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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.

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what part of an article is the literature review

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

As you write, you can follow these tips:

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

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

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

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

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

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

 Statistics

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

Research bias

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

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

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

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

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

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

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

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

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

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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.

The Writing Center • University of North Carolina at Chapel Hill

Literature Reviews

What this handout is about.

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

Introduction

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

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

What is a literature review, then?

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

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

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

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

Why do we write literature reviews?

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

Who writes these things, anyway?

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

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

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

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

Find models

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

Narrow your topic

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

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

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

Consider whether your sources are current

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

Strategies for writing the literature review

Find a focus.

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

Convey it to your reader

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

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

Consider organization

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

First, cover the basic categories

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

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

Organizing the body

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

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

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

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

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

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

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

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

Begin composing

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

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

Use evidence

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

Be selective

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

Use quotes sparingly

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

Summarize and synthesize

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

Keep your own voice

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

Use caution when paraphrasing

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

Revise, revise, revise

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

Works consulted

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

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

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

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

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

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

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

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  • Introduction

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

  • UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Literature Review

  • What is a Literature Review?
  • What is a good literature review?
  • Types of Literature Reviews
  • What are the parts of a Literature Review?
  • What is the difference between a Systematic Review and a Literature Review?

Parts of a Literature Review

Introduction      .

  • To explain the focus and establish the importance of the subject
  • provide the framework, selection criteria, or parameters of your literature review
  • provide background or history
  • outline what kind of work has been done on the topic
  • briefly identify any controversies within the field or any recent research that has raised questions about earlier assumptions
  • In a stand-alone literature review, this statement will sum up and evaluate the current state of this field of research
  • In a review that is an introduction or preparatory to a thesis or research report, it will suggest how the review findings will lead to the research the writer proposes to undertake.
  • To summarize and evaluate the current state of knowledge in the field
  • To note major themes or topics, the most important trends, and any findings about which researchers agree or disagree
  • Often divided by headings/subheadings
  • If the review is preliminary to your own thesis or research project, its purpose is to make an argument that will justify your proposed research. Therefore, the literature review will discuss only that research which leads directly to your own project.
  • To summarize the evidence presented and show its significance
  • Rather than restating your thesis or purpose statement, explain what your review tells you about the current state of the field
  • If the review is an introduction to your own research, the conclusion highlights gaps and indicates how previous research leads to your own research project and chosen methodology. 
  • If the review is a stand-alone assignment for a course, the conclusion should suggest any practical applications of the research as well as the implications and possibilities for future research.
  • Find out what style guide you are required to follow (e.g., APA, MLA, ASA)
  • Follow the guidelines to format citations and create a reference list or bibliography
  • Cite Your Sources

This work is licensed under a  Creative Commons Attribution-NonCommercial-ShareAlike 4.0  International License. adapted from UofG,McLaughlin Library

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What is a literature review?

A literature review discusses published information in a particular subject area. Often part of the introduction to an essay, research report or thesis, the literature review is literally a "re" view or "look again" at what has already been written about the topic, wherein the author analyzes a segment of a published body of knowledge through summary, classification, and comparison of prior research studies, reviews of literature, and theoretical articles. Literature reviews provide the reader with a bibliographic history of the scholarly research in any given field of study. As such,  as new information becomes available, literature reviews grow in length or become focused on one specific aspect of the topic.

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

A literature review is NOT:

  • An annotated bibliography – a list of citations to books, articles and documents that includes a brief description and evaluation for each citation. The annotations inform the reader of the relevance, accuracy and quality of the sources cited.
  • A literary review – a critical discussion of the merits and weaknesses of a literary work.
  • A book review – a critical discussion of the merits and weaknesses of a particular book.
  • Teaching Information Literacy Reframed: 50+ Framework-Based Exercises for Creating Information-Literate Learners
  • The UNC Writing Center – Literature Reviews
  • The UW-Madison Writing Center: The Writer’s Handbook – Academic and Professional Writing – Learn How to Write a Literature Review

What is the difference between a literature review and a research paper?

The focus of a literature review is to summarize and synthesize the arguments and ideas of others without adding new contributions, whereas academic research papers present and develop new arguments that build upon the previously available body of literature.

How do I write a literature review?

There are many resources that offer step-by-step guidance for writing a literature review, and you can find some of them under Other Resources in the menu to the left. Writing the Literature Review: A Practical Guide suggests these steps:

  • Chose a review topic and develop a research question
  • Locate and organize research sources
  • Select, analyze and annotate sources
  • Evaluate research articles and other documents
  • Structure and organize the literature review
  • Develop arguments and supporting claims
  • Synthesize and interpret the literature
  • Put it all together

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What is the purpose of writing a literature review?

Literature reviews serve as a guide to a particular topic: professionals can use literature reviews to keep current on their field; scholars can determine credibility of the writer in his or her field by analyzing the literature review.

As a writer, you will use the literature review to:

  • See what has, and what has not, been investigated about your topic
  • Identify data sources that other researches have used
  • Learn how others in the field have defined and measured key concepts
  • Establish context, or background, for the argument explored in the rest of a paper
  • Explain what the strengths and weaknesses of that knowledge and ideas might be
  • Contribute to the field by moving research forward
  • To keep the writer/reader up to date with current developments in a particular field of study
  • Develop alternative research projects
  • Put your work in perspective
  • Demonstrate your understanding and your ability to critically evaluate research in the field
  • Provide evidence that may support your own findings
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Scholarly Articles: How can I tell?

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Literature Review

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The literature review section of an article is a summary or analysis of all the research the author read before doing his/her own research. This section may be part of the introduction or in a section called Background. It provides the background on who has done related research, what that research has or has not uncovered and how the current research contributes to the conversation on the topic. When you read the lit review ask:

  • Does the review of the literature logically lead up to the research questions?
  • Do the authors review articles relevant to their research study?
  • Do the authors show where there are gaps in the literature?

The lit review is also a good place to find other sources you may want to read on this topic to help you get the bigger picture.

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what part of an article is the literature review

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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

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

Importance of a Good Literature Review

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

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

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

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

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

Types of Literature Reviews

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

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

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

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

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

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

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

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

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

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

Structure and Writing Style

I.  Thinking About Your Literature Review

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

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

The critical evaluation of each work should consider :

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

II.  Development of the Literature Review

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

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

III.  Ways to Organize Your Literature Review

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

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

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

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

IV.  Writing Your Literature Review

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

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

V.  Common Mistakes to Avoid

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

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

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

Writing Tip

Break Out of Your Disciplinary Box!

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

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

Another Writing Tip

Don't Just Review for Content!

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

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

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

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

Yet Another Writing Tip

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

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

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

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

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  • Last Updated: Mar 8, 2024 1:02 PM
  • URL: https://libguides.usc.edu/writingguide

Grad Coach

How To Structure Your Literature Review

3 options to help structure your chapter.

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

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

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

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

The function of the lit review

But wait – is this the right time?

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

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

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

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

Need a helping hand?

what part of an article is the literature review

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

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

1: The Introduction Section

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

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

Example of literature review outline structure

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

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

Free Webinar: Literature Review 101

2: The Body Section

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

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

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

The body section of your literature review is the where you'll present, analyse, evaluate and synthesise the existing research.

Option 1: Chronological (according to date)

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

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

Adopting the chronological structure allows you to discuss the developments and debates in the field as they emerged over time.

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

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

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

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

Option 2: Thematic (grouped by theme)

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

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

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

The thematic structure allows you to organise your literature by theme or category  – e.g. by independent variables.

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

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

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

Option 3: Methodological

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

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

The methodological structure allows you to organise your chapter by the analysis method  used - e.g. qual, quant or mixed.

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

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

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

3: The Conclusion Section

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

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

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

In the conclusion section, you’ll need to present the key findings of your literature review and highlight the gaps that exist in the literature. Based on this, you'll  need to make it clear what your study will add  to the literature.

Example: Thematically Structured Review

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

Let’s Recap

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

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

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

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 .

You Might Also Like:

Literature review 101 - how to find articles

27 Comments

Marin

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

ISHAYA JEREMIAH AYOCK

I agree with you Marin… A great piece

Qaiser

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

Maurice Kagwi

Awesome article for my research.

Ache Roland Ndifor

I thank you immensely for this wonderful guide

Malik Imtiaz Ahmad

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

Franklin Zon

Very educative and good time to get guide. Thank you

Dozie

Great work, very insightful. Thank you.

KAWU ALHASSAN

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

CYRUS ODUAH

Thank you very much, very helpful

Michael Sanya Oluyede

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

Karla Buchanan

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

Enang Lazarus

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

Biswadeb Dasgupta

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

Vik

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

S Dlamini

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

PATRICK MACKARNESS

Beautifully clear.nThank you!

Lucid! Thankyou!

Abraham

Brilliant work, well understood, many thanks

Nour

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

Lindiey

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

NAGARAJU K

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

Vakaloloma

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

Alphonse NSHIMIYIMANA

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

Resa

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

Gerald Gormanous

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

kan

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

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How To Write A Literature Review - A Complete Guide

Deeptanshu D

Table of Contents

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

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

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

Perform Literature reviews using SciSpace Copilot

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

What is a literature review?

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

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

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

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

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

A literature review paper

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

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

What is the purpose of a literature review?

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

What is the importance of a literature review?

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

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

How long should a literature review be?

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

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

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

What are the different types of literature reviews?

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

Here are the different types of literature reviews:

Argumentative review

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

Integrative review

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

Methodological review

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

Systematic review

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

Meta-analysis review

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

Historical review

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

Theoretical Review

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

Scoping Review

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

State-of-the-Art Review

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

Can you use the first person in a literature review?

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

Do you need an abstract for a literature review?

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

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

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

Abstract-of-a-literature-review

Is a literature review written in the past tense?

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

How many sources for a literature review?

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

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

Quick tips on how to write a literature review

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

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

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

1. Outline and identify the purpose of  a literature review

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

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

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

2. Search relevant literature

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

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

  • Google Scholar
  • Microsoft Academic
  • Science.gov

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

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

3. Examine and assess the sources

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

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

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

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

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

4. Discover connections

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

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

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

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

5. Structure planning to write a good literature review

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

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

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

Literature review samples

1. Standalone

Standalone-Literature-Review

2. As a section of a research paper

Literature-review-as-a-section-of-a-research-paper

How SciSpace Discover makes literature review a breeze?

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

Find the right information

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

Assess credibility of papers quickly

Assess-credibility-of-papers-quickly-using-SciSpace

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

Get the complete picture in no time

SciSpace's-personalized-informtion-engine

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

Make referring sources super easy

Make-referring-pages-super-easy-with-SciSpace

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

Final tips on how to write a literature review

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

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

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

Frequently Asked Questions (FAQs)

1. how to start a literature review.

• What questions do you want to answer?

• What sources do you need to answer these questions?

• What information do these sources contain?

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

2. What to include in a literature review?

• A brief background of the problem or issue

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

• A description of what you will do in your project

• How this study will contribute to research on the subject

3. Why literature review is important?

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

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

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

5. What are the components of a literature review?

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

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

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

6. What are common errors in writing literature review?

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

• Totally relying on secondary data while ignoring primary data.

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

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

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

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

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

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

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

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

8. How many sources should a literature review have?

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

9. Can literature review have diagrams?

• To represent an abstract idea or concept

• To explain the steps of a process or procedure

• To help readers understand the relationships between different concepts

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

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

11. What are the types of literature review?

• Argumentative review

• Integrative review

• Methodological review

• Systematic review

• Meta-analysis review

• Historical review

• Theoretical review

• Scoping review

• State-of-the-Art review

12. Is a literature review mandatory?

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

But before you go,

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

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  • 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.

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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The Research Proposal

83 Components of the Literature Review

Krathwohl (2005) suggests and describes a variety of components to include in a research proposal.  The following sections present these components in a suggested template for you to follow in the preparation of your research proposal.

Introduction

The introduction sets the tone for what follows in your research proposal – treat it as the initial pitch of your idea.  After reading the introduction your reader should:

  • Understand what it is you want to do;
  • Have a sense of your passion for the topic;
  • Be excited about the study´s possible outcomes.

As you begin writing your research proposal it is helpful to think of the introduction as a narrative of what it is you want to do, written in one to three paragraphs.  Within those one to three paragraphs, it is important to briefly answer the following questions:

  • What is the central research problem?
  • How is the topic of your research proposal related to the problem?
  • What methods will you utilize to analyze the research problem?
  • Why is it important to undertake this research? What is the significance of your proposed research?  Why are the outcomes of your proposed research important, and to whom or to what are they important?

Note : You may be asked by your instructor to include an abstract with your research proposal.  In such cases, an abstract should provide an overview of what it is you plan to study, your main research question, a brief explanation of your methods to answer the research question, and your expected findings. All of this information must be carefully crafted in 150 to 250 words.  A word of advice is to save the writing of your abstract until the very end of your research proposal preparation.  If you are asked to provide an abstract, you should include 5-7 key words that are of most relevance to your study. List these in order of relevance.

Background and significance

The purpose of this section is to explain the context of your proposal and to describe, in detail, why it is important to undertake this research. Assume that the person or people who will read your research proposal know nothing or very little about the research problem.  While you do not need to include all knowledge you have learned about your topic in this section, it is important to ensure that you include the most relevant material that will help to explain the goals of your research.

While there are no hard and fast rules, you should attempt to address some or all of the following key points:

  • State the research problem and provide a more thorough explanation about the purpose of the study than what you stated in the introduction.
  • Present the rationale for the proposed research study. Clearly indicate why this research is worth doing.  Answer the “so what?” question.
  • Describe the major issues or problems to be addressed by your research. Do not forget to explain how and in what ways your proposed research builds upon previous related research.
  • Explain how you plan to go about conducting your research.
  • Clearly identify the key or most relevant sources of research you intend to use and explain how they will contribute to your analysis of the topic.
  • Set the boundaries of your proposed research, in order to provide a clear focus. Where appropriate, state not only what you will study, but what will be excluded from your study.
  • Provide clear definitions of key concepts and terms. As key concepts and terms often have numerous definitions, make sure you state which definition you will be utilizing in your research.

Literature Review

This is the most time-consuming aspect in the preparation of your research proposal and it is a key component of the research proposal. As described in Chapter 5 , the literature review provides the background to your study and demonstrates the significance of the proposed research. Specifically, it is a review and synthesis of prior research that is related to the problem you are setting forth to investigate.  Essentially, your goal in the literature review is to place your research study within the larger whole of what has been studied in the past, while demonstrating to your reader that your work is original, innovative, and adds to the larger whole.

As the literature review is information dense, it is essential that this section be intelligently structured to enable your reader to grasp the key arguments underpinning your study. However, this can be easier to state and harder to do, simply due to the fact there is usually a plethora of related research to sift through. Consequently, a good strategy for writing the literature review is to break the literature into conceptual categories or themes, rather than attempting to describe various groups of literature you reviewed.  Chapter V, “ The Literature Review ,” describes a variety of methods to help you organize the themes.

Here are some suggestions on how to approach the writing of your literature review:

  • Think about what questions other researchers have asked, what methods they used, what they found, and what they recommended based upon their findings.
  • Do not be afraid to challenge previous related research findings and/or conclusions.
  • Assess what you believe to be missing from previous research and explain how your research fills in this gap and/or extends previous research

It is important to note that a significant challenge related to undertaking a literature review is knowing when to stop.  As such, it is important to know how to know when you have uncovered the key conceptual categories underlying your research topic.  Generally, when you start to see repetition in the conclusions or recommendations, you can have confidence that you have covered all of the significant conceptual categories in your literature review.  However, it is also important to acknowledge that researchers often find themselves returning to the literature as they collect and analyze their data.  For example, an unexpected finding may develop as one collects and/or analyzes the data and it is important to take the time to step back and review the literature again, to ensure that no other researchers have found a similar finding.  This may include looking to research outside your field.

This situation occurred with one of the authors of this textbook´s research related to community resilience.  During the interviews, the researchers heard many participants discuss individual resilience factors and how they believed these individual factors helped make the community more resilient, overall.  Sheppard and Williams (2016) had not discovered these individual factors in their original literature review on community and environmental resilience. However, when they returned to the literature to search for individual resilience factors, they discovered a small body of literature in the child and youth psychology field. Consequently, Sheppard and Williams had to go back and add a new section to their literature review on individual resilience factors. Interestingly, their research appeared to be the first research to link individual resilience factors with community resilience factors.

Research design and methods

The objective of this section of the research proposal is to convince the reader that your overall research design and methods of analysis will enable you to solve the research problem you have identified and also enable you to accurately and effectively interpret the results of your research. Consequently, it is critical that the research design and methods section is well-written, clear, and logically organized.  This demonstrates to your reader that you know what you are going to do and how you are going to do it.  Overall, you want to leave your reader feeling confident that you have what it takes to get this research study completed in a timely fashion.

Essentially, this section of the research proposal should be clearly tied to the specific objectives of your study; however, it is also important to draw upon and include examples from the literature review that relate to your design and intended methods.  In other words, you must clearly demonstrate how your study utilizes and builds upon past studies, as it relates to the research design and intended methods.  For example, what methods have been used by other researchers in similar studies?

While it is important to consider the methods that other researchers have employed, it is equally important, if not more so, to consider what methods have not been employed but could be.  Remember, the methods section is not simply a list of tasks to be undertaken. It is also an argument as to why and how the tasks you have outlined will help you investigate the research problem and answer your research question(s).

Tips for writing the research design and methods section:

  • Specify the methodological approaches you intend to employ to obtain information and the techniques you will use to analyze the data.
  • Specify the research operations you will undertake and he way you will interpret the results of those operations in relation to the research problem.
  • Go beyond stating what you hope to achieve through the methods you have chosen. State how you will actually do the methods (i.e. coding interview text, running regression analysis, etc.).
  • Anticipate and acknowledge any potential barriers you may encounter when undertaking your research and describe how you will address these barriers.
  • Explain where you believe you will find challenges related to data collection, including access to participants and information.

Preliminary suppositions and implications

The purpose of this section is to argue how and in what ways you anticipate that your research will refine, revise, or extend existing knowledge in the area of your study. Depending upon the aims and objectives of your study, you should also discuss how your anticipated findings may impact future research.  For example, is it possible that your research may lead to a new policy, new theoretical understanding, or a new method for analyzing data?  How might your study influence future studies?  What might your study mean for future practitioners working in the field?  Who or what may benefit from your study?  How might your study contribute to social, economic, environmental issues?  While it is important to think about and discuss possibilities such as these, it is equally important to be realistic in stating your anticipated findings.  In other words, you do not want to delve into idle speculation.  Rather, the purpose here is to reflect upon gaps in the current body of literature and to describe how and in what ways you anticipate your research will begin to fill in some or all of those gaps.

The conclusion reiterates the importance and significance of your research proposal and it provides a brief summary of the entire proposed study.  Essentially, this section should only be one or two paragraphs in length. Here is a potential outline for your conclusion:

  • Discuss why the study should be done. Specifically discuss how you expect your study will advance existing knowledge and how your study is unique.
  • Explain the specific purpose of the study and the research questions that the study will answer.
  • Explain why the research design and methods chosen for this study are appropriate, and why other design and methods were not chosen.
  • State the potential implications you expect to emerge from your proposed study,
  • Provide a sense of how your study fits within the broader scholarship currently in existence related to the research problem.

As with any scholarly research paper, you must cite the sources you used in composing your research proposal.  In a research proposal, this can take two forms: a reference list or a bibliography.  A reference list does what the name suggests, it lists the literature you referenced in the body of your research proposal.  All references in the reference list, must appear in the body of the research proposal.  Remember, it is not acceptable to say “as cited in …”  As a researcher you must always go to the original source and check it for yourself.  Many errors are made in referencing, even by top researchers, and so it is important not to perpetuate an error made by someone else. While this can be time consuming, it is the proper way to undertake a literature review.

In contrast, a bibliography , is a list of everything you used or cited in your research proposal, with additional citations to any key sources relevant to understanding the research problem.  In other words, sources cited in your bibliography may not necessarily appear in the body of your research proposal.  Make sure you check with your instructor to see which of the two you are expected to produce.

Overall, your list of citations should be a testament to the fact that you have done a sufficient level of preliminary research to ensure that your project will complement, but not duplicate, previous research efforts. For social sciences, the reference list or bibliography should be prepared in American Psychological Association (APA) referencing format. Usually, the reference list (or bibliography) is not included in the word count of the research proposal. Again, make sure you check with your instructor to confirm.

An Introduction to Research Methods in Sociology by Valerie A. Sheppard is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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What is a Literature Review?

What’s a literature review.

The straightforward answer is that a literature review is a review or synthesis of all the research published on a certain topic. But I’d rather explain it from a skateboarder’s perspective:

One of my favorite movies is the 1989 classic Back to the Future Part 2 where the bodacious skater Marty McFly time-travels to the future and sees a hoverboard. As a kid, I was a dabbling skateboarder and thought if I could just have one of those hoverboards, all my troubles would disappear. It was an optimistic time.

Trouble is, hoverboards are really hard to make. We’ve already passed the year 2015 when the “Future” of Back to the Future Part 2 takes place, and guess what? No hoverboards. I know you’ve seen a skateboard-like, two-wheeled device marketed with the name “Hoverboard” but that’s just an electric, no-handled scooter.

1024px-Hover_board_hovering.jpg

I want a real hoverboard. That you ride in the air . So how can we know when real hoverboards will be available? How can we know where the technology is now? Will we know a real hoverboard when we see one? Tony Hawk, the best skateboarder of all time (whose face was incidentally taped to my wall in the ’80s) recently filmed a 2-minute video of how far real hoverboard technology has come–filmed on the very day Marty McFly supposedly went to the future: October 21, 2015:

Tony Hawk and the cutting edge of hoverboard research

Image preview of a YouTube video

Although this “hoverboard” was really a huge black rectangle the size of Delaware floating only an inch off the ground, and although Tony Hawk fell off a lot, he was technically in the air, so I’m taking that as a good sign. Then recently, a professional jet ski rider broke the world record for longest time “hovering” in the air with a highly dangerous jet-engine-propelled contraption called Flyboard Air. It’s also definitely a step in the right direction, but there’s a big problem (beside extreme danger): it’s projected to cost around $250,000.

The good news is, now we’ve found the point where hoverboard research actually is. The bad news: we have to face the sad truth that it might still be a while before we get real flying hoverboards. But at least now we know.

The State of a Field on a Topic

That leads me to literature reviews. Whenever you want to know the state of a field of research like how far hoverboard technology has come, the best way to find out is probably not YouTube videos. It turns out you can do something much more reliable: conduct a literature review . In this case, “literature” doesn’t mean the Victorian novels you read in English class, it means all the research published on a certain topic. So a literature review is simply a review or a synthesis of the research published on a topic.

Researchers today don’t just start projects out of the blue–they do their homework first by finding out what others have already researched. So if you want to make a hoverboard, you don’t just go to Home Depot and buy random parts–you research what others have done and check out the conversation so you don’t have to reinvent the wheel.

“If I have seen further, it is by standing on the shoulders of giants.” –Sir Isaac Newton (and the motto of Google Scholar)

Before good researchers set up any surveys or experiments, or even write a proposal for funding, they figure out exactly which research questions have already been asked and answered. Same goes for anyone wanting to make a product that will sell. But more importantly, they look for the gaps in the research where answers have yet to be found. And then they focus their own research on filling in some of those gaps. That’ll be your job, too.

In other words, the goal of a literature review is to find the sweet spot where the most promising research is happening now–we call that the cutting edge.

How is a Literature Review different from a typical Research Paper?

You’ve probably been writing research papers most of your life– starting from the five-paragraph essay you learned in high school to the term paper you wrote last semester that had a thesis statement and lots of quotes. So it can seem daunting to switch gears to writing a literature review, but there are some distinct advantages to making the switch. The trick is first understanding the difference between the two.

Research Papers are Thesis Driven

The difference between a typical research paper and a literature review is your purpose and strategy. When you’re assigned to write a research paper, you start with a thesis or argument that you’d like to make. Your thesis has to do with changes you’d like to see in the future. Then you search for sources that support your point. You might adjust your thesis if you come across sources that challenge your claim, but generally, the sources you’ve gathered become evidence for your thesis and you use them to support your point. In other words, your argumentative research paper is driven by your thesis .

Literature Reviews are Source Driven

In contrast, when you write a Literature Review, the sources themselves dictate what you’ll say in your paper. Remember, your goal is to tell your audience the state of the field on a topic–what’s been happening in the published research–so you can find the cutting edge and where the research gaps are. Therefore, you need to find and evaluate the most relevant sources surrounding a topic and then write a review based on what you find . You can’t decide on a thesis statement or know what points you’ll make before you start because you have to find out what researchers are doing before you can report on that. Simply put, your literature review is driven by your sources .

You’ll still have an overarching point/thesis that controls your literature review paper structure, but it will be a claim about what patterns you found in the research– not an argument about a change you want to see in the future or a new way to look at something. And you’ll decide on your thesis much later in the writing process. Here’s a table that compares the writing process of a traditional research paper with that of a literature review:

Literature Reviews: Catching up with Old Friends

What do you do when you meet an old friend? You ask,

“How are you? What have you been up to? Fill me in!”

people-talking-908342_1280.jpg

Literature Reviews are like getting filled in by an old friend . Only this time, you’re explaining how a field of research has gotten to the present (like how far hoverboard technology has come). But like a conversation with an old friend, you want to review only the details most relevant to the situation. You don’t usually give a moment-by-moment chronology of what you’ve done in your life (no one has time for that); rather, you talk in terms of categories–work, family, travel, etc. This is like the synthesis that happens in a Literature Review. As you read sources about a specific topic, you’ll look for themes, for similarities and differences, for points of agreement and disagreement, for gaps in the research that haven’t been filled in yet. Those themes become the categories you’ll talk about in your literature review so your audience will understand the big picture about your topic.

Literature Reviews in the Sciences

Grant proposals.

Any grant proposal submitted to request research funding begins with an extensive literature review to justify the need for the research funds. If you can prove there’s a gap in knowledge, it makes it that much easier to convince your audience to give you funding to fill that gap.

IMRAD Articles

Wineglass_model_for_IMRaD_structure..png

The Introduction of an IMRAD article includes a literature review. Photo by Tom Toyosak i on Wikimedia Commons

IMRAD (pronounced “im-rad”) stands for Introduction, Methods, Results, and Discussion and is the most common genre published in the social sciences and sciences. Most of the sources you gather will likely be IMRAD-format papers. The I in IMRAD stands for Introduction and usually consists of a review of the literature on the authors’ research topic. The author(s) usually use the Introduction section to report on the published literature about their research topic and reveal the trends and gaps in current research. An added benefit to beginning an article this way is that by showing the gaps in the research, the author(s) can justify their own research and explain the significance of the topic they chose to examine. Clever!

As you might guess, the sections following the Introduction (Methods, Results, Discussion) describe the primary research the author(s) conducted to answer their research question. First they report on their quantitative and/or qualitative M ethods (M in IMRAD) including statistical analyses. Then they publish their R esults (R in IMRAD). Finally, the author(s) embark on a D iscussion (D in IMRAD) of their results in the context of the greater field of research and make suggestions for future research. This starts the research cycle over again as someone else reads their article as part of their own review of the literature and discovers a gap in the research that can be filled by new primary research. 

Published Literature Reviews

In the world of science and social science, literature reviews can also be published on their own. For example, if someone does an extensive investigation into an important topic, the publishers of academic journals will often publish that literature review on its own to help other researchers understand that topic better.

Popular Literature Reviews

196px-Wikipedia-logo-en-big.png

Lest you think nerdy academics are the only ones who rely on literature reviews, recall the last time you went on Wikipedia . If you think about it, Wikipedia is really just a giant literature review on millions of topics. Although the information on Wikipedia is not formally peer-reviewed like the reviews published in academic journals, they do cite all their sources and frequently revise to keep the information current. Clearly there’s a market for relevant information. If you really want your mind to explode Inception -style, look up “Wikipedia” on Wikipedia and you’ll find a literature review about a literature review.

Adapted from “What is a Literature Review?” in Writing in the Social Sciences. Authored by Christie Cowles Charles. Located at: https://edtechbooks.org/writing.

License: CC BY- SA

What is a Literature Review? Copyright © 2020 by Sara Rufner is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

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Literature Review: Conducting & Writing

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  • Published: 17 November 2021

The impact of behavioural risk factors on communicable diseases: a systematic review of reviews

  • Sara Wood 1 ,
  • Sophie E. Harrison 2 , 3 ,
  • Natasha Judd 1 , 2 ,
  • Mark A. Bellis   ORCID: orcid.org/0000-0001-6980-1963 1 , 2 ,
  • Karen Hughes 1 , 2 &
  • Andrew Jones 4  

BMC Public Health volume  21 , Article number:  2110 ( 2021 ) Cite this article

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The coronavirus (COVID-19) pandemic has highlighted that individuals with behavioural risk factors commonly associated with non-communicable diseases (NCDs), such as smoking, harmful alcohol use, obesity, and physical inactivity, are more likely to experience severe symptoms from COVID-19. These risk factors have been shown to increase the risk of NCDs, but less is known about their broader influence on communicable diseases. Taking a wide focus on a range of common communicable diseases, this review aimed to synthesise research examining the impact of behavioural risk factors commonly associated with NCDs on risks of contracting, or having more severe outcomes from, communicable diseases.

Literature searches identified systematic reviews and meta-analyses that examined the association between behavioural risk factors (alcohol, smoking, illicit drug use, physical inactivity, obesity and poor diet) and the contraction/severity of common communicable diseases, including infection or associated pathogens. An a priori, prospectively registered protocol was followed (PROSPERO; registration number CRD42020223890).

Fifty-three systematic reviews were included, of which 36 were also meta-analyses. Reviews focused on: tuberculosis, human immunodeficiency virus, hepatitis C virus, hepatitis B virus, invasive bacterial diseases, pneumonia, influenza, and COVID-19. Twenty-one reviews examined the association between behavioural risk factors and communicable disease contraction and 35 examined their association with communicable disease outcomes (three examined their association with both contraction and outcomes). Fifty out of 53 reviews (94%) concluded that at least one of the behavioural risk factors studied increased the risk of contracting or experiencing worse health outcomes from a communicable disease. Across all reviews, effect sizes, where calculated, ranged from 0.83 to 8.22.

Conclusions

Behavioural risk factors play a significant role in the risk of contracting and experiencing more severe outcomes from communicable diseases. Prevention of communicable diseases is likely to be most successful if it involves the prevention of behavioural risk factors commonly associated with NCDs. These findings are important for understanding risks associated with communicable disease, and timely, given the COVID-19 pandemic and the need for improvements in future pandemic preparedness. Addressing behavioural risk factors should be an important part of work to build resilience against any emerging and future epidemics and pandemics.

Peer Review reports

The recent coronavirus (COVID-19) pandemic has highlighted that individuals with potentially modifiable behavioural risk factors that are commonly associated with non-communicable diseases (NCDs), such as smoking, harmful alcohol use, obesity and physical inactivity, are more likely to experience severe symptoms from COVID-19 infection [ 1 ], resulting in greater risk of hospitalisation [ 2 ]. With these behavioural risk factors often having higher prevalence in the poorest communities, COVID-19 has disproportionately impacted those already suffering the greatest risks of ill health, thereby widening health and social inequalities [ 3 ]. Indeed, due to its associations with existing health and social risk factors, COVID-19 has been referred to as a syndemic; one in which existing health and social challenges increase an individual’s susceptibility to disease [ 4 ]. However, whilst addressing behavioural risk factors is routinely considered in the prevention of NCDs, their role in the contraction of communicable disease, and severity of symptoms in those who are infected, has had a lower public health prominence.

Many modifiable behavioural risk factors are highly prevalent among adults and adolescents in both higher (HICs) and lower and middle income countries (LMICs) [ 5 , 6 ], with levels increasing in many LMICs (e.g. obesity, alcohol) [ 7 , 8 ]. As a result, NCDs, such as cancer, respiratory disease and cardiovascular disease are the highest cause of mortality and morbidity in HICs and account for a rapidly increasing proportion of both in LMICs [ 9 ]. Across countries globally, the burden of NCDs has been found to correlate with levels of COVID-19 cases and deaths [ 10 ].

