literature reviews in social care

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Doing a Literature Review in Nursing, Health and Social Care

• Michael Coughlan - Trinity College Dublin, Ireland
• Patricia Cronin - Trinity College Dublin, Ireland
• Description

A clear and practical guide to completing a literature review in nursing and healthcare studies.

Providing students with straightforward guidance on how to successfully carry out a literature review as part of a research project or dissertation, this book uses examples and activities to demonstrate how to complete each step correctly, from start to finish, and highlights how to avoid common mistakes.

The third edition includes:

• Expert advice on selecting and researching a topic
• A chapter outlining the different types of literature review
• Increased focus on Critical Appraisal Tools and how to use them effectively
• New real-world examples presenting best practice
• Instructions on writing up and presenting the final piece of work

Perfect for any nursing or healthcare student new to literature reviews and for anyone who needs a refresher in this important topic.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

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Praise for the previous edition:

'This book is an excellent resource for practitioners wishing to develop their knowledge and understanding of reviewing literature and the processes involved. It uses uncomplicated language to signpost the reader effortlessly through key aspects of research processes. Practitioners will find this an invaluable companion for navigating through evidence to identify quality literature applicable to health and social care practice.' 

'Students often struggle with writing an effective literature review and this invaluable guide will help to allay their concerns. Key terms are clearly explained, and the inclusion of learning outcomes is a helpful feature for students and lecturers alike.  The examples are also very helpful, particularly for less confident students.  This is an accessible yet authoritative guide which I can thoroughly recommend.' 

'A must have - this book provides useful information and guidance to students and professionals alike. It guides the reader through various research methods in a theoretical and pragmatic manner.' 

' It's a very readable, concise, and accessible introduction to undertaking a literature review in the field of healthcare. The book’s layout has a logical format which really helped me to think methodically about my research question. An excellent reference for undergraduates who are about to undertake their first literature review.' 

'This book is an essential resource for students. Clearly written and excellently structured, with helpful study tools throughout, it takes the reader step by step through the literature review process in an easy, informative and accessible manner. This text gives students the skills they need to successfully complete their own review.' 

'The updating of the chapters will be exceptionally helpful given the rapid changes in online availability of resources and open-access literature.'  

Excellent resource. Useful for any stage of studying

Excellent text for masters and doctoral level students

An excellent primer to help the level 7 students write their systemised review for the assignment.

This book provides a comprehensive overview of the practical process of literature review in healthcare. It contains all details required to conduct a review by students.

This is an excellent clear and concise book on undertaking literature reviews being particularly good at demystifying jargon. It is timely given the move to student dissertations being primarily literature reviews in the current Covid pandemic. However nearly all the examples are drawn from nursing and health making the text less useful for social care and social work. A little disappointing given the title. SW students are likely to gravitate to texts where their subject is more prominent for a primary text.

Accessible, informative, step to step guide

This is a really helpful, accessible text for students and academic staff alike.

A really good addition to the repertoire of skills and techniques for understanding the essential process of literature reviewing.

Health and Social Care

• Getting Started
• Journals & Databases
• NHS Scotland Knowledge Network
• Literature Reviewing

Literature reviewing - the overview

• What is a literature review?
• How are literature reviews relevant to health and social care?
• Types of Literature Review
• Reporting and Conducting Guidance
• What's in a good literature review?
• Common mistakes?

A literature review:

• Finds existing literature/sources published on a specific topic/to answer a review question.
• Brings together the literature sources into a single body of literature.
• Makes comparisons between the different included sources to identify both patterns/similarities and conflicts/differences.

Within healthcare literature reviews are often known as 'evidence synthesis reviews' and usually have specific methods and processes which are detailed in more depth in the section below titled 'Literature reviewing - the process'. This can differ from other field areas so if you have not done a healthcare evidence synthesis review before you may find it very different to previous expectations or experiences.

There are also a number of different types of evidence synthesis reviews within healthcare and the type of review impacts the purpose and methods. The next tab gives more information about different types of review. If you are doing a review as part of an academic assignment then please ensure you follow the requirements and any methods set out in your assignment brief.

Taking a Systematic Approach

Within healthcare evidence synthesis reviews there is an expectation that the approach taken, no matter what type of review is being done, is systematic. Whilst a systematic review is a specific review type, any review type can still take a systematic approach which strengths the quality of the methods, and therefore also strengthens the quality of the findings, write up, and usefulness/applicability of the review.

• Wakefield, A.(2014). Searching and critiquing the research literature. Nursing Standard, 28(39), 49-57
• Kable, A. K., Pich, J., & Maslin-Prothero, S. E. (2012). A structured approach to documenting a search strategy for publication: a 12 step guideline for authors. Nurse Education Today, 32(8), 878-886
• Smith, J., Noble, H. (2016) Reviewing the literature. Evidence Based Nursing, 19 (1), 2-3.

In health and social care there are a number of different types of review. The resources below give an outline of the different types and outline the differences between them:

Grant, M. J., & Booth, A. (2009). A typology of reviews: an analysis of 14 review types and associated methodologies.  Health Information and Libraries Journal ,  26 (2), 91–108. https://doi.org/10.1111/j.1471-1842.2009.00848.x 

Sutton, A., Clowes, M., Preston, L., & Booth, A. (2019). Meeting the review family: exploring review types and associated information retrieval requirements.  Health Information and Libraries Journal ,  36 (3), 202–222. https://doi.org/10.1111/hir.12276   

If you are doing a literature review as part of an academic assignment then please ensure you follow the requirements and any methods set out in your assignment brief. You may be advised to do a specific type of review, but when reading the guidance of how to conduct one find that it differs from your assignment brief. If so, discuss this with your supervisor or module leader.

Choosing a Review Type

You need to understand the purpose of different review types and match this up with what you are intending to achieve from carrying out your review in order to select the most appropriate type. You can include this explanation and justification within your write up. As well as the guidance above please see some further resources below to support your decision making.

Munn, Z., Peters, M. D. J., Stern, C., Tufanaru, C., McArthur, A., & Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach.  BMC Medical Research Methodology ,  18 (1), 143–143. https://doi.org/10.1186/s12874-018-0611-x

Jonkoping University. (n.d.). Which review is right for you?   https://guides.library.ju.se/c.php?g=690269&p=4943634

Right Review. (2024). Right Review Tool.  https://rightreview.knowledgetranslation.net/

There are a number of published reporting and conducting guidelines and handbooks to support you in both carrying out and writing up your review. These help to ensure the quality and transparency of your review by ensuring you have included and conducted your review in a way that meets established methodological expectations.

Reporting guidelines give information on what you need to include in the write up of the review. Conducting guidelines provide more methodological guidance on how to carry out and undertake each stage of a review, not just stating what you need to include/report. When using these they need to be cited and referenced and the wording you would use needs to distinguish if it is a reporting or conducting resource, and therefore how it has been used. Examples:

'this review/protocol was reported using . . . '

'the conducting of this review was guided by . . . '

A lot of these were designed for quantitative systematic reviews of interventions, however a number of resources now exist for different types of evidence synthesis reviews. Below are resources of some of the most commonly used guidelines.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement consists of a 27-item checklist that covers the elements needed in the write up of a systematic review, and a flow diagram.

There is an article giving further explanation of every element of the checklist and a glossary of terms .

PRISMA also have guidance for reporting protocols, known as the  PRISMA-P extension.

There is also a checklist extension for Scoping Reviews called PRISMA- ScR , which is very similar to the Systematic Review checklist but with some key differences.

Also a more in-depth explanatory paper for this checklist as well.  

The Cochrane Handbook for Systematic Reviews of Interventions needs to be followed if you were to publish a review or review protocol in the Cochrane Library of Systematic Reviews.

There are a set a reporting guidelines for both review protocols and full reviews .

Key aspects of the Cochrane handbook are collated as the Methodological Expectations for Cochrane Intervention Reviews – takes you through steps needed to conduct.

The Cochrane Handbook Chapter V also details methodology for conducting Overviews of Reviews.

The Cochrane Qualitative and Implementation Methods Group have published a series of 6 papers covering qualitative evidence synthesis methods .

Other Guides

The JBI Manual for Evidence Synthesis separates SRs out by types of evidence included, as well as having chapters on Mixed Methods Reviews, Scoping Reviews and Umbrella Reviews.

RAMSES reporting can be used for realist reviews and meta-narrative reviews.

The ENTREQ checklist can be used to report reviews of qualitative literature, alongside a fuller article explaining the development of the checklist .

Further reporting and conducting guidelines can be found on this useful page from the University of Illinois .

Booth, A. (2016). EVIDENT Guidance for reviewing the evidence: a compendium of methodological literature and websites.  https://www.researchgate.net/publication/292991575_EVIDENT_Guidance_for_Reviewing_the_Evidence_a_compendium_of_methodological_literature_and_websites

A good literature review should:

• Address a focused, explicit research question.
• Take a systematic approach to the searching of the literature.
• Document the search process so that it is replicable  by others  (often a requirement for publication within many academic journals)
• Demonstrate that a wide range of sources have been searched.
• Undertake a critical analysis of the retrieved literature, not merely describe what has been read.
• Justify why particular items of literature are being referred to. They should summarise the current state of research,  perhaps debates that have taken place over a period of time within that topic or arguments for and against a particular aspect of the topic.
• Relate the question to the larger body of knowledge within which your topic sits, and to put your work into context.
• Summarise the current state of the research evidence.
• Identify the gap in the literature that your research question is going to answer.

Common Mistakes

• Review is too descriptive. No critiquing or critical evaluation of the evidence. No identification of strengths and weaknesses. It becomes an essay, not a review. It does not set the foundation for your own research process.
• It becomes a dumping ground to write down everything you know about the topic  or is presented as a series of quotes from the papers you have read.
• Not enough time has been allocated to searching and reviewing the literature. Do your literature reviewing early. It helps inform your final research question, future methodologies and identifies whether there is indeed a "gap" in the current research literature that your queston is going to answer.
• Literature used is not from scholarly peer reviewed sources.
• There is no documentation or explanation of how the search was undertaken and the key terms used. No explanation of inclusion/exclusion criteria.
• Referencing does not follow the School guidelines. It is not consistent in style or presentation.
• There has been no revision or proof reading. Thinking develops as you write. Go back over what you have written a few days after you have done it. Check grammar and language – give it to someone else to proof read.

Here are 5 top tips towards a stress free  literature review

• Top tips for literature reviewing

Literature reviewing - the process

• Question Development
• Eligibility Criteria
• Planning the Search Strategy
• Searching the Literature
• Selecting the Literature
• Keeping track of your literature
• Critical Appraisal
• Analysing and Discussing the Literature

Formulating a review question is a key stage of the review process as this impacts the development of the outcomes of the review, the eligibility criteria for selection, and the development of the search strategy. If you make changes to your review question after already moving on to other stages of the review you may need to go back and make changes to these other steps.

Ideally a review should add new knowledge to that topic or field, so you want to develop a question that has a new focus or outcomes that has not previously been explored. Sometimes it is appropriate to update a previous review using the same question and outcomes to see if the findings of the review have changed with the inclusion of new literature since the previous one was published.

If you are a Masters student it is particularly important that you choose a topic that is both viable and manageable within the word count and timescales for completion. Viable means a topic where there is published literature, you cannot do a literature review on a question where there is no available literature. Manageable means selecting a focused topic where there will not be too vast an amount of literature to include as you have a word count limit and a timescale in which to submit the assignment.

To help you develop a question try and identify an area from practice that you are interested in – ideally something the practice area can benefit from which will give value to your review findings.

The question you develop from this topic should be focused, manageable and answerable within the timescales you have.

Scoping the Literature

This is where we run initial literature searches around our topic of interest to get an initial idea of what literature is out there. This will help us to:

• Check what reviews have already been done on this topic.
• Check our topic is viable - there is enough literature out there.
• Check our topic is not too broad - too much literature out there.

From these initial searches of the literature you can start to refine your review question, broadening or focusing as necessary. Please see the following video on Scoping Searches to Refine Your Topic for an example of how this works in practice.

• Question Formulation Frameworks

Question formulation frameworks are used particularly within healthcare to help you identify the key concepts of your topic, to then structure into a research or review question. The following document shows you examples of the most commonly used ones in healthcare, breaking down each framework into what the concepts mean, giving examples in practice of questions structured using that framework, and suggestions of review outcomes and types best suited to each framework.

The eligibility criteria can also be referred to as the inclusion and exclusion criteria. This is a set of criteria you will develop which you will use during the selection process of the review to decide which sources of literature to include and exclude. This criteria helps to reduce selection bias, because every decision you make should be based on this pre-determined set of criteria. 

When take a systematic approach to searching and selecting the literature your eligibility criteria needs to be very detailed, both for you to be able to make decisions for each of the pieces of literature you have found, but also for someone else to be able to use the criteria with the same set of literature and make the same decisions as you. If you are doing a review as part of a review team for publication then there should be a minimum of two people involved in the selection of the literature, both using the same criteria to make selection decisions. This aligns to the systematic criteria of transparency . 

When developing your eligibility criteria think about the following elements:

• Each of your question concepts from your question formulation framework and detail exactly what criteria would mean a source would be included or excluded in relation to each question concept.

E.g. your population group is people with dementia, so as inclusion criteria you would state that each literature source needs this population group and any source without this population group would be excluded. But what about literature where participants and both people with dementia and people with Parkinsons. Would this be included or excluded? Your criteria needs to be detailed enough to capture all of the potential decisions you would need to make.

• The study criteria for research literature, so the methodology, design and any further details. Depending on your review question there will sometimes be specific types of data most suited to answer the question, so sometimes either quantitative or qualitative data only would be appropriate, and sometimes only specific study designs like randomised controlled trials

E.g. you're question is exploring the experiences and views of a particular group of participants, therefore the data most appropriate to 'answer' this question would be qualitative.

• Types of publications, so are you only including primary research or wider sources of literature? Even with primary research there are a number of different source types this could be presented in such as journal articles, theses, conference proceedings.
• Publication dates, so is there a specific date range you will only be including literature from? Try to think about the context of your specific topic/question and what would make something too old. 

E.g. there has been a new guideline in your topic area published in a specific year with major changes to how a specific procedure is done in practice, meaning that older literature is not relevant to the current guideline. Topics related to technology could be outdated more easily due to specific technological developments in a specific field or equipment. 

A search strategy includes where and how you are searching. Can someone else use your process to find what you found? This aligns with the systematic criteria of being  transparent.

You need to plan and include the following detail in your write up to allow someone else to replicate your search:

• Search Strategy Planning Template

When searching in databases most of the time you want to use the advanced search feature to build a search that will find a more relevant set of search results. To do this you need to be able to plan effective search strategies, using appropriate keyword search terms, and inputting these into the database in the most effective combination.

The videos below demonstrate how to input a planned systematic search strategy into a database. Different database platforms will look slightly different, but the principles for doing an advanced search are the same across them all, but differences are demonstrated.

Searching in EBSCO databases (CINAHL, Medline, APA PsycInfo etc.)

Searching in PubMed

Searching in Ovid

Searching in Web of Science

Searching in Proquest

The selection process is where you will use your eligibility criteria to select the literature for inclusion in your review. Considerations needed are:

Keeping track of literature

Writing a literature review will mean that you will collect a large number of pieces of information from many sources.  Before you begin searching, give some thought as to how you are going to manage this information. 

Reference management software will enable you to automatically  export references you collect from database searches and store them in the reference manager.   Once you have read each paper you can then make personal research notes and store these within each reference inside the reference manager.

Use the software  to format the citations within the text of your review. It will also produce the reference list at the end of your document formatted in a style of your choosing e.g.   APA 7th.

See  our Reference Management LibGuide  on how to get started with Endnote or Mendeley, Edinburgh Napier’s referencing management software.

NHS Scotland users can also use the Refworks ref management software supplied on the NHS Knowledge network site instead of Endnote,  if they would prefer.

What is critical appraisal? 

Critical appraisal/quality assessment is a specific aspect of critical analysis where you examine and assess research in order to judge its:

You are evaluating the quality of the research and how it has been conducted, as well as the findings themselves and how it has been reported. Please see the following video by Cochrane on an Introduction to Critical Appraisal for a more in depth description.

Why do we do it?

Critical appraisal is often carried out using checklists that help signpost areas to look for while reading a paper. There are different types of checklist depending on the type of research you are reviewing.

The following document lists some of the main appraisal tools used in published reviews and would be a good place to start when deciding on which tool to use. 

• Critical Appraisal/Quality Assessment Tools

Further Critical Appraisal Resources

Two excellent videos from Andrew Booth at SCHARR at the University of Sheffield. These take you through the actual process of appraising papers using the CASP tool.

Appraising a Quantitative Study              [13 mins]

Critical Appraisal of a Qualitative Study   [12 mins]

Data Extraction and Charting

Your literature findings need to be presented and discussed both descriptively and analytically. It is usually to present a summary of the included sources in the form of a data extraction or study characteristics table, a process also referred to as data extraction and charting your results.  The video below covers how to present your findings in this way.

• Presenting Your Results in a Study Characteristics Table

Analysing and Synthesising the Findings of the Literature

Depending on the type of review you are doing and also whether the review is being done as an assignment, there may be differing expectations of how you analyse the included literature sources.

