what is the difference between research and literature review

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Infographic: 5 Differences between a research paper and a review paper

Andrea Hayward

There are different types of scholarly literature . Some of these require researchers to conduct an original study, whereas others can be based on previously published research. Understanding each of these types and also how they differ from one another can be rather confusing for researchers, especially early career researchers. One of the most popular questions on our Q&A forum - What is the difference between a research paper and a review paper? - led us to conclude that of all the types of scholarly literature, researchers tend to be most perplexed by the distinction between a research paper and a review paper. This infographic explains the five main differences between these two types of scholarly papers.

Feel free to download a PDF version of this infographic and print it out as handy reference.

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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Next: How to Pick a Topic >>
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How to Write a Literature Review

What is a literature review

How is a literature review different from a research paper?

What should I do before starting my literature review?
What type of literature review should I write and how should I organize it?
What should I be aware of while writing the literature review?
For more information on Literature Reviews
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The purpose of an academic research paper is to develop a new argument. The literature review is one part of a research paper. In a research paper, you use the literature review as a foundation and as support for the new insight that you contribute. The focus of a literature review, however, is to summarize and analyze the arguments and ideas of others without adding new contributions.

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

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

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

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

There are five key steps to writing a literature review:

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

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

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

Quick Run-through
Step 1 & 2

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

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

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

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

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what is the difference between research and literature review

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

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

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

Download Word doc Download Google doc

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

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

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

For each publication, ask yourself:

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

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

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

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

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

Take notes and cite your sources

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

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

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

Prevent plagiarism, run a free check.

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

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

As you write, make sure to follow these tips:

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

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

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

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

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

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

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

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

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

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Research Methods

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Literature Review

What is a Literature Review?
What is NOT a Literature Review?
Purposes of a Literature Review
Types of Literature Reviews
Literature Reviews vs. Systematic Reviews
Systematic vs. Meta-Analysis

Literature Review is a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works.

Also, we can define a literature review as the collected body of scholarly works related to a topic:

Summarizes and analyzes previous research relevant to a topic
Includes scholarly books and articles published in academic journals
Can be an specific scholarly paper or a section in a research paper

The objective of a Literature Review is to find previous published scholarly works relevant to an specific topic

Help gather ideas or information
Keep up to date in current trends and findings
Help develop new questions

A literature review is important because it:

Explains the background of research on a topic.
Demonstrates why a topic is significant to a subject area.
Helps focus your own research questions or problems
Discovers relationships between research studies/ideas.
Suggests unexplored ideas or populations
Identifies major themes, concepts, and researchers on a topic.
Tests assumptions; may help counter preconceived ideas and remove unconscious bias.
Identifies critical gaps, points of disagreement, or potentially flawed methodology or theoretical approaches.
Indicates potential directions for future research.

All content in this section is from Literature Review Research from Old Dominion University

Keep in mind the following, a literature review is NOT:

Not an essay

Not an annotated bibliography in which you summarize each article that you have reviewed. A literature review goes beyond basic summarizing to focus on the critical analysis of the reviewed works and their relationship to your research question.

Not a research paper where you select resources to support one side of an issue versus another. A lit review should explain and consider all sides of an argument in order to avoid bias, and areas of agreement and disagreement should be highlighted.

A literature review serves several purposes. For example, it

provides thorough knowledge of previous studies; introduces seminal works.
helps focus one’s own research topic.
identifies a conceptual framework for one’s own research questions or problems; indicates potential directions for future research.
suggests previously unused or underused methodologies, designs, quantitative and qualitative strategies.
identifies gaps in previous studies; identifies flawed methodologies and/or theoretical approaches; avoids replication of mistakes.
helps the researcher avoid repetition of earlier research.
suggests unexplored populations.
determines whether past studies agree or disagree; identifies controversy in the literature.
tests assumptions; may help counter preconceived ideas and remove unconscious bias.

As Kennedy (2007) notes*, it is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the original studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally that become part of the lore of field. In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews.

Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are several approaches to how they can be done, depending upon the type of analysis underpinning your study. Listed below are definitions of types of literature reviews:

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

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

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

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

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyse data from the studies that are included in the review. Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?"

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

* Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147.

All content in this section is from The Literature Review created by Dr. Robert Larabee USC

Robinson, P. and Lowe, J. (2015), Literature reviews vs systematic reviews. Australian and New Zealand Journal of Public Health, 39: 103-103. doi: 10.1111/1753-6405.12393

What's in the name? The difference between a Systematic Review and a Literature Review, and why it matters . By Lynn Kysh from University of Southern California

Systematic review or meta-analysis?

A systematic review answers a defined research question by collecting and summarizing all empirical evidence that fits pre-specified eligibility criteria.

A meta-analysis is the use of statistical methods to summarize the results of these studies.

Systematic reviews, just like other research articles, can be of varying quality. They are a significant piece of work (the Centre for Reviews and Dissemination at York estimates that a team will take 9-24 months), and to be useful to other researchers and practitioners they should have:

clearly stated objectives with pre-defined eligibility criteria for studies
explicit, reproducible methodology
a systematic search that attempts to identify all studies
assessment of the validity of the findings of the included studies (e.g. risk of bias)
systematic presentation, and synthesis, of the characteristics and findings of the included studies

Not all systematic reviews contain meta-analysis.

Meta-analysis is the use of statistical methods to summarize the results of independent studies. By combining information from all relevant studies, meta-analysis can provide more precise estimates of the effects of health care than those derived from the individual studies included within a review. More information on meta-analyses can be found in Cochrane Handbook, Chapter 9 .

A meta-analysis goes beyond critique and integration and conducts secondary statistical analysis on the outcomes of similar studies. It is a systematic review that uses quantitative methods to synthesize and summarize the results.

An advantage of a meta-analysis is the ability to be completely objective in evaluating research findings. Not all topics, however, have sufficient research evidence to allow a meta-analysis to be conducted. In that case, an integrative review is an appropriate strategy.

Some of the content in this section is from Systematic reviews and meta-analyses: step by step guide created by Kate McAllister.

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Literature Review: A Definition

What is a literature review, then.

A literature review discusses and analyses published information in a particular subject area. Sometimes the information covers a certain time period.

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

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

While the main focus of an academic research paper is to support your own argument, the focus of a literature review is to summarize and synthesize the arguments and ideas of others. The academic research paper also covers a range of sources, but it is usually a select number of sources, because the emphasis is on the argument. Likewise, a literature review can also have an "argument," but it is not as important as covering a number of sources. In short, an academic research paper and a literature review contain some of the same elements. In fact, many academic research papers will contain a literature review section. What aspect of the study (either the argument or the sources) that is emphasized determines what type of document it is.

( "Literature Reviews" from The Writing Center, University of North Carolina at Chapel Hill )

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone.

For professionals, they are useful reports that keep them up to date with what is current in the field.

For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper's investigation.

Comprehensive knowledge of the literature of the field is essential to most research papers.

Journal Articles on Writing Literature Reviews

Research Methods for Comprehensive Science Literature Reviews Author: Brown,Barry N. Journal: Issues in Science & Technology Librarianship Date: Spring2009 Issue: 57 Page: 1 more... less... Finding some information on most topics is easy. There are abundant sources of information readily available. However, completing a comprehensive literature review on a particular topic is often difficult, laborious, and time intensive; the project requires organization, persistence, and an understanding of the scholarly communication and publishing process. This paper briefly outlines methods of conducting a comprehensive literature review for science topics. [ABSTRACT FROM AUTHOR];
Research: Considerations in Writing a Literature Review Authors: Black,K. Journal: The New Social Worker Date: 01/01; 2007 Volume: 14 Issue: 2 Page: 12 more... less... Literature reviews are ubiquitous in academic journals, scholarly reports, and social work education. Conducting and writing a good literature review is both personally and professionally satisfying. (Journal abstract).
How to do (or not to do) A Critical Literature Review Authors: Jesson,Jill; Lacey,Fiona Journal: Pharmacy Education Pub Date: 2006 Volume: 6 Issue: 2 Pages:139 - 148 more... less... More and more students are required to perform a critical literature review as part of their undergraduate or postgraduate studies. Whilst most of the latest research methods textbooks advise how to do a literature search, very few cover the literature review. This paper covers two types of review: a critical literature review and a systematic review. [ABSTRACT FROM AUTHOR]
Conducting a Literature Review Authors: Rowley,Jennifer; Slack,Frances Journal: Management Research News Pub Date: 2004 Volume: 27 Issue: 6 Pages:31-39 more... less... Abstract: This article offers support and guidance for students undertaking a literature review as part of their dissertation during an undergraduate or Masters course. A literature review is a summary of a subject field that supports the identification of specific research questions. A literature review needs to draw on and evaluate a range of different types of sources including academic and professional journal articles, books, and web-based resources. The literature search helps in the identification and location of relevant documents and other sources. Search engines can be used to search web resources and bibliographic databases. Conceptual frameworks can be a useful tool in developing an understanding of a subject area. Creating the literature review involves the stages of: scanning, making notes, structuring the literature review, writing the literature review, and building a bibliography.

Some Books from the WU Catalog

The SAGE handbook of visual research methods [electronic resource] by Edited by Luc Pauwels and Dawn Mannay. ISBN: 9781526417015 Publication Date: SAGE Publications, Inc., 2020.

Helpful Websites

"How to do a Literature Review" from Ferdinand D. Bluford Library
"The Literature Review: A Few Tips on Conducting It." from the University of Toronto
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Literature review vs research articles: how are they different.

Unlock the secrets of academic writing with our guide to the key differences between a literature review and a research paper! 📚 Dive into the world of scholarly exploration as we break down how a literature review illuminates existing knowledge, identifies gaps, and sets the stage for further research. 🌐 Then, gear up for the adventure of crafting a research paper, where you become the explorer, presenting your unique insights and discoveries through independent research. 🚀 Join us on this academic journey and discover the art of synthesizing existing wisdom and creating your own scholarly masterpiece! 🎓✨

We are always accepting submissions! Submit work within SRJ’s scope anytime while you’re a graduate student.

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Academic Skills
Reading, writing and referencing
Literature reviews

Writing a literature review

Find out how to write a lit review.

What is a literature review ?

A literature review explores and evaluates the literature on a specific topic or question. It synthesises the contributions of the different authors, often to identify areas that need further exploration.

You may be required to write a literature review as a standalone document or part of a larger body of research, such as a thesis.

The point of a standalone literature review is to demonstrate that you have read widely in your field and you understand the main arguments.
As part of a thesis or research paper, the literature review defines your project by establishing how your work will extend or differ from previous work and what contribution it will make.

What are markers looking for?

In the best literature reviews, the writer:

Has a clear understanding of key concepts within the topic.
Clarifies important definitions and terminology.
Covers the breadth of the specific topic.
Critically discusses the ideas in the literature and evaluates how authors present them.
Clearly indicates a research gap for future enquiry.

How do I write a literature review?

This video outlines a step by step approach to help you evaluate readings, organise ideas and write critically. It provides examples of how to connect, interpret and critique ideas to make sure your voice comes through strongly.

Tips for research, reading and writing

You may be given a specific question to research or broad topics which must be refined to a question that can be reasonably addressed in the time and word limit available.

Use your early reading to help you determine and refine your topic.

Too much literature? You probably need to narrow your scope. Try to identify a more specific issue of interest.
Not enough literature? Your topic may be too specific and needs to be broader.

Start with readings suggested by your lecturers or supervisors. Then, do your own research - the best place to go is the Library Website .

You can also use the Library Guides or speak to a librarian to identify the most useful databases for you and to learn how to search for sources effectively and efficiently.

Cover the field

Make sure your literature search covers a broad range of views and information relevant to your topic. Focussing on a narrow selection of sources may result in a lack of depth. You are not expected to cover all research and scholarly opinions on your topic, but you need to identify and include important viewpoints. A quality literature review examines and evaluates different viewpoints based on the evidence presented, rather than providing only material that reinforces a bias.

Use reading strategies

Survey, skim and scan to find the most relevant articles, and the most relevant parts of those articles. These can be re-read more closely later when you have acquired an overview of your topic.

Take notes as you read

This helps to organise and develop your thoughts. Record your own reactions to the text in your notes, perhaps in a separate column. These notes can form the basis of your critical evaluation of the text. Record any facts, opinions or direct quotes that are likely to be useful to your review, noting the page numbers, author and year.

Stop reading when you have enough

This depends on the word count required of this literature review. A review of one thousand words can only cover the major ideas and probably less than ten references. Longer reviews that form part of a large research paper will include more than fifty. Your tutor or supervisor should be able to suggest a suitable number.

As you read, ask yourself these questions:

Have I answered my question without any obvious gaps?
Have I read this before? Are there any new related issues coming up as I search the literature?
Have I found multiple references which cover the same material or just enough to prove agreement?

There are many possible ways to organise the material. For example:

chronologically
by theoretical perspective
from most to least important
by issue or theme

It is important to remember that you are not merely cataloguing or describing the literature you read. Therefore, you need to choose an organisation that will enable you to compare the various authors' treatment of ideas. This is often best achieved by organising thematically, or grouping ideas into sets of common issues tackled in the various texts. These themes will form the basis of the different threads that are the focus of your study.

A standalone literature review

A standalone literature review is structured much like an academic essay.

Introduction - establish the context for your topic and outline your main contentions about the literature
Main body - explain and support these inferences in the main body
Conclusion - summarise your main points and restate the contention.

The main difference between an essay and this kind of literature review is that an essay focuses on a topic and uses the literature as a support for the arguments. In a standalone literature review, the literature itself is the topic of discussion and evaluation. This means you evaluate and discuss not only the informational content but the quality of the author’s handling of the content.

A literature review as part of a larger research paper?

As part of a larger research paper, the literature review may take many forms, depending on your discipline, your topic and the logic of your research. Traditionally, in empirical research, the literature review is included in the introduction, or a standalone chapter immediately following the introduction. For other forms of research, you may need to engage more extensively with the literature and thus, the literature review may spread over more than one chapter, or even be distributed throughout the thesis.

Start writing early. Writing will clarify your thinking on the topic and reveal any gaps in information and logic. If your ideas change, sections and paragraphs can be reworked to change your contentions or include extra information.

Similarly, draft an overall plan for your review as soon as you are ready, but be prepared to rework sections of it to reflect your developing argument.

The most important thing to remember is that you are writing a review . That means you must move past describing what other authors have written by connecting, interpreting and critiquing their ideas and presenting your own analysis and interpretation.

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Literature Review: Types of literature reviews

Traditional or narrative literature reviews
Scoping Reviews
Systematic literature reviews
Annotated bibliography
Keeping up to date with literature
Finding a thesis
Evaluating sources and critical appraisal of literature
Managing and analysing your literature
Further reading and resources

Types of literature reviews

The type of literature review you write will depend on your discipline and whether you are a researcher writing your PhD, publishing a study in a journal or completing an assessment task in your undergraduate study.

A literature review for a subject in an undergraduate degree will not be as comprehensive as the literature review required for a PhD thesis.

An undergraduate literature review may be in the form of an annotated bibliography or a narrative review of a small selection of literature, for example ten relevant articles. If you are asked to write a literature review, and you are an undergraduate student, be guided by your subject coordinator or lecturer.

The common types of literature reviews will be explained in the pages of this section.

Narrative or traditional literature reviews
Critically Appraised Topic (CAT)
Scoping reviews
Annotated bibliographies

These are not the only types of reviews of literature that can be conducted. Often the term "review" and "literature" can be confusing and used in the wrong context. Grant and Booth (2009) attempt to clear up this confusion by discussing 14 review types and the associated methodology, and advantages and disadvantages associated with each review.

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

What's the difference between reviews?

Researchers, academics, and librarians all use various terms to describe different types of literature reviews, and there is often inconsistency in the ways the types are discussed. Here are a couple of simple explanations.

The image below describes common review types in terms of speed, detail, risk of bias, and comprehensiveness:

Description of the differences between review types in image form

"Schematic of the main differences between the types of literature review" by Brennan, M. L., Arlt, S. P., Belshaw, Z., Buckley, L., Corah, L., Doit, H., Fajt, V. R., Grindlay, D., Moberly, H. K., Morrow, L. D., Stavisky, J., & White, C. (2020). Critically Appraised Topics (CATs) in veterinary medicine: Applying evidence in clinical practice. Frontiers in Veterinary Science, 7 , 314. https://doi.org/10.3389/fvets.2020.00314 is licensed under CC BY 3.0

The table below lists four of the most common types of review , as adapted from a widely used typology of fourteen types of reviews (Grant & Booth, 2009).

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

See also the Library's Literature Review guide.

Critical Appraised Topic (CAT)

For information on conducting a Critically Appraised Topic or CAT

Callander, J., Anstey, A. V., Ingram, J. R., Limpens, J., Flohr, C., & Spuls, P. I. (2017). How to write a Critically Appraised Topic: evidence to underpin routine clinical practice. British Journal of Dermatology (1951), 177(4), 1007-1013. https://doi.org/10.1111/bjd.15873

Books on Literature Reviews

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The Writing Center • University of North Carolina at Chapel Hill

Literature Reviews

What this handout is about.

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

Introduction

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

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

What is a literature review, then?

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

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

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

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

Why do we write literature reviews?

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

Who writes these things, anyway?

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

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

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

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

Find models

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

Narrow your topic

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

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

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

Consider whether your sources are current

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

Strategies for writing the literature review

Find a focus.

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

Convey it to your reader

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

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

Consider organization

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

First, cover the basic categories

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

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

Organizing the body

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

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

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

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

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

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

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

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

Begin composing

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

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

Use evidence

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

Be selective

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

Use quotes sparingly

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

Summarize and synthesize

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

Keep your own voice

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

Use caution when paraphrasing

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

Revise, revise, revise

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

Works consulted

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

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

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

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

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

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

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

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Research Guides
Reviewing Research: Literature Reviews, Scoping Reviews, Systematic Reviews
Differentiating the Three Review Types

Reviewing Research: Literature Reviews, Scoping Reviews, Systematic Reviews: Differentiating the Three Review Types

Framework, Protocol, and Writing Steps
Working with Keywords/Subject Headings
Citing Research

The Differences in the Review Types

Grant, M.J. and Booth, A. (2009), A typology of reviews: an analysis of 14 review types and associated methodologies. H ealth Information & Libraries Journal , 26: 91-108. https://doi.org/10.1111/j.1471-1842.2009.00848.x The objective of this study is to provide descriptive insight into the most common types of reviews, with illustrative examples from health and health information domains.