With both international commerce and tourism connecting populations globally, it is highly likely that COVID-19 is only one in a series of existing and emerging infectious diseases likely to impact, to different extents, health and well-being on a global scale [ 11 ]. Although the exact nature or source of any future epidemic or pandemic threat is speculative, behavioural risk factors have also been found to increase the risk of infection and subsequent poorer outcomes across a range of other communicable diseases [ 12 , 13 , 14 ]. Understanding which factors may increase or reduce risk of contraction and severity of disease can provide important intelligence, both in increasing a population’s resilience to infectious disease, and in identifying which communities and individuals may be most at risk from the spread of different types of disease. Although previous research has explored links between behavioural risk factors and individual communicable diseases, few studies have synthesised information across a wider range of communicable diseases and their relationships with behavioural risks. Indeed, such relationships may elucidate how future pandemics threats will exploit behavioural risk factors.

Intending to explore whether communicable diseases and NCDs share a common set of behavioural risk factors, the aim of this review was to provide a synthesis of existing research examining the impact of behavioural risk factors commonly associated with NCDs on the risk of people (adults or children) contracting, or experiencing more severe outcomes from, common communicable diseases. With the breadth of communicable diseases requiring limitation, the focus of this review was on diseases common to high income countries. With an intentionally wide focus on a range of communicable diseases, the review focused specifically on systematic reviews and meta-analyses, clarifying existing knowledge and highlighting gaps in evidence to inform priority areas for future research.

This review was carried out in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An a priori protocol was followed and prospectively registered at the National Institute for Health Research international prospective register of systematic reviews (PROSPERO) (registration number CRD42020223890). The focus of this review was limited to behavioural risk factors and communicable diseases common in HICs, regardless of the geographical location of the review. Those more specific to LMICs or certain regions of the world (e.g. tropical diseases) were considered best examined in a separate study.

Search strategy

A systematic search was performed across multiple databases through ProQuest covering the 10-year period 28th October 2010 to 28th October 2020. Preliminary scans of the literature reviews and discussion between members of the research team were used to aid selection of common behavioural risk factors and communicable diseases. Thus, alcohol use, smoking, physical inactivity, obesity, illicit drug use and poor diet were chosen as behavioural risk factors, covering some of the most common behavioural contributors to NCDs [ 15 ]. The same process identified: Tuberculosis (TB), acquired immune deficiency syndrome (AIDS), human immunodeficiency virus (HIV), viral hepatitis, COVID-19, severe acute respiratory syndrome (SARS), middle-east respiratory syndrome (MERS), pneumonia, influenza, and meningitis as communicable diseases (including infections and pathogens) feasible for review. These communicable diseases were broadly consistent with some of the most prevalent disease/infection categories reported in the global burden of disease study for HICs (excluding those categories predominantly affecting specific groups (e.g. maternal, neonatal) or where a component may be associated with non-infectious causes (e.g. diarrheal) [ 9 ]) and with previous outbreaks or epidemics involving HICs [ 16 ]. In addition, it was intended to include diseases that arose from both bacterial and viral pathogens, with a range of transmission types, e.g. airborne, droplet, fomite, blood-borne and contact. Combinations of search terms were developed based on these key risk factors and diseases. Search results were restricted to English language and peer reviewed systematic reviews and meta-analyses. Whilst this strategy restricted literature to that which qualified for inclusion in systematic reviews, it allowed for the inclusion of multiple behavioural risk factors and communicable diseases at the same time. The search was restricted to a 10-year period, allowing coverage of a broad range of behavioural risk factors and communicable diseases, yet limiting the literature to a manageable volume. The full search strategy is available in Supplementary file  1 . Searches also included poor housing conditions as a risk factor given the impact of housing conditions on respiratory disease [ 17 ], but this study focuses specifically on behavioural risk factors.

Study selection and eligibility criteria

To identify eligible studies, the titles and abstracts of studies retrieved were screened by two reviewers, with a sample of 15% screened independently by both reviewers and achieving 98.5% agreement (SH, NJ). Discrepancies were resolved between reviewers. For full text screening, ten reviews (7%) were initially screened by three reviewers (SH, NJ, SW), with results later discussed and discrepancies resolved. Following this, the full text screening was divided across reviewers and any reviews that were not a clear exclude/include (20%) were discussed and agreed between reviewers. This meant that, across all reviews screened by full text, 27% were discussed and agreed by more than one reviewer. Where full texts could not be accessed, authors were contacted to request the full text.

Systematic reviews and meta-analyses of observational studies (including cohort and case-control studies) that examined the association between an identified behavioural risk factor and the contraction or outcomes of an identified communicable disease (including infection or related pathogens) were included in the review. Since there are no single definitions of the selected risk factors across the literature, all reviews that focused on an identified risk factor were included regardless of the definition used in the review (definitions are provided in Tables  1 and 2 and in the results section). An aim of the review was to explore risks associated with illicit drug use in general. However, it was recognised that injection drug use can be a mechanism of transmission for some pathogens relating to included communicable diseases (e.g. HIV, HCV). Studies that focused specifically on injection drug use were therefore included alongside those focusing on drug use more generally. Studies were excluded if they: were not a systematic review or meta-analysis; did not examine the association between an selected behavioural risk factor and the contraction or outcomes of an selected communicable disease; included only selected specialist sub-populations (e.g. sex workers, prisoners), or included sub-populations relating to a risk factor (e.g. people who inject drugs) without a general population comparison; or included behavioural risk factors or communicable diseases not relevant to HICs (see above). No restrictions were made for the age of participants included. A flow chart demonstrating the selection process is presented in Fig.  1 .

figure 1

PRISMA flow diagram of study identification, inclusion and exclusion

Data extraction and synthesis

Data were extracted by three reviewers (SH, NJ, SW) into a standardised, pre-piloted form. Each extraction was duplicated across reviewers and discrepancies resolved through discussion. Information extracted from the studies included: title, authors, abstract, behavioural risk factor(s) studied, communicable disease(s) studied (including infection or related pathogens), research question, geographical restrictions, population characteristics, number of reviews included in the systematic review or meta-analysis, main findings (including odds ratios (OR), relative risks (RR) or rate ratios where available), proposed mechanisms of association and conclusions related to identified behavioural risk factor(s) and communicable disease(s). Where information on the number of reviews included for each risk factor was not reported, the corresponding author of the paper was contacted for additional information.

Due to the variety of different communicable diseases, risk factor definitions, outcome measures, and methods of reporting in the included studies, as well as the challenges of conducting meta-analysis for observational studies [ 71 ], findings were not combined statistically through meta-analysis. Instead, a narrative synthesis of the findings was constructed [ 72 ], and effect size ranges reported for each behavioural risk factor. Key information that would have enabled calculation of a common effect size was often not available. To calculate these effect size ranges, it was assumed that ORs, RRs and rate ratios were approximately equivalent, a method suggested for umbrella reviews in these circumstances [ 73 ]. In addition, where studies reported reduced risk of a communicable disease with a health behaviour (e.g. physical activity, no alcohol drinking), an inverse OR (1/OR) for the corresponding risk behaviour was reported. Findings were structured according to the identified behavioural risk factors and their association with a) contraction of the identified communicable diseases, and b) experiencing more severe outcomes from these communicable diseases. Some study conclusions were amended for readability, to aid understanding. Further, where study conclusions were not relevant to the current research question, information was extracted from results sections and amended for readability (see Supplementary file  2 ).

Methodological quality of studies

The methodological quality of included studies was assessed using the Overview Quality Assessment Questionnaire (OQAQ); a frequently used, validated tool for assessing the methodological quality of systematic reviews [ 74 ]. Methodological quality assessment was carried out by three researchers (NJ, SH, SW), with any discrepancies resolved through discussion. Assessment ratings are available in Supplementary file  2 .

The database search yielded 1806 citations, of which 53 were included (Fig. 1 ). Research relating to the following communicable diseases (including infection and pathogens) was identified: TB, HIV, hepatitis C virus (HCV), hepatitis B virus (HBV), invasive bacterial disease (IBD), pneumonia, influenza, and COVID-19. No studies relating to SARS, MERS or meningitis were identified. Thirty-six of the identified systematic reviews also conducted meta-analyses. Reviews used a range of definitions of behavioural risk factors (e.g. current or former smoker, any alcohol use or heavy alcohol use). All definitions were included in the synthesis, and are presented for clarity in each section of the results and in the results tables (Tables 1 and 2 ). Eighteen reviews examined the association between behavioural risk factors and the contraction of a communicable disease only, 32 reviews examined the association between behavioural risk factors and the outcomes from communicable diseases only, and three reviews examined associations with both contraction of and outcomes from communicable diseases. Characteristics of all included reviews and their conclusions can be found in Supplementary file  2 . No systematic review had extensive or major flaws, with most reviews having only minimal or minor flaws (Supplementary file  2 ). Consequently, no reviews were excluded based on methodological quality. A breakdown of reviews by disease and risk factors is provided in Supplementary file  3 .

Behavioural risk factors for communicable diseases

Overall, 50 out of 53 reviews (94%) concluded that at least one of the behavioural risk factors studied increased the risk of contracting or having more severe outcomes of a communicable disease. Across all reviews, effect sizes, where calculated, ranged from 0.83 to 8.22 (Figs.  2 and 3 ; Tables 1 and 2 ). Nineteen out of 21 reviews (90%) concluded that at least one of the behavioural risk factors studied increased the risk of contracting a communicable disease (Table  1 ). Across all contraction reviews, effect sizes, where calculated, ranged from 1.03 to 8.22 (Fig.  2 ). Thirty-two out of 35 reviews (91%) concluded that at least one of the behavioural risk factors studied increased the likelihood of having more severe outcomes from a communicable disease (Table  2 ). Across all outcome reviews, effect sizes, where calculated, ranged from 0.83 to 3.96 (Fig.  3 ).

figure 2

Forest plot of meta-analysis effect sizes: contraction of a communicable disease. Effect sizes refer to odds ratios and relative risks, see Table 1 for more information. CAP = community acquired pneumonia; TB = tuberculosis; IBD = invasive bacterial disease

figure 3

Forest plot of meta-analysis effect sizes: more severe communicable disease outcomes. Effect sizes refer to odds ratios, relative risks and rate ratios, see Table 2 for more information. MDR = multi-drug resistant; TB = tuberculosis; DS = drug-susceptible; HIV = human immunodeficiency virus; HCV = hepatitis C virus; ICU = intensive care unit; IMV = invasive mechanical ventilation; OAT = opioid agonist therapy

Alcohol as a risk factor

Seventeen reviews included alcohol as a risk factor for a communicable disease, with a range of definitions used: any alcohol consumption [ 19 , 23 , 41 , 43 , 44 , 46 , 47 , 49 ]; any alcohol use or higher amounts [ 18 , 21 ]; binge drinking or alcohol misuse [ 20 ]; alcohol misuse [ 40 ]; alcohol use disorder (AUD) [ 22 , 45 ]; alcoholism [ 39 , 42 ]; or current/history of excess use [ 48 ]. The majority of reviews reported an increased risk of contraction (5/6 reviews; Table 1 ) and more severe outcomes (10/12 reviews; Table 2 ). Across all alcohol reviews, effect sizes, where calculated, ranged from 1.83–8.22 for contraction (Fig. 2 ) and 1.45–2.47 for severe outcomes (Fig. 3 ). Alcohol use (any use, higher amounts, binge drinking or AUD) was reported to increase the risk of contracting TB [ 18 ], HIV [ 20 ], pneumonia [ 21 , 22 ] and invasive pneumococcal diseases (IPD) [ 23 ]. One review did not draw a conclusion, but reported mixed findings for the association between alcohol consumption and contraction of TB [ 19 ]. Alcohol use (any use, misuse, current/history of excess use, alcoholism or AUD) was reported to increase the risk of having more severe outcomes from TB [ 39 , 40 , 41 , 42 , 43 , 44 ], HIV [ 45 , 46 ], and HCV [ 48 , 49 ]. One review reported mixed findings and made no clear conclusion about the association of alcohol consumption and TB outcomes [ 19 ], and one review reported variable results among studies examining the association between alcohol consumption and the progression of HIV [ 47 ].

Illicit drug use as a risk factor

Fifteen reviews examined the association between illicit drug use and communicable disease contraction or outcomes, with a wide range of definitions used: drug abuse [ 19 , 41 ]; illicit drug use [ 25 ]; regular/problem cocaine use [ 50 ]; recent drug use [ 51 ]; and injection drug use [ 20 , 24 , 26 , 27 , 28 , 29 , 39 , 48 , 52 , 53 ]. The majority of reviews reported an increased risk of contraction (8/9 reviews; Table 1 ) and more severe outcomes (6/8 reviews; Table 2 ). Across all drug use reviews, effect sizes, where calculated (for more severe outcomes only), ranged from 1.01–3.96 (Fig. 3 ). Both injection drug use and illicit drug use were reported to increase the risk of contracting TB [ 24 ] and HIV [ 20 , 24 , 25 ], whilst the prevalence of HCV was found to be higher among people who inject drugs (PWID) compared to general population or community groups [ 26 , 27 , 28 , 29 ]. One review did not draw a conclusion but reported mixed findings for the association between drug abuse and TB contraction [ 19 ]. Both injecting drug use and drug use/abuse were reported to increase the risk of having more severe outcomes from TB [ 39 , 41 ], HIV [ 50 ] and HCV [ 48 , 51 ]. Furthermore, among those with HBV, the prevalence of hepatitis D (HDV; co-infection with HDV is considered a more severe form of viral hepatitis) was substantially higher for PWID compared to a mixed population with no risk factors [ 53 ]. One review did not draw a conclusion but reported mixed findings for the association between drug abuse and TB outcomes [ 19 ], and one review concluded that treatment outcomes for HCV were similar between people who currently were and were not injecting drugs [ 52 ].

Physical inactivity as a risk factor

One systematic review was identified examining the association between physical activity and communicable disease contraction or outcomes. This study reported an association between increased prolonged, moderate aerobic exercise and reduced influenza-related mortality, and improved immunocompetence [ 38 ].

Obesity as a risk factor

Ten reviews focused on the relationship between obesity [ 30 , 31 , 54 , 55 , 56 , 57 , 58 , 60 ], or overweight and obesity [ 32 , 59 ], and communicable disease risk. The majority of reviews reported an increased risk of contraction (3/3 reviews; Table 1 ) and more severe outcomes (8/9 reviews; Table 2 ). Across all obesity reviews, effect sizes, where calculated, ranged from 1.03–1.33 for contraction (Fig. 2 ) and 0.83–2.74 for severe outcomes (Fig. 3 ). Obesity was reported to increase the risk of contracting influenza [ 30 ] and pneumonia [ 31 , 32 ]. Obesity was reported to increase the risk of having more severe outcomes from influenza [ 30 , 54 , 55 , 56 ] and COVID-19 [ 58 , 59 , 60 ]. One review concluded that most studies showed some degree of association between higher body mass index (BMI) and a worse clinical presentation of COVID-19 and the need for hospitalisation. This review suggested that obesity seemed to predict poor clinical evolution in patients with COVID-19, but that studies in the review had limited methodological quality [ 57 ]. However, one review, which concluded that obesity increased the risk of contracting pneumonia, also found that obese individuals had a lower mortality risk from pneumonia [ 32 ].

Smoking as a risk factor

Eighteen reviews examined the association between smoking (current, past or both) and communicable disease contraction or outcomes. The majority of reviews reported some evidence of an increased risk of contraction (3/3 reviews; Table 1 ) and more severe outcomes (13/15 reviews; Table 2 ). Across all smoking reviews, effect sizes, where calculated, ranged from 2.17–2.31 for contraction (Fig. 2 ) and 0.94–3.46 for severe outcomes (Fig. 3 ). Smoking was reported to increase the risk of contracting HIV [ 20 ], pneumonia [ 33 ] and invasive pneumococcal disease (IPD) [ 23 ]. Further, smoking was reported to increase the risk of having more severe outcomes from TB [ 19 , 41 , 42 , 43 , 61 , 62 ], influenza [ 56 ], and COVID-19 [ 63 , 64 , 65 , 66 , 68 ]. Two reviews reported no associations between smoking and more severe outcomes from communicable diseases, including death from TB [ 39 ] and TB treatment outcomes [ 40 ]. One review reported that active smoking may increase the risk of severe COVID-19, but found the result was heavily influenced by one study [ 67 ].

Second-hand smoke as a risk factor

Six reviews focused on second-hand smoke as a risk factor for a communicable disease. The majority of reviews reported some evidence of an increased risk of contraction (4/5 reviews; Table 1 ) and more severe outcomes (1/1 review; Table 2 ). Across all second-hand smoking reviews, effect sizes, where calculated, ranged from 1.11 to 2.80 for contraction (Fig. 2 ), and the one effect size calculated for severe outcomes was 1.52 (Fig. 3 ). One review suggested that second-hand smoke exposure increased the risk of TB infection and disease [ 34 ]. The remaining four reviews reported at least some evidence of second-hand smoke exposure increasing the risk of contracting a communicable disease, including TB [ 35 , 36 ], pneumonia (among those aged 65+ only) [ 33 ], and IBD (invasive meningococcal disease [IMD] only) [ 37 ]. Second-hand smoke exposure was reported to increase the risk of severe outcomes from acute lower respiratory infections (ALRIs), including pneumonia [ 69 ].

Poor diet as a risk factor

Only two reviews were identified that examined the association between poor diet and communicable disease outcomes, and no reviews examining the association between poor diet and communicable disease contraction were identified. One review found that vitamin D status may influence the course of HIV disease [ 70 ]. The second review reported that a high intake of polyunsaturated fatty acids was associated with non-response to HCV antiviral therapy [ 49 ].

The key finding of this systematic review is that behavioural risk factors play a significant role in the risk of contracting, and having more severe outcomes from, common communicable diseases. To the authors’ knowledge, this is the first time that a review has brought together studies exploring the impact of behavioural risk factors on a range of communicable diseases. Whilst the focus on selected communicable diseases and use of systematic reviews has led to inevitable gaps, the findings nevertheless provide strong evidence that both NCDs and communicable diseases share a common set of behavioural risk factors. This work indicates that the prevention of communicable disease is likely to be most successful if it involves the prevention of behavioural risk factors. These findings are timely, in light of the COVID-19 pandemic, and highlight potential additional benefits of addressing behavioural risk factors ahead of any future epidemics or pandemics. While the specific diseases that may be involved can only be speculated, they are likely to share at least some characteristics with diseases in this review.

Although this review has not examined the mechanisms connecting behavioural risk factors and communicable diseases, there are likely to be multiple mechanisms. Behavioural factors, such as alcohol use, smoking, obesity, and illicit drug use, are well documented to impair the immune system. For instance, smoking is known to influence both innate and adaptive immunity [ 75 ]. Impairments to the immune system can make individuals more susceptible to communicable diseases and less able to control or recover from infection, leading to worse outcomes [ 76 , 77 , 78 , 79 , 80 , 81 ]. Use of alcohol/drugs may also reduce the efficacy of treatment for communicable diseases [ 82 ]. The presence of comorbidities, such as diabetes and cardiovascular disease, in individuals with behavioural risk factors has also been implicated in the increased risk of communicable diseases [ 83 , 84 ]. However, behavioural risk factors, such as obesity, are also reported to independently influence communicable diseases, after adjusting for comorbidities [ 55 ]. Behavioural mechanisms may also be important, particularly for alcohol and drug use, which may reduce risk perception [ 78 ], interfere with the uptake of services, or lead to poorer treatment adherence [ 85 ]. Additionally, behavioural risk factors may be likely to appear in combination, for example combined alcohol use and smoking [ 86 ], to further increase influences on communicable diseases. Furthermore, behaviours associated with drug use, such as injecting drugs, have a high efficiency of transmission of communicable diseases and reinfection with communicable diseases [ 87 ]. Having a communicable disease could also lead to the presence of behavioural risk factors (e.g. alcohol may be used as a way of coping with the emotional distress of diseases such as HIV and HCV [ 88 ]). Finally, there may be social mechanisms, such as the social marginalisation of heavy drinkers that affects health service use or treatment [ 89 ], or social issues such as homelessness, incarceration and poverty, which may increase the risk of both behavioural risk factors and communicable diseases [ 90 , 91 ]. It is likely that there are multiple ways in which these different physiological, behavioural and social factors come together to affect the likelihood of transmission and severity of communicable disease, which require further investigation.

With behavioural risk factors influencing the contraction and severity of communicable diseases, their prevention is likely to play a role in addressing future communicable disease burden, potentially through improvements in the immune system, bodily functioning and risk behaviours. As the recent COVID-19 pandemic has highlighted, their prevention is also likely to impact on communicable disease burden through the potential reduction of NCDs commonly associated with behavioural risk factors, which can also alter immune system function [ 92 ] and increase the risk of communicable disease complications and death [ 10 , 93 ]. The review findings are important in understanding communicable disease risk, and timely, in light of COVID-19. They suggest that improvements in the prevention of behavioural risk factors may serve to reduce the negative impacts of future epidemics or pandemics, building resilience and helping to address the pressing need for greater investment in pandemic preparedness [ 94 ]. Indeed, COVID-19 should not only be a reminder that good communicable disease control is necessary, but that the more successful we are in addressing behavioural risk factors, the better we will also be at reducing the burden of communicable disease, including future epidemics or pandemics. The finding that both communicable diseases and NCDs share a common set of behavioural risk factors also lends support for a more holistic understanding of these two disease categories. For instance, research suggests that NCDs and communicable diseases can interact; whilst NCDs can increase the risk and severity of communicable diseases (e.g. individuals with diabetes, hypertension and respiratory illnesses are more likely to affected by COVID-19 [ 95 ]), at least some diseases previously considered NCDs are now known to have an infectious origin (e.g. HBV is a cause of heptatocellular carcinoma [ 96 ]).

Although the focus of this review is on HICs, findings will be of importance to LMICs, which often experience a much higher burden of communicable disease [ 9 ] and where, for many countries, the prevalence of behavioural risk factors is increasing [ 7 , 8 ]. Due to ageing populations, the negative impacts of globalisation, and ill-equipped health systems, these countries are also facing a rapidly growing burden of NCDs [ 97 , 98 , 99 ], which may reduce resistance to infection, increase communicable disease complications, or interfere with its treatment [ 100 , 101 ]. In the current global society, any negative effects of rising behavioural risk factors and related NCDs on communicable disease transmission have the potential to affect not only LMICs, but health and well-being globally.

Across both HICs and LMICs, behavioural risk factors and related NCDs are known to cluster in disadvantaged populations [ 97 , 102 , 103 , 104 ], with poverty contributing to behavioural risk factors and NCDs, and vice versa [ 97 ]. Disadvantaged communities are more likely, therefore, to experience dual burdens of NCDs and communicable disease, contributing to social and economic health inequalities. In the UK for instance, people living in the most disadvantaged communities have been over twice as likely to die from COVID-19 as those in the least disadvantaged areas [ 105 ]. Preventing behavioural risk factors, particularly among disadvantaged populations, is likely to play an important role in reducing future global and national health inequalities, as well as the unequal burden of future pandemics.

There are some limitations to this work. The wide-ranging nature of the research allowed for a broad view of the links between behavioural risk factors and communicable diseases. However, this did not allow for the exploration of causal pathways of specific associations. Further research exploring these pathways would aid understanding and inform prevention. The use of systematic reviews to achieve a broader range of information also meant that newer empirical research may have been missed, only more widely researched topics for which there is enough information to conduct a systematic review would have been included, and more in-depth information such as potential interactions between risk factors could not be included. With no single definitions of behavioural risk factors agreed across the literature, it was not possible to standardise the definitions of risk factors in this review, meaning that there was often variation in the definitions included in each risk factor category, hampering discussion of relationships. Low socio-economic status (SES) and other factors associated with low SES, such as poor housing, are likely to be an important element in the link between behavioural risk factors and communicable diseases, although little is currently known about the influence of low SES and associated factors. It was not possible to explore the role of low SES within the review since many of the reviews included did not explore low SES in their analyses. Many of the included studies are global syntheses, however, the relationships between behavioural risk factors and communicable diseases may vary between countries. Only papers written in English were included, meaning that research in other languages may have been missed. Finally, conclusions should be considered with publication bias in mind; papers are more likely to be published if they reveal significant effects rather than null findings [ 106 ], so those reporting that behavioural risk factors are associated with communicable diseases are more likely to be identified.

This work identified several gaps in the current systematic review literature relating to specific behavioural risk factors and common communicable diseases, including studies examining the association of physical inactivity and poor dietary habits with communicable diseases, which warrant urgent further exploration. For instance, recently published literature has indeed highlighted the important role of physical inactivity in severe COVID-19 risk [ 2 , 107 ]. Due to the study being limited to systematic reviews only, a comprehensive comparison of behavioural risk factors across different disease types could not be provided; although future reviews could provide such comparisons. However, it was noted that reviews examining the association of communicable diseases with alcohol and illicit drug use largely focused on TB, HIV and hepatitis, whereas reviews examining association with obesity largely focused on pneumonia, influenza and COVID-19 (see Supplementary file  3 ). Further research understanding the more intricate ways in which individual behavioural risk factors are linked to specific types of disease, and the mechanisms by which they are linked, would provide a valuable framework for understanding how current and future communicable diseases may affect different population groups. Finally, findings highlight an opportunity for future research to examine the efficacy of behavioural risk factor prevention efforts in reducing communicable disease burden.

Behavioural risk factors play a significant role in the risk of contracting, and having more severe outcomes from, common communicable diseases. These risk factors are largely modifiable or preventable. Prevention of communicable diseases is likely to be most successful if it involves the prevention of behavioural risk factors that are commonly associated with NCDs, particularly among disadvantaged populations. These findings are important for understanding risks associated with communicable disease, and timely, given the current COVID-19 pandemic and need for improvements in future pandemic preparedness. Addressing behavioural risk factors should be an important part of work to build resilience against any emerging and future epidemics and pandemics. Furthermore, the pandemic can offer a timely, teachable moment for the public on how improvements to general health, through addressing risk behaviours commonly associated with NCDs, may help protect them from infections like COVID-19 in the future.

Availability of data and materials

Not applicable.

Abbreviations

Acquired immune deficiency syndrome

Acute lower respiratory infections

Body mass index

Hepatitis C virus

Hepatitis D virus

High-income country

Human immunodeficiency virus

Invasive bacterial disease

Invasive pneumococcal disease

Invasive meningococcal disease

Lower-middle income country

Middle east respiratory syndrome

Non-communicable disease

Overview quality assessment questionnaire

Preferred reporting items for systematic reviews and meta-analyses

International prospective register of systematic reviews

Relative risk

Severe acute respiratory syndrome

Tuberculosis

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We would like to thank Rebecca Hill and Nel Griffith, Public Health Wales, for their assistance in reviewing this manuscript.

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Wood, S., Harrison, S.E., Judd, N. et al. The impact of behavioural risk factors on communicable diseases: a systematic review of reviews. BMC Public Health 21 , 2110 (2021). https://doi.org/10.1186/s12889-021-12148-y

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Managing logistics in sport: a comprehensive systematic literature review

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  • Christoph Pott   ORCID: orcid.org/0000-0002-7041-7165 1 , 2 ,
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Logistics and sport management are part of the globalized economy and interdisciplinary fields of science. Sporting events necessitate enormous logistical efforts by aiming to deliver certain tasks and materials at an exact time and a specific place in suitable quantity and quality. However, sport logistics not only is involved in the precise execution of events but deals with a wide range of topics. Sporting goods are transported along the supply chain to customers with economic objectives, stadium evacuation simulations are carried out using algorithms that originate in transportation logistics, and sport clubs are confronted with logistical issues both on their game days and during the rest of the year. A systematic literature review was undertaken to provide clarity regarding previous scientific endeavors and to offer orientation for interested practitioners. The authors propose a theoretical framework—the sport logistics triangle—that draws on the academic disciplines of logistics management and sport management and allows to classify all sport logistics activities. An in-depth categorization scheme and ten topic clusters illustrate how sport logistics has been studied thus far. Implications and research opportunities are elaborated for practitioners and scholars. The survey clearly underlines both the importance of sport logistics and its neglection in academics.

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1 Introduction

For the 2012 London Olympic Games 1.2 billion dollars were invested to plan and provide its comprehensive logistics and transportation for 6.2 million spectators (Hendy 2013 , p. 9; Kershaw 2012 , p. 243). Hence, the importance of logistics in modern sport should not be surprising. It is worth noting that the logistical efforts (Sumner 2011 , p. 55) of holding a hallmark event such as the FIFA World Cup or the Olympic Games (Ritchie 1984 , p. 2) include more than public transport. At the 2008 Beijing Olympic Games, 104 hospitals were prepared for possible emergencies, and when the Games began, 400,000 volunteers were dispersed all over the city (BOCOG 2008 , p. 21). Logistical considerations also play a role in the preparation of camps for athletes (Arnold et al. 2015 , p. 12) and in all activities to deliver the necessary equipment to the venues (Minis et al. 2006a , b , p. 622). In July 2008, Beijing prepared 6,698,000 goods for the Games (BOCOG 2008 , p. 150). The global sport market is estimated to be worth more than 600 billion dollars in 2023 (NPD Group 2019 ) and the revenue of the worldwide sport equipment market is expected to grow 27% between 2023 and 2027 (Statista Consumer Market Insights 2023 ). These figures lead to the conclusion that the demand for logistics in sport will continue to grow.

The potential consequences of poor logistics management in sport were on display, for instance, in 2019, when the Kansas City Chiefs were scheduled to play the New England Patriots. A container of player equipment had not been unloaded, and a defeat because of missing equipment was imminent (NBC 2019 ). Another example occurred in Formula One, where the Fédération Internationale de l'Automobile (FIA) has banned retrofitting of tires (BBC 2005b ). After a devastating 150 mph accident in practice at the 2005 Indianapolis Grand Prix, Michelin pinpointed its tires as the source of the failure (Pfahl and Bates 2008 , pp. 135–142). Had it been allowed to bring in new tires, it would have had to ship them from a warehouse in France to the racetrack in the United States (ESPN 2005 ). Consequently, all teams with Michelin tires had to withdraw from the race, leaving only six cars to finish (Pfahl and Bates 2008 , p. 138) and resulting in major damage to the image of the FIA (Pfahl and Bates 2008 ) and a curious victory for Michael Schumacher (BBC 2005a ). Due to the premise that "the consequences of operations failure have huge implications for the outcome of the on-field performance" (Bamford et al. 2015 , p. 14), precise logistics operations are required to successfully orchestrate sporting events (Minis et al. 2006a , b , p. 622).

Both sport management (Brown et al. 2018 , p. 75; Doherty 2013 , p. 7) and logistics management (Haghani 1997 , p. 250; Meng 2014 , p. 137) are known as applied science disciplines. Despite the low tolerance for error in the management of large sporting events (Jones et al. 2015 , p. 188), the fact that sport management researchers are entrusted with design issues related to competition venues (Slack 2014 , p. 460) and the need for guidelines for successful implementation (Minis et al. 2006a , b , p. 622), researchers have been extremely reluctant to recognize the far-reaching importance of managing logistics in sport (Herold et al. 2019 , p. 358). Therefore, a systematic literature review (SLR) rigorously collects all topic-related studies and provides groundwork for future regulations to which industry players can refer (Kitchenham et al. 2009 , p. 8) and for the development of new research areas in management (Tranfield et al. 2003 , p. 208).

Consequently, this paper defines the following leading research questions (RQ):

RQ1 What is the current state of the art in the field of sport logistics? RQ2 Which directions for future research can be identified?

On the way to answering them, the following subordinate research questions (SRQ) are posed:

SRQ1 In which core areas of logistics and sport management does sports logistics research operate? SRQ2 How can a framework for sport logistics look like that draws from both disciplines? SRQ3 Which fundamental academic approaches are applied in sport logistics research? SRQ4 Which topics does sport logistics deal with and how can the field be subdivided?

For a systematic overview of logistics management, researchers must consider intra-, extra- and interlogistical contexts (Gudehus and Kotzab 2012 , pp. 439–440). Sport management must be reviewed with the understanding that its business “is not limited to leagues and competition” (Kauppi et al. 2013 , p. 1369) while including its “commercial and not-for-profit forms” (Smith and Stewart 2010 , p. 1). By employing the methodological procedure outlined by Kitchenham ( 2004 , p. 3), this paper aims to facilitate the process of locating further research (Kitchenham and Brereton 2013 , p. 2). Moreover, it intends to inspire researchers to further sport logistics management research.

Within the set parameters, the scope of the literature search had a range of 37 keywords, divided in accordance with the aforementioned research topic. More than 60,000 resulting publications were exported from ten scientific search engines and databases. The overall process of applying the content criteria and excluding nonfitting scientific works resulted in 202 final contributions to the categorization scheme. In the upcoming chapter, a comprehensive framework for sport logistics research is proposed and a delimitation from previous SLRs with reference to sport logistics is provided. Subsequently, the detailed review methodology is presented in chapter 3 and the results are analyzed in chapter 4. Chapter 5 discusses and outlines potential follow-up research opportunities. Finally, a conclusion that revisits the research questions is composed.

