research papers on english poetry

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Dr Rebecca Pinner Dr Nonia Williams Poetry Editor Professor Tiffany Atkinson Book Reviews Editor Dr Jeremy Noel-Tod 

About the journal

English: Journal of the English Association is dedicated to new developments in English Studies. It publishes work that speaks to the discipline as a whole, including reflections on pedagogy and on the place of English Literature in the world beyond academia.

Call for Submissions 

English: Journal of the English Association publishes scholarship on a wide range of authors and literary texts, and particularly encourages submissions which speak to the discipline as a whole. Our readership comprises schoolteachers as well as academics, so we provide a platform for scholars and educators to reflect on the key questions facing our discipline. Recently published work includes a guest-edited special issue on Poetry in Expanded Translation, two fora on decolonizing English studies, and a recurring 'View From Here' section that features colleagues from around the world. English is one of the few academic literary journals to publish poetry. As well as publishing reviews, we are interested in receiving pitches for reviews of recent books which survey new developments in English Studies.

Read our author guidelines  

2022 Postgraduate Essay Prize

English is delighted to announce its 2022 Postgraduate Essay Prize. It is open to all students currently registered on a PhD and writing on a topic in English Literature. Winners get a cash prize and publication in the journal, while all entries are considered for publication and receive specialist peer review. Explore the past winning essays .

Winner : Georgia Walton, 'Emerson and the Lyric Essay in Maggie Nelson’s Bluets'

Runners up : Minh Vu, 'Leftover Liquids and The Moisture of Mourning and Melancholia in Ocean Vuong’s On Earth We’re Briefly Gorgeous'

William Taylor, '"A benevolent technology": Desiring-production and the Petromodern Death Drive in J. G. Ballard’s Crash'

Read the author guidelines Find out more about the prize

An Introduction From the Editors

We are delighted to welcome the new editors of English , Dr David Nowell Smith and Dr Nonia Williams. Read their inaugural editorial and learn more about their aims for the future of the journal. 

The View from Here

The View from Here is a feature in the journal that looks at global approaches to the discipline of English. All articles are free to read.

Read past The   View from Here  pieces

Spotlight on Poetry

Unlike many academic journals, English  publishes original poetry pieces in every issue. Read the latest  Spotlight on Poetry piece selected by our poetry editor.

Find out how to submit your original poetry piece.

Resource for Teachers

Drawing on the journal’s rich history of work on key texts in the canon of English literature, this issue has been designed to help teachers and students delve deeper into key exam board texts.

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e-Publications@Marquette

Home > ARTSSCI > English > dissertations

English Dissertations and Theses

The English Department Dissertations and Theses Series is comprised of dissertations and thesis authored by Marquette University's English Department doctoral and master's students.

Theses/Dissertations from 2023 2023

Lifting the Postmodern Veil: Cosmopolitanism, Humanism, and Decolonization in Global Fictions of the 21st Century , Matthew Burchanoski

Gothic Transformations and Remediations in Cheap Nineteenth-Century Fiction , Wendy Fall

Milton’s Learning: Complementarity and Difference in Paradise Lost , Peter Spaulding

“The Development of the Conceptive Plot Through Early 19th-Century English Novels” , Jannea R. Thomason

Theses/Dissertations from 2022 2022

Gonzo Eternal , John Francis Brick

Intertextuality and Sociopolitical Engagement in Contemporary Anglophone Women’s Writing , Jackielee Derks

Innovation, Genre, and Authenticity in the Nineteenth-Century Irish Novel , David Aiden Kenney II

Reluctant Sons: The Irish Matrilineal Tradition of Oscar Wilde, James Joyce, and Flann O’Brien , Jessie Wirkus Haynes

Britain's Extraterrestrial Empire: Colonial Ambition, Anxiety, and Ambivalence in Early Modern Literature , Mark Edward Wisniewski

Theses/Dissertations from 2021 2021

Re-Reading the “Culture Clash”: Alternative Ways of Reading in Indian Horse , Hailey Whetten

Theses/Dissertations from 2020 2020

When the Foreign Became Familiar: Modernism, Expatriation, and Spatial Identities in the Twentieth Century , Danielle Kristene Clapham

Reforming Victorian Sense/Abilities: Disabilities in Elizabeth Gaskell’s Social Problem Novels , Hunter Nicole Duncan

Genre and Loss: The Impossibility of Restoration in 20th Century Detective Fiction , Kathryn Hendrickson

A Productive Failure: Existentialism in Fin de Siècle England , Maxwell Patchet

Inquiry and Provocation: The Use of Ambiguity in Sixteenth-Century English Political Satire , Jason James Zirbel

Theses/Dissertations from 2019 2019

No Home but the World: Forced Migration and Transnational Identity , Justice Hagan

The City As a Trap: 20th and 21st Century American Literature and the American Myth of Mobility , Andrew Joseph Hoffmann

The Fantastic and the First World War , Brian Kenna

Insane in the Brain, Blood, and Lungs: Gender-Specific Manifestations of Hysteria, Chlorosis, & Consumption in 19th-Century Literature , Anna P. Scanlon

Reading Multicultural Novels Melancholically: Racial Grief and Grievance in the Joy Luck Club, Beloved, and Anil's Ghost , Jennifer Arias Sweeney

Theses/Dissertations from 2018 2018

The Ethos of Dissent: Epideictic Rhetoric and the Democratic Function of American Protest and Countercultural Literature , Jeffrey Lorino Jr

Literary Cosmopolitanisms of Salman Rushdie, Amitav Ghosh, and Arundhati Roy , Sunil Samuel Macwan

The View from Here: Toward a Sissy Critique , Tyler Monson

The Forbidden Zone Writers: Femininity and Anglophone Women War Writers of the Great War , Sareene Proodian

Theatrical Weddings and Pious Frauds: Performance and Law in Victorian Marriage Plots , Adrianne A. Wojcik

Theses/Dissertations from 2016 2016

Changing the Victorian Habit Loop: The Body in the Poetry and Painting of Dante Gabriel Rossetti and William Morris , Bryan Gast

Gendering Scientific Discourse from 1790-1830: Erasmus Darwin, Thomas Beddoes, Maria Edgeworth, and Jane Marcet , Bridget E. Kapler

Discarding Dreams and Legends: The Short Fiction of Elizabeth Madox Roberts, Flannery O’Connor, Katherine Anne Porter, and Eudora Welty , Katy L. Leedy

Theses/Dissertations from 2015 2015

Saving the Grotesque: The Grotesque System of Liberation in British Modernism (1922-1932) , Matthew Henningsen

The Pulpit's Muse: Conversive Poetics in the American Renaissance , Michael William Keller

A Single Man of Good Fortune: Postmodern Identities and Consumerism in the New Novel of Manners , Bonnie McLean

Julian of Norwich: Voicing the Vernacular , Therese Elaine Novotny

Theses/Dissertations from 2014 2014

Homecomings: Victorian British Women Travel Writers And Revisions Of Domesticity , Emily Paige Blaser

From Pastorals to Paterson: Ecology in the Poetry and Poetics of William Carlos WIlliams , Daniel Edmund Burke

Argument in Poetry: (Re)Defining the Middle English Debate in Academic, Popular, and Physical Contexts , Kathleen R. Burt

Apocalyptic Mentalities in Late-Medieval England , Steven A. Hackbarth

The Creation of Heaven in the Middle Ages , William Storm

(re)making The Gentleman: Genteel Masculinities And The Country Estate In The Novels Of Charlotte Smith, Jane Austen, And Elizabeth Gaskell , Shaunna Kay Wilkinson

Theses/Dissertations from 2013 2013

Brides, Department Stores, Westerns, and Scrapbooks--The Everyday Lives of Teenage Girls in the 1940s , Carly Anger

Placed People: Rootedness in G. K. Chesterton, C. S. Lewis, and Wendell Berry , David Harden

Rhetorics Of Girlhood Trauma In Writing By Holly Goddard Jones, Joyce Carol Oates, Sandra Cisneros, And Jamaica Kincaid , Stephanie Marie Stella

Theses/Dissertations from 2012 2012

A Victorian Christmas in Hell: Yuletide Ghosts and Necessary Pleasures in the Age of Capital , Brandon Chitwood

"Be-Holde the First Acte of this Tragedy" : Generic Symbiosis and Cross-Pollination in Jacobean Drama and the Early Modern Prose Novella , Karen Ann Zyck Galbraith

Pamela: Or, Virtue Reworded: The Texts, Paratexts, and Revisions that Redefine Samuel Richardson's Pamela , Jarrod Hurlbert

Violence and Masculinity in American Fiction, 1950-1975 , Magdalen McKinley

Gender Politics in the Novels of Eliza Haywood , Susan Muse

Destabilizing Tradition: Gender, Sexuality, and Postnational Identity in Four Novels by Irish Women, 1960-2000 , Sarah Nestor

Truth Telling: Testimony and Evidence in the Novels of Elizabeth Gaskell , Rebecca Parker Fedewa

Spirit of the Psyche: Carl Jung's and Victor White's Influence on Flannery O'Connor's Fiction , Paul Wakeman

Theses/Dissertations from 2011 2011

Performing the Audience: Constructing Playgoing in Early Modern Drama , Eric Dunnum

Paule Marshall's Critique of Contemporary Neo-Imperialisms Through the Trope of Travel , Michelle Miesen Felix

Hermeneutics, Poetry, and Spenser: Augustinian Exegesis and the Renaissance Epic , Denna Iammarino-Falhamer

Encompassing the Intolerable: Laughter, Memory, and Inscription in the Fiction of John McGahern , John Keegan Malloy

Regional Consciousness in American Literature, 1860-1930 , Kelsey Louise Squire

The Ethics of Ekphrasis: The Turn to Responsible Rhetoric in Mid-Twentieth Century American Poetry , Joshua Scott Steffey

Theses/Dissertations from 2010 2010

Cognitive Architectures: Structures of Passion in Joanna Baillie's Dramas , Daniel James Bergen

On Trial: Restorative Justice in the Godwin-Wollstonecraft-Shelley Family Fictions , Colleen M. Fenno

Theses/Dissertations from 2009 2009

What's the point to eschatology : multiple religions and terminality in James Joyce's Finnegans wake , Martin R. Brick

Economizing Characters: Harriet Martineau and the Problems of Poverty in Victorian Literature, Culture and Law , Mary Colleen Willenbring

Submissions from 2008 2008

"An improbable fiction": The marriage of history and romance in Shakespeare's Henriad , Marcia Eppich-Harris

Bearing the Mark of the Social: Notes Towards a Cosmopolitan Bildungsroman , Megan M. Muthupandiyan

The Gothic Novel and the Invention of the Middle-Class Reader: Northanger Abbey As Case Study , Tenille Nowak

Not Just a Novel of Epic Proportions: Ralph Ellison's Invisible Man As Modern American Epic , Dana Edwards Prodoehl

Recovering the Radicals: Women Writers, Reform, and Nationalist Modes of Revolutionary Discourse , Mark J. Zunac

Theses/Dissertations from 2007 2007

"The Sweet and the Bitter": Death and Dying in J.R.R. Tolkien's The Lord of the Rings , Amy M. Amendt-Raduege

The Games Men Play: Madness and Masculinity in Post-World War II American Fiction, 1946-1964 , Thomas P. Durkin

Denise Levertov: Through An Ecofeminist Lens , Katherine A. Hanson

The Wit of Wrestling: Devotional-Aesthetic Tradition in Christina Rossetti's Poetry , Maria M.E. Keaton

Genderless Bodies: Stigma and the Myth of Womanhood , Ellen M. Letizia

Envy and Jealousy in the Novels of the Brontës: A Synoptic Discernment , Margaret Ann McCann

Technologies of the Late Medieval Self: Ineffability, Distance, and Subjectivity in the Book of Margery Kempe , Crystal L. Mueller

"Finding-- a Map-- to That Place Called Home": The Journey from Silence to Recovery in Patrick McCabe's Carn and Breakfast on Pluto , Valerie A. Murrenus Pilmaier

Emily Dickinson's Ecocentric Pastoralism , Moon-ju Shin

The American Jeremiad in Civil War Literature , Jacob Hadley Stratman

Theses/Dissertations from 2006 2006

Literary Art in Times of Crisis: The Proto-Totalitarian Anxiety of Melville, James, and Twain , Matthew J. Darling

(Re) Writing Genre: Narrative Conventions and Race in the Novels of Toni Morrison , Jennifer Lee Jordan Heinert

"Amsolookly Kersse": Clothing in Finnegan's Wake , Catherine Simpson Kalish

"Do Your Will": Shakespeare's Use of the Rhetoric of Seduction in Four Plays , Jason James Nado

Woman in Emblem: Locating Authority in the Work and Identity of Katherine Philips (1632-1664) , Susan L. Stafinbil

When the Bough Breaks: Poetry on Abortion , Wendy A. Weaver

Theses/Dissertations from 2005 2005

Heroic Destruction: Shame and Guilt Cultures in Medieval Heroic Poetry , Karl E. Boehler

Poe and Early (Un)American Drama , Amy C. Branam

Grammars of Assent: Constructing Poetic Authority in An Age of Science , William Myles Carroll III

This Place is Not a Place: The Constructed Scene in the Works of Sir Walter Scott , Colin J. Marlaire

Cognitive Narratology: A Practical Approach to the Reader-Writer Relationship , Debra Ann Ripley

Theses/Dissertations from 2004 2004

Defoe and the Pirates: Function of Genre Conventions in Raiding Narratives , William J. Dezoma

Creative Discourse in the Eighteenth-Century Courtship Novel , Michelle Ruggaber Dougherty

Exclusionary Politics: Mourning and Modernism in the Works of Elizabeth Barrett Browning, Amy Levy, and Charlotte Mew , Donna Decker Schuster

Theses/Dissertations from 2003 2003

Toward a Re-Formed Confession: Johann Gerhard's Sacred Meditations and "Repining Restlessnesse" in the Poetry of George Herbert , Erik P. Ankerberg

Idiographic Spaces: Representation, Ideology and Realism in the Postmodern British Novel , Gordon B. McConnell

Theses/Dissertations from 2002 2002

Reading into It: Wallace Stegner's Novelistic Sense of Time and Place , Colin C. Irvine

Brisbane and Beyond: Revising Social Capitalism in Mid-Nineteenth-Century America , Michael C. Mattek

Theses/Dissertations from 2001 2001

Christians and Mimics in W. B. Yeats' Collected Poems , Patrick Mulrooney

Renaissance Roles and the Process of Social Change , John Wieland

'Straunge Disguize': Allegory and Its Discontents in Spenser's Faerie Queene , Galina Ivanovna Yermolenko

Theses/Dissertations from 2000 2000

Reading American Women's Autobiography: Spheres of Identity, Spheres of Influence , Amy C. Getty

"Making Strange": The Art and Science of Selfhood in the Works of John Banville , Heather Maureen Moran

Writing Guadalupe: Mediacion and (mis)translation in borderland text(o)s , Jenny T Olin-Shanahan

Writing Guadalupe: Mediacion and (Mis)Translation in Borderland Text(o)s , Jenny T. Olin-Shanahan

Theses/Dissertations from 1999 1999

Setting the Word Against the Word: The Search for Self-Understanding in Richard II , Richard J. Erable

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Dr. Obermeier's Sample Paper Files

You are advised to peruse these sample papers previous students have written for my classes. The papers are either pdf files or HTML files, in which I have embedded comments to explain why they are superior efforts. The comments refer to the following sentence, phrase, or word. Clicking on the comment link will bring up the content. You have to close a comment window before proceeding to the next one. Clicking on the header will give you instructions on how to make such a running header for your papers. Because of HTML restrictions, the formatting might appear slightly off. You still need to keep your papers double-spaced with 1/2-inch paragraph indent. Even if there is no specific explanation for a specific paper, the papers generally share the following superior qualities: descriptive and analytical titles; analytical theses; superior analysis of the texts; correct inclusion of quotations and formatting.

For instructions on how to do a running header for your paper in MS Word, click here .

Click on your class in the lineup.

For Engl. 250

• Paper 1 "Sheppard" Characterization
• This paper has it all: outstanding thought and content, excellent organization, superior sentence structure and diction. This student's command of the language is superb. A few minor problems could have been edited out. The paper received the grade of 96/A.
• Paper 1 "Girl" Characterization
• This paper is an excellent example of superior analysis coupled with stylistic economy and succinctness that avoid anything superfluous. The introduction and organization deserve high praise. The paper received the grade of 96/A.
• This explication of a Shakespeare sonnet is superbly done. The student outstandingly fused the analysis of the poem with an excellent and virtually error-free style. The paper received the grade of 98/A+.
• Paper 2 Explication of "Sonnet 42"

Here are the high-scoring essays for our assignment two. Per announcement in class, these uploads are not following the format as faithfully. I just wanted to get you the info without having to worry about getting everything lined up to MLA standards. Note also that I am providing these examples for the sophistication of the explication, the students' knowledge of technical aspects and detail of analysis; the essays, however, may still contain other weaknesses.