What Type of Review is Right for you (Cornell University)

Literature Reviews

Literature Review: it is a product and a process.

As a product , it is a carefully written examination, interpretation, evaluation, and synthesis of the published literature related to your topic. It focuses on what is known about your topic and what methodologies, models, theories, and concepts have been applied to it by others.

The process is what is involved in conducting a review of the literature.

It is ongoing
It is iterative (repetitive)
It involves searching for and finding relevant literature.
It includes keeping track of your references and preparing and formatting them for the bibliography of your thesis

Literature Reviews (University of North Carolina at Chapel Hill) This handout will explain what literature reviews are and offer insights into the form and construction of literature reviews in the humanities, social sciences, and sciences.

Scoping Reviews

Scoping reviews are a " preliminary assessment of potential size and scope of available research literature . Aims to identify nature and extent of research evidence (usually including ongoing research)." Grant and Booth (2009).

Scoping reviews are not mapping reviews: Scoping reviews are more topic based and mapping reviews are more question based.

examining emerging evidence when specific questions are unclear - clarify definitions and conceptual boundaries
identify and map the available evidence
a scoping review is done prior to a systematic review
to summarize and disseminate research findings in the research literature
identify gaps with the intention of resolution by future publications

Scoping review timeframe and limitations (Touro College of Pharmacy

Systematic Reviews

Many evidence-based disciplines use ‘systematic reviews," this type of review is a specific methodology that aims to comprehensively identify all relevant studies on a specific topic, and to select appropriate studies based on explicit criteria . ( https://cebma.org/faq/what-is-a-systematic-review/ )

clearly defined search criteria
an explicit reproducible methodology
a systematic search of the literature with the defined criteria met
assesses validity of the findings - no risk of bias
a comprehensive report on the findings, apparent transparency in the results

Better evidence for a better world Browsable collection of systematic reviews
Systematic Reviews in the Health Sciences by Molly Maloney Last Updated Apr 23, 2024 465 views this year
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CBE Life Sci Educ
v.21(3); Fall 2022

Literature Reviews, Theoretical Frameworks, and Conceptual Frameworks: An Introduction for New Biology Education Researchers

Julie a. luft.

† Department of Mathematics, Social Studies, and Science Education, Mary Frances Early College of Education, University of Georgia, Athens, GA 30602-7124

Sophia Jeong

‡ Department of Teaching & Learning, College of Education & Human Ecology, Ohio State University, Columbus, OH 43210

Robert Idsardi

§ Department of Biology, Eastern Washington University, Cheney, WA 99004

Grant Gardner

∥ Department of Biology, Middle Tennessee State University, Murfreesboro, TN 37132

Associated Data

To frame their work, biology education researchers need to consider the role of literature reviews, theoretical frameworks, and conceptual frameworks as critical elements of the research and writing process. However, these elements can be confusing for scholars new to education research. This Research Methods article is designed to provide an overview of each of these elements and delineate the purpose of each in the educational research process. We describe what biology education researchers should consider as they conduct literature reviews, identify theoretical frameworks, and construct conceptual frameworks. Clarifying these different components of educational research studies can be helpful to new biology education researchers and the biology education research community at large in situating their work in the broader scholarly literature.

INTRODUCTION

Discipline-based education research (DBER) involves the purposeful and situated study of teaching and learning in specific disciplinary areas ( Singer et al. , 2012 ). Studies in DBER are guided by research questions that reflect disciplines’ priorities and worldviews. Researchers can use quantitative data, qualitative data, or both to answer these research questions through a variety of methodological traditions. Across all methodologies, there are different methods associated with planning and conducting educational research studies that include the use of surveys, interviews, observations, artifacts, or instruments. Ensuring the coherence of these elements to the discipline’s perspective also involves situating the work in the broader scholarly literature. The tools for doing this include literature reviews, theoretical frameworks, and conceptual frameworks. However, the purpose and function of each of these elements is often confusing to new education researchers. The goal of this article is to introduce new biology education researchers to these three important elements important in DBER scholarship and the broader educational literature.

The first element we discuss is a review of research (literature reviews), which highlights the need for a specific research question, study problem, or topic of investigation. Literature reviews situate the relevance of the study within a topic and a field. The process may seem familiar to science researchers entering DBER fields, but new researchers may still struggle in conducting the review. Booth et al. (2016b) highlight some of the challenges novice education researchers face when conducting a review of literature. They point out that novice researchers struggle in deciding how to focus the review, determining the scope of articles needed in the review, and knowing how to be critical of the articles in the review. Overcoming these challenges (and others) can help novice researchers construct a sound literature review that can inform the design of the study and help ensure the work makes a contribution to the field.

The second and third highlighted elements are theoretical and conceptual frameworks. These guide biology education research (BER) studies, and may be less familiar to science researchers. These elements are important in shaping the construction of new knowledge. Theoretical frameworks offer a way to explain and interpret the studied phenomenon, while conceptual frameworks clarify assumptions about the studied phenomenon. Despite the importance of these constructs in educational research, biology educational researchers have noted the limited use of theoretical or conceptual frameworks in published work ( DeHaan, 2011 ; Dirks, 2011 ; Lo et al. , 2019 ). In reviewing articles published in CBE—Life Sciences Education ( LSE ) between 2015 and 2019, we found that fewer than 25% of the research articles had a theoretical or conceptual framework (see the Supplemental Information), and at times there was an inconsistent use of theoretical and conceptual frameworks. Clearly, these frameworks are challenging for published biology education researchers, which suggests the importance of providing some initial guidance to new biology education researchers.

Fortunately, educational researchers have increased their explicit use of these frameworks over time, and this is influencing educational research in science, technology, engineering, and mathematics (STEM) fields. For instance, a quick search for theoretical or conceptual frameworks in the abstracts of articles in Educational Research Complete (a common database for educational research) in STEM fields demonstrates a dramatic change over the last 20 years: from only 778 articles published between 2000 and 2010 to 5703 articles published between 2010 and 2020, a more than sevenfold increase. Greater recognition of the importance of these frameworks is contributing to DBER authors being more explicit about such frameworks in their studies.

Collectively, literature reviews, theoretical frameworks, and conceptual frameworks work to guide methodological decisions and the elucidation of important findings. Each offers a different perspective on the problem of study and is an essential element in all forms of educational research. As new researchers seek to learn about these elements, they will find different resources, a variety of perspectives, and many suggestions about the construction and use of these elements. The wide range of available information can overwhelm the new researcher who just wants to learn the distinction between these elements or how to craft them adequately.

Our goal in writing this paper is not to offer specific advice about how to write these sections in scholarly work. Instead, we wanted to introduce these elements to those who are new to BER and who are interested in better distinguishing one from the other. In this paper, we share the purpose of each element in BER scholarship, along with important points on its construction. We also provide references for additional resources that may be beneficial to better understanding each element. Table 1 summarizes the key distinctions among these elements.

Comparison of literature reviews, theoretical frameworks, and conceptual reviews

This article is written for the new biology education researcher who is just learning about these different elements or for scientists looking to become more involved in BER. It is a result of our own work as science education and biology education researchers, whether as graduate students and postdoctoral scholars or newly hired and established faculty members. This is the article we wish had been available as we started to learn about these elements or discussed them with new educational researchers in biology.

LITERATURE REVIEWS

Purpose of a literature review.

A literature review is foundational to any research study in education or science. In education, a well-conceptualized and well-executed review provides a summary of the research that has already been done on a specific topic and identifies questions that remain to be answered, thus illustrating the current research project’s potential contribution to the field and the reasoning behind the methodological approach selected for the study ( Maxwell, 2012 ). BER is an evolving disciplinary area that is redefining areas of conceptual emphasis as well as orientations toward teaching and learning (e.g., Labov et al. , 2010 ; American Association for the Advancement of Science, 2011 ; Nehm, 2019 ). As a result, building comprehensive, critical, purposeful, and concise literature reviews can be a challenge for new biology education researchers.

Building Literature Reviews

There are different ways to approach and construct a literature review. Booth et al. (2016a) provide an overview that includes, for example, scoping reviews, which are focused only on notable studies and use a basic method of analysis, and integrative reviews, which are the result of exhaustive literature searches across different genres. Underlying each of these different review processes are attention to the s earch process, a ppraisa l of articles, s ynthesis of the literature, and a nalysis: SALSA ( Booth et al. , 2016a ). This useful acronym can help the researcher focus on the process while building a specific type of review.

However, new educational researchers often have questions about literature reviews that are foundational to SALSA or other approaches. Common questions concern determining which literature pertains to the topic of study or the role of the literature review in the design of the study. This section addresses such questions broadly while providing general guidance for writing a narrative literature review that evaluates the most pertinent studies.

The literature review process should begin before the research is conducted. As Boote and Beile (2005 , p. 3) suggested, researchers should be “scholars before researchers.” They point out that having a good working knowledge of the proposed topic helps illuminate avenues of study. Some subject areas have a deep body of work to read and reflect upon, providing a strong foundation for developing the research question(s). For instance, the teaching and learning of evolution is an area of long-standing interest in the BER community, generating many studies (e.g., Perry et al. , 2008 ; Barnes and Brownell, 2016 ) and reviews of research (e.g., Sickel and Friedrichsen, 2013 ; Ziadie and Andrews, 2018 ). Emerging areas of BER include the affective domain, issues of transfer, and metacognition ( Singer et al. , 2012 ). Many studies in these areas are transdisciplinary and not always specific to biology education (e.g., Rodrigo-Peiris et al. , 2018 ; Kolpikova et al. , 2019 ). These newer areas may require reading outside BER; fortunately, summaries of some of these topics can be found in the Current Insights section of the LSE website.

In focusing on a specific problem within a broader research strand, a new researcher will likely need to examine research outside BER. Depending upon the area of study, the expanded reading list might involve a mix of BER, DBER, and educational research studies. Determining the scope of the reading is not always straightforward. A simple way to focus one’s reading is to create a “summary phrase” or “research nugget,” which is a very brief descriptive statement about the study. It should focus on the essence of the study, for example, “first-year nonmajor students’ understanding of evolution,” “metacognitive prompts to enhance learning during biochemistry,” or “instructors’ inquiry-based instructional practices after professional development programming.” This type of phrase should help a new researcher identify two or more areas to review that pertain to the study. Focusing on recent research in the last 5 years is a good first step. Additional studies can be identified by reading relevant works referenced in those articles. It is also important to read seminal studies that are more than 5 years old. Reading a range of studies should give the researcher the necessary command of the subject in order to suggest a research question.

Given that the research question(s) arise from the literature review, the review should also substantiate the selected methodological approach. The review and research question(s) guide the researcher in determining how to collect and analyze data. Often the methodological approach used in a study is selected to contribute knowledge that expands upon what has been published previously about the topic (see Institute of Education Sciences and National Science Foundation, 2013 ). An emerging topic of study may need an exploratory approach that allows for a description of the phenomenon and development of a potential theory. This could, but not necessarily, require a methodological approach that uses interviews, observations, surveys, or other instruments. An extensively studied topic may call for the additional understanding of specific factors or variables; this type of study would be well suited to a verification or a causal research design. These could entail a methodological approach that uses valid and reliable instruments, observations, or interviews to determine an effect in the studied event. In either of these examples, the researcher(s) may use a qualitative, quantitative, or mixed methods methodological approach.

Even with a good research question, there is still more reading to be done. The complexity and focus of the research question dictates the depth and breadth of the literature to be examined. Questions that connect multiple topics can require broad literature reviews. For instance, a study that explores the impact of a biology faculty learning community on the inquiry instruction of faculty could have the following review areas: learning communities among biology faculty, inquiry instruction among biology faculty, and inquiry instruction among biology faculty as a result of professional learning. Biology education researchers need to consider whether their literature review requires studies from different disciplines within or outside DBER. For the example given, it would be fruitful to look at research focused on learning communities with faculty in STEM fields or in general education fields that result in instructional change. It is important not to be too narrow or too broad when reading. When the conclusions of articles start to sound similar or no new insights are gained, the researcher likely has a good foundation for a literature review. This level of reading should allow the researcher to demonstrate a mastery in understanding the researched topic, explain the suitability of the proposed research approach, and point to the need for the refined research question(s).

The literature review should include the researcher’s evaluation and critique of the selected studies. A researcher may have a large collection of studies, but not all of the studies will follow standards important in the reporting of empirical work in the social sciences. The American Educational Research Association ( Duran et al. , 2006 ), for example, offers a general discussion about standards for such work: an adequate review of research informing the study, the existence of sound and appropriate data collection and analysis methods, and appropriate conclusions that do not overstep or underexplore the analyzed data. The Institute of Education Sciences and National Science Foundation (2013) also offer Common Guidelines for Education Research and Development that can be used to evaluate collected studies.

Because not all journals adhere to such standards, it is important that a researcher review each study to determine the quality of published research, per the guidelines suggested earlier. In some instances, the research may be fatally flawed. Examples of such flaws include data that do not pertain to the question, a lack of discussion about the data collection, poorly constructed instruments, or an inadequate analysis. These types of errors result in studies that are incomplete, error-laden, or inaccurate and should be excluded from the review. Most studies have limitations, and the author(s) often make them explicit. For instance, there may be an instructor effect, recognized bias in the analysis, or issues with the sample population. Limitations are usually addressed by the research team in some way to ensure a sound and acceptable research process. Occasionally, the limitations associated with the study can be significant and not addressed adequately, which leaves a consequential decision in the hands of the researcher. Providing critiques of studies in the literature review process gives the reader confidence that the researcher has carefully examined relevant work in preparation for the study and, ultimately, the manuscript.

A solid literature review clearly anchors the proposed study in the field and connects the research question(s), the methodological approach, and the discussion. Reviewing extant research leads to research questions that will contribute to what is known in the field. By summarizing what is known, the literature review points to what needs to be known, which in turn guides decisions about methodology. Finally, notable findings of the new study are discussed in reference to those described in the literature review.

Within published BER studies, literature reviews can be placed in different locations in an article. When included in the introductory section of the study, the first few paragraphs of the manuscript set the stage, with the literature review following the opening paragraphs. Cooper et al. (2019) illustrate this approach in their study of course-based undergraduate research experiences (CUREs). An introduction discussing the potential of CURES is followed by an analysis of the existing literature relevant to the design of CUREs that allows for novel student discoveries. Within this review, the authors point out contradictory findings among research on novel student discoveries. This clarifies the need for their study, which is described and highlighted through specific research aims.

A literature reviews can also make up a separate section in a paper. For example, the introduction to Todd et al. (2019) illustrates the need for their research topic by highlighting the potential of learning progressions (LPs) and suggesting that LPs may help mitigate learning loss in genetics. At the end of the introduction, the authors state their specific research questions. The review of literature following this opening section comprises two subsections. One focuses on learning loss in general and examines a variety of studies and meta-analyses from the disciplines of medical education, mathematics, and reading. The second section focuses specifically on LPs in genetics and highlights student learning in the midst of LPs. These separate reviews provide insights into the stated research question.

Suggestions and Advice

A well-conceptualized, comprehensive, and critical literature review reveals the understanding of the topic that the researcher brings to the study. Literature reviews should not be so big that there is no clear area of focus; nor should they be so narrow that no real research question arises. The task for a researcher is to craft an efficient literature review that offers a critical analysis of published work, articulates the need for the study, guides the methodological approach to the topic of study, and provides an adequate foundation for the discussion of the findings.

In our own writing of literature reviews, there are often many drafts. An early draft may seem well suited to the study because the need for and approach to the study are well described. However, as the results of the study are analyzed and findings begin to emerge, the existing literature review may be inadequate and need revision. The need for an expanded discussion about the research area can result in the inclusion of new studies that support the explanation of a potential finding. The literature review may also prove to be too broad. Refocusing on a specific area allows for more contemplation of a finding.

It should be noted that there are different types of literature reviews, and many books and articles have been written about the different ways to embark on these types of reviews. Among these different resources, the following may be helpful in considering how to refine the review process for scholarly journals:

Booth, A., Sutton, A., & Papaioannou, D. (2016a). Systemic approaches to a successful literature review (2nd ed.). Los Angeles, CA: Sage. This book addresses different types of literature reviews and offers important suggestions pertaining to defining the scope of the literature review and assessing extant studies.
Booth, W. C., Colomb, G. G., Williams, J. M., Bizup, J., & Fitzgerald, W. T. (2016b). The craft of research (4th ed.). Chicago: University of Chicago Press. This book can help the novice consider how to make the case for an area of study. While this book is not specifically about literature reviews, it offers suggestions about making the case for your study.
Galvan, J. L., & Galvan, M. C. (2017). Writing literature reviews: A guide for students of the social and behavioral sciences (7th ed.). Routledge. This book offers guidance on writing different types of literature reviews. For the novice researcher, there are useful suggestions for creating coherent literature reviews.

THEORETICAL FRAMEWORKS

Purpose of theoretical frameworks.

As new education researchers may be less familiar with theoretical frameworks than with literature reviews, this discussion begins with an analogy. Envision a biologist, chemist, and physicist examining together the dramatic effect of a fog tsunami over the ocean. A biologist gazing at this phenomenon may be concerned with the effect of fog on various species. A chemist may be interested in the chemical composition of the fog as water vapor condenses around bits of salt. A physicist may be focused on the refraction of light to make fog appear to be “sitting” above the ocean. While observing the same “objective event,” the scientists are operating under different theoretical frameworks that provide a particular perspective or “lens” for the interpretation of the phenomenon. Each of these scientists brings specialized knowledge, experiences, and values to this phenomenon, and these influence the interpretation of the phenomenon. The scientists’ theoretical frameworks influence how they design and carry out their studies and interpret their data.

