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What are Literature Reviews?
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What are Systematic Reviews? (3 minutes, 24 second YouTube Video)

Systematic Literature Reviews: Steps & Resources

These steps for conducting a systematic literature review are listed below .

Also see subpages for more information about:

The different types of literature reviews, including systematic reviews and other evidence synthesis methods
Tools & Tutorials

Literature Review & Systematic Review Steps

Develop a Focused Question
Scope the Literature (Initial Search)
Refine & Expand the Search
Limit the Results
Download Citations
Abstract & Analyze
Create Flow Diagram
Synthesize & Report Results

1. Develop a Focused Question

Consider the PICO Format: Population/Problem, Intervention, Comparison, Outcome

Focus on defining the Population or Problem and Intervention (don't narrow by Comparison or Outcome just yet!)

"What are the effects of the Pilates method for patients with low back pain?"

Tools & Additional Resources:

PICO Question Help
Stillwell, Susan B., DNP, RN, CNE; Fineout-Overholt, Ellen, PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek, PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M., PhD, RN Evidence-Based Practice, Step by Step: Asking the Clinical Question, AJN The American Journal of Nursing : March 2010 - Volume 110 - Issue 3 - p 58-61 doi: 10.1097/01.NAJ.0000368959.11129.79

2. Scope the Literature

A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature.

Eligible studies may be located by searching in:

Background sources (books, point-of-care tools)
Article databases
Trial registries
Grey literature
Cited references
Reference lists

When searching, if possible, translate terms to controlled vocabulary of the database. Use text word searching when necessary.

Use Boolean operators to connect search terms:

Combine separate concepts with AND (resulting in a narrower search)
Connecting synonyms with OR (resulting in an expanded search)

Search: pilates AND ("low back pain" OR backache )

Video Tutorials - Translating PICO Questions into Search Queries

Translate Your PICO Into a Search in PubMed (YouTube, Carrie Price, 5:11)
Translate Your PICO Into a Search in CINAHL (YouTube, Carrie Price, 4:56)

3. Refine & Expand Your Search

Expand your search strategy with synonymous search terms harvested from:

database thesauri
reference lists
relevant studies

Example:

(pilates OR exercise movement techniques) AND ("low back pain" OR backache* OR sciatica OR lumbago OR spondylosis)

As you develop a final, reproducible strategy for each database, save your strategies in a:

a personal database account (e.g., MyNCBI for PubMed)
Log in with your NYU credentials
Open and "Make a Copy" to create your own tracker for your literature search strategies

4. Limit Your Results

Use database filters to limit your results based on your defined inclusion/exclusion criteria. In addition to relying on the databases' categorical filters, you may also need to manually screen results.

Limit to Article type, e.g.,: "randomized controlled trial" OR multicenter study
Limit by publication years, age groups, language, etc.

NOTE: Many databases allow you to filter to "Full Text Only". This filter is not recommended . It excludes articles if their full text is not available in that particular database (CINAHL, PubMed, etc), but if the article is relevant, it is important that you are able to read its title and abstract, regardless of 'full text' status. The full text is likely to be accessible through another source (a different database, or Interlibrary Loan).

Filters in PubMed
CINAHL Advanced Searching Tutorial

5. Download Citations

Selected citations and/or entire sets of search results can be downloaded from the database into a citation management tool. If you are conducting a systematic review that will require reporting according to PRISMA standards, a citation manager can help you keep track of the number of articles that came from each database, as well as the number of duplicate records.

In Zotero, you can create a Collection for the combined results set, and sub-collections for the results from each database you search. You can then use Zotero's 'Duplicate Items" function to find and merge duplicate records.

File structure of a Zotero library, showing a combined pooled set, and sub folders representing results from individual databases.

Citation Managers - General Guide

6. Abstract and Analyze

Migrate citations to data collection/extraction tool
Screen Title/Abstracts for inclusion/exclusion
Screen and appraise full text for relevance, methods,
Resolve disagreements by consensus

Covidence is a web-based tool that enables you to work with a team to screen titles/abstracts and full text for inclusion in your review, as well as extract data from the included studies.

Screenshot of the Covidence interface, showing Title and abstract screening phase.

Covidence Support
Critical Appraisal Tools
Data Extraction Tools

7. Create Flow Diagram

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review. It depicts the number of records identified, included and excluded. It is best used in conjunction with the PRISMA checklist .

Example PRISMA diagram showing number of records identified, duplicates removed, and records excluded.