• "Sonnet 95"-First Example
• "Sonnet 95"-Second Example
• "Sonnet 96"-First Example
• "Sonnet 96"-Second Example
• Paper 3 Explication of "The Victim at Aulis"
• The student provides a superbly analyzed and written thematic poetry explication. Notice that the paper is organized around the student's thesis, ie., the major players in the myth and the poem, and not just the chronology of the paper. The paper received the grade of 98/A+.
• This paper is an excellent example of a thematic poetry explication, demonstrating superb intertextual understanding and control of the primary texts. Note the student's concise and honed style. The paper received the grade of 96/A.
• Paper 4 Synthesis of Millay Poems
• This paper offers a beautiful synthesis not only of three poems but also two critical approaches: Feminist and Freudian. It is almost flawlessly written and received the grade of 98/A+.
• The paper is up, but I am still working on the comments..
• This is an exquisite research paper utilizing a postmodern approach to Taming of the Shrew . Notice that the critical approach is incorporated into the paper; therefore, there is no extra Barry page. The paper received 98/A+. Sorry, no comment boxes yet.
• This is another outstanding research paper. It shows the incorporation of the research especially well. Notice that the Barry page is appended after the works cited page.The paper received 98/A+. Sorry, no comment boxes yet.
• Return to Student Resources Page

For Engl. 304

For Engl. 306

• Term Paper: "Color by Knight"
• Term Paper: "Four Fair-Unnamed Females"
• Term Paper: "Lancelot: As Great as He Is Destructive"
• Return to Engl. 306 Page

For Engl. 351

P aper 1a here was written for Chaucer's Canterbury Tales but also works for Love Visions . To save time, I did not create javascript comment boxes but inserted my comments in square brackets into the actual paper. Notice that the paper has all the aspects an outstanding paper should: original thought and analysis, clear organization and thesis, interesting intro, correct sentence structure, superior diction, and mostly correct MLA format. The paper received a score of 98/A+. Clicking on the header will give you instructions on how to make such a running header for your papers. Because of HTML restrictions, the formatting might appear slightly off. You still need to keep your papers double-spaced with 1/2-inch paragraph and 1-inch block quotation indents. Papers 2a and 2b were written for the shorter Love Visions assignment, 2c for the longer paper; these papers have no comments in them and are in pdf.

• Paper 1a "Sadness and Faith"
• Paper 2a "'The Poynt of Remembraunce': Chaucer’s Presentation of Women as Literary Characters"
• Paper 2b "A Dream as a Guide for the Dreamer in Parliament of Fowls by Geoffrey Chaucer"
• Paper 2c "Lies, Deception, and Criseyde's Heart"

For Engl 449/559

For Engl 450/550

For Engl 451/551

• Paper 2 "Dame Ragnell" Part 1
• Paper 2 "Dame Ragnell" Part 2
• Paper 2 "Dame Ragnell" Annotated Bib

For Engl 581

For Engl 650

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ENG 102 - Poetry Research

English 102 - Poetry Research

This guide is designed to help you complete an English 102 research paper about a poem. Follow the steps below in order - each step builds on the one before it, guiding you through the research project. We offer research advice/tips, as well as recommended sources, citation help, etc.

• Next: 1. Getting Started >>
• 1. Getting Started
• 2. Explore Your Topic
• 3. Narrow Your Topic
• 4. Find Sources
• 5. Cite Your Sources
• 6. Evaluate Your Sources
• 7. Write Your Paper
• Literary Criticism Guide

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English Literature Research Paper Topics

This guide, centered on English literature research paper topics , serves as a comprehensive resource for students seeking to delve deep into the diverse epochs, authors, and themes that have shaped English literary tradition. Navigating the intricate tapestry of English literature offers scholars a multitude of avenues for exploration. From the mystique of medieval tales to the introspective narratives of modernism, this guide not only provides a plethora of English literature research paper topics but also offers insights on choosing the ideal topic, structuring the research paper, and harnessing the unmatched writing services of iResearchNet. Dive in to unravel the rich heritage of English literature and discover the myriad opportunities it presents for academic exploration.

100 English Literature Research Paper Topics

Diving into English literature is like embarking on a journey through time and culture. From ancient ballads to modernist narratives, it offers a vast panorama of themes, styles, and societal reflections. Below is a comprehensive list of English literature research paper topics spanning across different eras and genres:

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Medieval Literature

• The significance of chivalry in Sir Gawain and the Green Knight .
• The Christian and Pagan elements in Beowulf .
• Courtly love in The Knight’s Tale from Chaucer’s Canterbury Tales .
• Dream visions in Pearl and Piers Plowman .
• The role of fate and providence in The Consolation of Philosophy .
• The art of storytelling in The Decameron vs. The Canterbury Tales .
• The Seven Deadly Sins in Everyman .
• The evolution of the English language: Old English vs. Middle English.
• Religious allegory in The Second Shepherd’s Play .
• Women and femininity in the Lais of Marie de France .

Renaissance and Elizabethan Age

• Shakespeare’s portrayal of power in Macbeth .
• Love and beauty in Sonnet 18 .
• The idea of the “New World” in The Tempest .
• The virtues in Spenser’s The Faerie Queene .
• Magic and science in Doctor Faustus by Christopher Marlowe.
• The pastoral settings of As You Like It .
• The politics of gender in Twelfth Night .
• Revenge and madness in Hamlet .
• John Donne’s metaphysical poetry and its innovation.
• The darker side of the Renaissance: The Duchess of Malfi by John Webster.

The Restoration and the 18th Century

• The satirical world of Jonathan Swift’s Gulliver’s Travels .
• Class struggles in Daniel Defoe’s Moll Flanders .
• Alexander Pope’s critique of society in The Rape of the Lock .
• Aphra Behn and the emergence of the woman writer.
• The wit and wisdom of Samuel Johnson’s essays.
• The rise of the novel: Richardson vs. Fielding.
• Sentimentality and society in Sterne’s Tristram Shandy .
• Politics and plays: John Gay’s The Beggar’s Opera .
• Women, education, and literature: Mary Wollstonecraft’s ideas.
• The mock-heroic in English literature.

Romantic Period

• Nature and transcendence in Wordsworth’s Tintern Abbey .
• The Byronic hero in Childe Harold’s Pilgrimage .
• Shelley’s Ozymandias and the ephemeral nature of power.
• The Gothic romance of Emily Bronte’s Wuthering Heights .
• George Gordon Lord Byron and the Romantic antihero.
• The visionary world of William Blake’s poems.
• The exotic and the familiar in Samuel Taylor Coleridge.
• Keats’s exploration of beauty and mortality.
• The industrial revolution’s reflection in literature.
• Mary Shelley’s Frankenstein and the dangers of ambition.

Victorian Era

• Charles Dickens and his critique of Victorian society.
• The challenges of morality in Thomas Hardy’s novels.
• The bildungsroman in Charlotte Bronte’s Jane Eyre .
• The plight of women in George Eliot’s Middlemarch .
• Oscar Wilde’s wit and irony in The Importance of Being Earnest .
• The debate on science and religion in In Memoriam A.H.H by Alfred Lord Tennyson.
• The mystery and suspense of Arthur Conan Doyle’s Sherlock Holmes stories.
• The “Woman Question” in Victorian literature.
• The realism of Anthony Trollope’s Chronicles of Barsetshire.
• Gothic elements in Dracula by Bram Stoker.
• The fragmented narrative of Virginia Woolf’s To the Lighthouse .
• T.S. Eliot’s The Waste Land and the disillusionment of the post-war era.
• The struggles of the working class in D.H. Lawrence’s novels.
• The impact of World War I on English poetry.
• James Joyce’s revolutionary narrative techniques in A Portrait of the Artist as a Young Man .
• E.M. Forster’s exploration of social and racial themes.
• The critique of colonialism in Joseph Conrad’s Heart of Darkness .
• W.B. Yeats and the Irish literary revival.
• The emergence of the stream-of-consciousness technique.
• The Jazz Age and decadence in the writings of F. Scott Fitzgerald.

The Gothic Tradition

• Origins of Gothic fiction: Horace Walpole’s The Castle of Otranto .
• The supernatural and macabre in Frankenstein by Mary Shelley.
• Ann Radcliffe’s influence on the Gothic novel.
• The role of the Byronic hero in The Vampyre by John Polidori.
• Duality of human nature in The Strange Case of Dr. Jekyll and Mr. Hyde .
• The haunting atmospheres in Wuthering Heights by Emily Brontë.
• Gender and sexuality in Carmilla by Sheridan Le Fanu.
• Edgar Allan Poe’s influence on English Gothic literature.
• Dracula by Bram Stoker: Themes of sexuality and fear of the unknown.
• The Gothic novel as a reflection of societal fears and anxieties.

The Angry Young Men Era

• Social criticism in John Osborne’s Look Back in Anger .
• Exploring masculinity in Saturday Night and Sunday Morning by Alan Sillitoe.
• The disillusionment of post-war Britain in The Loneliness of the Long-Distance Runner .
• The class struggle in Kingsley Amis’s Lucky Jim .
• Existential themes in John Wain’s Hurry on Down .
• Feminine perspectives in the era: Shelagh Delaney’s A Taste of Honey .
• The critique of academia in The History Man by Malcolm Bradbury.
• The Angry Young Men and their influence on modern theater.
• The transformation of British literature in the 1950s and 1960s.
• The lasting legacy of the Angry Young Men movement in contemporary literature.

Postmodern British Literature

• Metafiction in Julian Barnes’s Flaubert’s Parrot .
• The playfulness of language in Salman Rushdie’s The Satanic Verses .
• Intertextuality in Jeanette Winterson’s Oranges Are Not the Only Fruit .
• The fragmented narrative in Graham Swift’s Waterland .
• Reality and fiction in Ian McEwan’s Atonement .
• Gender and postcolonial themes in Angela Carter’s The Passion of New Eve .
• The exploration of identity in Zadie Smith’s White Teeth .
• The deconstruction of traditional narrative in Cloud Atlas by David Mitchell.
• Postmodern gothic in The Thirteenth Tale by Diane Setterfield.
• Magical realism in The Porcelain Doll by Julian Barnes.

Contemporary English Literature

• The multicultural London in Brick Lane by Monica Ali.
• Exploring family dynamics in On Beauty by Zadie Smith.
• The concept of time in Ian McEwan’s Amsterdam .
• The role of history in Hilary Mantel’s Wolf Hall .
• The exploration of love and loss in Julian Barnes’s The Sense of an Ending .
• Postcolonial Britain in Andrea Levy’s Small Island .
• The challenges of modern life in Nick Hornby’s High Fidelity .
• The evolution of the English detective novel: Kate Atkinson’s Case Histories .
• The legacy of the British Empire in The Inheritance of Loss by Kiran Desai.
• The digital age and its influence on literature: The Word Exchange by Alena Graedon.

English literature boasts a rich and varied tapestry of themes, periods, and genres. This comprehensive list is a testament to the dynamism and depth of the field, offering a myriad of research avenues for students. As they venture into each topic, they can appreciate the nuances and complexities that have shaped the literary tradition, making it an invaluable component of global culture and heritage.

English Literature and the Range of Topics It Offers

English literature, encompassing the vast historical, cultural, and artistic legacy of writings in the English language, boasts a rich tapestry of narratives, characters, and stylistic innovations. From the earliest Old English epic poems to the reflective and multifaceted postmodern novels, English literature offers an expansive array of topics for analysis, discussion, and research. The depth and breadth of this literary tradition are mirrored by the diverse range of English literature research paper topics it can inspire.

The Medieval Foundation

Diving into the early origins of English literature, we encounter works like Beowulf , an Old English epic poem of heroism, fate, and the struggle against malevolent forces. Medieval English literature, characterized by religious texts, chivalric romances, and philosophical treatises, sets the stage for the evolution of narrative styles and thematic explorations. The rich allegorical narratives, like Piers Plowman or Sir Gawain and the Green Knight , present intricate societal and spiritual commentaries that still resonate with readers today. These works invite inquiries into the socio-religious dynamics of medieval England, the evolution of the English language, and the literary techniques employed.

Renaissance and Enlightenment: A Burst of Creativity

The Renaissance and Elizabethan Age saw the emergence of revered playwrights like William Shakespeare and Christopher Marlowe, whose dramas, whether tragedies, comedies, or histories, plumbed the depths of human emotion, politics, and existence. The genius of Shakespeare’s Hamlet or Othello , juxtaposed against Marlowe’s Doctor Faustus , provides a fertile ground for investigating themes of ambition, betrayal, love, and existential angst. Moreover, with poets like Edmund Spenser and his epic The Faerie Queene , English literature expanded its horizons, both thematically and stylistically.

The subsequent Restoration and the 18th century ushered in a period of social and literary change. With authors like Jonathan Swift and Alexander Pope, satire became a powerful tool to critique society and politics. Furthermore, the emergence of the novel, as exemplified by Daniel Defoe’s Robinson Crusoe and Samuel Richardson’s Pamela , offered researchers a chance to explore the evolving societal values, gender norms, and narrative techniques.

Romanticism, Victorian Era to Modernism: A Spectrum of Emotion and Thought

The Romantic period, marked by poets like William Wordsworth, Samuel Taylor Coleridge, and John Keats, celebrated nature, emotion, and individualism. In contrast, the Victorian era, with novelists like Charles Dickens, Thomas Hardy, and the Brontë sisters, addressed societal change, morality, and industrialization. Both periods are a goldmine for English literature research paper topics around the individual vs. society, the role of nature, and the exploration of the self.

Modernism in English literature, with heavyweights like Virginia Woolf, James Joyce, and T.S. Eliot, revolutionized narrative structure and thematic depth. Works from this era, such as To the Lighthouse or The Waste Land , demand analysis on fragmented narrative, stream of consciousness, and the introspective exploration of the human psyche.

Contemporary Reflections

Contemporary English literature, shaped by postcolonial, feminist, and postmodern influences, gives voice to a plethora of perspectives. Authors like Salman Rushdie, Zadie Smith, and Julian Barnes tackle issues of identity, multiculturalism, history, and reality versus fiction. Such works present a plethora of avenues for research, from analyzing the postcolonial identity in Rushdie’s narratives to the intricate tapestries of familial and societal dynamics in Smith’s novels.

Concluding Thoughts

In essence, English literature is an evolving entity, reflecting and shaping societal, cultural, and individual values and challenges over the centuries. For students and researchers, the wealth of English literature research paper topics it offers ranges from historical and linguistic analyses to deep dives into thematic cores and stylistic innovations. Whether one wishes to explore the chivalric codes of medieval romances, the biting satires of the 18th century, the emotional landscapes of Romanticism, or the fragmented realities of postmodern narratives, English literature provides an inexhaustible reservoir of research opportunities.

How to Choose an English Literature Topic

Choosing a research paper topic, especially within the expansive field of English literature, can be a challenging endeavor. The centuries-spanning literature offers a treasure trove of stories, themes, characters, and socio-political contexts that beckon exhaustive exploration. As such, students often find themselves at a crossroads, wondering where to begin and how to narrow down their choices to find that one compelling topic. Here’s a detailed guide to streamline this process:

• Align with Your Interests: Dive into periods, genres, or authors that genuinely intrigue you. If Victorian novels captivate your imagination or if Shakespearean dramas resonate with you, use that as your starting point. Genuine interest ensures sustained motivation throughout your research journey.
• Evaluate Academic Relevance: While personal interest is vital, ensure your chosen topic aligns with academic goals and curriculum requirements. Some English literature research paper topics, while intriguing, might not offer substantial academic value for a particular course or level of study.
• Seek Familiar Ground (But Not Too Familiar): Leverage your previous readings and coursework. Familiarity offers a foundation, but challenge yourself to explore uncharted territories within that domain. If you enjoyed Jane Austen’s Pride and Prejudice , maybe delve into its feminist interpretations or comparative studies with other contemporaneous works.
• Embrace Complexity: Opt for English literature research paper topics that lend themselves to multifaceted exploration. Simple topics might not provide enough depth for comprehensive research papers. Instead of a general overview of Romantic poetry, explore the portrayal of nature in Wordsworth’s works versus Shelley’s.
• Historical and Cultural Context: Literature isn’t created in a vacuum. Understand the historical and societal backdrop of a literary work. This context can offer a fresh perspective and can be an excellent lens for your research.
• Contemporary Relevance: How does a particular work or literary period converse with today’s world? Exploring the modern implications or relevance of classic works can be both enlightening and academically rewarding.
• Diverse Interpretations: Embrace English literature research paper topics open to various interpretations. Works like George Orwell’s 1984 or Samuel Beckett’s Waiting for Godot can be analyzed from political, psychological, existential, or linguistic viewpoints.
• Consult with Peers and Professors: Engage in discussions with classmates and seek advice from professors. Their feedback can provide new perspectives or refine your existing topic ideas.
• Read Critiques and Literary Journals: Academic journals, critiques, and literary analyses offer insights into popular research areas and can help you identify gaps or lesser-explored aspects of a work or period.
• Flexibility is Key: As you delve deeper into your research, be open to tweaking or even changing your topic. New findings or challenges might necessitate slight shifts in your research focus.

