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are fully publicly available; full citations and DOIs can be found in the "Data Availability Statement" supporting information file.

Funding: Columbia University Data Science Institute Seeds Funds Program (VB, MT, KC). https://datascience.columbia.edu/ The Gordon and Betty Moore Foundation (Grant number: GBMF9048) (VB, MT, KC). https://health.ucdavis.edu/nursing/NurseLeaderFellows/index.html The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Racial and ethnic disparities in health care access, treatment, and outcomes have been documented for decades [ 1 ]. Prior studies have shown that concerns expressed by Black patients are more likely to be dismissed or ignored than White patients [ 2 ]. This differential treatment has been observed among Black and African American patients leading to disparities in outcomes, [ 1 , 3 , 4 ] and specifically in the treatment of cardiovascular diseases, [ 5 ] pain, [ 6 ] and breast cancer [ 7 ]. Racism occurring on the structural, interpersonal, or cultural levels has been identified as the primary reason for disparities in health outcomes [ 8 ]. Researchers have examined clinician biases by studying racial bias in patient-clinician interactions, finding that stereotyping and lack of empathy towards patients by race influenced health care outcomes [ 9 ].

Stigmatizing language has been defined as language that communicates unintended meanings that can perpetuate socially constructed power dynamics and result in bias [ 10 ]. Recent studies suggest that racial biases may also be identified by examining stigmatizing language in clinician notes documented in the electronic health record (EHR) [ 11 – 14 ]. Racial differences in documentation patterns may reflect unconscious biases and stereotypes that could negatively affect the quality of care [ 14 ]. Examples of stigmatizing language may include the use of quotations to identify disbelief in what the patient is reporting, questioning patient credibility, sentence construction that implies hearsay, and the use of judgment words [ 13 ]. Stigmatizing language in clinical notes has been associated with more negative attitudes towards the patient and less effective management of patient pain by physicians [ 14 ].

It is unknown to what extent and how stigmatizing language has been studied in healthcare settings, and study designs and foci differ. Emerging studies have used traditional qualitative methods, including interviews with patients and clinicians. Other research has used natural language processing (NLP), a computer science-based technique that helps extract meaning from large bodies of text, to quantify how EHR notes reflect stigmatizing language by race and ethnicity. The purpose of this scoping review was to identify, describe, and evaluate the presence and type of stigmatizing language in clinician documentation in the literature.

A scoping review was chosen instead of a systematic review as the purpose was to identify and map the emerging evidence [ 15 ]. This review was conducted using PRISMA-ScR guidelines for scoping reviews [ 16 ].

Materials & methods

Search strategy.

The authors discussed the selection and coverage of three concepts (i.e., stigmatizing language, clinician, and clinical documentation) for review based on the research question. For purposes of the current study, the concept of “clinician” includes physicians and nurses. We searched PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Embase databases in May 2022 to identify studies investigating stigmatizing language in clinical documentation. We also conducted an updated hand-search of the IEEE Explore database for articles published through April 2022. However, we did not identify additional articles that met inclusion criteria and were not already included in our review. The results for each search were uploaded into EndNote X9 software, de-duplicated using the Bramer method [ 17 ], and then exported to Covidence software for title and abstract screening. The search strategy is detailed in S1 Table .

Inclusion criteria

The initial search yielded 1,482 articles for review. After de-duplication, 897 articles were included for title and abstract screening. Two authors (BI, DS) independently screened all articles by title and abstract and documented reasons for exclusion, when applicable. Studies were included if they investigated stigmatizing language in clinical documentation. Studies that looked into stigmatizing language with patient-provider interaction that did not include documentation (e.g., verbal communication) were excluded. Articles not in English, review articles, editorials, commentaries, and articles without full-text availability were also excluded. The same reviewers independently assessed all potentially relevant articles in the full-text review to comprehensively determine eligibility for inclusion, as well as searching reference lists for additional articles. Discrepancies were discussed with the team to achieve consensus. From the 40 articles included for full-text review, nine articles were included for final synthesis ( Fig 1 ).

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0303653.g001

Data extraction and quality assessment

Relevant information categories from each included article were extracted by two authors (BI, DS). Two other co-authors with expertise in health informatics (MT, HM) reviewed and validated all the extracted data elements. These information categories included: authors, year of publication, study aim and design, clinical setting, data source, clinician specialty, clinical note type (when available), study population, number of clinical notes used, data analysis approach, outcomes, and stigmatizing language identified. The Mixed Methods Appraisal Tool (MMAT) [ 18 ] was used to evaluate study quality and the risk of bias in the included articles.

Nine articles meeting all inclusion criteria were included in this scoping review ( Table 1 ). Overall, study designs (N = 9) included cross-sectional (n = 3), [ 11 – 13 ] qualitative (n = 3), [ 19 – 21 ] mixed methods (n = 2), [ 22 , 23 ] and retrospective cohort (n = 1) [ 24 ]. Studies took place in exclusively inpatient (n = 3) [ 12 , 19 , 24 ] or outpatient (n = 4) [ 13 , 21 – 23 ] settings. One study was conducted in an emergency department (ED) (n = 1), [ 20 ] and another included participants from inpatient, outpatient, and ED settings (n = 1) [ 11 ]. In terms of patient population, six focused on general medicine, [ 11 – 13 , 19 , 21 , 23 ] and one article each on oncology, [ 22 ] psychiatry, [ 24 ] and pediatrics [ 20 ].

https://doi.org/10.1371/journal.pone.0303653.t001

Methods for measuring and defining stigmatizing language varied by study. Specifically, stigmatizing language was identified via interviews with clinicians [ 19 , 20 , 22 ] and patients, [ 19 ] content analysis of clinical documentation, [ 13 , 21 , 23 , 24 ] literature review, [ 11 , 12 ] expert panel consultation, [ 11 ] and task force guidelines from relevant professional organizations [ 12 ]. Definitions of stigmatizing language or bias varied as well by study, with most studies focusing on discipline-specific words communicating judgment or negative bias ( Table 1 ). Stigmatizing language often included stereotyping by race and ethnicity. An example found in clinician documentation in the EHR was in the form of quotes highlighting “unsophisticated” patient language, i.e., “…patient states that the wound ‘busted open’” [ 21 ]. Another study found that physician notes written about Black patients had up to 50% higher odds of containing evidentials (language used by the writer questioning the veracity of the patient’s words) and stigmatizing language than those of White patients [ 13 ]. Similarly, physicians documented more negative feelings such as disapproval, discrediting, and stereotyping toward Black patients than White patients [ 21 ].

Often, clinical documentation studied was in the form of clinical notes. The most commonly analyzed clinical notes included those documented by physicians (n = 3), [ 12 , 13 , 22 ] followed by nurses (n = 1), [ 24 ] advanced practice providers (n = 1), [ 12 ] and interdisciplinary team members including radiologists, respiratory therapists, nutritionists, social workers, case managers, and pharmacists (n = 1). Sun et al. examined history and physical notes written by medical providers, although no further detail about the type of providers was specified [ 11 ].

Reporting of race and ethnicity of study participants varied widely. In three studies, race was not specified at all, [ 20 , 22 , 24 ] or studies reported only White and Black participant races (n = 2) [ 13 , 21 ]. Two studies described findings by race and ethnicity, including Black (or African American), Hispanic, White, and Asian categories [ 12 , 23 ]. The remaining studies either reported race and ethnicity as: White, Black or Hispanic, [ 11 ] or White or Hispanic [ 19 ].

Studies that conducted interviews focused on how clinical notes were written and may be interpreted by patients, [ 22 ] barriers and facilitators to providing care, [ 19 ] patients’ perceptions of their hospitalization, [ 19 ] and clinician insights on racial bias and EHR documentation [ 20 ]. Qualitative themes identified related to stigmatizing language included a reluctance to describe patients as “difficult” or “obese” due to the social stigma attached to common medical language, [ 22 ] intentional and unintentional perpetration of stigma in clinical notes, [ 19 ] and identification of potential racial bias through documentation [ 20 ].

In terms of methods, four studies used NLP [ 11 – 13 , 22 ] to extract terms from clinical notes matching those in predefined vocabularies of stigmatizing language terms. After NLP, statistical analyses were conducted to calculate and compare the odds of stigmatizing language occurrence among different patient populations. Two of the NLP-based studies used Linguistic Inquiry and Word Count (LIWC: a standardized vocabulary of terms), while others created their own hand-crafted vocabularies. One of the studies that involved the use of NLP [ 11 ] developed a machine learning classifier that would automatically detect stigmatizing language. This was the only study that measured the accuracy of automated NLP-based stigmatizing language detection and found it very accurate (F1 score = 0.94).