Example from: Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46. https://doi.org/10.1007/s11892-021-01414-3

PRISMA Flow Diagram Generator (ShinyApp.io, Haddaway et al. )
PRISMA Diagram Templates (Word and PDF)
Make a copy of the file to fill out the template
Image can be downloaded as PDF, PNG, JPG, or SVG
Covidence generates a PRISMA diagram that is automatically updated as records move through the review phases

8. Synthesize & Report Results

There are a number of reporting guideline available to guide the synthesis and reporting of results in systematic literature reviews.

It is common to organize findings in a matrix, also known as a Table of Evidence (ToE).

Example of a review matrix, using Microsoft Excel, showing the results of a systematic literature review.

Reporting Guidelines for Systematic Reviews
Download a sample template of a health sciences review matrix (GoogleSheets)

Steps modified from:

Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach. Medical Education , 46 (10), 943–952.

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Literature Review Overview

What is a Literature Review? Why Are They Important?

A literature review is important because it presents the "state of the science" or accumulated knowledge on a specific topic. It summarizes, analyzes, and compares the available research, reporting study strengths and weaknesses, results, gaps in the research, conclusions, and authors’ interpretations.

Tips and techniques for conducting a literature review are described more fully in the subsequent boxes:

Literature review steps
Strategies for organizing the information for your review
Literature reviews sections
In-depth resources to assist in writing a literature review
Templates to start your review
Literature review examples

Literature Review Steps

Graphic used with permission: Torres, E. Librarian, Hawai'i Pacific University

1. Choose a topic and define your research question

Try to choose a topic of interest. You will be working with this subject for several weeks to months.
Ideas for topics can be found by scanning medical news sources (e.g MedPage Today), journals / magazines, work experiences, interesting patient cases, or family or personal health issues.
Do a bit of background reading on topic ideas to familiarize yourself with terminology and issues. Note the words and terms that are used.
Develop a focused research question using PICO(T) or other framework (FINER, SPICE, etc - there are many options) to help guide you.
Run a few sample database searches to make sure your research question is not too broad or too narrow.
If possible, discuss your topic with your professor.

2. Determine the scope of your review

The scope of your review will be determined by your professor during your program. Check your assignment requirements for parameters for the Literature Review.

How many studies will you need to include?
How many years should it cover? (usually 5-7 depending on the professor)
For the nurses, are you required to limit to nursing literature?

3. Develop a search plan

Determine which databases to search. This will depend on your topic. If you are not sure, check your program specific library website (Physician Asst / Nursing / Health Services Admin) for recommendations.
Create an initial search string using the main concepts from your research (PICO, etc) question. Include synonyms and related words connected by Boolean operators
Contact your librarian for assistance, if needed.

4. Conduct searches and find relevant literature

Keep notes as you search - tracking keywords and search strings used in each database in order to avoid wasting time duplicating a search that has already been tried
Read abstracts and write down new terms to search as you find them
Check MeSH or other subject headings listed in relevant articles for additional search terms
Scan author provided keywords if available
Check the references of relevant articles looking for other useful articles (ancestry searching)
Check articles that have cited your relevant article for more useful articles (descendancy searching). Both PubMed and CINAHL offer Cited By links
Revise the search to broaden or narrow your topic focus as you peruse the available literature
Conducting a literature search is a repetitive process. Searches can be revised and re-run multiple times during the process.
Track the citations for your relevant articles in a software citation manager such as RefWorks, Zotero, or Mendeley

5. Review the literature

Read the full articles. Do not rely solely on the abstracts. Authors frequently cannot include all results within the confines of an abstract. Exclude articles that do not address your research question.
While reading, note research findings relevant to your project and summarize. Are the findings conflicting? There are matrices available than can help with organization. See the Organizing Information box below.
Critique / evaluate the quality of the articles, and record your findings in your matrix or summary table. Tools are available to prompt you what to look for. (See Resources for Appraising a Research Study box on the HSA, Nursing , and PA guides )
You may need to revise your search and re-run it based on your findings.

6. Organize and synthesize

Compile the findings and analysis from each resource into a single narrative.
Using an outline can be helpful. Start broad, addressing the overall findings and then narrow, discussing each resource and how it relates to your question and to the other resources.
Cite as you write to keep sources organized.
Write in structured paragraphs using topic sentences and transition words to draw connections, comparisons, and contrasts.
Don't present one study after another, but rather relate one study's findings to another. Speak to how the studies are connected and how they relate to your work.