Choosing the right research topic in English literature requires a blend of personal passion, academic relevance, and the potential for in-depth exploration. By aligning your interests with academic goals, and being open to exploration and adaptation, you pave the way for a fulfilling and academically enriching research experience. Remember, the journey of researching and understanding literature can be as enlightening as the end result. Embrace the process, and let the vast ocean of English literature inspire and challenge you.

How to Write an English Literature Research Paper

Penning an English literature research paper is a task that demands meticulous planning, a deep understanding of the subject, and the ability to weave thoughts coherently. English literature, with its vast and rich tapestry, offers endless avenues for exploration, making it both an exciting and daunting endeavor. Below are step-by-step guidelines to craft a compelling research paper in this domain:

• Understanding the Assignment: Before diving into the research phase, ensure you fully understand the assignment’s requirements. Is there a specific format? Are certain sources mandatory? What’s the word count? This foundational clarity sets the stage for efficient research and writing.
• Preliminary Research: Start with a broad exploration of your topic. Read general articles, introductory chapters, or review papers. This will give you a general overview and can help narrow down your focus.
• Thesis Statement Formulation: Your thesis is the backbone of your research paper. It should be clear, precise, and arguable. For instance, instead of writing “Shakespeare’s plays are influential,” you might specify, “ Macbeth illustrates the dire consequences of unchecked ambition.”
• Diving Deeper – Detailed Research: With your thesis in hand, dive deeper into primary (original texts) and secondary sources (critiques, essays). Libraries, academic databases, and literary journals are treasure troves of valuable information.
• Organize Your Findings: Use digital tools, index cards, or notebooks to categorize and annotate your findings. Grouping similar ideas together will make the writing process smoother.
• Drafting an Outline: An organized structure is essential for clarity. Create an outline with clear headings and subheadings, ensuring a logical flow of ideas. This will serve as a roadmap as you write.
• Introduction Crafting: Your introduction should be engaging, offering a glimpse of your thesis and the significance of your study. Remember, first impressions count!
• Literary Analysis: Delve into the text’s intricacies – symbols, themes, character development, stylistic devices, and historical context.
• Critiques and Counter-arguments: Discuss various interpretations of the text, and don’t shy away from addressing dissenting views. This lends credibility and depth to your paper.
• Comparative Analysis (if applicable): Compare the chosen work with others, drawing parallels or highlighting contrasts.
• Maintaining Coherence and Transition: Each paragraph should have a clear main idea and transition smoothly to the next, maintaining the paper’s flow and ensuring the reader’s engagement.
• Conclusion Crafting: Reiterate your thesis and summarize your main findings. Discuss the broader implications of your study, potentially suggesting areas for further exploration.
• Citing Your Sources: Always attribute ideas and quotations to their original authors. Depending on the assigned format (MLA, APA, etc.), ensure that in-text citations and the bibliography are correctly formatted.
• Revision and Proofreading: Once your draft is complete, take a break before revisiting it. Read it aloud to catch awkward phrasings. Check for grammatical errors, consistency in argumentation, and clarity in presenting ideas. Consider seeking peer reviews or utilizing editing tools.
• Seek Feedback: Before final submission, consider sharing your paper with a mentor, professor, or knowledgeable peer. Their insights can be invaluable in refining your research paper.

Writing an English literature research paper is as much an art as it is a science. While meticulous research and structured writing are crucial, allowing your passion for literature to shine through will elevate your paper. Remember, literature is about exploring the human experience, and as you dissect these masterpieces, you’re not just analyzing texts but delving into profound insights about life, society, and humanity. Embrace the journey, and let every step, from research to writing, be a process of discovery.

iResearchNet Writing Services for Custom English Literature Research Paper

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How to write a Research Paper – Step by Step Guide

A Step-by-Step Guide to writing a research paper

Introduction:

Writing a research paper is a job that we all have to do in our academic life. A research paper represents the ideas of the person who writes it. In simple words, a research paper presents an original idea and substantiates it with logical arguments. Writing a research paper in the domain of English literature is very different compared to writing research articles in other domains. Literature inclines towards abstract thinking. In other subjects, one has to stick to the facts. Howsoever you try, disputing an idea of science becomes very difficult. On the other hand, to contradict an idea in the purview of literature, you just need a systematic flow of arguments (logical and valid) and it’s done! So, writing a research paper in the field of English literature becomes easy if arguments are strong, in a sequence and wisely crafted.

Step 1: Choose the topic of your research paper:

This is one of the most vital parts. Choosing a topic is a crucial choice to make and it has to be taken seriously. You have to choose the area of your interest in English literature and then narrow it down to the area of your expertise. You cannot write a paper on the topics which are wider than a Doctoral thesis! So, you have to be precise and wise while choosing your topic.

An example: Suppose a person has adequate knowledge about Matthew Arnold. Can he write a research article on Arnold alone? No! He will need to bring the topic to some specific idea related to Arnold. The possibilities may be in his prose or poetry writing. In certain states in India, students work on topics like “Matthew Arnold as a poet” and “Matthew Arnold as a great prose writer” which is invalid, injustice and academically a sin. It should not be encouraged! Someone being a poet cannot be a subject of a research article. Any special quality of someone’s poetry writing can certainly be an interesting topic of a research paper – now you must have the idea. ‘Hopelessness and Despair in the poetry of Matthew Arnold’ can be a topic for a brilliant research paper. The hint is very simple – narrow it down to the speciality and you will have your topic ready!

Read in detail – How to choose a research topic? 

Step 2: Collect information – primary and secondary sources:

Now that you have selected a topic for your research paper, you should find ‘credible sources’ that substantiate your ‘paper’s purpose’. Sources are divided into two major categories – primary and secondary. Primary sources are the materials produced by the people who feature in your topic. In the case of our example above, poetry by Matthew Arnold and other writings by him will be primary sources. Secondary sources are the writings ‘about the topic and anything related to the topic’. Therefore, you have to browse the internet, visit a library, check your bookshelves and do anything that will bring you information about the topic and anything that relates to the topic.

Step 3: Plan your research article:

Before you begin writing the paper, it’s always wise to have a clear plan in your mind. Planning a research paper in the domain of English literature should always begin with a clear ‘purpose of research’ in your mind. Why are you writing this paper? What point do you want to make? How significant is that point? Do you have your arguments to support the point (or idea) that you want to establish? Do you have enough credible sources that support the arguments you want to make in the body of the paper? If all the answers are positive, move to the next step and begin writing the drafts for your paper.

Step 4: Writing the first draft of your research paper:

Now it comes to writing the paper’s first draft. Before you begin writing, have a clear picture of your paper in your mind. It will make the job easier. What does a research paper look like? Or, rather, what’s the ideal structure of a research paper?

Beginning – Introduce your idea that drives the research paper. How do you approach that idea? What is your paper – an analysis, review of a book or two ideas compared or something else. The introduction must tell the story of your research in brief – ideas, a highlight or arguments and the glimpse of conclusion. It is generally advised that the introduction part should be written in the end so that you have the final research paper clearly justified, introduced and highlighted at the beginning itself.

Middle – And here goes the meat of your paper. All that you have to emphasise, euphemise, compare, collaborate and break down will take place in the middle or the body of your research paper. Please be careful once you begin writing the body of your paper. This is what will impact your readers (or the examiners or the teachers) the most. You have to be disciplined, systematic, clever and also no-nonsense. Make your points and support them with your arguments. Arguments should be logical and based on textual proofs (if required). Analyse, compare or collaborate as required to make your arguments sharp and supportive to the proposition that you make. The example topic of a research paper that we chose somewhere above in this article – Hopelessness and Despair in the Poetry of Matthew Arnold will require the person writing this paper to convince the readers (and so on) that actually Arnold’s poetry gives a sign of the two negative attitudes picked as the topic. It would be wise to analyse the works (and instances from them, to be specific) The Scholar Gypsy, Empedocles on Etna, Dover Beach and others that support the proposition made in the topic for research. You can use primary and secondary sources and cite them wisely as required. You have to convince the readers of your paper that what you propose in the purpose of the research paper stands on the ground as a logical and valid proposition.

End – Or the conclusion of a research paper that should be written wisely and carefully. You can use a few of your strongest arguments here to strike the final balance and make your proposition justified. After a few of your strongest arguments are made, you can briefly summarise your research topic and exhibit your skills of writing to close the lid by justifying why you are proposing that you have concluded what you began. Make sure that you leave the least possible loopholes for conjecture after you conclude your paper.

Reference: You can use two of the most used styles (or rather only used) to give a list of references in your paper – APA or MLA. Whatever you choose needs to be constant throughout the paper.

To summarise, here is what a research paper should look like:

• Introduction
• A list of References

Step 5: Read & re-read your draft: It gives you the chance to judge your research paper and find the possible shortcomings so that you can make amends and finalise your paper before you print it out for your academic requirements. While you read your first draft, treat it with a purpose to find contradictions and conjecture points as much as possible. Wherever you find the chances of contradiction possible, you have to make those arguments forceful and more logical and substantiate them to bypass the fear of being contradicted (and defeated). Let us be clear – it is English literature we are dealing with and there will be contradictions. Don’t fear it. However, make sure your arguments are not defeated. The defeat means your paper will not hold up to the scrutiny of the experts. And this is why you need to read and re-read the first draft of your literature research paper.

Step 6: Finalise & print your research paper: After reading your paper 1 or 2 times, you should be sure what needs to be changed and otherwise. Finalise it so that it appears the best and sounds good to be the final version. Print your work in the best possible quality and you are done! If there is a verbal question-answer associated with the paper you prepare, make sure you understand it completely and are ready for the questions from any possible side of your topic.

This was our step-by-step guide to writing a research paper in the field of English literature. We hope you have found it useful. We will write more articles associated with the concept – such as choosing a research topic, building arguments, writing powerful introductions. Make sure you subscribe to our website so that you are notified whenever we post a new article on English Literature Education! All the best with your paper!

More guides on How to Subjects: 

How to Study Poetry?

Read related articles from this category:

Bildungsroman – literary term definition, examples, notes & help you need

List of important literary terms associated with studying drama or play – Literature Guides

What is Drama? What is Drama in Literature? Features, Types & Details Students Must Know

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9 Comments . Leave new

Thank you so much, explanation about research work is a nice manner. (private information retracted)

Very well written article! Thanks for this. I was confused about my research paper. I am sure I can do it now.

Quite resourceful. thank you.

Very nice reseach paper

It was very nice reading, helpful for writing research paper.

Thanks for your kind sharing of the information

Normally, I don’t leave any replies after reading a blog, but I couldn’t help this time. I found this blog very useful. So, I’m writing my research paper and I’ve been racking my brain and the internet for a good topic, plus trying to learn how to write a research paper. Thank you so much for putting this up!

I want to work on The French Revolution and its impact on romantic poetry. Please help in this regard.

Thanks a lot for the information.

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When you locate a source that you  may want to use in your research, you should first make sure that the source is reliable, up to date, and relevant to your research topic. No matter what your source type (scholarly article, book, encyclopedia, etc.), ask yourself the following questions:

• When was this source published? Is the information outdated, or is it still up to date? (Currency)
• Who created this source, and what are their qualifications? Are they an expert on the topic? (Authority)
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• Why was this information published? To inform you? To sell you something? To convince you? (Purpose)
• Does the source help you answer your research question? Is it a relevant source? (Relevance)

Asking these questions will help you choose the best sources for your paper.

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• Published: 23 April 2024

Research on flipped classrooms in foreign language teaching in Chinese higher education

• Wen Kong 1 ,
• Di Li 2 &
• Quanjiang Guo   ORCID: orcid.org/0000-0002-7846-1363 3  

Humanities and Social Sciences Communications volume  11 , Article number:  525 ( 2024 ) Cite this article

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• Language and linguistics

This review examines 233 articles published in Chinese academic journals between 2011 and 2021, documenting the state of research concerning flipped classrooms (FCs) in foreign language teaching within the context of higher education in China. Employing the methodological approach of a scoping review, the investigation is underpinned by the five-stage framework articulated by Arksey and O’Malley. The results reveal a notable surge in FC-related studies between 2013 and 2017, with a subsequent decline in scholarly attention. The majority of the reviewed studies on FCs focused on English instruction at the college level, with a conspicuous dearth of inquiry into the application of FCs in the teaching of other foreign languages. All studies were categorized as either empirical or non-empirical, and the most frequently used instruments for data collection were surveys and interviews; case studies were underrepresented in the literature. Early studies focused on the introduction of the new model, while more recent investigations focused on the impact of its implementation. The findings of the in-depth content analysis unearthed a prevailing trend of high learner satisfaction with the FC model, along with favorable direct and indirect educational outcomes. Noteworthy factors influencing the efficacy of FCs included learners’ foreign language proficiency and their self-regulation or self-discipline abilities. The paper concludes with a discussion of the challenges in FC implementation and a call for future research on this promising pedagogy.

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Content validity of the Constructivist Learning in Higher Education Settings (CLHES) scale in the context of the flipped classroom in higher education

Introduction.

The flipped classroom (FC), also known as the “inverted classroom”, is a pedagogical approach that first emerged in the 1980s and came into more widespread use in the 2000s (Baker, 2000 ; Bergmann and Sams, 2012 ; Khan, 2012 ). It has gained prominence as advances in technology afford increasing opportunities for ubiquitous access to a variety of online resources. The FC model removes in-class lectures, freeing up classroom time for more in-depth exploration of topics through discussion with peers or problem-solving activities facilitated by instructors. The removed content is often delivered to learners through pre-class materials like video recordings. As a result, in the FC, learning activities that are active and social occur inside the classroom while most information transmission occurs outside the classroom. Today, the FC has been implemented in many different disciplines and in schools and universities around the world (Akcayir and Akcayir, 2018 ).

Proponents of the FC assert its pedagogical merits on several fronts. First, it alleviates the constraints associated with requiring all learning to happen at the same time and place, furnishing learners with an individualized education that enables flexible online study at their own pace as long as an internet connection is available (Hung, 2014 ). Second, it allocates class time to the cultivation of learners’ higher-order cognitive skills, emphasizing application, analysis, and evaluation, as opposed to lower-order skills such as knowledge and comprehension (Brinks-Lockwood, 2014 ; Lee and Wallace, 2018 ). Third, in contrast to traditional lecturing, the FC is a student-centered approach emphasizing engagement and active learning (Steen-Utheim and Foldnes, 2018 ), fostering students’ autonomy by endowing them with heightened responsibility for their learning (Brinks-Lockwood, 2014 ; O’Flaherty and Philips, 2015 ).

Vygotsky’s social constructivism ( 1978 ) has frequently been adopted as a theoretical foundation for designing learning experiences in technologically rich environments (Marzouki et al., 2017 ), and this framework highlights the particular benefits of technology-enhanced FC pedagogy (Jarvis et al., 2014 ). As mentioned above, in an FC model, learners can watch pre-recorded videos in their own time before class to remember basic information and understand concepts as they prepare for classroom activities, while the higher-order skills of analyzing, applying, evaluating, and creating can be collaborative and interactive, taking place in class with the guidance of a teacher, and thus facilitating progression within the learners’ proximal developmental zone.

Since its introduction in foreign language teaching (FLT) in China in 2011, the FC has attracted increasing research attention and has been welcomed by foreign language teachers (Yan and Zhou, 2021 ). Over the past decade, the Ministry of Education of the People’s Republic of China has exerted increasing pressure on higher education institutions to transition from traditional teacher-centered lecture-style approaches to innovative methods integrating technology and the internet, with the goals of enhancing learning, sustaining student engagement, and improving student satisfaction (Ministry of Education of People’s Republic China, 2021 ). The FC model, combined with traditional face-to-face teaching and personalized online learning, has emerged as a popular strategy in China to meet ministry requirements while delivering cost-effective and learner-centered curricula in response to the increasing student enrollment in higher education.

Despite the wide adoption of FCs in FLT in China, literature reviews about their implementation and effects have been notably scarce in the last decade. A search of the China National Knowledge Infrastructure (CNKI), the largest national research and information publishing company housing China’s most extensive academic database, revealed only three reviews—by Deng ( 2016 ), Qu ( 2019 ), and Su et al. ( 2019 )—published prior to the end of 2021. These reviews primarily focused on FCs in the context of English as a foreign language (EFL) education, overlooking most of the over 100 foreign languages taught in Chinese higher education. As a result, these reviews fell short of delivering a comprehensive analysis of research pertaining to FCs, and the reliability and generalizability of their findings in non-EFL contexts are questionable. Moreover, Deng ( 2016 ) and Su et al.’s (2019) reviews included all published papers without establishing clear inclusion and exclusion criteria. For example, they did not exclude articles that made a passing or token reference to the FC model, short papers of only one or two pages in length, book reviews, or editorials. Qu’s study ( 2019 ), on the other hand, was constrained in scope to articles within the Chinese Social Sciences Citation Index (CSSCI), a sub-database developed by Nanjing University of China Academy of Social Sciences Research Evaluation Center and the Hong Kong University of Science and Technology, and thus omitted relevant contributions from other academic journals. The CNKI incorporates both the CSSCI and the Core Journals of China (CJC), an equally significant sub-database overseen by the Peking University Library and experts from relevant institutions. Given the exclusion of the latter, a reevaluation of the scope and potential limitations of Qu’s study is warranted.

