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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

  • Quick Run-through
  • Step 1 & 2

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

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

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

Literature review guide

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

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

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

Download Word doc Download Google doc

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

For each publication, ask yourself:

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

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

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

Take notes and cite your sources

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

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

As you write, you can follow these tips:

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

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

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

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

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

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

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

 Statistics

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

Research bias

  • Optimism bias
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  • 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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  • 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 Basics

  • What is a Literature Review?
  • Synthesizing Research
  • Using Research & Synthesis Tables
  • Additional Resources

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About the Research and Synthesis Tables

Research Tables and Synthesis Tables are useful tools for organizing and analyzing your research as you assemble your literature review. They represent two different parts of the review process: assembling relevant information and synthesizing it. Use a Research table to compile the main info you need about the items you find in your research -- it's a great thing to have on hand as you take notes on what you read! Then, once you've assembled your research, use the Synthesis table to start charting the similarities/differences and major themes among your collected items.

We've included an Excel file with templates for you to use below; the examples pictured on this page are snapshots from that file.

  • Research and Synthesis Table Templates This Excel workbook includes simple templates for creating research tables and synthesis tables. Feel free to download and use!

Using the Research Table

Image of Model Research Excel Table

This is an example of a  research table,  in which you provide a basic description of the most important features of the studies, articles, and other items you discover in your research. The table identifies each item according to its author/date of publication, its purpose or thesis, what type of work it is (systematic review, clinical trial, etc.), the level of evidence it represents (which tells you a lot about its impact on the field of study), and its major findings. Your job, when you assemble this information, is to develop a snapshot of what the research shows about the topic of your research question and assess its value (both for the purpose of your work and for general knowledge in the field).

Think of your work on the research table as the foundational step for your analysis of the literature, in which you assemble the information you'll be analyzing and lay the groundwork for thinking about what it means and how it can be used.

Using the Synthesis Table

Image of Model Synthesis Excel Table

This is an example of a  synthesis table  or  synthesis matrix , in which you organize and analyze your research by listing each source and indicating whether a given finding or result occurred in a particular study or article ( each row lists an individual source, and each finding has its own column, in which X = yes, blank = no). You can also add or alter the columns to look for shared study populations, sort by level of evidence or source type, etc. The key here is to use the table to provide a simple representation of what the research has found (or not found, as the case may be). Think of a synthesis table as a tool for making comparisons, identifying trends, and locating gaps in the literature.

How do I know which findings to use, or how many to include?  Your research question tells you which findings are of interest in your research, so work from your research question to decide what needs to go in each Finding header, and how many findings are necessary. The number is up to you; again, you can alter this table by adding or deleting columns to match what you're actually looking for in your analysis. You should also, of course, be guided by what's actually present in the material your research turns up!

  • << Previous: Synthesizing Research
  • Next: Additional Resources >>
  • Last Updated: Sep 26, 2023 12:06 PM
  • URL: https://usi.libguides.com/literature-review-basics

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Nursing Literature and Other Types of Reviews

  • Literature and Other Types of Reviews
  • Starting Your Search
  • Constructing Your Search
  • Selecting Databases and Saving Your Search
  • Levels of Evidence
  • Creating a PRISMA Table
  • Literature Table and Synthesis
  • Other Resources

About Literature Tables and Writing a Synthesis

A literature table is a way to organize the articles you've selected for inclusion in your publication. There are many different types of literature tables-the main thing is to determine the important pieces that help draw out the comparisons and contrasts between the articles included in your review. The first few columns should include the basic info about the article (title, authors, journal), publication year, and the purpose of the paper.

While the table is a step to help you organize the articles you've selected for your research, the literature synthesis can take many forms and can have multiple parts. This largely depends on what type of review you've undertaken. Look back at the examples under Literature and Other Types of Reviews to see examples of different types of reviews.

  • Example of Literature Table

Examples of Literature Tables

example lit review table

Camak, D.J. (2015), Addressing the burden of stroke caregivers: a literature review. J Clin Nurs, 24: 2376-2382. doi: 10.1111/jocn.12884

example lit review table

Balcombe, L., Miller, C., & McGuiness, W. (2017). Approaches to the application and removal of compression therapy: A literature review. British Journal of Community Nursing , 22 , S6–S14. https://doi-org.proxy1.cl.msu.edu/10.12968/bjcn.2017.22.Sup10.S6

  • << Previous: Creating a PRISMA Table
  • Next: Other Resources >>
  • Last Updated: Sep 5, 2023 3:14 PM
  • URL: https://libguides.lib.msu.edu/nursinglitreview

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

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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

  • Quick Run-through
  • Step 1 & 2

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

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

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

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

Literature review guide

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

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

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

Download Word doc Download Google doc

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

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

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

For each publication, ask yourself:

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

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

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

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

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

Take notes and cite your sources

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

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

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

Prevent plagiarism, run a free check.

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

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

As you write, make sure to follow these tips:

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

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

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

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

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

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

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

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

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

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Literature reviews take time. here is some general information to know before you start.  .

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Steps to Completing a Literature Review

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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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Literature Review: Conducting & Writing

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Sample Lit Reviews from Communication Arts

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Common assignments: literature reviews, basics of literature reviews.

A literature review is a written approach to examining published information on a particular topic or field. Authors use this review of literature to create a foundation and justification for their research or to demonstrate knowledge on the current state of a field. This review can take the form of a course assignment or a section of a longer capstone project. Read on for more information about writing a strong literature review!

Students often misinterpret the term "literature review" to mean merely a collection of source summaries, similar to annotations or article abstracts. Although summarizing is an element of a literature review, the purpose is to create a comprehensive representation of your understanding of a topic or area of research, such as what has already been done or what has been found. Then, also using these sources, you can demonstrate the need for future research, specifically, your future research.

There is usually no required format or template for a literature review. However, there are some actions to keep in mind when constructing a literature review:

  • Include an introduction and conclusion . Even if the literature review will be part of a longer document, introductory and concluding paragraphs can act as bookends to your material. Provide background information for your reader, such as including references to the pioneers in the field in the beginning and offering closure in the end by discussing the implications of future research to the field.
  • Avoid direct quotations . Just like in an annotated bibliography, you will want to paraphrase all of the material you present in a literature review. This assignment is a chance for you to demonstrate your knowledge on a topic, and putting ideas into your own words will ensure that you are interpreting the found material for your reader. Paraphrasing will also ensure your review of literature is in your authorial voice.
  • Organize by topic or theme rather than by author. When compiling multiple sources, a tendency can be to summarize each source and then compare and contrast the sources at the end. Instead, organize your source information by your identified themes and patterns. This organization helps demonstrate your synthesis of the material and inhibits you from creating a series of book reports.
  •  Use headings . APA encourages the use of headings within longer pieces of text to display a shift in topic and create a visual break for the reader. Headings in a literature review can also help you as the writer organize your material by theme and note any layers, or subtopics, within the field.
  • Show relationships and consider the flow of ideas. A literature review can be lengthy and dense, so you will want to make your text appealing to your reader. Transitions and comparison terms will allow you to demonstrate where authors agree or disagree on a topic and highlight your interpretation of the literature.

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How to Conduct a Literature Review (Health Sciences and Beyond)

  • What is a Literature Review?
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Review Matrix

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Using a spreadsheet or table to organize the key elements (e.g. subjects, methodologies, results) of articles/books you plan to use in your literature review can be helpful. This is called a review matrix.

When you create a review matrix, the first few columns should include (1) the authors, title, journal, (2) publication year, and (3) purpose of the paper. The remaining columns should identify important aspects of each study such as methodology and findings.

Click on the image below to view a sample review matrix.

Sample health sciences review matrix

You can also download this template as a Microsoft Excel file .

The information on this page is from the book below. The 5th edition is available online through VCU Libraries.

example lit review table

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15 Literature Review Examples

literature review examples, types, and definition, explained below

Literature reviews are a necessary step in a research process and often required when writing your research proposal . They involve gathering, analyzing, and evaluating existing knowledge about a topic in order to find gaps in the literature where future studies will be needed.

Ideally, once you have completed your literature review, you will be able to identify how your research project can build upon and extend existing knowledge in your area of study.

Generally, for my undergraduate research students, I recommend a narrative review, where themes can be generated in order for the students to develop sufficient understanding of the topic so they can build upon the themes using unique methods or novel research questions.

If you’re in the process of writing a literature review, I have developed a literature review template for you to use – it’s a huge time-saver and walks you through how to write a literature review step-by-step:

Get your time-saving templates here to write your own literature review.

Literature Review Examples

For the following types of literature review, I present an explanation and overview of the type, followed by links to some real-life literature reviews on the topics.

1. Narrative Review Examples

Also known as a traditional literature review, the narrative review provides a broad overview of the studies done on a particular topic.

It often includes both qualitative and quantitative studies and may cover a wide range of years.

The narrative review’s purpose is to identify commonalities, gaps, and contradictions in the literature .

I recommend to my students that they should gather their studies together, take notes on each study, then try to group them by themes that form the basis for the review (see my step-by-step instructions at the end of the article).

Example Study

Title: Communication in healthcare: a narrative review of the literature and practical recommendations

Citation: Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., Mortier, E., … & Vogelaers, D. (2015). Communication in healthcare: a narrative review of the literature and practical recommendations. International journal of clinical practice , 69 (11), 1257-1267.

Source: https://onlinelibrary.wiley.com/doi/pdf/10.1111/ijcp.12686  

Overview: This narrative review analyzed themes emerging from 69 articles about communication in healthcare contexts. Five key themes were found in the literature: poor communication can lead to various negative outcomes, discontinuity of care, compromise of patient safety, patient dissatisfaction, and inefficient use of resources. After presenting the key themes, the authors recommend that practitioners need to approach healthcare communication in a more structured way, such as by ensuring there is a clear understanding of who is in charge of ensuring effective communication in clinical settings.

Other Examples

  • Burnout in United States Healthcare Professionals: A Narrative Review (Reith, 2018) – read here
  • Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review (Zestcott, Blair & Stone, 2016) – read here
  • A Narrative Review of School-Based Physical Activity for Enhancing Cognition and Learning (Mavilidi et al., 2018) – read here
  • A narrative review on burnout experienced by medical students and residents (Dyrbye & Shanafelt, 2015) – read here

2. Systematic Review Examples

This type of literature review is more structured and rigorous than a narrative review. It involves a detailed and comprehensive plan and search strategy derived from a set of specified research questions.

The key way you’d know a systematic review compared to a narrative review is in the methodology: the systematic review will likely have a very clear criteria for how the studies were collected, and clear explanations of exclusion/inclusion criteria. 

The goal is to gather the maximum amount of valid literature on the topic, filter out invalid or low-quality reviews, and minimize bias. Ideally, this will provide more reliable findings, leading to higher-quality conclusions and recommendations for further research.

You may note from the examples below that the ‘method’ sections in systematic reviews tend to be much more explicit, often noting rigid inclusion/exclusion criteria and exact keywords used in searches.

Title: The importance of food naturalness for consumers: Results of a systematic review  

Citation: Roman, S., Sánchez-Siles, L. M., & Siegrist, M. (2017). The importance of food naturalness for consumers: Results of a systematic review. Trends in food science & technology , 67 , 44-57.

Source: https://www.sciencedirect.com/science/article/pii/S092422441730122X  

Overview: This systematic review included 72 studies of food naturalness to explore trends in the literature about its importance for consumers. Keywords used in the data search included: food, naturalness, natural content, and natural ingredients. Studies were included if they examined consumers’ preference for food naturalness and contained empirical data. The authors found that the literature lacks clarity about how naturalness is defined and measured, but also found that food consumption is significantly influenced by perceived naturalness of goods.

  • A systematic review of research on online teaching and learning from 2009 to 2018 (Martin, Sun & Westine, 2020) – read here
  • Where Is Current Research on Blockchain Technology? (Yli-Huumo et al., 2016) – read here
  • Universities—industry collaboration: A systematic review (Ankrah & Al-Tabbaa, 2015) – read here
  • Internet of Things Applications: A Systematic Review (Asghari, Rahmani & Javadi, 2019) – read here

3. Meta-analysis

This is a type of systematic review that uses statistical methods to combine and summarize the results of several studies.

Due to its robust methodology, a meta-analysis is often considered the ‘gold standard’ of secondary research , as it provides a more precise estimate of a treatment effect than any individual study contributing to the pooled analysis.

Furthermore, by aggregating data from a range of studies, a meta-analysis can identify patterns, disagreements, or other interesting relationships that may have been hidden in individual studies.

This helps to enhance the generalizability of findings, making the conclusions drawn from a meta-analysis particularly powerful and informative for policy and practice.

Title: Cholesterol and Alzheimer’s Disease Risk: A Meta-Meta-Analysis

Citation: Sáiz-Vazquez, O., Puente-Martínez, A., Ubillos-Landa, S., Pacheco-Bonrostro, J., & Santabárbara, J. (2020). Cholesterol and Alzheimer’s disease risk: a meta-meta-analysis. Brain sciences, 10(6), 386.

Source: https://doi.org/10.3390/brainsci10060386  

O verview: This study examines the relationship between cholesterol and Alzheimer’s disease (AD). Researchers conducted a systematic search of meta-analyses and reviewed several databases, collecting 100 primary studies and five meta-analyses to analyze the connection between cholesterol and Alzheimer’s disease. They find that the literature compellingly demonstrates that low-density lipoprotein cholesterol (LDL-C) levels significantly influence the development of Alzheimer’s disease.

  • The power of feedback revisited: A meta-analysis of educational feedback research (Wisniewski, Zierer & Hattie, 2020) – read here
  • How Much Does Education Improve Intelligence? A Meta-Analysis (Ritchie & Tucker-Drob, 2018) – read here
  • A meta-analysis of factors related to recycling (Geiger et al., 2019) – read here
  • Stress management interventions for police officers and recruits (Patterson, Chung & Swan, 2014) – read here

Other Types of Reviews

  • Scoping Review: This type of review is used to map the key concepts underpinning a research area and the main sources and types of evidence available. It can be undertaken as stand-alone projects in their own right, or as a precursor to a systematic review.
  • Rapid Review: This type of review accelerates the systematic review process in order to produce information in a timely manner. This is achieved by simplifying or omitting stages of the systematic review process.
  • Integrative Review: This review method is more inclusive than others, allowing for the simultaneous inclusion of experimental and non-experimental research. The goal is to more comprehensively understand a particular phenomenon.
  • Critical Review: This is similar to a narrative review but requires a robust understanding of both the subject and the existing literature. In a critical review, the reviewer not only summarizes the existing literature, but also evaluates its strengths and weaknesses. This is common in the social sciences and humanities .
  • State-of-the-Art Review: This considers the current level of advancement in a field or topic and makes recommendations for future research directions. This type of review is common in technological and scientific fields but can be applied to any discipline.

How to Write a Narrative Review (Tips for Undergrad Students)

Most undergraduate students conducting a capstone research project will be writing narrative reviews. Below is a five-step process for conducting a simple review of the literature for your project.

  • Search for Relevant Literature: Use scholarly databases related to your field of study, provided by your university library, along with appropriate search terms to identify key scholarly articles that have been published on your topic.
  • Evaluate and Select Sources: Filter the source list by selecting studies that are directly relevant and of sufficient quality, considering factors like credibility , objectivity, accuracy, and validity.
  • Analyze and Synthesize: Review each source and summarize the main arguments  in one paragraph (or more, for postgrad). Keep these summaries in a table.
  • Identify Themes: With all studies summarized, group studies that share common themes, such as studies that have similar findings or methodologies.
  • Write the Review: Write your review based upon the themes or subtopics you have identified. Give a thorough overview of each theme, integrating source data, and conclude with a summary of the current state of knowledge then suggestions for future research based upon your evaluation of what is lacking in the literature.

Literature reviews don’t have to be as scary as they seem. Yes, they are difficult and require a strong degree of comprehension of academic studies. But it can be feasibly done through following a structured approach to data collection and analysis. With my undergraduate research students (who tend to conduct small-scale qualitative studies ), I encourage them to conduct a narrative literature review whereby they can identify key themes in the literature. Within each theme, students can critique key studies and their strengths and limitations , in order to get a lay of the land and come to a point where they can identify ways to contribute new insights to the existing academic conversation on their topic.

Ankrah, S., & Omar, A. T. (2015). Universities–industry collaboration: A systematic review. Scandinavian Journal of Management, 31(3), 387-408.