Organizing Information

Options to assist in organizing sources and information :

1. Synthesis Matrix

helps provide overview of the literature
information from individual sources is entered into a grid to enable writers to discern patterns and themes
article summary, analysis, or results
thoughts, reflections, or issues
each reference gets its own row
mind maps, concept maps, flowcharts
at top of page record PICO or research question
record major concepts / themes from literature
list concepts that branch out from major concepts underneath - keep going downward hierarchically, until most specific ideas are recorded
enclose concepts in circles and connect the concept with lines - add brief explanation as needed

3. Summary Table

information is recorded in a grid to help with recall and sorting information when writing
allows comparing and contrasting individual studies easily
purpose of study
methodology (study population, data collection tool)

Efron, S. E., & Ravid, R. (2019). Writing the literature review : A practical guide . Guilford Press.

Literature Review Sections

Lit reviews can be part of a larger paper / research study or they can be the focus of the paper
Lit reviews focus on research studies to provide evidence
New topics may not have much that has been published

* The sections included may depend on the purpose of the literature review (standalone paper or section within a research paper)

Standalone Literature Review (aka Narrative Review):

presents your topic or PICO question
includes the why of the literature review and your goals for the review.
provides background for your the topic and previews the key points
Narrative Reviews: tmay not have an explanation of methods.
include where the search was conducted (which databases) what subject terms or keywords were used, and any limits or filters that were applied and why - this will help others re-create the search
describe how studies were analyzed for inclusion or exclusion
review the purpose and answer the research question
thematically - using recurring themes in the literature
chronologically - present the development of the topic over time
methodological - compare and contrast findings based on various methodologies used to research the topic (e.g. qualitative vs quantitative, etc.)
theoretical - organized content based on various theories
provide an overview of the main points of each source then synthesize the findings into a coherent summary of the whole
present common themes among the studies
compare and contrast the various study results
interpret the results and address the implications of the findings
do the results support the original hypothesis or conflict with it
provide your own analysis and interpretation (eg. discuss the significance of findings; evaluate the strengths and weaknesses of the studies, noting any problems)
discuss common and unusual patterns and offer explanations
stay away from opinions, personal biases and unsupported recommendations
summarize the key findings and relate them back to your PICO/research question
note gaps in the research and suggest areas for further research
this section should not contain "new" information that had not been previously discussed in one of the sections above
provide a list of all the studies and other sources used in proper APA 7

Literature Review as Part of a Research Study Manuscript:

Compares the study with other research and includes how a study fills a gap in the research.
Focus on the body of the review which includes the synthesized Findings and Discussion

Literature Reviews vs Systematic Reviews

Systematic Reviews are NOT the same as a Literature Review:

Literature Reviews:

Literature reviews may or may not follow strict systematic methods to find, select, and analyze articles, but rather they selectively and broadly review the literature on a topic
Research included in a Literature Review can be "cherry-picked" and therefore, can be very subjective

Systematic Reviews:

Systemic reviews are designed to provide a comprehensive summary of the evidence for a focused research question
rigorous and strictly structured, using standardized reporting guidelines (e.g. PRISMA, see link below)
uses exhaustive, systematic searches of all relevant databases
best practice dictates search strategies are peer reviewed
uses predetermined study inclusion and exclusion criteria in order to minimize bias
aims to capture and synthesize all literature (including unpublished research - grey literature) that meet the predefined criteria on a focused topic resulting in high quality evidence

Literature Review Examples

Breastfeeding initiation and support: A literature review of what women value and the impact of early discharge (2017). Women and Birth : Journal of the Australian College of Midwives
Community-based participatory research to promote healthy diet and nutrition and prevent and control obesity among African-Americans: A literature review (2017). Journal of Racial and Ethnic Health Disparities

Vitamin D deficiency in individuals with a spinal cord injury: A literature review (2017). Spinal Cord

Resources for Writing a Literature Review

These sources have been used in developing this guide.

Resources Used on This Page

Aveyard, H. (2010). Doing a literature review in health and social care : A practical guide . McGraw-Hill Education.