Despite a wide variety of clinical settings in the reviewed studies, negative language, bias, racial bias, or stigmatizing language was identified in clinician attitudes and/or documentation across all studies that could negatively impact patient perception or outcomes. Disparities in stigmatizing language use in the EHR were evident by race and ethnicity both in clinician interviews [ 20 , 22 , 24 ] and analyses of clinical notes [ 11 – 13 , 19 , 21 , 23 ]. There may be discipline-specific stigmatizing language and terms [i.e., addiction [ 19 ]] and paternalistic attitudes that state that clinical notes are for clinician communication and not for patients to read [i.e., oncology [ 22 ]] that warrant further investigation.

In Table 2 , results of the study quality assessments are presented. All studies asked clear research questions and collected data to address the research questions. Among quantitative studies (n = 4), three met all five criteria for quality, and the remaining study did not adequately describe measurement, confounders, or intervention fidelity. The qualitative studies (n = 3) met the criteria for four of five quality components assessed, with two studies lacking an explicit discussion of the qualitative approach. Neither mixed methods studies (n = 2) met all quality criteria, as one did not include an adequate rationale for using this design, the other study did not discuss inconsistencies between quantitative and qualitative results, and both did not adhere to all criteria for quantitative and/or qualitative methods.

https://doi.org/10.1371/journal.pone.0303653.t002

In this review, we identified the types and frequency of stigmatizing language in EHR notes, establishing an underpinning for future research on the correlation between communication patterns and outcomes (i.e., hospitalization, mortality, complications, disease stability, symptom control). With continuous advancements in the field of NLP, we believe that these methods (including deep learning-based methods) will be essential tools in future stigmatizing language studies.

It is crucial to evaluate NLP-based system performance to ensure accurate concept identification and reliable results; however, this was only done in one study [ 11 ]. Further studies that use NLP are needed that evaluate the accuracy of the resulting NLP systems and to ensure stigmatizing language is identified correctly. The two studies reviewed here that used NLP did not assess clinical relevance, limiting their findings. In addition to accurate stigmatizing language identification, clinical relevance must be assessed to determine to what extent NLP systems are useful for predicting the association between language use and clinical outcomes. Finally, there is a gap in the literature for NLP-specific bias assessment. There is a need for further development of NLP for identifying stigmatizing language, as these methods may not detect all stigmatizing language, and outcomes may be driven by the level of bias among annotators. Quality from training data is vital in algorithm development, and more research should be done describing biases of people performing annotation. This type of acknowledgment is increasingly common in journals where authors are required to submit positionality statements, however, we suggest that this go further for annotators, as life experiences influence assessments of whether bias or stigma is present. We did not do a specific evaluation of the NLP-only studies, due to the small number. However, further studies should be done to evaluate the quality of NLP studies and the validity of NLP results. Specific criteria for this domain should be developed.

The identification of stigmatizing language use in EHR notes is vital as this language may foster the transmission of bias between clinicians and may represent a value judgment of the intrinsic worth assigned to a patient [ 11 ]. Further, with the passage of The 21 st Century Cures Act in the US, federal policy now requires the availability of clinical notes to patients [ 25 ]. Clinical notes that reflect clinician bias may harm the patient-clinician relationship and hinder or damage the establishment of trust required for positive interactions in health care settings. Medical mistrust is a persistent problem contributing to delays in seeking care and widening disparities in disease outcomes for many vulnerable populations, [ 26 ] hence efforts are needed to improve the current situation.

Definitions of stigmatizing language varied in the studies reviewed, and also represent an area for future research. Stigmatizing language may best be defined by the vulnerable populations at risk, in partnership with researchers. Further, discipline-specific language should be discussed and agreed upon, as this may vary by patient population. For example, guidelines have been suggested for addressing the intersectional nature of language in the care of birthing people [ 27 ].

Three studies reviewed here did not specify race or ethnicity of their clinician and patient participants [ 20 , 22 , 24 ]. This is a significant issue as patient-clinician race discordance has been associated with increased risk of mortality [ 28 ]. Racial concordance, however, does not necessarily lead to better communication as perceived by patients [ 29 ]. Given the inconsistency in reporting of race and ethnicity in the reviewed studies, future research in this area should carefully operationalize and define race and ethnicity variables extracted from the EHR. In addition, studies whose primary focus was to identify bias did not blind for patient race, as in many cases race was considered a primary predictor or variable of interest. This underscores an important gap in the literature for NLP-specific bias assessment. Blinding sensitive categories when screening records for bias may improve validity of outcome ascertainment, however, it is often necessary for reviewers to rely on context and include categories such as race and ethnicity when evaluating for stigmatizing language.

The measurement of race is a contentious issue in many medical and scientific disciplines, and though it is a social construction with no biological basis, it remains an indicator of likelihood of encountering racism and racist structures that lead to health disparities. EHR demographic data have been shown to have several quality issues, with some studies indicating that data from Latinos having higher rates of misclassification than other racial/ethnic groups [ 30 ]. It is important to consider who enters race and ethnicity data in the EHR, as patient self-identification is often used as the “gold-standard” in research, yet the patient’s apparent phenotype may be an even more important predictor of clinician perception and subsequent clinical documentation. Indeed, recent work has identified that patient race can be predicted using machine learning algorithms applied to other clinical indicators from the EHR [ 31 – 33 ]. From a validity and reliability perspective, researchers must align their methodological definition of race and ethnicity with the stated research objectives. Further, consistent definitions of racial and ethnic categories are essential to identifying associations between stigmatizing language use and patient outcomes as future studies developing interventions are considered. Future research should include larger proportions of minoritized patient and clinician participants to elucidate these issues further, and examine the underlying factors associated with poorer outcomes in various healthcare settings.

Finally, six of the studies reviewed [ 12 , 13 , 19 – 22 ] included physicians, and many included other health care provider types (i.e. nurses, respiratory therapists, pharmacists, etc.) either alone [ 24 ] or in addition to physician notes/participants [ 12 , 19 , 20 ]. Limited information was provided about the type of notes that were analyzed. Further detail about the type of clinicians and notes would allow for the identification of what other disciplines are reading or writing to draw conclusions about the transmission of bias over the trajectory of patient care.

There are several opportunities for policy change to address the use of stigmatizing language in clinical documentation. First, stigmatizing language can be identified automatically with NLP. NLP-based solutions can be developed and integrated into routine documentation systems to screen for stigmatizing language and alert clinicians or their supervisors. Previously published instances of flags in EHR documentation have provided evidence of improved outcomes of care, including in diagnosis of stroke, increasing health care access for patients at risk of suicide, and improving community rates of Hepatitis C screening for those at high risk [ 34 – 36 ]. To our knowledge, NLP findings of stigmatizing language use in the EHR has not yet been applied to clinical practice, identifying a need for future research that could lead to practice and policy change.

Second, clinicians’ less than optimal working conditions may contribute to burnout and negative language use toward patients. One study found that resident physicians who reported higher levels of burnout had greater explicit and implicit racial biases [ 37 ]. Individually-focused interventions for clinicians, such as mindfulness training, have also been suggested as a method to reduce bias in clinical care, [ 38 ] but have yet to be evaluated. A study carried out on nurses in Taiwan suggested that workplace burnout was associated with poorer patient care outcomes, though stigmatizing language was not examined [ 39 ]. The COVID-19 pandemic has also contributed to moral injury for nurses, affecting patient care [ 40 ]. Burnout does not foster an environment where clinicians can foster and sustain empathy for patients, and empathy is a critical component of reducing bias and building support for antiracism efforts to reduce inequities [ 41 , 42 ] Antiracism and bias efforts in hospitals should include analyzing if clinician burnout is associated with stigmatizing language use in EHR documentation, and if it reinforces bias between clinicians, potentially contributing to health inequities.

In summary, this review highlights a new and promising application of qualitative research and NLP to clinical documentation in the study of racial and ethnic disparities in health care. We suggest that further research be done applying NLP to identify stigmatizing language, with the ultimate goal of reducing clinicians’ stigmatizing language use in health documentation. By improving identification of stigmatizing language through NLP and other methods, potential interventions can be developed to generate awareness and design educational interventions about how implicit biases affect communication patterns and work to achieve equitable health care for diverse populations.