Asghari, P., Rahmani, A. M., & Javadi, H. H. S. (2019). Internet of Things applications: A systematic review. Computer Networks , 148 , 241-261.

Dyrbye, L., & Shanafelt, T. (2016). A narrative review on burnout experienced by medical students and residents. Medical education , 50 (1), 132-149.

Geiger, J. L., Steg, L., Van Der Werff, E., & Ünal, A. B. (2019). A meta-analysis of factors related to recycling. Journal of environmental psychology , 64 , 78-97.

Martin, F., Sun, T., & Westine, C. D. (2020). A systematic review of research on online teaching and learning from 2009 to 2018. Computers & education , 159 , 104009.

Mavilidi, M. F., Ruiter, M., Schmidt, M., Okely, A. D., Loyens, S., Chandler, P., & Paas, F. (2018). A narrative review of school-based physical activity for enhancing cognition and learning: The importance of relevancy and integration. Frontiers in psychology , 2079.

Patterson, G. T., Chung, I. W., & Swan, P. W. (2014). Stress management interventions for police officers and recruits: A meta-analysis. Journal of experimental criminology , 10 , 487-513.

Reith, T. P. (2018). Burnout in United States healthcare professionals: a narrative review. Cureus , 10 (12).

Ritchie, S. J., & Tucker-Drob, E. M. (2018). How much does education improve intelligence? A meta-analysis. Psychological science , 29 (8), 1358-1369.

Roman, S., Sánchez-Siles, L. M., & Siegrist, M. (2017). The importance of food naturalness for consumers: Results of a systematic review. Trends in food science & technology , 67 , 44-57.

Sáiz-Vazquez, O., Puente-Martínez, A., Ubillos-Landa, S., Pacheco-Bonrostro, J., & Santabárbara, J. (2020). Cholesterol and Alzheimer’s disease risk: a meta-meta-analysis. Brain sciences, 10(6), 386.

Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., Mortier, E., … & Vogelaers, D. (2015). Communication in healthcare: a narrative review of the literature and practical recommendations. International journal of clinical practice , 69 (11), 1257-1267.

Wisniewski, B., Zierer, K., & Hattie, J. (2020). The power of feedback revisited: A meta-analysis of educational feedback research. Frontiers in Psychology , 10 , 3087.

Yli-Huumo, J., Ko, D., Choi, S., Park, S., & Smolander, K. (2016). Where is current research on blockchain technology?—a systematic review. PloS one , 11 (10), e0163477.

Zestcott, C. A., Blair, I. V., & Stone, J. (2016). Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Processes & Intergroup Relations , 19 (4), 528-542

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Dr. Chris Drew is the founder of the Helpful Professor. He holds a PhD in education and has published over 20 articles in scholarly journals. He is the former editor of the Journal of Learning Development in Higher Education. [Image Descriptor: Photo of Chris]

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Grad Coach

Free Download 📥

Literature review catalogue (excel template).

Literature review catalogue - free template/worksheet

Crafting a high-quality literature review is a lot of work . Failure to keep track of all the literature you consume can result in a  lot of wasted time . You need to get (and stay) organized – in other words, you need a literature review catalog .

We developed a template, just for you.

Now you can keep on top of your literature using our intuitive literature review spreadsheet-based catalogue template. The spreadsheet will not only keep everything organized; it will also provide a summary of key metrics. 

Need a template for the actual literature review chapter ? You can get that here .

Free Webinar: Literature Review 101

How to use the Excel template effectively.

A quick overview. The first tab (labelled “Literature”) is where you’ll record specific details of all the reading you’ll do. The second tab (labelled “Literature Summary”) will auto-populate with descriptive statistics of the input as you enter data.

Internal tabs within the literature review template

The last two tabs are simply scratchpads for you to dump any additional resources you find along the way. In particular, we’ve made a tab for theoretical frameworks (you can simply dump screengrabs here and caption them) and a tab for measures and scales (the same principle applies). Measures and scales are specific to quantitative methodologies, but you could just as easily use this tab to jot down existing questionnaires if you’re taking a qualitative approach. 

Getting started.

The process is straightforward. For every piece of literature that you read , you log it as a line item. We’d encourage you to record everything you read. Something might seem irrelevant at first read, but you’ll be surprised how the focus of your research can change over time, leading you to inevitably ask the dreaded question, “where did I see that article again?”. Therefore, l og every piece of reading, regardless of perceived relevance at the time of reading . You’ll thank yourself later.

While you’re doing this, we’d encourage you to simultaneously capture the literature piece in your reference manager. We usually recommend Mendeley , but any of the popular reference management tools will do the trick. The key thing is to capture the references while you’re reading (and not when you’re writing, as this breaks your flow).

What goes where.

For every piece of literature you read, you’ll need to capture the following details:

  • Author – Enter the author(s) surname(s). The format you use here is up to you – just be consistent.
  • Year – Straightforward. Enter the year of publication only – no month is required.
  • Title – Enter the title exactly as it is shown on the book cover, journal article front page, presentation deck, etc. If you can copy and paste, do so. It’s easy to make mistakes on the long titles.
  • Category 1, 2 and 3 – Here, you’ll create categories and subcategories, which you can use at a later stage to help you find relevant literature. It is up to you what categories you want to use and how much detail you want to add here. At the very least, your choice of categories should be logical, comprehensive and mutually exclusive.
  • Document type – Click the drop-down arrow next to the cell and select an appropriate document type, for example, journal article, blog post, etc. If nothing matches your document type, you can use the “Other” field.
  • Publication setting – the two main options here are academic and practitioner. Academic refers to the classic academic sources such as textbooks and journal articles, while practitioner refers to publications such as industry reports, company reports, industry magazines, etc. There is also a mixed option here.
  • Theoretical refers to situations where an author is proposing a hypothetical theory or concept, but not testing it.
  • Empirical refers to situations where an author is testing the said theory by using some form of real-world observation.
  • Naturally, some literature will feature both of these (i.e. a model is hypothesized and then tested empirically).
  • Key arguments – Here you need to note the key takeaways of the respective piece of literature in relation to your research question(s) and objective(s). This is the most important column , so spend some time providing rich, detailed notes here. Keep in mind that you will be able to search and filter this column at a later stage, so use keywords that make sense.
  • Context – Here you should briefly note the context of the specific literature piece. For example, what industry, country, competitive context, etc. did it take place in? When it comes time to justify why your research is worth undertaking, you will likely need to draw on this column’s contents to demonstrate that research has not been undertaken within your specific context (i.e. is it unique?).
  • Methodology – Use this drop-down to note the primary methodology (qualitative, quantitative or mixed) used within the specific literature piece. As with the previous item (context), you will likely draw on this when you justify the choice of methodology for your research (i.e. which methodology is commonly used in the field?).
  • Key quotes – If there are any specific author quotations that you feel might be useful in your dissertation, add them here. Remember to include the page number if you’re using the Harvard referencing system.
  • My notes – Lastly, if there is anything else you feel might be useful, drop it here. You can also create additional columns if you need them.

Finding what you need.

Over time, you will build up a substantial list of literature. When you need to find something, whether it’s a specific piece of literature, a collection of literature within a category, or a summary of a specific author’s publication, you can use the following Excel features:

  • Find (Ctrl + F) – good for searching for specific keywords
  • Filter – good for filtering groups (for example, categories 1- 3, methodology or publication setting)
  • Sort – good for arranging numerical data (for example, publication year)

Once you’ve completed your reading, remember to have a look at the second tab (“Literature Summary”) for an overview of key statistics. As mentioned previously, some of these statistics can help you justify your choice of topic or methodology. Additionally, a review here may reveal that your literature is aged , or that you need to improve your balance of academic and practitioner literature.

Literature Review Course

Psst… there’s more!

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

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Statistics Cheatsheet

160 Comments

3lyojo

Hi, I can’t open the excel file, can you please check it? Thank you so much for your helpful contents!

Derek Jansen

Sure, no problem. We’ve checked the file and it is opening correctly. Please give it another go.

SYLVIA BAJELENI

Hi,do you have a vidoe on how to popolate the informatino in the spreed sheet ?if you have it i will like to have one.

Anande

Please may I know what you mean by categories or subcategories on your literature review catalogue? This also includes keywords.

I’ve downloaded it, but unable to enter any information. Is it possible to receive it as an excel document that I can save onto my documents, as I’m using an android phone?

Maria Fernandez

The Theoretical Framework of the Excel File is empty, sir…

This document is a template for you to populate with the relevant literature, models and frameworks from your reading. As such, it doesn’t contain any literature.

Zhanna

Thank you for such a useful video tutorial. Learnt a lot!

Pleasure, Zhanna!

Bernard Boamah Bekoe

you are amazing….the way you patiently reply to almost every enquiry is remarkable. Keep it up Derek.

Okwuchukwu

Very helpful as usual. Thank you so much.

Shah

I need an examplary literature review in mycology (botany) if you can provide it on any botanical topic so I would be able to start my Lit.review.

Phil

Why don’t you just ask him to do your thesis for you?

Tebogo Pule

What an invaluable presentation. Makes literature review so simple.

Derek Jansen

Thanks for the feedback, Tebogo. Good luck writing your literature review 🙂

Maureen

Very useful! Thanks.

Pleasure, Maureen 🙂

Curtis Sonny

Great tips! Just starting mine now….so I am using your template….to a mil!!

Ahmed

I need this tamplate, its amazing, I will need your consideration on related work. Thank you

Tahir

Really agreed

Nina

Hello, I am trying to download the excel but I am not receiving the email. Can it be that there is a technical problem or does it take some time to send it?

Thanks for your comment. It can take a few minutes for the email to go through. Please also check your spam box.

AK

Yes, I am also facing the same problem brother. Just check it once. Thanking you..!

Ahmed

Thanks for this very nice explanation

Great to hear that 🙂

Monger

very useful

Glad to hear that 🙂

Classgist

Thanks for the template. It helped in organizing my literature review and writing process

You’re welcome

Gianpiero Torrisi

Hi, thanks for sharing this file, very helpful! I’d like to share it with my students. Could you please advise on how to give proper credits (reference) to your work? Cheers, G

Hi Gianpiero

That’s great. Here’s the Harvard reference:

Jansen, D., 2019. Literature Review Excel Template (Spreadsheet/Matrix) – Grad Coach. [online] Grad Coach. Available at: https://gradcoach.com/how-to-manage-the-literature-review/ > [Accessed 6 April 2020].

Kind regards,

Sahar

Thank u Derek Your lectures are effectively informative and easily understood. They are clear and organized.

Rabia A

I’m so glad I came across this website. Thank you Derek !!!

You’re welcome, Rabia 🙂

Ajamu

Dear Derek,

Thanks for your extremely useful video tutorials. Please can you send me a link to open your Lit Review Excel Templates.

Thanks for your feedback. You can download the template following the instructions in the orange box.

All the best with your studies!

mubbsher

great effort

Jerry Robinson

Thank you for this document. I am in the beginning stages of the dissertation process.

You’re welcome, Jerry 🙂

Rishi Raghubar

The video on literature review was very useful. I especially like the cataloging suggestion.

Great to hear that, Rishi. All the best for your research!

NKULULEKO SKUNANA

I`m busy writing my minor dissertation my master’s in engineering. I’m following your videos on youtube for writing a literature review. I’m looking for the excel sheet to save a list of references.

Morakane Moletsane

The literature video was helpful. Thank you. I haven’t received the excel template its been a week now . Please assist me .

Hi Morakane

That’s very unusual. At most, it should take a few minutes. Please re-attempt the download (use an alternative address if need be).

nayeb

Thank you for the template. it seems useful to organize my literature review.

You’re very welcome.

Feyi

Thank you for this informative site and all the tips. Very useful for my research.

You’re welcome, Feyi.

Felicha

Currently writing a dissertation for a masters in social sciences. Found the youtube videos which are of great help.

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

Umair

Thank you very much for the support!!

Aws Thamir

your videos are great helpful.

Glad to hear that! Good luck with your lit review.

Annie

You are the BEST

Thanks for the feedback, Annie. I wish you best of luck with your literature review.

Lebogang Masilane

where is the download link for the excel template?

Hi Lebogang

The download is below the first image. Good luck with your literature review!

A really thankful Undergrad Student

Your videos literally saved me!!!! Due to recent issues, most of my classes were cancelled and i was completely lost. No words can explain how much grateful i am to you!!

Glad to hear we helped you! Good luck with your literature review.

Abel

You guys are the kinds of people who should survive covid-19. You are the type of people we really need in this planet. You are a star. You really saved me from many headaches. Thank you very much for the useful videos and the literature organisation spreadsheet.

Thanks for the kind words, Abel. All the best for your literature review!

Helen

Thanks so much for your video. I have consistently received comments that my arguments don’t flow well and I could never figure out how to successfully fix this issue. Now I feel I have a plan and someone to help me and provide feedback if I still don’t get it quite well. Looking forward to getting an improved mark on my next Lit review Thank you

Great to hear that, Helen. Good luck with your future literature reviews!

biren

Excellent lecture

Thanks Biren – good luck with your literature review

i have watched your video on three steps to write a literature review and i found it very useful. thank you for sharing. keep it up.

Thanks again

tanya Sifuentes

Thank you for providing such excellent information and sources. Your videos helped me so much. I was on the verge of quitting. Thank you again for your videos and recommended tools.

Great to hear that, Tanya. All the best for your literature review, and for your research.

Nina

The video was very informative and timely for me. I am about to start, so Gradcoach is a source I will be revisiitng

Thanks, Nina – glad to hear that. Good luck with your literature review 🙂

kavita

hey your video is awesome I had to make an assignment on literature Review and it helped me to get an outline on how I should start ! i was fed of reading books and online articles. Your video served as a boon and clarified my thought process – how I should move forward .Thank you so much!

Great to hear that, Kavita. All the best with your literature review!

Hi Derek, I have tried unsuccessfully to download the Excel template but it keeps bringing me back to this comment section. Is it a technical issue? Kindly help.

Sorry about that. Can you please send me a screenshot of what you’re seeing – [email protected] . I will send you the template as well.

Best of luck with your literature review.

Slackin in Colorado

This is so very helpful!! I am writing my first lit review within a proposal (rather last minute, yikes) and this is so helpful to stay organized!

Pleasure. Good luck with your lit review 🙂

Faith

Hi i like the video,it is very helpful especially now that I am working on my proposal for thesis project….Hope I will be able to use the excel template to organize for my literature review

Great to hear that, Faith. All the best with your literature review!

Rainy

hey Derek this video is absolutely amazing. One problem though I’m one of the few that are struggling to download excel. I keep clicking on it and nothing happens.

Thanks for letting us know. Please email me a screenshot of your error and I’ll sort you out – [email protected]

Thanks, Derek

Laura McLuckie

Thanks a lot! Very well explained and easy to follow…now I guess I have no excuse to actually do the work 😉

Thanks for your comment! Good luck with your literature review.

Abegail

Your video is very informative and useful. Thanks a lot. I also want to try the template but I can’t the find the download link…

The download button is below the main image.

Kader

Very helpful thank you

Grace

Hi! It is a big help for beginners, such as me. Thanks a lot for sharing!

Kimnrtly S

Thank you. All the best with your literature review.

Chima Hampo

This is brilliant, Pls sir, in writing a review article, how deep can u go. Is it necessary to go down to the inception of your area of research?

ABDUL HAMEED

How do I know the country/region of research article?

This will usually be covered somewhere in the article itself.

kori morris

I would like this free resource

You’re welcome to download it. The download button is below the main image. Good luck with your literature review 🙂

Chukwudinma Daniel

I’d love to have this resource pls. Thank you so much

You’re welcome to download it. The download button is below the main image.

Constance Williams

Thanks for the you tube videos. they are very informative

Kenton Chow

Thank you so much for the full tutorial with so much detailed information. I’m a Ph.D. Candidate in China. The whole syllabus of the Ph.D. program sucks. Thanks again for sharing all this helpful information. I hope your team will getting better in the future!

You’re very welcome. Good luck writing your literature review.

Fina

It’s such a big help for me. Thank you!

Austin Sanders

I’ve watched your video on writing a research proposal. I am interested in the lit review excel template.

Yonas Berhanu Hailu

I have watched your lecture video on writing a research proposal. I am interested in the literature review excel template and the book write smarter not harder.

J.

It is very helpful. Thank you for your experience sharing.