Thus, there persists an imperative for a comprehensive synthesis of the extant studies on FCs in FLT within Chinese higher education over the past decade. The restricted visibility of studies conducted in China, owing to their publication in Chinese and confinement to Chinese academic journals, makes it difficult for international researchers and practitioners to access and comprehend this body of literature. Such understanding among the global academic community is necessary for exploring both the strengths and limitations of FCs in diverse cultural and linguistic contexts.

Research method

The current study adopts a scoping review approach based on the methodological framework developed by Arksey and O’Malley ( 2005 ) to provide both quantitative and qualitative data for researchers and practitioners.

A scoping review is a relatively new approach to synthesizing research data which has been gaining popularity in many disciplines (Davis et al., 2009 ; Daudt et al., 2013 ). It is often undertaken as an independent project when a research area is complex, and no review of that area has previously been made available. A scoping review serves to highlight the relevant literature to researchers with the aim of rapidly mapping the key concepts characterizing a research area and the main sources and types of evidence available (Arksey and O’Malley, 2005 ; Mays et al., 2005 ; Levac et al., 2010 ). According to Arksey and O’Malley ( 2005 ), this kind of review addresses four goals: to examine the extent, range, and nature of research activity; to determine the value of undertaking a full systematic review; to summarize and disseminate research findings; and to identify research gaps in the existing literature. The scoping review is increasingly being employed in the field of foreign language education to provide a comprehensive view of FLT studies, identify implications for theory and pedagogy, or inform subsequent in-depth reviews and empirical studies (Chan et al., 2022 ; Hillman et al., 2020 ; Tullock and Ortega, 2017 ).

The difference between a scoping review and a narrative or traditional literature review lies in the transparency of the review process. A narrative review usually depends on the author’s own knowledge or experience to describe the studies reviewed and uses an implicit process to provide evidence (Garg et al., 2008 ). The reader cannot determine how much literature has been consulted or whether certain studies have been ignored due to contradictory findings. A scoping review, in contrast, uses an explicit, rigorous, and systematic approach to retrieve relevant articles to ensure the transparency and replicability of the data extraction process. For example, the methodological framework adopted by Arksey and O’Malley ( 2005 ) for conducting a scoping study comprises five stages: identifying the research questions; identifying relevant studies; selecting studies for inclusion; charting the data; and collating, summarizing, and reporting the results. By presenting the process and results in an accessible and summarized format, reviewers are in a position to illustrate the field of interest in terms of the volume, nature, and characteristics of the primary research, enabling researchers, practitioners, and policymakers to make effective use of the findings.

Figure 1 presents the process of the scoping review in the current study based on the five-stage methodological framework developed by Arksey and O’Malley ( 2005 ).

Process of the scoping review.

Process of the scoping review

Identifying research questions.

This scoping review is driven by four research questions:

RQ1. What is the current state of FC research in FLT within the context of higher education in China?

RQ2. What research methods and instruments have been employed in the included FC studies?

RQ3. What research foci and trends are displayed in the included FC studies?

RQ4. What are the major findings of the included FC studies?

RQ1 aims to provide an overview of studies on FCs in FLT in Chinese higher education by providing details about the basic information about existing publications, such as the number of publications per year and the distribution of publications by foreign language context. RQ2 leads to a classification of the research methods and instruments used to collect data in FC research. RQ3 explores the topics and trends in FC research over the past decade with the help of the literature visualization and analysis tool CiteSpace5.8R3. RQ4 reveals the effects of the FC model on direct and indirect educational outcomes, learners’ satisfaction with FCs, and the factors influencing the impact of FCs, as documented in the reviewed sources.

Searching for relevant studies

To be as comprehensive as possible in identifying primary evidence and to ensure the quality of the published articles, we searched both CSSCI and CJC in the CNKI database. The key search terms were developed and categorized based on two dimensions according to the purpose of the review. One dimension related to teaching or learning in FCs, while the other dimension related to the types of foreign languages. The key search terms and search methods are listed in Table 1 .

As the FC approach was introduced into FLT in China in 2011, the search included articles published between 2011 and 2021. Further inclusion and exclusion criteria were developed to focus on the scope of the review; these are outlined in Table 2 .

Study selection

Figure 2 shows a process diagram of the study selection process, which consisted of four phases: searching the databases; identifying the total number of articles in each database; screening titles, abstracts, and full texts; and selecting eligible articles for inclusion.

Flowchart diagram for article selection.

The final database search was conducted on January 16, 2022, and resulted in the identification of a total of 333 articles. Subsequently, all potentially relevant articles went through a three-step screening process. The first step excluded 9 duplicates. The second step excluded irrelevant articles by screening titles and abstracts; 37 articles were removed at this stage as they were book reviews, conference proceedings, reports, editorials, or other non-refereed publications. The third step filtered articles by screening full texts; 54 articles were excluded because they made only passing reference to the FC or were not related to higher education. This meticulous selection yielded a corpus of 233 articles suitable for in-depth analysis, each of which was scrutinized by the authors to confirm its suitability for inclusion. During the selection process, the 233 articles were also systematically categorized into two groups: 131 non-empirical and 102 empirical studies. The non-empirical studies were further divided into two subcategories. The first type was literature reviews; the second type was those drawing on personal observations, reflections on current events, or the authority or experience of the author (Dan, 2021 ). The empirical studies used a variety of systematic methods of collecting materials and analyzing data, including quantitative methods (e.g., survey, correlational research, experimental research) and/or qualitative methods (e.g., interview, case study, record keeping, observation, ethnographic research) (Dan, 2021 ).

Data charting and collation

The fourth stage of Arksey and O’Malley’s scoping review framework is the charting of the selected articles. Summaries of each study were developed. for all studies, these summaries included the author, year of publication, citations per year, foreign language taught, and a brief description of the outcomes. For empirical sources, details related to the research design, study population, and sample size were also provided. Tables 3 and 4 list the top ten most-cited non-empirical and empirical sources. In Table 4 , which references experimental and control groups in results summaries, the experimental group (EG) was the group that took courses in the FC model, while the control group (CG) took courses in a traditional classroom.

Results and analysis

In accordance with the fifth stage of Arksey and O’Malley’s framework for a scoping review, the findings from the 233 included studies are summarized and discussed in the following three sections. Section 4.1 summarizes basic information regarding the included studies; section 4.2 presents a holistic analysis of the research foci and trends over time using keyword clustering analysis and keyword burst analysis; and section 4.3 offers an in-depth content analysis focusing on the categorization of the included studies and discussion of the major findings.

Basic information on the included studies

Distribution by year of publication.

As Fig. 3 shows, the first studies on FCs in the field of FLT in China emerged in 2013. The number of such studies began to steadily increase and reached a peak in 2016 and 2017. Although there was some decrease after that, the FC model has continued to attract research attention, in line with global trends. According to Akçayir and Akçayir’s (2018) review of the literature on FCs published in Social Sciences Citation Index (SSCI) journals as of 31 December 2016, the first article about the FC was published in 2000, but the second was not published until more than a decade later, in 2012; 2013 was also the year that FC studies became popular among scholars. A possible explanation for this increase in interest is the growing availability of internet technologies and the popularity of online learning platforms, such as MOOCs and SPOCs (Small Private Online Courses), along with the view of the FC as a promising model that can open doors to new approaches in higher education in the new century.

Number of articles published by year.

Distribution by foreign language

Figure 4 shows the distribution of foreign languages discussed in the FC literature. The FC model was mainly implemented in EFL teaching (93%), which reflects the dominance of English in FLT in Chinese higher education. Only five articles discussed the use of FC models in Japanese teaching, while one article was related to French teaching. Ten non-empirical studies (4%) reported the feasibility of FC models in FLT without mentioning a specific foreign language.

Distribution by foreign language type.

Research methods of the included studies

Figure 5 shows a breakdown of the methodologies adopted by the studies included in our review. Among the 131 non-empirical studies, three were literature reviews, while the remaining 128 (55%) were descriptive studies based on the introduction of the FC model, including descriptions of its strengths and associated challenges and discussions of its design and implementation in FLT.

Methodological paradigms.

Of the 102 empirical studies, 60 (26%) used quantitative methods for data collection, eight (3%) used qualitative methods, and 34 (15%) used mixed methods. It is interesting to note that although quantitative methods are more common in FC studies, seven of the top ten most-cited empirical studies (as listed above in Table 4 ) used mixed methods. A potential reason may be that research findings collected with triangulation from various data sources or methods are seen as more reliable and valid and, hence, more accepted by scholars.

A breakdown of the data collection approaches used in the 102 reviewed empirical studies is displayed in Table 5 . It is important to note that most studies used more than one instrument, and therefore, it is possible for percentages to add up to more than 100%. The survey, as a convenient, cost-effective, and reliable research method, was the tool most frequently used to gain a comprehensive picture of the attitudes and characteristics of a large group of learners. Surveys were used in 79 of the 102 studies—73 times with learners and six times with teachers—to explore students’ learning experiences, attitudes, and emotions, as well as teachers’ opinions. Some studies used paper-based surveys, while others used online ones. Interviews with learners were used in 33 studies to provide in-depth information; one study used interviews with teachers. Surveys and interviews were combined in 24 studies to obtain both quantitative and qualitative data. Other research approaches included comparing the test scores between experimental and control groups (used in 25 studies) or using the results of course assessments (17 studies) to investigate the effects of the FC on academic performance. Learners’ self-reports (9 studies) were also used to capture the effects of the FC on learners’ experience and cognitive changes that could not be obtained in other ways, while one study used a case study for a similar purpose. Teachers’ class observations and reflections were used in eight studies to evaluate students’ engagement, interaction, activities, and learning performance.

Holistic analysis of the research foci and the changing trends of the included studies

A holistic analysis of the research foci in studies of FCs in China was conducted using CiteSpace5.8.R3, a software developed by Chaomei Chen ( http://cluster.cis.drexel.edu/~cchen/citespace/ , accessed on 20 February 2022), to conduct a visual analysis of the literature. This software can help conduct co-citation analysis, keyword co-occurrence analysis, keyword clustering analysis, keyword burst analysis, and social network analysis (Chen, 2016 ). In this study, keyword clustering analysis and keyword burst analysis were chosen to capture important themes and reveal changing trends in FC research.

Keyword clustering analysis primarily serves to identify core topics in a corpus. Figure 6 presents a graph of the top ten keyword clusters identified in the included studies. In this graph, the lower the ID number of a given cluster, the more keywords are in that cluster. As shown in the top left corner of Fig. 6 , the value of modularity q is 0.8122, which is greater than the critical value of 0.3, indicating that the clustering effect is good; the mean silhouette value is 0.9412, which is >0.5, indicating that the clustering results are significant and can accurately represent hot spots and topics in FC research (Hu and Song, 2021 ). The top ten keyword clusters include #0翻转课堂 (flipped classroom), #1大学英语 (college English), #2 MOOC, #3教学模式 (teaching model), #4元认知 (metacognition), #5微课 (micro lecture), #6微课设计 (micro lecture design), #7英语教学 (English teaching), #8 SPOC, and #9 POA (production-oriented approach).

The graph of the top ten keyword clusters.

Keyword burst analysis is used to showcase the changes in keyword frequencies over a given period of time. By analyzing the rise and decline of keywords, and in particular, the years in which some keywords suddenly become significantly more prevalent (“burst”), we can identify emerging trends in the evolution of FC research. Figure 7 displays the 11 keywords with the strongest citation bursts. We can roughly divide the evolution of FC research documented in Fig. 7 into two periods. The first period (2014 to 2017) focused on the introduction of the new model and the analysis of its feasibility in FLT. The keywords that underwent bursts in this period included “MOOC”, “自主学习” (independent learning), “模式” (model), “学习模式” (learning model), “教师话语” (teacher discourse), “茶文化” (tea culture), and “可行性” (feasibility). The reason for the appearance of the keyword “tea culture” lies in the fact that three articles discussing the use of FCs in teaching tea culture in an EFL environment were published in the same journal, entitled Tea in Fujian , during this period. The second period (2018–2021) focused on the investigation of the effect of FCs and the design of micro lectures. Keywords undergoing bursts during this period included “互联网+” (internet plus), “课堂环境” (classroom environment), “教学效果” (teaching effect), and “微课设计” (micro lecture design). The latter two topics (“teaching effect” and “micro lecture design”) may continue to be prevalent in the coming years.

Top 11 keywords with the strongest citation bursts.

In-depth content analysis of the included studies

Along with the findings from the keyword clustering analysis and keyword burst analysis, an open coding system was created to categorize the research topics and contents of the 233 articles for in-depth analysis. Non-empirical and empirical studies were classified further into detailed sub-categories based on research foci and findings. It is important to note that some studies reported more than one research focus. For such studies, more than one sub-category or more than one code was applied; therefore, it is possible for percentages to add up to more than 100%. The findings for each category are discussed in detail in the following sections.

Non-empirical studies

The 131 non-empirical studies can be roughly divided into two categories, as shown in Table 6 . The first category, literature reviews, has no sub-categories. The second, descriptive studies, includes discussions of how to use FCs in FLT; descriptions of the process of implementing the FC in FLT; and comparisons between FCs and traditional classes or comparisons of FCs in Chinese and American educational contexts.

The sub-categories of “introduction and discussion” and “introduction and description” in Table 6 comprise 91.6% of the non-empirical studies included in our review. The difference between them lies in that the former is based on the introduction of the FC literature, while the latter is based both on the introduction of the FC literature and exploration of researchers’ teaching experience; the latter might have become qualitative studies if researchers had gone further in providing systematic methods of collecting information or an analysis of the impact of FCs.

Empirical studies

The 102 empirical studies were divided into four categories based on the domain of their reported findings: the effect of FCs on learners; learners’ satisfaction with FCs; factors influencing FCs; or other research foci. Each group was further classified into more detailed sub-categories.

Effect of FCs on learners

Studies on the effect of FCs on learners were divided into two types, as presented in Table 7 : those concerned with the direct effect of FCs on learning performance and those exploring the indirect effect on learners’ perceptions. Eight codes were applied to categorize the direct effect of FCs on learning performance, which was usually evaluated through test scores; 14 codes were used to categorize the indirect effect of FCs on learners’ perceptions, which were usually investigated through surveys or questionnaires. We do not provide percentages for each code in Tables 7 – 9 because, given that the total number of empirical studies is 102, the percentages are almost identical to the frequencies.

The results shown in Table 7 reveal that 84 studies of direct educational outcomes reported that FCs had a positive effect on basic language skills, content knowledge, and foreign language proficiency. Of these, 64 were concerned with the positive effect of FCs on foreign language proficiency, speaking skills, or listening skills. This result might be explained by the features of FCs. The main difference between FCs and traditional classrooms is that the teaching of content in FCs has been removed from the classes themselves and is often delivered to the students through video recordings, which can be viewed repeatedly outside of the class. In-class time can thus be used for discussion, presentations, or the extension of the knowledge provided in the videos. It is evident that students have more opportunities to practice listening and speaking in FCs, and foreign language proficiency is naturally expected. Only three studies reported that FCs had no effect or a negative effect on the development of foreign language proficiency, speaking, listening, and writing skills. Yan and Zhou ( 2021 ) found that after the FC model had been in place for one semester, college students’ reading abilities improved significantly, while there was no significant improvement in their listening and writing abilities. Yin ( 2016 ) reported that after FC had been implemented for one semester, there was no significant difference in college students’ speaking scores.

A total of 96 studies reported positive effects on indirect educational outcomes, including: boosting learners’ motivation, interest, or confidence; enhancing engagement, interaction, cooperation, creativity, independent learning ability, or critical thinking ability; fostering information literacy, learning strategies, learning efficiency, or self-efficacy; or relieving stress or anxiety. The most frequently documented indirect effect of FCs is improvement in students’ independent learning ability. Only one study found that the FC did not significantly increase student interest in the course (Wang, 2015 ). Similarly, only one study found that students’ anxiety in the FC was significantly higher than that in a traditional class (Gao and Li, 2016 ).

Learners’ satisfaction with FCs

Table 8 presents the results regarding learners’ satisfaction with FCs. Nine codes were used to categorize the different aspects of learners’ satisfaction investigated in the 102 empirical studies. Some researchers represented learner satisfaction using the percentage of students choosing each answer on a five-point Likert scale from 1 (not at all satisfied) to 5 (very satisfied), while others used average scores based on Likert scale values. For the purposes of our synthesis of findings, if the percentage is above 60% or the average score is above 3, the finding is categorized as satisfied; otherwise, it is categorized as not satisfied.

The results in Table 8 show that among the nine aspects investigated, teaching approach and learning outcomes were most frequently asked about in the research, and learners were generally satisfied with both. Only one study (Li and Cao, 2015 ) reported significant dissatisfaction; in this case, 76.19% of students were not satisfied with the videos used in college English teaching due to their poor quality.

Factors influencing the effect of FCs

Eleven factors were found to influence the effect of FCs; these are categorized in Table 9 .