At Masters dissertation level you would be expected as a minimum to provide a narrative thematic analysis, where you compare and contrast the literature to identify patterns and themes and interpret these in relation to your review question. You can use a deductive approach where you start with a pre-existing framework of themes, or an inductive approach where themes are generated from reading the literature.

At PhD or researcher for publication level there would be an expectation of a more complex analysis of the literature, appropriate to the literature sources. A scoping review including a wide range of source types would likely best be suited to a narrative analysis, but if the review literature is all research then an appropriate quantitative, qualitative, or mixed methods form of analysis of the data would be expected.

Most Systematic Review conduction and reporting guidelines are designed around an analysis of quantitative data, so if this does not fit the data of your literature you may need to use different analysis and synthesis guidance. There are a number of different analysis methods, some examples and resources are listed below as a starting point but you may also want to look at examples of similar reviews fur further methods.

• Chapters 10 and 11 of the Cochrane Handbook covers quantitative meta-analysis.
• Chapter 12 covers over methods, however these are all still mainly quantitative methods.
• The eMergE reporting guidance covers meta-ethnography qualitative synthesis, and the ENTREQ statement can also be used for qualitative synthesis.

Recommended Reading

• << Previous: NHS Scotland Knowledge Network
• Last Updated: Mar 12, 2024 2:08 PM
• URL: https://libguides.napier.ac.uk/shsc

Doing a Literature Review in Health and Social Care A Practical Guide Second edition Helen Aveyard Doing a Literature Review in Health and Social Care A Practical Guide Second edition McGraw Hil / £17.99 170pp 9780335238859 0335238858 [Formula: see text]

• PMID: 27712339
• DOI: 10.7748/nr.18.4.45.s2

LITERATURE REVIEWS are an important preliminary step towards a research project or dissertation, as well as being an important source of information in their own right. But despite their value, literature reviews often present a major challenge to students at undergraduate and postgraduate level.

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Article Contents

Introduction, conclusions, recommendations and limitations of the study, supplementary data, data availability, a systematic review of literature examining the application of a social model of health and wellbeing.

• Article contents
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• Supplementary Data

Rachel Rahman, Caitlin Reid, Philip Kloer, Anna Henchie, Andrew Thomas, Reyer Zwiggelaar, A systematic review of literature examining the application of a social model of health and wellbeing, European Journal of Public Health , 2024;, ckae008, https://doi.org/10.1093/eurpub/ckae008

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Following years of sustained pressure on the UK health service, there is recognition amongst health professionals and stakeholders that current models of healthcare are likely to be inadequate going forward. Therefore, a fundamental review of existing social models of healthcare is needed to ascertain current thinking in this area, and whether there is a need to change perspective on current thinking.

Through a systematic research review, this paper seeks to address how previous literature has conceptualized a social model of healthcare and, how implementation of the models has been evaluated. Analysis and data were extracted from 222 publications and explored the country of origin, methodological approach, and the health and social care contexts which they were set.

The publications predominantly drawn from the USA, UK, Australia, Canada and Europe identified five themes namely: the lack of a clear and unified definition of a social model of health and wellbeing; the need to understand context; the need for cultural change; improved integration and collaboration towards a holistic and person-centred approach; measuring and evaluating the performance of a social model of health.

The review identified a need for a clear definition of a social model of health and wellbeing. Furthermore, consideration is needed on how a model integrates with current models and whether it will act as a descriptive framework or, will be developed into an operational model. The review highlights the importance of engagement with users and partner organizations in the co-creation of a model of healthcare.

Following years of sustained and increasing pressure brought about through inadequate planning and chronic under-resourcing including the unprecedented challenges of the Covid-19 pandemic, the UK NHS is at crisis point. 1 The incidents of chronic disease continue to increase alongside an ageing population who have more complex health and wellbeing needs, whilst recruitment and retention of staff continue to be insufficient to meet these increased demands. 1 Furthermore, the Covid-19 pandemic has only served to exacerbate pressures, resulting in delays in; patient presentation, 2 poor public mental health 3 strain and burnout amongst workforce. 4 However, preceding the pandemic there was already recognition of a need for a change to the current biomedical model of care to better prevent and treat the needs of the population. 5

While it is recognized that demands on the healthcare system are increasing rapidly, the biomedical model used to deal with these issues (which is the current model of healthcare provision in the UK) has largely remained unchanged over the years. The biomedical model takes the perspective that ill-health stems from biological factors and operates on the theory that good health and wellbeing is merely the absence of illness. Application of the model therefore focuses treatment on the management of symptoms and cure of disease from a biological perspective. This suggests that the biomedical approach is mainly reactive in nature and whilst rapid advancements in technology such as diagnostics and robotics have significantly improved patient outcomes and identification of early onset of disease, it does not fully extend into managing the social determinants that can play an important role in the prevention of disease. Therefore, despite its contribution in advancing many areas of biological and health research, the biomedical model has come under increasing scrutiny. 6 This is in part due to the growing recognition of the impact of those wider social determinants on health, ill-health and wellbeing including physical, mental and social wellbeing which moves the focus beyond individual physical abilities or dysfunction. 7–9 In order to address these determinants, action needs to be taken through developing policies in a range of non-medical areas such as social, economic and environment so that they regulate the commercial and corporate determinants. In this sense, we can quickly see that the traditional biological model rapidly becomes inadequate. With the current model, health care and clinical staff can do little to affect these determinants and as such can do little to assist the individual patient or society. The efficiency and effectiveness of clinical work will undoubtedly improve if staff have the ability to observe and understand the wider social determinants and consequences of the individual patients’ condition. Therefore, in order to provide a basis for understanding the determinants of disease and arriving at rational treatments and patterns of health care, a medical model must also take into account the patient, the social context in which they live, and a system devised by society to deal with the disruptive effects of illness, that is, the physician’s role and that of the health care system. Models such as Engel’s biopsychosocial model, 9 , 10 the social model of disability, social–ecological models of health 10 , 11 including the World Health Organisation’s framework for action on social determinants of health 8 , 9 are all proposed as attempting to integrate these wider social determinants.

However, the ability of health systems to effectively transition away from a dominant biomedical model to the adoption of a social model of health and care have yet to be fully developed. Responsibility for taking action on these social determinants will need to come from other sectors and policy areas and so future health policy will need to evolve into a more comprehensive and holistic social model of health and wellbeing. Wales’ flagship Wellbeing of Future Generations Act 12 for instance outlines ways of working towards sustainable development and includes the need to collaborate with society and communities in developing and achieving wellbeing goals. However, developing and implementing an effective operational model that allows multi-stakeholder integration will prove far more difficult to achieve than creating the polices. Furthermore, if the implementation of a robust model of social health is achievable, it’s efficiency, effectiveness and ability to deliver has yet to be proven. Therefore, any future model will need to extend past its conceptual development and provide an ability to manage the complex interactions that will exist between the stakeholders and polices.

Therefore, the use of the term ‘model’ poses its own challenges and debates. Different disciplines attribute differing parameters to what constitutes a model and this in turn may influence the interpretations or expectations surrounding what a model should comprise of or deliver. 13 According to numerous authors, a model has no ontological category and as such anything from physical entities, theoretical concepts, descriptive frameworks or equations can feasibly be considered a model. 14 It appears therefore, that much discussion has focussed on the move towards a ‘descriptive’ Social Model of Health and Wellbeing in an attempt to view health more holistically and identify a wider range of determinants that can impact on the health of the population. However, in defining an operational social model of health that can facilitate organizational change, there may be a need to consider a more systems- or process-based approach.

As a result, this review seeks to systematically explore the academic literature in order to better understand how a social model of health and wellbeing is conceptualized, implemented, operationalized and evaluated in health and social care.

The review seeks to address the research questions:

How is ‘a social model of health and wellbeing’ conceptualized?

How have social models of health and wellbeing been implemented and evaluated?

A systematic search of the literature was carried out between 6 January 2022 and 20 January 2022. Using the search terms shown in table 1 , a systematic search was carried out using online databases PsycINFO, ASSIA, IBSS, Medline, Web of Science, CINHAL and SCOPUS. English language and peer-reviewed journals were selected as limiters.

Search terms

Selection and extraction criteria

The search strategy considered research that explicitly included, framed, or adopted a ‘social model of health and wellbeing’. Each paper was checked for relevance and screened. The authors reviewed the literature using the Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) method using the updated guidelines from 2020. 15 Figure 1 represents the process followed.

PRISMA flow chart.

Data extraction and analysis

A systematic search of the literature identified 222 eligible papers for inclusion in the final review. A data extraction table was used to extract information regarding location of the research, type of paper (e.g. review, empirical), service of interest and key findings. Quantitative studies were explored with a view to conducting a quantitative meta-analysis; however, given the disparate nature of the outcome measures, and research designs, this was deemed unfeasible. All included papers were coded using NVivo software with the identified research questions in mind, and re-analysed using Thematic Analysis 16 to explore common themes of relevance.

The majority of papers were from the USA (34%), with the UK (28%), Australia (16%), Canada (6%) and wider Europe (10%) also contributing to the field. The ‘other’ category (6%) was made up of single papers from other countries. Papers ranged in date from 1983 to 2021 with no noticeable temporal patterns in country of origin, health context or model definition. However, the volume of papers published relating to the social model for healthcare in each decade increased significantly, thus suggesting the increasing research interest towards the social model of healthcare. Table 2 shows the number of publications per decade that were identified from this study.

Publications identifying social models of healthcare.

Most of the papers were narrative reviews ( n  = 90) with a smaller number of systematic reviews ( n  = 9) and empirical research studies including qualitative ( n  = 47), quantitative ( n  = 39) and mixed methods ( n  = 14) research. The remaining papers ( n  = 23) comprised small samples of, for example, clinical commentaries, cost effectiveness analysis, discussion papers and impact assessment development papers. The qualitative meta-analysis identified five overarching themes in relation to the research questions, some with underlying sub-themes, which are outlined in figure 2 .

Overview of meta-synthesis themes.

The lack of a clear and unified definition of a social model of health and wellbeing

There was common recognition amongst the papers that a key aim of applying a social model of health and wellbeing was to better address the social determinants of health. Papers identified and reviewed relevant frameworks and models, which they later used to conceptualize or frame their approach when attempting to apply a social model of health. Amongst the most commonly referenced was the WHO’s framework. 17 Engel’s biopsychosocial model 9 which was referred to as a seminal framework by many of the researchers. However, once criticism of the biopsychosocial model was its inability to fully address social needs. As a result, a number of papers reported the development of new or enhanced models that used the biopsychosocial model as their underpinning ‘social model’ 18 , 19 but then extended their work by including a wider set of social elements in their resulting models. 20 The Social ecological model, 11 the Society-Behaviour-Biology Nexus, 21 and the Environmental Affordances Model are such examples. 22 Further examples of ‘Social Models’ included the Model of Social Determinants of Health 23 which framed specific determinants of interest (namely social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food and transport). Similarly, Dahlgren and Whitehead’s ‘social model’ 10 illustrates social determinants via a range of influential factors from the individual to the wider cultural and socioeconomic influences. However, none of these papers formally developed a working ‘definition’ of a social model of health and wellbeing, instead applying guiding principles and philosophies associated with a social model to their discussions or interventions. 24 , 25

The need to understand context

Numerous articles highlight that in order to move towards a social model of health and wellbeing, it is important to understand the context of the environment in which the model will need to operate. This includes balancing the needs of the individual with the resulting model to have been co-created, developed and implemented within the community whilst ensuring that the complexity of interaction between the social determinants of health and their influence on health and wellbeing outcomes are delivered effectively and efficiently.

The literature identified the complex multi-disciplinary nature of a variety of conditions or situations involving medical care. These included issues such as, but not exclusively, chronic pain, 26 cancer, 27 older adult care 28 and dementia, 29 thus indicating the complex arrangement of medical issues that a model will need to address and, where many authors acknowledged that the frequently used biomedical models failed to fully capture the holistic nature and need of patients. Papers outlined some of the key social determinants of health affecting the specific population of interest in their own context, highlighting the interactions between wider socioeconomic and cultural factors such as poverty, housing, isolation and transport and health and wellbeing outcomes. Interventions that had successfully addressed individual needs and successful embedded services in communities reported improved outcomes for end users and staff in the form of empowerment, agency, education and belonging. 30 There was also recognition that the transition to more community-based care could be challenging for health and social care providers who were having to work outside of their traditional models of care and accept a certain level of risk.

The need for cultural change

A number of papers referred to the need for a ‘culture change’ or ‘cultural shift’ in order to move towards a social model of health and wellbeing. Papers identified how ‘culture change models’ were implemented as a way of adapting to a social model. It was recognized that for culture change models to be effective, staff and the general public needed to be fully engaged with the entire move towards a social model, informing and shaping the mechanisms for the cultural shift as well as the application of the model itself.

Integration and collaboration towards a holistic and person-centred approach

The importance of integration and collaboration between health professionals, (which includes public, private and third sector organizations), services users and patients were emphasized in the ambition to achieve best practice when applying a social model of health and wellbeing. Papers identified the reported benefits of improved collaboration between, and integration of services which included improved continuity of care throughout complex pathways, 31 improved return to home or other setting on discharge, 25 and social connectedness. 32 Numerous papers discussed the importance of multi-disciplinary teams who were able to support individuals beyond the medicalized model.

A number of papers suggested specific professional roles or structures that would be ideal to act as champions or integrators of collaborative services and communities. 25 , 33 These could act as a link between secondary, primary and community level care helping to identify patient needs and supporting the integration of relevant services.

Measuring and evaluating a social model of health

Individual papers applying and evaluating interventions based on a social model used a variety of methods to evaluate success. Amongst these, some of the most common outcome measures included; general self-report measures of outcomes such as mental health and perceptions of safety, 34 wellbeing, 35 life satisfaction and health social networks and support 19 Some included condition specific self-report outcomes relevant to the condition in question (e.g. pregnancy, anxiety) and pain inventories. 36 Other papers considered the in-depth experiences of users or service implementers through qualitative techniques such as in-person interviews. 37 , 38

However, the complexity of developing effective methods to evaluate social models of health were recognized. The need to consider the complex interactions between social determinants, and health, wellbeing, economic and societal outcomes posed particular challenges in developing consistency across evaluations that would enable a conclusive evaluation of the benefits of social models to wider health systems and societal health. Some criticized the over-reliance of quantitative and evidence-based practice methods of evaluation highlighting how these could fail to fully capture the complexity of human behaviour and the manner in which their lives could be affected.

The aim of this systematic review was to better understand how a social model of health and wellbeing is conceptualized, implemented and evaluated in health and social care. The review sought to address the research questions identified in the ‘Introduction’ section of this paper.

With regards to the conceptualization of a social model of health and wellbeing, analysis of the literature suggests that whilst the ethos, values and aspirations of achieving a unified model appears to have consensus. However, a fundamental weakness exists in that there is no single unified definition or operational model of a social model of health and wellbeing applied to the health and social care sector. The decision about how best to conceptualize a ‘social model’ is important both in terms of its operational value but also the implication of the associated semantics. However, without a single or unified definition then implementation or further, operationalization of any model will be almost impossible to develop. Furthermore, use of the term ‘social model’ arguably loses site of the biological factors that are clearly relevant in many elements of clinical medicine. Furthermore, there is no clarification in the literature about what would ‘not’ be considered a social model of health and wellbeing, potentially leading to confusion within health and social care sectors when addressing their wider social remit. This raises questions and requires decisions about whether implementation of a social model of health and wellbeing will need to work alongside or replace the existing biomedical approach.

Authors have advocated that a social model provides a way of ‘thinking’ or articulating an organization’s values and culture. 24 Common elements of the values associated with a social model amongst the papers reviewed included recognition and awareness of the social determinants of health, increased focus on preventative rather than reactive care, and similarly the importance of quality of ‘life’ as opposed to a focus on quality of ‘care’. However, whilst this approach enables individual services to consider how well their own practices align with a social model, the authors suggest that this does not provide large organizations such as the NHS, with multifaceted services and complex internal and external connections and networks, sufficient guidance to enable large scale evaluation or transition to a widespread operational model of a social model of health and wellbeing. This raises questions about what the model should be: whether its function is to support communication of a complex ethos to encourage reflection and engagement of its staff and end users, or to develop the current illustrative framework into a predictive model that can be utilized as an evaluative tool to inform and measure the success of widespread systems change.

Regarding the potential implementation of a future social model of health and wellbeing, none of the papers evaluated the complex widespread organizational implementation of a social model, instead focusing on specific organizational contexts of services such as long-term care in care homes, etc. Despite this, common elements of successful implementation did emerge from the synthesis. This included the need to wholeheartedly engage and be inclusive of end users in policy and practice change to fully understand the complexity of their social worlds and to ensure that changes to practice and policy were ‘developed with’, as opposed to ‘create for’, the wider public. This also involved ensuring that health, social care and wider multi-disciplinary teams were actively included in the process of culture change from an early stage.