You’re welcome – good luck with your literature review 🙂

Jamie Fern

Good afternoon, I recall listening/seeing in 1 of your videos *of saving the abstract (PDF) together with the excel database. How do you do this? is it also with this excel sheet

Thank you ..your videos are a confidence booster

*How To Write A Literature Review In 3 Steps (Full Tutorial)

Man Bahadur Khattri

Wonderful work !!! Please share more !!!! I will be very happy.

Benedict Ansere

Thanks so much for your precision in your presentation. I have not yet started practicing but it’s one of the best I have come across. More grease to your elbows.

Cecilia Brown

I love every video on research that you ve made so far. Thanks a lot

murtadha

انت رائع جدا

Siti Fatimah

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

Jesus Arturo Hernandez Soberon

Excellent work. Very helpful. I am starting in this beautiful activity of writing papers with my research . I am learning a lot. Thank you very much.

Glad to hear that. Good luck writing up your research papers!

Rebecca Kakilala

Thank you so much for the free Excel document! It’s such a huge time-saver!

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

Chuah Yi Ning

I am so grateful that I have found you on YouTube!

In the meantime, is it better to make another excel file for another variable of the same thesis or just put all articles of all variables in 1 excel file?

Thank you very much!

Juan Josephine

The notes have been very helpful to me thank you very much for sharing

You’re most welcome, Juan 🙂

Selvam Kalimuthu

Just recently seen your youtube video. Its very information. I usually gets running out of words while writing literature review. Example: XX et al investigated, YY et al shown that, ZZ et al demonstrated…….. After 4-5 references, I feels like again am repeating the words investigated, demonstrated… Could you please shoe some references with a set of vocabularies that can be used while writing literature review section.

Thank you in advance

Frank Ogbonna

Thank you so much. Amazing tutorial. Am feeling educated now. Lol…

Glad to hear that, Frank. Good luck with your literature review!

Manu

Very helpful stuff, thank you so much for the free Excel! I’m going to use it for my DBA and get your YT channel.

Ruben

Hi, thank you for the great insights! I was unable download the template even though I completed the form. Would you be able to help me?

Conslate

Derek thanks for sharing your sacrifices. I love the clarity and confidence, it takes experience to do such.

Akeem Adunfe Ajayi

I just downloaded the excel template for LR coupled with the explanation on how to use. I found it useful, thank you!

Abdallah Khirfan

Do you have any recommendations for adding Key quotes from a reference ?

Derick

Great content. Template very useful

Jojo

Awesome! An answer to my prayer. I found this in time I need it most. Thank you for the spirit of service.

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

Md. Bashir Uddin Khan

I am really impressed. This discussion helped me a lot to reconsider a lot of issues.

Thanks for the kind words. Good luck with your literature review!

Pat

This is amazing! I really like the guidance you are giving here. However, can you throw more light on the ‘category’ columns for me? I’m really nit clear on that. Thanks

Thanks for your comment. Please see my reply to Sasquia’s question re the same thing.

Good luck with your research!

Rose

I have been sitting on an enormous amount of articles for months with difficulties in organizing them until i discovered your video on literature review (YouTube). It brought me to this page where you also had a free template for us. Research process is so much bearable now than i expected. Highly recommended for all researchers. Thank you very much.

Sasquia Antúnez Pineda

Great template. Quick question: Are the categories KEYWORDS that I draw from each source? or pre-planned TOPICS that I come up with to organize the source content?

Thanks for your comment. You can use the category columns in whichever way works for you. It would be different for each student depending on the nature of their research and their research objectives.

Tracey

Hi there, can you suggest how the corresponding literature resources are best saved into a document folder for retrieval later.

I have seen some suggesting using a unique identifier in a master tab in the spreadsheet so as to be able to create a separate tab for quotes or similar thus using the id as the link

But no one has gone on to say if they are also saving the source document in a folder and naming it 57 or author last name, title or other.

I checked out your Literature Kickstarter and the screen shot of the articles didn’t look to correspond with the catalogue. Have been meaning to sort out my reference folders for sometime and am inspired by the use of an excel spreadsheet but not sure what to name files (currently saved in theme folders) Any help would be gratefully received. Thanks

Zinabu Gashaw

I am happy if I get a catalogue excel template on the research are of zeolite synthesis from local clay for water treatment mechanism. I need help.

Alexus

I love the template! But I would like to change the name of some of the headings, used in the dropdown, i.e. change “Audio Recording” to “Podcast”. How could I do that?

Odelia Sonia Caliz

Very helpful!

Dorcas Peprah

Great!!! Very handy.

Vidya R

Thankyou so much. The excel file is really helpful. This really means and is helping a lot for me.

Imaria

Hello, please, how can i get your excel document to catacogue the ideas for my literature review. Can you also assist on how to build the methodology section of my literature review? Thank you in advance.

Padliah Bahar

I’m a student from Indonesia..This is very useful for me.. Thank you Derek..

Bedoor

What is the better, download all literatures and then log them into the excel sheet or do that for one by one?

Stephanie Louw

Dear Derek.

I was utterly stressed when taking on an MSc Educational Leadership distance learning degree after 30 years of no academic studying. However, I found your literature review tutorial on Youtube and I immediately experienced a sense of calm direction. I am working full time in the Cayman Islands and am native Afrikaans speaking, so it was such a great help with my literature review for my first assignment. However, I have to write an evaluative essay for my second module and can not find any tutorial done by you about this. Do you perhaps have a template I could use? I have also used your services for editing and proofreading and am super grateful for the amazing help I have received! THANK YOU!

Thushara Mapalagama

Hi Mr Derek,

It really really helps me to summarise my LR in Excel form and start-up writing

Douglas Mabonga

Hi Derek I have tried to download the template and it has failed to. I am not receiving the email either, could this be network issues.

Hi Derek I have been able to download the template. thank you for all your support. let me get started

Dickson Egama

I have downloaded the template. I would like to print out the guide so I can easily follow. Hope that is fine with you.

Mahi

THANKS A LOTTTTT This template is exactly the one I needed when reading the literature review for my Bachelor’s dissertation

Abel

Thank you so much for your support ,I have downloaded your template and it is amazing .

Michael Howell

Derek, The products you and the team members have put together continue to provide exemplary help as I finish the journey toward completing my dissertation! I wish I would have known of GradCoach during both of my MBAs. It could have helped alleviate a lot of time and frustration! I look forward to learning and seeing new things as I complete the dissertation.

Thanks for the kind words 🙂

Ishtiaq Yousaf

Can data will be entered in excel sheet automatically like in Mendeley or i have to enter manually, pl?

Seleman Mozah

Thank you GRADCOACH, I’m keenly following your tutorials as I’m about to start my literature review. These videos have been very helpful. So for the literature review you recommend only checking abstract, introduction and conclusion of the relevant literature?

Thea

Thanks for providing such an amazing resource.

I wish I knew about this when I was doing my masters. I’m doing my PhD now and sitting on Word files of reference lists and quotes I made for my MEd. This catalog will help me to keep everything more organized in one place. I’ve already started making your template my own by adding additional columns that are important for my research topic. One of the best features of your template is the Literature summary page. My question is how do I get the information I put into my new columns to auto-populate with descriptive statistics on the Literature Summary page?

Fransisca

Hi, I still don’t understand what you would put as ‘Category 1’, ‘Category 2’, ‘Category X’. Are they like the sort of big topics covered in the paper?

Dorcas

This is very helpful

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  • What Is A Literature Review (In A Dissertation Or Thesis) - Grad Coach - […] theses and any other credible sources of information that relate to your topic. You’ll then summarise and catalogue these for easy…

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Ten Simple Rules for Writing a Literature Review

Marco pautasso.

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

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

Literature reviews are in great demand in most scientific fields. Their need stems from the ever-increasing output of scientific publications [1] . For example, compared to 1991, in 2008 three, eight, and forty times more papers were indexed in Web of Science on malaria, obesity, and biodiversity, respectively [2] . Given such mountains of papers, scientists cannot be expected to examine in detail every single new paper relevant to their interests [3] . Thus, it is both advantageous and necessary to rely on regular summaries of the recent literature. Although recognition for scientists mainly comes from primary research, timely literature reviews can lead to new synthetic insights and are often widely read [4] . For such summaries to be useful, however, they need to be compiled in a professional way [5] .

When starting from scratch, reviewing the literature can require a titanic amount of work. That is why researchers who have spent their career working on a certain research issue are in a perfect position to review that literature. Some graduate schools are now offering courses in reviewing the literature, given that most research students start their project by producing an overview of what has already been done on their research issue [6] . However, it is likely that most scientists have not thought in detail about how to approach and carry out a literature review.

Reviewing the literature requires the ability to juggle multiple tasks, from finding and evaluating relevant material to synthesising information from various sources, from critical thinking to paraphrasing, evaluating, and citation skills [7] . In this contribution, I share ten simple rules I learned working on about 25 literature reviews as a PhD and postdoctoral student. Ideas and insights also come from discussions with coauthors and colleagues, as well as feedback from reviewers and editors.

Rule 1: Define a Topic and Audience

How to choose which topic to review? There are so many issues in contemporary science that you could spend a lifetime of attending conferences and reading the literature just pondering what to review. On the one hand, if you take several years to choose, several other people may have had the same idea in the meantime. On the other hand, only a well-considered topic is likely to lead to a brilliant literature review [8] . The topic must at least be:

  • interesting to you (ideally, you should have come across a series of recent papers related to your line of work that call for a critical summary),
  • an important aspect of the field (so that many readers will be interested in the review and there will be enough material to write it), and
  • a well-defined issue (otherwise you could potentially include thousands of publications, which would make the review unhelpful).

Ideas for potential reviews may come from papers providing lists of key research questions to be answered [9] , but also from serendipitous moments during desultory reading and discussions. In addition to choosing your topic, you should also select a target audience. In many cases, the topic (e.g., web services in computational biology) will automatically define an audience (e.g., computational biologists), but that same topic may also be of interest to neighbouring fields (e.g., computer science, biology, etc.).

Rule 2: Search and Re-search the Literature

After having chosen your topic and audience, start by checking the literature and downloading relevant papers. Five pieces of advice here:

  • keep track of the search items you use (so that your search can be replicated [10] ),
  • keep a list of papers whose pdfs you cannot access immediately (so as to retrieve them later with alternative strategies),
  • use a paper management system (e.g., Mendeley, Papers, Qiqqa, Sente),
  • define early in the process some criteria for exclusion of irrelevant papers (these criteria can then be described in the review to help define its scope), and
  • do not just look for research papers in the area you wish to review, but also seek previous reviews.

The chances are high that someone will already have published a literature review ( Figure 1 ), if not exactly on the issue you are planning to tackle, at least on a related topic. If there are already a few or several reviews of the literature on your issue, my advice is not to give up, but to carry on with your own literature review,

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The bottom-right situation (many literature reviews but few research papers) is not just a theoretical situation; it applies, for example, to the study of the impacts of climate change on plant diseases, where there appear to be more literature reviews than research studies [33] .

  • discussing in your review the approaches, limitations, and conclusions of past reviews,
  • trying to find a new angle that has not been covered adequately in the previous reviews, and
  • incorporating new material that has inevitably accumulated since their appearance.

When searching the literature for pertinent papers and reviews, the usual rules apply:

  • be thorough,
  • use different keywords and database sources (e.g., DBLP, Google Scholar, ISI Proceedings, JSTOR Search, Medline, Scopus, Web of Science), and
  • look at who has cited past relevant papers and book chapters.

Rule 3: Take Notes While Reading

If you read the papers first, and only afterwards start writing the review, you will need a very good memory to remember who wrote what, and what your impressions and associations were while reading each single paper. My advice is, while reading, to start writing down interesting pieces of information, insights about how to organize the review, and thoughts on what to write. This way, by the time you have read the literature you selected, you will already have a rough draft of the review.

Of course, this draft will still need much rewriting, restructuring, and rethinking to obtain a text with a coherent argument [11] , but you will have avoided the danger posed by staring at a blank document. Be careful when taking notes to use quotation marks if you are provisionally copying verbatim from the literature. It is advisable then to reformulate such quotes with your own words in the final draft. It is important to be careful in noting the references already at this stage, so as to avoid misattributions. Using referencing software from the very beginning of your endeavour will save you time.

Rule 4: Choose the Type of Review You Wish to Write

After having taken notes while reading the literature, you will have a rough idea of the amount of material available for the review. This is probably a good time to decide whether to go for a mini- or a full review. Some journals are now favouring the publication of rather short reviews focusing on the last few years, with a limit on the number of words and citations. A mini-review is not necessarily a minor review: it may well attract more attention from busy readers, although it will inevitably simplify some issues and leave out some relevant material due to space limitations. A full review will have the advantage of more freedom to cover in detail the complexities of a particular scientific development, but may then be left in the pile of the very important papers “to be read” by readers with little time to spare for major monographs.

There is probably a continuum between mini- and full reviews. The same point applies to the dichotomy of descriptive vs. integrative reviews. While descriptive reviews focus on the methodology, findings, and interpretation of each reviewed study, integrative reviews attempt to find common ideas and concepts from the reviewed material [12] . A similar distinction exists between narrative and systematic reviews: while narrative reviews are qualitative, systematic reviews attempt to test a hypothesis based on the published evidence, which is gathered using a predefined protocol to reduce bias [13] , [14] . When systematic reviews analyse quantitative results in a quantitative way, they become meta-analyses. The choice between different review types will have to be made on a case-by-case basis, depending not just on the nature of the material found and the preferences of the target journal(s), but also on the time available to write the review and the number of coauthors [15] .

Rule 5: Keep the Review Focused, but Make It of Broad Interest

Whether your plan is to write a mini- or a full review, it is good advice to keep it focused 16 , 17 . Including material just for the sake of it can easily lead to reviews that are trying to do too many things at once. The need to keep a review focused can be problematic for interdisciplinary reviews, where the aim is to bridge the gap between fields [18] . If you are writing a review on, for example, how epidemiological approaches are used in modelling the spread of ideas, you may be inclined to include material from both parent fields, epidemiology and the study of cultural diffusion. This may be necessary to some extent, but in this case a focused review would only deal in detail with those studies at the interface between epidemiology and the spread of ideas.

While focus is an important feature of a successful review, this requirement has to be balanced with the need to make the review relevant to a broad audience. This square may be circled by discussing the wider implications of the reviewed topic for other disciplines.

Rule 6: Be Critical and Consistent

Reviewing the literature is not stamp collecting. A good review does not just summarize the literature, but discusses it critically, identifies methodological problems, and points out research gaps [19] . After having read a review of the literature, a reader should have a rough idea of:

  • the major achievements in the reviewed field,
  • the main areas of debate, and
  • the outstanding research questions.

It is challenging to achieve a successful review on all these fronts. A solution can be to involve a set of complementary coauthors: some people are excellent at mapping what has been achieved, some others are very good at identifying dark clouds on the horizon, and some have instead a knack at predicting where solutions are going to come from. If your journal club has exactly this sort of team, then you should definitely write a review of the literature! In addition to critical thinking, a literature review needs consistency, for example in the choice of passive vs. active voice and present vs. past tense.

Rule 7: Find a Logical Structure

Like a well-baked cake, a good review has a number of telling features: it is worth the reader's time, timely, systematic, well written, focused, and critical. It also needs a good structure. With reviews, the usual subdivision of research papers into introduction, methods, results, and discussion does not work or is rarely used. However, a general introduction of the context and, toward the end, a recapitulation of the main points covered and take-home messages make sense also in the case of reviews. For systematic reviews, there is a trend towards including information about how the literature was searched (database, keywords, time limits) [20] .

How can you organize the flow of the main body of the review so that the reader will be drawn into and guided through it? It is generally helpful to draw a conceptual scheme of the review, e.g., with mind-mapping techniques. Such diagrams can help recognize a logical way to order and link the various sections of a review [21] . This is the case not just at the writing stage, but also for readers if the diagram is included in the review as a figure. A careful selection of diagrams and figures relevant to the reviewed topic can be very helpful to structure the text too [22] .

Rule 8: Make Use of Feedback

Reviews of the literature are normally peer-reviewed in the same way as research papers, and rightly so [23] . As a rule, incorporating feedback from reviewers greatly helps improve a review draft. Having read the review with a fresh mind, reviewers may spot inaccuracies, inconsistencies, and ambiguities that had not been noticed by the writers due to rereading the typescript too many times. It is however advisable to reread the draft one more time before submission, as a last-minute correction of typos, leaps, and muddled sentences may enable the reviewers to focus on providing advice on the content rather than the form.