Within an educational study, a theoretical framework helps to explain a phenomenon through a particular lens and challenges and extends existing knowledge within the limitations of that lens. Theoretical frameworks are explicitly stated by an educational researcher in the paper’s framework, theory, or relevant literature section. The framework shapes the types of questions asked, guides the method by which data are collected and analyzed, and informs the discussion of the results of the study. It also reveals the researcher’s subjectivities, for example, values, social experience, and viewpoint ( Allen, 2017 ). It is essential that a novice researcher learn to explicitly state a theoretical framework, because all research questions are being asked from the researcher’s implicit or explicit assumptions of a phenomenon of interest ( Schwandt, 2000 ).

Selecting Theoretical Frameworks

Theoretical frameworks are one of the most contemplated elements in our work in educational research. In this section, we share three important considerations for new scholars selecting a theoretical framework.

The first step in identifying a theoretical framework involves reflecting on the phenomenon within the study and the assumptions aligned with the phenomenon. The phenomenon involves the studied event. There are many possibilities, for example, student learning, instructional approach, or group organization. A researcher holds assumptions about how the phenomenon will be effected, influenced, changed, or portrayed. It is ultimately the researcher’s assumption(s) about the phenomenon that aligns with a theoretical framework. An example can help illustrate how a researcher’s reflection on the phenomenon and acknowledgment of assumptions can result in the identification of a theoretical framework.

In our example, a biology education researcher may be interested in exploring how students’ learning of difficult biological concepts can be supported by the interactions of group members. The phenomenon of interest is the interactions among the peers, and the researcher assumes that more knowledgeable students are important in supporting the learning of the group. As a result, the researcher may draw on Vygotsky’s (1978) sociocultural theory of learning and development that is focused on the phenomenon of student learning in a social setting. This theory posits the critical nature of interactions among students and between students and teachers in the process of building knowledge. A researcher drawing upon this framework holds the assumption that learning is a dynamic social process involving questions and explanations among students in the classroom and that more knowledgeable peers play an important part in the process of building conceptual knowledge.

It is important to state at this point that there are many different theoretical frameworks. Some frameworks focus on learning and knowing, while other theoretical frameworks focus on equity, empowerment, or discourse. Some frameworks are well articulated, and others are still being refined. For a new researcher, it can be challenging to find a theoretical framework. Two of the best ways to look for theoretical frameworks is through published works that highlight different frameworks.

When a theoretical framework is selected, it should clearly connect to all parts of the study. The framework should augment the study by adding a perspective that provides greater insights into the phenomenon. It should clearly align with the studies described in the literature review. For instance, a framework focused on learning would correspond to research that reported different learning outcomes for similar studies. The methods for data collection and analysis should also correspond to the framework. For instance, a study about instructional interventions could use a theoretical framework concerned with learning and could collect data about the effect of the intervention on what is learned. When the data are analyzed, the theoretical framework should provide added meaning to the findings, and the findings should align with the theoretical framework.

A study by Jensen and Lawson (2011) provides an example of how a theoretical framework connects different parts of the study. They compared undergraduate biology students in heterogeneous and homogeneous groups over the course of a semester. Jensen and Lawson (2011) assumed that learning involved collaboration and more knowledgeable peers, which made Vygotsky’s (1978) theory a good fit for their study. They predicted that students in heterogeneous groups would experience greater improvement in their reasoning abilities and science achievements with much of the learning guided by the more knowledgeable peers.

In the enactment of the study, they collected data about the instruction in traditional and inquiry-oriented classes, while the students worked in homogeneous or heterogeneous groups. To determine the effect of working in groups, the authors also measured students’ reasoning abilities and achievement. Each data-collection and analysis decision connected to understanding the influence of collaborative work.

Their findings highlighted aspects of Vygotsky’s (1978) theory of learning. One finding, for instance, posited that inquiry instruction, as a whole, resulted in reasoning and achievement gains. This links to Vygotsky (1978) , because inquiry instruction involves interactions among group members. A more nuanced finding was that group composition had a conditional effect. Heterogeneous groups performed better with more traditional and didactic instruction, regardless of the reasoning ability of the group members. Homogeneous groups worked better during interaction-rich activities for students with low reasoning ability. The authors attributed the variation to the different types of helping behaviors of students. High-performing students provided the answers, while students with low reasoning ability had to work collectively through the material. In terms of Vygotsky (1978) , this finding provided new insights into the learning context in which productive interactions can occur for students.

Another consideration in the selection and use of a theoretical framework pertains to its orientation to the study. This can result in the theoretical framework prioritizing individuals, institutions, and/or policies ( Anfara and Mertz, 2014 ). Frameworks that connect to individuals, for instance, could contribute to understanding their actions, learning, or knowledge. Institutional frameworks, on the other hand, offer insights into how institutions, organizations, or groups can influence individuals or materials. Policy theories provide ways to understand how national or local policies can dictate an emphasis on outcomes or instructional design. These different types of frameworks highlight different aspects in an educational setting, which influences the design of the study and the collection of data. In addition, these different frameworks offer a way to make sense of the data. Aligning the data collection and analysis with the framework ensures that a study is coherent and can contribute to the field.

New understandings emerge when different theoretical frameworks are used. For instance, Ebert-May et al. (2015) prioritized the individual level within conceptual change theory (see Posner et al. , 1982 ). In this theory, an individual’s knowledge changes when it no longer fits the phenomenon. Ebert-May et al. (2015) designed a professional development program challenging biology postdoctoral scholars’ existing conceptions of teaching. The authors reported that the biology postdoctoral scholars’ teaching practices became more student-centered as they were challenged to explain their instructional decision making. According to the theory, the biology postdoctoral scholars’ dissatisfaction in their descriptions of teaching and learning initiated change in their knowledge and instruction. These results reveal how conceptual change theory can explain the learning of participants and guide the design of professional development programming.

The communities of practice (CoP) theoretical framework ( Lave, 1988 ; Wenger, 1998 ) prioritizes the institutional level , suggesting that learning occurs when individuals learn from and contribute to the communities in which they reside. Grounded in the assumption of community learning, the literature on CoP suggests that, as individuals interact regularly with the other members of their group, they learn about the rules, roles, and goals of the community ( Allee, 2000 ). A study conducted by Gehrke and Kezar (2017) used the CoP framework to understand organizational change by examining the involvement of individual faculty engaged in a cross-institutional CoP focused on changing the instructional practice of faculty at each institution. In the CoP, faculty members were involved in enhancing instructional materials within their department, which aligned with an overarching goal of instituting instruction that embraced active learning. Not surprisingly, Gehrke and Kezar (2017) revealed that faculty who perceived the community culture as important in their work cultivated institutional change. Furthermore, they found that institutional change was sustained when key leaders served as mentors and provided support for faculty, and as faculty themselves developed into leaders. This study reveals the complexity of individual roles in a COP in order to support institutional instructional change.

It is important to explicitly state the theoretical framework used in a study, but elucidating a theoretical framework can be challenging for a new educational researcher. The literature review can help to identify an applicable theoretical framework. Focal areas of the review or central terms often connect to assumptions and assertions associated with the framework that pertain to the phenomenon of interest. Another way to identify a theoretical framework is self-reflection by the researcher on personal beliefs and understandings about the nature of knowledge the researcher brings to the study ( Lysaght, 2011 ). In stating one’s beliefs and understandings related to the study (e.g., students construct their knowledge, instructional materials support learning), an orientation becomes evident that will suggest a particular theoretical framework. Theoretical frameworks are not arbitrary , but purposefully selected.

With experience, a researcher may find expanded roles for theoretical frameworks. Researchers may revise an existing framework that has limited explanatory power, or they may decide there is a need to develop a new theoretical framework. These frameworks can emerge from a current study or the need to explain a phenomenon in a new way. Researchers may also find that multiple theoretical frameworks are necessary to frame and explore a problem, as different frameworks can provide different insights into a problem.

Finally, it is important to recognize that choosing “x” theoretical framework does not necessarily mean a researcher chooses “y” methodology and so on, nor is there a clear-cut, linear process in selecting a theoretical framework for one’s study. In part, the nonlinear process of identifying a theoretical framework is what makes understanding and using theoretical frameworks challenging. For the novice scholar, contemplating and understanding theoretical frameworks is essential. Fortunately, there are articles and books that can help:

Creswell, J. W. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). Los Angeles, CA: Sage. This book provides an overview of theoretical frameworks in general educational research.
Ding, L. (2019). Theoretical perspectives of quantitative physics education research. Physical Review Physics Education Research , 15 (2), 020101-1–020101-13. This paper illustrates how a DBER field can use theoretical frameworks.
Nehm, R. (2019). Biology education research: Building integrative frameworks for teaching and learning about living systems. Disciplinary and Interdisciplinary Science Education Research , 1 , ar15. https://doi.org/10.1186/s43031-019-0017-6 . This paper articulates the need for studies in BER to explicitly state theoretical frameworks and provides examples of potential studies.
Patton, M. Q. (2015). Qualitative research & evaluation methods: Integrating theory and practice . Sage. This book also provides an overview of theoretical frameworks, but for both research and evaluation.

CONCEPTUAL FRAMEWORKS

Purpose of a conceptual framework.

A conceptual framework is a description of the way a researcher understands the factors and/or variables that are involved in the study and their relationships to one another. The purpose of a conceptual framework is to articulate the concepts under study using relevant literature ( Rocco and Plakhotnik, 2009 ) and to clarify the presumed relationships among those concepts ( Rocco and Plakhotnik, 2009 ; Anfara and Mertz, 2014 ). Conceptual frameworks are different from theoretical frameworks in both their breadth and grounding in established findings. Whereas a theoretical framework articulates the lens through which a researcher views the work, the conceptual framework is often more mechanistic and malleable.

Conceptual frameworks are broader, encompassing both established theories (i.e., theoretical frameworks) and the researchers’ own emergent ideas. Emergent ideas, for example, may be rooted in informal and/or unpublished observations from experience. These emergent ideas would not be considered a “theory” if they are not yet tested, supported by systematically collected evidence, and peer reviewed. However, they do still play an important role in the way researchers approach their studies. The conceptual framework allows authors to clearly describe their emergent ideas so that connections among ideas in the study and the significance of the study are apparent to readers.

Constructing Conceptual Frameworks

Including a conceptual framework in a research study is important, but researchers often opt to include either a conceptual or a theoretical framework. Either may be adequate, but both provide greater insight into the research approach. For instance, a research team plans to test a novel component of an existing theory. In their study, they describe the existing theoretical framework that informs their work and then present their own conceptual framework. Within this conceptual framework, specific topics portray emergent ideas that are related to the theory. Describing both frameworks allows readers to better understand the researchers’ assumptions, orientations, and understanding of concepts being investigated. For example, Connolly et al. (2018) included a conceptual framework that described how they applied a theoretical framework of social cognitive career theory (SCCT) to their study on teaching programs for doctoral students. In their conceptual framework, the authors described SCCT, explained how it applied to the investigation, and drew upon results from previous studies to justify the proposed connections between the theory and their emergent ideas.

In some cases, authors may be able to sufficiently describe their conceptualization of the phenomenon under study in an introduction alone, without a separate conceptual framework section. However, incomplete descriptions of how the researchers conceptualize the components of the study may limit the significance of the study by making the research less intelligible to readers. This is especially problematic when studying topics in which researchers use the same terms for different constructs or different terms for similar and overlapping constructs (e.g., inquiry, teacher beliefs, pedagogical content knowledge, or active learning). Authors must describe their conceptualization of a construct if the research is to be understandable and useful.

There are some key areas to consider regarding the inclusion of a conceptual framework in a study. To begin with, it is important to recognize that conceptual frameworks are constructed by the researchers conducting the study ( Rocco and Plakhotnik, 2009 ; Maxwell, 2012 ). This is different from theoretical frameworks that are often taken from established literature. Researchers should bring together ideas from the literature, but they may be influenced by their own experiences as a student and/or instructor, the shared experiences of others, or thought experiments as they construct a description, model, or representation of their understanding of the phenomenon under study. This is an exercise in intellectual organization and clarity that often considers what is learned, known, and experienced. The conceptual framework makes these constructs explicitly visible to readers, who may have different understandings of the phenomenon based on their prior knowledge and experience. There is no single method to go about this intellectual work.

Reeves et al. (2016) is an example of an article that proposed a conceptual framework about graduate teaching assistant professional development evaluation and research. The authors used existing literature to create a novel framework that filled a gap in current research and practice related to the training of graduate teaching assistants. This conceptual framework can guide the systematic collection of data by other researchers because the framework describes the relationships among various factors that influence teaching and learning. The Reeves et al. (2016) conceptual framework may be modified as additional data are collected and analyzed by other researchers. This is not uncommon, as conceptual frameworks can serve as catalysts for concerted research efforts that systematically explore a phenomenon (e.g., Reynolds et al. , 2012 ; Brownell and Kloser, 2015 ).

Sabel et al. (2017) used a conceptual framework in their exploration of how scaffolds, an external factor, interact with internal factors to support student learning. Their conceptual framework integrated principles from two theoretical frameworks, self-regulated learning and metacognition, to illustrate how the research team conceptualized students’ use of scaffolds in their learning ( Figure 1 ). Sabel et al. (2017) created this model using their interpretations of these two frameworks in the context of their teaching.

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Conceptual framework from Sabel et al. (2017) .

A conceptual framework should describe the relationship among components of the investigation ( Anfara and Mertz, 2014 ). These relationships should guide the researcher’s methods of approaching the study ( Miles et al. , 2014 ) and inform both the data to be collected and how those data should be analyzed. Explicitly describing the connections among the ideas allows the researcher to justify the importance of the study and the rigor of the research design. Just as importantly, these frameworks help readers understand why certain components of a system were not explored in the study. This is a challenge in education research, which is rooted in complex environments with many variables that are difficult to control.

For example, Sabel et al. (2017) stated: “Scaffolds, such as enhanced answer keys and reflection questions, can help students and instructors bridge the external and internal factors and support learning” (p. 3). They connected the scaffolds in the study to the three dimensions of metacognition and the eventual transformation of existing ideas into new or revised ideas. Their framework provides a rationale for focusing on how students use two different scaffolds, and not on other factors that may influence a student’s success (self-efficacy, use of active learning, exam format, etc.).

In constructing conceptual frameworks, researchers should address needed areas of study and/or contradictions discovered in literature reviews. By attending to these areas, researchers can strengthen their arguments for the importance of a study. For instance, conceptual frameworks can address how the current study will fill gaps in the research, resolve contradictions in existing literature, or suggest a new area of study. While a literature review describes what is known and not known about the phenomenon, the conceptual framework leverages these gaps in describing the current study ( Maxwell, 2012 ). In the example of Sabel et al. (2017) , the authors indicated there was a gap in the literature regarding how scaffolds engage students in metacognition to promote learning in large classes. Their study helps fill that gap by describing how scaffolds can support students in the three dimensions of metacognition: intelligibility, plausibility, and wide applicability. In another example, Lane (2016) integrated research from science identity, the ethic of care, the sense of belonging, and an expertise model of student success to form a conceptual framework that addressed the critiques of other frameworks. In a more recent example, Sbeglia et al. (2021) illustrated how a conceptual framework influences the methodological choices and inferences in studies by educational researchers.

Sometimes researchers draw upon the conceptual frameworks of other researchers. When a researcher’s conceptual framework closely aligns with an existing framework, the discussion may be brief. For example, Ghee et al. (2016) referred to portions of SCCT as their conceptual framework to explain the significance of their work on students’ self-efficacy and career interests. Because the authors’ conceptualization of this phenomenon aligned with a previously described framework, they briefly mentioned the conceptual framework and provided additional citations that provided more detail for the readers.

Within both the BER and the broader DBER communities, conceptual frameworks have been used to describe different constructs. For example, some researchers have used the term “conceptual framework” to describe students’ conceptual understandings of a biological phenomenon. This is distinct from a researcher’s conceptual framework of the educational phenomenon under investigation, which may also need to be explicitly described in the article. Other studies have presented a research logic model or flowchart of the research design as a conceptual framework. These constructions can be quite valuable in helping readers understand the data-collection and analysis process. However, a model depicting the study design does not serve the same role as a conceptual framework. Researchers need to avoid conflating these constructs by differentiating the researchers’ conceptual framework that guides the study from the research design, when applicable.

Explicitly describing conceptual frameworks is essential in depicting the focus of the study. We have found that being explicit in a conceptual framework means using accepted terminology, referencing prior work, and clearly noting connections between terms. This description can also highlight gaps in the literature or suggest potential contributions to the field of study. A well-elucidated conceptual framework can suggest additional studies that may be warranted. This can also spur other researchers to consider how they would approach the examination of a phenomenon and could result in a revised conceptual framework.

It can be challenging to create conceptual frameworks, but they are important. Below are two resources that could be helpful in constructing and presenting conceptual frameworks in educational research:

Maxwell, J. A. (2012). Qualitative research design: An interactive approach (3rd ed.). Los Angeles, CA: Sage. Chapter 3 in this book describes how to construct conceptual frameworks.
Ravitch, S. M., & Riggan, M. (2016). Reason & rigor: How conceptual frameworks guide research . Los Angeles, CA: Sage. This book explains how conceptual frameworks guide the research questions, data collection, data analyses, and interpretation of results.

CONCLUDING THOUGHTS

Literature reviews, theoretical frameworks, and conceptual frameworks are all important in DBER and BER. Robust literature reviews reinforce the importance of a study. Theoretical frameworks connect the study to the base of knowledge in educational theory and specify the researcher’s assumptions. Conceptual frameworks allow researchers to explicitly describe their conceptualization of the relationships among the components of the phenomenon under study. Table 1 provides a general overview of these components in order to assist biology education researchers in thinking about these elements.

It is important to emphasize that these different elements are intertwined. When these elements are aligned and complement one another, the study is coherent, and the study findings contribute to knowledge in the field. When literature reviews, theoretical frameworks, and conceptual frameworks are disconnected from one another, the study suffers. The point of the study is lost, suggested findings are unsupported, or important conclusions are invisible to the researcher. In addition, this misalignment may be costly in terms of time and money.