Implications for future research

The analysis identifies that a significant change of mindset and removal of perceived and actual hierarchical structures (that are historically embedded in health and social care structures) amongst both staff and public is needed although, eradicating socially embedded hierarchies will pose significant challenges in practice. Furthermore, the study revealed that many of the models proposed were conceptually underdeveloped and lacked the capability to be operationalized which in turn compromised their ability to be empirically tested. Therefore, in order that a future ‘implementable and operational’ model of social care and wellbeing can be created, further research into organizational behaviours, organizational learning and stakeholder theory (amongst others) applied to the social care and health environment is needed.

Towards defining a social model of health and wellbeing

In attempting to conceptualize a definition for a social model of health and wellbeing, it is important to note that the model needs to be sufficiently broad in scope in order to include the prevailing biomedical while also including the need to draw in the social determinants that provide a view and future trajectory towards social health and wellbeing. Therefore, the authors suggest that the ‘preventative’ approach brought by the improvements in the social health determinants (social, cultural, political, environmental ) need to be balanced effectively with the ‘remedial/preventative’ focus of the biomedical model (and the associated advancements in diagnostics, technology, vaccines, etc), ensuring that a future model drives cultural change; improved integration and collaboration towards a holistic and person-centred approach whilst ensuring engagement with citizens, users, multi-disciplinary teams and partner organizations to ensure that transition towards a social model of health and wellbeing is undertaken.

Through a comprehensive literature analysis, this paper has provided evidence that advocates a move towards a social model of health and wellbeing. However, the study has predominantly considered mainly literature from the USA, UK, Canada and Australia and therefore is limited in scope at this stage. The authors are aware of the need to consider research undertaken in non-English speaking countries where a considerable body of knowledge also exists and which will add to further discussion about how that work dovetails into this body of literature and, how it aligns with the biomedical perspective. There is a need for complex organizations such as the NHS and allied organizations to agree a working definition of their model of health and wellbeing, whether that be a social model of health and wellbeing, a biopsychosocial model, a combined model, or indeed a new or revised perspective. 39

One limitation seen of the models within this study is that at a systems level, most models were conceptual models that characterized current systems or conditions and interventions to the current system that result in localized improvements in systems’ performance. However, for meaningful change to occur, a ‘future state’ model may need to focus on a behavioural systems approach allowing modelling of the complete system to take place in order to understand how the elements within the model 40 behave under different external conditions and how these behaviours affect overall system performance.

Furthermore, considerable work will be required to engage on a more equal footing with the public, health and social care staff as well as wider supporting organizations in developing workable principles and processes that fully embrace the equality of a social model and challenging the ‘power’ imbalances of the current biomedical model.

Supplementary data are available at EURPUB online.

This research was funded/commissioned by Hywel Dda University Health Board. The research was funded in two phases.

Conflicts of interest: None declared.

The datasets generated and/or analysed during the current study are available in the Data Archive at Aberystwyth University and have been included in the supplementary file attached to this submission. A full table of references for studies included in the review will be provided as a supplementary document. The references below refer to citations in the report which are in addition to the included studies of the synthesis.

The review identified five themes namely: the lack of a clear definition of a social model of health and wellbeing; the need to understand context; the need for cultural change; improved integration and collaboration towards a holistic and person-centred approach; measuring and evaluating the performance of a social model of health.

The review identified a need for organizations to decide on how a social model is to be defined especially at the interfaces between partner organizations and communities.

The implications for public policy in this paper highlights the importance of engagement with citizens, users, multi-disciplinary teams and partner organizations to ensure that transition towards a social model of health and wellbeing is undertaken with holistic needs as a central value.

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• USC Libraries
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Organizing Your Social Sciences Research Paper

• 5. The Literature Review
• Purpose of Guide
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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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Why use literature reviews in health and social care?

Introduction.

Why use literature reviews in health and social care? is a free course which introduces and explains how literature reviews can support evidence-based practice in health and social care. A literature review can offer a systematic way in which to sift through information to produce relevant existing knowledge and discern knowledge gaps. This short course explores different examples of the use of literature reviews that have informed policy and practice; social work with older people, cessation of cigarette smoking in pregnant women and use of mindfulness therapy with respect to older people with dementia and their carers.

This OpenLearn course is an adapted extract from the Open University course K323 Investigating health and social care [ Tip: hold Ctrl and click a link to open it in a new tab. ( Hide tip ) ] .

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"If you want to understand, design, or carry out a literature review to improve the quality of care that you or others deliver, then look no further."

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"If I was to endorse only one research book in the future - this one would be it."

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"This new edition provides the straightforward and accessible manual for successfully understanding and conducting literature reviews that we have come to expect from Aveyard."

Victoria Sweetmore, University of Derby, UK

This best-selling book, now in its fifth edition, is a step-by-step guide to doing a literature review for students in all areas of health and social care. It is essential reading for all those doing their undergraduate dissertation or any study that involves doing a literature review.

The new edition maintains its signature 'can do' approach and provides a practical guide to doing a literature review from start to finish. This book includes:

- A broad and updated range of real life examples of how to overcome challenges in the process

- Tips on how to get your question right

- Updated guidance on following a clear search strategy for relevant literature using the appropriate technology

- Brand new and accessible chapter summaries

- An expanded guide for the application of critical appraisal tools

- An increased emphasis on presenting your findings or using them in practice

- Tips and coverage on how to write up your review

Doing a Literature Review in Health and Social Care is vital reading for anyone new to reviewing and presenting evidence in a review.

Helen Aveyard is a Principal Lecturer at Oxford Brookes University, UK with a background in nursing. Helen is co-author of A Postgraduates Guide to Doing a Literature Review in Health and Social Care, A Beginner's Guide to Evidence Based Practice and A Beginner's Guide to Critical Thinking and Writing in Health and Social Care.

• Print length 220 pages
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Open Access

Study Protocol

Exploring the inequalities experienced by health and care workforce and their bases – A scoping review protocol

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Current address: University of Essex, Colchester, United Kingdom

Affiliation School of Health & Social Care, University of Essex, Colchester, United Kingdom

Roles Conceptualization, Supervision, Writing – review & editing

• Roomi Aziz, 
• Anuj Kapilashrami, 
• Reza Majdzadeh

• Published: April 16, 2024
• https://doi.org/10.1371/journal.pone.0302175
• Reader Comments

Planning for investment in human resources for health (HRH) is critical to achieve Universal Health Coverage (UHC) and establish a sustainable health system. Informed planning warrants a better understanding of the health labour market (HLM) to tackle a variety of health and care workforce challenges: from addressing critical supply shortage, to ensuring optimal skills mix and distribution, and addressing motivation and performance challenges. Scant evidence around the overall role of socioeconomic and cultural factors like gender, race, marital status, citizenship (migrant) status, workplace hierarchy etc. in determining workforce composition, deployment, distribution, retention, un- and underemployment, sub-optimal work environments and other factors in the ‘HRH crisis’ warrants further exploration. This scoping review protocol aims to map and present the available evidence on inequalities experienced by health and care workforce, the socio-economic, cultural and other bases of these inequalities, and their outcomes/ consequences. PubMed, Web of Science, CINAHL and SCOPUS will be used to identify relevant literature. All types of published study designs in English language will be included if they discuss any inequality experienced by any category of health and care workers. Elaborate keyword categories for health and care workers and inequalities context have been developed, tested and reduced to the near-final search string. Eligible articles will be charted using the Joanna Briggs Institute checklist. The sample data extraction chart in JBI manual will be used as a basic skeleton with fields added to it to serve the needs of the scoping review. Descriptive analysis will be performed, depicting basic frequencies. While no further analysis has been advised in the JBI and PRISMA protocol, thematic analysis will be undertaken; following the Braun and Clarke’s method with some modification and open coding as suggested by Maquire and Delahunt.

Citation: Aziz R, Kapilashrami A, Majdzadeh R (2024) Exploring the inequalities experienced by health and care workforce and their bases – A scoping review protocol. PLoS ONE 19(4): e0302175. https://doi.org/10.1371/journal.pone.0302175

Editor: Steve Zimmerman, Public Library of Science, UNITED KINGDOM

Received: September 28, 2023; Accepted: March 25, 2024; Published: April 16, 2024

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

Data Availability: No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.

Funding: As a Commonwealth scholar, I am undertaking a funded PhD at the University of Essex, with my tuition and living supported by the Commonwealth. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors did not receive a salary from any of my funders.

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

Introduction

Human Resources for Health (HRH) is one of the six building blocks of health systems [ 1 ], and referred to as the backbone of health systems [ 2 , 3 ]. Adequate numbers, quality and diversity of HRH are critical for achieving Sustainable Development Goals (SDG) generally and target 3.8C Universal Health Coverage (UHC), indicator 3.C.1 ‘health worker density and distribution’ specifically. HRH ascertains the effectiveness of all other inputs in a country’s health system which in turn ensures the health and viability of national and global economies [ 4 ].

Although documented earlier, global HRH crisis was prominently first highlighted in WHO’s 2006 world health report [ 5 ], where the report identified crisis level shortages in 57 countries and estimated a global deficit of 2.4 million doctors, nurses and midwives then.

HRH crisis is most often expressed as shortage of health and care workers, demand or need, using measures like HRH density per 1000 population [ 6 , 7 ]. However, this measure limits the understanding of HRH to just a supply problem [ 8 , 9 ], and while useful for understanding the overall deficits in HRH availability, is not adequate for country level-planning for sustainable workforce [ 10 ].

Due to this evidence gap and emphasis on workers’ density, globally HRH planning at the policy and programmatic levels typically stays limited to supply strategies like scaling up of training capacities and building more medical/ nursing schools [ 11 ]. This is partly because most of the available evidence on HRH crisis focuses on workforce distribution and related challenges [ 12 – 19 ]. This traditional policy approach fails to see other systemic and structural factors and dimensions of the health labour market (HLM) [ 20 – 25 ].

In order to start changing that outlook, and drive evidence-informed policy design, it is important to first map the evidence available, before advocating for integration of this evidence in developing policies or programs.

In conclusion, effective HRH planning requires a deeper understanding of the structural and systematic inequalities that health and care workers experience. To accordingly inform the discourse on HRH, this scoping review aims to systematically map literature that attempts to understand the inequalities experienced by health and care workers, their bases, their subsequent outcomes and the resulting impact on HLM and health system. This mapping will present the key concepts, research methods, theories and sources of evidence in HRH research using an inequality lens [ 26 ].

Materials and methods

Existing directories of Prospero, Figshare and Open Science Framework (OSF) were reviewed to identify if any existing protocol for a similar study existed. In the absence of any relevant registration, a priori protocol for this scoping review was developed following the Joanna Briggs Institute (JBI) approach for scoping review steps [ 27 ], as also recommended by Cochrane [ 28 , 29 ]. These instructions expand upon Arksey and O’Malley’s work [ 30 ] and the protocol is guided by the Population-Concept-Context framework. This protocol is also in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and the latest PRISMA Scoping Review Extension Checklist (PRISMA-ScR) [ 31 – 33 ], which will guide the organisation and structure of the review ( S1 File ). Since the scoping review will only be based on published data with no data being collected from human participants, ethical approval is not required.

The following processes will be applied and are described in detail below:

Stage 1: Identifying the research question

Stage 2: identifying relevant studies, stage 3: study selection, stage 4: charting the data.

• Stage 5: Collating, summarising, and reporting the results.

The scoping review protocol was also pre-registered with the Open Science Framework [registration URL osf.io/ktrvm]

The WHO’s 2021 HLM analytical framework has for the first time described the HRH stock and HLM mismatches not just by a) numbers (shortage or surplus); or b) skills (over or under-qualified) but also c) discrimination due to the cultural and social context of the market [ 11 ]. Following this report, the new health and care workforce guides on utilising health and care workforce data are specifically highlighting how to capture discriminatory experiences of health and care workers. However, this is still a new understanding. Preliminary searches revealed limited works, and no existing systematic or scoping review looking at the range or intersectionality of inequalities experienced by health and care workers. Withing this context, PRISMA scoping review checklist guidance was followed to formulate the review questions as follows:

• What are the kinds of inequalities experienced by health and care workers?
• What are the bases of these inequalities and what are their outcomes?

Population–concept- context (PCC) framework was used to identify the main elements and conceptualize the review question. The framework was also used to identify the relevant keywords and inform the search strategy [ Table 1 ].

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https://doi.org/10.1371/journal.pone.0302175.t001

Existing scoping and systematic reviews on either of the components (population or concept) from the PCC framework were searched in PubMed and SCOPUS to identify keywords and phrases found in the titles and abstracts of papers that were likely to be included in the scoping review. Possible synonyms and combinations of the identified search terms were collected. Additional conditions like limiting to types of studies or geography were also considered and tested but eventually not included in the final protocol. The final keywords were also shared with three subject experts for their comments, to ensure that any essential HRH or inequality-related keywords are not missed.

Two sets of keywords were developed: For the population (health and care workforce) and for the concept (inequalities within health and care workforce). For health and care workforce, WHO’s definition and elaborations were used to search for possible cadres and job categories [ 34 , 35 ]. These definitions and categorizations encompass a wide range of health and care workers, including physicians, nurses, midwives, community health workers, and other health professionals. Understanding that literature around health and care workforce could be generic (human resources for health or health professionals or healthcare providers) or specific (nurses or dentists or surgeons) and this was incorporated in the search strategy. Categories of health and care workers unique to different national contexts were also included e.g. auxiliaries, health aides, Accredited Social Health Activists (ASHA) workers, Community Health Extension Workers (CHEWs), Lady Health Workers (LHWs) etc. Different iterations were run to reduce keywords and customize for the final database choices.

For the concept keywords set (inequalities experienced), a range of keywords was originally included, ranging from inequalities, bias and discrimination, to bullying, victimisation, micro aggressions, racism, violence and assault. However, it was decided that the search be kept open for the expected outcomes and experiences and not locked with the key words. Therefore the final words included were around inequalities, inequities and discrimination.

On the basis of the initial literature review, a list of relevant databases has been put together, including 20+ databases accessible through University of Essex’s registration with EBSCO. Based on the subsequent discussions and finalization of scoping review objectives, a review of literature will be performed in PubMED, CINAHL Ultimate, Web of Science and SCOPUS. In addition to this, a list of five-ten extremely relevant articles will be developed and entered into Research Rabbit App and Connected Papers App to identify closest network of relevant papers and expert authors, which will also be scoped and considered for inclusion.

Initial drafts of the search strategy have been reviewed by the Library Team at the University of Essex. Prior to finalization of the search string, multiple iterations were run with different keyword and search strategy combinations i.e. searching the concept keywords in title or abstract fields, before finalization of the root search string. The final search components (both population and concept) will be applied in the article TITLE to reduce the number of irrelevant articles.

Database-specific search string variants with the final key words and relevant index terms, Boolean operators, truncation and wildcard symbols will be developed for each of these databases.

Initially it was intended that only research after the year 2005 will be included, following the WHO’s 2006 World Health Report which was an exhaustive assessment of health and care workforce situation globally [ 36 ]. However, in the final search string no date restrictions have been placed, considering the fact that the World Health Report did not specifically frame any challenges experienced unequally by the health and care workers due to their positionality.

All published research articles in English language will be included. Papers will be excluded if they do not fit into the conceptual framework of the study, for example studying inequitable health and care workforce distribution without focusing on inequalities being experienced by health and care workers, papers focusing on health workers but not their experiences, papers focusing on inequalities being perpetuated by health and care workers or being addressed by them [ Table 2 ].

https://doi.org/10.1371/journal.pone.0302175.t002

The proposed search string will be run and based on outputs of the first 100 articles, the search strategy will be adjusted for sensitivity and specificity.

Data extraction: Data outputs from the four databases will be imported into Rayyan software, duplicates will be removed using software’s automated and AI detection, and a consolidated excel file will be exported for screening and data charting. For articles that the authors are unable to retrieve with the institutional access, support will be sought from the university library team.

Title and Abstract screening: First titles and then abstracts will be screened by two reviewers to exclude studies that qualify the exclusion criteria [ Table 2 ]. In addition to the first author, who has prior experience of HRH-related situational profiling, strategy development and research, an external relevant expert with experience of scoping reviews will be invited as a second reviewer to support with screening of articles. A small sample of scoped studies will be selected to pilot the application of eligibility criteria, and presented to the second and third authors to smooth out any disagreements and seek consensus before moving ahead with the final screening.

Text reading: Full text of included studies will be assessed for eligibility, and reasons for exclusion will be provided for studies that will be rejected. Data for the included studies will be charted.

Discrepancy assessment: Results of the two reviewers will be assessed, discrepancies will be discussed and if required, a third reviewed will be invited to make a final decision. The entire flow will be documented and presented in the PRISMA flow chart.

No critical quality appraisal will be undertaken for this scoping review, since this is not required in a scoping review and is completely optional as per JBI and PRISMA Guidelines for scoping reviews [ 33 ].

A preliminary data charting form has been developed to determine variables to extract. The sample data extraction chart in JBI manual was used as a basic skeleton with fields added to it to serve the needs of the scoping review. The initial review iterations and subsequent discussions with the supervisory team have aided in identifying the study features, types of inequalities, experiences, workforce outcomes, methodologies etc. to be extracted [ S2 Table ].