Supporting information

S1 checklist. preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) checklist..

https://doi.org/10.1371/journal.pone.0303653.s001

S1 File. Data availability statement.

https://doi.org/10.1371/journal.pone.0303653.s002

S1 Table. Search strategy.

https://doi.org/10.1371/journal.pone.0303653.s003

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• Published: 29 June 2024

Recommendations to advance digital health equity: a systematic review of qualitative studies

• Sarah Wilson   ORCID: orcid.org/0000-0001-7803-3978 1 ,
• Clare Tolley 1 ,
• Ríona Mc Ardle 2 ,
• Lauren Lawson   ORCID: orcid.org/0000-0003-0433-5214 1 ,
• Emily Beswick 3 ,
• Nehal Hassan   ORCID: orcid.org/0000-0002-8302-5769 1 ,
• Robert Slight 4 &
• Sarah Slight 1 , 4  

npj Digital Medicine volume  7 , Article number:  173 ( 2024 ) Cite this article

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The World Health Organisation advocates Digital Health Technologies (DHTs) for advancing population health, yet concerns about inequitable outcomes persist. Differences in access and use of DHTs across different demographic groups can contribute to inequities. Academics and policy makers have acknowledged this issue and called for inclusive digital health strategies. This systematic review synthesizes literature on these strategies and assesses facilitators and barriers to their implementation. We searched four large databases for qualitative studies using terms relevant to digital technology, health inequities, and socio-demographic factors associated with digital exclusion summarised by the CLEARS framework (Culture, Limiting conditions, Education, Age, Residence, Socioeconomic status). Following the PRISMA guidelines, 10,401 articles were screened independently by two reviewers, with ten articles meeting our inclusion criteria. Strategies were grouped into either outreach programmes or co-design approaches. Narrative synthesis of these strategies highlighted three key themes: firstly, using user-friendly designs, which included software and website interfaces that were easy to navigate and compatible with existing devices, culturally appropriate content, and engaging features. Secondly, providing supportive infrastructure to users, which included devices, free connectivity, and non-digital options to help access healthcare. Thirdly, providing educational support from family, friends, or professionals to help individuals develop their digital literacy skills to support the use of DHTs. Recommendations for advancing digital health equity include adopting a collaborative working approach to meet users’ needs, and using effective advertising to raise awareness of the available support. Further research is needed to assess the feasibility and impact of these recommendations in practice.

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Introduction.

The World Health Organisation (WHO) advocates Digital Health Technologies (DHTs) to advance population health 1 . Digital health can be defined as the use of information and communication technologies within healthcare to provide healthcare users with services relating to the prevention, detection, diagnosis and management of diseases and other health conditions 2 , 3 , 4 . Examples of DHTs include smartphone applications and wearable monitoring devices that can empower people to better manage their own conditions, such as keeping track of symptoms or remotely monitoring their condition(s) over time 2 , 3 , 4 . DHTs can pick up signs of deterioration in healthcare users’ symptoms longitudinally and provide real-time data to healthcare professionals to help support tailored clinical decision making 4 . DHTs can also enable individuals with mobility issues and those living in rural areas to access healthcare. Digital health has gained global momentum due to its potential to contribute to personalised health care for patients, improved quality of care, and lower healthcare costs 5 , 6 .

However, there are growing concerns that DHTs may not lead to health benefits in all populations, with underserved groups (i.e., those typically left out of research or experience inadequate access to healthcare) at particular risk 7 . One possible factor contributing to this is digital exclusion, denoting disparities in motivation, access and use of DHTs across different demographic groups 8 . Digital exclusion can potentially create a barrier for various underserved groups, such as those who are on a low income, are not fluent in English, or homeless, thus exacerbating health inequities for these groups 9 . Individuals with visual impairment may also find on-screen reading challenging and many older adults with hearing impairments have expressed low motivation to use phone calls as a remote option to access healthcare due to their disability 10 .

Technology has advanced rapidly over recent years, with some DHTs (e.g., telehealth services, mobile phones, wearable devices, smartphone apps and other software) having greater relevance to the direct inequities underserved groups face compared to other DHTs. For example, DHTs designed to be solely used by healthcare professionals (e.g., electronic patient records) are less likely to directly impact healthcare service users, and so it is prudent to focus on DHTs that underserved groups may be asked to use. Qualitative studies gathering rich in-depth experiences from those whose voices are rarely heard (i.e., underserved groups) 11 , 12 will provide valuable insights into the facilitators and barriers regarding access, motivated and/or use of DHTs.

The WHO Bellagio eHealth Evaluation Group (2019) recognised the need to mitigate digital exclusion 13 , with organisations such as NICE (National Institute for Health and Care Excellence) requiring evidence that health inequities have been considered in the design of DHTs 2 . This includes important aspects of design, development or implementation of a DHT that support digital inclusivity, such as strategies to increase an individual’s access to suitable devices or connectivity, and educational support in digital literacy to increase DHT use 14 . To support the development of such strategies, it is vital to understand the needs of underserved groups as well as their experiences and perspectives of these strategies to identify what does and does not support digital inclusivity. However, there is currently no qualitative systematic review of key strategies conducted in this area; a key knowledge gap in the literature. To advance digital health equity, we aimed to systematically synthesise the literature on what key strategies have been used to promote digital inclusivity, and assess the facilitators and barriers to implementing and adopting these in practice based on underserved groups’ experiences and perspectives.

Study descriptions

Our search yielded 13,216 results. After removing duplicates ( n  = 2815), titles ( n  = 10,401) abstracts ( n  = 1224) and full-texts ( n  = 143) were screened. Ten papers met our inclusion criteria (Fig. 1 ). Inter-reviewer reliability was high with 99.33% agreement at title stage, 99.43% at abstract stage, and 97.89% at full-text stage. All included studies were found to have moderate- to high-quality levels (Supplementary Tables 7 and 8 ). None of the included studies measured or reported any participants’ health literacy.

A PRIMSA flow chart detailing our search and selection process applied during the article screening process.

Included studies incorporated a range of participants at risk of digital exclusion, including those from different cultural backgrounds (ethnic diversity, languages and religion) ( n  = 8) 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , those with limiting conditions (visual and hearing impairments) ( n  = 2) 21 , 22 , low educational attainment ( n  = 4) 15 , 19 , 20 , 21 , aged over 65 ( n  = 4) 16 , 20 , 21 , 22 , homeless ( n  = 2) 19 , 24 , and those who had low socioeconomic status ( n  = 5) 15 , 16 , 17 , 18 , 21 (Supplementary Table 9 ). All 10 studies used interviews 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , with two studies also conducting focus groups with participants 18 , 21 . (Supplementary Table 10 ). Inclusive digital health strategies were grouped into either outreach programmes providing educational support and/or access to devices ( n  = 2) 19 , 22 , or co-designing DHTs with underserved groups ( n  = 8) to gain feedback on the usability and acceptability of DHT to enhance inclusivity in future versions of the DHT (Table 1 ) 15 , 16 , 17 , 18 , 20 , 21 , 23 , 24 .

Our narrative thematic synthesis generated three overarching themes; user-friendly designs (e.g., software and website design elements that promoted inclusivity), infrastructure (e.g., access to DHTs) and educational support (e.g., training to develop digital literacy skills required to use DHTs) (Supplementary Table 10 ). Facilitators and barriers to the adoption of these themes are embedded in the discussion below and summarised in Fig. 2 .

Summary of the key facilitators and barriers to strategies to support digital health equity (using a user-friendly design, providing infrastructure and providing educational support) alongside the specific CLEARS groups the strategy will support.

User-friendly designs

User-friendly designs were a key theme supporting access and use of DHTs across seven studies 15 , 16 , 20 , 21 , 22 , 24 . Health-related software and websites needed to be compatible across different digital platforms, operating systems and devices including smartphones and desktops, and assistive technologies (e.g., screen reading software) to accommodate the needs of ethnically and linguistically diverse groups 17 , 18 , 22 , individuals with limiting conditions (visual and hearing impairments) 20 , 21 , older adults (+65 years) 20 , 22 , those with low educational attainment and low socioeconomic status 17 , 18 . For example, Yeong et al. noted how older adults with visual impairments and of low socioeconomic status needed websites to be compatible with different magnification levels and assistive technologies (e.g., iOS Voiceover [Apple Inc]; a screen reading software) to aid visibility 21 . The authors also noted how certain features aided navigation and minimised scrolling to help the user find information, such as tables of contents, drop-down menus, and ‘jump to top’ buttons 21 . Older adults with limiting conditions (visual or hearing) also suggested that navigation features, such as search bars and hyperlinks, needed to be of high contrast (compared to the rest of the screen) to improve visibility 20 , 21 . Yeong et al. emphasised how search features should be designed in a similar way to commonly visited search engines, like Google, to improve usability and reduce confusion 21 .