Feedback is vital to writing a good review, and should be sought from a variety of colleagues, so as to obtain a diversity of views on the draft. This may lead in some cases to conflicting views on the merits of the paper, and on how to improve it, but such a situation is better than the absence of feedback. A diversity of feedback perspectives on a literature review can help identify where the consensus view stands in the landscape of the current scientific understanding of an issue [24] .

Rule 9: Include Your Own Relevant Research, but Be Objective

In many cases, reviewers of the literature will have published studies relevant to the review they are writing. This could create a conflict of interest: how can reviewers report objectively on their own work [25] ? Some scientists may be overly enthusiastic about what they have published, and thus risk giving too much importance to their own findings in the review. However, bias could also occur in the other direction: some scientists may be unduly dismissive of their own achievements, so that they will tend to downplay their contribution (if any) to a field when reviewing it.

In general, a review of the literature should neither be a public relations brochure nor an exercise in competitive self-denial. If a reviewer is up to the job of producing a well-organized and methodical review, which flows well and provides a service to the readership, then it should be possible to be objective in reviewing one's own relevant findings. In reviews written by multiple authors, this may be achieved by assigning the review of the results of a coauthor to different coauthors.

Rule 10: Be Up-to-Date, but Do Not Forget Older Studies

Given the progressive acceleration in the publication of scientific papers, today's reviews of the literature need awareness not just of the overall direction and achievements of a field of inquiry, but also of the latest studies, so as not to become out-of-date before they have been published. Ideally, a literature review should not identify as a major research gap an issue that has just been addressed in a series of papers in press (the same applies, of course, to older, overlooked studies (“sleeping beauties” [26] )). This implies that literature reviewers would do well to keep an eye on electronic lists of papers in press, given that it can take months before these appear in scientific databases. Some reviews declare that they have scanned the literature up to a certain point in time, but given that peer review can be a rather lengthy process, a full search for newly appeared literature at the revision stage may be worthwhile. Assessing the contribution of papers that have just appeared is particularly challenging, because there is little perspective with which to gauge their significance and impact on further research and society.

Inevitably, new papers on the reviewed topic (including independently written literature reviews) will appear from all quarters after the review has been published, so that there may soon be the need for an updated review. But this is the nature of science [27] – [32] . I wish everybody good luck with writing a review of the literature.

Acknowledgments

Many thanks to M. Barbosa, K. Dehnen-Schmutz, T. Döring, D. Fontaneto, M. Garbelotto, O. Holdenrieder, M. Jeger, D. Lonsdale, A. MacLeod, P. Mills, M. Moslonka-Lefebvre, G. Stancanelli, P. Weisberg, and X. Xu for insights and discussions, and to P. Bourne, T. Matoni, and D. Smith for helpful comments on a previous draft.

Funding Statement

This work was funded by the French Foundation for Research on Biodiversity (FRB) through its Centre for Synthesis and Analysis of Biodiversity data (CESAB), as part of the NETSEED research project. The funders had no role in the preparation of the manuscript.

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Chapter 14: completing ‘summary of findings’ tables and grading the certainty of the evidence.

Holger J Schünemann, Julian PT Higgins, Gunn E Vist, Paul Glasziou, Elie A Akl, Nicole Skoetz, Gordon H Guyatt; on behalf of the Cochrane GRADEing Methods Group (formerly Applicability and Recommendations Methods Group) and the Cochrane Statistical Methods Group

Key Points:

  • A ‘Summary of findings’ table for a given comparison of interventions provides key information concerning the magnitudes of relative and absolute effects of the interventions examined, the amount of available evidence and the certainty (or quality) of available evidence.
  • ‘Summary of findings’ tables include a row for each important outcome (up to a maximum of seven). Accepted formats of ‘Summary of findings’ tables and interactive ‘Summary of findings’ tables can be produced using GRADE’s software GRADEpro GDT.
  • Cochrane has adopted the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) for assessing certainty (or quality) of a body of evidence.
  • The GRADE approach specifies four levels of the certainty for a body of evidence for a given outcome: high, moderate, low and very low.
  • GRADE assessments of certainty are determined through consideration of five domains: risk of bias, inconsistency, indirectness, imprecision and publication bias. For evidence from non-randomized studies and rarely randomized studies, assessments can then be upgraded through consideration of three further domains.

Cite this chapter as: Schünemann HJ, Higgins JPT, Vist GE, Glasziou P, Akl EA, Skoetz N, Guyatt GH. Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane, 2023. Available from www.training.cochrane.org/handbook .

14.1 ‘Summary of findings’ tables

14.1.1 introduction to ‘summary of findings’ tables.

‘Summary of findings’ tables present the main findings of a review in a transparent, structured and simple tabular format. In particular, they provide key information concerning the certainty or quality of evidence (i.e. the confidence or certainty in the range of an effect estimate or an association), the magnitude of effect of the interventions examined, and the sum of available data on the main outcomes. Cochrane Reviews should incorporate ‘Summary of findings’ tables during planning and publication, and should have at least one key ‘Summary of findings’ table representing the most important comparisons. Some reviews may include more than one ‘Summary of findings’ table, for example if the review addresses more than one major comparison, or includes substantially different populations that require separate tables (e.g. because the effects differ or it is important to show results separately). In the Cochrane Database of Systematic Reviews (CDSR),  all ‘Summary of findings’ tables for a review appear at the beginning, before the Background section.

14.1.2 Selecting outcomes for ‘Summary of findings’ tables

Planning for the ‘Summary of findings’ table starts early in the systematic review, with the selection of the outcomes to be included in: (i) the review; and (ii) the ‘Summary of findings’ table. This is a crucial step, and one that review authors need to address carefully.

To ensure production of optimally useful information, Cochrane Reviews begin by developing a review question and by listing all main outcomes that are important to patients and other decision makers (see Chapter 2 and Chapter 3 ). The GRADE approach to assessing the certainty of the evidence (see Section 14.2 ) defines and operationalizes a rating process that helps separate outcomes into those that are critical, important or not important for decision making. Consultation and feedback on the review protocol, including from consumers and other decision makers, can enhance this process.

Critical outcomes are likely to include clearly important endpoints; typical examples include mortality and major morbidity (such as strokes and myocardial infarction). However, they may also represent frequent minor and rare major side effects, symptoms, quality of life, burdens associated with treatment, and resource issues (costs). Burdens represent the impact of healthcare workload on patient function and well-being, and include the demands of adhering to an intervention that patients or caregivers (e.g. family) may dislike, such as having to undergo more frequent tests, or the restrictions on lifestyle that certain interventions require (Spencer-Bonilla et al 2017).

Frequently, when formulating questions that include all patient-important outcomes for decision making, review authors will confront reports of studies that have not included all these outcomes. This is particularly true for adverse outcomes. For instance, randomized trials might contribute evidence on intended effects, and on frequent, relatively minor side effects, but not report on rare adverse outcomes such as suicide attempts. Chapter 19 discusses strategies for addressing adverse effects. To obtain data for all important outcomes it may be necessary to examine the results of non-randomized studies (see Chapter 24 ). Cochrane, in collaboration with others, has developed guidance for review authors to support their decision about when to look for and include non-randomized studies (Schünemann et al 2013).

If a review includes only randomized trials, these trials may not address all important outcomes and it may therefore not be possible to address these outcomes within the constraints of the review. Review authors should acknowledge these limitations and make them transparent to readers. Review authors are encouraged to include non-randomized studies to examine rare or long-term adverse effects that may not adequately be studied in randomized trials. This raises the possibility that harm outcomes may come from studies in which participants differ from those in studies used in the analysis of benefit. Review authors will then need to consider how much such differences are likely to impact on the findings, and this will influence the certainty of evidence because of concerns about indirectness related to the population (see Section 14.2.2 ).

Non-randomized studies can provide important information not only when randomized trials do not report on an outcome or randomized trials suffer from indirectness, but also when the evidence from randomized trials is rated as very low and non-randomized studies provide evidence of higher certainty. Further discussion of these issues appears also in Chapter 24 .

14.1.3 General template for ‘Summary of findings’ tables

Several alternative standard versions of ‘Summary of findings’ tables have been developed to ensure consistency and ease of use across reviews, inclusion of the most important information needed by decision makers, and optimal presentation (see examples at Figures 14.1.a and 14.1.b ). These formats are supported by research that focused on improved understanding of the information they intend to convey (Carrasco-Labra et al 2016, Langendam et al 2016, Santesso et al 2016). They are available through GRADE’s official software package developed to support the GRADE approach: GRADEpro GDT (www.gradepro.org).

Standard Cochrane ‘Summary of findings’ tables include the following elements using one of the accepted formats. Further guidance on each of these is provided in Section 14.1.6 .

  • A brief description of the population and setting addressed by the available evidence (which may be slightly different to or narrower than those defined by the review question).
  • A brief description of the comparison addressed in the ‘Summary of findings’ table, including both the experimental and comparison interventions.
  • A list of the most critical and/or important health outcomes, both desirable and undesirable, limited to seven or fewer outcomes.
  • A measure of the typical burden of each outcomes (e.g. illustrative risk, or illustrative mean, on comparator intervention).
  • The absolute and relative magnitude of effect measured for each (if both are appropriate).
  • The numbers of participants and studies contributing to the analysis of each outcomes.
  • A GRADE assessment of the overall certainty of the body of evidence for each outcome (which may vary by outcome).
  • Space for comments.
  • Explanations (formerly known as footnotes).

Ideally, ‘Summary of findings’ tables are supported by more detailed tables (known as ‘evidence profiles’) to which the review may be linked, which provide more detailed explanations. Evidence profiles include the same important health outcomes, and provide greater detail than ‘Summary of findings’ tables of both of the individual considerations feeding into the grading of certainty and of the results of the studies (Guyatt et al 2011a). They ensure that a structured approach is used to rating the certainty of evidence. Although they are rarely published in Cochrane Reviews, evidence profiles are often used, for example, by guideline developers in considering the certainty of the evidence to support guideline recommendations. Review authors will find it easier to develop the ‘Summary of findings’ table by completing the rating of the certainty of evidence in the evidence profile first in GRADEpro GDT. They can then automatically convert this to one of the ‘Summary of findings’ formats in GRADEpro GDT, including an interactive ‘Summary of findings’ for publication.

As a measure of the magnitude of effect for dichotomous outcomes, the ‘Summary of findings’ table should provide a relative measure of effect (e.g. risk ratio, odds ratio, hazard) and measures of absolute risk. For other types of data, an absolute measure alone (such as a difference in means for continuous data) might be sufficient. It is important that the magnitude of effect is presented in a meaningful way, which may require some transformation of the result of a meta-analysis (see also Chapter 15, Section 15.4 and Section 15.5 ). Reviews with more than one main comparison should include a separate ‘Summary of findings’ table for each comparison.

Figure 14.1.a provides an example of a ‘Summary of findings’ table. Figure 15.1.b  provides an alternative format that may further facilitate users’ understanding and interpretation of the review’s findings. Evidence evaluating different formats suggests that the ‘Summary of findings’ table should include a risk difference as a measure of the absolute effect and authors should preferably use a format that includes a risk difference .

A detailed description of the contents of a ‘Summary of findings’ table appears in Section 14.1.6 .

Figure 14.1.a Example of a ‘Summary of findings’ table

Summary of findings (for interactive version click here )

a All the stockings in the nine studies included in this review were below-knee compression stockings. In four studies the compression strength was 20 mmHg to 30 mmHg at the ankle. It was 10 mmHg to 20 mmHg in the other four studies. Stockings come in different sizes. If a stocking is too tight around the knee it can prevent essential venous return causing the blood to pool around the knee. Compression stockings should be fitted properly. A stocking that is too tight could cut into the skin on a long flight and potentially cause ulceration and increased risk of DVT. Some stockings can be slightly thicker than normal leg covering and can be potentially restrictive with tight foot wear. It is a good idea to wear stockings around the house prior to travel to ensure a good, comfortable fit. Participants put their stockings on two to three hours before the flight in most of the studies. The availability and cost of stockings can vary.

b Two studies recruited high risk participants defined as those with previous episodes of DVT, coagulation disorders, severe obesity, limited mobility due to bone or joint problems, neoplastic disease within the previous two years, large varicose veins or, in one of the studies, participants taller than 190 cm and heavier than 90 kg. The incidence for the seven studies that excluded high risk participants was 1.45% and the incidence for the two studies that recruited high-risk participants (with at least one risk factor) was 2.43%. We have used 10 and 30 per 1000 to express different risk strata, respectively.

c The confidence interval crosses no difference and does not rule out a small increase.

d The measurement of oedema was not validated (indirectness of the outcome) or blinded to the intervention (risk of bias).

e If there are very few or no events and the number of participants is large, judgement about the certainty of evidence (particularly judgements about imprecision) may be based on the absolute effect. Here the certainty rating may be considered ‘high’ if the outcome was appropriately assessed and the event, in fact, did not occur in 2821 studied participants.

f None of the other studies reported adverse effects, apart from four cases of superficial vein thrombosis in varicose veins in the knee region that were compressed by the upper edge of the stocking in one study.

Figure 14.1.b Example of alternative ‘Summary of findings’ table

14.1.4 Producing ‘Summary of findings’ tables

The GRADE Working Group’s software, GRADEpro GDT ( www.gradepro.org ), including GRADE’s interactive handbook, is available to assist review authors in the preparation of ‘Summary of findings’ tables. GRADEpro can use data on the comparator group risk and the effect estimate (entered by the review authors or imported from files generated in RevMan) to produce the relative effects and absolute risks associated with experimental interventions. In addition, it leads the user through the process of a GRADE assessment, and produces a table that can be used as a standalone table in a review (including by direct import into software such as RevMan or integration with RevMan Web), or an interactive ‘Summary of findings’ table (see help resources in GRADEpro).

14.1.5 Statistical considerations in ‘Summary of findings’ tables

14.1.5.1 dichotomous outcomes.

‘Summary of findings’ tables should include both absolute and relative measures of effect for dichotomous outcomes. Risk ratios, odds ratios and risk differences are different ways of comparing two groups with dichotomous outcome data (see Chapter 6, Section 6.4.1 ). Furthermore, there are two distinct risk ratios, depending on which event (e.g. ‘yes’ or ‘no’) is the focus of the analysis (see Chapter 6, Section 6.4.1.5 ). In the presence of a non-zero intervention effect, any variation across studies in the comparator group risks (i.e. variation in the risk of the event occurring without the intervention of interest, for example in different populations) makes it impossible for more than one of these measures to be truly the same in every study.

It has long been assumed in epidemiology that relative measures of effect are more consistent than absolute measures of effect from one scenario to another. There is empirical evidence to support this assumption (Engels et al 2000, Deeks and Altman 2001, Furukawa et al 2002). For this reason, meta-analyses should generally use either a risk ratio or an odds ratio as a measure of effect (see Chapter 10, Section 10.4.3 ). Correspondingly, a single estimate of relative effect is likely to be a more appropriate summary than a single estimate of absolute effect. If a relative effect is indeed consistent across studies, then different comparator group risks will have different implications for absolute benefit. For instance, if the risk ratio is consistently 0.75, then the experimental intervention would reduce a comparator group risk of 80% to 60% in the intervention group (an absolute risk reduction of 20 percentage points), but would also reduce a comparator group risk of 20% to 15% in the intervention group (an absolute risk reduction of 5 percentage points).

‘Summary of findings’ tables are built around the assumption of a consistent relative effect. It is therefore important to consider the implications of this effect for different comparator group risks (these can be derived or estimated from a number of sources, see Section 14.1.6.3 ), which may require an assessment of the certainty of evidence for prognostic evidence (Spencer et al 2012, Iorio et al 2015). For any comparator group risk, it is possible to estimate a corresponding intervention group risk (i.e. the absolute risk with the intervention) from the meta-analytic risk ratio or odds ratio. Note that the numbers provided in the ‘Corresponding risk’ column are specific to the ‘risks’ in the adjacent column.

For the meta-analytic risk ratio (RR) and assumed comparator risk (ACR) the corresponding intervention risk is obtained as:

example lit review table

As an example, in Figure 14.1.a , the meta-analytic risk ratio for symptomless deep vein thrombosis (DVT) is RR = 0.10 (95% CI 0.04 to 0.26). Assuming a comparator risk of ACR = 10 per 1000 = 0.01, we obtain:

example lit review table

For the meta-analytic odds ratio (OR) and assumed comparator risk, ACR, the corresponding intervention risk is obtained as:

example lit review table

Upper and lower confidence limits for the corresponding intervention risk are obtained by replacing RR or OR by their upper and lower confidence limits, respectively (e.g. replacing 0.10 with 0.04, then with 0.26, in the example). Such confidence intervals do not incorporate uncertainty in the assumed comparator risks.