Data abstraction will be conducted using the Excel output file that will be developed a priori and pilot-tested on a sample set of papers. Revisions, amendments, and additions will be made to the chart along the process to capture rich information, while simultaneously correcting the extraction of previously extracted studies. During the review process, inconsistencies in the charting will be resolved and fields may be reduced/ added to make data more meaningful. For example, multiple studies use race, culture and ethnicity interchangeably. These fields will be charted separately but at the time of descriptive analysis of the studies included, based on thematic overlaps categories may be folded/ collapsed. The data entry fields in Excel file have been designed to ensure pivoting and cross-tabulation for descriptive analysis later.

Both quantitative and qualitative data will be abstracted on study objectives, country of setting, existing frameworks or theories used to generate knowledge, types of knowledge synthesis approaches, key results, types of factors being studied (e.g. gender, race, parenthood etc.), types of experiences as a result (discrimination, prejudice, bullying, harassment etc.), the resulting impact on health and care workers’ career (barriers to career progress, leadership, penalties) or their well-being (psychosocial burnout, physical fatigue etc.), behaviours adopted by health and care workers embodying these experiences (choosing to ignoring, increasing effort, leaving work etc.). Fields like year of publication, country of publication, DOI and published keywords will be automatically extracted at the time of search and imported into the software.

Stage 5: Collating, summarising, and reporting the results

Basic descriptive analysis will be undertaken by the first author to map the origins/ country settings of the selected papers, types of papers, inequalities and bases, health and care workforce outcomes etc. This data will be presented in tables and graphs. MS Excel and Power Bi will be used to develop charts. Snapshot summaries of the final included studies will be presented.

Although scoping review guidelines do not call for analysis beyond basic descriptive analysis, such as frequency counts of concepts, populations etc. mapped in tables or graphs [ 37 , 38 ], a thematic analysis will also be undertaken [ 39 ] to capture the breadth and depth of information beyond the frequency of appearing of concepts in the scoped literature, following the Braun and Clarke’s method with some modification [ 40 , 41 ]. No software will be used for this thematic analysis. Based on the pilot studies reviewed earlier, on average any included study in this review is expected to unpack one-three bases of inequalities and discuss on average at least two possible outcomes. Keeping this in context, the articles will not be assigned individual codes. Instead multiple codes will be assigned to each article and Maguire and Delahunt‘s approach of theoretical thematic analysis will be used to capture information that is relevant to, or of interest vis-à-vis the scoping review objective [ 40 ]. Pre-set codes will not be assigned, and instead open coding will be done, developing and modifying the codes as more articles are scoped. The initial codes [ 42 ] will be captured in the Excel output form.

Once the coding is completed, the codes will be re-examined and if found similar/related, will be grouped under a theme. For example, articles studying mental health impact on health and care workers, distress, burn-out, exhaustion may be grouped as ‘burning out’, under ‘embodiment of discriminatory experiences by health and care workers and impact on their personal well-being’. The themes will be predominantly descriptive. Overlapping themes will be re-grouped. Finally, a thematic map will be drawn to conceptualize the evidence covered and respond to the original objective of the scoping review. In addition, codes derived by these themes will also be re-assigned to the included articles to develop an evidence heat map.

The sections of analysis, discussion and conclusion of the scoping review will be co-developed by the three authors, reflecting the rich experience and subject expertise of the authors: that of inequalities in health systems, social inequalities and intersectionality, and health systems strengthening and restructuring.

To the authors’ best knowledge, this review protocol is the most recent and comprehensive to report on the breadth of literature mapping the inequalities experienced by health and care workers. Its main aim is to understand the kinds of inequalities, their bases and health and care workforce outcomes covered in literature. The scoping review will reveal the different points within the HLM covered in the literature on health and care workers’ experiences, identifying gaps in knowledge for informing policies and planning, and it is hoped that its results will be relevant to policy makers as well as HRH workers.

Dissemination plans

The results of this review will be disseminated through publications in peer-reviewed journals, conference presentations, op-eds and social media discussion threads in researcher networks working on HRH and health systems strengthening.

Study design limitations

To authors’ knowledge and based on the literature search undertaken for this, this is the first scoping review to explore impact of multiple inequalities experienced by health and care workers on their professional and personal lives. Since a date restriction has not been set, as a consequence a broad extent of literature is expected to provide the basis for this scoping review. Furthermore, articles of interest published in other languages will be missing in this review, especially those from countries in East Asia and Europe.

Supporting information

S1 table. keywords developed for population and concept..

https://doi.org/10.1371/journal.pone.0302175.s001

S2 Table. Preliminary data extraction chart.

https://doi.org/10.1371/journal.pone.0302175.s002

S1 File. PRISMA scoping review checklist.

https://doi.org/10.1371/journal.pone.0302175.s003

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• Open access
• Published: 11 April 2024

Palliative care needs of people and/or their families with serious and/or chronic health conditions in low- or middle-income country (LMIC) humanitarian settings—a systematic scoping review protocol

• Michelle McGannan   ORCID: orcid.org/0000-0002-9809-9568 1 ,
• Liz Grant   ORCID: orcid.org/0000-0001-7248-7792 2 ,
• David Fearon   ORCID: orcid.org/0000-0002-0295-3118 1 ,
• Marshall Dozier   ORCID: orcid.org/0000-0002-5151-1252 3 &
• Victoria Barber-Fleming   ORCID: orcid.org/0000-0002-8047-0234 4  

Systematic Reviews volume  13 , Article number:  105 ( 2024 ) Cite this article

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Metrics details

Palliative care in low- or middle-income country (LMIC) humanitarian settings is a new area, experiencing a degree of increased momentum over recent years. The review contributes to this growing body of knowledge, in addition to identifying gaps for future research. The overall aim is to systematically explore the evidence on palliative care needs of patients and/or their families in LMIC humanitarian settings.

Arksey and O’Malley’s (Int J Soc Res Methodol. 8:19-32, 2005) scoping review framework forms the basis of the study design, following further guidance from Levac et al. (Implement Sci 5:1-9, 2010), the Joanna Briggs Institute (JBI) Peters et al. (JBI Reviewer’s Manual JBI: 406-452, 2020), and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) from Tricco et al. (Ann Intern Med 169:467-73, 2018). This incorporates a five-step approach and the population, concept, and context (PCC) framework. Using already identified key words/terms, searches for both published research and gray literature from January 2012 to October 2022 will be undertaken using databases (likely to include Cumulative Index of Nursing and Allied Health (CINAHL), MEDLINE, Embase, Global Health, Scopus, Applied Social Science Index and Abstracts (ASSIA), Web of Science, Policy Commons, JSTOR, Library Network International Monetary Fund and World Bank, Google Advanced Search, and Google Scholar) in addition to selected pre-print sites and websites. Data selection will be undertaken based on the inclusion and exclusion criteria and will be reviewed at each stage by two reviewers, with a third to resolve any differences. Extracted data will be charted in a table. Ethical approval is not required for this review.

Findings will be presented in tables and diagrams/charts, followed by a narrative description. The review will run from late October 2022 to early 2023. This is the first systematic scoping review specifically exploring the palliative care needs of patients and/or their family, in LMIC humanitarian settings. The paper from the review findings will be submitted for publication in 2023.

Peer Review reports

An estimated 274 million people are in need of humanitarian protection and assistance in 2022 [ 1 ], and while palliative care has rarely been undertaken in these situations [ 2 ], since 2016 a recognition of the need for palliative care integration into humanitarian settings has been growing [ 3 ] with the importance of this becoming increasingly recognized [ 4 ]. Palliative care has been incorporated into the Humanitarian Sphere Handbook [ 5 ], in addition to the WHO publication: “Integrating palliative care and symptom relief into the response to humanitarian crises and emergencies” in 2018 [ 2 ]. The first Field Manual for Palliative Care in Humanitarian Crises was published in 2020 [ 6 ].

The growing momentum in this area includes an ever-expanding body of literature, ranging across the spectrum from primary research studies to reports and anecdotal reflections. Since 2017, a small number of systematic or scoping reviews have been undertaken — these have included studies focusing on palliative care in LMIC humanitarian emergency/crisis settings [ 3 , 7 ]; death, dying, and end-of-life care for refugees, now residing in both high-income countries (HIC) and LMIC settings [ 8 ]; end-of-life care in natural disasters, including pandemics in both LMIC and HIC settings [ 9 ]; culturally sensitive palliative care in humanitarian contexts, in both HIC and LMIC settings [ 10 ]; exploring palliative care for forced migrant families and children now in HIC and LMIC settings [ 11 ]; and underrepresentation of palliative care guidelines in infectious disease outbreaks in both HIC and LMIC contexts [ 12 ]. None of the systematic or scoping reviews located has specifically explored the palliative care needs of the patient and/or their family in multiple LMIC humanitarian settings as the sole topic, thereby highlighting an apparent gap. Upon reviewing the PROSPERO — International Prospective Register of Systematic Reviews, and the Joanna Briggs Institute Systematic Review Register, there did not appear to be any systematic or scoping review protocols directly related to this specific topic.

This systematic scoping review will provide a current depiction of the palliative care needs of patients and/or their families in LMIC humanitarian settings. This type of review has been chosen as it ensures a broader scope, enabling less restrictive inclusion criteria and the bringing together of evidence from disparate sources [ 13 ].

Clarifying terms/definitions for the purpose of the review

The WHO in 2002 ([ 14 ] p. 84) defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” In 2018, the WHO publication “Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises” outlined how the “prevention and relief of suffering should be made accessible for anyone suffering physically, psychologically, socially or spiritually and not only for those with life- threatening conditions” ([ 2 ] p. 17). De Boer et al. [ 12 ] outlined how palliative care is for people with chronic or life-limiting illness, and the Field Manual for Palliative Care in Humanitarian Crises describes how palliative care has become a distinct subspecialty with the emphasis on care provision for people and their families with severe and life-limiting illness, regardless of the imminence of death [ 4 ].

For the purpose of this review, we will define palliative care as the care (outlined in the WHO 2002 definition [ 14 ]) provided for the needs of people with serious and/or chronic conditions and/or their families. The use of the term “serious and/or chronic conditions” is reflective of the discussions in the literature outlined above regarding defining palliative care in humanitarian contexts.

Palliative care needs will be defined as “multidimensional problems, symptoms, distress and concerns which can benefit from palliative care” [ 15 , 16 ]. LMIC humanitarian settings will include public health emergency, acute refugee context, protracted refugee context, and natural disaster, taken from the four sub-studies outlined by the Humanitarian Health Ethics Research Group [ 17 ]. We are adding two additional categories — conflict [ 2 , 18 ] and internally displaced people. As this is a rapidly growing area, a category of “other” will also be included.

Study design

Arksey and O’Malley’s [ 19 ] scoping review framework, with additions from Levac et al. [ 20 ], will be used to guide the broad outline of the methodology. The five steps from their frameworks will be broadly followed: (1) Identify the research question, (2) identify relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting the results. Additional methodology from the Joanna Briggs Institute (JBI) [ 13 ] and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) from Tricco et al. [ 21 ] will also be incorporated to enhance rigor.

Stage 1: Identify the research question

The JBI [ 13 ] recommended the use of the PCC pneumonic — “participants, concept and context” to guide both the development of the research question and the inclusion criteria. The PCC listed are as follows:

Participants

People who have serious and/or chronic health conditions which have the capacity to benefit from palliative care as outlined by the WHO [ 14 ], as reported by themselves, their relatives or a health professional, and/or their family members.

The palliative care needs of people with serious and/or chronic conditions and/or their family members.

LMIC (including low-, lower-middle-, and upper-middle-income country settings as identified by the World Bank [ 16 ]) humanitarian settings including, but not limited to, public health emergency, acute refugee context (including refugee and forced migration, acute (ongoing) conflict), protracted refugee context and natural disaster (various disasters, including earthquake, hurricane, tsunami, famine) [ 17 ], conflict [ 2 , 18 ], and internally displaced people.

Research questions

What are the palliative care needs of people with serious and/or chronic conditions in LMIC humanitarian contexts?

What are the palliative care needs of the families of people with serious and/or chronic conditions in LMIC humanitarian contexts?

Inclusion criteria

Published research/peer-reviewed studies (including, but not limited to, qualitative, quantitative, mixed-methods, case studies,), gray literature (including, but not limited to, unpublished reports, studies, and data obtained following either requests to key informants/experts in the field and/or from pertinent websites) guidelines and textbook chapters, conference abstracts (for both oral presentations and posters), and posters that meet the below criteria will be considered for inclusion:

Literature reporting individual palliative care needs for patient and/or family (including, but not limited to, symptoms, problems, concerns, and distress in the psychological, physical, social, and spiritual domains of life) which have the capacity to benefit from palliative care as outlined by the WHO (2002) [ 14 ] as reported by themselves, their relatives, or a health professional

Literature relating to serious and/or chronic health conditions, diseases, and injuries, which demonstrate palliative care needs. This can include, but is not limited to, cancers, organ failure (heart, lung, renal, and liver) dementia, and other diseases (such as, but not limited to, HIV, stroke, and neurological diseases) and injuries.

Date: From January 2012 to October 2022 (due to the dynamic nature of this field, it is envisaged that the majority of the literature will be relatively recent, and a 10-year period would maximize the opportunity to capture relevant data that remains current. Two previous systematic reviews [ 3 , 7 ] appear to show only a very small amount of data relevant to this study in earlier years).

Language: English and Arabic (Arabic is included as the second language due to the number of humanitarian crises in Arabic-speaking regions, which may result in Arabic language data — while data will only be extracted from literature in these languages, if literature in other languages is found, this only will be reported/cited but not included in the analysis due to practical issues relating to translation).

Population: Adults and children with serious and/or chronic health conditions which have the capacity to benefit from palliative care as outlined by the WHO (2002) [ 14 ], as reported by themselves, their relatives, or a health professional and/or their families

Literature from any LMIC (including low-, lower-middle-, and upper-middle-income country settings as identified/listed by the World Bank 2022 [ 16 ]) humanitarian setting (including, but not limited to, public health emergency, acute refugee context (including refugee and forced migration), acute (ongoing) conflict, protracted refugee context and natural disaster (various disasters, including, but not limited to, earthquake, hurricane, tsunami, famine), conflict, and internally displaced people).

Development of the inclusion criteria has been guided by Sepúlveda et al. (2002) [ 22 ] as cited by Afolabi et al. (2021) [ 15 ], Doherty et al. (2020) [ 23 ], Nouvet et al. (2018) [ 3 ], Amir et al. (2020) [ 17 ], WHO (2018) [ 2 ], and Krakauer et al. (2020) [ 18 ] and a small number of adapted inclusion criteria used by Afolabi et al. (2021) [ 15 ].

Exclusion criteria

Studies/literature relating solely to palliative care in high-income country (HIC) humanitarian contexts (i.e., palliative care in Covid in HIC settings)

Literature relating to palliative care in LMIC settings which are not classified as humanitarian settings (as identified in inclusion criteria)

Literature in languages other than English and Arabic will be reported/cited but not included in data analysis due to translation issues.

Papers that only include opinion — editorials and letters

Due to the limited work undertaken in this very new area, plus several key studies reporting on mixed populations of adults and children, literature relating to both adults and children will be included. This will ensure pertinent data is not excluded.

Conference abstracts will also be included to increase the opportunity to capture pertinent data in this novel field. If additional data or clarification is required from included conference abstracts/posters or full-text studies/literature, attempts will be made to contact the authors.

Stage 2: Identify relevant studies

The comprehensive strategy will comprise electronic database searches, examination of included text reference lists to identify further resources [ 13 , 19 ], and searching the gray literature [ 13 ].

Databases to be searched are likely to include CINAHL, MEDLINE, Embase, Global Health, Scopus, Applied Social Science Index and Abstracts (ASSIA), Web of Science, Policy Commons, JSTOR, Library Network International Monetary Fund and World Bank ( https://library.worldbankimflib.org/ ), Google Advanced Search, and Google Scholar. Pre-print databases to be searched are as follows: Preprints.org , medRxiv ( https://www.medrxiv.org/ ), and F1000Research ( https://f1000research.com/ ). Existing networks will be utilized [ 19 ], including communication to key experts to identify further unpublished reports/studies/data. Relevant websites will also be examined (these can be found listed in Additional file 1 ).

The search strategy for the majority of databases will combine three sets of terms/key words — palliative care descriptors, humanitarian setting descriptors, and LMIC descriptors, including all LMIC countries as defined by the World Bank [ 16 ]. This approach was adapted from the search strategy used by Nouvet et al. [ 3 ] for their systematic review of palliative care in humanitarian crises, where palliative care and humanitarian descriptor sets were used. However, following testing, some of the key words/terms were reviewed, aiming to ensure as far as possible that key indicator papers were located, in addition to attempting to reduce the volume of potentially irrelevant literature and to obtain a more manageable number of citations. For example, Ebola was included as a humanitarian descriptor due to the data written on this humanitarian crisis in LMIC; Covid-19 was also included, although combined with palliative care as a search term in the humanitarian descriptors due to the vast amount of literature on this subject alone. Individual words/terms within each set will be separated by the Boolean descriptor “or” with the Boolean operator “and” used to combine the sets. However, for a number of database, pre-print database, and website searches, it is likely that only two descriptor sets will be used (palliative care and humanitarian) with reduced key words, as this approach appeared more effective during preliminary testing. An example of key words/terms can be found in Additional file 2 . It is likely that the search strategy will be adapted for each database/website, to enhance specificity, with further filters applied to improve sensitivity of citations retrieved.