Older adults, homeless, ethnically diverse individuals and those with visual impairments all described how digital messages on software, health related websites or text messages should be simple, concise, and presented in a logical manner without time restrictions 18 , 20 , 21 , 24 . For example, older adults with visual impairments described how they did not have enough time to read the information when presented on a timed loop (i.e., rotating between different screens with information), and suggested that the user be able to manually control the timing of this loop 21 . Older adults interviewed in another study described how it would be useful if they could change the font size to improve the visibility of the text, and provide alternative languages for those who are not fluent in English 22 . Personalising information, such as allowing users to choose content that they are interested in, was felt to be one way of increasing the motivation to use health related websites and software amongst those with visual impairments 21 and ethnically diverse individuals 18 . Additionally, providing evidence that supported the key messages in healthcare information, such as the importance of reducing alcohol intake to reduce the risk of developing chronic health conditions, enhanced trust amongst ethnically diverse individuals 18 . Kramer et al. also emphasised how any communication should be culturally appropriate and avoid reinforcing stereotypes, especially for ethnically and linguistically diverse users 18 . For example, the language used to categorise different ethnicities on DHTs should avoid generic terms such as ‘men of colour’ as some ethnically diverse men found this offensive; they felt it defined them based on their skin colour and not their ethnic background. Instead, specific terminology should be used that accurately represented their ethnicities (e.g., African American for individuals with an African and American descent) 18 . Any imagery should also be inclusive to all cultural groups 18 .

It was felt that the overall user friendliness and engagement of health related software could be improved with the addition of engaging features 15 , 18 , 20 , 22 , 24 . This included interactive quiz elements 20 , notifications encouraging behavioural changes 18 , reminders about upcoming appointments (particularly for homeless individuals as this they may not have access to other reminders, like letters) 24 , ability to order a repeat prescription and schedule specific appointments (e.g., physiotherapy) 22 . Older adults of Jewish faith also suggested simplifying security features, as many found flicking between a text message with the password reset information and the screen (where the information should be entered) challenging 22 .

Infrastructure

Five studies described the need for supportive infrastructure, such as access to devices and connectivity (i.e., Wi-Fi) to support homeless individuals, ethnically and linguistically diverse groups, and individuals of low socioeconomic status 15 , 17 , 19 , 23 , 24 . For example, Howell et al. explained how community nurses in the UK provided homeless individuals with temporary access to smartphones during the pandemic so as to enable them to access vital digital healthcare support 19 . In the United States (US), homeless individuals were provided with phones (the Obama phone), credit and data plans financed through a government programme 24 . However, Asgary et al. found that some of these homeless individuals using the Obama phone plan often exceeded their limits when put on hold to schedule medical appointments 24 . They subsequently turned to friends and family for financial support to purchase credit 24 . Other homeless individuals were hesitant to accept this government support, with the authors reflecting on how this may have been due to the homeless experiencing a lack of government financial aid in the past 24 .

Homeless individuals 19 , ethnically and linguistically diverse groups 15 , 17 , 23 , and those of low educational attainment and low socioeconomic status 15 , 17 , 19 reported relying heavily on free Wi-Fi to be able to access healthcare. This included accessing free Wi-Fi in public spaces and transport systems, fast-food restaurants, clinics and families’ houses. However, they often experienced barriers to this connectivity with time limits set by the specific organisations (e.g., opening hours) 15 or restrictions placed on using shared devices (e.g., computer keyboards due to the risk of coronavirus spreading) 19 . Many participants suggested creating dedicated centres for digital health services with suitable devices and free Wi-Fi that would also include some private areas 15 . Access to these private spaces was felt to be important for some ethnic and linguistically diverse groups with low educational attainment and socioeconomic status, as they were concerned about being overheard when discussing/looking at confidential health information 17 . Many groups suggested that they would like the choice between both digital and non-digital access to healthcare, as this would help mitigate the risk of possibly excluding those with poor digital literacy skills, those who would prefer in-person consultations, or those who lack the resources to access digital healthcare 15 , 18 , 19 , 23 .

To complement infrastructural changes, ethnically diverse adults based in the US advocated for more resources to be provided by local government 15 . This included the introduction of new policies, such as reduced payment plans and regulations on the price of DHTs for lower income earners to make them affordable 15 . Older adults of Jewish faith and ethnically diverse adults with a low educational attainment and socioeconomic status also suggested that financial incentives could help promote greater access to DHTs and encourage motivation to use DHTs 15 , 22 . Alkureishi et al. highlighted how different organisations, such as hardware and Wi-Fi companies, might need to collaborate to ensure that these different components (e.g., devices, connectivity, financial aid) are jointly available to support successful implementation 15 .

Educational support

Provision of educational support was important for ethnically diverse individuals and older adults to enable their use of DHTs in five studies 15 , 16 , 19 , 20 , 22 . Ethnically diverse individuals with lower educational attainment and low socioeconomic status, and older adults of Jewish faith commonly reported asking family members to remain close during video healthcare consultations in case of technical issues 15 , or for their guidance with accessing online health information 22 . Mizrachi et al. found this support promoted independence over time as older adults’ digital skills developed through learning and they were further motivated to use DHTs on hearing positive experiences from their family and friends 22 .

Some individuals relied on educational support from professional services to use DHTs 19 . It was felt that in-person educational support from community workers or health care professionals with supplementary materials (e.g., videos and written information) would be beneficial prior to attending virtual appointments to support ethnically diverse adults (both above and below 65 years) from a low socioeconomic status and low educational attainment 15 , 16 Alternatively, Alkureishi et al. noted some participants expressed preference for accessing training classes at healthcare sites (e.g., hospitals) and community centres, where support was provided by ‘technology champions and coaches’ 15 . However, older adults of Jewish faith highlighted how advertisements to promote awareness of support services would be unlikely to reach individuals in their community and those who were socially isolated and arguably most in need of support 22 . Some studies also highlighted how certain groups (e.g., ethnically diverse adults with low socioeconomic status and low educational attainment, and older adults of Jewish faith) might also be reluctant to accept this educational support due to concerns around burdening others, feeling helpless, and/or reaffirming how they are unable to do something independently 15 , 22 .

This systematic review synthesises strategies that promote digital inclusivity and assess the barriers and facilitators to adopting these in practice. Our findings highlighted three key themes relating to user-friendly designs, supportive infrastructure, and provision of educational support. Barriers to adopting these strategies included a lack of acceptance amongst some underserved groups to receive such support, whilst facilitators included promoting trust amongst ethnically diverse groups by providing lay term friendly evidence that supports health claims.

Our findings highlighted how health-related software and websites must be interoperable across different devices to accommodate the needs of underserved groups. This form of user-friendly design is advocated by national healthcare providers and government bodies; for example, the UK and US have legislation in place which mandates that websites and software in the public sector be ‘perceivable, operable, understandable and robust’ to ensure that those with visual and hearing impairments, low reading ability (reading age of 9) and/or those who are not fluent in English can access and understand the information provided 25 , 26 . However, a recent study reported that public health authority websites in only three countries (UK, Italy, China) out of a total of 24 actually adhered to these accessibility standards when checked 27 . Additionally, the wider literature supports our findings on how the use of appropriate language and imagery can improve end-user satisfaction 18 , 28 . National bodies, such as the US National Institute of Health (NIH), have developed the ‘National Culturally and Linguistically Appropriate Services (CLAS) Standards’ to assist developers and researchers in developing culturally and linguistically appropriate services 29 . The wider literature also suggests co-designing DHTs with underserved groups at the earliest stages to help ensure that they meet the needs of all end-users 30 . This involves co-designing security features that are easy-to-use and align with the UK government ‘ secure by design principles’ , to help overcome any potential future barriers to usage 31 , 32 .