Purdue Online Writing Lab. (n.d.). Writing a literature review . Purdue University. https://owl.purdue.edu/owl/research_and_citation/conducting_research/writing_a_literature_review.html

Torres, E. (2021, October 21). Nursing - graduate studies research guide: Literature review. Hawai'i Pacific University Libraries. Retrieved January 27, 2022, from https://hpu.libguides.com/c.php?g=543891&p=3727230

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1 Institute of Biomedical Research, College of Medical and Dental Sciences, School of Immunity and Infection, University of Birmingham, UK

A necessary skill for any doctor

What causes disease, which drug is best, does this patient need surgery, and what is the prognosis? Although experience helps in answering these questions, ultimately they are best answered by evidence based medicine. But how do you assess the evidence? As a medical student, and throughout your career as a doctor, critical appraisal of published literature is an important skill to develop and refine. At medical school you will repeatedly appraise published literature and write literature reviews. These activities are commonly part of a special study module, research project for an intercalated degree, or another type of essay based assignment.

Formulating a question

Literature reviews are most commonly performed to help answer a particular question. While you are at medical school, there will usually be some choice regarding the area you are going to review.

Once you have identified a subject area for review, the next step is to formulate a specific research question. This is arguably the most important step because a clear question needs to be defined from the outset, which you aim to answer by doing the review. The clearer the question, the more likely it is that the answer will be clear too. It is important to have discussions with your supervisor when formulating a research question as his or her input will be invaluable. The research question must be objective and concise because it is easier to search through the evidence with a clear question. The question also needs to be feasible. What is the point in having a question for which no published evidence exists? Your supervisor’s input will ensure you are not trying to answer an unrealistic question. Finally, is the research question clinically important? There are many research questions that may be answered, but not all of them will be relevant to clinical practice. The research question we will use as an example to work through in this article is, “What is the evidence for using angiotensin converting enzyme (ACE) inhibitors in patients with hypertension?”

Collecting the evidence

After formulating a specific research question for your literature review, the next step is to collect the evidence. Your supervisor will initially point you in the right direction by highlighting some of the more relevant papers published. Before doing the literature search it is important to agree a list of keywords with your supervisor. A source of useful keywords can be obtained by reading Cochrane reviews or other systematic reviews, such as those published in the BMJ . 1 2 A relevant Cochrane review for our research question on ACE inhibitors in hypertension is that by Heran and colleagues. 3 Appropriate keywords to search for the evidence include the words used in your research question (“angiotensin converting enzyme inhibitor,” “hypertension,” “blood pressure”), details of the types of study you are looking for (“randomised controlled trial,” “case control,” “cohort”), and the specific drugs you are interested in (that is, the various ACE inhibitors such as “ramipril,” “perindopril,” and “lisinopril”).

Once keywords have been agreed it is time to search for the evidence using the various electronic medical databases (such as PubMed, Medline, and EMBASE). PubMed is the largest of these databases and contains online information and tutorials on how to do literature searches with worked examples. Searching the databases and obtaining the articles are usually free of charge through the subscription that your university pays. Early consultation with a medical librarian is important as it will help you perform your literature search in an impartial manner, and librarians can train you to do these searches for yourself.

Literature searches can be broad or tailored to be more specific. With our example, a broad search would entail searching all articles that contain the words “blood pressure” or “ACE inhibitor.” This provides a comprehensive list of all the literature, but there are likely to be thousands of articles to review subsequently (fig 1). ⇓ In contrast, various search restrictions can be applied on the electronic databases to filter out papers that may not be relevant to your review. Figure 2 gives an example of a specific search. ⇓ The search terms used in this case were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in the English language over the last 10 years, with the search terms appearing in the title of the study only. Thus the more specific the search strategy, the more manageable the number of articles to review (fig 3), and this will save you time. ⇓ However, this method risks your not identifying all the evidence in the particular field. Striking a balance between a broad and a specific search strategy is therefore important. This will come with experience and consultation with your supervisor. It is important to note that evidence is continually becoming available on these electronic databases and therefore repeating the same search at a later date can provide new evidence relevant to your review.

Fig 1 Results from a broad literature search using the term “angiotensin converting enzyme inhibitor”

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Fig 2 Example of a specific literature search. The search terms used were “angiotensin converting enzyme inhibitor” and “hypertension.” The limits applied to this search were all randomised controlled trials carried out in humans, published in English over the past 10 years, with the search terms appearing in the title of the study only

Fig 3 Results from a specific literature search (using the search terms and limits from figure 2)

Reading the abstracts (study summary) of the articles identified in your search may help you decide whether the study is applicable for your review—for example, the work may have been carried out using an animal model rather than in humans. After excluding any inappropriate articles, you need to obtain the full articles of studies you have identified. Additional relevant articles that may not have come up in your original search can also be found by searching the reference lists of the articles you have already obtained. Once again, you may find that some articles are still not applicable for your review, and these can also be excluded at this stage. It is important to explain in your final review what criteria you used to exclude articles as well as those criteria used for inclusion.