When dealing with risk ratios, it is critical that the same definition of ‘event’ is used as was used for the meta-analysis. For example, if the meta-analysis focused on ‘death’ (as opposed to survival) as the event, then corresponding risks in the ‘Summary of findings’ table must also refer to ‘death’.

In (rare) circumstances in which there is clear rationale to assume a consistent risk difference in the meta-analysis, in principle it is possible to present this for relevant ‘assumed risks’ and their corresponding risks, and to present the corresponding (different) relative effects for each assumed risk.

The risk difference expresses the difference between the ACR and the corresponding intervention risk (or the difference between the experimental and the comparator intervention).

For the meta-analytic risk ratio (RR) and assumed comparator risk (ACR) the corresponding risk difference is obtained as (note that risks can also be expressed using percentage or percentage points):

example lit review table

As an example, in Figure 14.1.b the meta-analytic risk ratio is 0.41 (95% CI 0.29 to 0.55) for diarrhoea in children less than 5 years of age. Assuming a comparator group risk of 22.3% we obtain:

example lit review table

For the meta-analytic odds ratio (OR) and assumed comparator risk (ACR) the absolute risk difference is obtained as (percentage points):

example lit review table

Upper and lower confidence limits for the absolute risk difference are obtained by re-running the calculation above while replacing RR or OR by their upper and lower confidence limits, respectively (e.g. replacing 0.41 with 0.28, then with 0.55, in the example). Such confidence intervals do not incorporate uncertainty in the assumed comparator risks.

14.1.5.2 Time-to-event outcomes

Time-to-event outcomes measure whether and when a particular event (e.g. death) occurs (van Dalen et al 2007). The impact of the experimental intervention relative to the comparison group on time-to-event outcomes is usually measured using a hazard ratio (HR) (see Chapter 6, Section 6.8.1 ).

A hazard ratio expresses a relative effect estimate. It may be used in various ways to obtain absolute risks and other interpretable quantities for a specific population. Here we describe how to re-express hazard ratios in terms of: (i) absolute risk of event-free survival within a particular period of time; (ii) absolute risk of an event within a particular period of time; and (iii) median time to the event. All methods are built on an assumption of consistent relative effects (i.e. that the hazard ratio does not vary over time).

(i) Absolute risk of event-free survival within a particular period of time Event-free survival (e.g. overall survival) is commonly reported by individual studies. To obtain absolute effects for time-to-event outcomes measured as event-free survival, the summary HR can be used in conjunction with an assumed proportion of patients who are event-free in the comparator group (Tierney et al 2007). This proportion of patients will be specific to a period of time of observation. However, it is not strictly necessary to specify this period of time. For instance, a proportion of 50% of event-free patients might apply to patients with a high event rate observed over 1 year, or to patients with a low event rate observed over 2 years.

example lit review table

As an example, suppose the meta-analytic hazard ratio is 0.42 (95% CI 0.25 to 0.72). Assuming a comparator group risk of event-free survival (e.g. for overall survival people being alive) at 2 years of ACR = 900 per 1000 = 0.9 we obtain:

example lit review table

so that that 956 per 1000 people will be alive with the experimental intervention at 2 years. The derivation of the risk should be explained in a comment or footnote.

(ii) Absolute risk of an event within a particular period of time To obtain this absolute effect, again the summary HR can be used (Tierney et al 2007):

example lit review table

In the example, suppose we assume a comparator group risk of events (e.g. for mortality, people being dead) at 2 years of ACR = 100 per 1000 = 0.1. We obtain:

example lit review table

so that that 44 per 1000 people will be dead with the experimental intervention at 2 years.

(iii) Median time to the event Instead of absolute numbers, the time to the event in the intervention and comparison groups can be expressed as median survival time in months or years. To obtain median survival time the pooled HR can be applied to an assumed median survival time in the comparator group (Tierney et al 2007):

example lit review table

In the example, assuming a comparator group median survival time of 80 months, we obtain:

example lit review table

For all three of these options for re-expressing results of time-to-event analyses, upper and lower confidence limits for the corresponding intervention risk are obtained by replacing HR by its upper and lower confidence limits, respectively (e.g. replacing 0.42 with 0.25, then with 0.72, in the example). Again, as for dichotomous outcomes, such confidence intervals do not incorporate uncertainty in the assumed comparator group risks. This is of special concern for long-term survival with a low or moderate mortality rate and a corresponding high number of censored patients (i.e. a low number of patients under risk and a high censoring rate).

14.1.6 Detailed contents of a ‘Summary of findings’ table

14.1.6.1 table title and header.

The title of each ‘Summary of findings’ table should specify the healthcare question, framed in terms of the population and making it clear exactly what comparison of interventions are made. In Figure 14.1.a , the population is people taking long aeroplane flights, the intervention is compression stockings, and the control is no compression stockings.

The first rows of each ‘Summary of findings’ table should provide the following ‘header’ information:

Patients or population This further clarifies the population (and possibly the subpopulations) of interest and ideally the magnitude of risk of the most crucial adverse outcome at which an intervention is directed. For instance, people on a long-haul flight may be at different risks for DVT; those using selective serotonin reuptake inhibitors (SSRIs) might be at different risk for side effects; while those with atrial fibrillation may be at low (< 1%), moderate (1% to 4%) or high (> 4%) yearly risk of stroke.

Setting This should state any specific characteristics of the settings of the healthcare question that might limit the applicability of the summary of findings to other settings (e.g. primary care in Europe and North America).

Intervention The experimental intervention.

Comparison The comparator intervention (including no specific intervention).

14.1.6.2 Outcomes

The rows of a ‘Summary of findings’ table should include all desirable and undesirable health outcomes (listed in order of importance) that are essential for decision making, up to a maximum of seven outcomes. If there are more outcomes in the review, review authors will need to omit the less important outcomes from the table, and the decision selecting which outcomes are critical or important to the review should be made during protocol development (see Chapter 3 ). Review authors should provide time frames for the measurement of the outcomes (e.g. 90 days or 12 months) and the type of instrument scores (e.g. ranging from 0 to 100).

Note that review authors should include the pre-specified critical and important outcomes in the table whether data are available or not. However, they should be alert to the possibility that the importance of an outcome (e.g. a serious adverse effect) may only become known after the protocol was written or the analysis was carried out, and should take appropriate actions to include these in the ‘Summary of findings’ table.

The ‘Summary of findings’ table can include effects in subgroups of the population for different comparator risks and effect sizes separately. For instance, in Figure 14.1.b effects are presented for children younger and older than 5 years separately. Review authors may also opt to produce separate ‘Summary of findings’ tables for different populations.

Review authors should include serious adverse events, but it might be possible to combine minor adverse events as a single outcome, and describe this in an explanatory footnote (note that it is not appropriate to add events together unless they are independent, that is, a participant who has experienced one adverse event has an unaffected chance of experiencing the other adverse event).

Outcomes measured at multiple time points represent a particular problem. In general, to keep the table simple, review authors should present multiple time points only for outcomes critical to decision making, where either the result or the decision made are likely to vary over time. The remainder should be presented at a common time point where possible.

Review authors can present continuous outcome measures in the ‘Summary of findings’ table and should endeavour to make these interpretable to the target audience. This requires that the units are clear and readily interpretable, for example, days of pain, or frequency of headache, and the name and scale of any measurement tools used should be stated (e.g. a Visual Analogue Scale, ranging from 0 to 100). However, many measurement instruments are not readily interpretable by non-specialist clinicians or patients, for example, points on a Beck Depression Inventory or quality of life score. For these, a more interpretable presentation might involve converting a continuous to a dichotomous outcome, such as >50% improvement (see Chapter 15, Section 15.5 ).

14.1.6.3 Best estimate of risk with comparator intervention

Review authors should provide up to three typical risks for participants receiving the comparator intervention. For dichotomous outcomes, we recommend that these be presented in the form of the number of people experiencing the event per 100 or 1000 people (natural frequency) depending on the frequency of the outcome. For continuous outcomes, this would be stated as a mean or median value of the outcome measured.

Estimated or assumed comparator intervention risks could be based on assessments of typical risks in different patient groups derived from the review itself, individual representative studies in the review, or risks derived from a systematic review of prognosis studies or other sources of evidence which may in turn require an assessment of the certainty for the prognostic evidence (Spencer et al 2012, Iorio et al 2015). Ideally, risks would reflect groups that clinicians can easily identify on the basis of their presenting features.

An explanatory footnote should specify the source or rationale for each comparator group risk, including the time period to which it corresponds where appropriate. In Figure 14.1.a , clinicians can easily differentiate individuals with risk factors for deep venous thrombosis from those without. If there is known to be little variation in baseline risk then review authors may use the median comparator group risk across studies. If typical risks are not known, an option is to choose the risk from the included studies, providing the second highest for a high and the second lowest for a low risk population.

14.1.6.4 Risk with intervention

For dichotomous outcomes, review authors should provide a corresponding absolute risk for each comparator group risk, along with a confidence interval. This absolute risk with the (experimental) intervention will usually be derived from the meta-analysis result presented in the relative effect column (see Section 14.1.6.6 ). Formulae are provided in Section 14.1.5 . Review authors should present the absolute effect in the same format as the risks with comparator intervention (see Section 14.1.6.3 ), for example as the number of people experiencing the event per 1000 people.

For continuous outcomes, a difference in means or standardized difference in means should be presented with its confidence interval. These will typically be obtained directly from a meta-analysis. Explanatory text should be used to clarify the meaning, as in Figures 14.1.a and 14.1.b .

14.1.6.5 Risk difference

For dichotomous outcomes, the risk difference can be provided using one of the ‘Summary of findings’ table formats as an additional option (see Figure 14.1.b ). This risk difference expresses the difference between the experimental and comparator intervention and will usually be derived from the meta-analysis result presented in the relative effect column (see Section 14.1.6.6 ). Formulae are provided in Section 14.1.5 . Review authors should present the risk difference in the same format as assumed and corresponding risks with comparator intervention (see Section 14.1.6.3 ); for example, as the number of people experiencing the event per 1000 people or as percentage points if the assumed and corresponding risks are expressed in percentage.

For continuous outcomes, if the ‘Summary of findings’ table includes this option, the mean difference can be presented here and the ‘corresponding risk’ column left blank (see Figure 14.1.b ).

14.1.6.6 Relative effect (95% CI)

The relative effect will typically be a risk ratio or odds ratio (or occasionally a hazard ratio) with its accompanying 95% confidence interval, obtained from a meta-analysis performed on the basis of the same effect measure. Risk ratios and odds ratios are similar when the comparator intervention risks are low and effects are small, but may differ considerably when comparator group risks increase. The meta-analysis may involve an assumption of either fixed or random effects, depending on what the review authors consider appropriate, and implying that the relative effect is either an estimate of the effect of the intervention, or an estimate of the average effect of the intervention across studies, respectively.

14.1.6.7 Number of participants (studies)

This column should include the number of participants assessed in the included studies for each outcome and the corresponding number of studies that contributed these participants.

14.1.6.8 Certainty of the evidence (GRADE)

Review authors should comment on the certainty of the evidence (also known as quality of the body of evidence or confidence in the effect estimates). Review authors should use the specific evidence grading system developed by the GRADE Working Group (Atkins et al 2004, Guyatt et al 2008, Guyatt et al 2011a), which is described in detail in Section 14.2 . The GRADE approach categorizes the certainty in a body of evidence as ‘high’, ‘moderate’, ‘low’ or ‘very low’ by outcome. This is a result of judgement, but the judgement process operates within a transparent structure. As an example, the certainty would be ‘high’ if the summary were of several randomized trials with low risk of bias, but the rating of certainty becomes lower if there are concerns about risk of bias, inconsistency, indirectness, imprecision or publication bias. Judgements other than of ‘high’ certainty should be made transparent using explanatory footnotes or the ‘Comments’ column in the ‘Summary of findings’ table (see Section 14.1.6.10 ).

14.1.6.9 Comments

The aim of the ‘Comments’ field is to help interpret the information or data identified in the row. For example, this may be on the validity of the outcome measure or the presence of variables that are associated with the magnitude of effect. Important caveats about the results should be flagged here. Not all rows will need comments, and it is best to leave a blank if there is nothing warranting a comment.

14.1.6.10 Explanations

Detailed explanations should be included as footnotes to support the judgements in the ‘Summary of findings’ table, such as the overall GRADE assessment. The explanations should describe the rationale for important aspects of the content. Table 14.1.a lists guidance for useful explanations. Explanations should be concise, informative, relevant, easy to understand and accurate. If explanations cannot be sufficiently described in footnotes, review authors should provide further details of the issues in the Results and Discussion sections of the review.

Table 14.1.a Guidance for providing useful explanations in ‘Summary of findings’ (SoF) tables. Adapted from Santesso et al (2016)

14.2 Assessing the certainty or quality of a body of evidence

14.2.1 the grade approach.

The Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE Working Group) has developed a system for grading the certainty of evidence (Schünemann et al 2003, Atkins et al 2004, Schünemann et al 2006, Guyatt et al 2008, Guyatt et al 2011a). Over 100 organizations including the World Health Organization (WHO), the American College of Physicians, the American Society of Hematology (ASH), the Canadian Agency for Drugs and Technology in Health (CADTH) and the National Institutes of Health and Clinical Excellence (NICE) in the UK have adopted the GRADE system ( www.gradeworkinggroup.org ).

Cochrane has also formally adopted this approach, and all Cochrane Reviews should use GRADE to evaluate the certainty of evidence for important outcomes (see MECIR Box 14.2.a ).

MECIR Box 14.2.a Relevant expectations for conduct of intervention reviews

For systematic reviews, the GRADE approach defines the certainty of a body of evidence as the extent to which one can be confident that an estimate of effect or association is close to the quantity of specific interest. Assessing the certainty of a body of evidence involves consideration of within- and across-study risk of bias (limitations in study design and execution or methodological quality), inconsistency (or heterogeneity), indirectness of evidence, imprecision of the effect estimates and risk of publication bias (see Section 14.2.2 ), as well as domains that may increase our confidence in the effect estimate (as described in Section 14.2.3 ). The GRADE system entails an assessment of the certainty of a body of evidence for each individual outcome. Judgements about the domains that determine the certainty of evidence should be described in the results or discussion section and as part of the ‘Summary of findings’ table.

The GRADE approach specifies four levels of certainty ( Figure 14.2.a ). For interventions, including diagnostic and other tests that are evaluated as interventions (Schünemann et al 2008b, Schünemann et al 2008a, Balshem et al 2011, Schünemann et al 2012), the starting point for rating the certainty of evidence is categorized into two types:

  • randomized trials; and
  • non-randomized studies of interventions (NRSI), including observational studies (including but not limited to cohort studies, and case-control studies, cross-sectional studies, case series and case reports, although not all of these designs are usually included in Cochrane Reviews).

There are many instances in which review authors rely on information from NRSI, in particular to evaluate potential harms (see Chapter 24 ). In addition, review authors can obtain relevant data from both randomized trials and NRSI, with each type of evidence complementing the other (Schünemann et al 2013).

In GRADE, a body of evidence from randomized trials begins with a high-certainty rating while a body of evidence from NRSI begins with a low-certainty rating. The lower rating with NRSI is the result of the potential bias induced by the lack of randomization (i.e. confounding and selection bias).

However, when using the new Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool (Sterne et al 2016), an assessment tool that covers the risk of bias due to lack of randomization, all studies may start as high certainty of the evidence (Schünemann et al 2018). The approach of starting all study designs (including NRSI) as high certainty does not conflict with the initial GRADE approach of starting the rating of NRSI as low certainty evidence. This is because a body of evidence from NRSI should generally be downgraded by two levels due to the inherent risk of bias associated with the lack of randomization, namely confounding and selection bias. Not downgrading NRSI from high to low certainty needs transparent and detailed justification for what mitigates concerns about confounding and selection bias (Schünemann et al 2018). Very few examples of where not rating down by two levels is appropriate currently exist.