The results shown in Table 9 indicate that learners’ foreign language proficiency and self-regulation or self-discipline abilities are two important factors influencing the effect of FCs. Learners with high foreign language proficiency benefited more from FCs than those with low foreign language proficiency (Lv and Wang, 2016 ; Li and Cao, 2015 ; Wang and Zhang, 2014 ; Qu and Miu, 2016 ; Wang and Zhang, 2013 ; Cheng, 2016 ; Jia et al., 2016 ; Liu, 2016 ), and learners with good self-regulation and self-discipline abilities benefited more than those with limited abilities (Wang and Zhang, 2014 ; Lu, 2014 ; Lv and Wang, 2016 ; Dai and Chen 2016 ; Jia et al. 2016 ; Ling, 2018 ). It is interesting to note that two studies explored the relationship between gender and FCs (Wang and Zhang, 2014 ; Zhang and He, 2020 ), and both reported that girls benefited more from FCs because they were generally more self-disciplined than boys.

Studies with other research foci

There were six studies with other research foci, three of which investigated teachers’ attitudes toward FCs (Liao and Zou, 2019 ; Zhang and Xu, 2018 ; Zhang et al., 2015 ). The results of the surveys in these three studies showed that teachers generally held positive attitudes towards FCs and felt that the learning outcomes were better than those of traditional classes. However, some problems were also revealed in these studies. First, 56% of teachers expressed the desire to receive training before using FCs due to a lack of theoretical and practical expertise regarding this new model. Second, 87% of teachers thought that the FC increased their workload, as they were spending a significant amount of time learning to use new technology and preparing online videos or materials, yet no policy was implemented in the schools to encourage them to undertake this work. Third, 72% of teachers felt that the FC increased the academic burden students faced in their spare time (Zhang and Xu, 2018 ; Zhang et al., 2015 ). The final three studies include Cheng’s ( 2016 ) investigation of the mediative functions of college EFL teachers in the FC, Wang and Ma’s ( 2017 ) construction of a model for assessing the teaching quality of classes using the FC model, and Luo’s ( 2018 ) evaluation of the learning environment of an FC-model college English MOOC.

Discussion and conclusions

This investigation employed literature visualization to systematically analyze 233 research papers sourced from CSSCI and CJC in the CNKI database, thereby conducting a scoping review delineating the landscape of FC research within the domain of FLT in the context of higher education in China.

Our findings in relation to RQ1 highlight a substantial surge in the number of articles relating to FCs in FLT between 2013 and 2017, followed by a discernible, albeit moderate, decrease. Despite this trend, FC studies continue to be of significant interest to foreign language educators and researchers. This may be attributed to Chinese government policies encouraging higher education reform, increased internet access among educators and learners, and the burgeoning popularity of online courses such as MOOCs and SPOCs. However, the majority of the reviewed FC studies were conducted in college English classes, with only 6 studies on classes teaching foreign languages other than English. It seems that foreign language education in China (and in much of the world) has become synonymous with the teaching and learning of English, with other languages occupying a marginal position, struggling to find space in educational programs. In a multilingual world in which each language offers different possibilities for understanding others, their cultures, their epistemologies, and their experiences, this monolingual approach to FLT is dangerous (Liddicoat, 2022 ). The promotion of linguistic diversity in foreign language education policies and research is thus imperative. Another gap that needs to be addressed is the paucity of studies on the implementation of FCs in adult education. The FC model is expected to be potentially effective for teaching adult learners because it is similar in some respects to online distance learning.

In answer to RQ2, we found that the commonly used research methods and instruments in studies of the FC model include surveys, interviews, comparisons of academic measures between EGs and CGs, and course assessments. The case study is the least used method, likely due to limitations such as time demand, researcher bias, and the fact that it provides little basis for the generalization of results to the wider population. However, more case studies are needed in future research on FCs because they can provide detailed and insightful qualitative information that cannot be gathered in other ways.

Our findings regarding RQ3 show that research foci within the FC domain have evolved over time from initial exploration and feasibility discussions to a subsequent focus on the design of FCs incorporating micro-lectures based on MOOC or SPOC structures, and then to the present focus on the examination of FCs’ impacts on learners. The results of the keyword burst analysis indicate that these thematic areas are likely to persist as prominent subjects of research interest for the foreseeable future.

In response to RQ4, our in-depth content analysis found that FCs, on the whole, yield positive outcomes, although isolated studies identify limited negative impacts. FCs are most frequently associated with enhancements in student learning performance, fostering independent learning, promoting engagement and cooperation, and mitigating stress or anxiety. The results of this study suggest that well-designed FCs present a significant opportunity for foreign language educators to revolutionize instructional approaches. Furthermore, well-structured FCs can facilitate the development of learners’ potential while concurrently enabling the seamless integration of digital technology into FLT.

Most learners are satisfied with FCs, particularly with the innovative pedagogical approach of reversing traditional classes. FCs are perceived as beneficial for improving learning outcomes, creating an environment conducive to peer interaction, and gaining immediate teacher feedback and support. In addition, students’ interest in classes is enhanced by the rich and diverse online learning materials uploaded by teachers, which can be accessed conveniently at any time in any place. Furthermore, the dynamic and formative online assessment approach is also welcomed by students because it provides immediate feedback and the ability to discuss any problems they have with teachers or peers online or offline.

However, it is worth noting that most of the reviewed studies on FCs focused on one course, usually over only one semester. Students’ increase in motivation or improvements in learning outcomes might, therefore, be a result of the Hawthorne effect. Compared with the traditional didactic lecture format, the novelty of FCs, when used for the first time, might generate excitement among students, thus increasing their attention and enhancing learning outcomes, but such benefits will diminish over time. Therefore, there is a need to examine whether this model is suitable for large-scale implementation and whether its effects might be sustained over longer periods of implementation.

Learners’ foreign language proficiency and self-regulation or self-discipline abilities are the two key factors influencing the effect of FCs. These two factors are closely related; self-regulation or self-discipline is a prerequisite for successful foreign language learning in FC contexts and plays a crucial role in students’ success in the pre-class sessions for which they are personally responsible. In addition, factors such as learners’ attitudes, expectations of and adaptability to the FC model, the learning tasks and learning environment, the teaching organization and assessment methods, and the learner’s gender also have some impact on the effect of FCs. However, due to the limited number of studies, there is not sufficient evidence to warrant the generalization of any of these effects.

This scoping review highlights some potential challenges that need to be addressed for the effective implementation of FCs.

First, despite the benefits of the FC model, FCs are not equally advantageous to all students due to the self-regulated nature of the model. Many learners have reported difficulties in completing their individual online tasks outside the classroom (Yoon et al., 2021 ). The non-traditional configuration of FCs poses a formidable challenge, particularly for students less inclined to engage in pre-class online activities characterized by a lack of interactivity and for those who are less self-disciplined. Consequentially, students may attend class without having assimilated the pre-assigned material, thereby diminishing the efficacy of this instructional approach. To address this issue, additional support or prompts for students should be provided to remind them of the need to self-regulate their learning. For example, Park and Jo ( 2015 ) employed a learning analytics dashboard displaying visual representations of students’ learning patterns derived from login traces, such as login frequency and interval regularity, within the course’s learning management system. These visual indicators allowed students to monitor their learning engagement and performance in comparison to those of their peers.

Second, a persistent problem with FCs is the inability of students to interact with their peers or receive prompt feedback from instructors after completing independent online learning activities. While some researchers identified a need for teachers to provide immediate online feedback or opportunities for peer discussion, our review of the literature shows that scant attention has been given to this issue. Researchers note that under-stimulation, low perceived control over tasks, and delayed or insufficient feedback in online learning contribute significantly to learner boredom or absenteeism (Yazdanmehr et al., 2021 ; Tao and Gao, 2022 ). Online pedagogical innovations are needed to solve these new problems. For instance, the establishment of online groups employing chat software like QQ or WeChat could facilitate instantaneous feedback or peer interaction through text-based communication, thereby enhancing learners’ satisfaction with FC courses.

Third, despite recognizing the value of FCs in enhancing the learning experience for students, teachers often lack the requisite training to implement FCs effectively. Insights derived from interviews with teachers, as noted in several of the reviewed studies, reveal a pronounced desire for increased opportunities to learn about the underlying theories of FCs and acquire the skills necessary for the translation of FC concepts into pedagogical practice. Specifically, teachers express a need for guidance in creating engaging instructional videos, determining optimal video length to sustain learner interest, and ascertaining the ideal duration for online quizzes to foster optimal learner performance. Further research is required on strategies and technologies that can help teachers produce high-quality videos despite limited time and technical skills. Support from professional communities, institutions, and technology specialists is thus essential for the provision of effective hybrid offline and online instruction.

Fourth, additional research is required to determine whether workloads for students and teachers are increased by the use of FCs. If this is the case, as found in some of the reviewed studies, then the compelling benefits of FCs would be offset by the extra time needed, making it difficult to draw the conclusion that FCs are more efficient than traditional classes. The majority of language teachers, due to limited skills in technology, online environment management, and online interaction, feel too physically and emotionally overworked to expend more time and energy on enhancing teaching effectiveness. With few teachers having excess spare time, the thought of designing and creating new content might discourage even the most enthusiastic teachers.

Finally, robust empirical evidence is needed to evaluate whether FCs can facilitate students’ higher-order thinking through the use of creative technologies and assessment approaches. Constructs such as creativity and critical thinking are not always easily reduced to measurable items on survey instruments or scores on examinations (Haladyna et al., 2002 ).

In conclusion, the insights garnered from this study have the potential to enrich the global discourse on the benefits and limitations of FCs in diverse cultural and linguistic contexts. Our review included literature accessible through CSSCI and CJC in the CNKI database, and while this provides a thorough selection of the Chinese literature on the subject, our search approach may have excluded valuable FC-related papers published in other languages and countries. Consequently, different search criteria might yield different selection and data results. Future researchers are encouraged to undertake more comprehensive literature reviews encompassing broader databases to fill the gaps in our work and to augment the depth and breadth of knowledge in this domain.

Data availability

The raw data for this paper were collected from articles in Chinese Social Sciences Citation Index (CSSCI) journals and A Guide to the Core Journals of China of Peking University (PKU journals) in the database of China National Knowledge Infrastructure (CNKI) ( https://www.cnki.net/ ). The raw data used to support the findings of this study are available from the corresponding author upon request.

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Acknowledgements

This research was funded by The 14th Five-year Plan for Education Science of Jiangsu Province (Grant number: D/2021/01/79), Changzhou University (Grant number: GJY2021013), and Department of Education of Zhejiang Province, China (Project of Ideological and Political Construction of Courses 2021-337).

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Conceptualization, WK and Q-JG; methodology, WK; software, DL; validation, WK, DL, and Q-JG; formal analysis, WK and Q-JG; investigation, WK and Q-JG; resources, DL; data curation, DL; writing—original draft preparation, WK and Q-JG; writing—review and editing, WK and Q-JG; visualization, WK and Q-JG; supervision, WK; project administration, WK; funding acquisition, WK and Q-JG. All authors have read and agreed to the published version of the manuscript.

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• Equitable and accessible informed healthcare consent process for people with intellectual disability: a systematic literature review
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• http://orcid.org/0000-0002-8498-7329 Manjekah Dunn 1 , 2 ,
• Iva Strnadová 3 , 4 , 5 ,
• Jackie Leach Scully 4 ,
• Jennifer Hansen 3 ,
• Julie Loblinzk 3 , 5 ,
• Skie Sarfaraz 5 ,
• Chloe Molnar 1 ,
• Elizabeth Emma Palmer 1 , 2
• 1 Faculty of Medicine & Health , University of New South Wales , Sydney , New South Wales , Australia
• 2 The Sydney Children's Hospitals Network , Sydney , New South Wales , Australia
• 3 School of Education , University of New South Wales , Sydney , New South Wales , Australia
• 4 Disability Innovation Institute , University of New South Wales , Sydney , New South Wales , Australia
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Objective To identify factors acting as barriers or enablers to the process of healthcare consent for people with intellectual disability and to understand how to make this process equitable and accessible.

Data sources Databases: Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL. Additional articles were obtained from an ancestral search and hand-searching three journals.

Eligibility criteria Peer-reviewed original research about the consent process for healthcare interventions, published after 1990, involving adult participants with intellectual disability.

Synthesis of results Inductive thematic analysis was used to identify factors affecting informed consent. The findings were reviewed by co-researchers with intellectual disability to ensure they reflected lived experiences, and an easy read summary was created.

Results Twenty-three studies were included (1999 to 2020), with a mix of qualitative (n=14), quantitative (n=6) and mixed-methods (n=3) studies. Participant numbers ranged from 9 to 604 people (median 21) and included people with intellectual disability, health professionals, carers and support people, and others working with people with intellectual disability. Six themes were identified: (1) health professionals’ attitudes and lack of education, (2) inadequate accessible health information, (3) involvement of support people, (4) systemic constraints, (5) person-centred informed consent and (6) effective communication between health professionals and patients. Themes were barriers (themes 1, 2 and 4), enablers (themes 5 and 6) or both (theme 3).

Conclusions Multiple reasons contribute to poor consent practices for people with intellectual disability in current health systems. Recommendations include addressing health professionals’ attitudes and lack of education in informed consent with clinician training, the co-production of accessible information resources and further inclusive research into informed consent for people with intellectual disability.

PROSPERO registration CRD42021290548.

• Decision making
• Healthcare quality improvement
• Patient-centred care
• Quality improvement
• Standards of care

Data availability statement

Data are available upon reasonable request. Additional data and materials such as data collection forms, data extraction and analysis templates and QualSyst assessment data can be obtained by contacting the corresponding author.

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What is already known on this topic

People with intellectual disability are frequently excluded from decision-making processes and not provided equal opportunity for informed consent, despite protections outlined in the United Nations Convention on the Rights of Persons with Disabilities.

People with intellectual disability have the capacity and desire to make informed medical decisions, which can improve their well-being, health satisfaction and health outcomes.

What this review study adds

Health professionals lack adequate training in valid informed consent and making reasonable adjustments for people with intellectual disability, and continue to perpetuate assumptions of incapacity.

Health information provided to people with intellectual disability is often inaccessible and insufficient for them to make informed decisions about healthcare.

The role of support people, systemic constraints, a person-centred approach and ineffective healthcare communication also affect informed consent.

How this review might affect research, practice or policy

Health professionals need additional training on how to provide a valid informed consent process for people with intellectual disability, specifically in using accessible health information, making reasonable adjustments (e.g., longer/multiple appointments, options of a support person attending or not, using plain English), involving the individual in discussions, and communicating effectively with them.

Inclusive research is needed to hear the voices and opinions of people with intellectual disability about healthcare decision-making and about informed consent practices in specific healthcare settings.

Introduction

Approximately 1% of the world’s population have intellectual disability. 1 Intellectual disability is medically defined as a group of neurodevelopmental conditions beginning in childhood, with below average cognitive functioning and adaptive behaviour, including limitations in conceptual, social and practical skills. 2 People with intellectual disability prefer an alternative strength-based definition, reflected in the comment by Robert Strike OAM (Order of Australia Medal): ‘We can learn if the way of teaching matches how the person learns’, 3 reinforcing the importance of providing information tailored to the needs of a person with intellectual disability. A diagnosis of intellectual disability is associated with significant disparities in health outcomes. 4–7 Person-centred decision-making and better communication have been shown to improve patient satisfaction, 8 9 the physician–patient relationship 10 and overall health outcomes 11 for the wider population. Ensuring people with intellectual disability experience informed decision-making and accessible healthcare can help address the ongoing health disparities and facilitate equal access to healthcare.

Bodily autonomy is an individual’s power and agency to make decisions about their own body. 12 Informed consent for healthcare enables a person to practice bodily autonomy and is protected, for example, by the National Safety and Quality Health Service Standards (Australia), 13 Mental Capacity Act (UK) 14 and the Joint Commission Standards (USA). 15 In this article, we define informed consent according to three requirements: (1) the person is provided with information they understand, (2) the decision is free of coercion and (3) the person must have capacity. 16 For informed consent to be valid, this process must be suited to the individual’s needs so that they can understand and communicate effectively. Capacity is the ability to give informed consent for a medical intervention, 17 18 and the Mental Capacity Act outlines that ‘a person must be assumed to have capacity unless it is established that he lacks capacity’ and that incapacity can only be established if ‘all practicable steps’ to support capacity have been attempted without success. 14 These assumptions of capacity are also decision-specific, meaning an individual’s ability to consent can change depending on the situation, the choice itself and other factors. 17

Systemic issues with healthcare delivery systems have resulted in access barriers for people with intellectual disability, 19 despite the disability discrimination legislation in many countries who are signatories to the United Nations (UN) Convention on the Rights of Persons with Disabilities. 20 Patients with intellectual disability are not provided the reasonable adjustments that would enable them to give informed consent for medical procedures or interventions, 21 22 despite evidence that many people with intellectual disability have both the capacity and the desire to make their own healthcare decisions. 21 23

To support people with intellectual disability to make independent health decisions, an equitable and accessible informed consent process is needed. 24 However, current health systems have consistently failed to provide this. 21 25 To address this gap, we must first understand the factors that contribute to inequitable and inaccessible consent. To the best of our knowledge, the only current review of informed consent for people with intellectual disability is an integrative review by Goldsmith et al . 26 Many of the included articles focused on assessment of capacity 27–29 and research consent. 30–32 The review’s conclusion supported the functional approach to assess capacity, with minimal focus on how the informed consent processes can be improved. More recently, there has been a move towards ensuring that the consent process is accessible for all individuals, including elderly patients 33 and people with aphasia. 34 However, there remains a paucity of literature about the informed consent process for people with intellectual disability, with no systematic reviews summarising the factors influencing the healthcare consent process for people with intellectual disability.