2 Theoretical background and differentiation from related surveys

In the first part of the chapter, the theoretical foundations of this paper are set by elaborating its theoretical background in the disciplines of logistics and sport management and proposing a framework for the management of logistics in sport: the sport logistics triangle. In the second part of the chapter the elaboration of this paper is distinguished from related works.

2.1 Theoretical background and the sport logistics triangle

Sport can be characterized as physical exercise determined by competition in a “nonhostile” manner (Wright 2009 , p. 161). As the largest nonmilitary logistics event (Minis et al. 2006a , b , p. 621), the Summer Olympics contribute to the fact that sport has "emerged as an industrial sector in its own” with multifaceted obstacles for managerial practitioners (Chadwick 2009 , p. 202). Although sport can be clearly distinguished from other sectors of the economy (Chadwick 2011 , p. 122), sport management must nevertheless draw on other areas of management research in order to develop its own potential (Slack 2014 , p. 462). In the current sport management literature, there is still a scarcity of contextual logistics research (Herold et al. 2019 , p. 358). Logistics management has become important owing to its ability to create crucial benefits for organizations (Christopher 2016 , p. 2), and an application to sport could create similar effects (Herold et al. 2019 , p. 358).

Issues in sport logistics are manifold. They spread from planning car fleets (Minis et al. 2009 ) and forecasting transport demands (Dosunmu 2012 ) to the legacy of logistics infrastructures (Kassens-Noor 2013a ). They include the coordination of athletes travel (Gupta et al. 2011 ) or spectator travel (Ceder and Perera 2014 ) to major events as well as its environmental impacts (Loewen & Wicker 2021 ) and supply chain emissions (Sampson et al. 2013 ). Issues of supply chain segmentation in the sporting goods industry (Roscoe & Baker 2014 ) are discussed from facility location (Pereira et al. 2017 ) to assort-packaging and distribution (Woong Sung et al. 2017 ). Consequently, this paper argues for a comprehensive view on sport logistics that is academically well-founded in the disciplines of logistics management and sport management. In the following, the key subjects of both disciplines will be discussed that lead to the key elements of our framework proposal that outlines the conceptual background for the systematic literature review: the sport logistics triangle (Fig. 1 ). Logistics management and sport management and their subfields form the professional and scientific foundation of sport logistics (gray triangle). Additionally, three triangle legs provide a classification scheme to contextualize any sport logistics activities.

figure 1

The sport logistics triangle and its foundation in the disciplines of logistics management and sport management

As basic starting point for theory development, this elaboration regards supply chain management, which “encompasses the planning and management of all activities involved in sourcing and procurement, conversion, and all logistics management activities” (CSCMP 2013 ). Subsequently, a functional view is adopted which focuses on the core part of logistics management activities. Logistics, in a broad definition, is defined as the link between marketplace and supply base and managing logistic means to plan and coordinate all activities necessary to deliver logistics services (Christopher 2016 , p. 11). The function of logistics management comprises integrative coordination as well as integrative service fulfillment inside and outside of organizations (Pfohl 2021 , p. 3 ff.). The scope can be divided into four areas: procurement, operations, distribution, and reverse logistics (Arnold et al. 2008 , p. 4; Christopher 2016 , p. 11; Gudehus and Kotzab 2012 , p. 6; Harrison et al. 2014 , p. 11).

Procurement focuses the supply side of an organization and includes the sourcing and receipt of goods and services from suppliers. Procurement is also referred to as inbound logistics or upstream. Operations focuses on the planning and control of flows within the boundaries of an organization. It is also referred to as internal logistics or production logistics (in the sense of producing a logistics service, e.g., order picking). Distribution is concerned with the delivery of products and services to customers. Distribution is also referred to as outbound logistics or downstream. Reverse logistics is the return of unwanted products, packaging or waste in the opposite direction, from the marketplace to the supply base. It is also referred to as returns or disposal management. (Arnold et al. 2008 ; Christopher 2016 ; Gudehus and Kotzab 2012 ; Harrison et al. 2014 ).

By the four areas of logistics management presented, all aspects of managing logistics in sport organizations can be described. Accordingly, a profound logistics management basis is provided for the sport logistics triangle.

The discipline of sport management comprises several areas of activities that are mainly derived from classic business management fields (Baker and Esherick 2013 ; Beech and Chadwick 2013 ; Bradbury and O’Boyle 2017 ; Covell et al. 2019 ; Gillentine and Crow 2009 ; Hoye and Parent 2017 ; Robinson 2012 ). Of these areas, marketing, operations, and organization have large intersections with logistics.

Marketing in sport comprises all activities for the production, pricing, promotion, and distribution of a sport product to meet the needs of customers (Pitts and Stotlar 2013 , p. 82). Its link to logistics is most evident in the aspect of distribution, the distribution of sporting goods from the productions site to the point of sale or the distribution of promotional articles at sporting events being specific examples. Sport marketing logistics meets the customers’ needs through purchasing and supply chain management (Schwarz and Hunter 2018 , p. 166). Operations in sport is a transformational process which creates, maintains and improves the delivery of sport products and services (Piekarz 2021 , p. 11). It comprises, e.g., facility and building management, merchandising and retail, or event and venue management. Operations and logistics share the input-transformation-output paradigm, Mentzer et al. ( 2008 ) identify logistics as the part of operations responsible for the transformation of time and place. Organization in sport is concerned with the structure, processes, and design of organizations and their subunits (Byers et al. 2012 , p. x). With the spread of Porter’s value chain approach (Porter 1998 ), also sport organizations have taken direction to outsource activities. As a result, the significance of thinking in processes, which is also the very approach of logistics, increases. In particular the outsourcing of activities that touch the physical value-adding structures (i.e., the physical structure of facilities to move goods Aronsson 2000 ; Hoekstra and Romme 1992 )), e.g., sporting goods manufacturing or event organization (Andreff and Andreff 2009 ; Burden and Li 2009 ), requires a holistic perspective on value creation, along the whole supply chain and with special attention to the interfaces of subprocesses and their integration (Houlihan 1985 ).

The three subjects described represent the central areas of sport management dealing with logistics challenges. As such they provide a profound sport management basis for the sport logistics triangle. After the foundation of sport logistics in the academic disciplines of logistics management and sport management was now built, the sport logistics triangle is outlined next. It is composed of three legs: flow type, network perspective, sport sector. Every sport logistics activity has an intersection with each of the three legs. On the basis of these three legs, the diverse logistical activities in sport organizations can be put into context.

The first leg, flow type, follows the flow-oriented definition of logistics, which states that logistics comprises all activities to efficiently manage all flows of material (goods), people and information from a source to a sink (Christopher 2011 ; CSCMP 2013 ; Pfohl 2018 ). While flowing, material, services and information are subject to different transformation processes with regard to time, space, quantity, type, composition, value, shape, and handling properties (Pfohl 2018 ; ten Hompel et al. 2018 ). Particular examples for each flow type are the production supply at sport equipment manufacturers (material), the coordination of spectator travel to major events (people), or order processing for fan shop sales (information).

Depending on where the flow takes place, intralogistics, transportation and supply chain are distinguished (Gudehus and Kotzab 2012 ). This network perspective represents the sport logistics triangle’s second leg. Intralogistics comprises flows in one location (at one site) (Günther 2006 ). Transportation, in contrast, comprises flows outside of buildings, often using public infrastructure (Clausen and Geiger 2013 ). Supply chains combine intralogistics and transportation in intercompany logistics networks of several participants (CSCMP 2013 ; Klaus 2012 ). Particular examples for each network perspective are the storage of event equipment at a sport venue (intralogistics), the shipping of a race car to the racetrack (transportation), or the distribution of sporting equipment along a sales channel (supply chain).

The third leg of the sport logistics triangle attributes the logistics activity the sector of sport. In the professional sport sector, sport organizations as professional leagues, equipment manufacturers or event managers pursue commercial interests. In the nonprofit sector, activities are on a voluntary basis (Hoye et al. 2015 , p. 7; Smith and Stewart 2015 , p. 19 ff.). Community based sport clubs and governing associations provide competition and participation opportunities, regulate and manage sporting codes, organize championship events (Hoye et al. 2015 , p. 7; Smith and Stewart 2015 , p. 19 ff.). The public sector comprises governments as well as specialist agencies that develop sport policy, provide funding, and support specialist roles, e.g., elite athlete development or drug control (Hoye et al. 2015 , p. 7; Smith and Stewart 2015 , p. 19 ff.). Particular examples for sport logistics activities in each sector are picking for the production of a sport shoe (professional), inventory management in a local sport club, or the transport of drug test kits between laboratories (public).

In summary, the sport logistics triangle defines sport logistics as dedicated to the management of flows in sport organizations.

2.2 Differentiation from related surveys

A first possible systematization of sport logistics management was proposed by Herold et al. ( 2019 ) who divide the field into four key pillars: venue logistics management, fan/spectator logistics management, equipment logistics management and athlete logistics management. To get to this suggestion, they regard sport logistics as a subfunction of sport event management. They draw on three event categorizations (regional, major, and mega sport events) and six typical characteristics of sport events to derive the four sport logistics pillars. Based on the SCOR model they define and discuss logistics activities in the context of their framework. The strict focus on event management is a clear limitation of the paper. Rather than a sport logistics framework, Herold et al. ( 2019 ) elaborated a sport event logistics framework. It does not offer theoretical foundation for the entire field of sport logistics management which goes far beyond requirement for sport events, specific examples being the production and distribution of sporting goods or inventory management in local sport and fitness clubs. Furthermore, Herold et al. ( 2019 ) predominantly focus the professional sport sector. This becomes most evident with regard to the athletes logistics management pillar. The nonprofit and public sectors are neglected. A comprehensive picture of sport logistics management is, thus, not drawn.

Another previous SLR with links to the management of logistics in sport was performed by Kauppi et al. ( 2013 ) and focuses operations management in sport. The authors categorize the papers reviewed in nine topics of operations management. Based on these topic areas and under consideration of four analysis units (organization, league, sector, industry) they sketch a research agenda for sport operations management. As Herold et al. ( 2019 ) the authors have a focus on sport events, as the reliance on the specific characteristics of sport reveals. Sport equipment manufacturing and retail are excluded from the scope of the paper as well as on-field performance. Considering the sport industry as part of the service industry leaves the handling of tangible goods by definition disregarded. With respect to the sport sectors the study is comprehensive and considers the commercial, nonprofit and public sport sectors alike. But even though operations management has many links to logistics, the paper’s focus is not the management of flows, the movement and storage of goods, the provision of logistics services.

In summary, it can be stated that there is no SLR that creates a full picture of sport logistics management. Table 1 compares the approaches of both papers with the approach of this contribution in order to highlight the originality of this contribution.

To map the planned scope, not only was the number of databases enlarged to 10, compared to Herold ( 2019 ) with two and Kauppi ( 2013 ) with three, but important topic-specific databases from the fields of sport management and logistics management, e.g., SportDiscus and Transport Research International Documentation (TRID), were also integrated for the first time. For multidisciplinary databases, the search areas were specially tailored where possible. Within this range of databases, in contrast to previous SLRs, conference proceedings were targeted in addition to journal papers, as recommended by Kitchenham et al. ( 2009 ). Due to the expansion of the research scope, the number of databases and the types of publications, the number of checked articles was remarkably higher. A keyword count of 37, divided into a sport and a logistics branch, further ensured the identification of all potentially relevant research. The research objective is implicit and is intended to clarify, as Denyer and Tranfield ( 2009 ) requested, what is and is not considered common knowledge about this particular management topic. From there, possible future research opportunities became recognizable.

In its analysis, unlike the previous SLRs, the paper not only offers a framework and builds topic clusters but also classifies the publications into classic fields of the sport management and logistics management disciplines and examines their scientific methodology. Moreover, not only are the findings described in writing, but the reader is also provided with visualizations (e.g., keyword cluster, word cloud) to deepen his or her understanding of the scope.

3 Methodology

The methodology used in this paper is based on the guidelines recommended for systematic reviews by Kitchenham ( 2004 ) and Kitchenham et al. ( 2009 ). Furthermore, the whole process of carrying out the research is aligned with the procedure of Tranfield et al. ( 2003 ) and Denyer and Tranfield ( 2009 ). The decision to use an SLR was made in the interest of the transparency and rigor of the research process (Fan et al. 2022 , p. 4). Review planning, as Tranfield et al. ( 2003 , p. 214) first put it, had already begun through differentiation from other SLRs in sport, logistics and linked management research. Thus, mandatory scoping studies were conducted. A separation into four sections, namely, inclusion, exclusion (selection process), reference recursion and analysis, accompanied by seven inherent stages, took place. The method is shown in Fig.  2 . When undertaking the systematic review, it was of great importance that only studies that complied with both the inclusion and exclusion criteria were considered (Tranfield et al. 2003 , p. 215).

figure 2

Outline of the SLR process

3.1 Inclusion criteria

At the beginning of the literature search, the criteria for inclusion were set (Table 2 ).

When searching in the above databases, it was determined that the results should contain at least one keyword from the world of sport and one keyword from the world of logistics. The selection of keywords was based on a consensus among more than 20 scientists collaborating with the authors. The final choice represents a series of important key terms in the two subject areas of sport and logistics. Thus, high accuracy in obtaining articles that dealt with an interrelation of the two areas was ensured. Per database, with the help of multiple operators, the search process was performed once in the title and once in the abstract with all possible combinations of the keywords at the same time. Special cases were Base and ScienceDirect. In the Bielefeld Academic Search Engine, the abstract search was not an available option, which led to an exchange of the abstract search with the publication-internal keyword search, while ScienceDirect automatically included title, abstract and publication-internal keywords in its search. An asterisk was used to include different word endings and spellings. The term “logistic regression” was excluded because it is a mathematical method for regression analysis and has no direct relation with logistics research.

A publication period of ten years was set up front for the included papers. Because the research was finalized 2022, the review horizon was expanded to a range of Jan 1, 2011, to Dec 31, 2021. This provided an up-to-date representation of the state of the art. The supplementary articles from the recursion process were not limited in terms of the publication period because it was assumed that the reference choices of an article concerned with sport logistics remained relevant further back in time. Other inclusion criteria still applied.

The articles had to be written in English. To ensure a certain level of quality and validity, the only accepted source types were conference papers and journals with peer-reviewed status. The chosen databases were selected in reference to Gusenbauer and Haddaway ( 2020 ), who evaluated 28 databases for their subject and for suitability when planning to carry out an SLR.

First, all databases that did not allow a bulk reference download were excluded due to the lack of suitability for an SLR. Second, the databases were chosen in accordance with their given subject; therefore, health, medicine, biomedicine, nursing, psychological and education study databases were not included. All chosen databases are listed in Table 3 alongside their subjects. A logistics-related database, a sport-related database and databases with other potentially important disciplines for sport logistics, such as management, computer science and engineering, as well as several multidisciplinary databases were chosen.

In ProQuest, six subdatabases shown in appendix B were included. The subdatabases were selected according to their deposited subject areas, e.g., economics and social sciences, and the provided source type. If the databases allowed the option of excluding certain topics and refining the search by doing so, such actions were taken only if the categories were clearly not in line with the research aim. Categories such as biology, chemistry and agriculture were eliminated. A full list of excluded topics for the Web of Science, Scopus and ACM databases is shown in appendix A. Furthermore, Base showed no more than 1,000 hits per search. In the same manner, ACM omitted any results above 2,000 hits. The retroactively added year of 2021 did not affect the results. A thorough application of the inclusion criteria to the databases resulted in potentially relevant hits, which in turn filled the created list of all contributions with possible relevance. An automatic duplicate removal based on titles was performed. Then, the list was approved for the selection process.

3.2 Selection process

To decide whether an article met the criteria for the sport logistics topic, a content criterion consisting of a link between sport and logistics was provided. Each of the studies that initially matched the inclusion criteria was examined independently and sequentially in the selection process by the authors in the areas of title, abstract and full text. Those articles had to fulfill the content criterion in all three segments. If there was a contradiction, the contribution was excluded at that point. In the event of discrepancies, discussions were held by the research panel to refine the thematic boundaries. The content criterion is shown in Table 4 .

Only if the examination of the contributions’ full texts within the selection process manifested the link were they approved for the deeper literature analysis. The contributions approved for the literature analysis were searched afterward for further references matching the topic and the inclusion criteria except for the set publication period of 2011–2021. The extension of the publication period for the references was justified previously by the fact that the references of the contributions that remained at the end of the selection process were possibly so closely related to the topic of logistics in sport that these contributions should be included even if they were outside the date range. An extension of the time period beforehand in the inclusion criteria would have led to a number of hits that would have exceeded the capacities of the search. Another duplicate removal was performed within the list of all references. The identified references also had to match in all three areas of the selection process.

3.3 Literature analysis

Starting with the fourth section, analysis, a final contributions list was compiled that contained all relevant studies identified in the selection process. Additional information for each study, such as title, abstract, author names, publication date, name of journal/conference, link, link date, digital object identifier (DOI) and APA citation, were added, as there had been no full extraction of information from all databases. In the final list, duplicates were removed, and publications without a DOI were eliminated.

The final contributions were now reread and analyzed. In addition, more data were extracted in terms of the main topic area and methodology. A categorization scheme was created with reasonable categories to classify the contributions. This scheme was continuously refined throughout the process. The final scheme is shown in Table 5 . Subsequently, the classification of the literature into the previously created scheme took place.

The type of work category distinguished between literature review, research article and project report. A literature review can be part of a broader methodology or can be the methodology itself (Cooper 1998 , pp. 3–4). A research article could therefore contain a literature review but might have a main objective in opposition to the literature review as a focus not only on reflecting the current state of the art but also on establishing a new or more in-depth state of research. Various research methods, such as data collection, were used for this purpose (Gastel and Day 2016 , p. 18). This could also be done in project reports, but these reports tended to be carried out "for operational reasons" (Perneger 2004 , p. 191). In such cases, the authors were directly involved in the project described; i.e., they were on site.

The network perspective describes flows in form of networks that consist of nodes and edges. Depending on the considered section of the network three parts were distinguished (Gudehus and Kotzab 2012 , pp. 439–440). Intralogistics takes place exclusively in one node and describes internal processes at one location. Extralogistics refers to transportation processes, or what happens on the edges between nodes, i.e., in channels. Interlogistics is an entire logistics network that combines the two previously mentioned disciplines and, in the form of supply chain management, refers to both nodes and edges. In addition, three types of flow could be distinguished: material flow, people flow, or information flow. Some contributions also looked at a combination.

The sport sectors were also trisected, creating a division into professional (commercial organizations, e.g., equipment manufacturers or franchises), nonprofit (e.g., community-based clubs or events), and public (e.g., government funded or related to drug control) (Hoye et al. 2015 , pp. 7–8). From there, the categorization distinguished between teams and individual athletes. These types of sport were supplemented by the undefined category to cover scientific work that did not explicitly deal with a particular type of sport.

To classify the publications according to their academic focus, a three-part approach consisting of conceptual, technological, and empirical aspects was utilized. Conceptual papers do not necessarily have a practical focus and deal with the development of new concepts, some of which are abstract, or the extension of existing ones. If the focus is technological, the research centers on a technology that is explained and occasionally described in terms of its application. Empirical contributions rely on data collected, e.g., through observations or experiments, and therefore are often based on the researchers' own findings (Kothari 2004 , p. 4).

Following Kothari ( 2004 ) once more regarding the research orientation of the final contributions, some complementary categories of the type of research were applied. The research objective could be descriptive if facts were sought in the past and present, which made the research "ex post facto" (Kothari 2004 , p. 3). Analytical research has the objective of evaluating, analyzing and providing instructions for future processes or procedures. The methodology type can be qualitative, quantitative or both. The data of qualitative studies are mostly nonnumerical, while quantitative studies use numbers or convert data into numerical values. In conclusion, the type of research distinguished between basic research, in which new knowledge is added to existing theories, and applied research, in which the analysis of empirical data is used to find solutions to problems. The solutions thus refer to the application in a practical environment such as companies.

Moving on from an overview of the categorization scheme, the following presents the SLR review outcome. First, the selection process across the individual process steps is presented and underpinned with numbers. This is followed by general facts about the publications that made it to the final list. The papers of the conclusive list are presented within the categorization scheme. The categories are utilized to gather information and help to draw conclusions regarding the state of the art of sport logistics research. When the follow-up literature analysis was conducted, it was consistent with the suggestions made by Tranfield et al. ( 2003 , pp. 218–219) about how to report the studies: (i) descriptive statements are followed by (ii) thematic analysis. The authors present the emerging themes, and connections are drawn between them.

4.1 Reduction of publications during the selection process

Initially, the finalized selection process is described in its entirety (Fig.  3 ). As mentioned before, a systematic literature search was conducted in the ten databases. As a result, tables containing all exportable articles were created for each database. Up to this point, no exclusion of journal/conference papers was performed with regard to the predefined criterion. Moreover, the search results were not scanned for duplicates. Specifically, the preliminary blocks/lists (n 1 …n 10 ) contained the raw data of the initial database searches with a total of 72,704 papers.

figure 3

Selection process with numbers

After an intralist search for duplicates and the deletion of duplicates, a merged list of 68,360 papers resulted. The lists from all the databases were then merged, and a second duplicate removal took place, which decreased the outcome to 49,960 contributions that became the focal point of the systematic review. The lack of combined coverage of sport and logistics led to an exclusion of 44,362 publications on the basis of the title alone. Then, the participating researchers excluded 1,300 papers on the basis of their abstracts by using the same content criterion (also see (3.2) Selection Process). A total of 399 papers were not considered further because of the missing link between sport and logistics in the full text of 329, and the remaining 70 were excluded because there was no available full text. Ultimately, 181 papers remained. The recursion process for those added another 124 papers to the final entries. A final duplicate removal and an exclusion for the absence of a DOI were performed. The definitive list for the literature analysis then consisted of 202 publications. It contains the authors cited in APA citation style, the year of publication, a classification in the previously created categorization scheme and a topic cluster (Table 6 ).

4.2 General publications analysis

4.2.1 publication year.

Beginning with (i) the descriptive statements as a preparation for (ii) the thematic analysis, the 202 selected scientific papers showed that there had been no crucial increase in publications relating to a combination of sport and logistics management topics over the previous decade (Fig.  4 ). The releases were almost evenly distributed over the time horizon, with a peak of 24 articles in 2021. Whether managing logistics in sport will receive intensified interest from researchers and businesses can be determined only by watching future years and expanding the research period.

figure 4

Sport logistics publications since 2011

4.2.2 Country of origin

Based on the affiliation of the first author, statistics were collected on the country of origin of each publication. Figure  5 gives an overview on all countries with more than five publications. Countries with four publications or less are subsumed under “others”.

figure 5

Countries of origin of the publications

4.2.3 Authors’ professional background

The professional background of the first author was analyzed based on his affiliation (Fig.  6 ). The vast majority of authors conducted their research at a university. Where their department/faculty affiliation was given, a distinction was made into publications from humanities and social sciences, engineering sciences, life sciences, and natural sciences. Professional backgrounds other than universities were public administrations, Olympic organization committees, or enterprises.

figure 6

Professional background of Authors

4.2.4 Subject areas of publications

From the publications examined, 85 could clearly be assigned to either the subject area of logistics or of sport. On the side of the journals, 40 publication were found in journals of logistics management such as International Journal of Logistics Management or International Journal of Physical Distribution & Logistics Management. From the 42 publications found in sport journals, 18 were released in sport management journals as Sport Management Review or European Sport Management Quarterly, and 24 were released in general sport journals such as Sport in Society or Journal of Sport and Tourism. On the side of the conference, three contributions are from logistics specific conventions (e.g., International IEEE Conference on Intelligent Transportation Systems), none from sport management specific conventions.

4.2.5 Leading authors and journals

The included publications were written by 547 different authors. Eva Kassens-Noor had the largest impact on the final list, with six published articles that showed a link between sport and logistics management. The journals European Sport Management Quarterly with 5 and Transportation Research Record: Journal of the Transportation Research Board with 7 articles each contributed the most to the final list. In total, 23 different conferences and 180 journals were included.

4.2.6 Type of work

As mentioned before, the type of work refers to the central research methodology. Mostly, the contributions could be classified as research articles. In some of those research articles, the authors used a literature review (Somabutr et al. 2020 ) to obtain a picture of the state of the art in the corresponding research area. A few of the contributions included in the final list contained a literature review as their main methodology (Savić et al. 2018 ). When the authors were on site and their results were based on observation of sport logistical processes, they were categorized in the project report category (Puangmanee and Saearlee 2020 ).

4.3 Analysis of titles and keywords

The previous look into the categorization scheme (Table 6 ) provided an extensive overview of research fields and research methods within sport logistics. The final list comprised 202 papers. A text-based description of all papers in detail would go beyond the scope of this study. Nevertheless, by utilizing a full title and keyword analysis, far-reaching statements about the content are possible. Following (Tranfield et al. 2003 ) once more, (i) the descriptive statements are ended, and (ii) the thematic analysis is now introduced in the wake of the reporting. It is based on the results of the title and keywords analysis.

The qualitative output for the title analysis is displayed in a word cloud (Fig.  7 ). The frequency of terms occurring in the titles is represented by the size ratio. Prepositions, connectors, and verbs as well as words such as “based”, “perceived” or “new”, which do not reveal the content of the works, were not incorporated. The word cloud reveals what topics are important when managing logistics in sport. It puts the management of events in the center of attention, namely the Olympics and games. From a sport management point of view especially football stands out as a sport and stadium as venue where sport is performed. Keywords sticking out from a logistics management point of view are transport, traffic, or delivery. They indicate that a major focus of the research is transportation, though not exclusively as they are accompanied by keywords such as logistics, supply, or chain which suggest further focal points.

figure 7

Qualitative title word cloud

On the basis of the keywords that the authors and publishers of the individual publications set themselves, far-reaching statements can be made in regard to the contents. The results of the keyword analysis are presented in Fig.  8 . It was carried out using VOSViewer (visualization of similarities) (van Eck and Waltman 2010 ). Only keywords that occurred at least twice were considered, and 104 keywords were thus identified. The distance between the keywords is an indicator of their proximity to each other. This means two publications with several joint keywords will be close to each other. The same applies to a group of publications with keywords that carry many cross connections. It is different for a paper that has only the minimum number of two connections via a single keyword in the overall cluster. All other keywords of this publication will be slightly offset from the others. The software identified a cluster that had the most connected keywords overall. Of the 104 keywords, not all had any connection to the defined main cluster. The software then offered to hide keywords or publications that were not connected. After this function was used, 87 connected keywords remained as the main cluster. The frequency of keyword occurrence is determined by the size of the spheres. The thickness of the lines indicates how often keywords occur together. The colors are another indicator of multiple co-occurrences of keywords, resulting in the formation of further clusters. The keyword clusters support the indication of the word cloud as the central and biggest clusters form around the Olympic Games, mega-events and the planning of its transportation. The topics of events and transportation also reoccur in a couple of smaller clusters, e.g. in the context of sustainability and public transport management. Two clusters stand out thematically: the blue cluster’s focus is on production, the red cluster’s focus is on supply chain management. Their points of connection are global value chains and sporting goods. They comprehend aspects such as manufacturing and labor standards as well as e-commerce, retail and outsourcing. By the size of the clusters, these sport logistics fields seem to be academically less developed than sport events and transportation.

figure 8

Keyword clusters arising from publication analysis

4.4 Sport sector and type of sport

The classification of sport sectors was not always clear-cut in the papers examined. For a deterministic assignment, a fixation on the sport sector that was the central focus was used. The public sector primarily included transportation papers, which could be traced back to public transportation (Ceder and Perera 2014 ) and infrastructure around large sporting events. Pre-event planning (Kassens-Noor 2019 ) and the evaluation of the postevent impacts on the host country in terms of transportation (Hensher and Brewer 2002 ; Sroka 2021 ) and economics (Li et al. 2013 ) were described.

Only limited allocations to the nonprofit sector could be made. The main topics within this sector were sport tourism and spectator travel (Humphreys 2017 ; Wicker 2018 ; Wise et al. 2019 ); community sport, which included sport for development (MacIntosh et al. 2016 ); and college sport (Gallucci and Petersen 2017 ).

A wide range of content was selected for the professional sector. With an intersection of 68 papers on material flow, it is hardly surprising that many publications focused on production (Kumar et al. 2021 ), innovation in the sport equipment business (Desbordes 2001 , 2002 ) or trade (Aguilera 2020 ; Roscoe and Baker 2014 ). In contrast to the nonprofit sector, the management of sport events in terms of monetary value was considered (Currie and Shalaby 2012 ; Sarasua et al. 2011 ; Sattayhatewa and Smith 2003 ). Additionally, management around and in stadiums was located in the professional sector (Henao and Marshall 2013 ; Klauser 2013 ; Zhang et al. 2018 ). The emphasis on professionalization led to the assignment of research on the management of big sport clubs (Memari et al. 2021 ; Szymoszowskyj et al. 2016 ) to the same sector.

The category type of sport was divided into team, single and undefined. The team sport category included mainly soccer (Earl et al. 2014 ; Vouillamoz et al. 2009 ) and American football (Herold et al. 2021 ; Judge et al. 2014 ), but some other team sport (Dolf and Teehan 2015 ) was also addressed. The focus was on team travel (Gupta et al. 2011 ) or more general supply chain management considerations (Serrano et al. 2019a , b ). No clear pattern was discernible in individual sport. The sport here was wide-ranging, from aquatics (Gerke 2016 ; Gerke et al. 2015 ) to skiing (Spector 2017 ; Wise et al. 2019 ) to golf (Humphreys 2017 ). Additionally, some publications did not deal with a specific sport (Clikeman 2012 ), or the paper included both team and individual sport (Hensher and Brewer 2002 ).

4.5 Network perspective and flow type

The classification of the network perspective shows a clear preponderance of interlogistics and transportation research. Central research topics of recent transportation studies were the XXX. Summer Olympics in London 2012 (Currie et al. 2014 ; Dosunmu 2012 ; Parkes et al. 2016 ; Sumner 2011 ) and the XXIV. Summer Olympics in Beijing (Jiang 2008 ; Liu et al. 2008a , b ; Zoghi et al. 2009 ) as well as major events such as the World Cup (Malhado and Rothfuss 2013 ; Wood 2019 ) and other game-day-related work (Dosumu et al. 2017 ; Loewen and Wicker 2021 ; Tóffano Pereira et al. 2019 ).

Intralogistics papers are either related to sport clubs and their facilities (Chelladurai et al. 1987 ; Gallucci and Petersen 2017 ) or have a connection to production logistics (Kumar et al. 2021 ; Meier et al. 2019 ; Subic et al. 2012 ), preparation (Arnold et al. 2015 ; Odoni et al. 2009 ), technology services (Wu and Li 2016 ) and evacuation (Bateman and Majumdar 2018 ; Mahmudzadeh et al. 2020 ) of stadiums or other sport event-related locations.

One of the core issues of SCM (interlogistics) is global value chains (Appelqvist et al. 2013 ; Mamic 2005 ). These included papers about the distribution of sporting goods (Asian et al. 2020 ; Harvey and Saint-Germain 2001 ) and case studies on sport equipment brands, such as Reebok (Hecox 2013 ). Papers on events described management and logistics with all involved entities (Kristiansen et al. 2016 ).

The logistical focus was nearly balanced among publications related to people flow and those related to material flow. In contrast to the other categories, a listing in more than one of the flow types was regarded a possibility for the reason that flows of materials and people always lead to information exchange. If one of the flow types stood out in particular, a deterministic approach was taken, as in the other categories.

The material flow was often recorded from the point of view of producers (Razavi et al. 2014 ). As a result, many of these material flow-related papers featured the handling of sport equipment along the supply chain (Andreff and Andreff 2009 ; Chen and Notteboom 2012 ; Woong Sung et al. 2017 ) but missed out on the opportunity to engage with sport equipment logistics in providing for athletes, as was partly done by Herold et al. ( 2021 ). However, there were also publications that illuminated the event-related supply of material (Brady and Davies 2014 ) and food (Li et al. 2019 ). What was evident was the fact that the supply chain management and material flow categories with 69 shared papers had a high degree of overlap.