Conducting a literature review, selecting a theoretical framework, and building a conceptual framework are some of the most difficult elements of a research study. It takes time to understand the relevant research, identify a theoretical framework that provides important insights into the study, and formulate a conceptual framework that organizes the finding. In the research process, there is often a constant back and forth among these elements as the study evolves. With an ongoing refinement of the review of literature, clarification of the theoretical framework, and articulation of a conceptual framework, a sound study can emerge that makes a contribution to the field. This is the goal of BER and education research.

Supplementary Material

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Literature Searching

Literature Searching vs. Literature Review

You may hear about conducting a literature search and literature review inter-changeably. In general, a literature search is the process of seeking out and identifying the existing literature related to a topic or question of interest, while a literature review is the organized synthesis of the information found in the existing literature.

In research, a literature search is typically the first step of a literature review. The search identifies relevant existing studies and articles, and the review is the end result of analyzing, synthesizing, and organizing the information found in the search.

When writing a research paper, the literature review gives you a chance to:

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

References/Additional Resources

Baker, J. D. (2016). T he Purpose, Process, and Methods of Writing a Literature Review . AORN Journal, 103(3), 265–269.

Patrick, L. J., & Munro, S. (2004). The Literature Review: Demystifying the Literature Search. The Diabetes Educator, 30(1), 30–38.

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Literature Review vs Systematic Review

Literature Review vs. Systematic Review
Primary vs. Secondary Sources
Databases and Articles
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Definitions

It’s common to confuse systematic and literature reviews because both are used to provide a summary of the existent literature or research on a specific topic. Regardless of this commonality, both types of review vary significantly. The following table provides a detailed explanation as well as the differences between systematic and literature reviews.

Kysh, Lynn (2013): Difference between a systematic review and a literature review. [figshare]. Available at: http://dx.doi.org/10.6084/m9.figshare.766364

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Answered By: Sarah Naomi Campbell Last Updated: Sep 07, 2018 Views: 213929

Watch this short video to learn about types of scholarly articles, including research articles and literature reviews!

Not in the mood for a video? Read on!

What's the difference between a research article and a review article?

Research articles , sometimes referred to as empirical or primary sources , report on original research. They will typically include sections such as an introduction, methods, results, and discussion.

Here is a more detailed explanation of research articles .

Review articles , sometimes called literature reviews or secondary sources , synthesize or analyze research already conducted in primary sources. They generally summarize the current state of research on a given topic.

Here is a more detailed explanation of review articles .

The video above was created by the Virginia Commonwealth University Libraries .

The defintions, and the linked detailed explanations, are paraphrased from the Publication Manual of the American Psychological Association , 6th ed .

The linked explanations are provided by the Mohawk Valley Community College Libraries .

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As you read research papers, you may notice that there are two very different kinds of review of prior studies. Sometimes, this section of a paper is called a literature review, and at other times, it is referred to as a critical review or a critical context . These differences may be more commonly seen across different fields. Although both these sections are about reviewing prior and existing studies, this article aims to clarify the differences between the two.

Literature review

A literature review is a summary of prior or existing studies that are related to your own research paper . A literature review can be a part of a research paper or can form a paper in itself . For the former, the literature review is designed as a basis upon which your own current study is designed and built. The latter forms a synthesis of prior studies and is a way to highlight future research agendas or a framework.

Writing a literature review

In a literature review, you should attempt to discuss the arguments and findings in prior studies and then work to build on these studies as you develop your own research. You can also highlight the connection between existing and prior literature to demonstrate how the current study you are presenting can advance your knowledge in the field .

When performing a literature review, you should aim to summarise your discussions using a specific aspect of the literature, such as by topic, time, methodology/ design and findings . By doing so, you should be able to establish an effective way to present the relevant literature and demonstrate the connection between prior studies and your research.

Do note that a literature review does not include a presentation or discussion of any results or findings – this should come at a later point in the paper or study. You should also not impose your subjective viewpoints or opinions on the literature you discuss.

Critical review

A critical review is also a popular way of reviewing prior and existing studies. It can cover and discuss the main ideas or arguments in a book or an article, or it can review a specific concept, theme, theoretical perspective or key construct found in the existing literature .

However, the key feature that distinguishes a critical review from a literature review is that the former is more than just a summary of different topics or methodologies. It offers more of a reflection and critique of the concept in question, and is engaged by authors to more clearly contextualise their own research within the existing literature and to present their opinions, perspectives and approaches .

Given that a critical review is not just a summary of prior literature, it is generally not considered acceptable to follow the same strategy as for a literature review. Instead, aim to organise and structure your critical review in a way that would enable you to discuss the key concepts, assert your perspectives and locate your arguments and research within the existing body of work.

Structuring a critical review

A critical review would generally begin with an introduction to the concepts you would like to discuss. Depending on how broad the topics are, this can simply be a brief overview or it could set up a more complex framework. The discussion that follows through the rest of the review will then address and discuss your chosen themes or topics in more depth.

Writing a critical review

The discussion within a critical review will not only present and summarise themes but also critically engage with the varying arguments, writings and perspectives within those themes. One important thing to note is that, similar to a literature review , you should keep your personal opinions, likes and dislikes out of a review. Whether you personally agree with a study or argument – and whether you like it or not – is immaterial. Instead, you should focus upon the effectiveness and relevance of the arguments , considering such elements as the evidence provided, the interpretations and analysis of the data, whether or not a study may be biased in any way, what further questions or problems it raises or what outstanding gaps and issues need to be addressed.

In conclusion

Although a review of previous and existing literature can be performed and presented in different ways, in essence, any literature or critical review requires a solid understanding of the most prominent work in the field as it relates to your own study. Such an understanding is crucial and significant for you to build upon and synthesise the existing knowledge, and to create and contribute new knowledge to advance the field .

Read previous (fourth) in series: How to refer to other studies or literature in the different sections of a research paper

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Key Differences Between the Background of a Study and Literature Review

Don’t be too hard on yourself if you didn’t realize the study background and literature review were two distinct entities. The study background and literature review are both important parts of the research paper; however, due to their striking similarities, they are frequently confused with one another 1 . In this article, we will look at the key differences between the background of a study and literature review and how to write each section effectively.

When it comes to similarities between the study background and the literature review, both provide information about existing knowledge in a specific field by discussing various studies and developments. They almost always address gaps in the literature to contextualize the study at hand. So, how do they differ from one another? Simple answer: A literature review is an expanded version of the study background, or a study background is a condensed version of a literature review. To put it another way, “a study background is to a literature review what an abstract is to a paper.”

Differences between the background of the study and a literature review

Though the distinctions are subtle, understanding them is critical to avoiding confusion between these two elements. The following are the differences between the background of the study and a literature review:

The background of a study is discussed at the beginning of the introduction while the literature review begins once the background of a study is completed (in the introduction section).
The study background sets the stage for the study; the main goal of the study background is to effectively communicate the need for the study by highlighting the gaps in answering the open-ended questions. In contrast, a literature review is an in-depth examination of the relevant literature in that field in order to prepare readers for the study at hand . Furthermore, the literature review provides a broad overview of the topic to support the case for identifying gaps.
The study background and literature review serve slightly different purposes; the study background emphasizes the significance of THE study, whereas the review of literature emphasizes advancement in the field by conducting a critical analysis of existing literature. It should be noted that a literature review also identifies gaps in the literature by comparing and analyzing various studies, but it is the study background that summarizes the critical findings that justifies the need for the research at hand.
Another interesting difference is how they are structured; the study background structure follows a top-down approach, beginning with a discussion of a broader area and eventually narrowing down to a specific question—study problem—addressed in the study.
The length of the background of the study and the literature review also differ, with the former being more concise and crisp and the latter being more detailed and elaborate.

Tips to effectively write the background of the study

Writing the background of the study is sometimes a difficult undertaking for early career researchers; however, because this is an important component of the paper, it is critical that once write it clearly and accurately. The background must convey the context of the study, defining the need to conduct the current study 2 . The study background should be organized in such a way that it provides a historical perspective on the topic, while identifying the gaps that the current study aims to fill. If the topic is multidisciplinary, it should concisely address the relevant studies, laying the groundwork for the research question at hand. To put it simply, the researchers can follow the structure below:

What is the state of the literature on the subject?
Where are the gaps in the field?
What is the importance of filling these gaps?
What are the premises of your research?

The idea is to present the relevant studies to build the context without going into detail about each one; remember to keep it concise and direct. It is recommended that the findings be organized chronologically in order to trace the developments in the field and provide a snapshot of research advancements. The best way is to create an engaging story to pique readers’ interest in the topic by presenting sequential findings that led to YOUR research question. The flow should be such that each study prepares for the next while remaining in accordance with the central theme. However, the author should avoid common blunders such as inappropriate length (too long or too short), ambiguity, an unfocused theme, and disorganization.

differences between the background of a study and literature review

Tips to write the literature review without mixing it up with the background of the study

As previously discussed in this article, the literature review is an extended version of the background of the study. It follows the background of the study and presents a detailed analysis of existing literature to support the background.

Authors must conduct a thorough research survey that includes various studies related to the broad topics of their research. Following an introduction to a broader topic, the literature review directs readers to relevant studies that are significant for the objectives of the present study.

The authors are advised to present the information thematically, preferably chronologically, for a better understanding of the readers from a wide range of disciplines. This arrangement provides a more complete picture of previous research, current focus, and future directions. Finally, there are two types of literature reviews that serve different purposes in papers; they are broadly classified as experimental and theoretical literature reviews. This, however, is a topic for another article.

We believe you can now easily distinguish between the study background and the literature review and understand how you can write them most effectively for your next study. Have fun writing!

References

Qureshi, F. 6 Differences between Study Background and Literature Review. Editage Insights, May 3, 2019. https://www.editage.com/insights/6-differences-between-a-study-background-and-a-literature-review .
Sachdev, R. How to Write the Background of Your Study. Editage Insights, November 27, 2018. https://www.editage.com/insights/how-to-write-the-background-of-your-study .

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Published: 23 April 2024

Designing feedback processes in the workplace-based learning of undergraduate health professions education: a scoping review

Javiera Fuentes-Cimma 1 , 2 ,
Dominique Sluijsmans 3 ,
Arnoldo Riquelme 4 ,
Ignacio Villagran ORCID: orcid.org/0000-0003-3130-8326 1 ,
Lorena Isbej ORCID: orcid.org/0000-0002-4272-8484 2 , 5 ,
María Teresa Olivares-Labbe 6 &
Sylvia Heeneman 7

BMC Medical Education volume 24 , Article number: 440 ( 2024 ) Cite this article

217 Accesses

Metrics details

Feedback processes are crucial for learning, guiding improvement, and enhancing performance. In workplace-based learning settings, diverse teaching and assessment activities are advocated to be designed and implemented, generating feedback that students use, with proper guidance, to close the gap between current and desired performance levels. Since productive feedback processes rely on observed information regarding a student's performance, it is imperative to establish structured feedback activities within undergraduate workplace-based learning settings. However, these settings are characterized by their unpredictable nature, which can either promote learning or present challenges in offering structured learning opportunities for students. This scoping review maps literature on how feedback processes are organised in undergraduate clinical workplace-based learning settings, providing insight into the design and use of feedback.

A scoping review was conducted. Studies were identified from seven databases and ten relevant journals in medical education. The screening process was performed independently in duplicate with the support of the StArt program. Data were organized in a data chart and analyzed using thematic analysis. The feedback loop with a sociocultural perspective was used as a theoretical framework.

The search yielded 4,877 papers, and 61 were included in the review. Two themes were identified in the qualitative analysis: (1) The organization of the feedback processes in workplace-based learning settings, and (2) Sociocultural factors influencing the organization of feedback processes. The literature describes multiple teaching and assessment activities that generate feedback information. Most papers described experiences and perceptions of diverse teaching and assessment feedback activities. Few studies described how feedback processes improve performance. Sociocultural factors such as establishing a feedback culture, enabling stable and trustworthy relationships, and enhancing student feedback agency are crucial for productive feedback processes.

Conclusions

This review identified concrete ideas regarding how feedback could be organized within the clinical workplace to promote feedback processes. The feedback encounter should be organized to allow follow-up of the feedback, i.e., working on required learning and performance goals at the next occasion. The educational programs should design feedback processes by appropriately planning subsequent tasks and activities. More insight is needed in designing a full-loop feedback process, in which specific attention is needed in effective feedforward practices.

Peer Review reports

The design of effective feedback processes in higher education has been important for educators and researchers and has prompted numerous publications discussing potential mechanisms, theoretical frameworks, and best practice examples over the past few decades. Initially, research on feedback primarily focused more on teachers and feedback delivery, and students were depicted as passive feedback recipients [ 1 , 2 , 3 ]. The feedback conversation has recently evolved to a more dynamic emphasis on interaction, sense-making, outcomes in actions, and engagement with learners [ 2 ]. This shift aligns with utilizing the feedback process as a form of social interaction or dialogue to enhance performance [ 4 ]. Henderson et al. (2019) defined feedback processes as "where the learner makes sense of performance-relevant information to promote their learning." (p. 17). When a student grasps the information concerning their performance in connection to the desired learning outcome and subsequently takes suitable action, a feedback loop is closed so the process can be regarded as successful [ 5 , 6 ].

Hattie and Timperley (2007) proposed a comprehensive perspective on feedback, the so-called feedback loop, to answer three key questions: “Where am I going? “How am I going?” and “Where to next?” [ 7 ]. Each question represents a key dimension of the feedback loop. The first is the feed-up, which consists of setting learning goals and sharing clear objectives of learners' performance expectations. While the concept of the feed-up might not be consistently included in the literature, it is considered to be related to principles of effective feedback and goal setting within educational contexts [ 7 , 8 ]. Goal setting allows students to focus on tasks and learning, and teachers to have clear intended learning outcomes to enable the design of aligned activities and tasks in which feedback processes can be embedded [ 9 ]. Teachers can improve the feed-up dimension by proposing clear, challenging, but achievable goals [ 7 ]. The second dimension of the feedback loop focuses on feedback and aims to answer the second question by obtaining information about students' current performance. Different teaching and assessment activities can be used to obtain feedback information, and it can be provided by a teacher or tutor, a peer, oneself, a patient, or another coworker. The last dimension of the feedback loop is the feedforward, which is specifically associated with using feedback to improve performance or change behaviors [ 10 ]. Feedforward is crucial in closing the loop because it refers to those specific actions students must take to reduce the gap between current and desired performance [ 7 ].

From a sociocultural perspective, feedback processes involve a social practice consisting of intricate relationships within a learning context [ 11 ]. The main feature of this approach is that students learn from feedback only when the feedback encounter includes generating, making sense of, and acting upon the information given [ 11 ]. In the context of workplace-based learning (WBL), actionable feedback plays a crucial role in enabling learners to leverage specific feedback to enhance their performance, skills, and conceptual understandings. The WBL environment provides students with a valuable opportunity to gain hands-on experience in authentic clinical settings, in which students work more independently on real-world tasks, allowing them to develop and exhibit their competencies [ 3 ]. However, WBL settings are characterized by their unpredictable nature, which can either promote self-directed learning or present challenges in offering structured learning opportunities for students [ 12 ]. Consequently, designing purposive feedback opportunities within WBL settings is a significant challenge for clinical teachers and faculty.

In undergraduate clinical education, feedback opportunities are often constrained due to the emphasis on clinical work and the absence of dedicated time for teaching [ 13 ]. Students are expected to perform autonomously under supervision, ideally achieved by giving them space to practice progressively and providing continuous instances of constructive feedback [ 14 ]. However, the hierarchy often present in clinical settings places undergraduate students in a dependent position, below residents and specialists [ 15 ]. Undergraduate or junior students may have different approaches to receiving and using feedback. If their priority is meeting the minimum standards given pass-fail consequences and acting merely as feedback recipients, other incentives may be needed to engage with the feedback processes because they will need more learning support [ 16 , 17 ]. Adequate supervision and feedback have been recognized as vital educational support in encouraging students to adopt a constructive learning approach [ 18 ]. Given that productive feedback processes rely on observed information regarding a student's performance, it is imperative to establish structured teaching and learning feedback activities within undergraduate WBL settings.

Despite the extensive research on feedback, a significant proportion of published studies involve residents or postgraduate students [ 19 , 20 ]. Recent reviews focusing on feedback interventions within medical education have clearly distinguished between undergraduate medical students and residents or fellows [ 21 ]. To gain a comprehensive understanding of initiatives related to actionable feedback in the WBL environment for undergraduate health professions, a scoping review of the existing literature could provide insight into how feedback processes are designed in that context. Accordingly, the present scoping review aims to answer the following research question: How are the feedback processes designed in the undergraduate health professions' workplace-based learning environments?

A scoping review was conducted using the five-step methodological framework proposed by Arksey and O'Malley (2005) [ 22 ], intertwined with the PRISMA checklist extension for scoping reviews to provide reporting guidance for this specific type of knowledge synthesis [ 23 ]. Scoping reviews allow us to study the literature without restricting the methodological quality of the studies found, systematically and comprehensively map the literature, and identify gaps [ 24 ]. Furthermore, a scoping review was used because this topic is not suitable for a systematic review due to the varied approaches described and the large difference in the methodologies used [ 21 ].

Search strategy

With the collaboration of a medical librarian, the authors used the research question to guide the search strategy. An initial meeting was held to define keywords and search resources. The proposed search strategy was reviewed by the research team, and then the study selection was conducted in two steps:

An online database search included Medline/PubMed, Web of Science, CINAHL, Cochrane Library, Embase, ERIC, and PsycINFO.

A directed search of ten relevant journals in the health sciences education field (Academic Medicine, Medical Education, Advances in Health Sciences Education, Medical Teacher, Teaching and Learning in Medicine, Journal of Surgical Education, BMC Medical Education, Medical Education Online, Perspectives on Medical Education and The Clinical Teacher) was performed.

The research team conducted a pilot or initial search before the full search to identify if the topic was susceptible to a scoping review. The full search was conducted in November 2022. One team member (MO) identified the papers in the databases. JF searched in the selected journals. Authors included studies written in English due to feasibility issues, with no time span limitation. After eliminating duplicates, two research team members (JF and IV) independently reviewed all the titles and abstracts using the exclusion and inclusion criteria described in Table 2 and with the support of the screening application StArT [ 25 ]. A third team member (AR) reviewed the titles and abstracts when the first two disagreed. The reviewer team met again at a midpoint and final stage to discuss the challenges related to study selection. Articles included for full-text review were exported to Mendeley. JF independently screened all full-text papers, and AR verified 10% for inclusion. The authors did not analyze study quality or risk of bias during study selection, which is consistent with conducting a scoping review.