The National Institute for Health and Clinical Excellence (NICE) publishes evidence based guidelines for the United Kingdom and therefore provides an additional resource for identifying the relevant literature in a particular field. 4 NICE critically appraises the published literature with recommendations for best clinical practice proposed and graded based on the quality of evidence available. Similarly, there are internationally published evidence based guidelines, such as those produced by the European Society of Cardiology and the American College of Chest Physicians, which can be useful when collecting the literature in a particular field. 5 6

Appraising the evidence

Once you have collected the evidence, you need to critically appraise the published material. Box 1 gives definitions of terms you will encounter when reading the literature. A brief guide of how to critically appraise a study is presented; however, it is advisable to consult the references cited for further details.

Box 1: Definitions of common terms in the literature 7

Prospective—collecting data in real time after the study is designed

Retrospective—analysis of data that have already been collected to determine associations between exposure and outcome

Hypothesis—proposed association between exposure and outcome. If presented in the negative it is called the null hypothesis

Variable—a quantity or quality that changes during the study and can be measured

Single blind—subjects are unaware of their treatment, but clinicians are aware

Double blind—both subjects and clinicians are unaware of treatment given

Placebo—a simulated medical intervention, with subjects not receiving the specific intervention or treatment being studied

Outcome measure/endpoint—clinical variable or variables measured in a study subsequently used to make conclusions about the original interventions or treatments administered

Bias—difference between reported results and true results. Many types exist (such as selection, allocation, and reporting biases)

Probability (P) value—number between 0 and 1 providing the likelihood the reported results occurred by chance. A P value of 0.05 means there is a 5% likelihood that the reported result occurred by chance

Confidence intervals—provides a range between two numbers within which one can be certain the results lie. A confidence interval of 95% means one can be 95% certain the actual results lie within the reported range

The study authors should clearly define their research question and ideally the hypothesis to be tested. If the hypothesis is presented in the negative, it is called the null hypothesis. An example of a null hypothesis is smoking does not cause lung cancer. The study is then performed to assess the significance of the exposure (smoking) on outcome (lung cancer).

A major part of the critical appraisal process is to focus on study methodology, with your key task being an assessment of the extent to which a study was susceptible to bias (the discrepancy between the reported results and the true results). It should be clear from the methods what type of study was performed (box 2).

Box 2: Different study types 7

Systematic review/meta-analysis—comprehensive review of published literature using predefined methodology. Meta-analyses combine results from various studies to give numerical data for the overall association between variables

Randomised controlled trial—random allocation of patients to one of two or more groups. Used to test a new drug or procedure

Cohort study—two or more groups followed up over a long period, with one group exposed to a certain agent (drug or environmental agent) and the other not exposed, with various outcomes compared. An example would be following up a group of smokers and a group of non-smokers with the outcome measure being the development of lung cancer

Case-control study—cases (those with a particular outcome) are matched as closely as possible (for age, sex, ethnicity) with controls (those without the particular outcome). Retrospective data analysis is performed to determine any factors associated with developing the particular outcomes

Cross sectional study—looks at a specific group of patients at a single point in time. Effectively a survey. An example is asking a group of people how many of them drink alcohol

Case report—detailed reports concerning single patients. Useful in highlighting adverse drug reactions

There are many different types of bias, which depend on the particular type of study performed, and it is important to look for these biases. Several published checklists are available that provide excellent resources to help you work through the various studies and identify sources of bias. The CONSORT statement (which stands for CONsolidated Standards Of Reporting Trials) provides a minimum set of recommendations for reporting randomised controlled trials and comprises a rigorous 25 item checklist, with variations available for other study types. 8 9 As would be expected, most (17 of 25) of the items focus on questions relating to the methods and results of the randomised trial. The remaining items relate to the title, abstract, introduction, and discussion of the study, in addition to questions on trial registration, protocol, and funding.

Jadad scoring provides a simple and validated system to assess the methodological quality of a randomised clinical trial using three questions. 10 The score ranges from zero to five, with one point given for a “yes” in each of the following questions. (1) Was the study described as randomised? (2) Was the study described as double blind? (3) Were there details of subject withdrawals, exclusions, and dropouts? A further point is given if (1) the method of randomisation was appropriate, and (2) the method of blinding was appropriate.