Another overlap was noticeable between the transportation category and people flow, with 95 joint papers. As with the transportation category, the people flow papers were primarily about the 2012 London Olympics (Browne et al. 2014 ; Jones and Woolley 2019 ; Lindsay 2013 ), other Olympic Games (Minis et al. 2009 ; Mulley and Moutou 2015 ), football games (Elbery et al. 2019b ) or different sport events (Han et al. 2018 ; Mosadeghi et al. 2020 ). Not mentioned before in the transportation category but still not to be overlooked was the number of papers concerned with the environment and so-called carbon footprint during sport events (Dolf and Teehan 2015 ; Sampson et al. 2013 ; Triantafyllidis et al. 2018 ).

In eight cases, even the flow of information was considered solely with reference to sport and logistics and without physical flows. Here, the findings revolved around facility location problems (Millstein and Campbell 2018 ; Pereira et al. 2017 ; Smith and Smith 2008 ), as observed in intralogistics, new technologies and planning processes (Kendall et al. 2010 ).

If the term sport logistics or related terms were deliberately coined (Herold et al. 2019 , 2021 ; Liu and Gao 2013 ; Ribeiro and Almeida 2020 ), all three categories were attributed since these papers chose a fully holistic approach. If information flows and all physical flows were considered for the Olympic Games and the tasks of logistics management were analyzed (Denicol et al. 2021 ; Ribeiro et al. 2021 ), the papers also received three crosses.

4.6 Academic focus and type of research

In the vast majority of the research articles, the academic focus was empirical in nature. Here, different approaches were taken with interviews (Arnold et al. 2016 ) or the production of the authors’ own research data (Rutten et al. 2021 ) through simulation (Fang et al. 2011a , b ) or via the conduction of a project report (Jiang 2008 ). Some of the contributions were only conceptual, meaning they considered the work of others by conducting a literature review and following it with a built-on framework or other concept (Robbins et al. 2007 ). Technological papers often included an empirical aspect because technology was often used to produce the authors’ own results (Ramadan et al. 2020 ).

In the type of research category, qualitative research often used interviews (Bateman and Majumdar 2018 ; Szymoszowskyj et al. 2016 ) or literature reviews (Luitzen et al. 2015 ). Sixty-eight papers from the qualitative category were assigned to the basic type of research, which illustrates the frequency of a joint occurrence. Quantitative research often relied on statistical analysis (Mahmudzadeh et al. 2020 ; Razavi et al. 2014 ), which was applied in 44 cases. Quantitative data ranged from survey results to simulations of traffic (Ramadan et al. 2020 ) or crowds (Xie et al. 2017 ). Some papers explicitly chose mixed methods. In mixed-methods papers, the authors ascertained the more significant method.

Many of the literature reviews fell into the basic type of research. Of the 30 literature reviews with a conceptual academic focus, 22 were basic research. The applied papers mostly had an economic focus (Lund-Thomsen 2013 ; Raza 2016 ), with 50 of the 76 papers being assigned to the third sector of sport.

Analytical papers nearly created an equilibrium by choosing a basic research approach in 50 cases and an applied research approach in 57 cases. Most descriptive papers were also basic research, with a congruency of 69 papers.

4.7 Topic clusters

In conducting (ii) the thematic analysis, topic clusters were formed (Fig.  9 ) that represent the central topics that occur across the board (Tranfield et al. 2003 , p. 219).

figure 9

Overview of the topic clusters and their frequency

Following the preceding statements about events and the final list, the authors concluded at this point that the management of logistics in sport was most prevalent in the event context. The research panel sorted 100 of the 202 final papers into event operations research. From there, a discussion led to the three central topics event operations planning with 30, event operations management with 49 and event operations legacy with 18 papers. The choice of a threefold partition was made because planning papers comprise primarily studies about future events or how former events were prepared, management papers include analysis of the management process during events and the general time horizon during or shortly after events and legacy papers evaluate persisting transport systems and infrastructure after events on the one hand and the perceptions of involved stakeholders or residents on the other.

The next central topic is sporting goods. Here, 14 papers were regarded as dealing with production, while 11 analyzed supply distribution. Sporting goods production papers were concerned with labor conditions, performance measurement or innovating processes. Sporting goods distribution mostly revolved around the supply chain from a trade perspective or its risks of disruption or focused on a specific company.

Next was technology management , to which 17 papers were distributed. These related primarily to new technologies such as the internet of things (IoT), artificial intelligence and big data or infrastructure planning with GIS. Security planning with specific technologies for upcoming events was also represented. The subsequent central topic was dealing with sport organization studies . Fourteen studies matched this topic. Those papers presented research on sport clubs, community sports, facility management or athlete management with travel and organizational stressors. Environmental studies as another central topic included 10 papers, mostly involving carbon dioxide emissions measured with the carbon footprint at football matches or events. With 7 papers stadium safety and security represents the smallest category. It deals with space management and crowd flow in stadiums, especially in evacuation and emergency scenarios.

There were 30 publications on peripheral themes that did not justify a central topic of their own ( others ). Ten of the publications dealt with the sport industry in very general terms, while seven focused on sport clusters. Further topics included a facility location problem, sport tourism, marketing, reverse logistics, sport history, accounting and sport management in general.

In the final list (Table 6 ), the central topics were represented by the upcoming numbers: event operations planning (1), event operations management (2), event operations legacy (3), sporting goods production (4), sporting goods distribution (5), technology management (6), sport organization studies (7), environmental studies (8), stadium safety and security (9), and others (10).

5 Discussion and research agenda

After the previous chapter comprehensively analyzed the current body of knowledge in the field of sport logistics management, this chapter discusses the implications for both practitioners and scholars, and derives future challenges. A detailed agenda for future research is derived from the analysis by classifying the upcoming research topics depending on the sport logistics triangle.

5.1 Implications and research opportunities for practitioners

In an ever growing sport industry, the need for and value of professional logistics services is continuously increasing, quantitatively as well as qualitatively. Logistics services are operations in the supply environment of systems. In sport, such systems can be enterprises, non-profit organizations, events, sporting facilities, traffic etc. These systems require physical supplies to exist.

In quantitative terms, practitioners face the need to establish new and extend existing logistics services in sport due to, e.g., increasing sport equipment sales, ever new and bigger sport events, growing sport tourism. In qualitative terms, the practitioners’ aim is to continuously improve existing logistics services in sport. This usually means the increase of the logistics performance, e.g., by reducing the delivery time, increasing the delivery capacity, increasing the delivery quality, increasing the delivery flexibility.

The topic clusters event operations planning, event operations management, sporting goods production, sporting goods distribution, and stadium safety and security can be regarded as cumulating mainly issues of special interest for practitioners. Table 7 outlines developments and potentials of logistics in sport that were identified in the literature for practitioners and classifies them on the basis of the sport logistics triangle (flow type: material (Mat), people (Peo), information (Inf); network perspective: intralogistics (Int), transportation (Tra), supply chain (Sup); sport sector: professional (Pro), nonprofit (Non), public (Pub)), listing the triangle fields in the center of attention.

5.2 Implications and research opportunities for scholars

As stated in the introduction, sport logistics management is a heavily under-researched field. It offers broad research opportunities in manifold directions. In particular, project reports, the second sector of sport, single sport, and intralogistics (see Table 6 ) are underrepresented in publications with sport logistics focus. Based on the findings and analyses in this review, Table 8 suggests research areas that need further attention and investigation and classifies them on the basis of the sport logistics triangle (flow type: material (Mat), people (Peo), information (Inf); network perspective: intralogistics (Int), transportation (Tra), supply chain (Sup); sport sector: professional (Pro), nonprofit (Non), public (Pub)), listing the triangle fields in the center of attention.

5.3 Superior/general future challenges

In addition to the specific aspects of the previous two sections, there are more general, superordinate future challenges affecting logistics in sport—practitioners and researchers alike.

Sustainability has arrived at the center of society. The sport industry increasingly recognizes the need to align its activities sustainably. Logistics can make a contribution in all three dimensions of sustainability: a good partner integration along the supply chain leads to economic sustainability, considering legacy usage when planning new transportation networks for mega events (e.g., new subway stations) leads to social sustainability, sourcing local for the production of sport equipment leads to environmental sustainability.

The growing globalization of sport is constantly raising the demands on logistics. Sporting equipment for Western markets is manufactured Far East. North American NFL teams play official matches in Europe, European soccer teams spend their preseasons for marketing tours through North America and Asia playing local teams. Racing series as the Formula One or the World Rally Championship travel back and forth between different continents in the course of a season. Amateur athletes in search of particular sporting challenges as well as fans following their teams around the world have turned sport tourism into a mass movement. From the logistics perspective, these globalization developments go hand in hand with a series of challenges. Most obvious is the need for significantly more transport capacity. In particular, demand is increasing along international air and shipping routes that are already heavily utilized, which requires good planning in advance to reserve the capacity needed, at a reasonable price. International transportation also is subject to customs restrictions. All material sent to other economic regions goes along with special requirements for packaging, labeling and registration. Due to the administrative processes, preparation and execution of the transport are more time-consuming and take longer. The complex processes of international supply chains have more imponderables, making their resilience particularly important.

Professional logistics, and international logistics chains in particular, goes hand in hand with an international division of labor. To successfully manage it, documentation and provision of information is key. In other words: material or people flows have to be accompanied by the right flow of information. A challenge that can only be adequately met with IT support. However, the realization of digital workflows for logistics in sport organizations still lags behind. Digitization stays one of the crucial challenges of sport logistics.

To this day, most sport logistics managers started their jobs as job as a logistician without sport education, as a sport manager without logistics education, or as a career changer. Neither is logistics management a subject in sport management curricula, nor is sport management a subject in logistics management curricula. There are not even further education programs or certificate programs to become a sport logistics manager. The establishment of education programs for sport logistics management is to be understood as a key piece of the puzzle towards further professionalization of sport logistics management. To raise awareness for the special remit of sport logistics has to become a mission for every sport logistics manager.

6 Conclusion

The motivation of the authors originated from their conviction of the undeniable pertinence of the management of logistics in sport. The underlying objective of this contribution was to elaborate a comprehensive image of the state of the art in sport logistics. To this intend, a new framework for sport logistics was developed, recent literature was reviewed, and an agenda for future research was established.

The sport logistics triangle draws from the academic disciplines of logistics management and sport management (SRQ 2): procurement, operations, distribution, and reverse logistics build its logistics management foundations, marketing, operations, and organization build its sport management foundations. The sport logistics triangle is composed of three legs: flow type, network perspective, sport sector. They allow a structured classification and contextualization of the diverse logistical activities in sport organizations. Every sport logistics activity has an intersection with each of the three legs.

To gain the most comprehensive insights, a systematic literature review was carried out and an extensive number of scientific papers was evaluated. In the interest of the inclusivity of the SLR, the authors decided to cover not only journal articles but also conference papers. A transparent four-section process of inclusion, exclusion, reference recursion and analysis resulted in the final list of 202 papers which were analyzed in content to represent the status quo of current research in sport logistics. The reader was introduced to developments in the research around the management of logistics in sport through a dichotomy of descriptive elements and thematic content. In doing so and to ensure increased transparency, the reader was provided with a comprehensible bridge between the documented information and the conclusions drawn from it. To allow the SLR to have an explanatory nature, studies were evaluated in a categorization scheme regarding their sport and logistics focuses as well as their methodological frame. Here, conclusions can be drawn about the state of the research. The numerical distributions of the type of work, type of research and the logistics and sport-related classifications (see SRQ 1 & 3) indicate the sophistication of the research and where there is still room for progress, e.g., investigations on the second sport sector, single sport, or intralogistics, especially in the form of project reports.

To complement this, the titles and keywords established by the authors were evaluated and presented in a chart. The keyword cluster indicated a hotchpotch of research. Work is being done in many areas, but not in a unified manner, which makes it much more difficult to base new research on past efforts. This publication is intended to contribute to a profound expansion of theory via the sport logistics triangle framework and to trigger a joint discourse at the interface of logistics management and sport management as the overall state of the art can be characterized as heterogenic, diffuse, and shallow (RQ 1).

Based on the evaluation of key words and titles and the content analysis, the research panel built nine topic clusters: event operations (planning, management and legacy), sporting goods (production and distribution), technology management, sport organization studies, environmental studies, and stadium safety and security (SRQ 4) that can serve as key starting points for further research on the management of logistics in sport. In the discussion chapter, more specific research opportunities, e.g., the outsourcing of logistics services in sport organizations, the location determination and design of sport logistics facilities, or the management of equipment and its provision to athletes derived from the papers examined were given and classified on the basis of the sport logistics triangle. Practitioners and researchers were addressed separately. On a global scale, general future challenges of sport logistics management were named, i.e. sustainability, globalization, digitization, education programs (RQ 2).

The paper showed that a comprehensive conceptional umbrella for sport logistics management as the intersection of logistics management and sport management is still missing. Hence, the authors call on logistics and sport management scholars alike to engage in the manifold research opportunities of managing logistics in sport.

Data availability

The author confirms that all data generated or analyzed during this study are included in this published article. Furthermore, primary and secondary sources and data supporting the findings of this study were all publicly available at the time of submission.

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Introduction, changes in global population: patterns of fertility, infertility prevalence and determinants, infertility awareness and prevention, access to fertility care, working toward equitable access to fertility care, conclusions, call to action, data availability, acknowledgements, authors’ roles, conflict of interest.

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Declining global fertility rates and the implications for family planning and family building: an IFFS consensus document based on a narrative review of the literature

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Bart C.J.M. Fauser and G. David Adamson are co-first authors.

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Bart C J M Fauser, G David Adamson, Jacky Boivin, Georgina M Chambers, Christian de Geyter, Silke Dyer, Marcia C Inhorn, Lone Schmidt, Gamal I Serour, Basil Tarlatzis, Fernando Zegers-Hochschild, Contributors and members of the IFFS Demographics and Access to Care Review Board , Declining global fertility rates and the implications for family planning and family building: an IFFS consensus document based on a narrative review of the literature, Human Reproduction Update , Volume 30, Issue 2, March-April 2024, Pages 153–173, https://doi.org/10.1093/humupd/dmad028

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Family-planning policies have focused on contraceptive approaches to avoid unintended pregnancies, postpone, or terminate pregnancies and mitigate population growth. These policies have contributed to significantly slowing world population growth. Presently, half the countries worldwide exhibit a fertility rate below replacement level. Not including the effects of migration, many countries are predicted to have a population decline of >50% from 2017 to 2100, causing demographic changes with profound societal implications. Policies that optimize chances to have a child when desired increase fertility rates and are gaining interest as a family-building method. Increasingly, countries have implemented child-friendly policies (mainly financial incentives in addition to public funding of fertility treatment in a limited number of countries) to mitigate decreasing national populations. However, the extent of public spending on child benefits varies greatly from country to country. To our knowledge, this International Federation of Fertility Societies (IFFS) consensus document represents the first attempt to describe major disparities in access to fertility care in the context of the global trend of decreasing growth in the world population, based on a narrative review of the existing literature.

The concept of family building , the process by which individuals or couples create or expand their families, has been largely ignored in family-planning paradigms. Family building encompasses various methods and options for individuals or couples who wish to have children. It can involve biological means, such as natural conception, as well as ART, surrogacy, adoption, and foster care. Family-building acknowledges the diverse ways in which individuals or couples can create their desired family and reflects the understanding that there is no one-size-fits-all approach to building a family. Developing education programs for young adults to increase family-building awareness and prevent infertility is urgently needed. Recommendations are provided and important knowledge gaps identified to provide professionals, the public, and policymakers with a comprehensive understanding of the role of child-friendly policies.

A narrative review of the existing literature was performed by invited global leaders who themselves significantly contributed to this research field. Each section of the review was prepared by two to three experts, each of whom searched the published literature (PubMed) for peer reviewed full papers and reviews. Sections were discussed monthly by all authors and quarterly by the review board. The final document was prepared following discussions among all team members during a hybrid invitational meeting where full consensus was reached.

Major advances in fertility care have dramatically improved family-building opportunities since the 1990s. Although up to 10% of all children are born as a result of fertility care in some wealthy countries, there is great variation in access to care. The high cost to patients of infertility treatment renders it unaffordable for most. Preliminary studies point to the increasing contribution of fertility care to the global population and the associated economic benefits for society.

Fertility care has rarely been discussed in the context of a rapid decrease in world population growth. Soon, most countries will have an average number of children per woman far below the replacement level. While this may have a beneficial impact on the environment, underpopulation is of great concern in many countries. Although governments have implemented child-friendly policies, distinct discrepancies in access to fertility care remain.

Declining fertility rates globally focus attention on the human right to build a family and the need for family-friendly policies and more accessible fertility care. LBGTQ, lesbian, gay, bisexual, transgender, queer, asexual, questioning.

Declining fertility rates globally focus attention on the human right to build a family and the need for family-friendly policies and more accessible fertility care. LBGTQ, lesbian, gay, bisexual, transgender, queer, asexual, questioning.

For over half a century, family-planning policies have focused on contraceptive approaches to avoid unintended pregnancies, postpone desired pregnancies and, in some countries, terminate unwanted pregnancies. Additionally, many policies were driven by the goal to reduce population growth because of concerns that overpopulation would result in overcrowding, poor sanitation, disease epidemics, famine, war, massive migrations, increasing human inequality, and environmental damage that would bring about human apocalypse ( Scott, 2022 ). This approach to family planning has contributed significantly to slowing population growth in many parts of the world. The global population is anticipated to peak at 9.7 billion around the year 2064, followed by a steady decline ( Bongaarts, 1994 ; Vollset et al. , 2020 ). Family planning has also facilitated economic development, increasing levels of education, the empowerment of women to pursue educational and career opportunities and has helped alleviate environmental consequences of an increasing global population. And while most would agree that draconian forced sterilization and other measures that occurred in many countries are no longer necessary, there are still legitimate and compelling arguments that human population growth creates existential risks to humanity ( Van Bavel, 2013 ; Lidicker, 2020 ; Wilmoth et al. , 2022 ).

Within this context, it is now recognized that the total fertility rate (TFR), defined as the number of children born per woman living to the end of childbearing years (15–49 years), has been decreasing dramatically for decades in many countries. By 2050 and 2100, respectively, 77% of predominantly high-income countries and 93% of all countries will have a TFR below the replacement level of 2.1 children per woman. Not including the effects of migration, many countries are predicted to have a population decline of more than 50% from 2017 to 2100 ( Vollset et al. , 2020 ; Dao et al. , 2021 ). This evolution of the world population will cause demographic changes with profound societal implications. The dramatically increasing ratio between elderly people and young adults already affects historical social norms concerning education, marriage, and care of the elderly, with major economic ramifications ( Mester, 2018 ). The ongoing trend of having fewer children may be irreversible and even accelerating ( Aitken, 2022 ).

The decreasing TFR can potentially impact societies in multiple ways, some advantageous, and some disadvantageous ( Qiao et al. , 2021 ). Population growth magnifies the harmful impact of economic processes on the environment; yet the rise in per capita income has been more important than population growth in driving increased production and consumption ( Götmark et al., 2018 ; Dodson et al. , 2020 ; Wilmoth et al., 2022 ). Increased resources for improving maternal and child health care can be offset by the impact of delayed childbearing on fertility, maternal health, and poorer pregnancy outcomes ( Balasch and Gratacos, 2012 ; Schmidt et al. , 2012 ). Maternal and child health can be improved if each child has access to more resources and parental time, but potentially negatively if many children have no siblings ( Fall et al. , 2015 ). Smaller families and delayed parenting will impact many social norms and activities ( Canning and Schultz, 2012 ; Schmidt et al. , 2012 ). Aging populations will require increased healthcare and pension costs at the same time there are fewer workers producing the wealth to support them, let alone provide the taxes to sustain other social welfare systems—including their own retirement funds—and grow economies. Countries will have to consider policies that address work-life balance, affordable childcare, and parental leave. Different TFRs among countries will promote immigration and emigration with important consequences for all countries, including increased political and social friction ( Vollset et al. , 2020 ). All these changes will create changing attitudes and ethical challenges with respect to cultural and societal values and norms of parenthood, gender roles, and gender equality. Different age groups will likely disagree on their proportionate contributions to society. The declining TFR will also raise questions about an individual’s reproductive rights relative to the needs of society ( Mburu et al. , 2023 ).

The optimal number of children per woman may be perceived differently in various countries, depending on cultural norms, economic status, existing TFR, population demographic distribution, and migration (Organization for Economic Cooperation and Development, OECD Family Database, SF2.2, 2016). Regardless of these differences, the overall decreasing fertility rate worldwide is of growing concern. In attempts to address these trends, an increasing number of countries have implemented child-friendly policies: mainly financial incentives, such as compensation for extended pregnancy leave, financial benefits related to childbirth, maternity and paternity leave, child tax deduction or credit strategies, and compensation for childcare.

Despite this entirely changed paradigm of population growth, the concept of family building (the process by which individuals or couples create or expand their families) has, until recently, been largely ignored in family-planning paradigms ( Ziebe and Devroey, 2008 ; Seifer et al. , 2015 ; Bakkensen and Goldman, 2022 ). Not only the general public but also health care professionals could benefit from (inter)national education programs for young adults to increase family-building awareness and improve reproductive life decisions.

While the global decline in fertility rate is due to multiple societal and environmental changes, it is important to emphasize that globally between 48 million couples and 186 million individuals of reproductive age live with infertility ( World Health Organization, 2020 ; Cox et al. , 2022 ). Infertility is a common chronic disease affecting many reproductive-age women and men and represents a major life burden, causing anxiety, depression, relationship dysfunction, and social marginalization ( World Health Organization, 2020 ). Major advances in infertility care, especially through ART, have dramatically improved family-building opportunities for infertile and fertile people over the last three decades in both developed and developing countries. Although up to 10% of all children are born as a result of infertility therapies in some wealthy countries, great variation in access to care can be observed ( DeWeerdt, 2020 ; Chiware et al. , 2021 ; Choi et al. , 2022 ). The high cost to patients of infertility treatment renders it unaffordable for most, particularly those in low- and middle-income countries (LMICs) ( Karaga et al. , 2023 ). Therefore, access to fertility care remains a major challenge and disproportionately impacts opportunities for family building globally. Currently, the overall contribution of fertility care to the global TFR is relatively small because access to fertility care globally is very limited.

Public funding of fertility treatment has occurred in a limited number of countries with the aim to mitigate decreasing national populations. However, the extent of public spending on child benefits varies greatly from country to country ( Fig. 1 ), and many barriers remain for the inclusion of fertility care in reproductive health policies, especially in LMICs (Organization for Economic Cooperation and Development, OECD Social Expenditure Database; Ethics Committee of the American Society for Reproductive Medicine, 2021; Afferri et al. , 2022 ). Moreover, distinct inconsistencies in regulations, the availability and funding of infertility treatment options and the involvement of patients have recently been described by the patient organization ‘Fertility Europe’ for various European countries ( Fig. 2 ) ( Atlas of Fertility Treatment Policies in Europe, 2021 ).

Public spending on child benefits by type of expenditure as percentage of GDP, 2017. GDP, gross domestic product; EU, European Union. Reprinted with permission from Organization for Economic Cooperation and Development. http://www.oecd.org/social/expenditure.htm.

Public spending on child benefits by type of expenditure as percentage of GDP, 2017. GDP, gross domestic product; EU, European Union. Reprinted with permission from Organization for Economic Cooperation and Development. http://www.oecd.org/social/expenditure.htm .

Infertility friendly treatment policies vary among countries in Europe. Published online at Atlas of fertility treatment policies in Europe—Fertility Europe. Reprinted with permission, Atlas of Fertility Treatment Policies in Europe. EFP, European Parliament Forum. https://fertilityeurope.eu/atlas/#:∼:text=Fertility%20Europe%20in%20conjunction%20with%20the%20European%20Parliamentary,The%20Atlas%20describes%20the%20current%20situation%20in%202021.

Infertility friendly treatment policies vary among countries in Europe. Published online at Atlas of fertility treatment policies in Europe—Fertility Europe. Reprinted with permission, Atlas of Fertility Treatment Policies in Europe. EFP, European Parliament Forum. https://fertilityeurope.eu/atlas/#:∼:text=Fertility%20Europe%20in%20conjunction%20with%20the%20European%20Parliamentary,The%20Atlas%20describes%20the%20current%20situation%20in%202021 .

Infertility has historically been defined as the inability to become pregnant within at least 1 year of regular unprotected intercourse in heterosexual couples who desire to have a child. For the past half-century concerns regarding global overpopulation have frequently led to the contention that infertility treatments should have a low priority because they promote population growth and, as a result, support for fertility care has often been opposed. Such perspectives and actions give rise to inequality, injustice, and discrimination ( Pennings, 2008 ; Gerrits et al. , 2017 ; Ombelet and Goossens, 2017 ). Such a view requires that couples or individuals who wish to have a child—who already suffer from the distinct burden of the disease—bear a disproportionate responsibility for reducing world population growth. Social policy should be equitable for all members of society, and any approach to population growth that places undue responsibility on people who wish to establish a family contravenes the principle of social justice. The same infertility treatments initially developed to treat infertile heterosexual couples are now also increasingly used to help single persons and lesbian, gay, bisexual, transgender, intersex, queer/questioning (LGBTQ+) persons so they can realize their desire to have a child. In this context, these broader scope interventions, which include fertility awareness, support, and fertility management with an intention to assist individuals and couples to realize their desires associated with reproduction and/or to build a family, are defined as fertility care ( Zegers-Hochschild et al. , 2017 ). Infertility treatment is a subset of fertility care.

In addition to the need to improve access to fertility care to mitigate the personal burden of this disease, social justice mandates that people wanting to found a family have a right to do so (United Nations (UN), https://www.ohchr.org/en/human-rights/universal-declaration/translations/english ). This right applies to couples or individuals who wish to have a first or subsequent child. Fertility is an important component of strong societal trends regarding the need to address diversity, equity, inclusion and social determinants of health. The inability to access fertility care disproportionately affects women and minorities ( World Health Organization, 2020 ). Societal trends in many countries encourage access for those in the LGBTQ+ community, single people, and those needing to use third-party reproduction (donor sperm, eggs, embryos, or surrogacy). Thus, providing access to fertility care is important for social justice. Furthermore, preliminary studies point to the increasing contribution of fertility care to the overall population and the economic benefits for society that result from every new person born from fertility care ( Connolly et al. , 2008 , 2009 , 2021 ; Leridon and Slama, 2008 ; Habbema et al. , 2009 ; Faddy et al. , 2018 ).

This article aims to provide global perspectives that support the need to harmonize family planning with family building: comparing patterns and determinants of TFR, societal and economic implications of a decreasing population, the prevalence and burden of infertility, societal trends impacting fertility care, fertility awareness and infertility prevention, economic and social justice aspects of access to fertility care, and policy recommendations that will benefit both individuals and society. More than ever, today the implementation of public policies needs to balance both the need of the individual and society.

Recommendations are provided, and important knowledge gaps identified, to provide professionals, the public, and policymakers a comprehensive understanding of the role of child friendly policies, including fertility care, in the context of the global trend of decreasing fertility rates. Hopefully, this will facilitate the formulation, now and in the future, of more effective family-building policies that are harmonized with family planning.

This article presents the IFFS consensus after a narrative review of the existing literature performed by global leaders who themselves have contributed significantly to the research in this field. These peers were selected by IFFS based on their scholarly publications, academic accomplishments, professional leadership roles, and reputation in respective areas of interest. Each section of the review was prepared by two to three of these experts, each of whom searched the published literature (PubMed), drawing upon decades of professional expertise, and academic accomplishment. Only peer reviewed full papers and reviews were included (if useful, we also refer to website of relevant global organizations), and searches were performed and updated until September 2023. The following keywords were used: world population growth, underpopulation, family planning, family building, fertility, infertility, fertility care, ART, LGBTQ (Introduction and Conclusion sections); world population, TFR, fecundity, fertility, maternal age, childbirth (global population paragraph section); infertility, infertility prevalence, population-based studies, reviews (infertility prevalence section); age-related fertility decline, fertility awareness, education, infertility risk (infertility awareness section); access to care, ART, ART utilization, fertility care (access to fertility care section), fertility care, access to care, affordability, health economics, and gender equality (equitable access section).

Multiple drafts were circulated electronically among each section’s team members for comment and editing. All sections were discussed monthly by all authors (January 2021–July 2022) and quarterly by the review board (July 2021–July 2022). Text was modified and distributed where needed based on these discussions until full agreement was reached by all participants. Repeated discussion also involved the overall scope of the paper, and the order in which the various topics were presented. The final document was prepared following discussions among all team members during a hybrid invitational 2-day meeting organized in Amsterdam, May 2022, where full consensus was reached. The final document was approved by all authors and members of the review board.

Assuming no net migration and unchanged mortality, a TFR of around 2.1 children per woman is the replacement level often cited for broad population stability (UN, Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, 2011). Between 1990 and 2021, global TFR dropped from 3.3 to 2.3 ( Table 1 ) ( United Nations, 2022 ). Factors affecting the TFR decline include changes in lifestyle choices, education levels, discrimination against women, and inadequate support of working parents ( D’Addio and d’Ercole, 2005 ). The declining global fertility rate has not been uniformly distributed ( United Nations, 2022 ) ( Table 2 ).

Trends in total fertility rate 1975–2021. a

United Nations (2022) .

More developed regions comprise Europe, Northern America, Australia/New Zealand, and Japan.

Less developed regions comprise all regions of Africa, Asia (excluding Japan), Latin America and the Caribbean plus Melanesia, Micronesia, and Polynesia.

The least developed countries (n = 48): 33 in Africa, 9 in Asia, 5 in Oceania; 1 in Latin America and the Caribbean. Total fertility rate (TFR) is also negatively correlated with the capacity of women to make their own reproductive decisions. It is difficult to isolate the freedom to exercise reproductive choice from other largely accepted cultural and religious reasons whereby women ‘voluntarily’ refrain from using contraceptives and place enormous value on having many children. Economic circumstances can modulate the desire to have children in different ways. For example, the TFR in some low- and middle-income countries that are economically restricted (e.g. Cuba) or emerging economies (e.g. Chile, Uruguay) has decreased to around 1.6; in Latin America, TFR decreased from 5.86 in 1950–1955 to 2.04 in 2022. Similar declines have taken place in most African countries. However, in most countries in Eastern, Western, and Central Africa the TFR remains extremely high (> 4.5) ( Table 2 ) ( Central Intelligence Agency, The World Factbook: Field Listing—Total Fertility Rate, 2022 ). Some high-income countries have experienced a slight rebound in their TFR, partly because of childcare friendly policies ( Organization for Economic Cooperation and Development, 2009 ; De Geyter et al. , 2020 ; UNFPA, 2022 ).

High total fertility rate in selected African countries (estimates, 2022). a

Central Intelligence Agency The World Factbook: Field Listing—Total Fertility Rate 2022 .

TFR, total fertility rate.

TFR refers to the average number of births per woman. Men’s fertility rate has received little attention, yet is similar or lower compared to women’s ( Schoumaker, 2017 ). Both similar and dissimilar factors affect the male fertility rate, including the higher male-to-female population, age when pregnancy occurs, registration rate of the father at birth, and biomedical factors ( Dudel and Klusener, 2019 ). Some evidence suggests that decreased male fertility is due to an annual decline of 1.4% in sperm concentration and 1.6% in total sperm count, although the impact on TRF is yet unknown ( Levine et al. , 2017 ; Jørgensen et al. , 2021 ; Levine et al. , 2023 ). Decreased male fertility has been associated with an increased disease burden including heart disease, cancer, and early death ( Kasman et al. , 2020 ). Moreover, both male and female reproductive health is deteriorating, especially in industrialized regions, suggesting important roles of environmental factors, such as endocrine-disrupting chemicals and pesticides, in causing the observed decline in fertility ( Le Moal et al., 2016 ; Skakkebæk et al. , 2022 ).

Fertility decline initially results in more working-age adults relative to children, potentially leading to accelerated economic growth and a temporary ‘demographic dividend’ ( Starrs et al. , 2018 ). However, in countries with fertility rates below the replacement level, a different population pyramid with more elderly people and fewer working adults will eventually occur. An increasing number of countries have implemented policies, including improved access to infertility treatments, aiming to increase their fertility rate, restore the demographic pyramid, and increase the working age group’s positive economic impact ( De Geyter et al. , 2020 ; Central Intelligence Agency, The World Factbook: Field Listing—Total Fertility Rate, 2022 ). Nevertheless, globally fertility care currently generates little impact on the fertility rate since most countries, especially LMICs irrespective of their TFR, do not have equitable and universal access to treatments—especially ART ( Inhorn and Patrizio, 2015 ; Chiware et al. , 2021 ; Duffy et al. , 2021 ; Brodeur et al. , 2022 ; Karaga et al. , 2023 ).