The analysis of the results incorporated a descriptive summary and a thematic analysis, which was carried out to clarify and give consistency to the results' reporting [ 22 , 24 , 26 ]. Quantitative data were analyzed to report the characteristics of the studies, populations, settings, methods, and outcomes. Qualitative data were labeled, coded, and categorized into themes by three team members (JF, SH, and DS). The feedback loop framework with a sociocultural perspective was used as the theoretical framework to analyze the results.

The keywords used for the search strategies were as follows:

Clinical clerkship; feedback; formative feedback; health professions; undergraduate medical education; workplace.

Definitions of the keywords used for the present review are available in Appendix 1 .

As an example, we included the search strategy that we used in the Medline/PubMed database when conducting the full search:

("Formative Feedback"[Mesh] OR feedback) AND ("Workplace"[Mesh] OR workplace OR "Clinical Clerkship"[Mesh] OR clerkship) AND (("Education, Medical, Undergraduate"[Mesh] OR undergraduate health profession*) OR (learner* medical education)).

Inclusion and exclusion criteria

The following inclusion and exclusion criteria were used (Table 1 ):

Data extraction

The research group developed a data-charting form to organize the information obtained from the studies. The process was iterative, as the data chart was continuously reviewed and improved as necessary. In addition, following Levac et al.'s recommendation (2010), the three members involved in the charting process (JF, LI, and IV) independently reviewed the first five selected studies to determine whether the data extraction was consistent with the objectives of this scoping review and to ensure consistency. Then, the team met using web-conferencing software (Zoom; CA, USA) to review the results and adjust any details in the chart. The same three members extracted data independently from all the selected studies, considering two members reviewing each paper [ 26 ]. A third team member was consulted if any conflict occurred when extracting data. The data chart identified demographic patterns and facilitated the data synthesis. To organize data, we used a shared Excel spreadsheet, considering the following headings: title, author(s), year of publication, journal/source, country/origin, aim of the study, research question (if any), population/sample size, participants, discipline, setting, methodology, study design, data collection, data analysis, intervention, outcomes, outcomes measure, key findings, and relation of findings to research question.

Additionally, all the included papers were uploaded to AtlasTi v19 to facilitate the qualitative analysis. Three team members (JF, SH, and DS) independently coded the first six papers to create a list of codes to ensure consistency and rigor. The group met several times to discuss and refine the list of codes. Then, one member of the team (JF) used the code list to code all the rest of the papers. Once all papers were coded, the team organized codes into descriptive themes aligned with the research question.

Preliminary results were shared with a number of stakeholders (six clinical teachers, ten students, six medical educators) to elicit their opinions as an opportunity to build on the evidence and offer a greater level of meaning, content expertise, and perspective to the preliminary findings [ 26 ]. No quality appraisal of the studies is considered for this scoping review, which aligns with the frameworks for guiding scoping reviews [ 27 ].

The datasets analyzed during the current study are available from the corresponding author upon request.

A database search resulted in 3,597 papers, and the directed search of the most relevant journals in the health sciences education field yielded 2,096 titles. An example of the results of one database is available in Appendix 2 . Of the titles obtained, 816 duplicates were eliminated, and the team reviewed the titles and abstracts of 4,877 papers. Of these, 120 were selected for full-text review. Finally, 61 papers were included in this scoping review (Fig. 1 ), as listed in Table 2 .

PRISMA flow diagram for included studies, incorporating records identified through the database and direct searching

The selected studies were published between 1986 and 2022, and seventy-five percent (46) were published during the last decade. Of all the articles included in this review, 13% (8) were literature reviews: one integrative review [ 28 ] and four scoping reviews [ 29 , 30 , 31 , 32 ]. Finally, fifty-three (87%) original or empirical papers were included (i.e., studies that answered a research question or achieved a research purpose through qualitative or quantitative methodologies) [ 15 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 ].

Table 2 summarizes the papers included in the present scoping review, and Table 3 describes the characteristics of the included studies.

The thematic analysis resulted in two themes: (1) the organization of feedback processes in WBL settings, and (2) sociocultural factors influencing the organization of feedback processes. Table 4 gives a summary of the themes and subthemes.

Organization of feedback processes in WBL settings.

Setting learning goals (i.e., feed-up dimension).

Feedback that focuses on students' learning needs and is based on known performance standards enhances student response and setting learning goals [ 30 ]. Discussing goals and agreements before starting clinical practice enhances students' feedback-seeking behavior [ 39 ] and responsiveness to feedback [ 83 ]. Farrell et al. (2017) found that teacher-learner co-constructed learning goals enhance feedback interactions and help establish educational alliances, improving the learning experience [ 50 ]. However, Kiger (2020) found that sharing individualized learning plans with teachers aligned feedback with learning goals but did not improve students' perceived use of feedback [ 64 ]

Two papers of this set pointed out the importance of goal-oriented feedback, a dynamic process that depends on discussion of goal setting between teachers and students [ 50 ] and influences how individuals experience, approach, and respond to upcoming learning activities [ 34 ]. Goal-oriented feedback should be embedded in the learning experience of the clinical workplace, as it can enhance students' engagement in safe feedback dialogues [ 50 ]. Ideally, each feedback encounter in the WBL context should conclude, in addition to setting a plan of action to achieve the desired goal, with a reflection on the next goal [ 50 ].

Feedback strategies within the WBL environment. (i.e., feedback dimension)

In undergraduate WBL environments, there are several tasks and feedback opportunities organized in the undergraduate clinical workplace that can enable feedback processes:

Questions from clinical teachers to students are a feedback strategy [ 74 ]. There are different types of questions that the teacher can use, either to clarify concepts, to reach the correct answer, or to facilitate self-correction [ 74 ]. Usually, questions can be used in conjunction with other communication strategies, such as pauses, which enable self-correction by the student [ 74 ]. Students can also ask questions to obtain feedback on their performance [ 54 ]. However, question-and-answer as a feedback strategy usually provides information on either correct or incorrect answers and fewer suggestions for improvement, rendering it less constructive as a feedback strategy [ 82 ].

Direct observation of performance by default is needed to be able to provide information to be used as input in the feedback process [ 33 , 46 , 49 , 86 ]. In the process of observation, teachers can include clarification of objectives (i.e., feed-up dimension) and suggestions for an action plan (i.e., feedforward) [ 50 ]. Accordingly, Schopper et al. (2016) showed that students valued being observed while interviewing patients, as they received feedback that helped them become more efficient and effective as interviewers and communicators [ 33 ]. Moreover, it is widely described that direct observation improves feedback credibility [ 33 , 40 , 84 ]. Ideally, observation should be deliberate [ 33 , 83 ], informal or spontaneous [ 33 ], conducted by a (clinical) expert [ 46 , 86 ], provided immediately after the observation, and clinical teacher if possible, should schedule or be alert on follow-up observations to promote closing the gap between current and desired performance [ 46 ].

Workplace-based assessments (WBAs), by definition, entail direct observation of performance during authentic task demonstration [ 39 , 46 , 56 , 87 ]. WBAs can significantly impact behavioral change in medical students [ 55 ]. Organizing and designing formative WBAs and embedding these in a feedback dialogue is essential for effective learning [ 31 ].

Summative organization of WBAs is a well described barrier for feedback uptake in the clinical workplace [ 35 , 46 ]. If feedback is perceived as summative, or organized as a pass-fail decision, students may be less inclined to use the feedback for future learning [ 52 ]. According to Schopper et al. (2016), using a scale within a WBA makes students shift their focus during the clinical interaction and see it as an assessment with consequences [ 33 ]. Harrison et al. (2016) pointed out that an environment that only contains assessments with a summative purpose will not lead to a culture of learning and improving performance [ 56 ]. The recommendation is to separate the formative and summative WBAs, as feedback in summative instances is often not recognized as a learning opportunity or an instance to seek feedback [ 54 ]. In terms of the design, an organizational format is needed to clarify to students how formative assessments can promote learning from feedback [ 56 ]. Harrison et al. (2016) identified that enabling students to have more control over their assessments, designing authentic assessments, and facilitating long-term mentoring could improve receptivity to formative assessment feedback [ 56 ].

Multiple WBA instruments and systems are reported in the literature. Sox et al. (2014) used a detailed evaluation form to help students improve their clinical case presentation skills. They found that feedback on oral presentations provided by supervisors using a detailed evaluation form improved clerkship students’ oral presentation skills [ 78 ]. Daelmans et al. (2006) suggested that a formal in-training assessment programme composed by 19 assessments that provided structured feedback, could promote observation and verbal feedback opportunities through frequent assessments [ 43 ]. However, in this setting, limited student-staff interactions still hindered feedback follow-up [ 43 ]. Designing frequent WBA improves feedback credibility [ 28 ]. Long et al. (2021) emphasized that students' responsiveness to assessment feedback hinges on its perceived credibility, underlining the importance of credibility for students to effectively engage and improve their performance [ 31 ].

The mini-CEX is one of the most widely described WBA instruments in the literature. Students perceive that the mini-CEX allows them to be observed and encourages the development of interviewing skills [ 33 ]. The mini-CEX can provide feedback that improves students' clinical skills [ 58 , 60 ], as it incorporates a structure for discussing the student's strengths and weaknesses and the design of a written action plan [ 39 , 80 ]. When mini-CEXs are incorporated as part of a system of WBA, such as programmatic assessment, students feel confident in seeking feedback after observation, and being systematic allows for follow-up [ 39 ]. Students suggested separating grading from observation and using the mini-CEX in more informal situations [ 33 ].

Clinical encounter cards allow students to receive weekly feedback and make them request more feedback as the clerkship progresses [ 65 ]. Moreover, encounter cards stimulate that feedback is given by supervisors, and students are more satisfied with the feedback process [ 72 ]. With encounter card feedback, students are responsible for asking a supervisor for feedback before a clinical encounter, and supervisors give students written and verbal comments about their performance after the encounter [ 42 , 72 ]. Encounter cards enhance the use of feedback and add approximately one minute to the length of the clinical encounter, so they are well accepted by students and supervisors [ 72 ]. Bennett (2006) identified that Instant Feedback Cards (IFC) facilitated mid-rotation feedback [ 38 ]. Feedback encounter card comments must be discussed between students and supervisors; otherwise, students may perceive it as impersonal, static, formulaic, and incomplete [ 59 ].

Self-assessments can change students' feedback orientation, transforming them into coproducers of learning [ 68 ]. Self-assessments promote the feedback process [ 68 ]. Some articles emphasize the importance of organizing self-assessments before receiving feedback from supervisors, for example, discussing their appraisal with the supervisor [ 46 , 52 ]. In designing a feedback encounter, starting with a self-assessment as feed-up, discussing with the supervisor, and identifying areas for improvement is recommended, as part of the feedback dialogue [ 68 ].

Peer feedback as an organized activity allows students to develop strategies to observe and give feedback to other peers [ 61 ]. Students can act as the feedback provider or receiver, fostering understanding of critical comments and promoting evaluative judgment for their clinical practice [ 61 ]. Within clerkships, enabling the sharing of feedback information among peers allows for a better understanding and acceptance of feedback [ 52 ]. However, students can find it challenging to take on the peer assessor/feedback provider role, as they prefer to avoid social conflicts [ 28 , 61 ]. Moreover, it has been described that they do not trust the judgment of their peers because they are not experts, although they know the procedures, tasks, and steps well and empathize with their peer status in the learning process [ 61 ].

Bedside-teaching encounters (BTEs) provide timely feedback and are an opportunity for verbal feedback during performance [ 74 ]. Rizan et al. (2014) explored timely feedback delivered within BTEs and determined that it promotes interaction that constructively enhances learner development through various corrective strategies (e.g., question and answers, pauses, etc.). However, if the feedback given during the BTEs was general, unspecific, or open-ended, it could go unnoticed [ 74 ]. Torre et al. (2005) investigated which integrated feedback activities and clinical tasks occurred on clerkship rotations and assessed students' perceived quality in each teaching encounter [ 81 ]. The feedback activities reported were feedback on written clinical history, physical examination, differential diagnosis, oral case presentation, a daily progress note, and bedside feedback. Students considered all these feedback activities high-quality learning opportunities, but they were more likely to receive feedback when teaching was at the bedside than at other teaching locations [ 81 ].

Case presentations are an opportunity for feedback within WBL contexts [ 67 , 73 ]. However, both students and supervisors struggled to identify them as feedback moments, and they often dismissed questions and clarifications around case presentations as feedback [ 73 ]. Joshi (2017) identified case presentations as a way for students to ask for informal or spontaneous supervisor feedback [ 63 ].

Organization of follow-up feedback and action plans (i.e., feedforward dimension).

Feedback that generates use and response from students is characterized by two-way communication and embedded in a dialogue [ 30 ]. Feedback must be future-focused [ 29 ], and a feedback encounter should be followed by planning the next observation [ 46 , 87 ]. Follow-up feedback could be organized as a future self-assessment, reflective practice by the student, and/or a discussion with the supervisor or coach [ 68 ]. The literature describes that a lack of student interaction with teachers makes follow-up difficult [ 43 ]. According to Haffling et al. (2011), follow-up feedback sessions improve students' satisfaction with feedback compared to students who do not have follow-up sessions. In addition, these same authors reported that a second follow-up session allows verification of improved performances or confirmation that the skill was acquired [ 55 ].

Although feedback encounter forms are a recognized way of obtaining information about performance (i.e., feedback dimension), the literature does not provide many clear examples of how they may impact the feedforward phase. For example, Joshi et al. (2016) consider a feedback form with four fields (i.e., what did you do well, advise the student on what could be done to improve performance, indicate the level of proficiency, and personal details of the tutor). In this case, the supervisor highlighted what the student could improve but not how, which is the missing phase of the co-constructed action plan [ 63 ]. Whichever WBA instrument is used in clerkships to provide feedback, it should include a "next steps" box [ 44 ], and it is recommended to organize a long-term use of the WBA instrument so that those involved get used to it and improve interaction and feedback uptake [ 55 ]. RIME-based feedback (Reporting, Interpreting, Managing, Educating) is considered an interesting example, as it is perceived as helpful to students in knowing what they need to improve in their performance [ 44 ]. Hochberg (2017) implemented formative mid-clerkship assessments to enhance face-to-face feedback conversations and co-create an improvement plan [ 59 ]. Apps for structuring and storing feedback improve the amount of verbal and written feedback. In the study of Joshi et al. (2016), a reasonable proportion of students (64%) perceived that these app tools help them improve their performance during rotations [ 63 ].

Several studies indicate that an action plan as part of the follow-up feedback is essential for performance improvement and learning [ 46 , 55 , 60 ]. An action plan corresponds to an agreed-upon strategy for improving, confirming, or correcting performance. Bing-You et al. (2017) determined that only 12% of the articles included in their scoping review incorporated an action plan for learners [ 32 ]. Holmboe et al. (2004) reported that only 11% of the feedback sessions following a mini-CEX included an action plan [ 60 ]. Suhoyo et al. (2017) also reported that only 55% of mini-CEX encounters contained an action plan [ 80 ]. Other authors reported that action plans are not commonly offered during feedback encounters [ 77 ]. Sokol-Hessner et al. (2010) implemented feedback card comments with a space to provide written feedback and a specific action plan. In their results, 96% contained positive comments, and only 5% contained constructive comments [ 77 ]. In summary, although the recommendation is to include a “next step” box in the feedback instruments, evidence shows these items are not often used for constructive comments or action plans.

Sociocultural factors influencing the organization of feedback processes.

Multiple sociocultural factors influence interaction in feedback encounters, promoting or hampering the productivity of the feedback processes.

Clinical learning culture

Context impacts feedback processes [ 30 , 82 ], and there are barriers to incorporating actionable feedback in the clinical learning context. The clinical learning culture is partly determined by the clinical context, which can be unpredictable [ 29 , 46 , 68 ], as the available patients determine learning opportunities. Supervisors are occupied by a high workload, which results in limited time or priority for teaching [ 35 , 46 , 48 , 55 , 68 , 83 ], hindering students’ feedback-seeking behavior [ 54 ], and creating a challenge for the balance between patient care and student mentoring [ 35 ].

Clinical workplace culture does not always purposefully prioritize instances for feedback processes [ 83 , 84 ]. This often leads to limited direct observation [ 55 , 68 ] and the provision of poorly informed feedback. It is also evident that this affects trust between clinical teachers and students [ 52 ]. Supervisors consider feedback a low priority in clinical contexts [ 35 ] due to low compensation and lack of protected time [ 83 ]. In particular, lack of time appears to be the most significant and well-known barrier to frequent observation and workplace feedback [ 35 , 43 , 48 , 62 , 67 , 83 ].

The clinical environment is hierarchical [ 68 , 80 ] and can make students not consider themselves part of the team and feel like a burden to their supervisor [ 68 ]. This hierarchical learning environment can lead to unidirectional feedback, limit dialogue during feedback processes, and hinder the seeking, uptake, and use of feedback [ 67 , 68 ]. In a learning culture where feedback is not supported, learners are less likely to want to seek it and feel motivated and engaged in their learning [ 83 ]. Furthermore, it has been identified that clinical supervisors lack the motivation to teach [ 48 ] and the intention to observe or reobserve performance [ 86 ].

In summary, the clinical context and WBL culture do not fully use the potential of a feedback process aimed at closing learning gaps. However, concrete actions shown in the literature can be taken to improve the effectiveness of feedback by organizing the learning context. For example, McGinness et al. (2022) identified that students felt more receptive to feedback when working in a safe, nonjudgmental environment [ 67 ]. Moreover, supervisors and trainees identified the learning culture as key to establishing an open feedback dialogue [ 73 ]. Students who perceive culture as supportive and formative can feel more comfortable performing tasks and more willing to receive feedback [ 73 ].