The highest certainty rating is a body of evidence when there are no concerns in any of the GRADE factors listed in Figure 14.2.a . Review authors often downgrade evidence to moderate, low or even very low certainty evidence, depending on the presence of the five factors in Figure 14.2.a . Usually, certainty rating will fall by one level for each factor, up to a maximum of three levels for all factors. If there are very severe problems for any one domain (e.g. when assessing risk of bias, all studies were unconcealed, unblinded and lost over 50% of their patients to follow-up), evidence may fall by two levels due to that factor alone. It is not possible to rate lower than ‘very low certainty’ evidence.

Review authors will generally grade evidence from sound non-randomized studies as low certainty, even if ROBINS-I is used. If, however, such studies yield large effects and there is no obvious bias explaining those effects, review authors may rate the evidence as moderate or – if the effect is large enough – even as high certainty ( Figure 14.2.a ). The very low certainty level is appropriate for, but is not limited to, studies with critical problems and unsystematic clinical observations (e.g. case series or case reports).

Figure 14.2.a Levels of the certainty of a body of evidence in the GRADE approach. *Upgrading criteria are usually applicable to non-randomized studies only (but exceptions exist).

14.2.2 Domains that can lead to decreasing the certainty level of a body of evidence   

We now describe in more detail the five reasons (or domains) for downgrading the certainty of a body of evidence for a specific outcome. In each case, if no reason is found for downgrading the evidence, it should be classified as 'no limitation or not serious' (not important enough to warrant downgrading). If a reason is found for downgrading the evidence, it should be classified as 'serious' (downgrading the certainty rating by one level) or 'very serious' (downgrading the certainty grade by two levels). For non-randomized studies assessed with ROBINS-I, rating down by three levels should be classified as 'extremely' serious.

(1) Risk of bias or limitations in the detailed design and implementation

Our confidence in an estimate of effect decreases if studies suffer from major limitations that are likely to result in a biased assessment of the intervention effect. For randomized trials, these methodological limitations include failure to generate a random sequence, lack of allocation sequence concealment, lack of blinding (particularly with subjective outcomes that are highly susceptible to biased assessment), a large loss to follow-up or selective reporting of outcomes. Chapter 8 provides a discussion of study-level assessments of risk of bias in the context of a Cochrane Review, and proposes an approach to assessing the risk of bias for an outcome across studies as ‘Low’ risk of bias, ‘Some concerns’ and ‘High’ risk of bias for randomized trials. Levels of ‘Low’. ‘Moderate’, ‘Serious’ and ‘Critical’ risk of bias arise for non-randomized studies assessed with ROBINS-I ( Chapter 25 ). These assessments should feed directly into this GRADE domain. In particular, ‘Low’ risk of bias would indicate ‘no limitation’; ‘Some concerns’ would indicate either ‘no limitation’ or ‘serious limitation’; and ‘High’ risk of bias would indicate either ‘serious limitation’ or ‘very serious limitation’. ‘Critical’ risk of bias on ROBINS-I would indicate extremely serious limitations in GRADE. Review authors should use their judgement to decide between alternative categories, depending on the likely magnitude of the potential biases.

Every study addressing a particular outcome will differ, to some degree, in the risk of bias. Review authors should make an overall judgement on whether the certainty of evidence for an outcome warrants downgrading on the basis of study limitations. The assessment of study limitations should apply to the studies contributing to the results in the ‘Summary of findings’ table, rather than to all studies that could potentially be included in the analysis. We have argued in Chapter 7, Section 7.6.2 , that the primary analysis should be restricted to studies at low (or low and unclear) risk of bias where possible.

Table 14.2.a presents the judgements that must be made in going from assessments of the risk of bias to judgements about study limitations for each outcome included in a ‘Summary of findings’ table. A rating of high certainty evidence can be achieved only when most evidence comes from studies that met the criteria for low risk of bias. For example, of the 22 studies addressing the impact of beta-blockers on mortality in patients with heart failure, most probably or certainly used concealed allocation of the sequence, all blinded at least some key groups and follow-up of randomized patients was almost complete (Brophy et al 2001). The certainty of evidence might be downgraded by one level when most of the evidence comes from individual studies either with a crucial limitation for one item, or with some limitations for multiple items. An example of very serious limitations, warranting downgrading by two levels, is provided by evidence on surgery versus conservative treatment in the management of patients with lumbar disc prolapse (Gibson and Waddell 2007). We are uncertain of the benefit of surgery in reducing symptoms after one year or longer, because the one study included in the analysis had inadequate concealment of the allocation sequence and the outcome was assessed using a crude rating by the surgeon without blinding.

(2) Unexplained heterogeneity or inconsistency of results

When studies yield widely differing estimates of effect (heterogeneity or variability in results), investigators should look for robust explanations for that heterogeneity. For instance, drugs may have larger relative effects in sicker populations or when given in larger doses. A detailed discussion of heterogeneity and its investigation is provided in Chapter 10, Section 10.10 and Section 10.11 . If an important modifier exists, with good evidence that important outcomes are different in different subgroups (which would ideally be pre-specified), then a separate ‘Summary of findings’ table may be considered for a separate population. For instance, a separate ‘Summary of findings’ table would be used for carotid endarterectomy in symptomatic patients with high grade stenosis (70% to 99%) in which the intervention is, in the hands of the right surgeons, beneficial, and another (if review authors considered it relevant) for asymptomatic patients with low grade stenosis (less than 30%) in which surgery appears harmful (Orrapin and Rerkasem 2017). When heterogeneity exists and affects the interpretation of results, but review authors are unable to identify a plausible explanation with the data available, the certainty of the evidence decreases.

(3) Indirectness of evidence

Two types of indirectness are relevant. First, a review comparing the effectiveness of alternative interventions (say A and B) may find that randomized trials are available, but they have compared A with placebo and B with placebo. Thus, the evidence is restricted to indirect comparisons between A and B. Where indirect comparisons are undertaken within a network meta-analysis context, GRADE for network meta-analysis should be used (see Chapter 11, Section 11.5 ).

Second, a review may find randomized trials that meet eligibility criteria but address a restricted version of the main review question in terms of population, intervention, comparator or outcomes. For example, suppose that in a review addressing an intervention for secondary prevention of coronary heart disease, most identified studies happened to be in people who also had diabetes. Then the evidence may be regarded as indirect in relation to the broader question of interest because the population is primarily related to people with diabetes. The opposite scenario can equally apply: a review addressing the effect of a preventive strategy for coronary heart disease in people with diabetes may consider studies in people without diabetes to provide relevant, albeit indirect, evidence. This would be particularly likely if investigators had conducted few if any randomized trials in the target population (e.g. people with diabetes). Other sources of indirectness may arise from interventions studied (e.g. if in all included studies a technical intervention was implemented by expert, highly trained specialists in specialist centres, then evidence on the effects of the intervention outside these centres may be indirect), comparators used (e.g. if the comparator groups received an intervention that is less effective than standard treatment in most settings) and outcomes assessed (e.g. indirectness due to surrogate outcomes when data on patient-important outcomes are not available, or when investigators seek data on quality of life but only symptoms are reported). Review authors should make judgements transparent when they believe downgrading is justified, based on differences in anticipated effects in the group of primary interest. Review authors may be aided and increase transparency of their judgements about indirectness if they use Table 14.2.b available in the GRADEpro GDT software (Schünemann et al 2013).

(4) Imprecision of results

When studies include few participants or few events, and thus have wide confidence intervals, review authors can lower their rating of the certainty of the evidence. The confidence intervals included in the ‘Summary of findings’ table will provide readers with information that allows them to make, to some extent, their own rating of precision. Review authors can use a calculation of the optimal information size (OIS) or review information size (RIS), similar to sample size calculations, to make judgements about imprecision (Guyatt et al 2011b, Schünemann 2016). The OIS or RIS is calculated on the basis of the number of participants required for an adequately powered individual study. If the 95% confidence interval excludes a risk ratio (RR) of 1.0, and the total number of events or patients exceeds the OIS criterion, precision is adequate. If the 95% CI includes appreciable benefit or harm (an RR of under 0.75 or over 1.25 is often suggested as a very rough guide) downgrading for imprecision may be appropriate even if OIS criteria are met (Guyatt et al 2011b, Schünemann 2016).

(5) High probability of publication bias

The certainty of evidence level may be downgraded if investigators fail to report studies on the basis of results (typically those that show no effect: publication bias) or outcomes (typically those that may be harmful or for which no effect was observed: selective outcome non-reporting bias). Selective reporting of outcomes from among multiple outcomes measured is assessed at the study level as part of the assessment of risk of bias (see Chapter 8, Section 8.7 ), so for the studies contributing to the outcome in the ‘Summary of findings’ table this is addressed by domain 1 above (limitations in the design and implementation). If a large number of studies included in the review do not contribute to an outcome, or if there is evidence of publication bias, the certainty of the evidence may be downgraded. Chapter 13 provides a detailed discussion of reporting biases, including publication bias, and how it may be tackled in a Cochrane Review. A prototypical situation that may elicit suspicion of publication bias is when published evidence includes a number of small studies, all of which are industry-funded (Bhandari et al 2004). For example, 14 studies of flavanoids in patients with haemorrhoids have shown apparent large benefits, but enrolled a total of only 1432 patients (i.e. each study enrolled relatively few patients) (Alonso-Coello et al 2006). The heavy involvement of sponsors in most of these studies raises questions of whether unpublished studies that suggest no benefit exist (publication bias).

A particular body of evidence can suffer from problems associated with more than one of the five factors listed here, and the greater the problems, the lower the certainty of evidence rating that should result. One could imagine a situation in which randomized trials were available, but all or virtually all of these limitations would be present, and in serious form. A very low certainty of evidence rating would result.

Table 14.2.a Further guidelines for domain 1 (of 5) in a GRADE assessment: going from assessments of risk of bias in studies to judgements about study limitations for main outcomes across studies

Table 14.2.b Judgements about indirectness by outcome (available in GRADEpro GDT)

Intervention:

Comparator:

Direct comparison:

Final judgement about indirectness across domains:

14.2.3 Domains that may lead to increasing the certainty level of a body of evidence

Although NRSI and downgraded randomized trials will generally yield a low rating for certainty of evidence, there will be unusual circumstances in which review authors could ‘upgrade’ such evidence to moderate or even high certainty ( Table 14.3.a ).

  • Large effects On rare occasions when methodologically well-done observational studies yield large, consistent and precise estimates of the magnitude of an intervention effect, one may be particularly confident in the results. A large estimated effect (e.g. RR >2 or RR <0.5) in the absence of plausible confounders, or a very large effect (e.g. RR >5 or RR <0.2) in studies with no major threats to validity, might qualify for this. In these situations, while the NRSI may possibly have provided an over-estimate of the true effect, the weak study design may not explain all of the apparent observed benefit. Thus, despite reservations based on the observational study design, review authors are confident that the effect exists. The magnitude of the effect in these studies may move the assigned certainty of evidence from low to moderate (if the effect is large in the absence of other methodological limitations). For example, a meta-analysis of observational studies showed that bicycle helmets reduce the risk of head injuries in cyclists by a large margin (odds ratio (OR) 0.31, 95% CI 0.26 to 0.37) (Thompson et al 2000). This large effect, in the absence of obvious bias that could create the association, suggests a rating of moderate-certainty evidence.  Note : GRADE guidance suggests the possibility of rating up one level for a large effect if the relative effect is greater than 2.0. However, if the point estimate of the relative effect is greater than 2.0, but the confidence interval is appreciably below 2.0, then some hesitation would be appropriate in the decision to rate up for a large effect. Another situation allows inference of a strong association without a formal comparative study. Consider the question of the impact of routine colonoscopy versus no screening for colon cancer on the rate of perforation associated with colonoscopy. Here, a large series of representative patients undergoing colonoscopy may provide high certainty evidence about the risk of perforation associated with colonoscopy. When the risk of the event among patients receiving the relevant comparator is known to be near 0 (i.e. we are certain that the incidence of spontaneous colon perforation in patients not undergoing colonoscopy is extremely low), case series or cohort studies of representative patients can provide high certainty evidence of adverse effects associated with an intervention, thereby allowing us to infer a strong association from even a limited number of events.
  • Dose-response The presence of a dose-response gradient may increase our confidence in the findings of observational studies and thereby enhance the assigned certainty of evidence. For example, our confidence in the result of observational studies that show an increased risk of bleeding in patients who have supratherapeutic anticoagulation levels is increased by the observation that there is a dose-response gradient between the length of time needed for blood to clot (as measured by the international normalized ratio (INR)) and an increased risk of bleeding (Levine et al 2004). A systematic review of NRSI investigating the effect of cyclooxygenase-2 inhibitors on cardiovascular events found that the summary estimate (RR) with rofecoxib was 1.33 (95% CI 1.00 to 1.79) with doses less than 25mg/d, and 2.19 (95% CI 1.64 to 2.91) with doses more than 25mg/d. Although residual confounding is likely to exist in the NRSI that address this issue, the existence of a dose-response gradient and the large apparent effect of higher doses of rofecoxib markedly increase our strength of inference that the association cannot be explained by residual confounding, and is therefore likely to be both causal and, at high levels of exposure, substantial.  Note : GRADE guidance suggests the possibility of rating up one level for a large effect if the relative effect is greater than 2.0. Here, the fact that the point estimate of the relative effect is greater than 2.0, but the confidence interval is appreciably below 2.0 might make some hesitate in the decision to rate up for a large effect
  • Plausible confounding On occasion, all plausible biases from randomized or non-randomized studies may be working to under-estimate an apparent intervention effect. For example, if only sicker patients receive an experimental intervention or exposure, yet they still fare better, it is likely that the actual intervention or exposure effect is larger than the data suggest. For instance, a rigorous systematic review of observational studies including a total of 38 million patients demonstrated higher death rates in private for-profit versus private not-for-profit hospitals (Devereaux et al 2002). One possible bias relates to different disease severity in patients in the two hospital types. It is likely, however, that patients in the not-for-profit hospitals were sicker than those in the for-profit hospitals. Thus, to the extent that residual confounding existed, it would bias results against the not-for-profit hospitals. The second likely bias was the possibility that higher numbers of patients with excellent private insurance coverage could lead to a hospital having more resources and a spill-over effect that would benefit those without such coverage. Since for-profit hospitals are likely to admit a larger proportion of such well-insured patients than not-for-profit hospitals, the bias is once again against the not-for-profit hospitals. Since the plausible biases would all diminish the demonstrated intervention effect, one might consider the evidence from these observational studies as moderate rather than low certainty. A parallel situation exists when observational studies have failed to demonstrate an association, but all plausible biases would have increased an intervention effect. This situation will usually arise in the exploration of apparent harmful effects. For example, because the hypoglycaemic drug phenformin causes lactic acidosis, the related agent metformin was under suspicion for the same toxicity. Nevertheless, very large observational studies have failed to demonstrate an association (Salpeter et al 2007). Given the likelihood that clinicians would be more alert to lactic acidosis in the presence of the agent and over-report its occurrence, one might consider this moderate, or even high certainty, evidence refuting a causal relationship between typical therapeutic doses of metformin and lactic acidosis.

14.3 Describing the assessment of the certainty of a body of evidence using the GRADE framework

Review authors should report the grading of the certainty of evidence in the Results section for each outcome for which this has been performed, providing the rationale for downgrading or upgrading the evidence, and referring to the ‘Summary of findings’ table where applicable.

Table 14.3.a provides a framework and examples for how review authors can justify their judgements about the certainty of evidence in each domain. These justifications should also be included in explanatory notes to the ‘Summary of Findings’ table (see Section 14.1.6.10 ).

Chapter 15, Section 15.6 , describes in more detail how the overall GRADE assessment across all domains can be used to draw conclusions about the effects of the intervention, as well as providing implications for future research.

Table 14.3.a Framework for describing the certainty of evidence and justifying downgrading or upgrading

14.4 Chapter information

Authors: Holger J Schünemann, Julian PT Higgins, Gunn E Vist, Paul Glasziou, Elie A Akl, Nicole Skoetz, Gordon H Guyatt; on behalf of the Cochrane GRADEing Methods Group (formerly Applicability and Recommendations Methods Group) and the Cochrane Statistical Methods Group

Acknowledgements: Andrew D Oxman contributed to earlier versions. Professor Penny Hawe contributed to the text on adverse effects in earlier versions. Jon Deeks provided helpful contributions on an earlier version of this chapter. For details of previous authors and editors of the Handbook , please refer to the Preface.

Funding: This work was in part supported by funding from the Michael G DeGroote Cochrane Canada Centre and the Ontario Ministry of Health.