Another factor responsible for lowering TFR is that many women in both developed and LMICs are delaying first birth and having children at an older age when there is a natural decline in fecundity (defined as the capacity to have a live birth). Therefore, later marriage and older age when attempting pregnancy increase the risk of infertility. UN statistics demonstrate that the average age of women at first childbirth has increased by ∼1 year per decade since 1970 in developed countries (Organization for Economic Cooperation and Development, OECD Family Database SF2.3). Furthermore, there is immense variation in maternal age at first childbirth depending on the country and region. Nineteen countries, mainly in central and west Africa, still have a mean age of women at first childbirth of under 20 years, compared with only one country in the Americas and none in Asia and Europe. On the other hand, the mean age of mothers at first childbirth in 35 countries in Europe and Asia is ≥28 years ( Central Intelligence Agency, Field Listing—Mother’s Mean Age at First Birth, 2022 ).

The National Survey of Family Growth reported 1-year infertility rates increased from 6% for women younger than 24 years of age to over 30% at ages 35–44 years ( Abma et al. , 1997 ). Mean monthly probability of pregnancy leading to live birth remains optimal until age 31 years. Relative fertility is decreased by about half at age 40 years compared with women in their late 20s and early 30s, the time of peak fertility ( Practice Committee of the American Society for Reproductive Medicine and the Practice Committee of the Society for Reproductive Endocrinology and Infertility, 2022 ). The average age at last childbirth in the general population is 40–41 years ( ESHRE Capri Workshop Group, 2010 ). Postponing childbearing contributes to fertility decline, having fewer children than desired or no children at all, increased need for infertility treatment, and increased morbidity and costs for both mothers and children, delivery, and post-birth ( Luke and Brown, 2007 ).

Environmental and lifestyle factors, such as smoking, excessive alcohol intake, obesity, and poor nutrition, can negatively affect both male and female fertility. Exposure to environmental pollutants, such as endocrine-disrupting chemicals, and toxicants, such as pesticides, can be directly deleterious to gametes (oocytes and spermatozoa), resulting in decreased numbers and quality, and subsequent infertility ( Gore et al. , 2015 ; Segal and Giudice, 2019 ; World Health Organization, 2021 ; Skakkebæk et al. , 2022 ; Giudice et al. , 2023 ). In addition, infertility, especially secondary, is more prevalent in areas with a high incidence of sexually transmitted infection (STI). In 2016 chlamydia, gonorrhea, syphilis, and trichomoniasis accounted for an estimated 376 million new infections worldwide ( Rowley et al. , 2019 ). Left untreated, pelvic inflammatory disease will result in infertility in one-quarter of people ( World Health Organization, 2008 ). Especially in LMICs, tubal disease with ensuing infertility also arises from complications of unsafe abortion, postpartum sepsis, pelvic tuberculosis, bilharzial salpingitis, and iatrogenic tubal obstructions ( Serour et al. , 1988 ; Scholes et al. , 1996 ; Tsevat et al. , 2017 ).

Factors associated with decreased TFR in the male and female vary globally. Major factors are socioeconomic, cultural, religious, educational, gender equity, and environmental ( Nargund, 2009 ; Population Reference Bureau, 2021 ; Skakkebæk et al. , 2022 ; World Economic Forum, 2022 ). Other factors include infertility prevalence, insufficient fertility knowledge and awareness, and limited access to care (including heterosexual couples, same-sex couples, single women and men, and transgender individuals). The use of donor eggs, sperm, embryos, and surrogacy has made it possible for these persons/couples to access treatment, including ART. The demographic impact of these new family forms, along with fertility preservation to postpone childbearing, is yet unknown.

In the last two decades, there has been a moderate recovery of fertility rates in some developed countries in Europe: e.g. Sweden from 1.54 to 1.67. Trends in other countries can be observed in Table 1 ( UNFPA, 2022 ). This may be due to an increase in births in women who had postponed motherhood, policy measures supporting families and working women, increased access to ART services, and the higher fertility rate among immigrant women ( Organization for Economic Cooperation and Development (OECD), 2009 ; De Geyter et al. , 2020 ). Furthermore, data from 2017 show that medically assisted reproduction (MAR)—defined as ‘reproduction brought about through various interventions, procedures, surgeries, and technologies (including ART) to treat different forms of fertility impairment and infertility’—contributed from 3.2% to almost 10% of births in European countries compared with <1% in Latin America and 2% in the USA ( Wyns et al. , 2021 ; Zegers-Hochschild et al. , 2017 ). While it is difficult to isolate the overall effect of ART in raising fertility rates from other behavioral and policy drivers, the impact appears to be approximately a 0.05–0.10 increase in TFR where access to fertility treatment is widely available ( Grant et al. , 2007 ; Habbema et al. , 2009 ; Lazzari et al. , 2021 ).

Conclusion and recommendations

TFR is declining globally in women and men, for multiple reasons.

While it is difficult to measure the overall impact of ART in raising fertility rates, the potential benefits for the many individuals or couples who wish to have a child are profound.

The global trend of delaying parenthood negatively affects TFR.

There is an urgent need for more and better data on all aspects of global fertility and associated demographics.

Identified key knowledge gaps

Reliable data on fertility patterns, trends and causes of fertility or infertility are missing in developing countries, especially for male fertility.

The impact of infertility treatment, including ART, on fertility patterns is missing in most countries of the world.

It is imperative to identify measurable health indicators in order to quantify disease and measure progress resulting from interventions. Prevalence is the only reproductive health indicator for infertility formally adopted by the World Health Organization (WHO) ( World Health Organization, 2008 ). Infertility prevalence tells us how many lives are affected; both prevalence and measurement of the magnitude of infertility’s impact on people’s lives inform the burden of disease. The definition of infertility and its prevalence and burden of disease are controversial. Different categories of infertility definitions (clinical, epidemiological, demographic) in conjunction with variations in methodology and study populations give rise to wide-ranging estimates ( Gnoth et al. , 2005 ; Barratt et al. , 2017 ; Cox et al., 2022 ; World Health Organization, 2023 ). For primary 12-month infertility (never pregnant), the pooled lifetime and period prevalence reported by WHO in 2023 were 9.6% and 9.0%, respectively. For secondary 12-month infertility (prior pregnancy, regardless of outcome), pooled lifetime and period prevalence were 6.5% and 4.9%, respectively: less than primary infertility but still a very large number of people ( World Health Organization, 2023 ). Quantitative burden-of-disease studies lack measurement of the qualitative impact of infertility disease and do not consider how bringing forth new life affects the quality of existing lives. Primary infertility is known generally to have a high burden of disease. Secondary infertility may or may not carry a similar burden for any given person depending on their personal and societal circumstances, including that a child is from a previous relationship. Additionally, secondary infertility applies to many who have become pregnant and/or delivered but subsequently suffered pregnancy loss or death of a child. A rich qualitative narrative describes the often-profound consequences of infertility as a social reality as well as a medical disease ( Greil et al. , 2010 ; Inhorn and Patrizio, 2015 ).

There are two commonly applied clinical definitions of infertility. According to the WHO, infertility is a disease defined by the absence of pregnancy after 12 months of regular unprotected intercourse, which is in line with the definition of male and female infertility in the International Classification of Diseases (ICD-11) ( Zegers-Hochschild et al. , 2009 ). The International Glossary on Infertility and Fertility Care, which reflects high-level international consensus, incorporates the WHO definition while being more comprehensive and inclusive by adding, ‘or due to an impairment of a person’s capacity to reproduce either as an individual or with his/her partner’ ( Zegers-Hochschild et al. , 2017 ). Moreover, by referring to infertility as a disability per se without specifying infertility as disability of the reproductive system, the International Glossary recognizes that fertility and parenthood transcend reproductive organs and affect the entire person, couple, and their social matrix.

Globally, infertility is one of the most frequent chronic diseases among reproductive-aged people. Until publication of the recent WHO document, the most comprehensive systematic review covering infertility studies from 1990 to 2021 gave pooled estimates for period and lifetime infertility prevalence of 12.6% (95% CI 10.7, 14.6) and 17.5% (95% CI 15.0, 20.3), respectively, when estimated among all study participants regardless of risk of pregnancy ( Cox et al. , 2022 ; World Health Organization, 2023 ). However, as most people are unaware of their fertility potential (fecundity) before trying to have children, it is also important to estimate infertility prevalence among those who are trying or have tried to have children. For this group, the range of the estimated point prevalence of infertility has been reported as 4–34% after 12 months of ‘trying’ and that of cumulative lifetime prevalence as 8–35% ( Schmidt and Münster, 1995 ; Chandra et al. , 2013 ; Zhou et al. , 2018 ; Cox et al. , 2022 ). This seeming paradox can be explained by pro-natal reproductive behaviors that are directly or indirectly associated with risk factors for infertility, including low uptake of contraceptive methods, early sexual debut, early age at first pregnancy, unsafe delivery practices, and high background rates of sexually transmitted diseases.

Causes and risk factors

Infertility can be caused by female and/or male factors or can be unexplained. Prominent female factors include advanced age and resultant diminished ovarian reserve associated with voluntary or involuntary delay of pregnancy, chronic anovulation, tubal factor infertility (especially secondary to STIs or pregnancy-related sepsis), other pelvic pathology (e.g. endometriosis, adenomyosis, uterine fibroids, adhesions, congenital anomalies), and exposure to environmental contaminants. The extent to which these factors contribute to female infertility varies from country to country. Male infertility—which accounts for or contributes to infertility in approximately one-half of couples—can result from impaired sperm production or sperm ejaculation due to a variety of underlying conditions including hormonal, infectious, and genetic and environmental etiologies ( World Health Organization, 2020 ). In addition, sexual and other factors may impact intercourse. Infertility may be caused by medical interventions, such as cancer therapy or complications of inappropriate care, as well as environmental factors and toxicant exposures during in utero development and/or in adulthood ( ASRM Practice Committee, 2019 ; Skakkebæk et al. , 2022 ; Giudice et al. , 2023 ). Many of these factors are aggravated by increasing age.

Most causes of infertility are acquired, and many are amenable to prevention. Health behaviors, such as smoking, obesity, use of cannabis and anabolic steroids, are risk factors for both women and men ( Bala et al. , 2021 ; Carson and Kallen, 2021 ; Eisenberg et al. , 2023 ). Traditionally, prevention has focused on STI prevention, safe obstetric practices, lifestyle modifications, avoidance of age-related female infertility, and early identification and treatment of male cryptorchidism (one of the most common congenital conditions in male neonates). There is a need for increased education and research on intervention strategies for environmental impacts on male and female infertility ( Giudice et al. , 2023 ).

Ultimately, prevention and intervention strategies need to be informed by the social determinants of infertility: the causes of the causes. For example, advanced female age is linked to the social determinants of education and gender equality, since both may delay acting on fertility desires and opportunities for procreation ( Broekmans et al. , 2009 ; Fall et al. , 2015 ; Van Roode et al. , 2017 ; Cedars, 2022 ; Choi et al. , 2023 ). At the same time, lack of gender equality may influence women’s ability to negotiate safe sexual practices or contraception usage, compromise health literacy, and limit women’s ability to access appropriate reproductive health services.

Conclusions and recommendations

Infertility is one of the most common chronic diseases in individuals of reproductive age.

Infertility is also common in men, accounting for ∼50% of all couples’ infertility.

Pooled period prevalence of infertility is 12.6% with regional differences when estimated among women/couples regardless of whether they are ‘trying’ to have children or not.

Pooled lifetime prevalence of infertility is 17.5% with regional differences when estimated among women/couples regardless of whether they are ‘trying’ or tried to have children or not.

Infertility has many causes and risk factors, including genetic and medical disorders, health behavior, age, and exposure to environmental contaminants.

We recommend global, regional, and national monitoring of infertility in population-based studies among persons trying or having tried to have children.

Lack of conclusive data pertaining to infertility prevalence.

Lack of national and global monitoring of population-based infertility prevalence.

Infertility is a common chronic disease and a major life burden. But awareness about infertility, its risk factors, and possible treatments vary widely across the globe ( Bunting et al. , 2013 ). Personal consequences of infertility can include a profound sense of shame, loss, anxiety, depression, anger, and feelings of failure, both physically and in sexual roles and social responsibilities ( van Balen and Bos, 2009 ). These effects can lead to isolation, ostracism, and violence specifically against women, regardless of the etiology of their infertility. The reasons for these variable effects are complex and include cultural mores, the status of women in each society, the importance of childbearing to the marital relationship, gender power dynamics within the family, and religious, political, and economic factors ( van Balen and Bos, 2009 ; Inhorn and Patrizio, 2015 ; Stellar et al. , 2016 ; Bayoumi et al. , 2018 ). They may also feel stigma and embarrassment about help-seeking, leading to a reduced chance of pregnancy (International Federation of Gynecology and Obstetrics, https://fertilitytool.com/tools/basic-tool-1-why-care/ ). While recent years have shown an increase in interventions to reduce the stigma of infertility in low-, middle-, and high-income countries, generally poor knowledge about infertility means that most people cannot avoid risks or seek help in a timely fashion when having difficulty achieving pregnancy or fathering a child ( Pedro et al. , 2018 ; Gerrits et al. , 2023 ). Thus, awareness about infertility and its prevention and treatment are key to well-being and to global family-building and family-planning efforts. A summary of global strategies and challenges to increase fertility awareness and infertility prevention underscores unmet needs of education and research.

Fertility awareness has been defined as ‘the understanding of reproduction, fecundity, fecundability, and related individual risk factors (e.g. advanced age, sexual health factors, such as STIs, and lifestyle factors such as smoking and obesity) and non-individual risk factors (e.g. environmental and workplace factors)’ including the awareness of societal and cultural factors affecting options to meet reproductive family planning, as well as family-building needs ( Zegers-Hochschild et al. , 2017 ). There is a general lack of awareness regarding reproductive health in most societies. Lay populations, especially, have a limited and misconstrued understanding of both the relationship of age to infertility and the limitations of available reproductive technologies to overcome the effects of age ( Bunting et al. , 2013 ; Pedro et al. , 2018 ; Delbaere et al. , 2020 ; Choi et al. , 2023 ). Many women are aware that age impacts fertility, but they lack specific knowledge about when and to what extent fertility declines, making it difficult for them to act on their knowledge in a way that does not undermine parenthood goals (e.g. when to start trying to become pregnant, use of fertility preservation). Due to poor knowledge levels, fertility education initiatives have been suggested to guide people making decisions about fertility ( ASRM Practice Committee, 2019 ; Delbaere et al. , 2020 ).

Qualitative research shows that culturally tailored fertility awareness tools are feasible and acceptable ( Bayoumi et al. , 2021 ). This tailoring is needed because evidence is emerging that prevalence of risk factors for infertility varies according to country. Anthropologists have documented infertility campaigns in LMICs led by government, professional societies, patient groups, and activists ( Gerrits et al. , 2023 ). For example, in Iran reproductive health authorities have initiated educational campaigns to ‘create a culture’ of infertility awareness through films, books, and leaflets intended for popular audiences ( Tremayne, 2009 ). Most campaigns in LMICs have not been shown to have major impact because they have lacked visibility and formal evaluation ( Ombelet and Campo, 2007 ; Thevenon and Gauthier, 2011 ; Tan, 2020 ).

Prevention of infertility has targeted different societal levels and pathways. Figure 3 illustrates a conceptual model of infertility prevention based on theory and extant research ( Boivin and Inhorn, 2022 ). Four aspects of prevention should be considered in evaluating these efforts, namely the target of intervention (individual, couple, society), the proposed mechanism of action (behavior change, early detection), the intervention outcomes (e.g. prevalence of infertility), and any moderators that could impact the effectiveness of interventions (e.g. ethnicity). Figure 3 also makes clear that prevention efforts could be at primary, secondary, and tertiary care levels. Specifically, prevention efforts can be directed before the disease is present (i.e. primary prevention), for example, delivered opportunistically during contraceptive or smoking cessation programs ( Macaluso et al. , 2010 ; Delbaere et al. , 2020 ). Secondary prevention can occur when a health condition is present but not yet fertility limiting (e.g. early detection and treatment of endometriosis or fertility preservation for cancer patients). Tertiary prevention can apply to existing infertility, with prevention aiming to limit impacts of fertility care on health and quality of life (e.g. single embryo transfer to avoid multiple pregnancy).

Conceptual model of infertility prevention based on theory and existing infertility research. Modified and reprinted with permission from Boivin and Inhorn (2022).

Conceptual model of infertility prevention based on theory and existing infertility research. Modified and reprinted with permission from Boivin and Inhorn (2022) .

Research is needed to address the effect of prevention strategies on significant clinical outcomes, which could be behavior change targets (e.g. weight loss) and fertility outcomes (e.g. live births). Prevention research should also examine the moderators of the effects of prevention (e.g. gender, age, ethnicity, education). The effects of prevention at primary, secondary, and tertial levels on fertility have not been extensively evaluated. Effects of primary prevention strategies targeting behavior changes to eliminate or minimize risk associated with infertility are uncertain due to the paucity of high-quality evidence. One non-randomized trial in India suggested that men willing to stop smoking showed better quality sperm within 3 months of smoking cessation than men unwilling to stop smoking ( Kulaksiz et al. , 2022 ). One randomized controlled trial (RCT) showed that in Japan provision of fertility information accelerated the timing of births in partnered women, and that couples tried to achieve pregnancy 15 months earlier, important in Japan where people typically start family building in their mid to late 30s ( Maeda et al. , 2018 ). Qualitative research suggests gaps in primary awareness campaigns, for example, not being inclusive across cultures and not targeting men presenting specific risks for male infertility ( Berthelsen et al. , 2021 ).

Benefits of secondary and tertiary prevention strategies that target early treatment of STIs and pelvic inflammatory disease, or avoidance of pregnancy or abortion-related infections, are effective in eliminating infection, but subsequent effects on fertility are unknown because fertility outcomes are not being measured in research ( Savaris et al. , 2020 ). One public health RCT showed that provision of fertility information in undiagnosed men meeting the definition of infertility was associated with timely medical help-seeking compared to control groups ( Maeda et al. , 2018 ). Systematic reviews and prevention campaigns among the diagnosed infertile (e.g. pre-conception, lifestyle advice) are effective in reducing intermediate endpoints (weight loss, biomarkers) but not in markedly increasing fertility outcomes such as live births ( Boedt et al. , 2021 ). Often, conclusions are uncertain due to low-quality evidence.

Prevention at societal level exists but is incidental rather than targeted. About 60% of countries with below-replacement fertility levels have adopted fertility-friendly policies (e.g. reducing costs of childcare, healthcare, and MAR) or fertility risk-reducing policies (e.g. occupational safety and environmental health) ( Bergsvik et al. ,2020 ). However, systematic reviews demonstrate that infertility itself is not integrated into sexual and reproductive health policies or, if it is, prevention is not included ( Morshed-Behbahani e t al. , 2020 ; Ravindran and Govender, 2020 ). Major barriers to inclusion are limited political commitment and under-recognition of the burden of infertility, in addition to costs of MAR ( Afferri et al. , 2022 ). Other societal level interventions, such as regulation about exposure to occupational and environmental hazards, potentially reduce rates of infertility but are not specifically designed with fertility outcomes in mind despite compelling evidence supporting recent recommendations from ESHRE to collect more surveillance data and initiate public awareness campaigns ( Skakkebæk et al. , 2022 ; ESHRE Environment Seminar, 2023). Concern over the impact of endocrine disruptor exposure on reproductive health has led to calls for a multi-country monitoring system ( Le Moal et al. , 2016 ).

The significant gaps in knowledge about the efficacy of prevention efforts point to the need for policy and research to implement and evaluate prevention strategies on fertility outcomes and the moderators of these effects. Most prevention efforts continue to target women in high-income countries despite repeated calls for such efforts to also target people in LMICs.

The quality of research into effects of prevention campaigns needs to be more rigorous and include fertility outcomes.

Advocacy and additional educational efforts, which will require appropriate funding, are needed to increase awareness and acceptance of infertility as a disease with a high burden.

Prevention through (in)fertility awareness and access to care should be prioritized in national health and education agendas globally and at all levels (primary, secondary, tertiary).

Appropriate conceptual models of prevention of infertility that are culturally informed should be used to guide the design of education and prevention resources and in the selection of fertility indicators.

The creation of sustainable multidisciplinary and multi-stakeholder consortia to deliver prevention programs should be supported.

High-quality actionable evidence should be generated to direct policy about the value of prevention efforts.

Geographic regions with a high proportion of LMICs are poorly represented in research on prevention.

Men, single persons, LGBTQ+ individuals and couples, and people with disabilities or health conditions are largely omitted in research; this needs to change.

Attention is needed on causal impacts and assessment of relevant fertility outcomes.

Co-production of educational resources with multiple stakeholders (i.e. people with a current or future child wish, policymakers, researchers, healthcare professionals, community groups, schools) is needed, as in other areas of reproductive health.

Infertility treatment and fertility care are increasingly being recognized globally as effective therapies to achieve family-building goals, especially in most high-income countries (HICs). Data on access to non-ART fertility care are minimal globally, so only available data on access to ART can be used. Access to fertility care can only be realized when ART services are present, and the geographical location and activities are known ( Markets and Markets, 2021 ). However, large variations exist in the number of clinics per capita. Reducing these disparities will require the global effort of governments, industry, and non-governmental organizations to provide accessible infrastructure, training, and affordable models ( Ombelet, 2011 ; Chiware et al. , 2021 ).

Access to fertility care, as with healthcare in general, has multiple dimensions (availability, accessibility, acceptability, and quality) and does not comprise a single, measurable entity ( Dyer et al. , 2020 ). Access to healthcare is disease-specific and determined by the demand for health services (reflecting individual perceptions of illness, preferences, economic resources, sociocultural, and epidemiological factors), as well as supply (reflecting health system factors such as availability, cost, funding, affordability, regulations, and quality) ( Chambers et al. , 2009 ). Distinct disparities in infertility care exist, largely due to barriers to access aligned with race, class, socioeconomic status, gender, sexual orientation, and other forms of difference ( ASRM The Ethics Committee, 2021 ). Evaluation of access to fertility care is complex and includes variable metrics, populations, as well as the absence of data—especially in LMICs ( Zegers-Hochschild et al. , 2017 ; Canadian Assisted Reproductive Technologies Register Plus (CARTR Plus), 2018 ; Dyer et al. , 2019 ; Ishihara et al. , 2020 ; De Geyter et al. , 2020 ; Hu et al. , 2020 ; Lanes et al. , 2020 ; Wyns et al. , 2021 ; Australia and New Zealand Assisted Reproduction Database (ANZARD), 2022 ; Centers for Disease Control and Prevention (CDC), https://www.cdc.gov/art/artdata/index.html ). ART utilization is considered to reflect ‘realized access’ and is a proxy for access. It is calculated based on annually collected global data. The estimated annual demand for ART in 2001 was treatment of 1500 couples (not 1500 cycles) per million population ( ESHRE Capri Workshop Group, 2001 ). Countries with high ART utilization generally have good access to non-ART fertility care, whereas poor access to ART is usually paralleled by poor access to non-ART fertility care ( Botha et al. , 2018 ).

Utilization of ART is multifactorial

Utilization rates require both a numerator and denominator. In ART, there are numerous possible denominators depending on which aspect of the continuum of treatment is being considered. Standardizing global results requires using commonly available metrics such as start of an ART cycle. Arguably, the best metric is the number of couples utilizing services, but such data are rarely available. It is essential to compare similar metrics when assessing utilization ( Adashi and Dean, 2016 ; Dyer et al. , 2020 ; Kawwass et al. , 2021 ; Beroukhim et al. , 2022 ).

The denominator of utilization rate usually reflects the entire population, millions of women, or females of reproductive age. Different countries have different age and gender distributions, and data are often not available and/or inconsistently defined. Population demographics are usually determined only once every 10 years or more from census counts and often overall age distribution is extrapolated from subgroups of ages. Finally, there are almost no data available regarding men’s access to fertility care ( Nachtigall, 2006 ; Tarsi and Tuff, 2012 ; Rogers, 2017 ; Dyer et al. , 2020 ).

ART availability, which affects utilization, is affected by the number of clinics and service locations, and geographic locations. Larger clinics are generally more available than smaller ones. High population density countries have more availability than low. Larger countries geographically and those with difficult topography tend to have lower availability. Other population variables include geographic and urban/rural distribution, as well as country development, which affects the ease of transportation ( Brodeur et al. , 2022 ).

Accessibility and utilization are affected by physical features of clinics (e.g. access for the disabled, male services available only in female clinics), limitation of reproductive health information, and a regulatory environment that might restrict services and/or discriminate, e.g. LGBTQ+ or single people ( ASRM The Ethics Committee, 2021 ; Oliveira et al. , 2021 ). The acceptability of care influences utilization. This includes the structure of the health system and its ability to provide respectful, culturally appropriate, gender, and life-cycle-sensitive care according to patient preferences ( Rich and Domar, 2016 ; Beroukhim et al. , 2022 ). Finally, the actual and perceived quality of treatment based on a scientific approach, its medically appropriate use, and quality of service impacts utilization ( Dyer et al. , 2020 ). Countries with different TFRs, immigration and social policies could perceive utilization rates differently. The variable effectiveness of ART treatments impacts the number of cycles performed, multiple pregnancy rates, and the number of babies born.

The International Committee for Monitoring Assisted Reproductive Technologies (ICMART) collects global data annually from ∼80 countries reflecting over 90% of global ART activity ( Chambers et al. , 2021 ). China has just begun reporting utilization rates of 657 per million for 2017 ( Bai et al. , 2020 ). The global utilization rate is 535/million population with dramatic country differences ranging from 16 to 5203 ( Chambers et al. , 2021 ). Country-specific utilization rates have varied only slightly over time. Not all countries collect ART data, in many countries not all clinics report, and data quality and validation are variable ( De Geyter et al. , 2020 ; Chambers et al. , 2021 ). A minority of countries collect cycle-by-cycle data; most collect only aggregated clinic data. Very few countries report the number of women or men utilizing treatment as opposed to the number of ART cycles performed. Cross-border care is poorly reported. Few report non-ART treatments, and these are mostly IUI cycles. There are almost no registry data on ovulation induction, empirical ovarian stimulation, female surgical interventions, or other treatments, and essentially no registries or data for men.

Consensus is needed on the optimal way to measure access to care and success of treatment. The numerator and the denominator for calculation need standardization, and confounding variables quantified. The following should be documented: total oocyte aspirations, freeze-all cycles, preimplantation genetic testing, frozen embryo transfers, third-party cycles, and cross-border care; restrictions on access; number of clinic service locations, population, area, and urbanization index; live birth rate, multiple birth, and complication rates; women, men, and number of treatment cycles for each; number of singletons, twins, and triplets or higher babies; detailed demographic information on gender and age; proportion of the non-fecund population at age 50 years, including those choosing to remain child-free, IUI, non-traditional family-building services for LGBTQ+ and singles; number of children per couple/person; and age of childbearing.

In most countries ART is under-utilized. High costs related to ART and/or insufficient reimbursement making ART unaffordable to many or most people result in reduced access, whereas uncontrolled reimbursement or consumer behavior in a commercial environment may provoke over-utilization ( Bai et al. , 2020 ). More complete and robust data would help health authorities develop appropriate ART policies.

Understanding the status of access to fertility care is essential to ensure individual reproductive rights and promote societal population goals.

Current data have identified the need for significantly increased access to quality fertility care in almost all global jurisdictions.

Many complexities, deficiencies, and challenges remain to improve available data so that individual rights and societal reproductive goals can be optimized through public health policies.

Identified key knowledge gaps can only be rectified by significantly increased and more detailed surveillance.

Unrestricted access to fertility care may result in over utilization.

The underlying population need for ART remains largely unknown.

The association between ART utilization and access to non-ART fertility care is uncertain.

Almost no data exist on non-ART fertility treatments.

The major deficiency regarding access is its complexity and lack of a standardized quantifiable approach.

The major deficiency regarding measurement of utilization of infertility care is that data are limited or absent for all populations, especially LGBTQ+, singles, minorities, and males.

Policymakers have insufficient knowledge and lack awareness of the true demand for infertility treatment in high-, middle-, and low-income countries.

A human right

Article 16.1 of the UN Declaration of Human Rights states that ‘men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family’: United Nations Charter Article 16 (United Nations, https://www.ohchr.org/en/human-rights/universal-declaration/translations/english ). The human right of persons to access infertility treatment is consistent with the 1948 UN Declaration of Human Rights and the ICPD plan of action Cairo 1994 (United Nations, http://www.ohchr.org ; International Conference on Population and Development, https://partners-popdev.org/icpd/ICPD_POA_summary.pdf ). Therefore, addressing infertility is fundamental to realizing the right of individuals and couples to found a family ( Zegers‐Hochschild et al. , 2013 ; Mburu et al. , 2023 ). Infertility treatments must not be limited to the affluent. Although both male and female factors can be the cause of infertility, women bear the most severe consequences and burdens even if they are not the cause of infertility ( Starrs et al. , 2018 ; Vollset et al. , 2020 ).

Ways to improve access to care include reducing cost and other structural barriers to access, addressing diversity, equity, inclusion, and belonging, providing culturally appropriate care, increasing availability in low resource settings, and demonstrating the economic burden of infertility ( Ombelet, 2011 ; Chiware et al. , 2021 ; Afferri et al. , 2022 ; International Federation of Gynecology and Obstetrics, https://fertilitytool.com/tools/basic-tool-1-why-care/ ).

Affordability

Consumer affordability is clearly a strong driver of access ( Fig. 4 ) and is defined as the consumer out-of-pocket cost relative to average disposable income. Affordability can be increased by reducing the cost and complexity of infertility interventions, increasing reimbursement, and increasing individuals’ disposable income ( Chambers et al. , 2014 ). However, only treatment cost and reimbursement arrangements are amenable to policy interventions. Since ART is a widely practiced, mature technology, its cost should be decreasing. However, the primary focus on maximizing pregnancy rates per cycle—especially in HICs—has often created very complex and expensive ART. Often such efforts do not result in increased success rates proportionate to the cost, especially from a cumulative (multiple cycles) live birth rate perspective compared to non-ART treatments such as ovulation induction, ovarian stimulation with IUI or surgery in selected patients. Furthermore, ART is usually offered in a free-market economy where providers, and often commercial owners of clinics, are incentivized to make a profit.

Correlation between affordability (mean cost of a fresh IVF cycle as a percentage of average disposable income) and the utilization (number of fresh non-donor cycles per million women of reproductive age (15–49 years)). Correlation co-efficient = −0.35. Reprinted with permission from Chambers et al. (2014).

Correlation between affordability (mean cost of a fresh IVF cycle as a percentage of average disposable income) and the utilization (number of fresh non-donor cycles per million women of reproductive age (15–49 years)). Correlation co-efficient = −0.35. Reprinted with permission from Chambers et al. (2014) .

Reducing the societal cost of infertility treatment also includes reducing pregnancy, neonatal, and long-term costs associated with multiple pregnancies resulting from ART. By improving affordability, the incentive to transfer more than one embryo is minimized and promotes this goal ( Chambers et al. , 2014 ). The Belgian reimbursement policy in which reimbursement of ART-related laboratory activities is linked to a transfer policy aiming at substantial multiple pregnancy reduction, turned out to become a good example of cost-efficient health care through responsible, well considered clinical practice ( Ombelet et al. , 2005 ). The cost of multiple births that have been associated with fertility treatment is a legitimate concern of policymakers, providers, and patients. Fertility providers have responded by decreasing substantially the percentage of multiple pregnancies. In 2022, the percentage of twins globally is approaching 10% and in some countries is only slightly higher than naturally occurring twin rates. There are strong trends in technology advances and clinical practice that should ensure continued reduction in multiple births from fertility care. Due to high cost and/or unaffordability, ART remains out of reach for many, even in resource-rich countries ( Dyer et al. , 2020 ; ASRM The Ethics Committee, 2021 ; Njagi et al. , 2023 ). There is wide variation in regulatory and funding arrangements by governments and third parties. Less than half of reporting countries provide any financial support for ART, and only 20% offer full reimbursement ( International Federation of Fertility Societies’ Surveillance (IFFS), 2022 ).