The results of a draft search history, undertaken using Ovid MEDLINE database on 30th July 2022, can be found in Additional file 3 . There were no language filters used, and the dates in the search were from 2012 to 2022. This search strategy will be adapted for other databases.

Stage 3: Study selection

This is an iterative team process involving searching, refinement of the search strategy (if necessary) and reviewing literature for inclusion [ 20 ]. Initial searches of databases will be undertaken, with results exported into the EndNote bibliographic system and duplicates removed. Two reviewers will independently review titles and abstracts against the inclusion and exclusion criteria.

If abstracts are not available, full-text data will be reviewed at this stage; it is predicted this will be for a minority of data, probably websites and some gray literature. The number of papers screened and rejected based on title and abstract screening, in addition to the number of papers retrieved for full text screening, will be recorded. Reviewers will meet at the beginning, middle, and end of the title and abstract review stage, to discuss any issues related to study selection and, if needed, to refine the search strategy [ 20 ]. Unresolved disagreements will be resolved by a third reviewer [ 13 ].

Two reviewers will then independently review full-text literature, gray literature, guidelines, textbook chapters, conference abstracts, and posters for inclusion or exclusion, with input from a third reviewer in the event of any disagreements [ 13 , 20 ] using a table developed by the research team from the eligibility criteria. A summary of this process can be found in Fig. 1 .

Scoping review flow diagram, showing phases for data extraction and selection (adapted PRISMA-ScR reporting flow diagram, taken from Moher et al. (2009) [ 28 ])

Reference lists of included documents will be searched, and any relevant abstracts identified will be reviewed following the process outlined above. The websites will also be searched, and any relevant abstracts/data will be reviewed using the process outlined above.

Stage 4: Charting the data

Data will then be extracted and charted in a table, which aims to provide a summary of the results which is both descriptive and logical [ 13 ]. This will be created by the review team collaboratively, ensuring the inclusion of variables to answer the research question(s) [ 20 ]. It is currently proposed that this will be developed from a combination of the JBI list [ 13 ] with specific pertinent areas added (as outlined in Fig. 2 ).

Data extraction chart variables

Following a pilot of the table [ 13 ], data entry will commence, with the chart being updated as agreed by the reviewers, as charting is an iterative process [ 20 ]. It is aimed to incorporate both academic and gray literature in the same table, as limited data in this area is predicted.

Stage 5: Collating, summarizing, and reporting the results

Extracted data will be initially presented in an overall summary table focusing on the main characteristics of each piece of literature; it is currently planned that this will include origin/humanitarian setting, adult, child or adult/child mixed population, aim, methods, and key findings. Further numerical data, probably relating to literature category, palliative care domain, and humanitarian setting, will be presented visually using tables, diagrams, and/or charts.

Using the principles of framework synthesis, where data in a scoping review is sorted/charted against an a priori framework ([ 24 , 25 , 26 ] as cited by 3), it is planned that literature on palliative care needs will then be extracted and categorized into palliative care domain/sub-domain and mapped to a specific humanitarian setting in a table (see table in Additional file 4 ).

Following the tables and charts, a narrative description will outline how the results relate to the research question(s) [ 13 ]. This plan for presenting the results may undergo further revisions during the review process when there is greater awareness of the data available [ 27 ].

Following the full search and review, the results will be reported as outlined in stage 5, subject to review depending on the data extracted. It is aimed to publish the review in a peer-reviewed journal, thereby adding to the growing body of evidence on palliative care in humanitarian contexts.

Research ethics approval is not required for this scoping review.

The inclusion of conference abstracts and posters may be a potential limitation, as there is a risk that data may be missing, due to the brevity of the format; authors will be contacted to request further data if possible. However, their inclusion can be justified due to the limited full-text peer-reviewed research in this area.

As patient and family palliative care needs in humanitarian contexts may be a challenging area to identify from article and data titles, literature may be unintentionally omitted; although with the broad search strategy employed in this review, every effort will be made to mitigate this risk.

The inclusion of data relating to both adult and child participants is a strength of this study. The reporting will clearly identify adult, child, or mixed adult/child data (including proportion of adult and child participants where identification is possible).

This is the first systematic scoping review to specifically explore the palliative care needs of the patient and/or their family, in LMIC humanitarian settings. This format is being utilized to ensure a broad scope is undertaken, enabling the inclusion of literature from disparate sources. This review will form part of a wider research project, exploring palliative care learning needs and evidence-based palliative care curricula for humanitarian health workers, and will contribute to the rapidly growing body of knowledge in this area. It is further anticipated that the findings will highlight research gaps.

Availability of data and materials

Not applicable

Abbreviations

Low- or middle-income country

Joanna Briggs Institute

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

Cumulative Index of Nursing and Allied Health

Applied Social Science Index and Abstracts

High-income countries

World Health Organization

Participants, concept, and context

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Acknowledgements

Dr. Ruth McQuillan (University of Edinburgh) who provided valuable critique of an earlier version of the protocol.

The review is not funded by any funding bodies. Victoria Barber-Fleming’s role in this research is independent of her PhD research project which is funded by the Legal & General Group (research grant to establish the independent Advanced Care Research Centre at University of Edinburgh). The funders had no role in conduct of the study, interpretation, or the decision to submit for publication. The views expressed are those of the authors and not necessarily those of Legal & General.

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MM, LG, and DF developed the concept. MM, LG, and MD developed the protocol. MM, LG, MD, and VB-F developed the search strategy. MM drafted the manuscript, under the supervision of LG. All authors have made intellectual contributions to the development of this protocol. All authors read and gave approval to the publishing of this protocol manuscript. MM is the guarantor.

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Draft search history

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Proposed table mapping palliative care needs in relation to domains/sub-domains and humanitarian settings

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McGannan, M., Grant, L., Fearon, D. et al. Palliative care needs of people and/or their families with serious and/or chronic health conditions in low- or middle-income country (LMIC) humanitarian settings—a systematic scoping review protocol. Syst Rev 13 , 105 (2024). https://doi.org/10.1186/s13643-024-02521-4

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Arts and creativity interventions for improving health and wellbeing in older adults: a systematic literature review of economic evaluation studies

• Grainne Crealey 1 ,
• Laura McQuade 2 ,
• Roger O’Sullivan 2 &
• Ciaran O’Neill 3  

BMC Public Health volume  23 , Article number:  2496 ( 2023 ) Cite this article

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As the population ages, older people account for a larger proportion of the health and social care budget. A significant body of evidence suggests that arts and creativity interventions can improve the physical, mental and social wellbeing of older adults, however the value and/or cost-effectiveness of such interventions remains unclear.

We systematically reviewed the economic evidence relating to such interventions, reporting our findings according to PRISMA guidelines. We searched bibliographic databases (MEDLINE, EMBASE, Econlit and Web of Science and NHSEED), trial registries and grey literature. No language or temporal restrictions were applied. Two screening rounds were conducted independently by health economists experienced in systematic literature review. Methodological quality was assessed, and key information extracted and tabulated to provide an overview of the published literature. A narrative synthesis without meta-analysis was conducted.

Only six studies were identified which provided evidence relating to the value or cost-effectiveness of arts and creativity interventions to improve health and wellbeing in older adults. The evidence which was identified was encouraging, with five out of the six studies reporting an acceptable probability of cost-effectiveness or positive return on investment (ranging from £1.20 to over £8 for every £1 of expenditure). However, considerable heterogeneity was observed with respect to study participants, design, and outcomes assessed. Of particular concern were potential biases inherent in social value analyses.

Conclusions

Despite many studies reporting positive health and wellbeing benefits of arts and creativity interventions in this population, we found meagre evidence on their value or cost-effectiveness. Such evidence is costly and time-consuming to generate, but essential if innovative non-pharmacological interventions are to be introduced to minimise the burden of illness in this population and ensure efficient use of public funds. The findings from this review suggests that capturing data on the value and/or cost-effectiveness of such interventions should be prioritised; furthermore, research effort should be directed to developing evaluative methods which move beyond the confines of current health technology assessment frameworks, to capture a broader picture of ‘value’ more applicable to arts and creativity interventions and public health interventions more generally.

PROSPERO registration

CRD42021267944 (14/07/2021).

Peer Review reports

The number and proportion of older adults in the population has increased in virtually every country in the world over past decades [ 1 ]. In 2015, there were around 901 million people aged 60 years and over worldwide, by 2030, this will have increased to 1.4 billion [ 2 ]. An ageing population is one of the greatest successes of public health but it has implications for economies in numerous ways: slower labour force growth; working-age people will have to make greater provisions in welfare payments for older people who are no longer economically active; provisions for increased long-term care; and, society must adjust to the changing needs, expectations and capabilities of an expanding group of its citizens.

The Covid-19 pandemic shone an uncompromising light on the health and social care sector, highlighting the seriousness of gaps in policies, systems and services. It also focused attention on the physical and mental health consequences of loneliness and social isolation. To foster healthy ageing and improve the lives of older people, their families and communities, sustained and equitable investment in health and wellbeing is required [ 3 ]. The prevailing model of health and social care which is based ostensibly on formal care provision is unlikely to be sustainable over the longer term. New models, which promote healthy ageing and recognise the need for increasing reliance on self-care are required, as will be evidence of their effectiveness, cost-effectiveness and scalability.

Arts and creativity interventions (ACIs) can have positive effects on health and well-being, as several reviews have shown [ 4 , 5 ]. For older people, ACI’s can enhance wellbeing [ 6 , 7 , 8 , 9 ], quality of life [ 10 , 11 ] and cognitive function [ 12 , 13 , 14 , 15 , 16 ]. They can also foster social cohesion [ 17 , 18 , 19 ] and reduce social disparities and injustices [ 20 ]; promote healthy behaviour; prevent ill health (including enhancing well-being and mental health) [ 21 , 22 , 23 , 24 , 25 ], reducing cognitive decline [ 26 , 27 ], frailty [ 28 , 29 , 30 , 31 , 32 , 33 ] and premature mortality [ 34 , 35 , 36 , 37 , 38 ]); support people with stroke [ 39 , 40 , 41 , 42 ]; degenerative neurological disorders and dementias and support end of life care [ 43 , 44 ]. Moreover, ACIs can benefit not only individuals, but also others, such as supporting the well-being of formal and informal carers, enriching our knowledge of health, and improving clinical skills [ 4 , 5 ].

The benefits of ACIs have also been acknowledged at a governmental level by those responsible for delivering health and care services: The UK All-Party Parliamentary Special Interest group on Arts, Health and Wellbeing produced a comprehensive review of creative intervention for health and wellbeing [ 45 ]. This report contained three key messages: that the arts can keep us well, aid recovery and support longer better lived lives; they can help meet major challenges facing health and social care; and that the arts can save money for the health service and social care.

Despite robust scientific evidence and governmental support, no systematic literature review has collated the evidence with respect to the value, cost or cost-effectiveness of such interventions. Our objective was to assess the economic impact of ACIs aimed at improving the health and wellbeing of older adults; to determine the range and quality of available studies; identify gaps in the evidence-base; and guide future research, practice and policy.

A protocol for this review was registered at PROSPERO, an international prospective register of systematic reviews (Registration ID CRD42021267944). We used pre-determined criteria for considering studies to include in the review, in terms of types of studies, participant and intervention characteristics.

The review followed the five-step approach on how to prepare a Systematic Review of Economic Evaluations (SR-EE) for informing evidence-based healthcare decisions [ 46 , 47 , 48 ]. Subsequent to developing and registering the protocol, the International Society for Pharmacoeconomic Outcomes and Research (ISPOR) published a good practice task force report for the critical appraisal of systematic reviews with costs and cost-effectiveness outcomes (SR-CCEOs) [ 49 ]. This was also used to inform the conduct of this review.

Eligibility criteria

Full economic evaluations are regarded as the optimal type of evidence for inclusion in a SR-EE [ 46 ], hence cost-minimisation analyses (CMA), cost-effectiveness analyses (CEA), cost-utility analyses (CUA) and cost–benefit analyses (CBA) were included. Social value analyses were also included as they are frequently used to inform decision-making and commissioning of services within local government. Additionally, they represent an important intermediate stage in our understanding of the costs and consequences of public health interventions, where significant challenges exist with regard to performing full evaluations [ 50 , 51 , 52 , 53 ].

Development of search strategies

The population (P), intervention (I), comparator (C) and outcomes (O) (PICO) tool provided a framework for development of the search strategy. Studies were included if participants were aged 50 years or older (or if the average age of the study population was 50 years or over). Interventions could relate to performance art (dance, singing, theatre, drama etc.), creative and visual arts (painting, sculpture, art making and design), or creative writing (writing narratives, poetry, storytelling). The intervention had to be active (for example, creating art as opposed to viewing art; playing an instrument as opposed to listening to music). The objective of the intervention had to be to improve health and wellbeing; it had to be delivered under the guidance of a professional; delivered in a group setting and delivered on more than one occasion. No restrictions were placed on the type of comparator(s) or the type of outcomes captured in the study. We deliberately limited the study to professionally led activities to provide a sharper distinction between social events where arts and creativity may occur and arts and creativity interventions per se. We set no language restriction nor a restriction on the date from which studies were reported.

Search methods

PRESS (peer-review electronic search strategies) guidelines informed the design our search strategy [ 54 , 55 ] and an information specialist adapted the search terms (outlined in Table S 1 ) for the following electronic bibliographic databases: MEDLINE, PubMed, EMBASE, Econlit and Web of Science and NHSEED. We also inspected references of all relevant studies; and searched trials registers (ClinicalTrials.gov). Search terms used included cost, return on investment, economic, arts, music, storytelling, dancing, writing and older adult as well as social return on investment (SROI). The last search was performed on 09/11/2022. As many economic evaluations of ACIs (especially SROIs) are commissioned by government bodies or charitable organisations, a search of the grey literature was undertaken.

Handling searches

A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow chart was used to document study selection, illustrating the numbers of records retrieved and selection flow through the screening rounds [ 56 , 57 , 58 ]; all excluded records (with rationale for exclusion) were documented.

Selection of studies

Two screening rounds were conducted independently by two health economists experienced in undertaking reviews (GC, CO’N). The first round screened the title and abstract of articles based on the eligibility criteria; those selected at this stage entered a second round of full text screening with eligibility based on the inclusion and exclusion criteria. Any disagreements were discussed among the two reviewers, with access to a third reviewer available to resolve disagreements, though this proved unnecessary.

Data extraction and management

Two reviewers extracted relevant information independently using an proforma developed specifically for the purposes of this study, which included all 35 items suggested by Wijnen et al. (2016) [ 48 ]. Information was extracted in relation to the following factors: (1) general information including study title, author, year, funding source, country, setting and study design; (2) recruitment details, sample size, demographic characteristics (age, gender) and baseline health data (diagnosis, comorbidities); (3) interventions, effectiveness and cost data; (4) type of economic evaluation, perspective, payer, beneficiary, time horizon, measure of benefit and scale of intervention; (5) quality assessment, strength of evidence, any other important information; (6) results; (7) analysis of uncertainty and (8) conclusions. The quality assessment/risk of bias checklists were included in the data extraction proforma, and picklists were used to enhance uniformity of responses. The data extraction form was piloted by two reviewers (GC and CON) on one paper and discussion used to ensure consistent application thereafter.

Assessment of study quality

Two reviewers (GC & CON) independently assessed study quality, with recourse to a third reviewer for resolution of differences though this proved unnecessary. Quality assessment was based on the type of economic evaluation undertaken. Full and partial trial-based economic evaluations were assessed using the CHEC-extended checklist [ 59 ]. SROI analyses were assessed using a SROI-specific quality framework developed for the purpose of systematic review [ 60 ].

Data analysis methods

Due to the small number of evaluations detected, possible sources of heterogeneity and a lack of consensus on appropriate methods for pooling cost-effectiveness estimates [ 61 ] a narrative synthesis analysis was undertaken.

Database searches returned 11,619 records; from this, 402 duplicates were removed leaving 11,214 reports. From these 113 reports were assessment against the inclusion and exclusion criteria resulting in 4 studies for inclusion in the review. Over 40 websites were searched for relevant content returning 2 further studies for inclusion. The PRISMA 2020 diagram is presented in Fig.  1 . A high sensitivity search strategy was adopted to ensure all relevant studies were identified, resulting in a large number of studies being excluded at the first stage of screening.

PRISMA 2020 flow diagram for new systematic reviews which include searches of databases, registers and other sources

A total of six studies were identified; key characteristics are presented in Table 1 . Identified studies were published between 2011 and 2020. Two studies used a health technology assessment (HTA) framework alongside clinical trials [ 62 , 63 ] to assess the cost-effectiveness of community singing interventions. Both evaluations scored highly on the CHEC-extended checklist (Table 2 ), with findings reported in line with the CHEERS (Consolidated Health Economic Estimation Reporting Standards) checklist 2022 [ 64 ].