14.5 References

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Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, Devereaux PJ, Montori VM, Freyschuss B, Vist G, Jaeschke R, Williams JW, Jr., Murad MH, Sinclair D, Falck-Ytter Y, Meerpohl J, Whittington C, Thorlund K, Andrews J, Schünemann HJ. GRADE guidelines 6. Rating the quality of evidence--imprecision. Journal of Clinical Epidemiology 2011b; 64 : 1283-1293.

Iorio A, Spencer FA, Falavigna M, Alba C, Lang E, Burnand B, McGinn T, Hayden J, Williams K, Shea B, Wolff R, Kujpers T, Perel P, Vandvik PO, Glasziou P, Schünemann H, Guyatt G. Use of GRADE for assessment of evidence about prognosis: rating confidence in estimates of event rates in broad categories of patients. BMJ 2015; 350 : h870.

Langendam M, Carrasco-Labra A, Santesso N, Mustafa RA, Brignardello-Petersen R, Ventresca M, Heus P, Lasserson T, Moustgaard R, Brozek J, Schünemann HJ. Improving GRADE evidence tables part 2: a systematic survey of explanatory notes shows more guidance is needed. Journal of Clinical Epidemiology 2016; 74 : 19-27.

Levine MN, Raskob G, Landefeld S, Kearon C, Schulman S. Hemorrhagic complications of anticoagulant treatment: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126 : 287S-310S.

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Santesso N, Carrasco-Labra A, Langendam M, Brignardello-Petersen R, Mustafa RA, Heus P, Lasserson T, Opiyo N, Kunnamo I, Sinclair D, Garner P, Treweek S, Tovey D, Akl EA, Tugwell P, Brozek JL, Guyatt G, Schünemann HJ. Improving GRADE evidence tables part 3: detailed guidance for explanatory footnotes supports creating and understanding GRADE certainty in the evidence judgments. Journal of Clinical Epidemiology 2016; 74 : 28-39.

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Redesigning Continuing Education in the Health Professions (2010)

Chapter: appendix a: literature review tables, appendix a literature review tables.

E vidence on the effectiveness of continuing education (CE) and CE methods was identified through a literature review. Although nonexhaustive, the review included a comprehensive search of the Research and Development Resource Base (RDRB), a bibliographic database of more than 18,000 articles from fields including CE, knowledge translation, interprofessional literature, and faculty development. Articles in the RDRB are culled from Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Excerpta Medica Database (EMBASE), Education Resources Information Center (ERIC), Sociological Abstracts, PsychoInfo, Library Information and Science Abstracts (LISA), and business databases, as well as automatic retrieval of articles from journals dedicated to medical education (e.g., Journal of Continuing Education in the Health Professions , Medical Education , Studies in Continuing Education ).

The RDRB was searched using keywords, 1 and the results of the searches were culled by two independent reviewers using an iterative approach. Studies collected were from 1989 to April 2009.

Abstracts of search results were reviewed to eliminate articles that clearly did not pertain to CE methods, cost-effectiveness, or educational theory and to categorize the studies as informative, equivocal, or not informative of CE effectiveness. A wide range of designs were classified as informative, including randomized controlled trials, prospective cohort studies, observational studies, and studies with pre- and post-intervention assessment methodologies. Quantitative and qualitative approaches were included, and inclusion was not limited to studies with positive results. The most common reasons articles were classified as not informative were absence of a trial design, small sample size, and high likelihood of confounding factors in the design that could affect outcomes. The two reviewers independently classified abstracts and full texts of the articles and then compared their classification results. Interreviewer reliability was greater than 80 percent, and discrepancies were resolved by a consensus process. A third reviewer verified the results classified as informative or equivocal in a final round of detailed assessment of the study design, populations, intervention, type of outcome, and conclusions for each article. Systematic reviews and metaanalyses are included in Table A-1 ; studies and articles are included in Table A-2 .

Table A-1 begins on the next page.

TABLE A-1 Summary of Systematic Reviews on Effectiveness of CE Methods

TABLE A-2 Literature Review on the Effectiveness of CE Methods

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Today in the United States, the professional health workforce is not consistently prepared to provide high quality health care and assure patient safety, even as the nation spends more per capita on health care than any other country. The absence of a comprehensive and well-integrated system of continuing education (CE) in the health professions is an important contributing factor to knowledge and performance deficiencies at the individual and system levels.

To be most effective, health professionals at every stage of their careers must continue learning about advances in research and treatment in their fields (and related fields) in order to obtain and maintain up-to-date knowledge and skills in caring for their patients. Many health professionals regularly undertake a variety of efforts to stay up to date, but on a larger scale, the nation's approach to CE for health professionals fails to support the professions in their efforts to achieve and maintain proficiency.

Redesigning Continuing Education in the Health Professions illustrates a vision for a better system through a comprehensive approach of continuing professional development, and posits a framework upon which to develop a new, more effective system. The book also offers principles to guide the creation of a national continuing education institute.

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  • Open access
  • Published: 14 February 2024

Citizens’ perspectives on relocating care: a scoping review

  • L. J. Damen 1 ,
  • L. H. D. Van Tuyl 1 ,
  • J. C. Korevaar 1 , 3 ,
  • B. J. Knottnerus 1 &
  • J. D. De Jong 1 , 2  

BMC Health Services Research volume  24 , Article number:  202 ( 2024 ) Cite this article

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Healthcare systems around the world are facing large challenges. There are increasing demands and costs while at the same time a diminishing health workforce. Without reform, healthcare systems are unsustainable. Relocating care, for example, from hospitals to sites closer to patients’ homes, is expected to make a key contribution to keeping healthcare sustainable. Given the significant impact of this initiative on citizens, we conducted a scoping review to provide insight into the factors that influence citizens’ attitudes towards relocating care.

A scoping review was conducted. The search was performed in the following databases: Pubmed, Embase, Cinahl, and Scopus. Articles had to include relocating healthcare and citizens’ perspectives on this topic and the articles had to be about a European country with a strong primary care system. After applying the inclusion and exclusion criteria, 70 articles remained.

Factors positively influencing citizens’ attitudes towards relocating care included: convenience, familiarity, accessibility, patients having more control over their disease, and privacy. Factors influencing negative attitudes included: concerns about the quality of care, familiarity, the lack of physical examination, contact with others, convenience, and privacy. Furthermore, in general, most citizens preferred to relocate care in the studies we found, especially from the hospital to care provided at home.

Several factors influencing the attitude of citizens towards relocating care were found. These factors are very important when determining citizens’ preferences for the location of their healthcare. The majority of studies in this review reported that citizens are in favour of relocating care. In general citizens’ perspectives on relocating care are very often missing in articles. It was significant that very few studies on relocation from the hospital to the general practitioner were identified.

Peer Review reports

Introduction

Demand for healthcare is increasing across the world due to a number of developments including populations ageing, technical advances in medical care, and rising incomes [ 1 , 2 , 3 ]. With an increase in demand, costs will also rise, while at the same time a diminishing health workforce. [ 1 , 2 , 3 , 4 , 5 ]. Consequently, reforms within the healthcare system will be necessary in order to control increasing healthcare costs and staff shortages [ 1 , 2 , 3 ]. It is assumed that reforming healthcare systems with a view to making better use of resources will make a key contribution to keeping healthcare sustainable. Estimates suggest that one fifth of health spending could be channelled towards better use, thus improving healthcare efficiency [ 6 ]. Increased efficiency could be accomplished in several ways. These may include: reducing the number of patients who receive low-value or unnecessary care; providing the same care with fewer resources, for instance by providing care in more cost-effective settings rather than in hospitals; or by reducing administrative processes that add no value [ 6 ]. This article focuses on providing care with fewer resources by relocating it to more cost-effective settings. This, in the first instance, would mean from secondary care to primary care. The thought behind this is that general practitioners (GPs) can generally provide care at less expense than hospitals for certain procedures that do not need hospital staff or environment [ 6 ]. These may include minor interventions, such as the placement of an intra-uterine device (IUD), or follow-up care, such as yearly blood- and ultrasounds, for patients who have been treated for cancer[ 6 , 7 , 8 , 9 ]. Relocating care to control costs could also include relocating care from secondary to homecare, self-care or eHealth [ 10 ]. Delivering care digitally can prevent a patient from having to go to the hospital. For example, an app could be used to monitor a patient receiving oxygen at home. Care commonly provided by the GP could also be relocated, to self-care, eHealth or to other healthcare providers (HCPs), like a physiotherapist or dietitian. This could result in more time for the GP to take on other secondary or primary care tasks.

It is important for relocating care to succeed, to get insights into the perspectives and needs of healthcare providers and citizens. Although involving citizens is a very important aspect of policy-making processes, it is an often overlooked form of evidence according to the World Health Organization (WHO) [ 11 ]. Citizen engagement will strengthen societal trust, will lead to more effective public policies and will lead to an improved quality of care. Furthermore, citizen engagement is essential because healthcare systems are transitioning towards a patient-centered approach, where citizens' perspectives on quality are inherently meaningful and should be a primary focus within healthcare systems [ 12 ].Extensive research has already been undertaken regarding the perspective of healthcare providers [ 9 , 13 , 14 , 15 , 16 ], the quality and outcomes of care [ 17 , 18 , 19 , 20 ] and the cost perspectives [ 10 , 17 , 18 , 20 , 21 ], but not regarding the citizens' perspective on relocating care. To our knowledge, a review about citizens’ perspectives on relocating care does not exist yet. We have, therefore, conducted a scoping review with the goal of describing the findings and range of research concerning citizens’ perspectives on relocating care in more detail. A strong primary care system is required to make relocating care possible [ 6 ]. We, therefore, searched for studies that were undertaken in countries in Europe with a strong primary care [ 22 ]. Table 1 describes the characteristics of countries with strong primary care. The research questions answered in this review are: (1) Which factors influence citizens’ attitudes towards relocating care? (2) What are citizens’ preferences towards the location of care?

The aim of this review is to understand citizens’ attitudes and preferences towards relocating care. As this topic is quite broad and may be studied using many different study designs, and considering that we are not aware of any prior synthesis on this topic, a scoping review rather than a systematic review was conducted. This scoping review was carried out on the basis of the guideline by Arksey and O’Malley [ 23 ]. The review includes the following key phases: 1) identifying the research question; 2) identifying relevant studies; 3) study selection; 4) charting the data, and; 5) collating, summarising, and reporting the results.

The search strategy and selection of literature

An initial broad search of the literature was undertaken by the first author in order to identify relevant articles that could be used for designing a search strategy. During this search, 18 key articles were identified, which included citizens, preference, and relocating care, these three terms formed the basis of our search strategy. A qualified medical information specialist was consulted in order to design and execute a sensitive search strategy. The medical information specialist also advised on which databases were most likely to contain the type of studies we were seeking and thus constituted an initial search strategy. This was refined several times after consultation. The final version was first used on the Pubmed database and then converted for each of these subsequent databases, Embase, Cinahl, and Scopus. The final search strategy, shown in Appendix A , was able to find 16 out of the 18 key articles identified. In total, it identified 19.587 articles. Duplicate references were removed, leaving 11.080 unique references. The most recent search was executed on 5 July 2022.

The selection process was performed by all authors. First, inclusion and exclusion criteria were developed. There were several inclusion criteria for this scoping review. The topic of the articles had to be citizens’ perspectives on relocating care. Only articles related to European countries with strong primary care systems were included, as a strong primary care system is required to make relocating care possible [ 6 ]. These countries were: the Netherlands, the United Kingdom, Belgium, Spain, Portugal, Finland, Estonia, Lithuania, Denmark, and Slovenia [ 22 ]. Only articles written in English, Dutch, or German were included as these were languages sufficiently mastered by the authors. In addition, all study designs were included. An overview of inclusion and exclusion criteria are shown in Table  2 . In order to calibrate the inclusion process, the researchers independently applied the inclusion and exclusion criteria to a selection of three hundred articles. The task was to include, or exclude, articles based on the title alone. The results were discussed by the researchers to see if there was a maximum margin of disagreement up to 10%. This percentage was agreed in advance by the researchers. During this process, the inclusion and exclusion criteria were further refined (See Table  2 ). As disagreement remained, a second round of calibration was performed on 50 articles, including both titles and abstracts. The disagreement rate was now only 4% and therefore all the remaining articles were distributed among the reviewers to be scored, based on the title and abstract. After screening on the title and abstract, 167 references remained and two key articles that were not found with the search were added. These articles were distributed among the researchers once more in order to read the full text. While reading the full texts, another three relevant articles were identified through the references. These were then added too. This resulted in a total of 172 full text articles. Results from included articles were charted in a spreadsheet, which was tested by the researchers before using it. When one of the reviewers had doubts about an article, it was read by a second reviewer and the outcomes were discussed until the two researchers came to an agreement.

Data extraction

A spreadsheet was created to categorise the information that contributed to answering the research questions.

The information extracted from the articles was structured according to the type of relocation, including: relocating from the hospital to the GP, to care at home, to self-care, or to eHealth, and relocating from the GP to self-care, to care at home, or to eHealth. The difference between self-care and care at home is that self-care does not involve a healthcare provider, unlike care at home. Both forms of relocating do not involve eHealth. When the article was about eHealth it was catalogued with the eHealth category. Articles that remained, of which there was only one, were placed within the category ‘other’.

The information extracted included factors that determined citizens’ attitudes towards relocating care. All of these factors were coded by highlighter and categorised. The categories were discussed within the research team. Subsequently, we made a top three of factors for each form of relocation that occurred most often.

Furthermore, we extracted information regarding preferences for healthcare location in the articles. Citizens could have a preference for either keeping care its current location, relocating care, or a combination of both, suggesting that citizens may prefer a hybrid approach where some aspects of healthcare are relocated, while others remain in their current location. Citizens could also express equal preferences for both locations. In addition, we compared the outcomes of the one-armed, the two-armed, and the hypothetical studies, to see if there were major differences, in the preferences for healthcare location, resulting from their methodological approaches. In the one-armed studies, care was relocated for all participants in the study [ 24 ]. In the two-armed studies there was one group of participants where care was relocated, but also one group who received care as usual. The outcomes of the two groups were then compared. Hypothetical studies, presented scenarios without actual choices. They asked citizens how they would feel if care were relocated. Two-armed studies are generally considered of higher quality than one-armed and hypothetical studies, due to the presence of both an experimental group and a control group, which increases their internal validity [ 25 ].

Search flow

A total of 19,587 references were identified from the databases, of which 8,507 were duplicates, as shown in Fig.  1 . At the end of the selection process, 70 full text articles were included. The characteristics of these studies are shown in Table  3 .

figure 1

Flowchart of the review process

The majority of studies of citizens’ perspectives on relocating care took place in the UK ( N  = 44), followed by the Netherlands ( N  = 13), and Denmark ( N  = 11). One study is from Spain and one from Estonia. Most studies are one-armed ( N  = 42), followed by two-armed ( n  = 19), and nine studies were hypothetical. While eight studies are from 2013, most studies were published quite recently in 2019 ( N  = 7), 2020 ( N  = 6), 2021 ( N  = 16), and 2022 ( N  = 9). Relocating care from the hospital to eHealth is the form of relocating that is most often examined within the studies identified ( N  = 28) [ 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 ]. This is followed by relocating from the hospital to self-care ( N  = 15) [ 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 ] and care at home ( N  = 13) [ 30 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 ]. Forms of relocating care that are not frequently studied include relocating from the hospital to the GP ( N  = 7) [ 16 , 69 , 81 , 82 , 83 , 84 , 85 ] and from the GP to self-care ( N  = 4) [ 86 , 87 , 88 , 89 ]. Five more forms of relocating are listed under the heading “other”. These include: relocating from the hospital to a community-based clinic [ 90 ]; from outpatient visits to a one-stop clinic [ 91 ]; nurse home visits that were replaced by eHealth [ 92 ]; hospital care relocated to a mobile chemotherapy unit [ 93 ]; and, care relocated from the GP to eHealth [ 94 ]. Most studies are about the relocation of care for oncology patients ( N  = 19), followed by citizens in general ( N  = 10), and cardiology patients ( N  = 8).

Which factors influence citizens’ attitudes towards relocating care?

Convenience.