Societal economic benefit

Fertility care is often not affordable for individuals who have to pay out of pocket for such treatments ( Dyer, 2002 ; Ombelet et al. , 2008 ; Chambers et al. , 2013 ; Bahamondes and Makuch, 2014 ; Koniares et al. , 2022 ). In contrast, fertility care is very affordable from a societal perspective ( Chambers et al. , 2009 ; Connolly et al. , 2010 ; Vélez et al., 2014 ). Indeed, fertility care is cost-effective and represents a positive return on public investment through the future economic value of babies resulting from fertility treatments ( ESHRE Capri Workshop Group, 2015 ). Identifying the optimal economic framework to assess the cost and benefits of fertility care remains challenging because infertility and its treatment are unique in the health care system because its goal is the creation of a new life ( Martins and Connolly, 2022 ). Compelling economic reasons to support increased access to fertility care in most countries include the relatively low societal cost to obtain a live birth, future economic productivity of the resulting individuals, and the high net present value of future tax payments from those individuals ( Connolly et al. , 2008 ; Martins and Connolly, 2022 ). For instance, lifetime revenue from tax-paying citizens, calculated in the UK, was eight times the return on investment from the total cost of fertility care ( Connolly et al. , 2009 ). Comparable benefits have been reported for other countries such as Canada, USA, Denmark, Sweden, and South Africa ( Connolly et al. , 2008 ; Svensson et al. , 2008 ). IVF and naturally conceived individuals in the Netherlands have negative yet similar discounted net tax revenue at the end of life in an analytic framework that undervalues the incremental value of an additional birth because it only considers the fiscal consequences of life and does not take into consideration broader macroeconomic benefits ( Moolenaar et al. , 2014 ). Another way to conceptualize the importance of fertility care is to assess the statistical value of a human life (estimated to be US$5.7 million), which far exceeds the cost of creating a life through fertility treatment ( Keller et al. , 2021 ). This median value ranged from $858 599 in developing countries to $8 342 027 in developed countries. Estimates of the statistical value of a human life were up to 4.66 times higher when parents were asked to value their children’s rather than their own lives ( Keller et al. , 2021 ). In addition to improving the quality of life of individuals and couples, by any measure, the net economic impact of fertility care is highly positive for all societies.

Socio-cultural factors

Religion and cultural beliefs about fertility reflect the level of acceptability of ART and thus influence access to fertility care. Indeed, the moral status of the embryo, use of frozen gametes, and third-party reproduction have been central to many religious debates, particularly in the Middle East, Latin America, parts of Europe (where there is reduced acceptability of ART), and the USA ( Serour and Serour, 2021 ). Although most world religions support the use of ART, fostering culturally appropriate care (e.g. accommodating language barriers, respecting gender, and privacy norms), and removing structural barriers would ameliorate many of the disparities in access to infertility care (International Federation of Gynecology and Obstetrics, https://fertilitytool.com ).

Gender equity

The increasing understanding of how gender norms and disparities affect pathways to health outcomes helps explain why there are such inequalities in access to fertility care. Countries with high ART utilization rates (a proxy for access) generally have high levels of gender equality, particularly reflected in education, labor force participation, empowerment, and reproductive rights ( Fig. 5 ) ( Chambers and Fauser, 2021 ). Infertility and its treatment are particularly sensitive to gender inequalities because it largely remains a gendered problem, with women carrying much of the stigma and burden ( Greil et al. , 2010 ). Emphasizing the importance of a life-course approach to the integration of fertility care in women’s social and physical health, both the WHO and the UN recently included fertility care under the definitions of sexual and reproductive health and rights ( United Nations, 2019 ).

Relation between ART utilization (cycles per million population) and the degree of gender equality in countries reporting to the United Nation’s Development Program Gender Inequality Index. Each black dot represents a country. Utilization from the ICMART 2012 World Registry. Reprinted with permission from Chambers and Fauser (2021).

Relation between ART utilization (cycles per million population) and the degree of gender equality in countries reporting to the United Nation’s Development Program Gender Inequality Index. Each black dot represents a country. Utilization from the ICMART 2012 World Registry. Reprinted with permission from Chambers and Fauser (2021) .

Diversity, equity, inclusion, and belonging

Infertility can negate the realization of the right of every person to found a family. Inequities in access to fertility care adversely affect all minorities, whether racial, religious, gender-based, or other. Such disparities in access often arise from restrictive legislation, government policies, and inappropriate care pathways ( Seifer et al. , 2022 ). Embracing the principles of diversity, equity, and inclusion while addressing infertility and fertility care improves emotional health and well-being, promotes gender equity, advances diversity, equity, inclusion, and belonging goals, and enhances social justice.

ART has predominantly been developed in HICs. Approximately three-quarters of all global ART cycles are performed in just 10 countries. Complex and expensive ART protocols are less applicable in low-resource settings because the context is significantly different ( Macklon and Fauser, 2020 ). Comparing ART from many parts of the world in a useful manner remains challenging because standardized outcome measures, involving success rates along with the burden of treatment, risks and cost, are not yet available ( Fauser 2019 ). Simplified, lower cost, high-quality ART procedures are urgently needed to establish affordable ART, especially in LMICs ( Ombelet 2011 ; Chiware et al. , 2021 ).

Cost, affordability, socio-cultural and diversity factors, and gender inequality represent the most important drivers in unequal access to fertility care.

Fertility care is not affordable for many people around the world, especially in low-resource settings.

The child who results from fertility care represents a strong economic benefit for society.

Policies and practices need to be developed to reduce disparities in fertility care based on class, gender, sexual orientation, and other differences.

Striving for gender equality and universal reproductive rights will foster more equitable, culturally appropriate access to fertility care.

There is an urgent need to develop simpler, less expensive ART.

Infrastructure and training support are needed to increase access to care, especially in low-resource countries.

The development and evaluation of simplified fertility treatments, especially ART.

Effective ways to reduce disparities in access to fertility care for single women and men, and LGBTQ+ people.

Quantification of economic benefits of infertility care in different settings.

Economic development, urbanization, improved education, secularization, gender equity, and family-planning policies have all contributed to slowing world population growth. Global TFR is decreasing, which will eventually result in a declining global population and radically changed demographics in most countries worldwide during this century. Although all declining, major regional differences in absolute TFR numbers remain. While a beneficial impact on the environment is anticipated, these drastic changes will have major societal and economic implications that will severely challenge nations and the global community. Policies will need to be developed to optimize the management of these changes. More focus on developing effective family-building policies should represent an important component of such strategies.

Globally, infertility is one of the most frequent chronic diseases among women and men of reproductive age, with several well-known risk factors and a high burden globally. Both success and safety of infertility treatments have improved significantly in recent decades. More recently, these technologies are also increasingly applied in other populations of individuals and the LGBTQ+ community in need of fertility care to form a family. Since the right to found a family is fundamental to every person, appropriate funding should be provided for fertility care, evaluation, and treatment. Because of a lack of awareness and appreciation of the prevalence and burden of infertility, however, only a few countries globally meet these needs. Fertility care, including infertility treatment, should be considered a principal component of family building and family planning.

Fertility care is now successful enough to justify its widespread global availability for those in need of reproductive assistance to realize their family goals and improve their personal well-being. Doing so will also help mitigate the declining TFR. This mitigation can be achieved in harmony with goals related to climate change, since it is human activity—linked to rising gross domestic product per capita and resultant consumption—rather than human numbers per se that does the greatest damage to the environment ( United Nations, 2021 ).

The economic benefits to society of providing fertility care clearly exceed the cost of treatment, and these benefits will only increase as populations become more aged. The medical profession, policymakers, other stakeholders, and the public can use the information provided to increase their understanding of fertility care. Such increased understanding will enable the development of integrative family-planning policies that meet the needs of those needing fertility care to establish their family, while also helping societies manage the decreasing TFR and resulting demographic and societal challenges.

Concerning awareness

Increase awareness that family building should become an integral part of global family-planning policies.

Increase awareness of stakeholders, policymakers, and the public regarding the distinct societal implications of decreasing TFR.

Focus more on family building and the prevention of infertility in educational programs for young adults.

Promote research that provides answers to critical gaps in the knowledge of family building.

Recognize the distinct global need for nations to develop and implement effective strategies to prevent infertility.

Educate stakeholders, policymakers, and the public regarding the ability of fertility care to help mitigate the consequences of a reducing TFR.

Promote research on the diagnosis and treatment of male infertility.

Concerning human rights

Recognize and promote the right of all individuals to have children if desired.

Concerning access to care

Recognize the global need to improve access to fertility care, especially in LMICs, by developing less complex and more affordable, high quality fertility care (both diagnosis and treatment).

Reduce complications of fertility care, especially multiple pregnancies, to diminish the societal cost of fertility care.

Realize more equitable access by increasing public and insurance funding of fertility care and expanding coverage to individuals and same-sex couples.

All data are incorporated into the article. The data underlying this article are available in the article and in the source references listed at the end of the article.

The authors acknowledge the work of Samantha Adams and Yannik Bramer for administrative support and Mimi Wainwright (Wainwright Medical Communications) for editorial support. The authors are grateful to the following members and contributors from the International Federation of Fertility Societies Demographics and Access to Care Review Board for their review and feedback of the manuscript drafts (listed alphabetically): Oladapo Ashiru, PhD; Simon Brown, MA; Karianne Bye, MA on behalf of Fertility Europe; Carlos Calhaz-Jorge, MD president of the European Society of Human Reproduction and Embryology (ESHRE); Barbara Collura, MA on behalf of RESOLVE, The National Infertility Association; Petra De Sutter, MD; Luca Gianaroli, MD; Linda Giudice, MD; Osamu Ishihara, MD; Edgar V. Mocanu, MD president of IFFS; Willem Ombelet, MD; Rishma Pai, MD, Chair of the IFFS Demographics and Access to Care Review Board; Guido Pennings, PhD; James Raymer, PhD; and Hugh Taylor, MD past president of the American Society for Reproductive Medicine (ASRM).

B.C.F. and G.D.A. contributed project conceptualization, data curation, analysis, investigation, methodology, project administration, supervision, validation, writing the original draft and review, and editing; B.C.F. also acquired funding. J.B. contributed to project conceptualization, data curation, analysis, investigation, methodology, validation, writing the original draft and review, and editing. G.C. provided data curation, analysis, investigation, methodology, validation, writing the original draft and review, and editing. C.d.G. contributed to data curation, analysis, validation, writing the original draft and review, and editing. S.D. contributed to project conceptualization, data curation, analysis, investigation, methodology, validation, writing the original draft and review, and editing. M.C.I. contributed to project conceptualization, analysis, validation, writing the original draft and review, and editing. L.S., G.S., B.T., and F.Z. contributed to project conceptualization, data curation, analysis, investigation, methodology, validation, writing the original draft and review, and editing.

This work was funded in part by an unrestricted educational grant from Ferring to the International Federation of Fertility Societies (IFFS) for administrative and editorial support.

B.C.F. reports grants from Dutch Medical Research Counsel (paid to University of Utrecht) and Nederlandse Hartstichting (paid to Erasmus University); he has received consulting fees from Ferring; honoraria from Ferring, Bain Capital, Celmatix, Pantharei Bioscience, Shieldler, UpToDate; Meeting and travel support from Ferring, ESHRE, IFFS; participation on an advisory board for Myovant; holds position of Director of Science for IFFS and co-chair of Controversies in Obstetrics & Gynecology. G.D.A. reports funding from IFFS (administrative and editorial support; authors’ meeting) for the subject manuscript; consulting fees to ARC Fertility from Labcorp and Cooper; and noncompensated leadership roles with ICMART (Chair) and WERF (President). J.B. reports study support to her institution from Merck Serono Ltd; consulting fees from Ferring BV and Ferring Pharmaceuticals A/S; speakers bureau honoraria from Organon JJC, Merck Group, and Ferring Arzneimittel GmbH; payment for expert testimony from the British Parliament; precongress meeting travel support from ESHRE; compensation as Director of Psych-Fertility Consulting Ltd. G.C. reports research and study grants from ICMART, Australian Medical Future Fund, and Australian National Health Medical Research Committee; non-compensated board member of ICMART. C.d.G. reports no conflict of interests. S.D. reports travel funding from IFFS, grant to institution; consulting fees from Science for Africa Foundation to Institution, honoraria paid to institution; travel support paid to institution from the Egyptian Foundation of Reproductive Medicine and Embryology; member of Science and Technology Advisory Group, HRP WHO (meeting travel expenses); Board member ICMART (non-compensated), Director ANARA (non-compensated), member of IFFS Education Committee (non-compensated); Observer, Board of the African Federation of Fertility Societies (non-compensated). M.C.I. reports no conflicts of interest. L.S. reports no conflicts of interest. G.S. reports no conflicts of interest. B.T. reports no conflicts of interest. F.Z.-H. reports honoraria from Ferring and Merck for two industry-funded conferences at regional symposia and also declares positions as Chair of the Latin American Registry of ART, Vice Chair International Committee for Monitoring ART (ICMART), Board member of Chilean Institute for Reproductive Medicine, Director of Ethics Committee of the Chilean Society of Obstetrics and Gynecology, and Board member of the Latin American Network of Assisted Reproduction (REDLARA).

Appendix: Contributors (listed alphabetically)

Contributors and members of the IFFS Demographics and Access to Care Review Board:

Oladapo Ashiru, PhD

Simon Brown, MA

Karianne Bye, MA on behalf of Fertility Europe

Carlos Calhaz-Jorge, MD, past president of the European Society of Human Reproduction and Embryology (ESHRE)

Barbara Collura, MA on behalf of RESOLVE, The National Infertility Association

Petra De Sutter, MD

Luca Gianaroli, MD

Linda Giudice, MD, past president IFFS

Osamu Ishihara, MD

Edgar V. Mocanu, MD, president of IFFS

Willem Ombelet, MD

Rishma Pai, MD, Chair of the review board

Guido Pennings, PhD

James Raymer, PhD

Hugh Taylor, MD, past president of the American Society for Reproductive Medicine (ASRM)

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Key terminology used in current document

(No consensus concerning definitions exists in this complex field, and alternative explanations (clinical, epidemiological, or demographic) may exist.)

Author notes

  • family planning
  • health services accessibility
  • infertility
  • population growth
  • reproductive physiological process
  • fertility rate
  • infertility therapy
  • narrative review
  • fertility care

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Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.

Cover of Handbook of eHealth Evaluation: An Evidence-based Approach

Handbook of eHealth Evaluation: An Evidence-based Approach [Internet].

Chapter 9 methods for literature reviews.

Guy Paré and Spyros Kitsiou .

9.1. Introduction

Literature reviews play a critical role in scholarship because science remains, first and foremost, a cumulative endeavour ( vom Brocke et al., 2009 ). As in any academic discipline, rigorous knowledge syntheses are becoming indispensable in keeping up with an exponentially growing eHealth literature, assisting practitioners, academics, and graduate students in finding, evaluating, and synthesizing the contents of many empirical and conceptual papers. Among other methods, literature reviews are essential for: (a) identifying what has been written on a subject or topic; (b) determining the extent to which a specific research area reveals any interpretable trends or patterns; (c) aggregating empirical findings related to a narrow research question to support evidence-based practice; (d) generating new frameworks and theories; and (e) identifying topics or questions requiring more investigation ( Paré, Trudel, Jaana, & Kitsiou, 2015 ).

Literature reviews can take two major forms. The most prevalent one is the “literature review” or “background” section within a journal paper or a chapter in a graduate thesis. This section synthesizes the extant literature and usually identifies the gaps in knowledge that the empirical study addresses ( Sylvester, Tate, & Johnstone, 2013 ). It may also provide a theoretical foundation for the proposed study, substantiate the presence of the research problem, justify the research as one that contributes something new to the cumulated knowledge, or validate the methods and approaches for the proposed study ( Hart, 1998 ; Levy & Ellis, 2006 ).

The second form of literature review, which is the focus of this chapter, constitutes an original and valuable work of research in and of itself ( Paré et al., 2015 ). Rather than providing a base for a researcher’s own work, it creates a solid starting point for all members of the community interested in a particular area or topic ( Mulrow, 1987 ). The so-called “review article” is a journal-length paper which has an overarching purpose to synthesize the literature in a field, without collecting or analyzing any primary data ( Green, Johnson, & Adams, 2006 ).

When appropriately conducted, review articles represent powerful information sources for practitioners looking for state-of-the art evidence to guide their decision-making and work practices ( Paré et al., 2015 ). Further, high-quality reviews become frequently cited pieces of work which researchers seek out as a first clear outline of the literature when undertaking empirical studies ( Cooper, 1988 ; Rowe, 2014 ). Scholars who track and gauge the impact of articles have found that review papers are cited and downloaded more often than any other type of published article ( Cronin, Ryan, & Coughlan, 2008 ; Montori, Wilczynski, Morgan, Haynes, & Hedges, 2003 ; Patsopoulos, Analatos, & Ioannidis, 2005 ). The reason for their popularity may be the fact that reading the review enables one to have an overview, if not a detailed knowledge of the area in question, as well as references to the most useful primary sources ( Cronin et al., 2008 ). Although they are not easy to conduct, the commitment to complete a review article provides a tremendous service to one’s academic community ( Paré et al., 2015 ; Petticrew & Roberts, 2006 ). Most, if not all, peer-reviewed journals in the fields of medical informatics publish review articles of some type.

The main objectives of this chapter are fourfold: (a) to provide an overview of the major steps and activities involved in conducting a stand-alone literature review; (b) to describe and contrast the different types of review articles that can contribute to the eHealth knowledge base; (c) to illustrate each review type with one or two examples from the eHealth literature; and (d) to provide a series of recommendations for prospective authors of review articles in this domain.

9.2. Overview of the Literature Review Process and Steps

As explained in Templier and Paré (2015) , there are six generic steps involved in conducting a review article:

  • formulating the research question(s) and objective(s),
  • searching the extant literature,
  • screening for inclusion,
  • assessing the quality of primary studies,
  • extracting data, and
  • analyzing data.

Although these steps are presented here in sequential order, one must keep in mind that the review process can be iterative and that many activities can be initiated during the planning stage and later refined during subsequent phases ( Finfgeld-Connett & Johnson, 2013 ; Kitchenham & Charters, 2007 ).

Formulating the research question(s) and objective(s): As a first step, members of the review team must appropriately justify the need for the review itself ( Petticrew & Roberts, 2006 ), identify the review’s main objective(s) ( Okoli & Schabram, 2010 ), and define the concepts or variables at the heart of their synthesis ( Cooper & Hedges, 2009 ; Webster & Watson, 2002 ). Importantly, they also need to articulate the research question(s) they propose to investigate ( Kitchenham & Charters, 2007 ). In this regard, we concur with Jesson, Matheson, and Lacey (2011) that clearly articulated research questions are key ingredients that guide the entire review methodology; they underscore the type of information that is needed, inform the search for and selection of relevant literature, and guide or orient the subsequent analysis. Searching the extant literature: The next step consists of searching the literature and making decisions about the suitability of material to be considered in the review ( Cooper, 1988 ). There exist three main coverage strategies. First, exhaustive coverage means an effort is made to be as comprehensive as possible in order to ensure that all relevant studies, published and unpublished, are included in the review and, thus, conclusions are based on this all-inclusive knowledge base. The second type of coverage consists of presenting materials that are representative of most other works in a given field or area. Often authors who adopt this strategy will search for relevant articles in a small number of top-tier journals in a field ( Paré et al., 2015 ). In the third strategy, the review team concentrates on prior works that have been central or pivotal to a particular topic. This may include empirical studies or conceptual papers that initiated a line of investigation, changed how problems or questions were framed, introduced new methods or concepts, or engendered important debate ( Cooper, 1988 ). Screening for inclusion: The following step consists of evaluating the applicability of the material identified in the preceding step ( Levy & Ellis, 2006 ; vom Brocke et al., 2009 ). Once a group of potential studies has been identified, members of the review team must screen them to determine their relevance ( Petticrew & Roberts, 2006 ). A set of predetermined rules provides a basis for including or excluding certain studies. This exercise requires a significant investment on the part of researchers, who must ensure enhanced objectivity and avoid biases or mistakes. As discussed later in this chapter, for certain types of reviews there must be at least two independent reviewers involved in the screening process and a procedure to resolve disagreements must also be in place ( Liberati et al., 2009 ; Shea et al., 2009 ). Assessing the quality of primary studies: In addition to screening material for inclusion, members of the review team may need to assess the scientific quality of the selected studies, that is, appraise the rigour of the research design and methods. Such formal assessment, which is usually conducted independently by at least two coders, helps members of the review team refine which studies to include in the final sample, determine whether or not the differences in quality may affect their conclusions, or guide how they analyze the data and interpret the findings ( Petticrew & Roberts, 2006 ). Ascribing quality scores to each primary study or considering through domain-based evaluations which study components have or have not been designed and executed appropriately makes it possible to reflect on the extent to which the selected study addresses possible biases and maximizes validity ( Shea et al., 2009 ). Extracting data: The following step involves gathering or extracting applicable information from each primary study included in the sample and deciding what is relevant to the problem of interest ( Cooper & Hedges, 2009 ). Indeed, the type of data that should be recorded mainly depends on the initial research questions ( Okoli & Schabram, 2010 ). However, important information may also be gathered about how, when, where and by whom the primary study was conducted, the research design and methods, or qualitative/quantitative results ( Cooper & Hedges, 2009 ). Analyzing and synthesizing data : As a final step, members of the review team must collate, summarize, aggregate, organize, and compare the evidence extracted from the included studies. The extracted data must be presented in a meaningful way that suggests a new contribution to the extant literature ( Jesson et al., 2011 ). Webster and Watson (2002) warn researchers that literature reviews should be much more than lists of papers and should provide a coherent lens to make sense of extant knowledge on a given topic. There exist several methods and techniques for synthesizing quantitative (e.g., frequency analysis, meta-analysis) and qualitative (e.g., grounded theory, narrative analysis, meta-ethnography) evidence ( Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005 ; Thomas & Harden, 2008 ).

9.3. Types of Review Articles and Brief Illustrations

EHealth researchers have at their disposal a number of approaches and methods for making sense out of existing literature, all with the purpose of casting current research findings into historical contexts or explaining contradictions that might exist among a set of primary research studies conducted on a particular topic. Our classification scheme is largely inspired from Paré and colleagues’ (2015) typology. Below we present and illustrate those review types that we feel are central to the growth and development of the eHealth domain.

9.3.1. Narrative Reviews

The narrative review is the “traditional” way of reviewing the extant literature and is skewed towards a qualitative interpretation of prior knowledge ( Sylvester et al., 2013 ). Put simply, a narrative review attempts to summarize or synthesize what has been written on a particular topic but does not seek generalization or cumulative knowledge from what is reviewed ( Davies, 2000 ; Green et al., 2006 ). Instead, the review team often undertakes the task of accumulating and synthesizing the literature to demonstrate the value of a particular point of view ( Baumeister & Leary, 1997 ). As such, reviewers may selectively ignore or limit the attention paid to certain studies in order to make a point. In this rather unsystematic approach, the selection of information from primary articles is subjective, lacks explicit criteria for inclusion and can lead to biased interpretations or inferences ( Green et al., 2006 ). There are several narrative reviews in the particular eHealth domain, as in all fields, which follow such an unstructured approach ( Silva et al., 2015 ; Paul et al., 2015 ).

Despite these criticisms, this type of review can be very useful in gathering together a volume of literature in a specific subject area and synthesizing it. As mentioned above, its primary purpose is to provide the reader with a comprehensive background for understanding current knowledge and highlighting the significance of new research ( Cronin et al., 2008 ). Faculty like to use narrative reviews in the classroom because they are often more up to date than textbooks, provide a single source for students to reference, and expose students to peer-reviewed literature ( Green et al., 2006 ). For researchers, narrative reviews can inspire research ideas by identifying gaps or inconsistencies in a body of knowledge, thus helping researchers to determine research questions or formulate hypotheses. Importantly, narrative reviews can also be used as educational articles to bring practitioners up to date with certain topics of issues ( Green et al., 2006 ).

Recently, there have been several efforts to introduce more rigour in narrative reviews that will elucidate common pitfalls and bring changes into their publication standards. Information systems researchers, among others, have contributed to advancing knowledge on how to structure a “traditional” review. For instance, Levy and Ellis (2006) proposed a generic framework for conducting such reviews. Their model follows the systematic data processing approach comprised of three steps, namely: (a) literature search and screening; (b) data extraction and analysis; and (c) writing the literature review. They provide detailed and very helpful instructions on how to conduct each step of the review process. As another methodological contribution, vom Brocke et al. (2009) offered a series of guidelines for conducting literature reviews, with a particular focus on how to search and extract the relevant body of knowledge. Last, Bandara, Miskon, and Fielt (2011) proposed a structured, predefined and tool-supported method to identify primary studies within a feasible scope, extract relevant content from identified articles, synthesize and analyze the findings, and effectively write and present the results of the literature review. We highly recommend that prospective authors of narrative reviews consult these useful sources before embarking on their work.

Darlow and Wen (2015) provide a good example of a highly structured narrative review in the eHealth field. These authors synthesized published articles that describe the development process of mobile health ( m-health ) interventions for patients’ cancer care self-management. As in most narrative reviews, the scope of the research questions being investigated is broad: (a) how development of these systems are carried out; (b) which methods are used to investigate these systems; and (c) what conclusions can be drawn as a result of the development of these systems. To provide clear answers to these questions, a literature search was conducted on six electronic databases and Google Scholar . The search was performed using several terms and free text words, combining them in an appropriate manner. Four inclusion and three exclusion criteria were utilized during the screening process. Both authors independently reviewed each of the identified articles to determine eligibility and extract study information. A flow diagram shows the number of studies identified, screened, and included or excluded at each stage of study selection. In terms of contributions, this review provides a series of practical recommendations for m-health intervention development.

9.3.2. Descriptive or Mapping Reviews

The primary goal of a descriptive review is to determine the extent to which a body of knowledge in a particular research topic reveals any interpretable pattern or trend with respect to pre-existing propositions, theories, methodologies or findings ( King & He, 2005 ; Paré et al., 2015 ). In contrast with narrative reviews, descriptive reviews follow a systematic and transparent procedure, including searching, screening and classifying studies ( Petersen, Vakkalanka, & Kuzniarz, 2015 ). Indeed, structured search methods are used to form a representative sample of a larger group of published works ( Paré et al., 2015 ). Further, authors of descriptive reviews extract from each study certain characteristics of interest, such as publication year, research methods, data collection techniques, and direction or strength of research outcomes (e.g., positive, negative, or non-significant) in the form of frequency analysis to produce quantitative results ( Sylvester et al., 2013 ). In essence, each study included in a descriptive review is treated as the unit of analysis and the published literature as a whole provides a database from which the authors attempt to identify any interpretable trends or draw overall conclusions about the merits of existing conceptualizations, propositions, methods or findings ( Paré et al., 2015 ). In doing so, a descriptive review may claim that its findings represent the state of the art in a particular domain ( King & He, 2005 ).

In the fields of health sciences and medical informatics, reviews that focus on examining the range, nature and evolution of a topic area are described by Anderson, Allen, Peckham, and Goodwin (2008) as mapping reviews . Like descriptive reviews, the research questions are generic and usually relate to publication patterns and trends. There is no preconceived plan to systematically review all of the literature although this can be done. Instead, researchers often present studies that are representative of most works published in a particular area and they consider a specific time frame to be mapped.

An example of this approach in the eHealth domain is offered by DeShazo, Lavallie, and Wolf (2009). The purpose of this descriptive or mapping review was to characterize publication trends in the medical informatics literature over a 20-year period (1987 to 2006). To achieve this ambitious objective, the authors performed a bibliometric analysis of medical informatics citations indexed in medline using publication trends, journal frequencies, impact factors, Medical Subject Headings (MeSH) term frequencies, and characteristics of citations. Findings revealed that there were over 77,000 medical informatics articles published during the covered period in numerous journals and that the average annual growth rate was 12%. The MeSH term analysis also suggested a strong interdisciplinary trend. Finally, average impact scores increased over time with two notable growth periods. Overall, patterns in research outputs that seem to characterize the historic trends and current components of the field of medical informatics suggest it may be a maturing discipline (DeShazo et al., 2009).

9.3.3. Scoping Reviews

Scoping reviews attempt to provide an initial indication of the potential size and nature of the extant literature on an emergent topic (Arksey & O’Malley, 2005; Daudt, van Mossel, & Scott, 2013 ; Levac, Colquhoun, & O’Brien, 2010). A scoping review may be conducted to examine the extent, range and nature of research activities in a particular area, determine the value of undertaking a full systematic review (discussed next), or identify research gaps in the extant literature ( Paré et al., 2015 ). In line with their main objective, scoping reviews usually conclude with the presentation of a detailed research agenda for future works along with potential implications for both practice and research.

Unlike narrative and descriptive reviews, the whole point of scoping the field is to be as comprehensive as possible, including grey literature (Arksey & O’Malley, 2005). Inclusion and exclusion criteria must be established to help researchers eliminate studies that are not aligned with the research questions. It is also recommended that at least two independent coders review abstracts yielded from the search strategy and then the full articles for study selection ( Daudt et al., 2013 ). The synthesized evidence from content or thematic analysis is relatively easy to present in tabular form (Arksey & O’Malley, 2005; Thomas & Harden, 2008 ).

One of the most highly cited scoping reviews in the eHealth domain was published by Archer, Fevrier-Thomas, Lokker, McKibbon, and Straus (2011) . These authors reviewed the existing literature on personal health record ( phr ) systems including design, functionality, implementation, applications, outcomes, and benefits. Seven databases were searched from 1985 to March 2010. Several search terms relating to phr s were used during this process. Two authors independently screened titles and abstracts to determine inclusion status. A second screen of full-text articles, again by two independent members of the research team, ensured that the studies described phr s. All in all, 130 articles met the criteria and their data were extracted manually into a database. The authors concluded that although there is a large amount of survey, observational, cohort/panel, and anecdotal evidence of phr benefits and satisfaction for patients, more research is needed to evaluate the results of phr implementations. Their in-depth analysis of the literature signalled that there is little solid evidence from randomized controlled trials or other studies through the use of phr s. Hence, they suggested that more research is needed that addresses the current lack of understanding of optimal functionality and usability of these systems, and how they can play a beneficial role in supporting patient self-management ( Archer et al., 2011 ).

9.3.4. Forms of Aggregative Reviews

Healthcare providers, practitioners, and policy-makers are nowadays overwhelmed with large volumes of information, including research-based evidence from numerous clinical trials and evaluation studies, assessing the effectiveness of health information technologies and interventions ( Ammenwerth & de Keizer, 2004 ; Deshazo et al., 2009 ). It is unrealistic to expect that all these disparate actors will have the time, skills, and necessary resources to identify the available evidence in the area of their expertise and consider it when making decisions. Systematic reviews that involve the rigorous application of scientific strategies aimed at limiting subjectivity and bias (i.e., systematic and random errors) can respond to this challenge.

Systematic reviews attempt to aggregate, appraise, and synthesize in a single source all empirical evidence that meet a set of previously specified eligibility criteria in order to answer a clearly formulated and often narrow research question on a particular topic of interest to support evidence-based practice ( Liberati et al., 2009 ). They adhere closely to explicit scientific principles ( Liberati et al., 2009 ) and rigorous methodological guidelines (Higgins & Green, 2008) aimed at reducing random and systematic errors that can lead to deviations from the truth in results or inferences. The use of explicit methods allows systematic reviews to aggregate a large body of research evidence, assess whether effects or relationships are in the same direction and of the same general magnitude, explain possible inconsistencies between study results, and determine the strength of the overall evidence for every outcome of interest based on the quality of included studies and the general consistency among them ( Cook, Mulrow, & Haynes, 1997 ). The main procedures of a systematic review involve:

  • Formulating a review question and developing a search strategy based on explicit inclusion criteria for the identification of eligible studies (usually described in the context of a detailed review protocol).
  • Searching for eligible studies using multiple databases and information sources, including grey literature sources, without any language restrictions.
  • Selecting studies, extracting data, and assessing risk of bias in a duplicate manner using two independent reviewers to avoid random or systematic errors in the process.
  • Analyzing data using quantitative or qualitative methods.
  • Presenting results in summary of findings tables.
  • Interpreting results and drawing conclusions.