Four further studies employed an SROI framework to assess art and/or craft interventions: two studies were published in the peer-reviewed literature [ 65 , 66 ] and a further two in the grey literature [ 67 , 68 ]. All four adhered closely to the suggested steps for performing an SROI and consequently secured high scores (Table 3 ). No quality differential was discerned between those studies published in the academic literature when compared with those from the grey literature.

Five of the studies were undertaken in the UK [ 63 , 66 , 67 , 68 , 69 ] and one in the US [ 63 ]. Four of the studies were designed for older adults with no cognitive impairment [ 62 , 63 , 67 , 68 ]; one was designed for participants with or without dementia [ 65 ], and another was specifically for older adults with dementia and their caregivers [ 66 ]. Three of the studies were delivered in a community setting [ 62 , 63 , 67 ], two in care homes [ 65 , 68 ] and one across a range of settings (hospital, community and residential) [ 66 ]. The length and duration of the ACIs varied; some lasted 1–2 h (with multiple classes available to participants) [ 65 ], whereas others were structured programmes with sessions lasting 90 min over a 14-week period [ 62 ]. The number of participants included in studies varied; the largest study contained data from 390 participants [ 63 ], whereas other studies measured engagement using numbers of care homes or housing associations included [ 67 , 68 ].

Costs were captured from a narrower perspective (i.e., the payer—health service) for those economic evaluations which followed a health technology assessment (HTA) framework [ 62 , 63 ]. Costs associated with providing the programme and health and social care utilisation costs were captured using cost diaries. Valuation of resource usage was in line with the reference case specified for each jurisdiction.

Social value analyses included in the review [ 65 , 66 , 67 , 68 ] captured a broader picture of cost; programme provision costs included were similar in nature to those identified using an HTA framework, however, the benefits captured went beyond the individual to capture costs to a wide range of stakeholders such as family members, activity co-ordinations and care home personnel. Costs were apportioned using financial proxies from a range of sources including HACT Social Value Bank [ 69 ] and market-based valuation methods.

The range of outcomes captured and valued across HTAs and SROIs was extensive: including, but not limited to, wellbeing, quality of life, physical health, cognitive functioning, communication, control over daily life choices, engagement and empowerment, social isolation, mobility, community inclusion, depressive symptoms, sadness, anxiety, loneliness, positive affect and interest in daily life. In the programmes assessed using an HTA framework, outcomes were captured using standardised and validated instruments, for both control and intervention groups across multiple time points. Statistical methods were used to assess changes in outcomes over time. Programmes assessed using SROI relied primarily on qualitative methods (such as reflective diaries and in-depth interviews) combined with routinely collected administrative data.

The evidence from the singing interventions was encouraging but not conclusive. The ‘Silver Song Club’ programme [ 62 ] reported a 64% probability of being cost-effective at a willingness-to-pay threshold of £30,000. This study was also included in the Public Health England (PHE) decision tool to support local commissioners in designing and implementing services to support older people’s healthy ageing, reporting a positive societal return on investment [ 70 ]. Evidence from the ‘Community of Voices’ trial [ 63 ] suggested that although intervention group members experienced statistically significant improvements in loneliness and interest in life compared to control participants, no significant group differences were observed for cognitive or physical outcomes or for healthcare costs.

A positive return on investment was reported by all social value analyses undertaken. The ‘Imagine Arts’ programme, reported a positive SROI of £1.20 for every £1 of expenditure [ 65 ]. A higher yield of between £3.20-£6.62 for each £1 invested was reported in the ‘Dementia and Imagination’ programme [ 66 ]. The ‘Craft Café’ programme, reported an SROI of £8.27 per £1 invested [ 68 ], and the ‘Creative Caring’ programme predicted a SROI of between £3 to £4 for every £1 spent [ 67 ]. The time period over which return on investment was calculated differed for each evaluation from less than one year to 4 years.

The primary finding from our review concerns the paucity of evidence relating to the value, cost and/or cost-effectiveness of ACIs aimed at improving health and wellbeing in this population. Despite few restrictions being applied to our search, only six studies were found which met our inclusion criteria. This is not indicative of research into ACIs in this population, as evidenced by the identification of ninety-three studies where arts and creativity interventions were found to support better health and wellbeing outcomes in another recent review [ 5 ]. An alternative explanation is that funders do not see the added value of undertaking such evaluations in this area. That is, for funders, the cost of evaluating an ACIs is likely to be deemed unjustified given the relatively small welfare loss a misallocation of resources to them might produce. While at first glance this may seem reasonable, it disadvantages ACIs in competing with other interventions for funding and arguably exposes an implicit prejudice in the treatment of interventions from which it may be difficult to extract profit in general. That is, the paucity of evidence, may reflect inherent biases within our political economy that favour the generation of marketable solutions to health issues from which value can be appropriated as profit. Pharmaceuticals are an obvious example of such solutions, where the literature is replete with examples of evaluations sponsored by pharmaceutical companies or where public funds are used to test the claims made by pharmaceutical companies in respect of the value of their products. If the potential of ACIs to improve health and well-being is to be robustly established, ACIs must effectively compete for funding with other interventions including those from pharma. This requires a larger, more robust evidence base than is currently available and investment in the creation of such an evidence base. As there is currently no ‘for-profit’ industry to generate such an evidence base, public funding of evaluations will be central to its creation.

Our second finding concerns the values reported in the meagre evidence we did find. In five of the six studies we identified, evidence indicated that ACIs targeted at older people offered value for money [ 62 , 65 , 66 , 67 , 68 ]. One study provided mixed evidence [ 63 ], however, in this study a ‘payer’ perspective was adopted when applying an HTA framework which, by virtue of the perspective adopted, excluded a range of benefits attributable to ACIs and public health interventions more generally. Among the four studies that adopted a SROI approach, estimated returns per £1 invested ranged from £1.20 to £8.27. Given the evident heterogeneity among studies in terms of context and methods, care is warranted in comparing estimates with each other or with other SROIs. Care is also required in accepting at face value the estimates reported given methodological issues that pertain to the current state of the art with respect to SROI. With these caveats in mind noted, the values reported for ACIs using the SROI approach are comparable with those from other SROI studies in other contexts including those as diverse as a first aid intervention [ 71 ], investment in urban greenways [ 72 ] and the provision of refuge services to those experiencing domestic violence [ 73 ] (a return on investment of £3.50-£4, £2.88-£5.81 and £4.94 respectively). Similarly, with respect to the study that adopted a cost-effectiveness approach, Coulton and colleagues (2015) reported a 64% probability of the intervention being cost-effective at a threshold of £30,000 [ 62 ]. Again, it is difficult to compare studies directly, but this is similar to that reported for interventions as diverse as a falls prevention initiative [ 74 ] and the treatment of depression using a collaborative approach [ 75 ] both in the UK. That the evidence base is meagre notwithstanding, there is, in other words, a prima facie case that ACIs are capable of offering value for money when targeted at older persons.

Our third finding relates to the state of the art with respect to SROIs in this area. Over the past 40 years, considerable time, effort and resources have been expended in the development of cost-effectiveness techniques in health and social care. While considerable heterogeneity can exist around their conduct, national guidance exists in many jurisdictions on the conduct of cost-effectiveness analyses (CEA) – such as the NICE reference case in the UK [ 76 ]– as well as in the reporting of these as set out in the CHEERS 2022 guidance [ 64 ]. This has helped raise the quality of published evaluations and the consistency with which they are reported. Despite the existence of a step-by-step guidance document on how to perform SROIs [ 77 ] which outlines how displacement effects, double counting, effect attribution and drop-off should be addressed, a significant body of work still remains to ensure that the methodology addresses a range of known biases in a robust manner. Where there is no comparator to the intervention being evaluated (as was the case in the SROIs reported here) it may be difficult to convince funders that the implicit incremental costs and benefits reported are indeed incremental and attributable to the intervention. Equally, where a comparator is present, greater consensus and standardisation is required regarding the identification, generation and application of, for example, financial proxies. Currently, SROI ratios combine value across a wide range of stakeholders, which is understandable if the objective is to capture all aspects of social benefit generated. This ratio, however, may not reflect the priorities and statutory responsibilities of healthcare funders. Whist all of the aforementioned issues can be addressed, investment is required to develop the SROI methodology further to more closely meet the needs of commissioning bodies.

Notwithstanding these challenges, social value analyses play a pivotal role within the procurement processes employed by government, local authorities and other non-departmental public bodies and should not be dismissed simply because the ‘burden of proof’ falls short of that required to secure remuneration within the health sector. As most SROIs are published in the grey literature, this means they often avoid peer scrutiny prior to publication and the potential quality assurance this can offer. It is noteworthy however that two of the SROIs included in this review [ 65 , 66 ] were published in the academic literature, suggesting that the academic community are engaging with this method which is to be applauded.

Moving forward, it is unlikely we will be able to meet all of the health and wellbeing needs of our ageing population solely in a primary or secondary care setting. New models of care are required, as are new models of funding to support interventions which can be delivered in non-healthcare settings. New hybrid models of evaluation will be required to provide robust economic evidence to assist in the allocation of scarce resources across health and non-healthcare settings; such evaluative frameworks must have robust theoretical underpinnings and be capable of delivering evidence from a non-clinical setting in a timely and cost-effective manner.

In the absence of a definitive evaluation framework for ACIs being currently available, we have a number of recommendations. First, and most importantly, all impact assessments should have a control group or credible counterfactual. This is currently not required when performing an SROI making it difficult to determine if all of the benefits ascribed to an intervention are in fact attributable. This recommendation is in line with the conclusion of a report by the London School of Economics [ 78 ] for the National Audit Office (NAO) which concluded that ‘any impact evaluation (and subsequent value for money calculation) requires construction of a counterfactual’. Second, a detailed technical appendix should accompany all impact assessments to allow independent review by a subject specialist. While this would assist peer review, it would allow providing greater transparency where peer review was not undertaken prior to publication. Furthermore, it would enable recalculation of SROI ratios to exclude ‘value’ attributable to stakeholders which are not relevant to a particular funder. Third, equity considerations should be addressed explicitly in all evaluations (this is currently not required in HTAs). Fourth, both costs and outcomes should be captured from a ‘broad’ perspective (adopting a ‘narrow’ healthcare perspective may underestimate the full economic impact), with non-healthcare sector costs being detailed as part of the analysis. Finally, data should be collected post-implementation to ensure that resources continue to be allocated efficiently.

As with any review, there are limitations which should be noted. A search of the grey literature was included as evaluations of applied public health interventions are not always reported in the academic literature. Systematically identifying grey literature and grey data can be problematic [ 79 , 80 , 81 , 82 , 83 ] as it is not collected, organised or stored in a consistent manner. Hence it is possible that we have not identified all relevant studies. Furthermore, as applied public health interventions can be performed in a non-healthcare setting we included SROIs in our review of economic evaluations. Current guidance on the systematic review of economic evaluations has been developed primarily for review of HTA as opposed to public health interventions and hence SROIs would be excluded, or if included would score poorly due to the inherent biases arising from no comparator or counterfactual being included.

This systematic review found that participation in group-based arts and creativity programmes was generally cost-effective and/or produced a positive return on investment whilst having a positive impact on older people’s physical, psychological, and social health and wellbeing outcomes. Unfortunately, the small number of studies identified, coupled with differences in methods used to assess economic impact hinders our ability to conclusively determine which types of art and creativity-based activities are more cost-effective or represent best value for money.

As well as the need for a greater focus on prevention of poor health as we age, new hybrid models of healthcare delivery are necessary to meet the needs of our ageing population. These models will integrate traditional medical care with other services such as home health aides (some of which may include artificial intelligence), telemedicine and social support networks. Alongside these, ACIs have the potential to provide a low cost, scalable, easily implementable and cost-effective solution to reduce the burden of illness in this age group and support healthy ageing.

Evidence on the cost-effectiveness of a range of ACIs is of utmost importance for policy and decision makers as it can both inform the development of policies that support the provision of ACIs in the context of ageing, but also identify the most cost-effective approaches for delivering such interventions. The development of hybrid models of evaluation, capable of capturing cost-effectiveness and social value, is becoming increasingly necessary as healthcare delivery for this age group moves beyond the realms of primary and secondary care and into the community. The development and refinement of such models will ensure a more comprehensive assessment of the impact of a diverse range of interventions providing a more nuanced understanding of the impact of an intervention. This will help inform decision making and ensure interventions are implemented in a cost-effective and socially beneficial manner.

Availability of data and materials

All data generated or analysed during this study are included in the published article and its supplementary information files.

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Acknowledgements

We would like to thank Ms. Louise Bradley (Information Resource Officer, Institute of Public Health) for her assistance in refining search strategies and literature search.

This study was supported by the Institute of Public Health (IPH), 200 South Circular Road, Dublin 8, Ireland, D08 NH90. This study was a collaboration between two health economists (GC, CO’N) and two members of staff from the funding organisation (LM, RO’S). Input from IPH staff was fundamental in defining the scope of work and research question, refining search terms and review and editing of the manuscript. Staff from IPH were not involved in quality assurance or review of papers included in the manuscript.

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LMcQ and ROS were involved in defining the scope of work, refining the research question, provision of subject specific (public health) context, review of search strategy, review & editing of manuscript. CON and GC were involved in refining the research question and search strategy, provision of health economics and systematic reviewing expertise, review of returned reports, original draft preparation, review, editing and submission of manuscript. All authors read and approved the final manuscript.

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Crealey, G., McQuade, L., O’Sullivan, R. et al. Arts and creativity interventions for improving health and wellbeing in older adults: a systematic literature review of economic evaluation studies. BMC Public Health 23 , 2496 (2023). https://doi.org/10.1186/s12889-023-17369-x

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Sexual and reproductive health among forcibly displaced persons in urban environments in low and middle-income countries: scoping review findings

• Carmen H. Logie   ORCID: orcid.org/0000-0002-8035-433X 1 , 2 , 3 , 4 ,
• Frannie MacKenzie   ORCID: orcid.org/0000-0002-3517-8330 1 ,
• Kalonde Malama   ORCID: orcid.org/0000-0001-7655-5916 1 ,
• Nicole Lorimer   ORCID: orcid.org/0000-0001-5759-3247 1 ,
• Anoushka Lad   ORCID: orcid.org/0000-0003-3851-6822 1 ,
• Michelle Zhao   ORCID: orcid.org/0000-0002-6249-8364 1 ,
• Manjulaa Narasimhan   ORCID: orcid.org/0000-0003-0598-6887 5 ,
• Sasha Fahme   ORCID: orcid.org/0000-0003-0265-2582 6 , 7 ,
• Bülent Turan   ORCID: orcid.org/0000-0003-2008-227X 8 ,
• Julia Kagunda   ORCID: orcid.org/0000-0002-7229-9932 9 , 10 ,
• Kelika Konda   ORCID: orcid.org/0000-0003-2836-0174 11 , 12 ,
• Aryssa Hasham   ORCID: orcid.org/0009-0004-9216-1772 1 &
• Amaya Perez-Brumer   ORCID: orcid.org/0000-0003-2441-4358 11 , 13  

Reproductive Health volume  21 , Article number:  51 ( 2024 ) Cite this article

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Most forcibly displaced persons are hosted in low- and middle-income countries (LMIC). There is a growing urbanization of forcibly displaced persons, whereby most refugees and nearly half of internally displaced persons live in urban areas. This scoping review assesses the sexual and reproductive health (SRH) needs, outcomes, and priorities among forcibly displaced persons living in urban LMIC.

Following The Joanna Briggs Institute scoping review methodology we searched eight databases for literature published between 1998 and 2023 on SRH needs among urban refugees in LMIC. SHR was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception; fertility care; safe abortion care). Searches included peer-reviewed and grey literature studies across quantitative, qualitative, or mixed-methods designs.

The review included 92 studies spanning 100 countries: 55 peer-reviewed publications and 37 grey literature reports. Most peer-reviewed articles ( n  = 38) discussed sexual health domains including: GBV ( n  = 23); HIV/STI ( n  = 19); and CSE ( n  = 12). Over one-third ( n  = 20) discussed reproductive health, including: antenatal, intrapartum and postnatal care ( n  = 13); contraception ( n  = 13); fertility ( n  = 1); and safe abortion ( n  = 1). Eight included both reproductive and sexual health. Most grey literature ( n  = 29) examined GBV vulnerabilities. Themes across studies revealed social-ecological barriers to realizing optimal SRH and accessing SRH services, including factors spanning structural (e.g., livelihood loss), health institution (e.g., lack of health insurance), community (e.g., reduced social support), interpersonal (e.g., gender inequitable relationships), and intrapersonal (e.g., low literacy) levels.

Conclusions

This review identified displacement processes, resource insecurities, and multiple forms of stigma as factors contributing to poor SRH outcomes, as well as producing SRH access barriers for forcibly displaced individuals in urban LMIC. Findings have implications for mobilizing innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing) to address these gaps. Regions such as Africa, Latin America, and the Caribbean are underrepresented in research in this review. Our findings can guide SRH providers, policymakers, and researchers to develop programming to address the diverse SRH needs of urban forcibly displaced persons in LMIC.