Our results also highlighted the need for supportive infrastructure to facilitate access and use of DHTs. Government schemes in high-income countries are already available; for example, the ‘Obama phone’ in the USA and the Emergency Broadband Benefits and social tariffs (reduced payment phone plans) in the UK, to support those on a low income to access smartphones and phone plans 24 , 33 . However, implementing supportive infrastructure might not be viable for low to middle income countries as they may have less suitable centres to provide devices and free public Wi-Fi spots, which high income countries already have access to 34 . Some charity organisations, such as the Good Things Foundation, have started to repurpose donated corporate IT devices and deliver them to those who are digitally excluded 35 . However, better promotion of the support available and a collaborative working environment is needed, especially by healthcare professionals, social services, and charities. Free phone numbers would also help to facilitate access to healthcare services. Some underserved groups would like the option of accessing healthcare via non digital means, thus questioning the temptation to always use technology to potentially address healthcare challenges 36 . Researchers need to consider whether a new DHT will provide an equitable solution to the healthcare problem and whether other means of accessing healthcare should also be provided within healthcare systems 37 .

This systematic review also underlined the importance of providing educational support, from family or professional services, to encourage motivation and capability to use DHTs. There is a need for effective advertising of this support to groups at particular risk of both digital and social exclusion, such as older adults and homeless individuals, in order to increase their awareness 38 . A systematic review conducted by Ige et al. 39 suggested using a combination of two or more strategies to reach socially isolated individuals, including referrals from relevant agencies (e.g., GPs, pharmacists etc), as this might be a more effective approach than relying solely on public facing methods 39 .

Previous recommendations to promote digital health equity have centred around guidance for behavioural and social science researchers with limited insight to the facilitators and barriers to implementing strategies into society and appear limited to research settings 40 . Previous reviews have applied the socioeconomic model to inform recommendations to promote digital health equity, such as providing devices (individual level support), educational support (relationship/interpersonal level support), access to connectivity infrastructure (community level support) and implementing policies (societal level support) 41 , 42 . However, there has been little consideration given to those individuals who belong to two or more underserved groups at risk of digital exclusion. Our systematic review considered this intersectionality and provides practical recommendations that focus on two main areas: collaborative working and effective advertising (Fig. 3 ). Collaborative working between the DHT developer, healthcare professionals, policy-makers, voluntary sectors, patients and public members of underserved groups is vital to help improve the co-design of DHTs and provision of support and should be embedded from the very beginning of the design and development process 30 . Effective advertising strategies are also vital to raise public awareness and ensure that those who are, or know of an individual, at risk of digital exclusion are made aware of in-person support that is available and how to access it. DHT developers and researchers should also be aware of the accessibility and inclusivity standards (e.g., government legislation and CLAS) and on how to use them to support digital health equity.

Summary of the two key recommendations to advance digital health equity, centring around adopting a collaborative working environment and using effective advertisement.

This review used a comprehensive and systematic approach to identify relevant literature. Included studies were published within the last decade to remain relevant to the current digital healthcare landscape. We opted to focus on qualitative research to gather rich detailed information on the facilitators and barriers to each strategy. Despite no geographical restrictions being placed on this search, we found that all included studies were conducted in high-income countries, which may limit the applicability of these findings to low- and middle-income countries; this also highlights the importance of further work in this area. Representation of the different religious groups and languages was limited, highlighting a gap in the literature and a need for greater diverse inclusion in research. None of the included studies reported on participants’ health literacy, which has previously been suggested to overlap with low digital literacy 43 ; this information would have aided our understanding of whether the participants included in the qualitative studies were truly representative of the groups that they were intended to represent. Future research should incorporate a standardised health literacy measure, such as the Newest Vital Sign (NVS) 44 or the Health Literacy Questionnaire (HLQ) 45 , into their methodology to provide greater detail on the participants in their study.

The appropriateness of recommendations from this systematic review could be further explored using an established framework, such as the APEASE criteria (Affordability, Practicability, Effectiveness, Acceptability, Size effects/safety, and Equity) 46 . This would involve seeking the perspectives of CLEARS demographic groups’ and relevant stakeholders’ (e.g., policy makers and community workers) on the practicalities of implementing these different strategies and recommendations to further advance this important area of digital health equity. The facilitators and barriers to implementing government-issued public health website accessibility standards should also be explored to further understand how to encourage use of these standards.

This systematic review identified three key themes relating to digital inclusivity, associated facilitators and barriers, and recommendations for advancing digital health equity. This information will guide individuals when designing, developing and implementing digital health interventions to ensure it is done in a digitally inclusive manner. This review also highlighted the need for further work to explore the feasibility and acceptance of implementing different strategies and recommendations to support digital health equity amongst those at risk of digital exclusion.

Identification of key groups at risk of digital exclusion

We conducted a scoping review of the literature to identify the sociodemographic factors that could put an individual at risk of digital exclusion. Based on the findings published in peer-reviewed articles 24 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , systematic reviews 61 , 62 , 63 , 64 , government reports 8 , 65 , and regulatory organisation documents 66 , we identified a number of sociodemographic factors that we complied into six groups, relating to Culture (ethnicity, language, and religion) 8 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 62 , Limiting conditions (visual and hearing impairments) 6 , 54 , 66 , Education (at or below United Kingdom (UK) government mandated level or equivalent) 52 , 55 , 56 , 66 , Age (over 65 years) 51 , 54 , 55 , 56 , 62 , 66 , Residence (rural or deprived areas [based on consensus data within a country], or homeless) 8 , 24 , 51 , 60 , and Socioeconomic status (low income [earns less than 60% of the median household annual income within a country] and unemployed individuals) 8 , 52 , 55 , 56 , 62 , 65 , 66 abbreviated to CLEARS (Fig. 4 ). These factors often intersect (i.e. intersectionality), placing an individual at even greater risk of digital exclusion 8 , 64 , 65 , 66 .

A framework which encompasses sociodemographic factors associated with digital exclusion and recognises the role of intersectionality.

Search strategy

This systematic review was registered with PROSPERO (CRD42022378199) and followed PRISMA guidelines 67 . The search string utilised terms from two relevant scoping reviews 8 , 68 , with additional relevant terms included when searching four large online databases (Medline, Embase, PsycINFO and Scopus) (Supplementary Tables 1 – 4 ). The search focused on words associated with digital technology, health inequities, and CLEARS (Table 2 ).

Eligibility criteria

The eligibility criteria followed the Population, Intervention, Comparison, Outcomes and Study design (PICOS) framework, recommended by the Cochrane Handbook for Systematic Reviews 69 , and provided an organising framework to list the main concepts in the search. The Population criteria included any group represented by our CLEARS framework (see above). The Intervention criteria focused on inclusive digital health strategies, which we defined as an action designed to alleviate the digital exclusion of individuals by promoting access, motivation, and/or use of information and communication technologies 2 , 3 , 4 , 5 . Articles needed to have discussed the facilitators or barriers associated with the inclusive digital health strategy (outcome criteria) to be included. This allowed the researchers to reflect on what currently worked or did not work to inform key recommendations. Only qualitative studies that provided rich in-depth experiences from CLEARS groups were included to aid our understanding of how a complex phenomenon, i.e., intersectionality, can affect digital exclusion 11 , 12 . Quantitative studies were excluded as they are designed to test a hypothesis or enumerate events or phenomena 11 , 12 , which was not aligned with the aim of this review. Only peer-reviewed articles published between 2012 and 2022 in the English language were included; this ensured only the latest advancements in digital technologies were considered.

Study selection

Results from each database were exported into EndNote (version 20.5, Clarivate, International) and duplicates removed. Remaining articles were uploaded to Rayyan (Qatar Foundation, State of Qatar) 70 , where titles, abstracts, and full-texts were screened independently by two reviewers (SW, LL, EB) to minimise bias. The lead author (SW) screened all articles, acting as a constant throughout the process. Disagreements were resolved by a third reviewer (RMA). The reasons for excluding full text articles were recorded (Fig. 1 ).

Data extraction and synthesis

The lead author (SW) developed a data-extraction sheet with the research team to extract and record specific study details, including participant demographics and a description of the inclusive digital health strategy under investigation (Supplementary Tables 5 and 6 ). Any measure used to record participants’ health literacy in the included studies, such as the Newest Vital Sign (NVS) 44 or the Health Literacy Questionnaire (HLQ) 45 , was also extracted. A quality assessment was carried out on the included studies using the Critical Appraisal Skills Programme (CASP) Qualitative Review Checklist 71 . Quality was measured by reporting the frequency of ‘yes’ (denoting the study met the criteria on the checklist) (Supplementary Tables 7 and 8 ).