Many systematic reviews, but not all, use statistical methods to combine the results of independent studies into a single quantitative estimate or summary effect size. Known as meta-analyses , these reviews use specific data extraction and statistical techniques (e.g., network, frequentist, or Bayesian meta-analyses) to calculate from each study by outcome of interest an effect size along with a confidence interval that reflects the degree of uncertainty behind the point estimate of effect ( Borenstein, Hedges, Higgins, & Rothstein, 2009 ; Deeks, Higgins, & Altman, 2008 ). Subsequently, they use fixed or random-effects analysis models to combine the results of the included studies, assess statistical heterogeneity, and calculate a weighted average of the effect estimates from the different studies, taking into account their sample sizes. The summary effect size is a value that reflects the average magnitude of the intervention effect for a particular outcome of interest or, more generally, the strength of a relationship between two variables across all studies included in the systematic review. By statistically combining data from multiple studies, meta-analyses can create more precise and reliable estimates of intervention effects than those derived from individual studies alone, when these are examined independently as discrete sources of information.

The review by Gurol-Urganci, de Jongh, Vodopivec-Jamsek, Atun, and Car (2013) on the effects of mobile phone messaging reminders for attendance at healthcare appointments is an illustrative example of a high-quality systematic review with meta-analysis. Missed appointments are a major cause of inefficiency in healthcare delivery with substantial monetary costs to health systems. These authors sought to assess whether mobile phone-based appointment reminders delivered through Short Message Service ( sms ) or Multimedia Messaging Service ( mms ) are effective in improving rates of patient attendance and reducing overall costs. To this end, they conducted a comprehensive search on multiple databases using highly sensitive search strategies without language or publication-type restrictions to identify all rct s that are eligible for inclusion. In order to minimize the risk of omitting eligible studies not captured by the original search, they supplemented all electronic searches with manual screening of trial registers and references contained in the included studies. Study selection, data extraction, and risk of bias assessments were performed inde­­pen­dently by two coders using standardized methods to ensure consistency and to eliminate potential errors. Findings from eight rct s involving 6,615 participants were pooled into meta-analyses to calculate the magnitude of effects that mobile text message reminders have on the rate of attendance at healthcare appointments compared to no reminders and phone call reminders.

Meta-analyses are regarded as powerful tools for deriving meaningful conclusions. However, there are situations in which it is neither reasonable nor appropriate to pool studies together using meta-analytic methods simply because there is extensive clinical heterogeneity between the included studies or variation in measurement tools, comparisons, or outcomes of interest. In these cases, systematic reviews can use qualitative synthesis methods such as vote counting, content analysis, classification schemes and tabulations, as an alternative approach to narratively synthesize the results of the independent studies included in the review. This form of review is known as qualitative systematic review.

A rigorous example of one such review in the eHealth domain is presented by Mickan, Atherton, Roberts, Heneghan, and Tilson (2014) on the use of handheld computers by healthcare professionals and their impact on access to information and clinical decision-making. In line with the methodological guide­lines for systematic reviews, these authors: (a) developed and registered with prospero ( www.crd.york.ac.uk/ prospero / ) an a priori review protocol; (b) conducted comprehensive searches for eligible studies using multiple databases and other supplementary strategies (e.g., forward searches); and (c) subsequently carried out study selection, data extraction, and risk of bias assessments in a duplicate manner to eliminate potential errors in the review process. Heterogeneity between the included studies in terms of reported outcomes and measures precluded the use of meta-analytic methods. To this end, the authors resorted to using narrative analysis and synthesis to describe the effectiveness of handheld computers on accessing information for clinical knowledge, adherence to safety and clinical quality guidelines, and diagnostic decision-making.

In recent years, the number of systematic reviews in the field of health informatics has increased considerably. Systematic reviews with discordant findings can cause great confusion and make it difficult for decision-makers to interpret the review-level evidence ( Moher, 2013 ). Therefore, there is a growing need for appraisal and synthesis of prior systematic reviews to ensure that decision-making is constantly informed by the best available accumulated evidence. Umbrella reviews , also known as overviews of systematic reviews, are tertiary types of evidence synthesis that aim to accomplish this; that is, they aim to compare and contrast findings from multiple systematic reviews and meta-analyses ( Becker & Oxman, 2008 ). Umbrella reviews generally adhere to the same principles and rigorous methodological guidelines used in systematic reviews. However, the unit of analysis in umbrella reviews is the systematic review rather than the primary study ( Becker & Oxman, 2008 ). Unlike systematic reviews that have a narrow focus of inquiry, umbrella reviews focus on broader research topics for which there are several potential interventions ( Smith, Devane, Begley, & Clarke, 2011 ). A recent umbrella review on the effects of home telemonitoring interventions for patients with heart failure critically appraised, compared, and synthesized evidence from 15 systematic reviews to investigate which types of home telemonitoring technologies and forms of interventions are more effective in reducing mortality and hospital admissions ( Kitsiou, Paré, & Jaana, 2015 ).

9.3.5. Realist Reviews

Realist reviews are theory-driven interpretative reviews developed to inform, enhance, or supplement conventional systematic reviews by making sense of heterogeneous evidence about complex interventions applied in diverse contexts in a way that informs policy decision-making ( Greenhalgh, Wong, Westhorp, & Pawson, 2011 ). They originated from criticisms of positivist systematic reviews which centre on their “simplistic” underlying assumptions ( Oates, 2011 ). As explained above, systematic reviews seek to identify causation. Such logic is appropriate for fields like medicine and education where findings of randomized controlled trials can be aggregated to see whether a new treatment or intervention does improve outcomes. However, many argue that it is not possible to establish such direct causal links between interventions and outcomes in fields such as social policy, management, and information systems where for any intervention there is unlikely to be a regular or consistent outcome ( Oates, 2011 ; Pawson, 2006 ; Rousseau, Manning, & Denyer, 2008 ).

To circumvent these limitations, Pawson, Greenhalgh, Harvey, and Walshe (2005) have proposed a new approach for synthesizing knowledge that seeks to unpack the mechanism of how “complex interventions” work in particular contexts. The basic research question — what works? — which is usually associated with systematic reviews changes to: what is it about this intervention that works, for whom, in what circumstances, in what respects and why? Realist reviews have no particular preference for either quantitative or qualitative evidence. As a theory-building approach, a realist review usually starts by articulating likely underlying mechanisms and then scrutinizes available evidence to find out whether and where these mechanisms are applicable ( Shepperd et al., 2009 ). Primary studies found in the extant literature are viewed as case studies which can test and modify the initial theories ( Rousseau et al., 2008 ).

The main objective pursued in the realist review conducted by Otte-Trojel, de Bont, Rundall, and van de Klundert (2014) was to examine how patient portals contribute to health service delivery and patient outcomes. The specific goals were to investigate how outcomes are produced and, most importantly, how variations in outcomes can be explained. The research team started with an exploratory review of background documents and research studies to identify ways in which patient portals may contribute to health service delivery and patient outcomes. The authors identified six main ways which represent “educated guesses” to be tested against the data in the evaluation studies. These studies were identified through a formal and systematic search in four databases between 2003 and 2013. Two members of the research team selected the articles using a pre-established list of inclusion and exclusion criteria and following a two-step procedure. The authors then extracted data from the selected articles and created several tables, one for each outcome category. They organized information to bring forward those mechanisms where patient portals contribute to outcomes and the variation in outcomes across different contexts.

9.3.6. Critical Reviews

Lastly, critical reviews aim to provide a critical evaluation and interpretive analysis of existing literature on a particular topic of interest to reveal strengths, weaknesses, contradictions, controversies, inconsistencies, and/or other important issues with respect to theories, hypotheses, research methods or results ( Baumeister & Leary, 1997 ; Kirkevold, 1997 ). Unlike other review types, critical reviews attempt to take a reflective account of the research that has been done in a particular area of interest, and assess its credibility by using appraisal instruments or critical interpretive methods. In this way, critical reviews attempt to constructively inform other scholars about the weaknesses of prior research and strengthen knowledge development by giving focus and direction to studies for further improvement ( Kirkevold, 1997 ).

Kitsiou, Paré, and Jaana (2013) provide an example of a critical review that assessed the methodological quality of prior systematic reviews of home telemonitoring studies for chronic patients. The authors conducted a comprehensive search on multiple databases to identify eligible reviews and subsequently used a validated instrument to conduct an in-depth quality appraisal. Results indicate that the majority of systematic reviews in this particular area suffer from important methodological flaws and biases that impair their internal validity and limit their usefulness for clinical and decision-making purposes. To this end, they provide a number of recommendations to strengthen knowledge development towards improving the design and execution of future reviews on home telemonitoring.

9.4. Summary

Table 9.1 outlines the main types of literature reviews that were described in the previous sub-sections and summarizes the main characteristics that distinguish one review type from another. It also includes key references to methodological guidelines and useful sources that can be used by eHealth scholars and researchers for planning and developing reviews.

Table 9.1. Typology of Literature Reviews (adapted from Paré et al., 2015).

Typology of Literature Reviews (adapted from Paré et al., 2015).

As shown in Table 9.1 , each review type addresses different kinds of research questions or objectives, which subsequently define and dictate the methods and approaches that need to be used to achieve the overarching goal(s) of the review. For example, in the case of narrative reviews, there is greater flexibility in searching and synthesizing articles ( Green et al., 2006 ). Researchers are often relatively free to use a diversity of approaches to search, identify, and select relevant scientific articles, describe their operational characteristics, present how the individual studies fit together, and formulate conclusions. On the other hand, systematic reviews are characterized by their high level of systematicity, rigour, and use of explicit methods, based on an “a priori” review plan that aims to minimize bias in the analysis and synthesis process (Higgins & Green, 2008). Some reviews are exploratory in nature (e.g., scoping/mapping reviews), whereas others may be conducted to discover patterns (e.g., descriptive reviews) or involve a synthesis approach that may include the critical analysis of prior research ( Paré et al., 2015 ). Hence, in order to select the most appropriate type of review, it is critical to know before embarking on a review project, why the research synthesis is conducted and what type of methods are best aligned with the pursued goals.

9.5. Concluding Remarks

In light of the increased use of evidence-based practice and research generating stronger evidence ( Grady et al., 2011 ; Lyden et al., 2013 ), review articles have become essential tools for summarizing, synthesizing, integrating or critically appraising prior knowledge in the eHealth field. As mentioned earlier, when rigorously conducted review articles represent powerful information sources for eHealth scholars and practitioners looking for state-of-the-art evidence. The typology of literature reviews we used herein will allow eHealth researchers, graduate students and practitioners to gain a better understanding of the similarities and differences between review types.

We must stress that this classification scheme does not privilege any specific type of review as being of higher quality than another ( Paré et al., 2015 ). As explained above, each type of review has its own strengths and limitations. Having said that, we realize that the methodological rigour of any review — be it qualitative, quantitative or mixed — is a critical aspect that should be considered seriously by prospective authors. In the present context, the notion of rigour refers to the reliability and validity of the review process described in section 9.2. For one thing, reliability is related to the reproducibility of the review process and steps, which is facilitated by a comprehensive documentation of the literature search process, extraction, coding and analysis performed in the review. Whether the search is comprehensive or not, whether it involves a methodical approach for data extraction and synthesis or not, it is important that the review documents in an explicit and transparent manner the steps and approach that were used in the process of its development. Next, validity characterizes the degree to which the review process was conducted appropriately. It goes beyond documentation and reflects decisions related to the selection of the sources, the search terms used, the period of time covered, the articles selected in the search, and the application of backward and forward searches ( vom Brocke et al., 2009 ). In short, the rigour of any review article is reflected by the explicitness of its methods (i.e., transparency) and the soundness of the approach used. We refer those interested in the concepts of rigour and quality to the work of Templier and Paré (2015) which offers a detailed set of methodological guidelines for conducting and evaluating various types of review articles.

To conclude, our main objective in this chapter was to demystify the various types of literature reviews that are central to the continuous development of the eHealth field. It is our hope that our descriptive account will serve as a valuable source for those conducting, evaluating or using reviews in this important and growing domain.

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The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review

  • S’thembile Thusini 1 ,
  • Maria Milenova 1 ,
  • Noushig Nahabedian 2 ,
  • Barbara Grey 2 ,
  • Tayana Soukup 1 ,
  • Kia-Chong Chua 1 &
  • Claire Henderson 1  

BMC Health Services Research volume  22 , Article number:  1492 ( 2022 ) Cite this article

5298 Accesses

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A Correction to this article was published on 22 December 2022

This article has been updated

Return on Investment (ROI) is increasingly being used to evaluate financial benefits from healthcare Quality Improvement (QI). ROI is traditionally used to evaluate investment performance in the commercial field. Little is known about ROI in healthcare. The aim of this systematic review was to analyse and develop ROI as a concept and develop a ROI conceptual framework for large-scale healthcare QI programmes.

We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google Scholar using ROI or returns-on-investment concepts (e.g., cost–benefit, cost-effectiveness, value). We combined this terms with healthcare and QI. Included articles discussed at least three organisational QI benefits, including financial or patient benefits. We synthesised the different ways in which ROI or return-on-investment concepts were used and discussed by the QI literature; first the economically focused, then the non-economically focused QI literature. We then integrated these literatures to summarise their combined views.

We retrieved 10 428 articles. One hundred and two (102) articles were selected for full text screening. Of these 34 were excluded and 68 included. The included articles were QI economic, effectiveness, process, and impact evaluations as well as reports and conceptual literature. Fifteen of 68 articles were directly focused on QI programme economic outcomes. Of these, only four focused on ROI. ROI related concepts in this group included cost-effectiveness, cost–benefit, ROI, cost-saving, cost-reduction, and cost-avoidance. The remaining articles mainly mentioned efficiency, productivity, value, or benefits. Financial outcomes were not the main goal of QI programmes. We found that the ROI concept in healthcare QI aligned with the concepts of value and benefit, both monetary and non-monetary.

Our analysis of the reviewed literature indicates that ROI in QI is conceptualised as value or benefit as demonstrated through a combination of significant outcomes for one or more stakeholders in healthcare organisations. As such, organisations at different developmental stages can deduce benefits that are relevant and legitimate as per their contextual needs.

Trial registration

Review registration: PROSPERO; CRD42021236948.

Peer Review reports

Introduction

Quality Improvement (QI) programmes are being increasingly used to improve care quality in healthcare organisations [ 1 ]. QI is defined as a methodical approach to making improvements in a number of healthcare service aspects [ 1 – 3 ]. In particular, large-scale QI programmes are used to effect organisational level outcomes e.g., financial, and patient outcomes or even health system level outcomes e.g., population health [ 4 , 5 ]. Large-scale QI combines various strategic elements into a coherent improvement process to improve safety, quality, capability, and capacity of organisations [ 4 , 5 ]. Some QI programmes are delivered through local, national, or international collaboratives. A QI collaborative (QIC) combines multidisciplinary teams from different organisations to test solutions, and share learning in a specific clinical or operational area [ 6 ]. Whatever the type, QI programmes can have significant cost implications [ 7 ].

Investing in a QI programme may redirect money from other healthcare initiatives. In economic terms, this is called an “opportunity cost”, roughly meaning a lost opportunity for alternative investment [ 8 ]. For this reason, healthcare leaders must justify investments made or proposed for particular programmes. This is called making a QI business case. Return on Investment (ROI) is one such justification tool, used to decide how best to allocate limited healthcare funds [ 9 , 10 ]. Investment allocation decisions have ethical, moral, political, and equity implications [ 11 , 12 ]. Thus, the need to understand the meaning of ROI in the context of healthcare QI.

ROI is a financial tool that forecasts financial returns or profit from an investment [ 13 , 14 ]. The forecasting process is called ROI analysis. This uses a methodology to convert (monetise) costs and benefits into ROI [ 15 – 17 ]. ROI is reported as metric (percentage or a ratio), e.g., ROI = 1:1 means a 100% return was made. ROI is one of many financial metrics used to judge efficiency of an investment [ 32 ]. ROI can be viewed independently, in comparison to other programmes, or against the counterfactual (doing nothing) [ 18 ]. In healthcare, ROI has been used to evaluate financial value of a programme post implementation [ 16 ]. ROI has also been used commercially as an economic performance measure for meeting product quality specifications [ 19 ]. ROI is sometimes used as a performance management tool, that is to ensure that organisations achieve their desired strategic goals [ 20 ]. These traditional definitions and uses of ROI are not disputed here. However, as ROI moved from commerce to healthcare frontlines, it became more than a metric. It became a concept of returns or gains from an investment.

ROI’s introduction into healthcare has caused concern [ 11 , 21 ]. As well as the rationale for ROI being to justify investment business cases [ 22 ], the language also used is to “defend” against disinvestment [ 11 , 23 ]. In many industries, including healthcare, there are several ROI technical and philosophical challenges [ 21 , 24 – 28 ]. The major concerns are ROI’s de-emphasizing of wider organisational benefits. Modifications of ROI methodology have been attempted, for example detailing non-monetisable programme benefits as additional (not primary) benefits [ 9 , 16 ]. This was in recognition that only a small fraction of QI benefits are actually monetisable [ 9 ]. However, there is still a general belief that only monetisable benefits should be seen as ROI [ 9 , 16 , 29 ]. This is in-spite of the recognition that non-monetisable benefits are highly valued by most organisations [ 9 , 16 ]. This has created scepticism as to the extent of  the influence of non-monetisable benefits on investment decision-making [ 11 , 30 , 31 ].

Unsurprisingly, some deem the current ROI approach as aesthetic and synthetic [ 23 ], an insincere “placebo” and an oversimplification [ 27 ,  32 ]. As such, some industries appear to have rebranded ROI. In marketing and commercial service industries there is return-on-quality [ 33 ], and value-on-investment [ 34 ]. In healthcare, Leggat [ 35 ], called for a return-to-care, and Fischer & Duncan [ 36 ], a return-to-value. Healthcare researchers have also been slow to embrace ROI. Currently, many published QI-ROI studies involve small projects, often in health promotion, public health, or back-office services like laboratories (e.g., [ 21 , 37 – 40 ]. This calls for an understanding and reconciliation of healthcare views on ROI. This endeavour must be based on a logical assessment of ROI as a concept, not as a metric. Further, this must be driven by a logic of contextual appropriateness [ 41 ].

Studying concepts such as ROI in context invites the understanding of institutional logics. Logics are socially constructed sets of assumptions, values, and beliefs that are used to ascribe meaning, as well as frame reasoning and legitimise choices [ 42 ]. As such, they reflect embedded cultures. Healthcare is a complex social environment, filled with sub-cultures [ 43 ]. Thus here, complexity constitutes multiple actions and interactions of not only humans, but technologies, processes, and systems [ 44 , 45 ]. Healthcare has various stakeholders or groups and individuals that affect and are affected by healthcare [ 46 ]. These stakeholders have multiple, at times conflicting objectives and values [ 47 ]. Therefore, contextual interactions also entail multiple embedded theories, cognitive or symbolic systems [ 41 , 47 , 48 ]. For this reason, QI in healthcare is a complex intervention, with varied emergent and unpredictable outcomes [ 49 ].

Healthcare is at the juncture of many logics, primarily scientific, clinical, social, and economic logics [ 41 , 47 , 48 ]. Medical professionals may use science logic by emphasising a curing by focusing on evidence-based medicine, and or a care logic by focusing on interpersonal aspects. Managers may use an economic logic and focus on competition, markets, and financial outcomes. Further, some may use societal logics and focus on population health and socio-economic outcomes [ 41 , 47 , 48 ]. The presence of multiple logics explains the multiple ways used to define healthcare quality [ 48 ]. For example, some may describe quality as that which save costs; economic logic [ 50 ], is evidence based; science logic, or prioritises positive patient experience; care logic [ 51 ].

In the current study, the interest is the conceptualisation of ROI as a concept that is meaningful for healthcare stakeholders, particularly healthcare leaders as decision-makers. Concepts are mental abstractions which package complex meaning [ 52 ], and must be unpacked (or analysed) for effective application [ 53 ]. In this endeavour, concept analysis must be part of development of testable and practical theories [ 54 ]. Through concept analysis, scholars can produce evidence of their best estimate of the ‘probable truth’ about concepts [ 55 ]. This is a complex entangled task of concept analysis and development. In modern philosophy such as Critical Realism [ 56 ], this undertaking assumes that concepts are contextual and changeable [ 54 , 55 ]. Further, this presupposes moderate philosophies about the nature (Ontology) of concepts [ 54 ].

Moderate philosophies are different from traditional philosophies where the ‘truth’ is seen as absolute and or residing on one end of the spectrum. In Realism, reality exists regardless of human perception, whilst Relativism views reality as based on human perception and socially constructed. Lack of clarity about concepts can lead to poor communication, poor application in research and in practice [ 52 , 57 ]. As healthcare organisations are complex dynamic contexts, modern philosophy insights could support relations between QI implementers and investors. A scientific study of ROI as a concept grounded on a moderate philosophy may help engage QI researchers, improve practical application for practitioners, and improve communication amongst improvement stakeholders.

The aim of this study was to learn how the concept of a return-on-investment for healthcare large-scale QI is understood, and how this differs from related concepts. We first analysed, then developed the large-scale QI-ROI concept for healthcare based on the systematic literature review. We then proposed a framework for analysis of return-on-investment from QI programmes.

This paper is part of a larger integrative systematic literature review on the conceptualisation of ROI in healthcare QI. Our review is registered with PROSPERO, CRD42021236948. A link to our PRISMA reporting checklist [ 58 ] can be found in the supplementary files . We followed review guidance by Whittemore and Knafl [ 59 ] and conceptual analysis and development by Hupcey and Penrod [ 55 ] and Jabareen [ 53 ]. This led to 8 separate review stages. Stage 1; clarifying research question, involved background reading as discussed in our protocol on PROSPERO. The remainder of the stages are reported here. Stages 2–3 involved searching and selecting literature. In stage 4 we assessed the quality of research studies, stages 5–8 are reported in the synthesis, analysis, and results sections below.

Search strategy

The identification of suitable search terms was an iterative processes. To compile a list of ROI-like terms, we referred to the National Institute of Health and Care Excellence (NICE) ROI guide. NICE [ 60 ] views ROI as a term for various economic evaluation tools and processes used to evaluate value-for-money of healthcare programmes. Economic evaluation is the comparative analysis of alternative courses of action in relation to both their costs and consequences [ 61 ]. Economic evaluation methods include cost–benefit analysis (CBA), cost-effectiveness analysis (CEA), and cost consequence analysis (CCA). Search terms were also derived from background reading in healthcare and commercial literature. The final search terms were in three categories (Table 1 ): (i) context, (ii) QI methods, and (iii) QI outcomes. Category 2 terms were the most frequently mentioned QI methods in literature. Category 3 terms denote some form of outcome (return, benefit) derived from some form of input (investment, cost, resource).

We searched Medline, Embase, Global health, PsycInfo, EconLit, NHS EED, Web of Science, Google, Google scholar, organisational journals, as well hand-searched citations. No language and date limits were set to enable us to note any changes in QI-ROI conceptualisation over time. The search ended January 30, 2021. An example of the search strategy for Web of Science has been provided as Supplementary Table 1 . A link to more of our search strategies can be found in the Supplementary files. The main search terms are defined in Table 2 .

Eligibility

As ROI is an investment allocation decision tool, our stakeholder of interest were the healthcare leaders, and level of analysis the organisation, where decision-making outcomes are assessed. During our initial search, many articles identified themselves as large-scale QI programmes. However, at closer inspection, some of these only impacted a small part of an organisation and were therefore equivalent to a small organisational unit intervention. To focus our selection criteria, we developed a preliminary ROI conceptual framework ( Fig.  1 ). The preliminary framework contained various needs and obligations of healthcare organisations [ 71 , 72 ]. We assumed these to signal desired organisational outcomes.

figure 1

Preliminary QI-ROI Conceptual Framework

The Framework had four criteria: 1) organisational performance (patients and financial outcomes), 2) organisational capacity and capability, 3) external relations (e.g., accreditation), and 4) unintended consequences (positive/negative). Organisational performance is a marker of how well organisations perform on delivering value for its stakeholders [ 73 ]. Thus, in a way it includes external relations, e.g., population health. However, external outcomes were isolated here to deduce some unique external outcomes and obligations towards external stakeholders. We included negative outcomes as potential indicators of the lack of ROI positive returns. We then used this framework to decide on eligibility.

To be included, the literature that had to mention at least three QI organisational goals or benefits, two of which had to be patient or financial outcomes. Through this, we sought to isolate articles that discussed a range of QI outcomes, with patient and financial outcomes as basic organisational goals. In addition, articles had to mention use of at least one QI method, and involvement of various stakeholders, in at least two organisational units. Altogether, this denoted a three-dimensional criteria: depth, breath, and complexity of QI programmes per organisation. We included literature on discussions of large-scale QI programmes outcomes across healthcare globally. Table 3 has included/excluded article types.

Screening and selection of articles

Data were managed using Endnote citation manager [ 74 ] and Ryann systematic review app [ 75 ]. Screening and selection were performed by two independent reviewers, ST, and MM. To refine our selection criteria, five articles were initially selected and discussed to clarify any uncertainties. The two reviewers then completed the screening and selection of the remaining articles independently: ST 100%, MM 5%. Overall agreement was over 90%. Disagreements were discussed and settled by ST and MM, as well as with co-authors CH and K-CC.

Quality assessment

For researchers of integrative reviews and conceptual development, quality assessment is optional as the quality of studies has little or no bearing on concept development [ 53 , 59 ]. As such, there was no intention to exclude articles based on their quality. However, to understand the scientific context in which QI benefits are discussed, we assessed all empirical studies using specific quality assessment and reporting tools. For reviews, we used the  Critical Appraisal Skills Programme (CASP) tool [ 76 ], for mixed methods, we used the Mixed Methods Appraisal Tool (MMAT) [ 77 ], for implementation studies, we used Standards for Reporting Implementation Studies (STaRI) [ 78 ]. For economic evaluations, we used the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) [ 79 ], and for QI, we used the Standards for QUality Improvement Reporting Excellence (SQUIRE) tool [ 80 ]. As these are different tools, there was no single criteria to judge collective study quality. We therefore assessed the number of appropriate items reported or addressed as per respective study’s tool. We assigned good if 80–100% items were addressed, moderate if 50–79% of items were addressed, and poor if less than 50%.

Data extraction

Data extraction was performed using words and phrases in the preliminary conceptual framework as well as outcomes in the reviews search terms. We searched for these from all parts of an article where QI benefits, outcomes, and goals may be discussed. Articles were tabulated according to type of article, type of focus, country, setting, programme type, and outcomes discussed. The data collection tool can be found as Supplementary Table 2 .

Data synthesis and analysis

The synthesis and analysis section forms stages 5–7 of the integrative review process (integrate, synthesise, analyse). The synthesis, analysis, and framework development were performed iteratively by ST. All steps in the synthesis and analysis were discussed with co-authors CH and K-CC. We used the principle-based analysis method [ 55 ], to assess the maturity of the QI-ROI concept in healthcare literature. This involved asking four principle-based questions: 1) Epistemological principle: is the concept clearly defined and well differentiated from other concepts? 2) Pragmatic principle: is the concept applicable and useful within the scientific realm of inquiry? Has it been operationalised? 3) Linguistic principle: is the concept used consistently and appropriately within context? 4) Logical principle: does the concept hold its boundaries through theoretical integration with other concepts?

Once the ROI concept maturity was established, we followed Jabareen’s [ 53 ] conceptual framework development process. Jabareen describes a conceptual framework as “a network…of interlinked concepts that…provide a comprehensive understanding of a phenomenon or phenomena” (p.51). A framework was developed by identifying and naming concepts, describing concepts. Concepts were then categorised according to their ontological, epistemological, or methodological role. This was followed by synthesising, sense-making, and integration of similar concepts into one new concept, the QI-ROI. We also contextualise the ROI concept by highlighting how the concept is defined in the healthcare context, the alternative explanations afforded by the new concept which are not normally enabled by similar concepts, and the patterns in which the QI-ROI concept appear in the healthcare context [ 54 ].

A total of 10 428 articles were retrieved, 10 327 were excluded for various reason as seen in Fig.  2 . One hundred and two (102) articles were eligible, 34 were excluded and 68 included. Included articles were: Conceptual n  = 24, Quantitative n  = 19, including three economic evaluations (CEA n  = 1, Economic Impact n  = 1, ROI n  = 1) , Qualitative n  = 3, Mixed-Methods n  = 8, Systematic Reviews n  = 8 (2 economic; 1 SROI), Literature reviews n  = 2, Brief Report n  = 4, Thirty three of the excluded articles engaged a single department and/or discussed two or less QI outcomes/goals. Thirteen of these were collaboratives. There was one pre-print. A link to the excluded studies document is available on the supplementary files .

figure 2

PRISMA Flow-chart

Article characteristics

Included articles covered different healthcare levels and disciplines globally. Primary care included public health, child and maternal health, and mental health. Secondary or tertiary healthcare included mental health, medical and surgical care, critical care, accident and emergency and acute care services, paediatrics and neonatal care, outpatients, pharmacy, and laboratories. One article covered both health and social care, and another was about a charitable organisation. Global regions were Africa, Asia, Europe, Australia, and Canada, with the US and UK the mostly represented. The summary of included studies can be found in supplementary files (Supplementary Table 3 ).

Quality of studies

From the 68 articles, 30 were not subject to quality assessment. This included conceptual articles, unsystematic literature reviews, brief reports. Thirty eight articles were subject to quality assessment: 19 quantitative studies, three qualitative studies, eight mixed-methods studies, and eight systematic reviews. Of the 38, 39% reported or addressed 80%-100% all items required, 43% reported on 50%-79% the data required, and 18% reported below 50% of items by their respective reporting tool. Thirty out of thirty eight studies were primary studies. In these, there were three main areas of poor reporting and or poor rigour on all types of studies: ethics (29%), statistical analysis methods (75%), discussion of study limitations and their management (42%), integration of quantitative and qualitative data unclear (29%). Reporting of funding and affiliations missing on three of all 35 studies. Therefore, the quality of the studies was summed up as moderate. The quality assessment summary is available as Supplementary Table 4 .

Synthesis summary

Qi economically-focused literature.

Economically-focused literature were those articles whose specific focus was on either studying or discussing QI economic benefits. This made up 15 articles of the 68 QI literature. Amongst these were four conceptual literature, (three of which were business case discussions) [ 22 , 36 , 81 , 82 ], four QI evaluation frameworks [ 83 – 86 ], two systematic reviews of economic evaluations [ 87 , 88 ], one article discussed cost effectiveness of QI programmes [ 89 ], one article calculated an organisation’s QI related cost-savings [ 90 ], and two were economic evaluations [ 91 , 92 ]. One article discussed cost–benefit analysis [ 93 ]. Of the total 15 articles, ROI was a specific subject of only four [ 81 , 84 , 87 , 91 ].

Business case conceptual literature

Conceptual literature authors discussed QI business case development [ 22 , 36 , 81 , 82 ]. Their views were based on literature reviews, expert opinions, case studies, or all three. This literature were mostly sources of information for how to develop business cases that justify QI programme from a financial benefit perspective. However, they also highlighted multiple QI objectives and stakeholders. As such, there was a requirement to present QI outcomes as a monetised ratio, and or use of ROI as a financial performance measurement method [ 81 ]. However, this literature also highlighted multiple QI objectives as well as multiple stakeholders as QI beneficiaries.

ROI Frameworks

These authors advanced on the conceptual literature by developing QI business case frameworks that incorporate monetary and non-monetary benefits [ 83 – 86 , 93 ]. QI was seen to serve various organisational interests, for various internal and external stakeholders. As such, business case frameworks centred around these principles. Swensen et al. [ 86 ]focused on four organisational interests: patient’s needs, organisational reputation, pride, and financial returns. There was also an interest in organisational productivity and efficiency. Bailit and Dyer [ 83 ], described 10 business case arguments that combine financial, strategic, and internal organisational objectives.

Shah and course [ 85 ] had a six category framework containing three as financial measures (revenue, cost-reduction cost-avoidance) and one measure for patients, family and carers experience, and one for staff experience, and lastly one for productivity and efficiency. Financial objectives and outcomes included cost-avoidance such future legal costs [ 86 ]. Internal outcomes also included capacity building, whilst external outcomes examples included market share [ 84 – 86 ].

QI economic evaluation literature

There were three economic evaluations [ 89 , 91 , 92 ], and two systemic reviews of QI economic evaluations [ 87 , 88 ]. By the virtue of their study foci, their measure of ROI was the monetary. These authors saw savings as an important QI outcome, however also discussed a wide range of QI benefits. For example, Crawley-stout et al. [ 91 ] considered internal outcomes (e.g., cost-reduction, productivity, and time savings) and external benefits (e.g., patient costs and carer time). Crawley-stout et al. described ROI as a performance measure used to evaluate investment efficiency in financial terms. de la Perrele et al. reported a lack of QI economic evaluations in their review. They concluded that collaboratives are potentially cost-saving. However, they found that studies used variable methods to assess cost and effectiveness, and that studies did not report negative findings. They recommended that future research should include societal perspectives of costs and savings [ 88 ]. Banke-Thomas et al. stated that SROI (a societal version of ROI) can be used across healthcare [ 87 ]. However, there were challenges with inadequate skills for ROI evaluation, lack of credible financial proxies, a lack of consensus on; who to include as beneficiaries, how to account for counterfactual and appropriate study-time horizon [ 87 ].