Relationships

There is a consensus in the literature that trusting and long-term relationships improve the chances of actionable feedback. However, relationships between supervisors and students in the clinical workplace are often brief and not organized as more longitudinally [ 68 , 83 ], leaving little time to establish a trustful relationship [ 68 ]. Supervisors change continuously, resulting in short interactions that limit the creation of lasting relationships over time [ 50 , 68 , 83 ]. In some contexts, it is common for a student to have several supervisors who have their own standards in the observation of performance [ 46 , 56 , 68 , 83 ]. A lack of stable relationships results in students having little engagement in feedback [ 68 ]. Furthermore, in case of summative assessment programmes, the dual role of supervisors (i.e., assessing and giving feedback) makes feedback interactions perceived as summative and can complicate the relationship [ 83 ].

Repeatedly, the articles considered in this review describe that long-term and stable relationships enable the development of trust and respect [ 35 , 62 ] and foster feedback-seeking behavior [ 35 , 67 ] and feedback-giver behavior [ 39 ]. Moreover, constructive and positive relationships enhance students´ use of and response to feedback [ 30 ]. For example, Longitudinal Integrated Clerkships (LICs) promote stable relationships, thus enhancing the impact of feedback [ 83 ]. In a long-term trusting relationship, feedback can be straightforward and credible [ 87 ], there are more opportunities for student observation, and the likelihood of follow-up and actionable feedback improves [ 83 ]. Johnson et al. (2020) pointed out that within a clinical teacher-student relationship, the focus must be on establishing psychological safety; thus, the feedback conversations might be transformed [ 62 ].

Stable relationships enhance feedback dialogues, which offer an opportunity to co-construct learning and propose and negotiate aspects of the design of learning strategies [ 62 ].

Students as active agents in the feedback processes

The feedback response learners generate depends on the type of feedback information they receive, how credible the source of feedback information is, the relationship between the receiver and the giver, and the relevance of the information delivered [ 49 ]. Garino (2020) noted that students who are most successful in using feedback are those who do not take criticism personally, who understand what they need to improve and know they can do so, who value and feel meaning in criticism, are not surprised to receive it, and who are motivated to seek new feedback and use effective learning strategies [ 52 ]. Successful users of feedback ask others for help, are intentional about their learning, know what resources to use and when to use them, listen to and understand a message, value advice, and use effective learning strategies. They regulate their emotions, find meaning in the message, and are willing to change [ 52 ].

Student self-efficacy influences the understanding and use of feedback in the clinical workplace. McGinness et al. (2022) described various positive examples of self-efficacy regarding feedback processes: planning feedback meetings with teachers, fostering good relationships with the clinical team, demonstrating interest in assigned tasks, persisting in seeking feedback despite the patient workload, and taking advantage of opportunities for feedback, e.g., case presentations [ 67 ].

When students are encouraged to seek feedback aligned with their own learning objectives, they promote feedback information specific to what they want to learn and improve and enhance the use of feedback [ 53 ]. McGinness et al. (2022) identified that the perceived relevance of feedback information influenced the use of feedback because students were more likely to ask for feedback if they perceived that the information was useful to them. For example, if students feel part of the clinical team and participate in patient care, they are more likely to seek feedback [ 17 ].

Learning-oriented students aim to seek feedback to achieve clinical competence at the expected level [ 75 ]; they focus on improving their knowledge and skills and on professional development [ 17 ]. Performance-oriented students aim not to fail and to avoid negative feedback [ 17 , 75 ].

For effective feedback processes, including feed-up, feedback, and feedforward, the student must be feedback-oriented, i.e., active, seeking, listening to, interpreting, and acting on feedback [ 68 ]. The literature shows that feedback-oriented students are coproducers of learning [ 68 ] and are more involved in the feedback process [ 51 ]. Additionally, students who are metacognitively aware of their learning process are more likely to use feedback to reduce gaps in learning and performance [ 52 ]. For this, students must recognize feedback when it occurs and understand it when they receive it. Thus, it is important to organize training and promote feedback literacy so that students understand what feedback is, act on it, and improve the quality of feedback and their learning plans [ 68 ].

Table 5 summarizes those feedback tasks, activities, and key features of organizational aspects that enable each phase of the feedback loop based on the literature review.

The present scoping review identified 61 papers that mapped the literature on feedback processes in the WBL environments of undergraduate health professions. This review explored how feedback processes are organized in these learning contexts using the feedback loop framework. Given the specific characteristics of feedback processes in undergraduate clinical learning, three main findings were identified on how feedback processes are being conducted in the clinical environment and how these processes could be organized to support feedback processes.

First, the literature lacks a balance between the three dimensions of the feedback loop. In this regard, most of the articles in this review focused on reporting experiences or strategies for delivering feedback information (i.e., feedback dimension). Credible and objective feedback information is based on direct observation [ 46 ] and occurs within an interaction or a dialogue [ 62 , 88 ]. However, only having credible and objective information does not ensure that it will be considered, understood, used, and put into practice by the student [ 89 ].

Feedback-supporting actions aligned with goals and priorities facilitate effective feedback processes [ 89 ] because goal-oriented feedback focuses on students' learning needs [ 7 ]. In contrast, this review showed that only a minority of the studies highlighted the importance of aligning learning objectives and feedback (i.e., the feed-up dimension). To overcome this, supervisors and students must establish goals and agreements before starting clinical practice, as it allows students to measure themselves on a defined basis [ 90 , 91 ] and enhances students' feedback-seeking behavior [ 39 , 92 ] and responsiveness to feedback [ 83 ]. In addition, learning goals should be shared, and co-constructed, through a dialogue [ 50 , 88 , 90 , 92 ]. In fact, relationship-based feedback models emphasize setting shared goals and plans as part of the feedback process [ 68 ].

Many of the studies acknowledge the importance of establishing an action plan and promoting the use of feedback (i.e., feedforward). However, there is yet limited insight on how to best implement strategies that support the use of action plans, improve performance and close learning gaps. In this regard, it is described that delivering feedback without perceiving changes, results in no effect or impact on learning [ 88 ]. To determine if a feedback loop is closed, observing a change in the student's response is necessary. In other words, feedback does not work without repeating the same task [ 68 ], so teachers need to observe subsequent tasks to notice changes [ 88 ]. While feedforward is fundamental to long-term performance, it is shown that more research is needed to determine effective actions to be implemented in the WBL environment to close feedback loops.

Second, there is a need for more knowledge about designing feedback activities in the WBL environment that will generate constructive feedback for learning. WBA is the most frequently reported feedback activity in clinical workplace contexts [ 39 , 46 , 56 , 87 ]. Despite the efforts of some authors to use WBAs as a formative assessment and feedback opportunity, in several studies, a summative component of the WBA was presented as a barrier to actionable feedback [ 33 , 56 ]. Students suggest separating grading from observation and using, for example, the mini-CEX in informal situations [ 33 ]. Several authors also recommend disconnecting the summative components of WBAs to avoid generating emotions that can limit the uptake and use of feedback [ 28 , 93 ]. Other literature recommends purposefully designing a system of assessment using low-stakes data points for feedback and learning. Accordingly, programmatic assessment is a framework that combines both the learning and the decision-making function of assessment [ 94 , 95 ]. Programmatic assessment is a practical approach for implementing low-stakes as a continuum, giving opportunities to close the gap between current and desired performance and having the student as an active agent [ 96 ]. This approach enables the incorporation of low-stakes data points that target student learning [ 93 ] and provide performance-relevant information (i.e., meaningful feedback) based on direct observations during authentic professional activities [ 46 ]. Using low-stakes data points, learners make sense of information about their performance and use it to enhance the quality of their work or performance [ 96 , 97 , 98 ]. Implementing multiple instances of feedback is more effective than providing it once because it promotes closing feedback loops by giving the student opportunities to understand the feedback, make changes, and see if those changes were effective [ 89 ].

Third, the support provided by the teacher is fundamental and should be built into a reliable and long-term relationship, where the teacher must take the role of coach rather than assessor, and students should develop feedback agency and be active in seeking and using feedback to improve performance. Although it is recognized that institutional efforts over the past decades have focused on training teachers to deliver feedback, clinical supervisors' lack of teaching skills is still identified as a barrier to workplace feedback [ 99 ]. In particular, research indicates that clinical teachers lack the skills to transform the information obtained from an observation into constructive feedback [ 100 ]. Students are more likely to use feedback if they consider it credible and constructive [ 93 ] and based on stable relationships [ 93 , 99 , 101 ]. In trusting relationships, feedback can be straightforward and credible, and the likelihood of follow-up and actionable feedback improves [ 83 , 88 ]. Coaching strategies can be enhanced by teachers building an educational alliance that allows for trustworthy relationships or having supervisors with an exclusive coaching role [ 14 , 93 , 102 ].

Last, from a sociocultural perspective, individuals are the main actors in the learning process. Therefore, feedback impacts learning only if students engage and interact with it [ 11 ]. Thus, feedback design and student agency appear to be the main features of effective feedback processes. Accordingly, the present review identified that feedback design is a key feature for effective learning in complex environments such as WBL. Feedback in the workplace must ideally be organized and implemented to align learning outcomes, learning activities, and assessments, allowing learners to learn, practice, and close feedback loops [ 88 ]. To guide students toward performances that reflect long-term learning, an intensive formative learning phase is needed, in which multiple feedback processes are included that shape students´ further learning [ 103 ]. This design would promote student uptake of feedback for subsequent performance [ 1 ].

Strengths and limitations

The strengths of this study are (1) the use of an established framework, the Arksey and O'Malley's framework [ 22 ]. We included the step of socializing the results with stakeholders, which allowed the team to better understand the results from another perspective and offer a realistic look. (2) Using the feedback loop as a theoretical framework strengthened the results and gave a more thorough explanation of the literature regarding feedback processes in the WBL context. (3) our team was diverse and included researchers from different disciplines as well as a librarian.

The present scoping review has several limitations. Although we adhered to the recommended protocols and methodologies, some relevant papers may have been omitted. The research team decided to select original studies and reviews of the literature for the present scoping review. This caused some articles, such as guidelines, perspectives, and narrative papers, to be excluded from the current study.

One of the inclusion criteria was a focus on undergraduate students. However, some papers that incorporated undergraduate and postgraduate participants were included, as these supported the results of this review. Most articles involved medical students. Although the authors did not limit the search to medicine, maybe some articles involving students from other health disciplines needed to be included, considering the search in other databases or journals.

The results give insight in how feedback could be organized within the clinical workplace to promote feedback processes. On a small scale, i.e., in the feedback encounter between a supervisor and a learner, feedback should be organized to allow for follow-up feedback, thus working on required learning and performance goals. On a larger level, i.e., in the clerkship programme or a placement rotation, feedback should be organized through appropriate planning of subsequent tasks and activities.

More insight is needed in designing a closed loop feedback process, in which specific attention is needed in effective feedforward practices. The feedback that stimulates further action and learning requires a safe and trustful work and learning environment. Understanding the relationship between an individual and his or her environment is a challenge for determining the impact of feedback and must be further investigated within clinical WBL environments. Aligning the dimensions of feed-up, feedback and feedforward includes careful attention to teachers’ and students’ feedback literacy to assure that students can act on feedback in a constructive way. In this line, how to develop students' feedback agency within these learning environments needs further research.

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J.F-C, D.S, and S.H. made substantial contributions to the conception and design of the work. M.O-L contributed to the identification of studies. J.F-C, I.V, A.R, and L.I. made substantial contributions to the screening, reliability, and data analysis. J.F-C. wrote th e main manuscript text. All authors reviewed the manuscript.

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Fuentes-Cimma, J., Sluijsmans, D., Riquelme, A. et al. Designing feedback processes in the workplace-based learning of undergraduate health professions education: a scoping review. BMC Med Educ 24 , 440 (2024). https://doi.org/10.1186/s12909-024-05439-6

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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
5 Self Advocacy Sydney , Sydney , New South Wales , Australia
Correspondence to Dr Manjekah Dunn, Paediatrics & Child Health, University of New South Wales Medicine & Health, Sydney, New South Wales, Australia; manjekah.dunn{at}unsw.edu.au

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.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjqs-2023-016113

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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
Data supplement 3
Data supplement 4
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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Open access
Published: 25 April 2024

A scoping review of academic and grey literature on migrant health research conducted in Scotland

G. Petrie 1 ,
K. Angus 2 &
R. O’Donnell 2

BMC Public Health volume 24 , Article number: 1156 ( 2024 ) Cite this article

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Migration to Scotland has increased since 2002 with an increase in European residents and participation in the Asylum dispersal scheme. Scotland has become more ethnically diverse, and 10% of the current population were born abroad. Migration and ethnicity are determinants of health, and information on the health status of migrants to Scotland and their access to and barriers to care facilitates the planning and delivery of equitable health services. This study aimed to scope existing peer-reviewed research and grey literature to identify gaps in evidence regarding the health of migrants in Scotland.

A scoping review on the health of migrants in Scotland was carried out for dates January 2002 to March 2023, inclusive of peer-reviewed journals and grey literature. CINAHL/ Web of Science/SocIndex and Medline databases were systematically searched along with government and third-sector websites. The searches identified 2166 journal articles and 170 grey literature documents for screening. Included articles were categorised according to the World Health Organisation’s 2016 Strategy and Action Plan for Refugee and Migrant Health in the European region. This approach builds on a previously published literature review on Migrant Health in the Republic of Ireland.

Seventy-one peer reviewed journal articles and 29 grey literature documents were included in the review. 66% were carried out from 2013 onwards and the majority focused on asylum seekers or unspecified migrant groups. Most research identified was on the World Health Organisation’s strategic areas of right to health of refugees, social determinants of health and public health planning and strengthening health systems. There were fewer studies on the strategic areas of frameworks for collaborative action, preventing communicable disease, preventing non-communicable disease, health screening and assessment and improving health information and communication.

While research on migrant health in Scotland has increased in recent years significant gaps remain. Future priorities should include studies of undocumented migrants, migrant workers, and additional research is required on the issue of improving health information and communication.

Peer Review reports

The term migrant is defined by the International Organisation for Migration as “ a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons. The term includes several well-defined legal categories of people, including migrant workers; persons whose particular types of movements are legally-defined, such as smuggled migrants; as well as those whose status are not specifically defined under international law, such as international students.” [ 1 ] Internationally there are an estimated 281 million migrants – 3.6% of the world population, including 26.4 million refugees and 4.1 million asylum seekers – the highest number ever recorded [ 2 ]. The UN Refugee Society defines the term refugee as “ someone who has been forced to flee his or her country because of persecution, war or violence…most likely, they cannot return home or are afraid to do so .” The term asylum-seeker is defined as “someone whose request for sanctuary has yet to be processed.” [ 3 ].

Net-migration to Europe was negative in the 19th century due to higher levels of emigration, however in the mid-20th century immigration began to rise, because of an increase in migrant workers and following conflicts in the Middle East and North Africa [ 4 ]. Current migration drivers include conflicts alongside world-wide economic instability, exacerbated by the Covid-19 pandemic [ 5 ]. Environmental damage due to climate change is expected to inflate the number of asylum seekers entering Europe in future [ 6 ]. The increase in migration to Europe is not a short-term influx but a long-term phenomenon, and European nations must adapt and find solutions to resulting financial, safeguarding and health challenges [ 7 ].

Data on healthcare use by migrants in Europe is variable, which means cross-country comparisons are inadequate [ 8 ]. Many countries do not record migration information within health records and all use disparate criteria to classify migrant status. The lack of comparative data hinders public health surveillance and effective interventions [ 9 ]. Even where information is available, results can be contradictory due to the multifarious migrant population. Migrants have a wide range of origin countries, socio-economic position, age and journeys undertaken which can affect health status [ 10 ].

Migrants initially may have better health than the general population, known as the ‘Healthy Migrant effect’ [ 11 ]. However, health declines with increasing length of residence [ 12 ] and over time to levels comparable with the general population [ 13 ]. Second generation immigrants may have higher mortality than average [ 14 ]. The process of acculturation to the host country, with adoption of unhealthy lifestyle and behaviours, increases the risk for chronic disease [ 15 ]. In addition, inequalities in health of migrants compared to host populations has been confirmed by wide-ranging research [ 16 ].

Host countries may limit healthcare access, with undocumented migrants sometimes only entitled to emergency care [ 17 ]. Even when access is granted, inequitable services can affect quality of care due to language barriers and cultural factors [ 18 ]. Poor working/living conditions and discrimination can exacerbate health inequalities [ 12 ]. Processing facilities for asylum seekers are frequently overpopulated, stressful environments [ 19 ] and threat of deportation, lack of citizenship rights and integration can negatively affect health and access to care [ 20 ]. Undocumented workers are unprotected by health and safety legislation leading to dangerous working conditions and injuries [ 15 ].

A systematic review of migrant health in the European Union (EU) found migrants have worse self-perceived health than the general population [ 21 ]. Research evidence indicates increased prevalence of cardiovascular disease, diabetes, mental health disorders and adverse pregnancy outcomes. Exposure to conflict, harsh travel conditions and suboptimal vaccine programmes can mean higher risk of communicable disease [ 22 ]. Scoping reviews have also been conducted to describe trends within migration health research in the United Kingdom (UK) [ 23 ] and identify gaps for future research agendas in the UK [ 23 ] and in the Republic of Ireland [ 24 ].

Almost three-quarters (73%) of published migration health research in the UK has been conducted in England, focusing primarily on infectious diseases and mental health. There is limited evidence on the social determinants of health, access to and use of healthcare and structural and behavioural factors behaviours that influence migrant health in the UK [ 23 ]. By contrast, a large amount of the migration research conducted in the Republic of Ireland has focused on the social determinants of health, and on health system adaptations, with a paucity of research focusing on improving health information systems [ 24 ].

Migration and Health in Scotland

Immigration to Scotland began to rise in 2003 with the expansion of the EU [ 25 ]. The population in Scotland increased from 5.11 million to 5.47 million between 2005 and 2020 and is predicted to continue rising until 2028 [ 26 ] despite low birth rates, with the increased population resulting from inward migration [ 27 ]. Scotland’s population is becoming more ethnically diverse [ 28 ] and susceptibility to different health conditions varies by ethnic group, which has implications for the planning and provision of health services [ 29 ]. 7% of the current Scottish population are non-UK nationals and 10% were born outside Britain. The commonest countries of origin were Poland, Ireland, Italy, Nigeria and India [ 30 ].