To identify barriers to and enablers of the informed healthcare consent process for people with intellectual disability, and to understand how this can be made equitable and accessible.

A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) systematic literature review protocol. 35 The PRISMA 2020 checklist 36 and ENhancing Transparency in REporting the synthesis of Qualitative research (ENTREQ) reporting guidelines were also followed. 37 The full study protocol is included in online supplemental appendix 1 .

Supplemental material

No patients or members of the public were involved in this research for this manuscript.

Search strategy

A search strategy was developed to identify articles about intellectual disability, consent and healthcare interventions, described in online supplemental appendix 2 . Multiple databases were searched for articles published between January 1990 to January 2022 (Embase, MEDLINE, PsychINFO, PubMed, SCOPUS, Web of Science and CINAHL). These databases include healthcare and psychology databases that best capture relevant literature on this topic, including medical, nursing, social sciences and bioethical literature. The search was limited to studies published from 1990 as understandings of consent have changed since then. 38 39 This yielded 4853 unique papers which were imported into Covidence, a specialised programme for conducting systematic reviews. 40

Study selection

Citation screening by abstract and titles was completed by two independent researchers (MD and EEP). Included articles had to:

Examine the informed consent process for a healthcare intervention for people with intellectual disability.

Have collected more than 50% of its data from relevant stakeholders, including adults with intellectual disability, families or carers of a person with intellectual disability, and professionals who engage with people with intellectual disability.

Report empirical data from primary research methodology.

Be published in a peer-reviewed journal after January 1990.

Be available in English.

Full text screening was completed by two independent researchers (MD and EEP). Articles were excluded if consent was only briefly discussed or if it focused on consent for research, capacity assessment, or participant knowledge or comprehension. Any conflicts were resolved through discussion with an independent third researcher (IS).

Additional studies were identified through an ancestral search and by hand-searching three major journals relevant to intellectual disability research. Journals were selected if they had published more than one included article for this review or in previous literature reviews conducted by the research team.

Quality assessment

Two independent researchers (MD and IS) assessed study quality with the QualSyst tool, 41 which can assess both qualitative and quantitative research papers. After evaluating the distribution of scores, a threshold value of 55% was used, as suggested by QualSyst 41 to exclude poor-quality studies but capture enough studies overall. Any conflicts between the quality assessment scores were resolved by a third researcher (EEP). For mixed-method studies, both qualitative and quantitative quality scores were calculated, and the higher value used.

Data collection

Two independent researchers (MD and JH) reviewed each study and extracted relevant details, including study size, participant demographics, year, country of publication, study design, data analysis and major outcomes reported. Researchers used standardised data collection forms designed, with input from senior researchers with expertise in qualitative research (IS and EEP), to extract data relevant to the review’s research aims. The form was piloted on one study, and a second iteration made based on feedback. These forms captured data on study design, methods, participants, any factors affecting the process of informed consent and study limitations. Data included descriptions and paragraphs outlining key findings, the healthcare context, verbatim participant quotes and any quantitative analyses or statistics. Missing or unclear data were noted.

Data analysis

A pilot literature search showed significant heterogeneity in methodology of studies, limiting the applicability of traditional quantitative analysis (ie, meta-analysis). Instead, inductive thematic analysis was chosen as an alternative methodology 42 43 that has been used in recent systematic reviews examining barriers and enablers of other health processes. 44 45 The six-phase approach described by Braun and Clarke was used. 46 47 A researcher (MD) independently coded the extracted data of each study line-by-line, with subsequent data grouped into pre-existing codes or new concepts when necessary. Codes were reviewed iteratively and grouped into categories, subthemes and themes framed around the research question. Another independent researcher (JH) collated and analysed the data on study demographics, methods and limitations. The themes were reviewed by two senior researchers (EEP and IS).

Qualitative methods of effect size calculations have been described in the literature, 48 49 which was captured in this review by the number of studies that identified each subtheme, with an assigned frequency rating to compare their relative significance. Subthemes were given a frequency rating of A, B, C or D if they were identified by >10, 7–9, 4–6 or <3 articles, respectively. The overall significance of each theme was estimated by the number of studies that mentioned it and the GRADE framework, a stepwise approach to quality assessment using a four-tier rating system. Each study was evaluated for risk of bias, inconsistency, indirectness, imprecision and publication bias. 50 51 Study sensitivity was assessed by counting the number of distinct subthemes included. 52 The quality of findings was designated high, moderate or low depending on the frequency ratings, the QualSyst score and the GRADE scores of studies supporting the finding. Finally, the relative contributions of each study were evaluated by the number of subthemes described, guided by previously reported methods for qualitative reviews. 52

Co-research

The findings were reviewed by two co-researchers with intellectual disability (JL and SS), with over 30 years combined experience as members and employees of a self-advocacy organisation. Guidance on the findings and an easy read summary was produced in line with best-practice inclusive research 53 54 over multiple discussions. Input from two health professional researchers (MD and EEP) provided data triangulation and sense-checking of findings.

Twenty-three articles were identified ( figure 1 ): 14 qualitative, 6 quantitative and 3 mixed-methods. Two papers included the same population of study participants: McCarthy 55 and McCarthy, 56 but had different research questions. Fovargue et al 57 was excluded due to a quality score of 35%. Common quality limitations were a lack of verification procedures to establish credibility and limited researcher reflexivity. No studies were excluded due to language requirements (as all were in English) or age restrictions (all studies had majority adult participants).

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PRISMA 2020 flowchart for the systematic review. 36

Studies were published from 1999 to 2020 and involved participant populations from the UK (n=18), USA (n=3), Sweden (n=1) and Ireland (n=1). Participant numbers ranged from 9 to 604 (median 21), and participants included people with intellectual disability (n=817), health professionals (n=272), carers and support people (n=48), and other professionals that work with people with intellectual disability (n=137, community service agency directors, social workers, administrative staff and care home staff). Ages of participants ranged from 8 to 84 years, though only Aman et al 58 included participants <18 years of age. This study was included as the article states very few children were included. Studies examined consent in different contexts, including contraception and sexual health (6/23 articles), 58–60 medications (5/23 articles), 58–62 emergency healthcare, 63 cervical screening, 64 community referrals, 58–61 65 mental health, 66 hydrotherapy, 64 blood collection 67 and broad decision-making consent without a specific context. 65 68–71 A detailed breakdown of each study is included in online supplemental appendix 3 .

Six major themes were identified from the studies, summarised in figure 2 . An overview of included studies showing study sensitivity, effect size, QualSyst and GRADE scores is given in online supplemental appendix 4 . Studies with higher QualSyst and GRADE scores contributed more to this review’s findings and tended to include more subthemes; specifically, Rogers et al , 66 Sowney and Barr, 63 Höglund and Larsson, 72 and McCarthy 55 and McCarthy. 56 Figure 3 gives the easy read version of theme 1, with the full easy read summary in online supplemental appendix 5 .

Summary of the identified six themes and subthemes.

Theme 1 of the easy read summary.

Theme 1—Health professionals’ attitudes and lack of education about informed consent

Health professionals’ attitudes and practices were frequently (18/21) identified as factors affecting the informed consent process, with substantial evidence supporting this theme. Studies noted the lack of training for health professionals in supporting informed consent for people with intellectual disability, their desire for further education, and stereotypes and discrimination perpetuated by health professionals.

Lack of health professional education on informed consent and disability discrimination legislation

Multiple studies reported inconsistent informed consent practices, for various reasons: some reported that health professionals ‘forgot’ to or ‘did not realise consent was necessary’, 63 73 but inconsistent consent practices were also attributed to healthcare providers’ unfamiliarity with consent guidelines and poor education on this topic. Carlson et al 73 reported that only 44% of general practitioners (GPs) were aware of consent guidelines, and there was the misconception that consent was unnecessary for people with intellectual disability. Similarly, studies of psychologists 66 and nurses 63 found that many were unfamiliar with their obligations to obtain consent, despite the existence of anti-discrimination legislation. People with intellectual disability describe feeling discriminated against by health professionals, reflected in comments such as ‘I can tell, my doctor just thinks I’m stupid – I'm nothing to him’. 74 Poor consent practices by health professionals were observed in Goldsmith et al , 67 while health professionals surveyed by McCarthy 56 were unaware of their responsibility to provide accessible health information to women with intellectual disability. Improving health professional education and training was suggested by multiple studies as a way to remove this barrier. 63 65–67 69 73

Lack of training on best practices for health professions caring for people with intellectual disability

A lack of training in caring for and communicating with people with intellectual disability was also described by midwives, 72 psychologists, 66 nurses, 63 pharmacists 61 and GPs. 56 72 75 Health professionals lacked knowledge about best practice approaches to providing equitable healthcare consent processes through reasonable adjustments such as accessible health information, 56 60 66 longer appointments times, 60 72 simple English 62 67 and flexible approaches to patient needs. 63 72

Health professionals’ stereotyping and assumptions of incapacity

Underlying stereotypes contributed to some health professionals’ (including nurses, 63 GPs 56 and physiotherapists 64 ) belief that people with intellectual disability lack capacity and therefore, do not require opportunities for informed consent. 56 64 In a survey of professionals referring people with intellectual disability to a disability service, the second most common reason for not obtaining consent was ‘patient unable to understand’. 73

Proxy consent as an inappropriate alternative

People with intellectual disability are rarely the final decision-maker in their medical choices, with many health providers seeking proxy consent from carers, support workers and family members, despite its legal invalidity. In McCarthy’s study (2010), 18/23 women with intellectual disability said the decision to start contraception was made by someone else. Many GPs appeared unaware that proxy consent is invalid in the UK. 56 Similar reports came from people with intellectual disability, 55 56 60 64 69 76 health professionals (nurses, doctors, allied health, psychologists), 56 63 64 66 77 support people 64 77 and non-medical professionals, 65 73 and capacity was rarely documented. 56 62 77

Exclusion of people with intellectual disability from decision-making discussions

Studies described instances where health professionals made decisions for their patients with intellectual disability or coerced patients into a choice. 55 72 74 76 77 In Ledger et al 77 , only 62% of women with intellectual disability were involved in the discussion about contraception, and only 38% made the final decision, and others stated in Wiseman and Ferrie 74 : ‘I was not given the opportunity to explore the different options. I was told what one I should take’. Three papers outlined instances where the choices of people with intellectual disability were ignored despite possessing capacity 65 66 69 and when a procedure continued despite them withdrawing consent. 69

Theme 2—Inadequate accessible health information

Lack of accessible health information.

The lack of accessible health information was the most frequently identified subtheme (16/23 studies). Some studies reported that health professionals provided information to carers instead, 60 avoided providing easy read information due to concerns about ‘offending’ patients 75 or only provided verbal information. 56 67 Informed consent was supported when health professionals recognised the importance of providing medical information 64 and when it was provided in an accessible format. 60 Alternative approaches to health information were explored, including virtual reality 68 and in-person education sessions, 59 with varying results. Overall, the need to provide information in different formats tailored to an individual’s communication needs, rather than a ‘one size fits all’ approach, was emphasised by both people with intellectual disability 60 and health professionals. 66

Insufficient information provided

Studies described situations where insufficient information was provided to people with intellectual disability to make informed decisions. For example, some people felt the information from their GP was often too basic to be helpful (Fish et al 60 ) and wanted additional information on consent forms (Rose et al 78 ).

Theme 3—The involvement of support people

Support people (including carers, family members and group home staff) were identified in 11 articles as both enablers of and barriers to informed consent. The antagonistic nature of these findings and lower frequency of subthemes are reflected in the lower quality assessments of evidence.

Support people facilitated communication with health professionals

Some studies reported carers bridging communication barriers with health to support informed consent. 63 64 McCarthy 56 found 21/23 of women with intellectual disability preferred to see doctors with a support person due to perceived benefits: ‘Sometimes I don’t understand it, so they have to explain it to my carer, so they can explain it to me easier’. Most GPs in this study (93%) also agreed that support people aided communication.

Support people helped people with intellectual disability make decisions

By advocating for people with intellectual disability, carers encouraged decision-making, 64 74 provided health information, 74 77 emotional support 76 and assisted with reading or remembering health information. 55 58 76 Some people with intellectual disability explicitly appreciated their support person’s involvement, 60 such as in McCarthy’s 55 study where 18/23 participants felt supported and safer when a support person was involved.

Support people impeded individual autonomy

The study by Wiseman and Ferrie 74 found that while younger participants with intellectual disability felt family members empowered their decision-making, older women felt family members impaired their ability to give informed consent. This was reflected in interviews with carers who questioned the capacity of the person with intellectual disability they supported and stated they would guide them to pick the ‘best choice’ or even over-ride their choices. 64 Studies of psychologists and community service directors described instances where the decision of family or carers was prioritised over the wishes of the person with intellectual disability. 65 66 Some women with intellectual disability in McCarthy’s studies (2010, 2009) 55 56 appeared to have been coerced into using contraception by parental pressures or fear of losing group home support.

Theme 4—Systemic constraints within healthcare systems

Time restraints affect informed consent and accessible healthcare.

Resource limitations create time constraints that impair the consent process and have been identified as a barrier by psychologists, 66 GPs, 56 hospital nurses 63 and community disability workers. 73 Rogers et al 66 highlighted that a personalised approach that could improve informed decision-making is restricted by inflexible medical models. Only two studies described flexible patient-centred approaches to consent. 60 72 A survey of primary care practices in 2007 reported that most did not modify their cervical screening information for patients with intellectual disability because it was not practical. 75

Inflexible models of consent

Both people with intellectual disability 76 and health professionals 66 recognised that consent is traditionally obtained through one-off interactions prior to an intervention. Yet, for people with intellectual disability, consent should ideally be an ongoing process that begins before an appointment and continues between subsequent ones. Other studies have tended to describe one-off interactions where decision-making was not revisited at subsequent appointments. 56 60 72 76

Lack of systemic supports

In one survey, self-advocates highlighted a lack of information on medication for people with intellectual disability and suggested a telephone helpline and a centralised source of information to support consent. 60 Health professionals also want greater systemic support, such as a health professional specialised in intellectual disability care to support other staff, 72 or a pharmacist specifically to help patients with intellectual disability. 61 Studies highlighted a lack of guidelines about healthcare needs of people with intellectual disabilities such as contraceptive counselling 72 or primary care. 75

Theme 5—Person-centred informed consent

Ten studies identified factors related to a person-centred approach to informed consent, grouped below into three subthemes. Health professionals should tailor their practice when obtaining informed consent from people with intellectual disability by considering how these subthemes relate to the individual. Each subtheme was described five times in the literature with a relative frequency rating of ‘C’, contributing to overall lower quality scores.

Previous experience with decision-making

Arscott et al 71 found that the ability of people with intellectual disability to consent changed with their verbal and memory skills and in different clinical vignettes, supporting the view of ‘functional’ capacity specific to the context of the medical decision. Although previous experiences with decision-making did not influence informed consent in this paper, other studies suggest that people with intellectual disability accustomed to independent decision-making were more able to make informed medical decisions, 66 70 and those who live independently were more likely to make independent healthcare decisions. 56 Health professionals should be aware that their patients with intellectual disability will have variable experience with decision-making and provide individualised support to meet their needs.

Variable awareness about healthcare rights

Consent processes should be tailored to the health literacy of patients, including emphasising available choices and the option to refuse treatment. In some studies, medical decisions were not presented to people with intellectual disability as a choice, 64 and people with intellectual disability were not informed of their legal right to accessible health information. 56

Power differences and acquiescence

Acquiescence by people with intellectual disability due to common and repeated experiences of trauma—that is, their tendency to agree with suggestions made by carers and health professionals, often to avoid upsetting others—was identified as an ongoing barrier. In McCarthy’s (2009) interviews with women with intellectual disability, some participants implicitly rejected the idea that they might make their own healthcare decisions: ‘They’re the carers, they have responsibility for me’. Others appeared to have made decisions to appease their carers: ‘I have the jab (contraceptive injection) so I can’t be blamed for getting pregnant’. 55 Two studies highlighted that health professionals need to be mindful of power imbalances when discussing consent with people with intellectual disability to ensure the choices are truly autonomous. 61 66

Theme 6—Effective communication between health professionals and patients

Implementation of reasonable adjustments for verbal and written information.