The lead author (SW) performed a narrative thematic synthesis of the included studies. Firstly, the authors began by developing a preliminary synthesis of findings from included studies to identify the key strategies and list the facilitators and barriers to implementation. We then considered the factors that might explain any commonalities and differences in the successful implementation of these digital inclusive strategies across included studies. This involved exploring the directly reported verbatim quotations obtained from particular CLEARS groups and seeking to draw descriptive and explanatory conclusions around key themes 72 , 73 . All data management and analysis was carried out within N-Vivo (version 1.6.1, QSR International). Discussions with co-authors (SPS, RM, CT) were conducted at several stages throughout the analysis to discuss, refine and define themes to ensure a coherent narrative that reflected the data. Detailed descriptions and contextual material from the included studies was kept throughout the analysis to ensure that the trustworthiness was upheld 74 , 75 . Ethics approval was not required for this systematic review.

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

All relevant data used for the study has been included in the manuscript and supplementary information.

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Acknowledgements

We would like to thank the social sciences librarian, Karen Crinnion, at Philip Robinson Library, Newcastle University, for her help and advice regarding the search strategy, choice of databases and search keywords for this systematic review. This work has been supported by the Early Detection of Neurodegenerative diseases (EDoN) research initiative, funded by Alzheimer’s Research UK with support from Gates Ventures and the Alzheimer’s Drug Discovery Foundation through its Diagnostic Accelerator Project. This project is also funded by the NIHR, (NIHR205190). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. Ríona Mc Ardle is funded by the National Institute for Health Research (NIHR) (NIHR 301677) and the NIHR Newcastle Biomedical Research Centre (BRC) based at The Newcastle upon Tyne Hospital National Health Service (NHS) Foundation Trust; Newcastle University; and the Cumbria, Northumberland and Tyne and Wear (CNTW) NHS Foundation Trust. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.

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Wilson, S., Tolley, C., Mc Ardle, R. et al. Recommendations to advance digital health equity: a systematic review of qualitative studies. npj Digit. Med. 7 , 173 (2024). https://doi.org/10.1038/s41746-024-01177-7

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• Open access
• Published: 02 July 2024

Developing a quality and safety assessment framework for Iran’s military hospitals

• Nader Markazi-Moghaddam 1 , 2 ,
• Mojgan Mohammadimehr 3 ,
• Mahdi Nikoomanesh 2 , 4 ,
• Ramin Rezapour 5 &
• Sanaz Zargar Balaye Jame 2  

BMC Health Services Research volume  24 , Article number:  775 ( 2024 ) Cite this article

Metrics details

The first crucial step towards military hospitals performance improvement is to develop a local and scientific tool to assess quality and safety based on the context and aims of military hospitals. This study introduces a Quality and Safety Assessment Framework (Q&SAF) for Iran’s military hospitals.

This is a literature review which continued with a qualitative study. The Q&SAF for Iran’s military hospitals was developed initially, through a review of the WHO’s framework for hospital performance, literature review (other related framework), review of military hospital-related local documents, consultations with a national and sub-national expert. Finally, the Delphi technique used to finalize the framework.

Based on the literature review results; 13 hospital Q&SAF were identified. After reviewing literature review results and expert opinions; Iran’s military hospitals Q&SAF was developed with 58 indictors in five dimensions including clinical effectiveness, safety, efficiency, patient-centeredness, and Responsive Management (Command and Control). The efficiency dimension had the highest number of indictors (19 indictors), whereas the patient-centered dimension had the lowest number of indices (4 indictors).

Regarding the comprehensiveness of the developed assessment framework due to its focus on the majority of quality dimensions and important components of the hospital’s performance, it can be used as a useful tool for assessing and continuously improving the quality of hospitals, particularly military hospitals.

Peer Review reports

Military healthcare structures, particularly military hospitals, play an important role in achieving the health system’s goals and responding to the population health needs by supporting and providing medical services to the armed forces in military operations as well as assisting the civilian healthcare system [ 1 ].

In the hospital, due to the importance of services and dealing with human lives, quality assurance and improvement have become increasingly crucial [ 2 ]. Quality is a broad and multifaceted concept including technical competence, access to services, effectiveness, interpersonal relationships, efficiency, continuity and safety [ 3 ]. Quality improvement has gained increased attention in recent decades as an approach to increase service effectiveness, particularly in developing countries, and significant efforts have been made to improve the quality of healthcare services [ 4 ]. Service quality assessment is the first step to quality improvement [ 5 ]. Quality Assessment Framework (QAF) (including quality dimensions and assessment indicators) is one of the standard quality assessment methods [ 6 ]. QAFs are developed in accordance with health system requirements, strategies, and objectives. Each country has proposed different dimensions and indicators for quality assessment [ 7 , 8 , 9 ]. The USA has proposed the dimensions of efficiency, access, health system infrastructure, patient-centeredness, effectiveness, safety, coordination, and timeliness to assess quality of health care [ 10 ]. The World Health Organization (WHO) Regional Office for Europe has introduced Performance Assessment Tools for Hospital (PATH) with six dimensions including clinical effectiveness, staff orientation, responsible governance, safety and patient-centered [ 11 ]. The variation in QAFs demonstrates the necessity of considering each health system needs, strategies, goals, and service delivery infrastructure when developing these frameworks [ 12 , 13 ].

To measure the quality and safety of hospitals and create the basis for analyzing the strengths and weaknesses regarding hospital performance, it is crucial to acquire a local and scientific tool based on the hospital conditions [ 9 ]. Military hospitals should be assessed based on their unique indicators due to their unique missions and services related to receipting special patients or dealing with biological, chemical, and nuclear disasters [ 14 ]. It is necessary to pay special attention to the organizational structure, manpower, type and amount of equipment in developing the performance assessment of military hospitals [ 15 , 16 ].

To the best of our knowledge, there is currently no local and national framework for assessing the Iran’s military hospitals, while majority of countries in the world use a specific national framework to assess the performance and quality of hospital. This research seeks to develop a comprehensive and scientific framework for measuring multiple dimensions of quality using worldwide experiences. Hospital managers can acquire a comprehensive insight of current performance with the assistance of the data provided by this framework. This study was conducted to develop a Quality and Safety Assessment Framework (Q&SAF) for Iran’s military hospitals through an adjusted framework from WHO.

This is a qualitative study which was conducted in 2023. In order to develop a Q&SAF for Iran’s military hospitals, first, the quality dimensions and indicators as well as the frameworks and models in the scientific literature were identified (Literature review). Then, the expert panels held meetings to adapt the models and frameworks to the local conditions of the country and military hospitals as well as to introduce new indicators in accordance with the potentials and capacities of military hospitals (Expert panel). The results of the expert panel meetings led to the preparation of the initial list of quality and safety assessment dimensions and indicators. After preparing the initial list of indicators, in order to select the final indicators and reach a consensus regarding the final indicators, a qualitative survey was used (Modified Delphi survey). In the next step, the indicators selected based on the expert’s opinion were categorized quality dimensions, and the initial Q&SAF for Iran’s military hospitals was developed (Expert panel). In the last step; content validity index and Modified Kappa were used to finalize and validate the developed framework (Modified Delphi survey). The steps of developing the framework are indicated in Fig.  1 .

Step 1: Identifying frameworks, models, dimensions and indicators of quality and safety assessment in the hospital

Irans military hospitals quality and safety assessment framework development flow

The methodology of overview was used in order to identify the models and frameworks for assessing the quality and safety in the hospital, as well as the indicators associated with each framework. Databases of PubMed, Scopus, web of science, and websites related to the WHO using related keywords and their Persian equivalents in Persian databases in the period from 2000 to 2023 were reviewed. The keywords included quality indicator, quality assessment, quality evaluation, quality assurance, performance indicator, standard, quality improvement, Hospital, health center, health facility, inpatient car, model, framework, project, plan. Additionally, a manual search of specialized journals and references of selected articles, organizational reports and other available information sources was done.

The studies that were developed for the hospital environment and also provided a comprehensive framework for assessing quality and safety (considering all aspects of quality and safety and not focusing on a specific dimension or service) were selected for review. Due to the variety of studies, papers written in languages other than Persian and English, studies conducted in settings outside of hospitals, and studies which focused on the quality of specific service or procedure were excluded from the review. Review and screening of studies was done according to Prisma guideline [ 17 ] and using Endnote software. In this step, the functional dimensions, the list of indicators and the scope of the identified frameworks were extracted.