In addition, the Critical Appraisal Skills Programme provides excellent tools for assessing the evidence in all study types (box 2). 11 The Oxford Centre for Evidence-Based Medicine levels of evidence is yet another useful resource for assessing the methodological quality of all studies. 12

Ensure all patients have been accounted for and any exclusions, for whatever reason, are reported. Knowing the baseline demographic (age, sex, ethnicity) and clinical characteristics of the population is important. Results are usually reported as probability values or confidence intervals (box 1).

This should explain the major study findings, put the results in the context of the published literature, and attempt to account for any variations from previous work. Study limitations and sources of bias should be discussed. Authors’ conclusions should be supported by the study results and not unnecessarily extrapolated. For example, a treatment shown to be effective in animals does not necessarily mean it will work in humans.

The format for writing up the literature review usually consists of an abstract (short structured summary of the review), the introduction or background, methods, results, and discussion with conclusions. There are a number of good examples of how to structure a literature review and these can be used as an outline when writing your review. 13 14

The introduction should identify the specific research question you intend to address and briefly put this into the context of the published literature. As you have now probably realised, the methods used for the review must be clear to the reader and provide the necessary detail for someone to be able to reproduce the search. The search strategy needs to include a list of keywords used, which databases were searched, and the specific search limits or filters applied. Any grading of methodological quality, such as the CONSORT statement or Jadad scoring, must be explained in addition to any study inclusion or exclusion criteria. 6 7 8 The methods also need to include a section on the data collected from each of the studies, the specific outcomes of interest, and any statistical analysis used. The latter point is usually relevant only when performing meta-analyses.

The results section must clearly show the process of filtering down from the articles obtained from the original search to the final studies included in the review—that is, accounting for all excluded studies. A flowchart is usually best to illustrate this. Next should follow a brief description of what was done in the main studies, the number of participants, the relevant results, and any potential sources of bias. It is useful to group similar studies together as it allows comparisons to be made by the reader and saves repetition in your write-up. Boxes and figures should be used appropriately to illustrate important findings from the various studies.

Finally, in the discussion you need to consider the study findings in light of the methodological quality—that is, the extent of potential bias in each study that may have affected the study results. Using the evidence, you need to make conclusions in your review, and highlight any important gaps in the evidence base, which need to be dealt with in future studies. Working through drafts of the literature review with your supervisor will help refine your critical appraisal skills and the ability to present information concisely in a structured review article. Remember, if the work is good it may get published.

Originally published as: Student BMJ 2012;20:e404

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

↵ The Cochrane Library. www3.interscience.wiley.com/cgibin/mrwhome/106568753/HOME?CRETRY=1&SRETRY=0 .
↵ British Medical Journal . www.bmj.com/ .
↵ Heran BS, Wong MMY, Heran IK, Wright JM. Blood pressure lowering efficacy of angiotensin converting enzyme (ACE) inhibitors for primary hypertension. Cochrane Database Syst Rev 2008 ; 4 : CD003823 , doi: 10.1002/14651858.CD003823.pub2. OpenUrl PubMed
↵ National Institute for Health and Clinical Excellence. www.nice.org.uk .
↵ European Society of Cardiology. www.escardio.org/guidelines .
↵ Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed). Chest 2008 ; 133 : 381 -453S. OpenUrl CrossRef
↵ Wikipedia. http://en.wikipedia.org/wiki .
↵ Moher D, Schulz KF, Altman DG, Egger M, Davidoff F, Elbourne D, et al. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001 ; 357 : 1191 -4. OpenUrl CrossRef PubMed Web of Science
↵ The CONSORT statement. www.consort-statement.org/ .
↵ Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996 ; 17 : 1 -12. OpenUrl CrossRef PubMed Web of Science
↵ Critical Appraisal Skills Programme (CASP). www.sph.nhs.uk/what-we-do/public-health-workforce/resources/critical-appraisals-skills-programme .
↵ Oxford Centre for Evidence-based Medicine—Levels of Evidence. www.cebm.net .
↵ Van den Bruel A, Thompson MJ, Haj-Hassan T, Stevens R, Moll H, Lakhanpaul M, et al . Diagnostic value of laboratory tests in identifying serious infections in febrile children: systematic review. BMJ 2011 ; 342 : d3082 . OpenUrl Abstract / FREE Full Text
↵ Awopetu AI, Moxey P, Hinchliffe RJ, Jones KG, Thompson MM, Holt PJ. Systematic review and meta-analysis of the relationship between hospital volume and outcome for lower limb arterial surgery. Br J Surg 2010 ; 97 : 797 -803. OpenUrl CrossRef PubMed

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

What is a literature review, traditional (narrative) literature review, integrative literature review, systematic reviews, meta-analysis, scoping review.