Plain English summary

Most forcibly displaced individuals live in low- and middle-income countries (LMICs), with a significant number residing in urban areas. This scoping review examines the sexual and reproductive health (SRH) outcomes of forcibly displaced individuals in urban LMICs. We searched eight databases for relevant literature published between 1998 and 2023. Inclusion criteria encompassed peer-reviewed articles and grey literature. SRH was defined to include various dimensions of sexual health (comprehensive sexuality education; sexual and gender-based violence; HIV/ STI prevention; sexual function, and psychosexual counseling) and reproductive health (antenatal, intrapartum, and postnatal care; contraception; fertility care; and safe abortion care). We included 90 documents (53 peer-reviewed articles, 37 grey literature reports) spanning 100 countries. Most peer-reviewed articles addressed sexual health and approximately one-third centered reproductive health. The grey literature primarily explored sexual and gender-based violence vulnerabilities. Identified SRH barriers encompassed challenges across structural (livelihood loss), health institution (lack of insurance), community (reduced social support), interpersonal (gender inequities), and individual (low literacy) levels. Findings underscore gaps in addressing SRH needs among urban refugees in LMICs specifically regarding sexual function, fertility care, and safe abortion, as well as regional knowledge gaps regarding urban refugees in Africa, Latin America, and the Caribbean. Self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, abortion self-management) hold significant promise to address SRH barriers experienced by urban refugees and warrant further exploration with this population. Urgent research efforts are necessary to bridge these knowledge gaps and develop tailored interventions aimed at supporting urban refugees in LMICs.

Peer Review reports

As of mid-2022, the global number of forcibly displaced individuals reached an estimate of 103 million [ 1 ], a significant majority of this population (53.2 million individuals) are internally displaced [ 1 ]. While approximately one-third, totaling 32.5 million people, hold recognized refugee status, another 4.9 million individuals are actively seeking asylum in another country [ 1 , 2 ]. Forcibly displaced persons may experience poorer sexual and reproductive (SRH) outcomes than non-displaced persons due to the interplay of complex social ecological factors [ 3 ]. For instance, forcibly displaced persons may be exposed to sexual and gender-based violence (GBV) before, during, and/or following displacement, and/or upon resettlement. Further, they may experience reduced access to SRH services, including contraception and sexually transmitted infection (STI) prevention and treatment, due to poverty, socio-cultural differences, language, and literacy barriers [ 4 , 5 , 6 , 7 ]. Social and structural barriers such as intersectional stigma related to forcibly displaced status, gender, age, and limited SRH literacy can further constrain SRH engagement [ 8 , 9 ].

Low- and middle-income countries (LMIC) host 74% of the globally forcibly displaced population, and it is estimated that the majority of refugees and nearly half (48%) of internally displaced people live in urban areas [ 1 , 2 , 10 ]. There is the potential that forcibly displaced persons residing in urban settings LMIC may live in poorer housing conditions with less economic and social support than those living in refugee camps or refugee settlement environments managed by humanitarian agencies [ 11 , 12 ]. For instance, challenges facing forcibly displaced persons living in urban LMIC contexts can include transportation costs, higher living costs that may result in overcrowded living conditions, poverty, and language barriers to accessing relevant employment, education, health and other services [ 13 , 14 , 15 ]. It is plausible that these factors can also reduce the accessibility and utilization of SRH services. Inadequate SRH service provision is associated with increased gender-based violence (GBV), elevated risks for acquisition and transmission of HIV and other STIs, unintended pregnancies, and unsafe abortions [ 8 , 16 ]. Further, urbanization among refugees may contribute to poverty and exacerbate gender inequities, both associated with increased likelihood of GBV [ 3 , 17 , 18 ]. With rising urbanization among forcibly displaced persons, there is a need for greater understanding of the sexual and reproductive health (SRH) outcomes and priorities to inform tailored intervention and programs.

Existing systematic reviews have reported evidence-based approaches to improve antenatal, postnatal, and newborn health, HIV prevention and treatment outcomes, and uptake of family planning resources and services, for forcibly displaced persons at large [ 19 , 20 ]. There is evidence that interpersonal, health-system, and socio-cultural factors shape access to SRH care among forcibly displaced peoples [ 21 ]. Literature has also documented relationships between climate migration and GBV, decreased maternal and neonatal health, and increased barriers to accessing and using SRH services [ 22 ]. While these important reviews document factors that shape SRH among forcibly displaced peoples at large, there remains a notable lack of research focused on forcibly displaced persons regarding SRH issues including GBV prevention, STI transmission and treatment, menstruation hygiene management, and disrupted access to SRH care [ 19 , 22 ]. Further, findings have not distinguished between urban or refugee camp/settlement contexts, resulting in a lack of clarity regarding specific needs, priorites, and SRH outcomes among forcibly displaced persons in urban LMIC contexts.

The objective of this scoping review is to identify, critically appraise, and synthesize the literature on sexual and reproductive health needs, outcomes, and priorities of forcibly displaced persons living in urban LMICs. A comprehensive understanding of these dimensions and existing research gaps can inform future practice, research, and policy.

The Joanna Briggs Institute methodology for scoping reviews was followed throughout this review [ 23 ]. A complete and comprehensive explanation of the methods used can be found in the published study protocol [ 24 ].

Search strategy

Completed in January 2023, we searched eight databases, MEDLINE, EMBASE, PsycINFO, CINAHL, IBSS, ASSIA, SSCI, and Global Medicus Index, for literature published between 1998 and 2022 on SRH needs among forcibly displaced persons in LMIC. The search structure first grouped terms for each of urban, refugees, sexual health, low and middle-income countries, and reproductive health using the Boolean operator OR. Following this, terms for urban and refugees were combined using the Boolean operator AND, and terms for sexual health and reproductive health were combined using the Boolean operator OR. Lastly, the search terms for urban refugees, sexual health or reproductive health, and low and middle-income countries were combined using the Boolean operator AND – ((urban OR cities OR municipal) AND (refugee* OR displace* OR asylum)) AND ((sexual health OR gender-based violence OR sexually transmitted disease*) OR (reproductive health OR prenatal OR contraception)) AND (low income countries OR middle income countries OR developing nations). A detailed search strategy for all databases can be found in the Supplementary File 1 . A grey literature search was also conducted in accordance with a search guide developed by Godin et al. [ 25 ].

Study selection

The study population was a) any forcibly displaced person, following UNHCR’s definition that includes refugee, migrant, asylum seeker, or internally displaced persons forced to flee due to persecution, conflict, human rights violations, or other serious events disrupting order [ 1 , 2 ], b) living in a LMIC as defined by the World Bank Atlas Method [ 26 ] and c) living in an urban context, including urban, semi-urban, city, metropolis, or if study location is listed as urban in the UN World Urbanization Prospects database of country-specific definitions of ‘urban’ [ 27 ]. SRH was operationalized as any dimension of sexual health (comprehensive sexuality education [CSE]; sexual and gender based violence [GBV]; HIV and STI prevention and control; sexual function and psychosexual counseling) and/or reproductive health (antental, intrapartum, and postnatal care; contraception counselling and provision; fertility care; safe abortion care) [ 28 , 29 ].

We included peer-reviewed or gray literature studies using quantitative, qualitative, or mixed-methods designs focused on any dimension of sexual/reproductive health written in the English language. Studies were excluded if they a) did not include forcibly displaced persons; b) included migrants by choice; c) did not focus on SRH; d) were not based in urban contexts; e) had metadata not in English; and f) there was no full-text article available. Key subject terms were searched among websites of governmental, non-governmental, and international organizations working with forcibly displaced persons.

Data extraction and analysis

Once both the database search and grey literature search were completed, data from included records were extracted by a reviewer into a spreadsheet. All records were uploaded on to Covidence systematic review software (VeritasHealth Innovation, Melbourne, Australia) and duplicates were removed. On Covidence, each record’s title and abstract were screened by at least 2 study team members for inclusion eligibility. The full texts of all included articles were further screened by two study team members. At this point, the reference list of each included article was manually hand searched. If a relevant article was found via hand search, it was entered into Covidence and put through the screening process as outlined. All discrepancies were reviewed by a third team member and/or discussed with all reviewers. Extracted data points included the record’s general characteristics, population, concept, context, main outcome measure, and key findings relevant to this review. Every record’s data extraction was examined by a second team member for accuracy. All data were then summarized and collated into the accompanying narrative summaries.

Our peer-reviewed article search returned 1151 results across eight databases and 2275 grey literature reports. In total, 92 documents including 55 peer-reviewed articles and 37 grey literature pieces met the inclusion criteria for this scoping review. Among the peer-reviewed articles, PRISMA Flow Chart in Fig.  1 shows the selection process for 53 peer-reveiewed articles (Fig.  1 ). Six additional peer-reviewed articles were hand searched, 2 of which met the inclusion criteria and were included.

PRISMA flow diagram of a scoping review on urban forcibly displaced persons' sexual and reproductive health in low and middle-income countries

The peer-reviewed articles were mapped onto dimensions of sexual health and reproductive health [ 29 ] (Table  1 ). The majority of peer-reviewed articles ( n  = 40; 72.7%) discussed sexual health domains including: GBV prevention, support and care ( n  = 23); HIV and STI prevention and control ( n  = 21); and comprehensive sexuality education ( n  = 12). Under the sexual health domain, no articles were located that discussed sexual function and psychosexual counselling. More than one-third ( n  = 20; 36.3%) discussed reproductive health areas including: antenatal, intrapartum and postnatal care ( n  = 13); contraception counselling & provision ( n  = 13); fertility care ( n  = 1); and safe abortion care ( n  = 1). While not within the SRH framework [ 28 , 29 ], menstrual hygiene management was included as a SRH issue in this review as it was discussed in three articles. Eight articles discussed intervention areas that included both reproductive and sexual health domains. Sexual and reproductive health dimensions covered in peer-reviewed articles are displayed in Table  2 .

Sexual and gender-based violence (GBV)

Among the 17 studies that examined GBV [ 32 , 33 , 36 , 37 , 40 , 41 , 42 , 45 , 46 , 52 , 61 , 68 , 69 , 73 , 74 , 75 , 76 ] in urban contexts, all explored GBV as it was experienced by women and girls, and one examined experiences of both adolescent boys and girls [ 52 ]. Most articles explored experiences of adult women: two explored GBV among adolescent girls [ 75 , 76 ] and one explored GBV experiences among young women [ 68 ].

Prevalence and health correlates of intimate partner violence

Of the 17 articles that examined GBV, most ( n  = 11; 64.7%) specifically examined intimate partner violence (IPV) [ 32 , 33 , 40 , 41 , 42 , 45 , 52 , 61 , 69 , 73 , 76 ]. Prevalence ranged from 11.1%-86.0% and varied by age, type of IPV, and external factors. All studies examined the experience of adults, with the exception of two that looked at adolescents, and these found the highest prevalences of IPV at 85.8% and 86.0% [ 52 , 76 ]. Two articles examined the prevalence of different types of IPV. One study found partner control followed by economic abuse and emotional abuse to be the most common forms of IPV at 73%, 53.3%, and 50.3% respectively [ 33 ]. Another study found slapping and throwing objects to be the most common forms of physical IPV [ 41 ].

More than half of these articles reported associations between IPV and health and wellbeing ( n  = 6), incuding mental, physical, and other SRH outcomes. For instance, there were associations between experiencing IPV and mental health concerns such as post-traumatic stress disorder symptoms [ 61 ] and frequent alcohol use [ 52 ]. One study with refugee women in Amman, Irbid and Zarqa, Jordan found an association between psychological IPV and higher rates of health problems including heart, gastrointestinal, liver, respiratory, and urinary problems, recurrent dizziness, fibromyalgia, joint pain, and back pain [ 32 ]. Another study with refugee women in Semnan, Iran found IPV exposure was associated with a range of SRH outcomes, including early marriage, sexual coercion, unwanted pregnancy, and a high number of children [ 40 ].

The different ways that IPV was measured across studies make it difficult to synthesize these findings, however across studies it appears that a) urban forcibly displaced girls and women are disproportionately exposed to polvictimization (multiple forms of violence); b) there is a range of health challenges linked with IPV exposure, including and extending beyond SRH; and c) married women reported a high prevalence of IPV, including during pregnancy.

Risk factors associated with GBV exposure

Seven of the 17 articles that examined GBV explored risks associated with GBV exposure (41.2%) [ 36 , 37 , 42 , 46 , 52 , 68 , 75 ]. Three studies collected data from women only [ 36 , 42 , 46 ] while the other four collected data from both women and men [ 37 , 52 , 68 , 75 ]. One study found that women were more likely to share stories about sexual harassment while men more likely to discuss other forms of GBV [ 68 ].

GBV exposure risks varied across social categories, including age, education, changing social structures and norms, and disruption to social networks and livelihoods. For instance, studies with adolescent girls and young women, including refugees in Beirut, Beqaa, and Tripoli, Lebanon [ 68 ] and displaced people in Izmir, Turkey [ 75 ], reported that early marriage was associated with risks for further GBV [ 68 , 75 ]. Among those experiencing early marriage, factors that increased risks for GBV included limited educational opportunities, financial strains, and being alone outside the home [ 75 ]. Further, urbanization may change parents’ perspectives on child marriage after arriving in Lebanon, as they may be more likely to view early marriage as a pathway to protecting their daughters and reducing parental responsibility [ 39 ].

Among internally displaced adult women, displacement and subsequent loss of social support networks elevated risks for GBV [ 36 , 37 ]. For instance, in a study conducted in Port-au-Prince, Haiti, destruction of livelihood elevated risks for GBV [ 36 ]. Findings paralleled another study in Abidjan, Côte d’Ivoire that documented that poverty, food and housing instability, and changing gender roles and norms increased GBV exposure [ 37 ]. Partner characteristics and relationship dynamics were also associated with GBV, including partner alcohol misuse [ 41 , 42 ]. Among pregnant refugees in Sidon, Lebanon, odds of IPV were higher among those whose husbands did not want the pregnancy [ 42 ].

Polyvictimization was also reported [ 73 , 74 , 76 ]. For instance, forcibly displaced women with a history of childhood abuse may be more likely to experience adulthood violence [ 76 ], and as adult, forcibly displaced women may report multiple forms (e.g., physical violence, abductions, forced imprisonment, sexual violence, early/forced marriage) and contexts of violence (country of origin, host country) [ 74 ]. Together these studies on GBV suggest that multi-level factors, including structural (poverty, livelihood and educational barriers), social (gender inequitable norms, disrupted social networks), and relational (relationship power dynamics, partner alcohol use) level factors increase vulnerability to multiple forms of GBV among urban forcibly displaced persons.

HIV and other sexually transmitted infections (STIs)

Among the 20 articles examining HIV and STIs, 17 focused only on HIV, one article focused on HIV and transactional sex [ 50 ], one on STIs [ 49 ], and one on both HIV and STIs [ 54 ].

HIV and STI testing and prevention

Half of the HIV/STI articles focused on HIV testing and prevention ( n  = 10, 50%) [ 13 , 44 , 47 , 50 , 51 , 53 , 56 , 70 , 71 , 77 ]. Most of these were quantitative ( n  = 7) with three qualitative studies. Studies explored experiences among urban forcibly displaced men and women in Uganda [ 13 , 47 , 50 , 51 , 53 , 77 ], Nepal [ 44 ], and Peru [ 56 ], and refugee men who have sex with men (MSM) in Lebanon [ 70 , 71 ]. Testing uptake, recorded in six studies, ranged from 29–62% and varied by gender and population [ 44 , 47 , 50 , 70 , 71 , 77 ]. For instance, a study with refugees engaged in transactional sex in Kampala, Uganda found that engaging in transactional sex was associated with lower HIV testing among men, and was not associated with HIV testing among women [ 50 ].

Among articles that examined HIV testing [ 13 , 44 , 47 , 51 , 53 , 56 ], transportation costs, overcrowded living conditions, low literacy, and inequitable gender norms were identified as testing barriers [ 13 , 53 ]. Intersecting stigma—including stigma related to HIV, refugees, sexually active adolescents, and sex workers—also presented barriers to HIV testing among urban refugee youth in Kampala, Uganda [ 44 , 47 , 51 ]. Among urban Venezuelan forcibly displaced women in 6 cities in Peru (Metropolitan Lima, Callao, Tumbes, Cusco, Trujillo, Arequipa), not having health insurance was a barrier to HIV and STI testing [ 56 ]. Among MSM in Beirut, Lebanon, lack of comfort with doctors, not seeing a doctor in the past year, and not knowing where to access testing posed as barriers to testing [ 70 , 71 ] Among forcibly displaced urban refugee youth in Kampala, Uganda, factors associated with STI testing were lower food insecurity and lower adolescent SRH stigma [ 49 ].