Simple language was always preferred by people with intellectual disability. 60 67 Other communication aids used in decision-making included repetition, short sentences, models, pictures and easy read brochures. 72 Another reasonable adjustment is providing the opportunity to ask questions, which women with intellectual disability in McCarthy’s (2009) study reported did not occur. 55

Tailored communication methods including non-verbal communication

Midwives noted that continuity of care allows them to develop rapport and understand the communication preferences of people with intellectual disability. 72 This is not always possible; for emergency nurses, the lack of background information about patients with intellectual disability made it challenging to understand their communication preferences. 63 The use of non-verbal communication, such as body language, was noted as underutilised 62 66 and people with intellectual disability supported the use of hearing loops, braille and sign language. 60

To the best of our knowledge, this is the first systematic review investigating the barriers and enablers of the informed consent process for healthcare procedures for people with intellectual disability. The integrative review by Goldsmith et al 26 examined capacity assessment and shares only three articles with this systematic review. 69 71 73 Since the 2000s, there has been a paradigm shift in which capacity is no longer considered a fixed ability that only some individuals possess 38 39 but instead as ‘functional’: a flexible ability that changes over time and in different contexts, 79 reflected in Goldsmith’s review. An individual’s capacity can be supported through various measures, including how information is communicated and how the decision-making process is approached. 18 80 By recognising the barriers and enablers identified in this review, physicians can help ensure the consent process for their patients with intellectual disability is both valid and truly informed. This review has highlighted the problems of inaccessible health information, insufficient clinical education on how to make reasonable adjustments and lack of person-centred trauma-informed care.

Recommendations

Health professionals require training in the informed consent process for people with intellectual disability, particularly in effective and respectful communication, reasonable adjustments and trauma-informed care. Reasonable adjustments include offering longer or multiple appointments, using accessible resources (such as easy read information or shared decision-making tools) and allowing patient choices (such as to record a consultation or involve a support person). Co-researchers reported that many people with intellectual disability prefer to go without a support person because they find it difficult to challenge their decisions and feel ignored if the health professional only talks to the support person. People with intellectual disability also feel they cannot seek second opinions before making medical decisions or feel pressured to provide consent, raising the possibility of coercion. These experiences contribute to healthcare trauma. Co-researchers raised the importance of building rapport with the person with intellectual disability and of making reasonable adjustments, such as actively advocating for the person’s autonomy, clearly stating all options including the choice to refuse treatment, providing opportunities to contribute to discussions and multiple appointments to ask questions and understand information. They felt that without these efforts to support consent, health professionals can reinforce traumatic healthcare experiences for people with intellectual disability. Co-researchers noted instances where choices were made by doctors without discussion and where they were only given a choice after requesting one and expressed concern that these barriers are greater for those with higher support needs.

Co-researchers showed how these experiences contributed to mistrust of health professionals and poorer health outcomes. In one situation, a co-researcher was not informed of a medication’s withdrawal effects, resulting in significant side-effects when it was ceased. Many people with intellectual disability describe a poor relationship with their health professionals, finding it difficult to trust health information provided due to previous traumatic experiences of disrespect, coercion, lack of choice and inadequate support. Many feel they cannot speak up due to the power imbalance and fear of retaliation. Poor consent practices and lack of reasonable adjustments directly harm therapeutic alliances by reducing trust, contribute to healthcare trauma and lead to poorer health outcomes for people with intellectual disability.

Additional education and training for health professionals is urgently needed in the areas of informed consent, reasonable adjustments and effective communication with people with intellectual disability. The experiences of health professionals within the research team confirmed that there is limited training in providing high-quality healthcare for people with intellectual disability, including reasonable adjustments and accessible health information. Co-researchers also suggested that education should be provided to carers and support people to help them better advocate for people with intellectual disability.

Health information should be provided in a multimodal format, including written easy read information. Many countries have regulation protecting the right to accessible health information and communication support to make an informed choice, such as UK’s Accessible Information Standard, 81 and Australia’s Charter of Health Care Rights, 24 yet these are rarely observed. Steps to facilitate this include routinely asking patients about information requirements, system alerts for an individual’s needs or routinely providing reasonable adjustments. 82 Co-researchers agreed that there is a lack of accessible health information, particularly about medications, and that diagrams and illustrations are underutilised. There is a critical need for more inclusive and accessible resources to help health professionals support informed consent in a safe and high-quality health system. These resources should be created through methods of inclusive research, such as co-production, actively involving people with intellectual disability in the planning, creation, and feedback process. 53

Strengths and limitations

This systematic review involved two co-researchers with intellectual disability in sense-checking findings and co-creating the easy read summary. Two co-authors who are health professionals provided additional sense-checking of findings from a different stakeholder perspective. In future research, this could be extended by involving people with intellectual disability in the design and planning of the study as per recommendations for best-practice inclusive research. 53 83

The current literature is limited by low use of inclusive research practices in research involving people with intellectual disability, increasing vulnerability to external biases (eg, inaccessible questionnaires, involvement of carers in data collection, overcompliance or acquiescence and absence of researcher reflexivity). Advisory groups or co-research with people with intellectual disability were only used in five studies. 58 60 68 74 76 Other limitations include unclear selection criteria, low sample sizes, missing data, using gatekeepers in patient selection and predominance of UK-based studies—increasing the risk of bias and reducing transferability. Nine studies (out of 15 involving people with intellectual disability) explicitly excluded those with severe or profound intellectual disability, reflecting a selection bias; only one study specifically focused on people with intellectual disability with higher support needs. Studies were limited to a few healthcare contexts, with a focus on consent about sexual health, contraception and medications.

The heterogeneity and qualitative nature of studies made it challenging to apply traditional meta-analysis. However, to promote consistency in qualitative research, the PRISMA and ENTREQ guidelines were followed. 36 37 Although no meta-analyses occurred, the duplication of study populations in McCarthy 2009 and 2010 likely contributed to increased significance of findings reported in both studies. Most included studies (13/23) were published over 10 years ago, reducing the current relevance of this review’s findings. Nonetheless, the major findings reflect underlying systemic issues within the health system, which are unlikely to have been resolved since the articles were published, as the just-released final report of the Australian Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability highlights. 84 There is an urgent need for more inclusive studies to explore the recommendations and preferences of people with intellectual disability about healthcare choices.

Informed consent processes for people with intellectual disability should include accessible information and reasonable adjustments, be tailored to individuals’ needs and comply with consent and disability legislation. Resources, guidelines and healthcare education are needed and should cover how to involve carers and support people, address systemic healthcare problems, promote a person-centred approach and ensure effective communication. These resources and future research must use principles of inclusive co-production—involving people with intellectual disability at all stages. Additionally, research is needed on people with higher support needs and in specific contexts where informed consent is vital but under-researched, such as cancer screening, palliative care, prenatal and newborn screening, surgical procedures, genetic medicine and advanced therapeutics such as gene-based therapies.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

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Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

• Data supplement 1
• Data supplement 2
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• Data supplement 5

Contributors MD, EEP and IS conceived the idea for the systematic review. MD drafted the search strategy which was refined by EEP and IS. MD and EEP completed article screening. MD and IS completed quality assessments of included articles. MD and JH completed data extraction. MD drafted the original manuscript. JL and SS were co-researchers who sense-checked findings and were consulted to formulate dissemination plans. JL and SS co-produced the easy read summary with MD, CM, JH, EEP and IS. MD, JLS, EEP and IS reviewed manuscript wording. All authors critically reviewed the manuscript and approved it for publication. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. MD is the guarantor responsible for the overall content of this manuscript.

Funding This systematic literature review was funded by the National Health & Medical Research Council (NHMRC), Targeted Call for Research (TCR) into Improving health of people with intellectual disability. Research grant title "GeneEQUAL: equitable and accessible genomic healthcare for people with intellectual disability". NHMRC application ID: 2022/GNT2015753.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Linked Articles

• Editorial It is up to healthcare professionals to talk to us in a way that we can understand: informed consent processes in people with an intellectual disability Jonathon Ding Richard Keagan-Bull Irene Tuffrey-Wijne BMJ Quality & Safety 2024; 33 277-279 Published Online First: 30 Jan 2024. doi: 10.1136/bmjqs-2023-016830

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• Published: 24 April 2024

Breast cancer screening motivation and behaviours of women aged over 75 years: a scoping review

• Virginia Dickson-Swift 1 ,
• Joanne Adams 1 ,
• Evelien Spelten 1 ,
• Irene Blackberry 2 ,
• Carlene Wilson 3 , 4 , 5 &
• Eva Yuen 3 , 6 , 7 , 8  

BMC Women's Health volume  24 , Article number:  256 ( 2024 ) Cite this article

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Metrics details

This scoping review aimed to identify and present the evidence describing key motivations for breast cancer screening among women aged ≥ 75 years. Few of the internationally available guidelines recommend continued biennial screening for this age group. Some suggest ongoing screening is unnecessary or should be determined on individual health status and life expectancy. Recent research has shown that despite recommendations regarding screening, older women continue to hold positive attitudes to breast screening and participate when the opportunity is available.

All original research articles that address motivation, intention and/or participation in screening for breast cancer among women aged ≥ 75 years were considered for inclusion. These included articles reporting on women who use public and private breast cancer screening services and those who do not use screening services (i.e., non-screeners).

The Joanna Briggs Institute (JBI) methodology for scoping reviews was used to guide this review. A comprehensive search strategy was developed with the assistance of a specialist librarian to access selected databases including: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Web of Science and PsychInfo. The review was restricted to original research studies published since 2009, available in English and focusing on high-income countries (as defined by the World Bank). Title and abstract screening, followed by an assessment of full-text studies against the inclusion criteria was completed by at least two reviewers. Data relating to key motivations, screening intention and behaviour were extracted, and a thematic analysis of study findings undertaken.

A total of fourteen (14) studies were included in the review. Thematic analysis resulted in identification of three themes from included studies highlighting that decisions about screening were influenced by: knowledge of the benefits and harms of screening and their relationship to age; underlying attitudes to the importance of cancer screening in women's lives; and use of decision aids to improve knowledge and guide decision-making.

The results of this review provide a comprehensive overview of current knowledge regarding the motivations and screening behaviour of older women about breast cancer screening which may inform policy development.

Peer Review reports

Introduction

Breast cancer is now the most commonly diagnosed cancer in the world overtaking lung cancer in 2021 [ 1 ]. Across the globe, breast cancer contributed to 25.8% of the total number of new cases of cancer diagnosed in 2020 [ 2 ] and accounts for a high disease burden for women [ 3 ]. Screening for breast cancer is an effective means of detecting early-stage cancer and has been shown to significantly improve survival rates [ 4 ]. A recent systematic review of international screening guidelines found that most countries recommend that women have biennial mammograms between the ages of 40–70 years [ 5 ] with some recommending that there should be no upper age limit [ 6 , 7 , 8 , 9 , 10 , 11 , 12 ] and others suggesting that benefits of continued screening for women over 75 are not clear [ 13 , 14 , 15 ].

Some guidelines suggest that the decision to end screening should be determined based on the individual health status of the woman, their life expectancy and current health issues [ 5 , 16 , 17 ]. This is because the benefits of mammography screening may be limited after 7 years due to existing comorbidities and limited life expectancy [ 18 , 19 , 20 , 21 ], with some jurisdictions recommending breast cancer screening for women ≥ 75 years only when life expectancy is estimated as at least 7–10 years [ 22 ]. Others have argued that decisions about continuing with screening mammography should depend on individual patient risk and health management preferences [ 23 ]. This decision is likely facilitated by a discussion between a health care provider and patient about the harms and benefits of screening outside the recommended ages [ 24 , 25 ]. While mammography may enable early detection of breast cancer, it is clear that false-positive results and overdiagnosis Footnote 1 may occur. Studies have estimated that up to 25% of breast cancer cases in the general population may be over diagnosed [ 26 , 27 , 28 ].

The risk of being diagnosed with breast cancer increases with age and approximately 80% of new cases of breast cancer in high-income countries are in women over the age of 50 [ 29 ]. The average age of first diagnosis of breast cancer in high income countries is comparable to that of Australian women which is now 61 years [ 2 , 4 , 29 ]. Studies show that women aged ≥ 75 years generally have positive attitudes to mammography screening and report high levels of perceived benefits including early detection of breast cancer and a desire to stay healthy as they age [ 21 , 30 , 31 , 32 ]. Some women aged over 74 participate, or plan to participate, in screening despite recommendations from health professionals and government guidelines advising against it [ 33 ]. Results of a recent review found that knowledge of the recommended guidelines and the potential harms of screening are limited and many older women believed that the benefits of continued screening outweighed the risks [ 30 ].

Very few studies have been undertaken to understand the motivations of women to screen or to establish screening participation rates among women aged ≥ 75 and older. This is surprising given that increasing age is recognised as a key risk factor for the development of breast cancer, and that screening is offered in many locations around the world every two years up until 74 years. The importance of this topic is high given the ambiguity around best practice for participation beyond 74 years. A preliminary search of Open Science Framework, PROSPERO, Cochrane Database of Systematic Reviews and JBI Evidence Synthesis in May 2022 did not locate any reviews on this topic.

This scoping review has allowed for the mapping of a broad range of research to explore the breadth and depth of the literature, summarize the evidence and identify knowledge gaps [ 34 , 35 ]. This information has supported the development of a comprehensive overview of current knowledge of motivations of women to screen and screening participation rates among women outside the targeted age of many international screening programs.

Materials and methods

Research question.

The research question for this scoping review was developed by applying the Population—Concept—Context (PCC) framework [ 36 ]. The current review addresses the research question “What research has been undertaken in high-income countries (context) exploring the key motivations to screen for breast cancer and screening participation (concepts) among women ≥ 75 years of age (population)?

Eligibility criteria

Participants.

Women aged ≥ 75 years were the key population. Specifically, motivations to screen and screening intention and behaviour and the variables that discriminate those who screen from those who do not (non-screeners) were utilised as the key predictors and outcomes respectively.

From a conceptual perspective it was considered that motivation led to behaviour, therefore articles that described motivation and corresponding behaviour were considered. These included articles reporting on women who use public (government funded) and private (fee for service) breast cancer screening services and those who do not use screening services (i.e., non-screeners).

The scope included high-income countries using the World Bank definition [ 37 ]. These countries have broadly similar health systems and opportunities for breast cancer screening in both public and private settings.

Types of sources

All studies reporting original research in peer-reviewed journals from January 2009 were eligible for inclusion, regardless of design. This date was selected due to an evaluation undertaken for BreastScreen Australia recommending expansion of the age group to include 70–74-year-old women [ 38 ]. This date was also indicative of international debate regarding breast cancer screening effectiveness at this time [ 39 , 40 ]. Reviews were also included, regardless of type—scoping, systematic, or narrative. Only sources published in English and available through the University’s extensive research holdings were eligible for inclusion. Ineligible materials were conference abstracts, letters to the editor, editorials, opinion pieces, commentaries, newspaper articles, dissertations and theses.

This scoping review was registered with the Open Science Framework database ( https://osf.io/fd3eh ) and followed Joanna Briggs Institute (JBI) methodology for scoping reviews [ 35 , 36 ]. Although ethics approval is not required for scoping reviews the broader study was approved by the University Ethics Committee (approval number HEC 21249).

Search strategy

A pilot search strategy was developed in consultation with an expert health librarian and tested in MEDLINE (OVID) and conducted on 3 June 2022. Articles from this pilot search were compared with seminal articles previously identified by the members of the team and used to refine the search terms. The search terms were then searched as both keywords and subject headings (e.g., MeSH) in the titles and abstracts and Boolean operators employed. A full MEDLINE search was then carried out by the librarian (see Table  1 ). This search strategy was adapted for use in each of the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science and PsychInfo databases. The references of included studies have been hand-searched to identify any additional evidence sources.

Study/source of evidence selection

Following the search, all identified citations were collated and uploaded into EndNote v.X20 (Clarivate Analytics, PA, USA) and duplicates removed. The resulting articles were then imported into Covidence – Cochrane’s systematic review management software [ 41 ]. Duplicates were removed once importation was complete, and title and abstract screening was undertaken against the eligibility criteria. A sample of 25 articles were assessed by all reviewers to ensure reliability in the application of the inclusion and exclusion criteria. Team discussion was used to ensure consistent application. The Covidence software supports blind reviewing with two reviewers required at each screening phase. Potentially relevant sources were retrieved in full text and were assessed against the inclusion criteria by two independent reviewers. Conflicts were flagged within the software which allows the team to discuss those that have disagreements until a consensus was reached. Reasons for exclusion of studies at full text were recorded and reported in the scoping review. The Preferred Reporting Items of Systematic Reviews extension for scoping reviews (PRISMA-ScR) checklist was used to guide the reporting of the review [ 42 ] and all stages were documented using the PRISMA-ScR flow chart [ 42 ].

Data extraction

A data extraction form was created in Covidence and used to extract study characteristics and to confirm the study’s relevance. This included specific details such as article author/s, title, year of publication, country, aim, population, setting, data collection methods and key findings relevant to the review question. The draft extraction form was modified as needed during the data extraction process.

Data analysis and presentation

Extracted data were summarised in tabular format (see Table  2 ). Consistent with the guidelines for the effective reporting of scoping reviews [ 43 ] and the JBI framework [ 35 ] the final stage of the review included thematic analysis of the key findings of the included studies. Study findings were imported into QSR NVivo with coding of each line of text. Descriptive codes reflected key aspects of the included studies related to the motivations and behaviours of women > 75 years about breast cancer screening.