Within Scotland, linking health data to ethnicity is standard in order to monitor and improve health of minority groups [ 31 ]. Ethnic background can differ from country of birth which means migration status cannot be assumed [ 32 ], although health inequalities experienced by migrants often extend to affect all ethnic minority groups [ 33 ]. The Scottish Health and Ethnicity Linkage Study (SHELS) linked census data to health records of 91% of the population which has provided information on mortality and morbidity by ethnic group and country of birth [ 34 ]. SHELS research indicates that the white-Scottish population have a higher mortality rate than other ethnic groups. This may be consequent to the comparatively poor health of the Scottish population relative to other European nations: high mortality rates in the general population may cause a perception that the health of minorities is more advantageous than in reality [ 35 ].

Cezard et al’s [ 13 ] analysis of self-perceived health among people in Scotland found that being born abroad had a positive impact on health status. Health declined with increased length of residence, which may be explained by cultural convergence with the majority population. Allik et al. [ 36 ] compared health inequalities by ethnic background and found that with increasing age, health differences reduced thus people aged over 75 of all ethnicities had similar or worse health status than White-Scottish people. While working-age migrants appear to be healthier than the White Scottish population, it cannot be assumed that in future this would extend to older age groups.

Research has shown deprivation as a cause of heath inequalities among ethnic minority and migrant groups [ 37 ]. The socio-economic status of minority ethnic groups in Scotland is unusual, as most are of similar or higher status than the white-Scottish population [ 38 ]. Therefore, public health interventions targeting deprivation may not address risk-factors for ethnic minorities and migrants [ 36 ]. Further research on determinants of health in migrants can help with planning and design of inclusive policies.

The 2011 census indicated that 50% of immigrants lived in the cities of Edinburgh, Glasgow, and Aberdeen. Glasgow had a greater percentage of non-European immigrants due to participation in the Asylum dispersal programme [ 39 ]. 10% of UK asylum seekers are placed in Glasgow, but records are not kept following approval of asylum claims, therefore the size of the refugee population is unknown [ 40 ]. While immigration is controlled by the British government, in policy areas devolved to the Scottish government, refugees and asylum seekers have more rights than elsewhere in UK, including access to primary healthcare for undocumented migrants [ 40 ]. Despite the mitigating effect of Scottish policies, asylum seekers’ health is worsened by the asylum process and associated poverty, marginalisation, and discrimination [ 40 ]. Health deteriorates with increasing length of time in the asylum system [ 40 ] and asylum seekers and refugees have additional health needs and require enhanced support [ 41 ]. Research on the health needs of asylum seekers in Scotland is required to ensure adequate healthcare.

Aim and objectives

While scoping reviews on migrant health have been carried out in Europe [ 12 ], Ireland [ 24 ] and the UK [ 23 ] none are currently specific to the Scottish context. Given the devolved government of Scotland and demographics described above, a targeted review would help to clarify research priorities, with the aim of improving health and health care within the migrant community in Scotland. This work therefore builds on the published scoping review of migrant health in the Republic of Ireland [ 24 ]. The authors recommend replication of the study in other countries to facilitate cross-country comparison. Our aim was to scope peer-reviewed research and grey literature on migrant health conducted in Scotland and identify any gaps in the evidence. Our objectives were to: [1] understand the extent of the available research by topic area [2] summarise the types of research already conducted, populations studied, topics covered and approaches taken [3], map the existing research conducted in Scotland and [4] identify areas for future research based on any gaps in the evidence identified.

A scoping review was conducted as they can aid detection of evidence gaps [ 42 ] and allow incorporation of grey literature in topics with insufficient published research [ 43 ]. Arksey and O’Malley’s [ 44 ] five stage scoping review framework was used.

Stage 1: identifying the research question

Arskey and O’Malley [ 44 ] suggest maintaining a broad approach to identifying the research question, in order to generate breadth of coverage. On this basis, and in line with the research question identified in the Villarroel et al. [ 24 ] scoping review, our research question was framed as follows: What is the scope, main topics and gaps in evidence in the existing literature on health of international migrants living in Scotland? Arksey and O’Malley [ 44 ] highlight the importance of defining terminology at the outset of scoping reviews. For consistency, we used the broad definition of ‘migrant’ as per Villaroel et al. [ 24 ], from the International Organisation for Migration (IOM) [ 1 ]. References to refugees or asylum seekers followed the United Nations Refugee Agency definitions [ 3 ].

Stage 2: identifying relevant studies

Electronic database searches identified reports alongside a grey literature search, in line with Arskey and O’Malley’s [ 44 ] guidance to search for evidence via different sources. CINAHL, Web of Science, SocIndex and Medline academic databases were selected with input from co-authors. Search terms for the review were based upon those used by Villaroel et al. [ 24 ] with additional relevant terms from Hannigan et al. [ 9 ] The strategy combined three sets of terms for: Migrants (e.g., refugee, migrant, immigrant or newcomer), Scotland and Health. Both free text terms and index terms were used and adapted to the 4 academic databases and searches were run on 10th March 2023 (see Additional File 1 for database search strategies). Thirteen Government, University, and third-sector websites in Scotland were scoped for selection then hand-searched for grey literature (listed in Additional File 1 ).

Stage 3: study selection

Net-migration to Scotland increased in the 2000s [ 27 ] hence a date range of January 2002-March 2023 was used to identify evidence. The search was limited to English only. Inclusion/exclusion criteria for the studies were based on those used by Villaroel et al. [ 24 ] and expanded upon following discussion with co-authors (see Table 1 ). Reports were included if based on primary or secondary research on the health of international migrants in Scotland and used qualitative, quantitative or mixed methods research design. International or UK based reports were only included if Scottish results were documented separately. Reports on the health of ethnic minority groups in Scotland was included if place of birth was recorded. Research on internal (non-international) migrants within Scotland, either moving from one Scottish area to another or from another part of the United Kingdom to Scotland, were excluded.

Stage 4: data charting

All records were saved to RefWorks for screening. Records were first screened at title/abstract stage with 10% independently checked by the co-authors. The remaining reports were single screened using full text by the first author. Data from the included records was extracted and organised in tabular form under the following headings, which were agreed by team members: article type (peer-reviewed article or grey literature), publication date, geographical setting, study/intervention’s target population, funding, primary research focus on migrant health (y/n), study objective, data collection method, study design (qualitative/quantitative/mixed) and main finding. Reports were not critically appraised in this scoping review.

Stage 5: collating, summarising and reporting results

A report (either a peer-reviewed journal article or grey literature report) is used as our unit of analysis. In order to present the range of research identified, reports were grouped by the different headings in our data charting table and the outcomes considered for relevance to our scoping review’s aim. Our Results summarise the recency, focus, study designs and funding sources of the identified research, followed by the geographical settings and whether Scotland was included in international research reports. Reports were grouped by their study population and further sub-divided by publication type and geographical area for summarising. Finally, the WHO’s European strategy and action plan (SAAP) for refugee and migrant health [ 7 ] is a policy framework designed to help governments and other stakeholders monitor and improve migrant health in Europe. There are nine strategic areas in the WHO’s SAAP, which prioritise the most salient issues. In line with Villaroel et al’s [ 24 ] approach and in order to compare scoping review outcomes, these areas were used to categorise the findings of this review. Each report was matched to the most appropriate SAAP:

Establishing a Framework for Collaborative Action.

Advocating for the right to health of refugees.

Addressing the social determinants of health.

Achieving public health preparedness and ensuring an effective response.

Strengthening health systems and their resilience.

Preventing communicable disease.

Preventing and reducing the risks caused by non-communicable disease.

Ensuring ethical and effective health screening and assessment.

Improving health information and communication.

The primary focus (aims and objectives) of each report was used to identify the relevant SAAP area/areas. To improve reliability, results were compared using coding criteria used in Villaroel et al’s study (MacFarlane 2023, personal communication, 31st May). 10% of the reports were checked by one co-author to ensure consistent coding to SAAP categories. Any instances of uncertainty in mapping reports to the relevant SAAP area/areas were discussed and resolved by team members.

This scoping review of the literature on migrant health in Scotland identified 2166 records from academic literature databases, following duplicate removal, and 170 records from website searches (see Fig. 1 ). Following screening, a total of 71 peer-reviewed journal articles and 29 grey literature studies (totalling 100 reports) were included for analysis (Results table and reference list are presented in Additional File 2 ).

Flow chart illustrating the identification of sources of evidence included in the scoping review

Overall findings

The majority of reports were published between 2013 and 2022. Fifty-eight reports (58%) focused exclusively on migrant health [ 18 , 39 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 ]. 23 centred on health but included other populations in addition to migrants – for example research on ethnic minorities or other vulnerable groups [ 13 , 31 , 35 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 ]. Seventeen reports were included where the sample population were migrants, but the primary topic was not health – for example destitution, integration, and service needs [ 27 , 73 , 74 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 ]. Health data was reported as part of the wider subject matter. One report [ 136 ] looked at the social determinants of breastfeeding including migrant status and one [ 137 ] compared attitudes to aging and family support between countries.

Funding sources were not declared for 35 (35%) of reports. The Scottish Government funded 20 reports (20%) [ 13 , 27 , 32 , 39 , 45 , 46 , 47 , 66 , 77 , 88 , 99 , 100 , 101 , 102 , 113 , 116 , 119 , 121 , 129 , 134 ]. Other common sources of funding included Government funded public bodies ( n = 13) [ 45 , 48 , 49 , 50 , 51 , 52 , 53 , 104 , 107 , 113 , 116 , 131 , 136 ], the Scottish Health Service ( n = 18) (either the National Health Service (NHS) [ 13 , 54 , 56 , 57 , 58 , 59 , 102 , 113 , 116 ], local NHS trusts [ 45 , 60 , 61 , 77 , 102 , 103 , 112 ] or by Public Health Scotland [ 13 , 113 ]) Eleven reports (11%) were funded by Universities. The charity sector financed 15 (15%) reports [ 53 , 63 , 66 , 69 , 70 , 71 , 72 , 73 , 74 , 103 , 111 , 123 , 125 , 132 , 138 ] and the EU and Scottish local authorities funded four reports each [ 45 , 62 , 75 , 76 , 77 , 102 , 125 , 135 ]. Professional bodies financed one report [ 126 ] as did the Japanese government [ 64 ]. No reports received funding from the business sector. The biggest sources of funding for grey literature were Refugee charities (40%) and the Scottish government (30%) (see Fig. 2 ).

Sources of funding for migrant health research in Scotland

Research methods and data collection

52% of reports used qualitative research methods. Forty-five reports (86%) collected data using 1–1 interviews and 24 (46%) used focus groups. Other methods of data collection included questionnaires (six studies (11%)), workshops (two studies (3.85%)) and observation (two studies (3.85%)). Oral/written evidence, guided play sessions, family case studies and participatory activity sessions were used in one report each.

28% of reports used quantitative research methods, most commonly cross section design (ten studies (36%)) and cohort design (18 studies (64%)). Information was obtained from databases including medical records, Census data and national records in 21 reports (75%). Questionnaires were used in six reports (21%). Other methods including body measurements, food diaries, blood samples, interviews and case reviews were used in 1 report each.

20% of reports used mixed methods. The most common method of data collection was questionnaires in 14 reports (70%), interviews in ten reports (50%), focus groups in seven reports (35%), workshops in three reports (13.6%), and databases in three reports (13.6%). Other methods included literature review in two reports (10%), case note reviews in two reports (10%) and one reports each used mapping and school records.

Geographical areas of study

Ninety-one reports were situated in Scotland, of which 35 (38.5%) covered the whole country and 56 (61.5%) specified a city or area where research was undertaken. Some UK and international reports also specified the area of Scotland. The largest share of research within Scotland overall was in Glasgow with 36 reports, followed by Edinburgh with 16 reports, Lothian with six reports, Aberdeen with five reports and Grampian with three reports. The Northeast, Stirling, Highlands, Inverness, Lanarkshire, Motherwell and Selkirk had one report in each area.

There were seven international reports, three on mortality by country of birth [ 75 , 76 , 78 ], one on cross cultural communication [ 79 ], one on maternity care in Poland and Scotland [ 99 ], one comparing attitudes to aging in China and Scotland [ 137 ] and one on the link between birthweights and integration of migrants [ 64 ]. The remaining two reports were UK based, one on immunisation of Roma and traveller communities [ 117 ] and one on the link between ethnic diversity and mortality [ 104 ]. All the included international and UK reports documented the Scottish data separately within results.

Migrant population

Thirty-one reports included all migrants in the study population. The remaining reports included 30 studies on asylum seekers/refugees, 11 on Polish migrants, ten on Africans, six each on South Asians/Chinese/European, three on Arabs, and two on Roma populations (see Fig. 3 ). Most reports did not specify the country of origin for Asylum seekers and refugees - where country of birth was specified, reports were also included in the appropriate category.

Migrant populations studied in health research in Scotland

Grey literature and peer-reviewed reports differed in population focus. The most common populations of interest in grey literature were asylum seekers/refugees consisting of 18 reports (62%) [ 27 , 47 , 54 , 55 , 59 , 63 , 70 , 71 , 72 , 73 , 74 , 123 , 125 , 127 , 128 , 132 , 134 , 138 ] while for peer-reviewed journals 24 reports (34%) focused on all migrants [ 13 , 35 , 45 , 48 , 64 , 76 , 78 , 79 , 80 , 81 , 104 , 105 , 108 , 109 , 113 , 114 , 115 , 116 , 118 , 120 , 121 , 122 , 136 ].

Migrant study population also differed by local area; Glasgow city, where the majority of research occurred, had 18 reports of 36 (50%) on Asylum seekers/refugees [ 47 , 48 , 52 , 53 , 54 , 55 , 58 , 63 , 70 , 71 , 72 , 82 , 83 , 127 , 128 , 130 , 138 , 139 ] eight reports (22%) on Africans [ 52 , 53 , 84 , 85 , 86 , 87 , 106 , 107 ], seven reports (19%) on all migrants [ 45 , 48 , 80 , 102 , 104 , 105 , 121 ] and two reports (5.5%) on Roma migrants [ 103 , 117 ]. Other populations had one reports each. In Edinburgh five reports of 16 (31%) were on the Polish population [ 56 , 67 , 68 , 89 , 90 ], and two reports (12.5%) on Asylum seekers/refugees [ 60 , 133 ], Chinese [ 62 , 137 ], South Asian [ 46 , 119 ], all migrants [ 105 , 121 ] and Africans [ 87 , 107 ]. The remaining migrant groups had one report each. Other areas of Scotland show no clear pattern with studies in disparate migrant population groups.

Number of reports per Strategic and Action Plan (SAAP) Area

SAAP Area mapping

1. establishing a framework for collaborative action.

Nine reports had a primary focus on collaborative action and were categorised under SAAP area 1 (see Fig. 4 ) [ 66 , 70 , 72 , 73 , 103 , 125 , 129 , 132 , 134 ]. Four reports (33%) used a mixed methods study design, the remaining five reports (67%) used a qualitative design. One report [ 66 ] focused on the epidemiology of female genital mutilation and a proposed intervention strategy. One report [ 66 ] focused on the epidemiology of female genital mutilation and a proposed intervention strategy. One report [ 103 ] evaluated service provision to the Roma community in Glasgow. The remaining reports focused on refugees and asylum seekers: four [ 73 , 125 , 132 , 134 ] evaluations of refugee integration projects, one [ 70 ] on services available to pregnant women, and one [ 72 ] an assessment of a peer-education service. One report [ 129 ] was a review of service provisions for migrants during the Covid-19 pandemic. All reports in SAAP area 1 were grey literature and three (37.5%) had a primary focus on migrant health while four (50%) focused on integration, one (11%) included data on ethnic minorities and one (11%) on services during the covid-19 pandemic. The majority (seven reports (78%)) were also categorised to another SAAP area most commonly area 2 (five studies (55%)) or area 5 (four studies (44%)).

2. Advocating for the right to health of refugees

Nineteen reports focused on SAAP area 2, advocating for the right to health of refugees (see Fig. 4 ) [ 47 , 52 , 53 , 54 , 55 , 63 , 70 , 71 , 83 , 103 , 123 , 124 , 125 , 127 , 128 , 129 , 134 , 138 , 140 ]. Sixteen reports (84%) had a qualitative study design and the remaining three (16%) reports used mixed methods. Nine reports (47%) focused on the health impact of the asylum system [ 52 , 55 , 71 , 74 , 123 , 127 , 128 , 129 , 138 ], five (26%) on health and access to care [ 47 , 54 , 83 , 103 , 124 ], two (10.5%) on maternity care [ 63 , 70 ], two (10.5%) on integration services [ 125 , 134 ] and one report on mental health in HIV positive migrants [ 53 ]. Nine reports (47%) had a primary focus on migrant health while the remaining 10 (53%) also involved wider social issues. The majority (15 (79%)) of reports were grey literature. All the articles in this group overlapped with another SAAP area. Area 3 is the most common joint category with ten reports (53%) followed by area 5 with seven reports (37%), area 1 shares five reports (26%), while areas 4 and 8 share one report each (5%).