Step 2: Preparation of the initial list of quality and safety dimensions and indicators

In this step, the frameworks and models extracted from the literature were reviewed according to the capacities and potentials of military hospitals as well as the condition of Iran’s health system. A qualitative study (expert panel) was used for this objective. Following an initial meeting with experts, the dimensions of the Q&SAF for Iran’s military hospitals were selected. These dimensions were those that were most frequent among the identified frameworks and were most consistent with the conditions of Iranian hospitals. Next, the assessment indicators related to each of the dimension were reviewed. The primary criteria for selecting indicators included: the ability to measure the indicator in the hospital, the importance of the indicator, and the relevance of the indicator to the operational processes of the military hospitals.

Members of the expert panel included individuals with an experience in hospital performance assessment and the quality and safety improvement, as well as other individuals and academic members with related knowledge. These members were selected through the heterogeneous purposeful sampling technique (participants with maximum diversity).

Reviewing dimensions and indicators was done during two face-to-face meetings (Skype platform) for about 1.5 h. During these meetings, in addition to reviewing and selecting the dimensions and indicators extracted from the literature, new indicators suitable to the conditions of military hospitals were also introduced by the experts. In this way, a list of quality and safety assessment indicators was prepared.

Step 3: Final selection of quality and safety indicators

After preparing the initial list of indicators based on the results of the previous steps, a modified Delphi survey [ 18 , 19 ] was used to reach a consensus about the indicators.

A purposeful sampling technique (according to the type of dimensions and indicators) was used to select participants of survey. The inclusion criteria for the participants included officials and managers of military hospitals and vice chancellor of treatment with at least 5 years of experience, policy makers of the Ministry of Health, and academic members in the fields of health and services management and health economics, health emergencies disaster and health information management.

The selection criteria of the indicators according to the criteria introduced by the WHO [ 20 ] included: the importance, feasibility and relevance of the indicator. Each of indicator scored between 1 and 5 based on the three criteria. The indicators were selected using the following parameters: indications with an average of less than 2 were disqualified, those with scores between 2 and 3.5 were returned to the second round of Delphi, and those with a score of 3.5 or more were accepted as the final indicators.

Step 4: Development of an initial Q&SAF for Military Hospitals

The initial framework was developed by the research team and experts based on the findings of the literature review and the qualitative part of the study. To develop the initial framework; the selected final indicators were classified in the selected dimensions in the second step. Also, in this step, for each dimension, related sub-dimensions were defined. The selection process for member of expert panel was similar to the second step.

Step 5: Validation of Q&SAF for military hospitals

The validity of the developed framework was assessed based on the opinions of experts. Accordingly, the initial framework with a detailed description of dimension and indicators sent to 10 experts throughout the Delphi questionnaire. To assess the validity of the framework, 10 items were evaluated. These items included (1) Applicability of the framework (2) Adaptation of the developed framework to the upstream documents (3) Ability to accept the framework by stakeholders (4) Efficiency (5) Flexibility (6) Effectiveness (7) Simplicity (8) Coherence and integration between framework dimensions (9) Comprehensiveness and (10) Overall.

In order to confirm the validity of the framework, modified content validity index and modified Kappa were used. This method was presented by Polit et al. in 2007 [ 21 ]. The following formulas were used to calculate Kappa.

N = Number of Experts.

A = the number of experts with score of a completely agree and agree.

Experts scored each of the items based on a 4-point Likert scale (completely agree to completely disagree). According to Polit et al.‘s proposal, Kappa lower than 0.40 be considered (necessary), between 0.6 and 0.74 (good) and above0.74 (Excellent).

The Q&SAF for Iran’s military hospitals was developed in five main steps. During the first step, 13 frameworks, 10 dimensions, and 1591 indicators related to each framework were extracted. In the next step, 5 dimensions and 60 indicators were selected based on the findings of the literature review and the recommendations of experts. Based on the results of the Delphi survey, 2 indicators were removed from the 60 indicators and finally 58 indicators were selected. The selected indicators were categorized in the five dimensions (Fig.  2 ). In the last step, ten experts were asked to assess validity of the framework, and after receiving their feedback, the estimated Kappa index for the framework was 8.9 out of 10.

The results of the development steps of Irans Military Hospitals Quality and Safety Assessment Framework

Step 1: Identifying frameworks, models, dimensions and indicators of quality and safety assessment in the hospitals

After screening the studies and reports extracted from the literature, finally; 13 frameworks along with 10 dimensions and 1591 indicators were identified. The dimensions were compared in order to determine their frequency (Table  1 ). The identified indicators were initially screened and after removing duplicate and unrelated indicators and merging similar ones, finally 137 indicators were selected.

Experts’ meetings with the participation of 9 experts (3 experts from the army hospital assessment and monitoring department, 6 academic faculty members (2 health management specialist with a focus on service quality assessment, 2 health information management specialist and 2 health emergencies disaster specialist) were held. In addition to the results of the literature review, the list of performance assessment indicators of military hospitals and other related documents about Iranian hospital performance assessment, were also reviewed by an experts’ panel. Based on the results of expert panel meetings, 5 dimensions including clinical effectiveness, safety, efficiency, patient-centeredness and Responsive Management (Command and Control) along with 60 quality and safety assessment indicators (14 indicators by experts and 46 indicators from literature) according to conditions and potential of Iran’s military hospitals were selected. Among the dimensions, the Responsive Management (Command and Control) dimension specifically focuses on the processes and performance of military hospitals.

The initial list of indicators was reviewed by experts through the modified Delphi survey. The participants in the Delphi survey included 2 experts from the regional office of the WHO, 2 faculty members of the Army University of Medical Sciences, 4 faculty members of medical sciences universities across the country, and 2 hospital managers. Based on the results of the Delphi survey; finally, 58 indicators (out of 60 indicators) scored higher than 3.5 and were selected as final indicators (Table  2 ).

Step 4: Development of an initial Q&SAF for military hospitals

Expert panel meetings were held to review the final indicators and classify them among the dimensions. Also, in these meetings, sub-dimensions were defined for each dimension. Finally; The Q&SAF for military hospitals was developed with 5 dimensions and 15 sub-dimensions (Table  3 ). Among the dimensions, the most indicators were related to the efficiency dimension (19 indicators) and the lowest indicators were related to the patient-centered dimension (4 indicators).

Also, among the following sub-dimensions; the most indicators are related to the sub-dimension of financial performance (9 indicators) and the lowest indicators are related to the information security and management (1 indicator), environmental safety management (1 indicator) and combat medicine and military health management (1 indicator).

Validation of Q&SAF for military hospitals

The developed framework was sent to 10 experts (similar to the step 3) in order to validate it. Due to the obtained score above 0.74 in all 12 criteria of the questionnaire, the Delphi survey was completed in the first round and the Q&SAF for Military Hospitals was finalized (Table  4 ).

The Q&SAF for Iran’s military hospitals was developed through the utilization of a mixed-method approach and parallel use of review methods, quantitative, and qualitative methods. This framework has 58 quality and safety assessment indicators categorized under 15 sub-dimensions and 5 main dimensions, including clinical effectiveness, safety, efficiency, patient-centeredness, and Responsive Management (Command and Control).

Utilization of the indicators and dimensions identified from the literature and using the experiences of national and sub-national experts in developing the framework strengthened the study. Developing performance assessment frameworks using the qualitative studies approach and the Delphi technique and expert panel is a common and scientific way that has been used in many studies at different levels of the health system. Bruno et al. (2015) regarding the providing of guideline-based quality indicators for primary care in England, Veena et al. (2005) in the development of coronary artery bypass surgery quality indicators and also, Tabrizi et al. (2013) to develop performance indicators for patient and community engagement and to improve educational management in hospitals, have used the Delphi method and expert panel [ 36 , 37 , 38 , 39 ].

According to a review of several assessment frameworks that provided for hospital quality and safety, the primary challenges were related to the incompleteness of some frameworks and inability of some other to coverage all of hospital functional areas [ 40 ]. The Q&SAF for Iran’s military hospitals is sufficiently thorough and covers all functions, from clinical to administrative and financial. This important issue has been considered in the WHO-PATH framework and the American Medicare Hospital Comparison Program.

In accordance with most previous frameworks, the majority of the indicators utilized to assess the Iran’s military hospitals quality and safety were at the level of outcome assessment. The experts also believed that the results of the hospital’s performance should be quality-oriented and the framework should assess the results of the activities.