In line with the reporting requirements for scoping reviews the search results for this review are presented in Fig.  1 [ 44 ].

PRISMA Flowchart. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71

A total of fourteen [ 14 ] studies were included in the review with studies from the following countries, US n  = 12 [ 33 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ], UK n  = 1 [ 23 ] and France n  = 1 [ 56 ]. Sample sizes varied, with most containing fewer than 50 women ( n  = 8) [ 33 , 45 , 46 , 48 , 51 , 52 , 55 ]. Two had larger samples including a French study with 136 women (a sub-set of a larger sample) [ 56 ], and one mixed method study in the UK with a sample of 26 women undertaking interviews and 479 women completing surveys [ 23 ]. One study did not report exact numbers [ 50 ]. Three studies [ 47 , 53 , 54 ] were undertaken by a group of researchers based in the US utilising the same sample of women, however each of the papers focused on different primary outcomes. The samples in the included studies were recruited from a range of locations including primary medical care clinics, specialist medical clinics, University affiliated medical clinics, community-based health centres and community outreach clinics [ 47 , 53 , 54 ].

Data collection methods varied and included: quantitative ( n  = 8), qualitative ( n  = 5) and mixed methods ( n  = 1). A range of data collection tools and research designs were utilised; pre/post, pilot and cross-sectional surveys, interviews, and secondary analysis of existing data sets. Seven studies focused on the use of a Decision Aids (DAs), either in original or modified form, developed by Schonberg et al. [ 55 ] as a tool to increase knowledge about the harms and benefits of screening for older women [ 45 , 47 , 48 , 49 , 52 , 54 , 55 ]. Three studies focused on intention to screen [ 33 , 53 , 56 ], two on knowledge of, and attitudes to, screening [ 23 , 46 ], one on information needs relating to risks and benefits of screening discontinuation [ 51 ], and one on perceptions about discontinuation of screening and impact of social interactions on screening [ 50 ].

The three themes developed from the analysis of the included studies highlighted that decisions about screening were primarily influenced by: (1) knowledge of the benefits and harms of screening and their relationship to age; (2) underlying attitudes to the importance of cancer screening in women's lives; and (3) exposure to decision aids designed to facilitate informed decision-making. Each of these themes will be presented below drawing on the key findings of the appropriate studies. The full dataset of extracted data can be found in Table  2 .

Knowledge of the benefits and harms of screening ≥ 75 years

The decision to participate in routine mammography is influenced by individual differences in cognition and affect, interpersonal relationships, provider characteristics, and healthcare system variables. Women typically perceive mammograms as a positive, beneficial and routine component of care [ 46 ] and an important aspect of taking care of themselves [ 23 , 46 , 49 ]. One qualitative study undertaken in the US showed that few women had discussed mammography cessation or the potential harms of screening with their health care providers and some women reported they would insist on receiving mammography even without a provider recommendation to continue screening [ 46 ].

Studies suggested that ageing itself, and even poor health, were not seen as reasonable reasons for screening cessation. For many women, guidance from a health care provider was deemed the most important influence on decision-making [ 46 ]. Preferences for communication about risk and benefits were varied with one study reporting women would like to learn more about harms and risks and recommended that this information be communicated via physicians or other healthcare providers, included in brochures/pamphlets, and presented outside of clinical settings (e.g., in community-based seniors groups) [ 51 ]. Others reported that women were sometimes sceptical of expert and government recommendations [ 33 ] although some were happy to participate in discussions with health educators or care providers about breast cancer screening harms and benefits and potential cessation [ 52 ].

Underlying attitudes to the importance of cancer screening at and beyond 75 years

Included studies varied in describing the importance of screening, with some attitudes based on past attendance and some based on future intentions to screen. Three studies reported findings indicating that some women intended to continue screening after 75 years of age [ 23 , 45 , 46 ], with one study in the UK reporting that women supported an extension of the automatic recall indefinitely, regardless of age or health status. In this study, failure to invite older women to screen was interpreted as age discrimination [ 23 ]. The desire to continue screening beyond 75 was also highlighted in a study from France that found that 60% of the women ( n  = 136 aged ≥ 75) intended to pursue screening in the future, and 27 women aged ≥ 75, who had never undergone mammography previously (36%), intended to do so in the future [ 56 ]. In this same study, intentions to screen varied significantly [ 56 ]. There were no sociodemographic differences observed between screened and unscreened women with regard to level of education, income, health risk behaviour (smoking, alcohol consumption), knowledge about the importance and the process of screening, or psychological features (fear of the test, fear of the results, fear of the disease, trust in screening impact) [ 56 ]. Further analysis showed that three items were statistically correlated with a higher rate of attendance at screening: (1) screening was initiated by a physician; (2) the women had a consultation with a gynaecologist during the past 12 months; and (3) the women had already undergone at least five screening mammograms. Analysis highlighted that although average income, level of education, psychological features or other types of health risk behaviours did not impact screening intention, having a mammogram previously impacted likelihood of ongoing screening. There was no information provided that explained why women who had not previously undergone screening might do so in the future.

A mixed methods study in the UK reported similar findings [ 23 ]. Utilising interviews ( n  = 26) and questionnaires ( n  = 479) with women ≥ 70 years (median age 75 years) the overwhelming result (90.1%) was that breast screening should be offered to all women indefinitely regardless of age, health status or fitness [ 23 ], and that many older women were keen to continue screening. Both the interview and survey data confirmed women were uncertain about eligibility for breast screening. The survey data showed that just over half the women (52.9%) were unaware that they could request mammography or knew how to access it. Key reasons for screening discontinuation were not being invited for screening (52.1%) and not knowing about self-referral (35.1%).

Women reported that not being invited to continue screening sent messages that screening was no longer important or required for this age group [ 23 ]. Almost two thirds of the women completing the survey (61.6%) said they would forget to attend screening without an invitation. Other reasons for screening discontinuation included transport difficulties (25%) and not wishing to burden family members (24.7%). By contrast, other studies have reported that women do not endorse discontinuation of screening mammography due to advancing age or poor health, but some may be receptive to reducing screening frequency on recommendation from their health care provider [ 46 , 51 ].

Use of Decision Aids (DAs) to improve knowledge and guide screening decision-making

Many women reported poor knowledge about the harms and benefits of screening with studies identifying an important role for DAs. These aids have been shown to be effective in improving knowledge of the harms and benefits of screening [ 45 , 54 , 55 ] including for women with low educational attainment; as compared to women with high educational attainment [ 47 ]. DAs can increase knowledge about screening [ 47 , 49 ] and may decrease the intention to continue screening after the recommended age [ 45 , 52 , 54 ]. They can be used by primary care providers to support a conversation about breast screening intention and reasons for discontinuing screening. In one pilot study undertaken in the US using a DA, 5 of the 8 women (62.5%) indicated they intended to continue to receive mammography; however, 3 participants planned to get them less often [ 45 ]. When asked whether they thought their physician would want them to get a mammogram, 80% said “yes” on pre-test; this figure decreased to 62.5% after exposure to the DA. This pilot study suggests that the use of a decision-aid may result in fewer women ≥ 75 years old continuing to screen for breast cancer [ 45 ].

Similar findings were evident in two studies drawing on the same data undertaken in the US [ 48 , 53 ]. Using a larger sample ( n  = 283), women’s intentions to screen prior to a visit with their primary care provider and then again after exposure to the DA were compared. Results showed that 21.7% of women reduced their intention to be screened, 7.9% increased their intentions to be screened, and 70.4% did not change. Compared to those who had no change or increased their screening intentions, women who had a decrease in screening intention were significantly less likely to receive screening after 18 months. Generally, studies have shown that women aged 75 and older find DAs acceptable and helpful [ 47 , 48 , 49 , 55 ] and using them had the potential to impact on a women’s intention to screen [ 55 ].

Cadet and colleagues [ 49 ] explored the impact of educational attainment on the use of DAs. Results highlight that education moderates the utility of these aids; women with lower educational attainment were less likely to understand all the DA’s content (46.3% vs 67.5%; P < 0.001); had less knowledge of the benefits and harms of mammography (adjusted mean ± standard error knowledge score, 7.1 ± 0.3 vs 8.1 ± 0.3; p < 0.001); and were less likely to have their screening intentions impacted (adjusted percentage, 11.4% vs 19.4%; p  = 0.01).

This scoping review summarises current knowledge regarding motivations and screening behaviours of women over 75 years. The findings suggest that awareness of the importance of breast cancer screening among women aged ≥ 75 years is high [ 23 , 46 , 49 ] and that many women wish to continue screening regardless of perceived health status or age. This highlights the importance of focusing on motivation and screening behaviours and the multiple factors that influence ongoing participation in breast screening programs.

The generally high regard attributed to screening among women aged ≥ 75 years presents a complex challenge for health professionals who are focused on potential harm (from available national and international guidelines) in ongoing screening for women beyond age 75 [ 18 , 20 , 57 ]. Included studies highlight that many women relied on the advice of health care providers regarding the benefits and harms when making the decision to continue breast screening [ 46 , 51 , 52 ], however there were some that did not [ 33 ]. Having a previous pattern of screening was noted as being more significant to ongoing intention than any other identified socio-demographic feature [ 56 ]. This is perhaps because women will not readily forgo health care practices that they have always considered important and that retain ongoing importance for the broader population.

For those women who had discontinued screening after the age of 74 it was apparent that the rationale for doing so was not often based on choice or receipt of information, but rather on factors that impact decision-making in relation to screening. These included no longer receiving an invitation to attend, transport difficulties and not wanting to be a burden on relatives or friends [ 23 , 46 , 51 ]. Ongoing receipt of invitations to screen was an important aspect of maintaining a capacity to choose [ 23 ]. This was particularly important for those women who had been regular screeners.

Women over 75 require more information to make decisions regarding screening [ 23 , 52 , 54 , 55 ], however health care providers must also be aware that the element of choice is important for older women. Having a capacity to choose avoids any notion of discrimination based on age, health status, gender or sociodemographic difference and acknowledges the importance of women retaining control over their health [ 23 ]. It was apparent that some women would choose to continue screening at a reduced frequency if this option was available and that women should have access to information facilitating self-referral [ 23 , 45 , 46 , 51 , 56 ].

Decision-making regarding ongoing breast cancer screening has been facilitated via the use of Decision Aids (DAs) within clinical settings [ 54 , 55 ]. While some studies suggest that women will make a decision regardless of health status, the use of DAs has impacted women’s decision to screen. While this may have limited benefit for those of lower educational attainment [ 48 ] they have been effective in improving knowledge relating to harms and benefits of screening particularly where they have been used to support a conversation with women about the value of screening [ 54 , 55 , 56 ].

Women have identified challenges in engaging in conversations with health care providers regarding ongoing screening, because providers frequently draw on projections of life expectancy and over-diagnosis [ 17 , 51 ]. As a result, these conversations about screening after age 75 years often do not occur [ 46 ]. It is likely that health providers may need more support and guidance in leading these conversations. This may be through the use of DAs or standardised checklists. It may be possible to incorporate these within existing health preventive measures for this age group. The potential for advice regarding ongoing breast cancer screening to be available outside of clinical settings may provide important pathways for conversations with women regarding health choices. Provision of information and advice in settings such as community based seniors groups [ 51 ] offers a potential platform to broaden conversations and align sources of information, not only with health professionals but amongst women themselves. This may help to address any misconception regarding eligibility and access to services [ 23 ]. It may also be aligned with other health promotion and lifestyle messages provided to this age group.

Limitations of the review

The searches that formed the basis of this review were carried in June 2022. Although the search was comprehensive, we have only captured those studies that were published in the included databases from 2009. There may have been other studies published outside of these periods. We also limited the search to studies published in English with full-text availability.

The emphasis of a scoping review is on comprehensive coverage and synthesis of the key findings, rather than on a particular standard of evidence and, consequently a quality assessment of the included studies was not undertaken. This has resulted in the inclusion of a wide range of study designs and data collection methods. It is important to note that three studies included in the review drew on the same sample of women (283 over > 75)[ 49 , 53 , 54 ]. The results of this review provide valuable insights into motivations and behaviours for breast cancer screening for older women, however they should be interpreted with caution given the specific methodological and geographical limitations.

Conclusion and recommendations

This scoping review highlighted a range of key motivations and behaviours in relation to breast cancer screening for women ≥ 75 years of age. The results provide some insight into how decisions about screening continuation after 74 are made and how informed decision-making can be supported. Specifically, this review supports the following suggestions for further research and policy direction:

Further research regarding breast cancer screening motivations and behaviours for women over 75 would provide valuable insight for health providers delivering services to women in this age group.

Health providers may benefit from the broader use of decision aids or structured checklists to guide conversations with women over 75 regarding ongoing health promotion/preventive measures.

Providing health-based information in non-clinical settings frequented by women in this age group may provide a broader reach of information and facilitate choices. This may help to reduce any perception of discrimination based on age, health status or socio-demographic factors.

Availability of data and materials

All data generated or analysed during this study is included in this published article (see Table  2 above).

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Acknowledgements

We would like to acknowledge Ange Hayden-Johns (expert librarian) who assisted with the development of the search criteria and undertook the relevant searches and Tejashree Kangutkar who assisted with some of the Covidence work.

This work was supported by funding from the Australian Government Department of Health and Aged Care (ID: Health/20–21/E21-10463).

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Virginia Dickson-Swift, Joanne Adams & Evelien Spelten

Care Economy Research Institute, La Trobe University, Wodonga, Australia

Irene Blackberry

Olivia Newton-John Cancer Wellness and Research Centre, Austin Health, Melbourne, Australia

Carlene Wilson & Eva Yuen

Melbourne School of Population and Global Health, Melbourne University, Melbourne, Australia

Carlene Wilson

School of Psychology and Public Health, La Trobe University, Bundoora, Australia

Institute for Health Transformation, Deakin University, Burwood, Australia

Centre for Quality and Patient Safety, Monash Health Partnership, Monash Health, Clayton, Australia

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VDS conceived and designed the scoping review. VDS & JA developed the search strategy with librarian support, and all authors (VDS, JA, ES, IB, CW, EY) participated in the screening and data extraction stages and assisted with writing the review. All authors provided editorial support and read and approved the final manuscript prior to submission.

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Dickson-Swift, V., Adams, J., Spelten, E. et al. Breast cancer screening motivation and behaviours of women aged over 75 years: a scoping review. BMC Women's Health 24 , 256 (2024). https://doi.org/10.1186/s12905-024-03094-z

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DOI : https://doi.org/10.1186/s12905-024-03094-z

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Foreign states targeting sensitive research at UK universities, MI5 warns

Ministers considering more funding to protect important research sites, with China seen as a particular concern

MI5 has warned universities that hostile foreign states are targeting sensitive research, as ministers consider measures to bolster protections.

Vice-chancellors from 24 leading institutions, including Oxford, Cambridge and Imperial College London , were briefed on the threat by the domestic security service’s director general, Ken McCallum, and National Cybersecurity Centre (NCSC) chief, Felicity Oswald.

In addition, the UK government is looking at increased funding to improve security at sensitive sites. Oliver Dowden, the deputy prime minister, announced plans for a consultation on a package of measures that could include looking at key university personnel being given security clearance and a strengthened process to improve the transparency of funding, particularly with foreign institutions.

The measures will be focused on a small proportion of academic work, with a particular focus on research with potential dual uses in civilian and military life.

McCallum told the vice-chancellors that hostile states are targeting universities to steal technology that can “deliver their authoritarian, military and commercial priorities”, the Times reported.

The government ordered a review of protections for higher education in its refreshed foreign and security policy last year amid concerns that hostile states – and particularly China – were gaining undue influence over the sector.

Dowden has previously warned that some universities’ reliance on overseas funding could leave them open to being “influenced, exploited, or even coerced” by a foreign power.

After the security briefing, Dowden said: “For a millennium, our universities have thrived on being open – open to ideas, open to innovation, open to being independent of government.

“This is not about erecting fences, this is about balancing evolving threats and protecting the integrity and security of our great institutions.”

The consultation will explore proposals to protect cutting-edge technology under development in sensitive sectors that are being targeted by states intent on stealing intellectual property to enhance their own economic and military capabilities.

The NCSC and the National Protective Security Authority have also launched a tool to help universities assess their research security.

Michelle Donelan, the science and technology secretary, said: “I believe that universities are on the frontlines of a battle for information.

“Maintaining the UK’s world-leading reputation as an academic superpower relies on having strong safeguards to protect research from those who wish to do us harm.”

Tim Bradshaw, chief executive of the Russell Group of leading research universities, said: “Russell Group universities take their national security responsibilities incredibly seriously and already work closely with government and the intelligence community to help protect UK breakthroughs in fields like AI, which are important to our national interest.

“But we also recognise security is a dynamic and evolving challenge which means we need the right expertise and intelligence to keep pace with this.”

Universities UK chief executive Vivienne Stern said: “For several years, Universities UK has worked with government to ensure that universities are supported and equipped to recognise and mitigate risks to national security.

“This is important and necessary, and we welcome the government’s approach to working hand in hand with us to get the mechanisms right.”

• Universities
• University of Oxford
• University of Cambridge
• Imperial College London

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