The most frequently cited factors influencing citizens’ attitudes towards relocating care are shown in Table  4 . Convenience was most often reported, from the citizens’ perspective, as an advantage of relocating care. This was true for all forms of relocation [ 27 , 28 , 29 , 30 , 32 , 33 , 34 , 38 , 41 , 42 , 45 , 47 , 49 , 52 , 53 , 54 , 58 , 59 , 60 , 65 , 66 , 67 , 69 , 70 , 73 , 78 , 82 , 84 , 85 , 86 , 88 , 90 , 93 , 94 ]. Citizens think of relocating as convenient because in most cases it saves travel time [ 26 , 29 , 53 ]. It saves costs [ 26 , 69 ]. It avoids stress due to factors such as transport problems, busy traffic, travelling while you are sick, or long sojourns in waiting rooms [ 26 , 53 , 73 , 93 ]. When relocating to self-care it was very often mentioned that it is an advantage to have more flexibility [ 30 , 86 ]. Citizens can do a self-test whenever and wherever they want, without having to consider opening hours, for example [ 59 , 66 , 67 ]. Convenience was also mentioned as a reason for not wanting to relocate care. This factor was especially mentioned when relocating from the hospital or GP to self-care [ 59 , 60 , 86 ]. With regard to home dialysis, some citizens said that they did not have the space at home to do this. It was, therefore, not convenient [ 60 ]. In addition, for citizens living close to the hospital, self-care was sometimes more expensive and did not save time [ 59 , 86 ].

Familiarity

Familiarity was another factor which was reported as important to citizens regarding their attitude towards relocating care [ 29 , 30 , 31 , 32 , 33 , 58 , 61 , 67 , 68 , 69 , 70 , 73 , 74 , 77 , 83 , 84 , 85 , 86 , 90 , 94 ]. Some citizens feel more familiar with their GP than with a hospital specialist and would, therefore, want to relocate care [ 83 , 84 ]. Other citizens experience a sense of familiarity due to the environment in which care is provided. When receiving care at home, citizens feel more familiar, because they are in their own environment with their own support system [ 29 , 30 , 50 , 58 , 70 , 77 ]. In addition, when receiving care at home, the HCP enters the personal space of the patient. This, according to some of the patients, provided a better and more personal connection with the HCP. As shown in Table  4 , familiarity is also named as a reason not to want to relocate. While some citizens said that they had a better relationship with their GP, others said they were more familiar with the specialist so they would rather go there [ 85 ]. Some citizens thought that personal contact was reduced when using eHealth. They felt that it was more distant [ 31 , 33 , 36 , 47 , 51 ]. In addition, during telephone consultations, citizens did not feel a sense of familiarity if they had never seen the HCP before and therefore could not picture the face belonging to the voice. [ 29 ]. With regard to self-care, some citizens did not feel a sense of familiarity because this care is usually performed alone, while they preferred to have the support of a HCP [ 60 , 63 ].

Accessibility

The third most frequently mentioned factor that influenced citizens’ perceptions of relocating care was “accessibility”. Citizens were more willing to relocate care when waiting times became shorter and so the accessibility became better [ 28 , 29 , 30 , 45 , 49 , 54 , 58 , 82 , 83 , 84 , 88 , 90 , 91 , 93 ]. For example when relocating from the hospital to the GP [ 82 , 83 , 84 ]. Regarding self-tests, citizens mentioned that they had very rapid access. They can pick up the test and then apply it directly, without having to make an appointment with a HCP, who is often not immediately available [ 30 , 54 , 55 , 58 ]. In addition, with a self-test you often get the results without delay [ 55 , 59 ]. With regard to eHealth, citizens said that access to the HCP improved because they could contact them easily when they had questions [ 28 , 49 ].

Patients have more control

Another advantage of relocating care, mentioned by citizens, is being more in control, especially when relocating care from the hospital to eHealth, self-care, or to care at home [ 30 , 54 , 58 , 60 , 70 , 73 ]. The sense of increased control can stem from two primary factors. Firstly, patients become more actively engaged in their healthcare, leading to a better understanding of their diagnoses and consequently, greater control over their condition [ 38 , 49 , 53 , 59 , 86 ]. Secondly, citizens felt more involved in the process of decision making regarding their healthcare, affording them the ability to influence what happens and when [ 49 , 50 , 59 , 74 ]. This gives them the feeling of having more control over their lives.

The last factor named as an advantage, but also as a disadvantage of relocating care, is ‘privacy’. Citizens who saw it as an advantage mentioned that there is more privacy at home using eHealth or self-care than there is in a hospital [ 53 , 54 , 55 , 58 , 60 , 66 , 69 , 70 , 74 ]. With regard to self-care there are a lot of articles about using self-tests to check for sexually transmitted infections or about administering drugs oneself at home in order to induce an abortion. Citizens indicated that having such tests carried out at a clinic may cause a lot of embarrassment [ 54 ]. You may run into acquaintances for example [ 67 ]. Self-care, on the other hand, is more anonymous and thus offers more privacy [ 55 ]. However, privacy is also named as an disadvantage by citizens. Regarding eHealth, some citizens are concerned about whether the privacy of their data can be guaranteed [ 33 ]. In addition, some citizens said that it was hard to find a private space in their house during the covid-19 crisis [ 30 ]. Furthermore, when care is being given at home, some citizens do not like the fact that other family members may witness them being treated [ 69 ] or that caregivers are having to enter their home, thus violating their privacy [ 70 ].

Quality of care

The most frequently mentioned factor for having a negative attitude towards relocating care is that citizens have concerns about the quality of care when care is being relocated, due to less expertise of the HCP or insufficient quality of the instrument or self-test, which will be involved in the new location [ 28 , 32 , 33 , 34 , 36 , 47 , 51 , 54 , 55 , 59 , 60 , 63 , 65 , 67 , 69 , 70 , 73 , 77 , 82 , 85 , 86 , 87 , 90 , 94 ]. Regarding relocating care to eHealth or self-care a lack of trust in eHealth technology [ 33 , 34 , 36 , 47 ], or a particular self-care device, [ 54 , 55 , 59 , 60 , 63 , 65 , 67 ] was reported very often. Citizens fear technical problems or that important factors might be overlooked. Neither do some citizens feel that they have the right skills for using the new eHealth technology [ 36 ] or performing self-care in the right way [ 54 , 60 , 65 , 67 ]. Regarding care at home, citizens were concerned with the absence of constant surveillance and a diminished contact with the doctor. Moreover, citizens felt that the hospital is better equipped [ 77 ]. With regard to relocating from the hospital to the GP, some citizens thought that the specialist had more expertise which was a reason for them not wanting to relocate [ 82 , 85 ].

No physical examination

Another factor for not wanting to relocate care is where it results in an absence of physical examination. This reason was named many times when relocating care from the hospital to eHealth [ 27 , 29 , 31 , 34 , 47 , 51 , 52 ] and relocating from the GP to self-care [ 86 , 89 ]. With regard to eHealth, some citizens say that they found it difficult because they are not able to demonstrate physical symptoms and they find it hard to describe problems without seeing the HCP [ 31 , 33 ].

Contact with others

The last factor, frequently mentioned as a disadvantage of relocating care, is less contact with their peers. This aspect was most mentioned regarding relocating from the hospital to care at home [ 69 , 70 , 73 ]. Some citizens enjoyed going to the hospital because of the social interaction with other citizens. They were afraid of social isolation [ 60 ].

What are citizens’ preferences regarding the location of care?

A total of 49 articles investigated citizens’ preferences regarding the location of healthcare. Their location preferences for each form of relocating care will be discussed below and are shown in Table  5 .

Within the articles about relocating from the hospital to eHealth, 23 articles out of 28 provided the preferences of respondents towards the location of care. In ten articles there was a preference for eHealth [ 28 , 32 , 33 , 34 , 42 , 44 , 45 , 46 , 50 , 53 ] and in six articles a preference for the hospital [ 26 , 31 , 36 , 39 , 43 , 48 ]. In four articles, citizens expressed a wish for a combination of eHealth and face to face contact [ 37 , 47 , 49 , 52 ]. In the remaining articles ( N  = 3), the preference was equal for the hospital and for eHealth [ 35 , 41 , 51 ].

Eight out of 15 articles about relocating from the hospital to self-care investigated citizens preferences for the location of care. In five articles citizens showed a preference for self-care [ 56 , 57 , 61 , 64 , 66 ] and in three articles for the hospital [ 55 , 60 , 65 ].

With regard to articles about relocating from the hospital to care at home, ten out of 13 articles investigated a preference for healthcare location. In eight articles, the participants had a preference for care at home [ 68 , 69 , 72 , 74 , 75 , 78 , 79 , 80 ]. In two articles, preferences for care at home and the hospital were equal [ 71 , 76 ]. There were no articles with a preference for the hospital.

Regarding relocating from the hospital to the GP, there were five out of seven articles investigating citizens preferences regarding healthcare location. In two articles, participants preferred the hospital over the GP [ 81 , 85 ]. In one they preferred the GP [ 84 ], and in the other, preferences were equal [ 16 ]. In the fifth study citizens could choose between three locations: the hospital, the GP, or care at Home. Here they preferred care at home followed by care at the general practice [ 69 ].

Two out of four articles about relocating from the GP to self-care investigated a preference for a healthcare location. In one article, citizens preferred self-care [ 86 ], and in the other, they preferred the GP [ 89 ].

Within the category “other”, there were two articles which investigated a preference for a healthcare location. In the article about relocating from the hospital to one-and-a-half line care, citizens preferred one-and-a-half line care [ 91 ]. The last article was about nurse home visits that were relocated to eHealth. Here, citizens preferred eHealth over the nurse visits [ 93 ].

Most articles adopted a one-armed approach. Since two-armed articles are often of higher quality, we compared the results of the one-armed, and the two-armed, articles. In total there were 19 two-armed articles of which 14 investigated a preference for healthcare location. In nine out of 14 articles citizens preferred relocating healthcare and in two articles they did not. In the other articles, preferences were equal. Of the 35 one-armed articles which investigated healthcare preferences in 18 articles, citizens gave a preference for relocating healthcare. Thus, in both cases, there is a preference for relocating care in just over half of the articles. We see here a different outcome than with the hypothetical studies ( N  = 10). Here there was no preference for relocating care in five out of seven articles.

This scoping review was conducted in order to provide insight into the factors that influence citizens attitudes towards relocating care. Seventy articles were included and most which were found were about relocating care from the hospital to eHealth. Most of these articles about eHealth were published in 2020 or later ( N  = 20). Only eight articles were published in 2019 or earlier. This is likely due to covid-19, which started in 2020 in Europe and required healthcare providers in many places to offer care online.

The first research question concerned which factors influence citizens attitudes towards relocating care. The most frequent reported factor for a positive attitude towards relocating care is “convenience”, according to citizens, followed by “familiarity”. Other factors that were in the top three of reasons for a positive attitude towards relocating care were “accessibility”, “patients have more control”, and “privacy”. The positive drivers for relocating care are almost the same for all forms of relocating. The two most mentioned factors for a negative attitude towards relocating care are, first of all, citizens having concerns about the quality of care and, secondly, citizens feel less familiar when care is being relocated. Other reasons to have a negative attitude towards relocating are “the lack of physical examination”, “contact with others”, “convenience”, and “privacy”.

The second research question concerned citizens’ preferences for healthcare location. In general, as far as the conditions and treatments mentioned in the articles are concerned, most citizens favoured relocating healthcare. Especially with regard to care at home, there were no articles found where citizens had a preference for the hospital instead of care at home. In addition, eHealth and self-care are also carried out from home. Citizens thus prefer receiving care at home.

Not all articles investigated preferences for the location of healthcare, and of those which did, most were one-armed. However, there were no major differences found when comparing the outcomes of the one-armed and two-armed studies. This contrasted with the hypothetical studies, where citizens did not prefer relocating care in the majority of cases. This may be due to the fact that citizens are familiar with the current situation and do not know, or find it difficult to imagine, what a new situation will look like. Citizens may not want to relocate because familiarity is an important aspect of healthcare, as described earlier.

The articles found included a wide variety of conditions and phases of treatment. We would have preferred to distinguish between different conditions and treatment phases, as these aspects may determine the preference for healthcare location. For example, it might be the case that citizens would like to relocate follow-up cancer care to care at home, while keeping the treatment itself in the hospital. However, the large variation in conditions and phases of treatment resulted in a small N per condition or phase of treatment and this hampered further in-depth analysis.

Relocating care often involves not only the location changing, but also other aspects. For instance, the care provider may change too, for example a telephone consultation with a nurse instead of a face to face appointment with the specialist in the hospital [ 32 , 53 ]. And in some cases, the purpose of treatment changed, for example, a telephone consultation that was meant for providing information and supporting patients, while a face to face consultation was more focused on looking for signs of recurrent disease [ 29 ]. All of these factors together determine the preference for healthcare location. So it is not only the location on which citizens base their preference. It is, therefore, important to take all aspects into account, not only the geography when investigating the preferences for healthcare location.

Strengths and limitations

A strength of this scoping review is that it has a broad search strategy developed together with a medical information specialist. This resulted in over 11.000 references that were all assessed. However, the search strategy may not have been broad enough, as some articles were missed, including two of the 18 key articles. This was known beforehand and so we investigated why the two key articles were not found. One key article was not found because we did not use the word “experience” [ 16 ] while the other focused on the terms “breast cancer”, “follow-up care”, and “healthcare models” [ 81 ], which we did not use in our search strategy. The words used in these two articles were not words we saw repeated in other relevant articles. Adding any of the key words yielded about 5,800 additional results in Pubmed alone. Therefore, we chose to add the key articles manually and left these words out of the search string. All statements made in this article are based on the conditions and forms of care that recurred in the studies we found. There may be other forms of care that could be relocated that have not been discussed in this article.

Another limitation of this study is that the articles are not double reviewed because of the large number of references found. However, to calibrate the inclusion process, the researchers applied the inclusion and exclusion criteria to a selection of 350 articles. Also, it was decided to start with reviewing abstracts, instead of titles, which is the normal procedure [ 23 ].

A limitation of a scoping review is that it analyses studies that use a range of data collection and techniques. This makes it more difficult to synthesise the results of the studies [ 23 ]. A strong point of this review is that we made a comparison between one-armed and two-armed articles and that approximately the same results emerged in the articles.

Research implications

A knowledge gap we identified is that citizens’ perspectives on relocating care received relatively little attention within the current literature. In particular, we found limited literature focusing on citizens’ perspectives regarding the relocation of care from the hospital to the GP. This gap is significant, because this is one of the forms of relocating that governments think of first in order to limit healthcare costs [ 6 , 7 , 8 ]. There are several studies about this subject but they do not involve the citizens’ perspective. Despite the importance of including citizens' perspectives in policy-making processes, it often remains underrepresented in the literature [ 11 ]. The World Health Organization (WHO) emphasizes that citizen engagement can enhance societal trust and lead to more effective public policies.

Another knowledge gap we identified is that insufficient research has been done on different treatment phases and conditions in healthcare with regard to citizens’ perspectives and relocating care. To fill this gap, future research should delve deeper into the relationship between the factors leading to particular attitudes towards relocating care, and preferences for location of care and different conditions and treatment phases, including diagnosis, treatment phase and aftercare.

Our study has also revealed practical implications that can inform healthcare policy and decision-making. Firstly, the factors we have identified can serve as conditions that governments can use to improve acceptance among citizens regarding healthcare location. They can be used as conditions that have to be met, and that can be used to direct citizens to a particular location. Secondly, it's evident from our findings that citizens generally prefer receiving care from home. This preference presents an opportunity for governments to invest in home-based healthcare services, potentially leading to higher citizen satisfaction and more cost-effective healthcare delivery.

Positive factors influencing the attitude of citizens towards relocating care are almost the same for all forms of this development—with convenience as the most important. The most often reported factor for having a negative attitude towards relocating care are concerns about the quality of care. The factors found are very important when determining a citizens’ preference for a particular healthcare location. The majority of studies in this review reported that citizens are in favour of relocating care, especially to care at home. Several knowledge gaps were identified. Strikingly, very few studies on relocation from the hospital to the GP were identified.

Availability of data and materials

Not applicable. The studies we used are accessible to everyone. All studies used are included in the references.

Abbreviations

General practitioner

Healthcare provider

Intra-uterine device

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Acknowledgements

We would like to thank Linda Schoonmade, medical information specialist, for her contribution to this research in helping develop the search strategy.

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Damen, L.J., Van Tuyl, L.H.D., Korevaar, J.C. et al. Citizens’ perspectives on relocating care: a scoping review. BMC Health Serv Res 24 , 202 (2024). https://doi.org/10.1186/s12913-024-10671-3

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