3. Addressing the social determinants of health

Twenty-nine reports were categorised to SAAP area 3 – addressing the social determinants of health (see Fig. 4 ) [ 13 , 27 , 45 , 50 , 52 , 55 , 60 , 62 , 63 , 65 , 68 , 71 , 74 , 80 , 81 , 82 , 91 , 92 , 93 , 102 , 112 , 123 , 124 , 127 , 128 , 136 , 137 , 138 ]. The majority (14 (48%)) used a qualitative study method, eight (28%) used quantitative methodology and the remaining seven reports (24%) used mixed methods. Nineteen reports (65.5%) were peer-reviewed journals [ 13 , 45 , 50 , 52 , 60 , 62 , 63 , 65 , 68 , 80 , 81 , 82 , 91 , 92 , 93 , 104 , 112 , 124 , 136 , 137 ] and ten (34.5%) were grey literature [ 27 , 55 , 63 , 71 , 74 , 102 , 123 , 127 , 128 , 138 ]. Ten reports (34.5%) discussed the effects of the asylum system on health [ 27 , 52 , 63 , 71 , 74 , 123 , 124 , 127 , 128 , 137 ] and one (3.5%) migration and health [ 50 ]. Six reports (21%) focused on culture and ethnicity [ 82 , 92 , 102 , 104 , 112 , 137 ], five reports (17%) discussed economic and environmental determinants of health [ 13 , 45 , 67 , 81 , 93 ] and five reports (17%) the health impact of social activities [ 55 , 60 , 62 , 80 , 91 ]. Of the remaining reports, one [ 65 ] discussed Brexit and mental health of European migrants and one discussed the effect of coping strategies on wellbeing in Polish migrants [ 68 ]. Most reports, 18 (62%) had a primary focus on migrant health [ 45 , 50 , 52 , 55 , 60 , 62 , 63 , 65 , 67 , 68 , 71 , 80 , 81 , 82 , 91 , 92 , 93 , 102 ], six reports (21%) discussed wider social factors in addition to health [ 74 , 123 , 124 , 127 , 128 , 138 ]. Of the remaining reports three (10%) looked at ethnic background and country of birth [ 13 , 112 , 136 ], one [ 27 ] included other vulnerable groups and one [ 137 ] included people living in China and Chinese migrants to Scotland. Thirteen reports were also categorised to one or more additional SAAP area - ten (34%) were also applicable to area 2 [ 52 , 55 , 63 , 71 , 74 , 123 , 124 , 127 , 128 , 138 ], three (10%) to area 5 [ 63 , 82 , 92 ] and one (7%) to area 4 [ 27 ].

4. Achieving public health preparedness and ensuring an effective response

Twenty-one reports were assigned to SAAP area 4 (see Fig. 4 ) [ 27 , 31 , 35 , 39 , 47 , 57 , 64 , 75 , 76 , 77 , 78 , 94 , 104 , 108 , 109 , 111 , 113 , 114 , 116 , 120 , 135 ] of which fourteen (67%) used quantitative research methods, four (19%) mixed methods and three (14%) qualitative methods. Thirteen (62%) reports were peer-reviewed journals [ 35 , 59 , 64 , 75 , 78 , 104 , 108 , 109 , 111 , 113 , 114 , 116 , 120 ] and eight (38%) grey literature [ 27 , 31 , 39 , 47 , 57 , 77 , 94 , 135 ]. Most reports (12 (57%)) focused on morbidity and mortality in migrant populations [ 31 , 35 , 64 , 75 , 76 , 78 , 104 , 108 , 109 , 113 , 114 , 116 ]. Six (29%) investigated health status and healthcare needs in migrant groups in Scotland [ 39 , 47 , 57 , 77 , 94 , 135 ]. Two reports (9.5%) analysed the epidemiology of HIV infections [ 111 , 120 ] and the remaining report focused on the health needs of young people during the covid-19 pandemic [ 27 ]. Nine reports (43%) had a primary focus on migrant health [ 39 , 47 , 55 , 64 , 75 , 76 , 77 , 78 , 94 ] while eight (38%) also analysed data by ethnicity [ 31 , 35 , 104 , 108 , 109 , 113 , 114 , 116 ]. Of the remaining reports, three (14%) included other populations within Scotland [ 27 , 111 , 120 ] and one (5%) included other characteristics in addition to health information [ 135 ]. Ten reports (48%) were also categorised to another SAAP area; one to area 2 [ 47 ], one to area 3 [ 27 ], four to area 5 [ 47 , 57 , 77 , 135 ], two to area 6 [ 111 , 120 ] and two to area 9 [ 31 , 108 ].

5. Strengthening health systems and their resilience

Twenty-nine reports were assigned to SAAP area 5 (see Fig. 4 ) [ 18 , 47 , 48 , 49 , 54 , 57 , 63 , 69 , 70 , 72 , 77 , 79 , 82 , 83 , 92 , 95 , 96 , 97 , 99 , 101 , 103 , 118 , 119 , 126 , 129 , 131 , 133 , 135 , 141 ] of which 23 (79%) used qualitative research methods. Three reports used quantitative methods (10.3%) and the remaining three used mixed methods (10.3%). Twelve reports (41%) examined migrants needs and experiences of health care [ 47 , 49 , 54 , 57 , 58 , 77 , 83 , 95 , 103 , 119 , 129 , 135 ], eight (24%) focused on pregnancy and childcare [ 63 , 70 , 92 , 96 , 97 , 99 , 101 , 118 ] and two (7%) on barriers to healthcare access [ 48 , 131 ]. Two reports (7%) evaluated healthcare programmes [ 72 , 133 ] and two focused on communication in primary care [ 79 ] and maternity services [ 69 ]. The remaining three reports (10%) covered sexual health [ 82 ], health information needs of Syrian refugees [ 126 ] and general practitioner training [ 18 ]. Nineteen (65.5%) were peer reviewed journals [ 18 , 48 , 49 , 58 , 69 , 79 , 82 , 83 , 92 , 95 , 96 , 97 , 99 , 101 , 118 , 119 , 125 , 131 , 133 ] and ten (34.5%) were grey literature [ 47 , 54 , 57 , 63 , 70 , 72 , 77 , 103 , 129 , 135 ]. Twenty-one (72%) had a primary focus on migrant health [ 18 , 47 , 48 , 49 , 54 , 57 , 58 , 63 , 69 , 70 , 72 , 77 , 79 , 82 , 83 , 92 , 95 , 96 , 97 , 99 , 101 ]. Six reports (21%) included research on other characteristics or services [ 103 , 126 , 129 , 131 , 133 , 135 ]. The remaining two reports (7%) included ethnic groups as well as migrants in the data [ 118 , 119 ]. Nineteen reports (65.5%) were also assigned to one or more other category areas: five reports (17%) to area 1 [ 47 , 70 , 72 , 103 , 129 ], five reports (17%) to area 2 [ 54 , 63 , 83 , 103 , 129 ], three reports (10%) to area 3 [ 63 , 82 , 92 ], four reports (14%) to area 4 [ 47 , 57 , 77 , 135 ], one (3.5%) to area 7 [ 119 ] and one (3.5%) to area 9 [ 48 ].

6. Preventing communicable diseases

Fourteen reports were assigned to SAAP area 6 (see Fig. 4 ) [ 56 , 61 , 87 , 88 , 89 , 90 , 105 , 106 , 107 , 111 , 115 , 117 , 120 , 122 ] of which four (31%) used quantitative methods, five (38%) used qualitative methods and five (38%) used mixed methods. Five reports (38.5%) examined immunisation behaviour [ 56 , 61 , 89 , 90 , 117 ], five (38%) on epidemiology and treatment of HIV [ 106 , 107 , 111 , 120 , 122 ]. The remaining four reports (31%) focused on tuberculosis in healthcare workers [ 115 ], malaria [ 105 ] and sexual health services [ 87 , 88 ]. Only one reports was grey literature [ 88 ], the remainder were peer-reviewed journals. Six reports (46%) had a primary focus on migrant health [ 56 , 61 , 87 , 88 , 89 , 90 ] while seven reports (54%) also included other at-risk groups in the analysis. Four reports (31%) were also assigned to another SAAP category, two (15%) to area 4 [ 111 , 120 ] and two (15%) to area 8 [ 88 , 115 ].

7. Preventing and reducing the risks posed by non-communicable diseases

Eight reports were categorised to SAAP area 7 (see Fig. 4 ) [ 46 , 51 , 59 , 84 , 85 , 86 , 98 , 119 ] of which six (75%) used qualitative research methods, one (12.5%) used quantitative methods and one (12.5%) used mixed methods. Only one report (12.5%) was grey literature [ 59 ] the remaining seven reports (87.5%) were peer-reviewed journals [ 48 , 87 , 92 , 126 , 127 , 128 , 140 ]. Three reports (37.5%) focused on health behaviours [ 51 , 85 , 98 ], two (25%) on mental health, two (25%) on diabetes and one (12.5%) on chronic disease. Seven reports(87.5%) had a primary focus on migrant health [ 46 , 51 , 59 , 84 , 85 , 86 , 98 ], with the remaining report (12.5%) including ethnic minority groups [ 119 ]. One report (12.5%) was also assigned to SAAP area number 5 [ 119 ].

8. Ensuring ethical and effective health screening and assessment

There were six reports assigned to category 8 (see Fig. 4 ) [ 53 , 88 , 100 , 110 , 115 , 121 ] of which two (33%) used a quantitative research method, three (50%) used a qualitative method and one used mixed methods. One report (14%) was grey literature [ 88 ] the remaining five reports (83%) were peer reviewed journals [ 53 , 100 , 110 , 115 , 121 ]. Three reports (50%) focused on cancer screening in migrant women [ 21 , 100 , 110 ], one (17%) analysed access to HIV testing among African migrants [ 53 ], one (17%) on T.B in healthcare workers [ 72 ] and one (17%) on sexual health [ 36 ]. Three reports (50%) had a primary focus on migrant health [ 53 , 88 , 100 ] while the remaining three reports (50%) included other at-risk groups in the analysis [ 110 , 115 , 121 ]. There were three reports which overlapped with other SAAP areas: one [ 53 ] (17%) was categorised to area 2 while two [ 88 , 115 ] (33%) were categorised to area 6.

9. Improving health information and communication

Three reports were assigned to SAAP area 9 (see Fig. 4 ) [ 31 , 108 , 130 ]. One of these (33%) used a qualitative approach, one (33%) used a quantitative approach and one (33%) used mixed methods. Two [ 108 , 130 ] (66%) were peer-reviewed journal articles and one [ 31 ] (33%) was grey literature. Two reports (66%) focused on improving migrant demographics and health information using databases [ 31 , 108 ] while one (33%) described an information-needs matrix for refugees and asylum seekers [ 130 ]. Two [ 31 , 108 ] included ethnicities in the data while one [ 130 ] had a primary focus on migrant health. Two reports [ 31 , 108 ] (66%) also applied to SAAP area 4 while one report [ 130 ] (33%) was in SAAP area 9 only.

To our knowledge this is the first scoping review conducted on migrant health in Scotland. A previous rapid literature review [ 94 ] found most research focused on health behaviours, mental health, communicable disease and use of and access to healthcare; however, the review limited migrant definition to those who had immigrated within five years and asylum seekers were not included.

In our review, the majority of reports were published from 2013 onwards, aligning with the expansion in migrant research internationally [ 142 ]. 52% used qualitative research methods, 28% used quantitative methods and 20% used mixed methods. 58% focused on migrant health: the remaining papers included other populations or health as part of a wider remit. Research funding was mostly provided by the Scottish Government, NHS, refugee charities and Universities. No studies received funding from the private sector, although this sector has the potential resource and capacity to play a key role in funding future research to improve migrant health in Scotland. Geographically, most studies took place in Glasgow (36%), nationwide (38.5%) or Edinburgh (16%) – other areas were under-represented including Aberdeen (5%), despite being the city with the largest migrant population [ 30 ]. There was a lack of studies in rural localities. These findings concur with a UK migrant health review by Burns et al. [ 23 ] where research was concentrated in larger cities and data was sparse in rural areas relative to the migrant population.

Half of the research identified that was conducted in Glasgow focused on asylum seekers/refugees. Glasgow was previously the only Scottish city to host asylum seekers [ 143 ] and currently supports the most asylum seekers of any local authority in the UK [ 29 ]. In April 2022, the UK government widened the Asylum dispersal scheme to all local authorities [ 144 ]. Around 70% of Scotland’s refugee support services are based in Glasgow and the South-west [ 145 ]. As reduced access to services may impact the health of asylum seekers, research in Glasgow may not be generalizable to other regions of Scotland.

Almost one-third (30%) of all reports focused on asylum seekers and refugees – an overrepresentation given that only 18% of migrants to the UK are asylum seekers [ 146 ] and as low as 2% of all migrants in Scotland [ 147 ]. Asylum seekers and refugees are at risk of poor health due to trauma, difficult journeys, overcrowded camps, poor nutrition and lack of access to healthcare [ 148 ]. They have worse maternity outcomes and increased rates of mental illness [ 149 ]. Increased research on health of asylum seekers and refugees is necessary due to their additional vulnerabilities [ 142 ]. However, asylum seeker’s country of origin was generally not specified. Asylum seekers have heterogenic backgrounds [ 150 ] and nationality and trauma experience affect health status [ 151 ]. Further research focused on specific nationalities of asylum seekers would enhance understanding of the health needs in this population.

Almost one-third (31%) of studies did not specify a migrant group. This concurs with a Norwegian migrant health study by Laue et al. [ 152 ] where 36% of research did not identify country of birth. Where nationality was identified, Polish, African and South Asian were most prevalent. Poles are the largest migrant group in Scotland, however for the other most common immigrant groups of Irish, Italian and Nigerian [ 30 ] there was an absence of research. No studies took place on Nigerian migrants – nine studies indicated African populations, but country of birth was not specified. Since March 2022, 23,000 Ukrainians have migrated to Scotland [ 153 ], however no studies on Ukrainians were identified currently. Research may be underway which is yet to be published.

Only one study explored the impact of Brexit on European migrants’ health despite 56% of migrants to Scotland being EU nationals [ 30 ]. Again, research may be taking place currently, which is yet to be published. No studies involved undocumented migrants despite this populations’ high rates of poor physical/mental health exacerbated by poor housing and working conditions [ 154 ]. An estimated 7.2–9.5% of the workforce in the UK are migrant workers who have higher risks of poor working conditions and injury [ 155 ]. Scotland depends on a migrant workforce for some industries such as agriculture [ 156 ] but only two research papers specified migrant workers.

Most research papers related to the right to health of refugees (SAAP 2), social determinants of health (SAAP 3), public health planning (SAAP 4) and strengthening health systems (SAAP 5). Areas with less research were frameworks for collaborative action (SAAP 1), preventing communicable disease (SAAP 6), preventing non-communicable disease (SAAP 7) and health screening and assessment (SAAP 8). Only three studies related to improving health information and communication (SAAP 9). Lebano et al. [ 12 ] conducted a literature review of migrant health in Europe and found data collection unreliable and disorganised. There is a lack of data on the numbers and types of migrants entering Scotland and research tends not to differentiate between ethnic minorities and migrants [ 94 ]. As poor-quality information hinders surveillance and planning of services SAAP area 9 is an important consideration for increased research.

Villarroel et al. [ 24 ] also found more research in SAAP areas 3 to 5 and less in areas 6 to 9. However, their study returned no results in category 1, collaborative action, or 2, the right to health of refugees, while this study assigned 9% of articles to category 1 and 19% to category 2. Most articles in our study relating to categories 1 and 2 were grey literature, which was excluded from the original Irish scoping review. This highlights a potential difference in the focus of peer-reviewed articles compared to government/refugee charity commissioned reports. Collaborative action and the right to health of refugees and asylum seekers are entwined in Scotland due to the complex policy environment; the social determinants of health such as housing, education, welfare rights and social integration are influenced by a variety of UK and Scottish statutory bodies as well as third sector organisations [ 157 ]. Despite this complexity, organisations work well together [ 158 ]. Further academic research in this area would enhance joint working practices and networks.

A scoping review in the UK [ 23 ] found similar quantities of research corresponding to SAAP areas 3, 2 and 9. However in Scotland areas 1, 5 and 8 were a combined 44% of included papers compared with 27.8% of results on health systems and structures in Burns et al’s [ 23 ] study. Almost half of the articles in SAAP areas 1,5 and 8 were grey literature, which was not included in Burns et al’s [ 23 ] review. Conversely, Burns et al. [ 23 ] found 81.9% of research in the UK related to epidemiology, equivalent to SAAP categories 4,6 and 7. In a Norwegian scoping review of migrant health [ 152 ] 65% of research was related to epidemiological data on health and disease. Only 42% of the research in this current study related to epidemiological data; the quantity of evidence was reduced by excluding combined research from the UK. As Scotland has higher mortality and morbidity than elsewhere in the UK [ 29 ] it is important to undertake further epidemiological research limited to Scotland.

Strengths and weaknesses

Strengths of this review include the use of the WHO’s SAAP categories [ 7 ] to classify data, in accordance with the Villarroel et al’s [ 24 ] study: this means results are linked to policy on migrant health and facilitates comparability to the Irish study results. Additionally results include data on migrant groups, locality, and funding of included papers; these highlight potential omissions for future research consideration. Results include diverse research methods and published and grey literature giving a wide overview of available evidence, reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) checklist (see Additional File 3 ) [ 159 ].

Limitations included the lack of an open-access protocol and search limitations of English language and selected databases. This means some relevant reports may be omitted. Due to time and resource limitations no quality appraisal was planned for included reports. Whilst we did not synthesise the findings for each topic area and migrant group, future systematic reviews could be undertaken to address this limitation and build on this work.

Conclusions

Immigration and ethnic diversity in Scotland have increased since 2002 which is reflected in the expansion of migrant health research. This review highlights evidence gaps including a lack of research in rural areas, undocumented migrants and migrant workers. There is a tendency to cluster asylum seekers together rather than differentiate between national groups. Within the SAAP areas there is less evidence relating to collaborative action, preventing communicable disease, preventing non-communicable disease and health screening and assessment. Further research is required on improving health information and communication for migrant populations in Scotland – a significant omission given the importance of accurate information for health service planning.

Availability of data and materials

All data analysed during this review comes from the papers listed in Additional file 2 .

Abbreviations

European Union

Human Immunodeficiency Virus

National Health Service

Strategy and Action Plan

The Scottish Health and Ethnicity Linkage Study

United Kingdom

World Health Organisation

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Acknowledgements

Thank-you to Professor Anne MacFarlane and PHD student Anne Cronin, of the University of Limerick, Ireland for sharing the coding guidelines currently used in an update to Villarroel et. al’s 2019 study on Migrant Health in the Republic of Ireland.

No funding was received for this work, which was undertaken as G. Petrie’s Master of Public Health dissertation module at the University of Stirling.

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Petrie, G., Angus, K. & O’Donnell, R. A scoping review of academic and grey literature on migrant health research conducted in Scotland. BMC Public Health 24 , 1156 (2024). https://doi.org/10.1186/s12889-024-18628-1

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