Several studies focused on HIV vulnerabilities among forcibly displaced persons in urban Uganda [ 52 , 66 , 78 ]. For instance, a study in Gulu with internally displaced men and women reported an HIV prevalence of 12.8%, and risk factors associated with HIV infection included non-consensual sexual debut, past-year STI symptoms, and practicing dry sex (which was defined as sexual intercourse without foreplay or lubrication so that the vagina is dry upon penetration) [ 66 ]. Another study in Kampala, Uganda with refugee youth found that depression, alcohol use, and GBV were associated with HIV vulnerabilities, including recent transactional sex and multiple sex partners [ 52 ]. There may also be gender differences in HIV vulnerabilities; among urban refugee adolescents in Kampala, Uganda, young men reported higher condom self-efficacy than young women [ 62 , 63 ]. A study in Beirut, Lebanon found that over half (56.7%) of refugee MSM reported unprotected anal intercourse with men who were HIV positive or did not know their HIV serostatus, and over a third (36%) had engaged in transactional sex [ 70 , 71 ]. A qualitative study with internally displaced women in Northern Uganda found that the shift away from traditional belief systems, collapse of livelihoods, commuting away from home at night, and inadequate access to SRH information and services elevated HIV vulnerabilities among adolescent girls [ 78 ]. Another qualitative study, with forcibly displaced adult women in Medellin, Colombia, found that social and family fragmentation, GBV, abrupt changes in daily lives, and inequitable gender norms elevated HIV and STI acquisition risks [ 54 ]. These studies taken together reveal the ways that conflict-related life disruptions (e.g., belief systems, livelihoods, social networks), alongside structural factors (e.g., gender inequities, SGBV across the lifecourse, barriers to accessing SRH services) and relational factors (e.g., sexual practices, low condom efficacy), may increase exposure to HIV and STIs and reduce access to testing.

HIV treatment and care

Four articles focused on antiretroviral therapy (ART) and HIV care among urban refugee adult men and women [ 58 , 59 , 60 , 64 ]. Two quantitative studies in Kuala Lumpur, Malaysia that compared HIV treatment and clinical outcomes between refugees, displaced people, asylum seekers, and host community members found no differences in viral suppression among groups [ 58 , 59 ]. Qualitative studies explored challenges associated with achieving optimal treatment adherence [ 60 , 64 ]. One of these studies that included forcibly displaced persons in Kuala Lumpur, Malaysia found that limited access to food, pharmacy stock-outs, and difficulty navigating a new health system were barriers to optimal treatment adherence [ 60 ]. The few studies on HIV treatment and care that were included in this review span wide-ranging contexts, presenting challenges in drawing conclusions from this evidence-base and signal the need for more research with urban forcibly displaced persons living with HIV.

Antenatal care, postnatal care, and contraception

Among the 13 articles that explored antenatal and postnatal care and contraception, six focused on antenatal and postnatal care (46.2%) [ 30 , 34 , 35 , 38 , 65 , 72 ] and seven on contraception and family planning (53.8%) [ 31 , 43 , 55 , 56 , 62 , 63 , 67 ]. Most of these studies were conducted with adult forcibly displaced women ( n  = 9); one was conducted with healthcare workers and policy makers alongside adult women [ 34 ]. The remaining three studies were conducted with forcibly displaced adolescents, one of which explored experiences of only women [ 55 ].

Antenatal and postnatal care

Two of the 13 articles that examined antenatal and postnatal care used quantitative methods to explore uptake of antenatal care [ 30 , 35 ]. One study found that 82.9% of pregnant refugees had received some antenatal care in 14 high refugee density sites, including Beirut, in Lebanon [ 35 ], while another study found that pregnant refugees in Tehran, Iran attended an average of 3.73 out of 8 possible antenatal appointments [ 30 ]. Four articles explored barriers to accessing care and related risks [ 34 , 38 , 65 , 72 ]. One of these studies with pregnant refugees in South Tehran, Iran found that financial constraints, lack of health insurance, transportation challenges, stigma, cultural concerns, legal and immigration issues, and healthcare staff behaviour presented barriers to utilizing prenatal services [ 38 ]. Moreover, an article with pregnant forced migrant mothers in Mumbai, India reported that they could not access the antenatal care they need due to unfamiliarity with the local context and a lack of knowledge regarding where to access antenatal care, putting them at a greater risk for poor health outcomes [ 65 ]. From these limited studies, structural level challenges (e.g., health insurance barriers, healthcare mistreatment, immigration issues) alongside socio-cultural challenges (e.g., stigma, cultural and religious concerns) posed barriers to antenatal and postnatal care.

Contraception

Among the seven articles that explored family planning, five used quantitative methods to explore the access and utilization of contraceptives [ 55 , 56 , 62 , 63 , 67 ]. One study found that only 20.2% of migrant and refugee women in six urban cities in Peru had access to modern contraceptives [ 56 ]. Contraceptive access was reported to be influenced by family and relationship status as well as dynamics. For instance, among migrant and refugee women in six urban sites in Peru, lower socio-economic status was associated with reduced likelihood of emergency contraceptive use, and those who were married or lived with a partner were more likely to use modern and emergency contraceptives [ 56 ]. A qualitative study with forcibly displaced women in West Bekaa, Lebanon described that beliefs about wanting a large family size were often in tension with the financial hardships they experienced in displacement, men held the dominant role in making decisions about family planning, and contraceptive access was hindered by the unaffordability of the privatised health system [ 43 ]. Another qualitative study found that internally displaced women in Maputo, Mozambique experienced social isolation excluding them from the contraceptive revolution in their host community [ 31 ]. Together these studies paint a complex picture of contraceptive access and needs, where some factors associated with low contraception uptake may include structural barriers (e.g., low socio-economic status), relational factors, (e.g., relationship status), and socio-cultural values and priorities (e.g., wishes for larger family sizes) shaped by community norms and experiences of conflict.

Grey literature findings

Among the 37 included grey literature reports, over three-quarters ( n  = 29) examined GBV [ 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 ]; these studies are detailed in Table  3 . Emergent GBV themes centered on vulnerabilities to experiencing sexual, physical, and psychological abuse. Reports describe forcibly displaced persons in urban humanitarian contexts were at elevated risk for GBV exposure due to various social, cultural, and political dynamics, such as income insecurity, overcrowded living conditions, inequitable gender dynamics, inequitable power dynamics with administrative authorities, and limited awareness of rights [ 86 , 88 , 90 , 91 , 92 , 93 , 94 , 97 , 101 , 104 , 105 , 108 ]. Perpetrators of GBV included landlords, neighbors and employers, all of whom displaced people may be dependent on, and in lower positions of power [ 104 , 105 ]. The main reported targets of violence were women, sexual minorities, and transgender people [ 83 , 85 , 86 , 87 , 94 , 95 , 96 , 100 , 107 , 108 ]. These reports, taken together, emphasize the importance of integrated policies, research, and SRH services to reduce GBV and promote health equity among individuals at risk, including sexually and gender diverse persons. Additionally, the reports emphasize the critical need for support services to aid GBV survivors [ 79 , 82 , 85 , 98 , 103 ].

Other themes identified from the grey literature include sex work, disability, contraception needs, and the needs of people living with HIV. Two reports addressed sex work among displaced people who may fear social and legal consequences (including stigma and prosecution) if their sex work was disclosed; accordingly, mobile clinics were suggested as an appropriate entry point for SRH services tailored for forcibly displaced sex workers [ 80 , 109 ]. Another report described barriers to accessing SRH services, including HIV/STI testing and family planning, for forcibly displaced persons with disabilities, noting stigma faced by forcibly displaced people with disabilities [ 106 ]. Multiple studies described SRH service gaps, notably a lack of choice regarding a variety of family planning methods for forcibly displaced women, and limited access to HIV care for forcibly displaced people living with HIV [ 113 , 115 , 116 ]. Recommendations for improving access to SRH services for urban forcibly displaced people included: (1) improved collaboration between various systems and authorities that forcibly displaced people interface with; (2) wider dissemination of SRH knowledge to forcibly displaced persons; (3) the need to create safe, inclusive, and culturally-aware SRH spaces; and (4) the importance of empowering women and girls in humanitarian contexts to mitigate gender inequity as a barrier to SRH access [ 110 , 111 , 112 , 114 ].

Findings from this scoping review underscore that forcibly displaced individuals in urban LMIC settings face multiple barriers to SRH. These barriers encompass structural (e.g., loss of livelihoods, lack of health insurance), social (e.g., limited access to community support), interpersonal (e.g., gender inequitable relationship dynamics), and intrapersonal (e.g., poor mental health) factors. These barriers align with a social ecological [ 117 , 118 ] approach to health that accounts for the complex interplay between different spheres of influence, and can inform tailored interventions that target one or more levels for change (see Fig.  2 ). Our findings also identify understudied sexual health (i.e., sexual function and psychosexual counseling) and reproductive health (i.e., fertility care, safe abortion care) domains with this population.

Conceptual framework of multi-level sexual and reproductive health care barriers and challenges among urban forcibly displaced persons in low and middle-income countries

We found across included studies that displacement processes were discussed as exacerbating SRH vulnerabilities among forcibly displaced persons in urban LMIC settings [ 31 , 36 , 37 , 54 , 57 , 60 , 65 , 78 ]. These included the role of displacement in the breakdown of social support networks and loss of livelihoods in increasing exposure to GBV while also reducing access to sexual health services such as HIV/STI testing. However, the paucity of studies precludes synthesizing experiences by SRH domain (e.g., safe abortion), setting (e.g., slums/informal settlement), or population (e.g., adolescent). A similar limitation was identified by Singh et al. in their 2018 systematic review on the utilization of SRH services in humanitarian crises at large [ 119 ]. This observation signals a persistent lack of substantial progress in advancing the field as a whole, and in turn the contextually specific needs of urban forcibly displaced persons. We also found a limited focus on safe abortion and STIs beyond HIV. This suggests a need for additional attention to these understudied SRH issues.

Our findings indicate that stigma experienced by urban forcibly displaced persons presents barriers to SRH prevention, access, and care. Stigma is intersectional, targeting various identities such as refugee status and gender and spans across social-ecological levels, including being manifested at structural (e.g., laws and policies), health institution (e.g., healthcare mistreatment), community (e.g., stigma toward refugees), interpersonal (e.g. gender-based stigma), and intrapersonal (e.g., self-stigma) levels. Moreover, stigma is rooted in drivers and facilitators that could be effectively addressed through targeted stigma-reduction interventions [ 120 ]. Stigma within healthcare facilities can reinforce a wider mistrust of health systems among refugee and displaced persons [ 17 , 51 ]. There is scarcity of SRH interventions focused on stigma reduction with this population.

We documented that resource scarcities (e.g., food, housing, economic) were associated with worse SRH outcomes among urban forcibly displaced persons [ 37 , 60 , 75 , 76 ]. This reflects the long-standing insufficient funding and resources for SRH (and health care more generally) in humanitarian settings [ 48 ]. Once a forcibly displaced person leaves a formal refugee settlement/camp to migrate to urban regions, many forgo formal financial support offered by UNHCR or other refugee settlement-based organizations to refugees living in settlements, such as food, land/housing, or economic stipends. They may then experience financial challenges, such as transportation costs to accessing healthcare, high rent in cities and/or substandard housing in urban informal settlements, in addition to lack of health insurance in some contexts. These resource scarcity barriers to SRH care are further exacerbated by individual-level barriers such as low literacy and language barriers, and systemic-level barriers such as insufficient staffing and medication stock-outs.

Our study has limitations. We focused on a select range of SRH outcomes as defined by a SRH conceptual framework [ 28 , 29 ] and may have overlooked other important issues relevant to SRH outside of this (e.g., fistulae). Our criteria for language inclusion may have omitted some relevant articles. As there was so many different contexts, article types, refugee types (e.g., displaced, refugee), and populations (e.g., adolescents, pregnant adult women), we could not conduct a meta-analysis, and even when synthesizing key findings this heterogeneity presented challenges in contextualizing SRH findings within each setting and its socio-cultural norms, geography, country income, and laws and other social determinants of health. It is plausible that urban refugees may share health status outcomes with host communities while living in urban informal settlements or slums due to the nature of shared socio-cultural and economic conditions in slums [ 121 ], yet these similarities and/or differences in SRH outcomes with host communities were beyond the scope of this review. Further, the studies included in our analysis exhibited a significant underrepresentation of large global regions, namely Africa, Latin America, and the Caribbean. This limited inclusion of studies from these regions hampers our understanding of the specific needs and priorities of urban forcibly displaced persons residing in these urban contexts (Figs.  3 and  4 ). Despite these limitations, this review’s strengths include its unique focus on urban forcibly displaced persons in LMIC contexts, where the majority of forcibly displaced persons live. Our review also reinforces the need to include multiply marginalized communities in future SRH research—including urban forcibly displaced sex workers, people who use drugs, and lesbian, gay, bisexual, and transgender persons [ 122 , 123 , 124 ].

Map of countries of included peer-reviewed studies in this scoping review of urban forcibly displaced persons' sexual and reproductive health in low and middle-income countries. Included countries are represented with colours reflecting the number of studies from each country reported in the figure legend

Map of countries of included grey literature studies in this scoping review of urban forcibly displaced persons' sexual and reproductive health in low and middle-income countries. Included countries are represented with colours reflecting the number of studies from each country reported in the figure legend

Urgent research and interventions are needed to address SRH challenges faced by urban forcibly displaced persons; these strategies can ultimately advance health equity and well-being not only for forcibly displaced persons, but in the case of those living in slums, interventions may have multiplier effects [ 121 ]. Future research can identify targets for stigma reduction (e.g., healthcare workers, refugee women) and implement evidence-based intersectional stigma reduction strategies to mitigate barriers to accessing SRH care [ 125 ]. Effectively advancing SRH in humanitarian settings requires resources for implementing and evaluating multi-level interventions integrated within existing health systems, as well as community-level, family-level, and individual-level approaches. Such interventions can specifically address health literacy and language needs of urban forcibly displaced persons, transportation-related challenges (e.g., via mobile clinics), and, when needed, extend health insurance coverage to forcibly displaced individuals. Additionally, innovative approaches such as self-care strategies for SRH (e.g., HIV self-testing, long-acting self-injectable contraception, over-the-counter oral contraception, abortion self-management) hold significant promise in addressing some of these aforementioned SRH barriers and can be explored and tested with urban forcibly displaced persons. These self-care strategies may help to overcome challenges related to privacy, transportation, and healthcare provider mistrust [ 48 , 126 ], yet they also require an enabling social and health environment, so can be offered in tandem with strategies focused on advancing social and health equity [ 126 ].

This review identified barriers to SRH care spanning social-ecological levels [ 117 , 118 ] among urban forcibly displaced persons in LMIC contexts. The process of displacement, resource insecurity, and stigma exacerbate and drive SRH vulnerabilities for urban forcibly displaced persons in LMIC contexts. However, there remain critical knowledge gaps regarding a range of SRH issues across diverse LMIC settings, with particular knowledge gaps regarding socially marginalized populations. Our findings signal that in urban LMIC settings, there may be unique barriers to accessing SRH information, resources and care faced by forcibly displaced persons (e.g., no financial support from UNHCR or other refugee agencies, social isolation, language barriers at clinics) compared to formal refugee settlements where persons may have more access to refugee communities, translators at clinics, and financial stipends (e.g., housing, land, food supplements). Future research and action are required to address the unique and often unmet SRH needs among urban forcibly displaced persons to advance health and rights.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Acknowledgements

The authors wish to acknowledge the assistance of the University of Toronto librarians.

CHL received funding from the Canada Research Chairs Program and the Canadian Institutes of Health Research (CIHR). They played no role in the research process, focus, analysis or other aspects of research.

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Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street W, Toronto, M5S 1V4, Canada

Carmen H. Logie, Frannie MacKenzie, Kalonde Malama, Nicole Lorimer, Anoushka Lad, Michelle Zhao & Aryssa Hasham

Centre for Gender and Sexual Health Equity, Vancouver, Canada

Carmen H. Logie

Women’s College Research Institute, Women’s College Hospital, Toronto, Canada

United Nations University Institute for Water, Environment, and Health, Hamilton, Canada

Department of Sexual and Reproductive Health and Research, including the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland

Manjulaa Narasimhan

Center for Global Health, Weill Cornell Medicine, New York, NY, USA

Sasha Fahme

Department of Health Promotion and Community Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon

Department of Psychology, Koc University, Istanbul, Turkey

Bülent Turan

Elim Trust, Nairobi, Kenya

Julia Kagunda

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Universidad Peruana Cayetano Heredia, Lima, Peru

Kelika Konda & Amaya Perez-Brumer

Department of Population and Public Health Sciences, Keck School of Medicine of USC, University of Southern California, Los Angeles, USA

Kelika Konda

Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

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CHL conceptualized the study and led the writing. FM substantially contributed to writing the manuscript as well as screening, data extraction and synthesis. FM, KM, NL, AL, KD, MZ, conducted the searches, screening and extraction. APB contributed to drafting and editing the manuscript. MN, SF, BT, JK, KK and ABP contributed to editing the manuscript and providing interpretation of findings. CHL, AH, and FM contributed to the revision process. All authors approved the final version of the manuscript.All authors approved the final version of the manuscript.

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Logie, C.H., MacKenzie, F., Malama, K. et al. Sexual and reproductive health among forcibly displaced persons in urban environments in low and middle-income countries: scoping review findings. Reprod Health 21 , 51 (2024). https://doi.org/10.1186/s12978-024-01780-7

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Received : 28 June 2023

Accepted : 22 March 2024

Published : 12 April 2024

DOI : https://doi.org/10.1186/s12978-024-01780-7

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