QI non-economically focused literature

These made up 53 [ 94 – 147 ] of the selected 68 articles. These articles included QI effectiveness, process, and impact evaluations as well as discussions of QI achievements over time e.g., [ 94 , 110 , 116 , 117 , 130 , 138 ]. These articles did not focus on ROI or economic measures, but nonetheless highlighted financial outcomes as important benefits for consideration. Some QI implementation studies assessed their implementation costs [ 109 , 140 , 145 ], as part of their study reporting guidelines [ 78 , 148 ]. Authors here also discussed improving QI effectiveness determinants such as staff and safety culture development. Authors discussed or mentioned financial value or benefit, financial returns or outcomes, cost savings, reduction, containment, and economic impact, as well as productivity, efficiency, value, and benefits. Of these, cost-saving was the most frequently used term. These articles considered ROI as one of many organisational outcomes [ 103 , 130 , 135 ].

There were three QI evaluation frameworks [ 103 , 104 , 124 ]. These frameworks also considered various elements of organisational benefits. Chow-Chua and Goh [ 103 ] combined existing organisational performance tools; the Singapore Quality Award (SQA) model (modelled after Baldrige Award) and balanced scorecard (BSC) to develop a performance and quality improvement evaluation framework for hospitals. Four strategic components were seen as crucial: the drivers of QI (e.g., leadership), internal performance, knowledge management, and QI outcomes. McLees et al.’s [ 124 ] framework for QI in public health was described as a performance management tool, and focused on two key constructs: efficiency and effectiveness. Ciarniene et al.’s [ 104 ] framework envisioned broad value creation through QI.

Integrated synthesis

Morganti et al. [ 126 ] remarked that there is a lack of an agreed concept of QI success, and by extension, ROI. This was seen in how authors gave priority to certain outcomes. Van den Heuwel et al. [ 141 ] for an example, referred to quality improvement as business improvement, viewed ROI quantitatively, and expected quality improvement to be a valuable “side effect” of value improvement (often a euphemism financial improvement). Alternatively, others proclaimed to value patient safety and quality first, and saw financial matters as the valuable “side-effect” of QI [ 85 ]. Hunter et al. [ 116 ] considered “cost savings or increased efficiency “helpful by-products” (p. 129).

Swensen et al. [ 86 ] QI business case discussion stated that their QI investment decisions were never based purely on positive ROIs but on broader qualitative considerations. A similar view was held by O’Sullivan et al. [ 130 ] and Shah and Course (2020). Bailit and Dyer [ 83 ], advocated for broad business cases that embrace different rationales for QI investment. Fischer and Duncan [ 36 ] stated that some interventions are purely designed to produce health outcomes. They also called for a broader QI outcome definition that acknowledges the utility of differing projects and value for all stakeholders. The review also indicated that even failed goal attainment can be useful in providing insights and legacies like building capacities and safety cultures [ 94 , 110 , 116 , 117 , 130 , 138 , 146 ].

Overall, financial outcomes were not the primary or commonly sought goal or addressed outcome. However, it was seen as directly or indirectly significant by the majority of the authors. The perception that QI is an expense used for revenue generation was seen to be due to faulty assumptions by some authors [ 86 ]. For example, authors suggested that profit-seeking through QI first emerged as an optional strategy to increase revenue and market-shares by for-profit healthcare organisations [ 22 , 83 , 86 ]. However, grey areas on views existed and views appear to have shifted towards integrating or emphasising non-monetary outcomes over time. The literature also agreed that QI does not always save cost, and financial outcomes are not the only organisational objectives [ 22 , 36 , 82 , 83 , 89 , 93 ]. These literatures portrayed ROI as any value or benefit from QI for various stakeholders.

The reviewed literature illustrated five main ROI uses related to QI: ROI as 1) a strategic business case development tool, 2) an investment performance measure, 3) a comparative evaluation tool, 4) a cost management tool, and 5) a performance management tool. ROI was also used to create fiscal awareness [ 81 ]. Some of this ROI use was similar to commercial ROI use. Various concepts were used to denote a return-on-investment. These concepts were used in relation to changes and improvements in various organisational outcomes including patients, staff, financial, and overall organisational development. Both economic and non-economic focused literature used almost identical concepts to denote an investment and a return as seen in Fig. 3 .

figure 3

ROI-like concepts

However, profit, revenue, and market share were mainly found in the few economic focused literature. The majority of literature put greater emphasis on non-monetary QI benefits. This indicates that although different logics were applied in the conceptualisation of healthcare QI-ROI, the dominant logic was that of health and social care and not economics or markets.

At face value, there were two broad QI-ROI philosophies: the economic and the healthcare ROI philosophies. However, our synthesis indicated a merging meaning of ROI from different schools of thought. Through markets logic, the economic philosophy perspective views outcomes in terms of their tangible, quantitative, or financial offerings. The economic philosophy is related to managerial logics as managers’ roles require them to monitor organisational financial performance. Alternatively, the healthcare perspective suggested a more dulled though increasing financial focus. Healthcare logics (medical, societal) tended to view ROI qualitatively, primarily from a patient and staff perspectives but also wider internal and external stakeholders. The integrated literature indicated that healthcare leaders value these perspectives too. Table 4 illustrates this finding.

Although concept analysis, concept development, and conceptual framework development are traditionally separate steps [ 55 ], they have been performed concurrently in this review. Firstly, we sought to understand the nature of the ROI concept in healthcare QI. Using the Hupcey and Penrod [ 55 ] principle-based concept analysis method, we found that the QI-ROI concept is not clearly defined or developed (principle 1), the ROI application method is unclear (principle 2), its appropriate use is unestablished (principle 3), and conceptual boundaries are unclear (principle 4). These determinations answered the first part of our research question; the nature of the ROI concept in healthcare QI.

We then sought to answer the second part of our research question; the definition of the QI-ROI concept and its relationship with similar concepts. We did this by following the concept development and conceptual framework development guide described earlier by Hupcey and Penrod [ 55 ], and Jabareen [ 53 ]. Our review confirmed that various concepts and terms are used to denote returns or investment vs returns in healthcare QI. Some of these concepts (e.g., CEA, CBA, value) were identified in the background literature and used as the review’s search terms. These concepts, including the differences between costs, investments, and revenue have been discussed in more details in economic literature (e.g., [ 61 , 149 – 151 ]. We refer interested readers to such text for nuanced descriptions.

QI-ROI concept development

To develop the QI-ROI concept, we first eliminated similar concepts by differentiating QI-ROI from other ROI-like concepts and terms. To start with, financial or economic returns are alternative ways of saying ROI [ 60 ]. Other terms used to a lesser extent in the review were economic impact, which denotes only the cost of illness [ 152 ], and cost management which is a process of managing and controlling costs of a programme to fit desired criteria, e.g., to reduce costs [ 153 ]. Cost-reduction is described as resulting from providing the same or better quality for a lower cost, through new ways of working that eliminate waste ([ 178 ], p.4). Cost avoidance is cost-reduction related to preventing future costs [ 178 ]. Very few articles mentioned profit or revenue. Publicly funded healthcare such as the UK NHS does not customarily engage in profit-making. Net profit is what remains after all expenses have been subtracted from net revenue (income generated minus costs). The remaining concepts: SROI, cost–benefit, cost-effectiveness, productivity, efficiency, value, and benefit were seen as the most mimicking ROI. These concepts have varying degrees of association with ROI depending on the ultimate objective sought through a QI programme.

(1a) ROI vs other economic evaluation methods

In health economics, cost-effectiveness is assessed using CEA and whilst costs-benefits are assessed using CBA. CEA and CBA goals are to ensure that fixed allocated quantity of healthcare resources result in most health outcomes improvement (CEA) or maximum social advantage (CBA) [ 61 ]. CEA and CBA denote cost vs goal achievement. Although conceptually different, in practice, researchers do conflate the different types of evaluation [ 154 , 155 ] or see them as interchangeable [ 60 ]. Comparative ROI mimics CEA, but ROI reports an aggregated cost–benefit metric similar to CBA’s cost–benefit ratio (CBR). Alternatively, CEA reports an incremental cost-effectiveness ratio (ICER) per health outcomes. Incremental benefits using ROI of new QI programmes have been compared by some researchers [ 156 , 157 ]. However, given the multiple healthcare objectives, these metrics represent only a fraction of programme benefits or consequences [ 15 ]. This point is supported by the current literature review.

CBA is the basis of ROI and SROI. SROI and CBA are monetisation of broad programme benefits and costs such as societal costs and benefits. SROI extends CBA by including environmental and other stakeholder benefits [ 37 ]. Alternatively, ROI generally focuses on programme specific costs and benefits from a managerial perspective [ 9 , 16 ]. As returns-on-investments evaluation methods, CEA, CBA, SROI, and traditional ROI are too narrowly focused as they all ultimately only emphasise monetary focus. According to Bridges [ 101 ], CBA, does not account for how care is produced, and thus excludes many crucial organisational outcomes. Bridges suggested that what is needed is a systematic value assessment approach.

(1b) ROI vs input–output based measures

CEA, CBA, productivity, and efficiency are similar as their goals are using resources without waste. However, they are all a single focus outcomes. CEA/CBA are an input vs goal measures, efficiency and productivity are input vs output measures. Productivity and efficiency are ROI-like as they denote a return (output) of an investment (input) [ 158 ]. Inputs and outputs may be both monetary and non-monetary. Productivity is the quantity of outputs per investment/input. Efficiency is achieving those outputs with least or no waste (e.g., in time, money, effort). Therefore, unlike CBA and CEA, efficiency and productivity are related to exactly how care is produced. For example, increasing productivity by increasing patients seen (output) per clinician (input), whilst providing quality care without wasting resources (efficiency).

Efficiency is divided into allocative, productive, and technical efficiency [ 61 ]. Simply put, allocative efficiency refers to allocation of healthcare resources such that the most benefits are delivered [ 159 ]. Productive efficiency is increasing output per given resource/input/investment (e.g., seeing more patients by same staff member). If this is done such that more is obtained from the same resource, or less resource is required for the same output, it is technically efficient [ 151 ]. This description also fits CEA, with outputs being effectiveness. It also mimics the concept of value-for-money (VfM), used to describe the optimal balance between efficiency, economy (lowest cost), and effectiveness [ 60 ]. Efficiency and productivity are crucial in healthcare as profit-based ROI is deemed improbable [ 160 ]. Efficiency can translate to both monetary ROI (e.g., savings), and non-monetary benefits (e.g., improved staff work experience).

Productivity and efficiency are often used to measure performance of healthcare organisations [ 150 , 158 ]. Productivity may enable allocative efficiency of funds or better time allocation for tasks by staff. Productivity can be an efficiency measure (input/output) [ 158 ]. It can also be a combined effectiveness and efficiency measure (goal/input/output), or of all that makes an organisation function better [ 150 ]. The latter is what the reviewed literature indicated QI-ROI to be. Effectiveness through attainment of goals alone is therefore also insufficient to describe QI-ROI. Goals may be achieved, but inefficiently. In a balanced productivity-efficiency-effectiveness relationship, all three contribute to the overall QI-ROI [ 161 ]. This may then mean avoiding, reducing, and containing costs, and thus saving costs.

(1c) ROI vs cost saving

Cost-saving is also a more likely outcome than hard-cash profit in healthcare QI [ 16 ]. Cost-saving was a particularly prevalent term in the reviewed literature and ROI in healthcare has been called savings [ 21 ]. The current desire to save costs is thought to have driven the change in focus from  cost-effectiveness studies to ROI [ 162 ]. Cost-saving means saving money that would have otherwise been spent. Savings (time/money) often result from better efficiency and productivity. Similar terms such as cost-containment, cost-minimisation, cost-avoidance, cost-reduction are also not seen here as complete representations of QI-ROI. Here, these terms are seen as representing outputs, initial or intermediate outcomes that lead to savings. These terms (including cost-management) can also be processes or abilities that enable cost-saving or profit-making. Together, these terms refer to mechanisms (or processes that enable an outcome) [ 163 ] through which long-term financial ROI may be achieved. Alternatively, some may see these initial outcomes as benefits themselves.

QI-ROI framework development

For some organisations, initial outputs and intermediate outcomes may be the intended outcomes and therefore may represent a form of ROI. In Phillips et al. [ 16 ] for example, productivity and efficiency were viewed as final intended outcomes of improvements. In other instances, cost-effectiveness may be the intended goal. Often in healthcare the ultimate objective is to achieve higher goals, such as financial stability. In such cases, implementing QI leads to change and development and possibly improvement in desired outcomes. Improvement may result in improved productivity and efficiency. This in turn improves abilities to better avoid, reduce, or manage costs, leading to savings, and potentially monetary ROI. All of this is a benefit in and of itself. Monetary ROI depends on each output, ability, or outcome, most of which is non-monetary. This conceptualisation of QI-ROI is illustrated in Fig.  4 below.

figure 4

QI-ROI conceptual framework

The QI-ROI conceptualisation can be translated as follows: value is any outcome seen to be of importance, utility, or usefulness [ 64 ]; attaining a return-on-investment whatever that/those are, is valued and therefore of benefit. A benefit is any outcome that produces useful, helpful, or advantageous outcomes [ 164 ]. Any benefit is of value in of itself. Based on this review, a fuller description of QI-ROI is suggested as follows: QI-ROI is any value or benefit (or any valued benefit) derived from or contributed to by QI programmes. This value or benefit maybe in a form of an improved output, process, ability, outcome, and or overall impacts, depending on an organisation’s values and objectives.This description reflects the Healthcare Financial Management Association (HFMA), NHS England, and NHS Improvement (NHSE&I)'s view. The NHSE&I differentiates from cash-releasing benefits that enable resource allocation, and non-cash-releasing benefits that provide economic benefit, without releasing cash [ 178 ].

This definition is different from that which supports the economic logics. For example, Phillip et al. [ 16 ], and Solid [ 9 ] who discussed value and ROI as separate (presumed to mean non-monetary and monetary value). Here, only monetary value is seen as ROI. This assertion is based on viewing ROI as a purely quantitative metric. However, Solid’s writing also refers to value as being subjective (p. 5). The definition of ROI concept as any benefit may be deemed an abuse of ROI [ 16 , 29 ]. However, this definition was based on the review of numerous healthcare stakeholders’ views. This may be an indication that new constructive conversations about how to integrate economic and accounting concepts in healthcare are needed [ 57 , 165 ]. After-all, value was not always seen as a ratio between perceived benefits and perceived costs [ 166 ]. It was initially viewed as multi-dimensional by earlier economic scholars [ 57 , 166 – 168 ]. Therefore, other QI programme effects that are regarded as valuable must not only be considered [ 61 ], but prioritised where appropriate.

The view of QI-ROI in healthcare as a broad and no-specific concept, encompassing both monetary and non-monetary outcomes, opens ROI to being a context-specific and dynamic concept. This is in-line with the moderate ontological expectations of modern concepts [ 54 , 55 ]. This suggests abilities to compromise and accommodate varied logics that govern healthcare [ 169 ]. The concepts of ROI, value, and benefit, denote the beliefs about what is a true return, value, or benefit (Ontology) as well as what seen as a moral good (Axiology) in healthcare QI. As such, the QI-ROI can be seen as a value-based ROI. Traditional ROI is a monetary measure (Realism), benefits in general tend to be described as non-monetary (Relativism), and value can denote either a monetary or a non-monetary outcome (Critical Realism). These beliefs then influence how evidence is created, viewed, and studied (Epistemology and Methodology) [ 53 ].

The lack of convincing vocabulary to argue against the logics of the markets in healthcare was seen as the limiting factor by Bozeman [ 170 ]. In the current review this has also been demonstrated. In non-economic literature, financial outcomes mentions appeared to be nebulous, or in general use of terms as in everyday language. Authors here focused on non-monetary outcomes. They discussed aspirations to raise fiscal awareness and encourage financial outcomes focus on QI evaluations. This can be contrasted with economic focussed literature where for example, economic evaluations referred to ROI as a specific scientific quantitative measure. Traditional ROI is portrayed as a rational  measure of objectively assessed inputs leading to objective outputs [ 171 ]. This suggests that the scientific language of healthcare stakeholders for ROI is currently underdeveloped. It reflects general challenges of legitimising and aligning qualitative benefits with specific scientific measures that are seen as valid and trusted [ 48 ].

The QI literature discussed the use of ROI in several ways, including to create fiscal awareness. Such a use for ROI was noted by Botchkarev & Andru [ 29 ] in their analysis of ROI definitions. Their typology included the use of ROI as a persuasive device to gain credibility for a desired programme [ 9 ]. Healthcare leaders need credible recourse or language to articulate large-scale QI benefits [ 85 , 170 ]. If we accept that reality is socially constructed, then we can view various logics as both coercive and emancipating [ 41 ]. That is, although political and market logics may constrain freedoms of local expressions, the mere tendency for humans to create their own meanings has potential to liberate from such constraints. Logics ‘in situ’ provide symbolic systems and vocabularies for expression. Hence, the prevailing logic both shapes and is shaped by contexts. Scientifically developing concepts for healthcare is essential to support this.

Establishing ways of expressing QI-ROI from healthcare programmes is crucial to avoid missing opportunities for essential healthcare improvements [ 30 ]. Additionally, insisting on inflexible use of a certain (ROI) policy may lead to data manipulation in bids to increase credibility [ 172 , 173 ]. The view of ROI as both monetary and non-monetary benefits reflects the multi-stakeholder healthcare context. The lean towards non-monetary benefits is influenced by persistent healthcare and societal logics [ 11 , 23 , 47 ]. These logics emphasise relief of suffering and ethical principles such as beneficence (benefiting others) and non-maleficence (do no harm) [ 174 ]. It is therefore important to differentiate ROI as concept and as a metric. A concept is more than a metric, it encapsulates mental abstractions about how it is perceived by those using it and influences the decisions that then may follow [ 175 ].

Strengths and limitations

This review has a few strengths and limitations. Concept analysis, concept development, and conceptual framework development are traditionally separate steps [ 55 ], unlike in this review. It is however accepted that these processes are intertwined [ 55 ]. However, we based our analysis on intensive background reading as well as a large review of different QI literature. This enabled us to gain some understanding of the current “state of the science” [ 55 ] surrounding the ROI concept as used in healthcare QI. We then followed a well-recognised Hupcey and Penrod [ 55 ], and Jabareen [ 53 ] development process to start to develop the concept QI-ROI in healthcare.

Secondly, productivity and efficiency proved to be crucial parts of the QI-ROI concept. These concepts were not included as search terms, however the large amount of literature retrieved means that it is unlikely that this made a significant difference in the review. Alternatively, it could be argued that our inclusion of specific ROI-like concepts in our search terms constitutes sampling bias. However, this strategy helped identify relevant literature for a more in-depth review. Thirdly, a significant amount of the literature reviewed was non-empirical in nature. Although this literature lacks a scientific focus, it was nonetheless very insightful in understanding the nature of the QI-ROI concept. Fourthly, some of the literature is quite dated, however newer literature suggest continuance of some trends and issues in QI-ROI and business case development. Lastly, subjectivity in the synthesis and analysis cannot be ruled out. As Parkinson et al. [ 176 ] put it “…findings are a consequence of intersubjective meaning-making through imagination, interpretation, and conceptual input…” (p15).

Implications for research and practice

Implementation and Improvement Sciences are faced with the challenge of developing the ROI concept that is theoretically sound, and scientifically valid. This means a QI-ROI framework must clearly isolate constructs that can and should be included in an evaluation tool. The development of the QI-ROI concept and its conceptual framework must also ensure it is fit for purpose by incorporating both monetary and non-monetary benefits. This means finding more innovative and accessible ways for evaluating the QI-ROI aspects that are hard to measure and or monetise. Developing the QI-ROI concept in this way will enable the field to progress and take ownership in QI fiscal matters, and leaders to justify investments. This is crucial as justification for investment is unavoidable and necessary in the current economic climate.

The review indicated that the use of reporting tools is having a positive effect on the quality of QI studies. However, there remains room for improvement. QI researchers have a responsibility to show more transparency on ethical aspects of their studies. QI studies may not require ethical permissions, and if so, it must be stated as such. Current QI reporting tools allow for this [ 78 , 148 ]. QI studies must also be clear about their statistical analysis methods use. Another area of improvement is the integration of qualitative and quantitative data in their analysis. This is important in strengthening research findings [ 177 ]. Further, reporting of study limitations was limited in the reviewed literature. The knowledge of QI implementation or research challenges can help arm other researchers and field practitioners in their QI initiatives. This is crucial for developing a stronger evidence-base as we develop the QI-ROI concept.

Return-on-investment is an important tool with great potential to communicate QI benefits not covered by CEA and CBA. However, in its traditional form, ROI does not take advantage of this potential use. Ignoring the paradoxes contained within the traditional ROI use in healthcare may continue to keep ROI in the fringes of QI evaluation or cause conflict amongst stakeholders if enforced. Therefore, continued application of ROI must be based on its conceptualisation within healthcare QI and must be grounded on scientific inquiry that considers relevance to practice and policy. If QI-ROI is developed in this way, its legitimacy within healthcare stakeholders may be established and increased. In this review, we have begun to unpack what ROI is and means for healthcare stakeholders in QI at the organisational level. We hope to continue to develop this framework into a practical tool that is meaningful to its users: the QI teams and healthcare leaders, and QI investors.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Some data has been included in this article as its supplementary information files.

Change history

22 december 2022.

A Correction to this paper has been published: https://doi.org/10.1186/s12913-022-08978-0

Abbreviations

  • Quality Improvement

Return on Investment

Social Return on Investment

Return on Investment from healthcare quality improvement

Cost Effectiveness Analysis

Cost Utility Analysis

Cost Benefit Analysis

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Acknowledgements

The authors would like to acknowledge Professor Judith E. Hupcey for her advice on concept development. The authors would also like to thank Mr Andy Healy for his advice on economic evaluation.

This work is supported by the Economic and Social Research Council, grant number ES/P000703/1. TS is supported by the Welcome Trust (219425/Z/19/Z) and Diabetes UK (19/0006055).

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Two reviewers ST and MM worked independently under the guidance of co-authors CH and KC-C. MM reviewed 5% of articles from search to synthesis, and ST 100% of all stages. Agreement in the co-review stages was over 90%. The synthesis and analysis was performed iteratively by ST. All steps in the synthesis and analysis were discussed with co-authors CH and K-CC. Any disagreements were discussed with N.N, B.G, T.S and KC-C, and C.H. S.T wrote the manuscript, compiled all the tables and figures in this manuscript. All authors advised, reviewed, and approved the development of this manuscript, its tables, and figures.

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TS received funding from Cancer Alliance and Health Education England for training cancer multidisciplinary teams (MDTs) in assessment and quality improvement methods in the United Kingdom. TS received consultancy fees from Roche Diagnostics. The other authors declare that they have no competing interests.

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Thusini, S., Milenova, M., Nahabedian, N. et al. The development of the concept of return-on-investment from large-scale quality improvement programmes in healthcare: an integrative systematic literature review. BMC Health Serv Res 22 , 1492 (2022). https://doi.org/10.1186/s12913-022-08832-3

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Healthcare Technologies and Space: Therapeutic Built Environment as a Health Technology and Technologies for Improved Healthcare Settings

Designing Chinese Hospital Emergency Departments to Leverage Artificial Intelligence -A Systematic Literature Review on the Challenges and Opportunities Provisionally Accepted

  • 1 Bartlett School of Sustainable Construction, Bartlett Faculty of the Built Environment, University College London, United Kingdom

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Artificial intelligence (AI) has witnessed rapid advances in the healthcare domain in recent years, especially in the emergency field, where AI is likely to radically reshape medical service delivery. Although AI has substantial potential to enhance diagnostic accuracy and operational efficiency in hospitals, research on its applications in Emergency Department building design remains relatively scarce. Therefore, this study aims to investigate Emergency Department facility design by identifying the challenges and opportunities of using AI. Two systematic literature reviews are combined, one in AI and the other in sensors, to explore their potential application to support decision-making, resource optimisation and patient monitoring. These reviews have then informed a discussion on integrating AI sensors in contemporary Emergency Department designs for use in China to support the evidence base on resuscitation units, emergency operating rooms and Emergency Department Intensive Care Unit (ED-ICU) design. We hope to inform the strategic implementation of AI sensors and how they might transform Emergency Department design to support medical staff and enhance the patient experience.

Keywords: AI, Design, emergency department, literature review, Sensors

Received: 04 Oct 2023; Accepted: 08 Mar 2024.

Copyright: © 2024 Tan and Mills. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Grant Mills, Bartlett School of Sustainable Construction, Bartlett Faculty of the Built Environment, University College London, London, WC1E 6BT, England, United Kingdom

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  1. How to 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.

  2. Writing a Literature Review

    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 ...

  3. The Literature Review: A Foundation for High-Quality Medical Education

    The literature review is a crucial step for conducting high-quality research, but it can be challenging and time-consuming. This article provides a comprehensive guide for conducting a literature review, covering the types, purposes, methods, and quality assessment of literature reviews. It also offers practical tips and examples for researchers and students who want to improve their ...

  4. Literature Reviews

    A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period. A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis.

  5. Literature Review: The What, Why and How-to Guide

    What kinds of literature reviews are written? Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified.

  6. Writing a literature review

    A formal literature review is an evidence-based, in-depth analysis of a subject. There are many reasons for writing one and these will influence the length and style of your review, but in essence a literature review is a critical appraisal of the current collective knowledge on a subject. Rather than just being an exhaustive list of all that ...

  7. What are the parts of a Literature Review?

    In a stand-alone literature review, this statement will sum up and evaluate the current state of this field of research; In a review that is an introduction or preparatory to a thesis or research report, it will suggest how the review findings will lead to the research the writer proposes to undertake. Body Purpose:

  8. Literature Review Overview

    A literature review discusses published information in a particular subject area. Often part of the introduction to an essay, research report or thesis, the literature review is literally a "re" view or "look again" at what has already been written about the topic, wherein the author analyzes a segment of a published body of knowledge through summary, classification, and comparison of prior ...

  9. LibGuides: Scholarly Articles: How can I tell?: Literature Review

    The literature review section of an article is a summary or analysis of all the research the author read before doing his/her own research.This section may be part of the introduction or in a section called Background. It provides the background on who has done related research, what that research has or has not uncovered and how the current research contributes to the conversation on the topic.

  10. How to Write a Literature Review: Six Steps to Get You from ...

    Step One: Decide on your areas of research: Before you begin to search for articles or books, decide beforehand what areas you are going to research. Make sure that you only get articles and books in those areas, even if you come across fascinating books in other areas. A literature review I am currently working on, for example, explores ...

  11. 5. The Literature Review

    A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories.A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that ...

  12. What Is A Literature Review?

    The word "literature review" can refer to two related things that are part of the broader literature review process. The first is the task of reviewing the literature - i.e. sourcing and reading through the existing research relating to your research topic. The second is the actual chapter that you write up in your dissertation, thesis or ...

  13. How To Structure A Literature Review (Free Template)

    Demonstrate your knowledge of the research topic. Identify the gaps in the literature and show how your research links to these. Provide the foundation for your conceptual framework (if you have one) Inform your own methodology and research design. To achieve this, your literature review needs a well-thought-out structure.

  14. Writing a literature review

    Writing a literature review requires a range of skills to gather, sort, evaluate and summarise peer-reviewed published data into a relevant and informative unbiased narrative. Digital access to research papers, academic texts, review articles, reference databases and public data sets are all sources of information that are available to enrich ...

  15. How To Write A Literature Review

    The literature review is a critical part of research papers because it helps you: ... or articles in the literature review. 3. Examine and assess the sources. It is nearly impossible for you to go through every detail in the research article. So rather than trying to fetch every detail, you have to analyze and decide which research sources ...

  16. 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.

  17. Ten Simple Rules for Writing a Literature Review

    Literature reviews are in great demand in most scientific fields. Their need stems from the ever-increasing output of scientific publications .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 .Given such mountains of papers, scientists cannot be expected to examine in detail every ...

  18. Approaching literature review for academic purposes: The Literature

    Therefore, this paper discusses the purposes of LRs in dissertations and theses. Second, the paper considers five steps for developing a review: defining the main topic, searching the literature, analyzing the results, writing the review and reflecting on the writing. Ultimately, this study proposes a twelve-item LR checklist.

  19. Components of the Literature Review

    Literature Review. This is the most time-consuming aspect in the preparation of your research proposal and it is a key component of the research proposal. As described in Chapter 5, the literature review provides the background to your study and demonstrates the significance of the proposed research. Specifically, it is a review and synthesis ...

  20. What is a Literature Review?

    What's a Literature Review? The straightforward answer is that a literature review is a review or synthesis of all the research published on a certain topic. But I'd rather explain it from a skateboarder's perspective: One of my favorite movies is the 1989 classic Back to the Future Part 2 where the bodacious skater Marty McFly time-travels to the future and sees a hoverboard.

  21. Literature review as a research methodology: An ...

    The data analysis part of an integrative or critical review is not particularly developed according to a specific standard (Whittemore & Knafl, 2005). However, while there is no strict standard, the general aim of a data analysis in an integrative review is to critically analyze and examine the literature and the main ideas and relationships of ...

  22. Literature Review: Conducting & Writing

    Steps for Conducting a Lit Review; Finding "The Literature" Organizing/Writing; APA Style This link opens in a new window; Chicago: Notes Bibliography This link opens in a new window; MLA Style This link opens in a new window; Sample Literature Reviews. Sample Lit Reviews from Communication Arts; Have an exemplary literature review? Get Help!

  23. A review of the global climate change impacts, adaptation, and

    This review-based article followed systematic literature review techniques that have proved the literature review as a rigorous framework ... As southern parts are generally warmer than their counterparts, it is evident from this example how CC-induced global warming can augment the spread of antibiotic-resistant strains within the biosphere ...

  24. The impact of behavioural risk factors on communicable diseases: a

    Addressing behavioural risk factors should be an important part of work to build resilience against any emerging and future epidemics and pandemics. ... This work identified several gaps in the current systematic review literature relating to specific behavioural risk factors and common communicable diseases, including studies examining the ...

  25. Managing logistics in sport: a comprehensive systematic literature review

    A literature review can be part of a broader methodology or can be the methodology itself (Cooper 1998, pp. 3-4). A research article could therefore contain a literature review but might have a main objective in opposition to the literature review as a focus not only on reflecting the current state of the art but also on establishing a new or ...

  26. Full article: Misinformation, disinformation, and fake news: lessons

    As part of a broader societal trend, ... Review articles were identified more rarely, but still account for 90 (7.1%) of the articles in our sample (e.g. Arqoub et al., 2020; ... Summing up, this systematic literature review shows that research on misinformation, disinformation, and fake news is a highly interdisciplinary field that has ...

  27. Declining global fertility rates and the implications for family

    A narrative review of the existing literature was performed by invited global leaders who themselves significantly contributed to this research field. Each section of the review was prepared by two to three experts, each of whom searched the published literature (PubMed) for peer reviewed full papers and reviews.

  28. Chapter 9 Methods for Literature Reviews

    Literature reviews play a critical role in scholarship because science remains, first and foremost, a cumulative endeavour (vom Brocke et al., 2009). As in any academic discipline, rigorous knowledge syntheses are becoming indispensable in keeping up with an exponentially growing eHealth literature, assisting practitioners, academics, and graduate students in finding, evaluating, and ...

  29. The development of the concept of return-on-investment from large-scale

    Background Return on Investment (ROI) is increasingly being used to evaluate financial benefits from healthcare Quality Improvement (QI). ROI is traditionally used to evaluate investment performance in the commercial field. Little is known about ROI in healthcare. The aim of this systematic review was to analyse and develop ROI as a concept and develop a ROI conceptual framework for large ...

  30. Frontiers

    This article is part of the Research Topic. Healthcare Technologies and Space: Therapeutic Built Environment as a Health Technology and Technologies for Improved Healthcare Settings ... Designing Chinese Hospital Emergency Departments to Leverage Artificial Intelligence -A Systematic Literature Review on the Challenges and Opportunities ...