Developing a Research Question
Selection Criteria
Database Search
Documenting Your Search
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Related Guides

Systematic Reviews by Roy Brown Last Updated Oct 17, 2023 415 views this year
Write a Literature Review by John Glover Last Updated Oct 16, 2023 2324 views this year

A literature review provides an overview of what's been written about a specific topic. There are many different types of literature reviews. They vary in terms of comprehensiveness, types of study included, and purpose.

The other pages in this guide will cover some basic steps to consider when conducting a traditional health sciences literature review. See below for a quick look at some of the more popular types of literature reviews.

For additional information on a variety of review methods, the following article provides an excellent overview.

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009 Jun;26(2):91-108. doi: 10.1111/j.1471-1842.2009.00848.x. Review. PubMed PMID: 19490148.

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Bashir Y, Conlon KC. Step by step guide to do a systematic review and meta-analysis for medical professionals. Ir J Med Sci. 2018; 187:(2)447-452 https://doi.org/10.1007/s11845-017-1663-3

Bettany-Saltikov J. How to do a systematic literature review in nursing: a step-by-step guide.Maidenhead: Open University Press; 2012

Bowers D, House A, Owens D. Getting started in health research.Oxford: Wiley-Blackwell; 2011

Hierarchies of evidence. 2016. http://cjblunt.com/hierarchies-evidence (accessed 23 July 2019)

Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2008; 3:(2)37-41 https://doi.org/10.1191/1478088706qp063oa

Developing a framework for critiquing health research. 2005. https://tinyurl.com/y3nulqms (accessed 22 July 2019)

Cognetti G, Grossi L, Lucon A, Solimini R. Information retrieval for the Cochrane systematic reviews: the case of breast cancer surgery. Ann Ist Super Sanita. 2015; 51:(1)34-39 https://doi.org/10.4415/ANN_15_01_07

Dixon-Woods M, Cavers D, Agarwal S Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006; 6:(1) https://doi.org/10.1186/1471-2288-6-35

Guyatt GH, Sackett DL, Sinclair JC Users' guides to the medical literature IX. A method for grading health care recommendations. JAMA. 1995; 274:(22)1800-1804 https://doi.org/10.1001/jama.1995.03530220066035

Hanley T, Cutts LA. What is a systematic review? Counselling Psychology Review. 2013; 28:(4)3-6

Cochrane handbook for systematic reviews of interventions. Version 5.1.0. 2011. https://handbook-5-1.cochrane.org (accessed 23 July 2019)

Jahan N, Naveed S, Zeshan M, Tahir MA. How to conduct a systematic review: a narrative literature review. Cureus. 2016; 8:(11) https://doi.org/10.7759/cureus.864

Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1997; 33:(1)159-174

Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res. 2014; 14:(1) https://doi.org/10.1186/s12913-014-0579-0

Moher D, Liberati A, Tetzlaff J, Altman DG Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009; 6:(7) https://doi.org/10.1371/journal.pmed.1000097

Mueller J, Jay C, Harper S, Davies A, Vega J, Todd C. Web use for symptom appraisal of physical health conditions: a systematic review. J Med Internet Res. 2017; 19:(6) https://doi.org/10.2196/jmir.6755

Murad MH, Asi N, Alsawas M, Alahdab F. New evidence pyramid. Evid Based Med. 2016; 21:(4)125-127 https://doi.org/10.1136/ebmed-2016-110401

National Institute for Health and Care Excellence. Methods for the development of NICE public health guidance. 2012. http://nice.org.uk/process/pmg4 (accessed 22 July 2019)

Sambunjak D, Franic M. Steps in the undertaking of a systematic review in orthopaedic surgery. Int Orthop. 2012; 36:(3)477-484 https://doi.org/10.1007/s00264-011-1460-y

Siddaway AP, Wood AM, Hedges LV. How to do a systematic review: a best practice guide for conducting and reporting narrative reviews, meta-analyses, and meta-syntheses. Annu Rev Psychol. 2019; 70:747-770 https://doi.org/0.1146/annurev-psych-010418-102803

Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008; 8:(1) https://doi.org/10.1186/1471-2288-8-45

Wallace J, Nwosu B, Clarke M. Barriers to the uptake of evidence from systematic reviews and meta-analyses: a systematic review of decision makers' perceptions. BMJ Open. 2012; 2:(5) https://doi.org/10.1136/bmjopen-2012-001220