Based on the finding of literature review and comparative review of Q&SAF; The most focus on quality in hospital was the clinical effectiveness dimension, which is assessed in all of current frameworks [ 41 ]. This reflects the current trend toward adhering to clinical and evidence-based medical guidelines and highlights the significance of initiatives and methods for assessing the cost effectiveness of services [ 42 ]. Accordingly, clinical effectiveness has been considered in the Iran’s military hospitals Q&SAF, and 11 indicators have been assigned to it.

As frontline defenders, health workers are at high risk of infection during the COVID-19 pandemic [ 43 , 44 , 45 ]. The safety of health workers and patients is a unique advantage in the quality of healthcare and an important priority in healthcare systems [ 32 , 41 , 46 ]. The 13th general work plan of the WHO and the strategic vision of EMRO all prioritize the safety of health workers, and the WHO has considered September 17 as the World Patient Safety Day since 2019 [ 47 , 48 ]. According to the reviewed frameworks (ACHS and QIP) which pay special attention to the safety dimension, in the Iran’s military hospitals Q&SAF, the patient and health worker safety were emphasized and 14 indicators have been assigned to safety dimension. Hospital efficiency is a lever to improve the development of a health care system. It is important for a hospital to maintain the level of quality in healthcare services while achieving efficient services at the lowest cost [ 49 ]. Military hospitals are financed annually through the Global budget [ 50 ]. The government’s budget deficit and financial challenges have increased pressure on Iran’s military hospitals to reduced costs [ 50 ]. Efficiency must be accurately monitored in order to identify improvements in healthcare productivity [ 51 ]. In order to improve the efficiency of military hospitals and in accordance with 9 frameworks extracted from the literature (out of 13 frameworks); efficiency dimension by the largest number of indicators was considered.

The mission of military hospitals is to enhance the health of military personnel by providing health support to a wide range of covered military personnel [ 50 ]. Military hospitals are tasked with caring for injured soldiers as well as offering routine medical care to active-duty military members, their families, and retirees [ 50 ]. Due to increasing the health literacy of patients and changing the needs of the population; the responsiveness of hospitals has faced fundamental changes. Therefore, the hospital’s response should be patient-centered and should consider the patient’s priorities, needs, values, and clinical decisions in providing health services [ 52 ]. Based on this and in accordance with the WHO suggestion regarding the centrality role of patients in the hospital and involving them in providing service processes; one of the important dimensions of the Iran’s military hospitals Q&SAF was assigned to the patient-centered dimension.

In addition to the many similarities that military hospitals have with civilian hospitals in providing health services to the community; in some functional aspects; due to the specific population coverage and specific missions, they have few differences with civilian hospitals [ 53 ]. Therefore, in the developed framework, it was necessary to define a specific dimension for military hospitals in accordance with its specific missions. Accordingly, the Responsive Management (Command and Control) dimension with the sub-dimensions of staff management, accidents and disasters management, management and security of data and information, environmental safety management and management of combat medicine and military health were considered. The assessment of these sub-dimensions will be done based on the specific guidelines that were used for military hospitals assessment. Using global experiences to assess the quality of hospitals and combining it with the specific missions of military hospitals can improve the performance of these hospitals similar to civilian hospitals.

The developed assessment framework and associated quality and safety improvement indicators can be tailored for use in civilian hospitals to enhance patient care. The applicability and adaptability of this framework in civilian hospitals can be greatly improved by considering key influencing factors, such as customizing the indicators to fit the local context to ensure their relevance and applicability, integrating them with existing information systems and reporting mechanisms, and conducting pilot tests to gather feedback and make necessary adjustments [ 54 , 55 ].

The participation of patients and community could increase the comprehensiveness and effectiveness of the framework. One of the study’s limitations is the absence of patient engagement in the framework development process. In order to reduce the impact of this limitation, indicators related to the patient-centered dimension were included.

The Iran’s military hospitals Q&SAF; as a comprehensive tool, provides a suitable opportunity for policy makers and managers to assess the hospitals quality and safety and formulate effective strategies to improve the hospital performance. It is suggested that this framework and its suggested indicators be used for the quantitative and qualitative assessment of Iran’s military hospitals, including the financial resources required to provide health services, human resource management, quality of care, patient and health worker safety, and other functional aspects. Also, this framework can be considered as a reference in assessing and comparing the performance of military hospitals.

Data availability

Data will be made available on request.

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Nader Markazi-Moghaddam

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Nader Markazi-Moghaddam, Mahdi Nikoomanesh & Sanaz Zargar Balaye Jame

Infectious Diseases Research Center, Aja University of Medical Sciences, Tehran, Iran

Mojgan Mohammadimehr

Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran

Mahdi Nikoomanesh

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Nader Markazi-Moghaddam: Wrote the paper; Analyzed and interpreted the data, materials.Mojgan Mohammadimehr: Supervised the study methodologyMahdi Nikoomanesh: Interpreted the dataRamin Rezapour: Wrote the paper; collected and analyzed the dataSanaz Zargar Balaye Jame: Supervised the study methodology and drafted the initial manuscript.

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Markazi-Moghaddam, N., Mohammadimehr, M., Nikoomanesh, M. et al. Developing a quality and safety assessment framework for Iran’s military hospitals. BMC Health Serv Res 24 , 775 (2024). https://doi.org/10.1186/s12913-024-11248-w

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DOI : https://doi.org/10.1186/s12913-024-11248-w

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Autonomous self-healing agents in cementitious materials: parameters and impacts on mortar properties.

1. Introduction

2. systematic literature review, bibliometric analysis, 3. results and discussion, 3.1. parameters for the preparation and composition of self-healing material mixtures, 3.2. parameters adopted in the encapsulation of healing agents, 3.3. parameters adopted for crack control and curing environment, 3.4. the influence of pellets/granules/capsules on the properties of mortar, 3.5. the influence of healing agents on the self-healing properties of mortars, 4. conclusions and research gaps.

• The predominant encapsulation method used for healing agents was the simultaneous use of granules and pellets in equipment designated as granulators and pelletizers, respectively. Additionally, the predominant surface coating mainly consists of a PVA film. However, cementitious materials incorporating pellets with a PVA film coating significantly reduced spreading and compressive strength properties.
• Adverse behavior was observed in these properties for capsules coated with Portland cement and sprayed with a water and sodium silicate solution. This indicates a trend towards their use, as it reduces the negative effect of pellet/capsule incorporation on mortar properties. Additionally, this type of coating, regarding the use of expansive agents through pellets/capsules as the core, may provide benefits in crack sealing and increase the incorporation content in cementitious materials to promote self-healing.
• It was observed in this systematic review that the preferred pre-crack test method is the three-point flexural test. Steel wires are used to prevent the complete rupture of the prismatic sample, and a small notch (1.5 mm) at the bottom center of the sample is made to induce a crack at a specific point. The CMOD device is the central apparatus for crack control to observe crack opening.
• Regarding the parameters for evaluating self-healing, it was observed that for pellets, granules, or capsules composed of expansive agents, the pre-crack test is generally conducted at 7 days, and the curing time and duration of the crack sealing monitoring process are both approximately 28 days. Additionally, the environment for conducting the autonomous healing of cement-based materials was water.

Supplementary Materials

Author contributions, data availability statement, acknowledgments, conflicts of interest.

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Lima, G.T.d.S.; Silvestro, L.; Tambara Júnior, L.U.D.; Cheriaf, M.; Rocha, J.C. Autonomous Self-Healing Agents in Cementitious Materials: Parameters and Impacts on Mortar Properties. Buildings 2024 , 14 , 2000. https://doi.org/10.3390/buildings14072000

Lima GTdS, Silvestro L, Tambara Júnior LUD, Cheriaf M, Rocha JC. Autonomous Self-Healing Agents in Cementitious Materials: Parameters and Impacts on Mortar Properties. Buildings . 2024; 14(7):2000. https://doi.org/10.3390/buildings14072000

Lima, Geannina Terezinha dos Santos, Laura Silvestro, Luís Urbano Durlo Tambara Júnior, Malik Cheriaf, and Janaíde Cavalcante Rocha. 2024. "Autonomous Self-Healing Agents in Cementitious Materials: Parameters and Impacts on Mortar Properties" Buildings 14, no. 7: 2000. https://doi.org/10.3390/buildings14072000

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