Carrying out systematic literature reviews: an introduction

Alan Davies

Lecturer in Health Data Science, School of Health Sciences, University of Manchester, Manchester

View articles · Email Alan

Systematic reviews provide a synthesis of evidence for a specific topic of interest, summarising the results of multiple studies to aid in clinical decisions and resource allocation. They remain among the best forms of evidence, and reduce the bias inherent in other methods. A solid understanding of the systematic review process can be of benefit to nurses that carry out such reviews, and for those who make decisions based on them. An overview of the main steps involved in carrying out a systematic review is presented, including some of the common tools and frameworks utilised in this area. This should provide a good starting point for those that are considering embarking on such work, and to aid readers of such reviews in their understanding of the main review components, in order to appraise the quality of a review that may be used to inform subsequent clinical decision making.

Since their inception in the late 1970s, systematic reviews have gained influence in the health professions ( Hanley and Cutts, 2013 ). Systematic reviews and meta-analyses are considered to be the most credible and authoritative sources of evidence available ( Cognetti et al, 2015 ) and are regarded as the pinnacle of evidence in the various ‘hierarchies of evidence’. Reviews published in the Cochrane Library ( https://www.cochranelibrary.com) are widely considered to be the ‘gold’ standard. Since Guyatt et al (1995) presented a users' guide to medical literature for the Evidence-Based Medicine Working Group, various hierarchies of evidence have been proposed. Figure 1 illustrates an example.

Systematic reviews can be qualitative or quantitative. One of the criticisms levelled at hierarchies such as these is that qualitative research is often positioned towards or even is at the bottom of the pyramid, thus implying that it is of little evidential value. This may be because of traditional issues concerning the quality of some qualitative work, although it is now widely recognised that both quantitative and qualitative research methodologies have a valuable part to play in answering research questions, which is reflected by the National Institute for Health and Care Excellence (NICE) information concerning methods for developing public health guidance. The NICE (2012) guidance highlights how both qualitative and quantitative study designs can be used to answer different research questions. In a revised version of the hierarchy-of-evidence pyramid, the systematic review is considered as the lens through which the evidence is viewed, rather than being at the top of the pyramid ( Murad et al, 2016 ).

Both quantitative and qualitative research methodologies are sometimes combined in a single review. According to the Cochrane review handbook ( Higgins and Green, 2011 ), regardless of type, reviews should contain certain features, including:

Clearly stated objectives
Predefined eligibility criteria for inclusion or exclusion of studies in the review
A reproducible and clearly stated methodology
Validity assessment of included studies (eg quality, risk, bias etc).

The main stages of carrying out a systematic review are summarised in Box 1 .

Formulating the research question

Before undertaking a systemic review, a research question should first be formulated ( Bashir and Conlon, 2018 ). There are a number of tools/frameworks ( Table 1 ) to support this process, including the PICO/PICOS, PEO and SPIDER criteria ( Bowers et al, 2011 ). These frameworks are designed to help break down the question into relevant subcomponents and map them to concepts, in order to derive a formalised search criterion ( Methley et al, 2014 ). This stage is essential for finding literature relevant to the question ( Jahan et al, 2016 ).

It is advisable to first check that the review you plan to carry out has not already been undertaken. You can optionally register your review with an international register of prospective reviews called PROSPERO, although this is not essential for publication. This is done to help you and others to locate work and see what reviews have already been carried out in the same area. It also prevents needless duplication and instead encourages building on existing work ( Bashir and Conlon, 2018 ).

A study ( Methley et al, 2014 ) that compared PICO, PICOS and SPIDER in relation to sensitivity and specificity recommended that the PICO tool be used for a comprehensive search and the PICOS tool when time/resources are limited.

The use of the SPIDER tool was not recommended due to the risk of missing relevant papers. It was, however, found to increase specificity.

These tools/frameworks can help those carrying out reviews to structure research questions and define key concepts in order to efficiently identify relevant literature and summarise the main objective of the review ( Jahan et al, 2016 ). A possible research question could be: Is paracetamol of benefit to people who have just had an operation? The following examples highlight how using a framework may help to refine the question:

What form of paracetamol? (eg, oral/intravenous/suppository)
Is the dosage important?
What is the patient population? (eg, children, adults, Europeans)
What type of operation? (eg, tonsillectomy, appendectomy)
What does benefit mean? (eg, reduce post-operative pyrexia, analgesia).

An example of a more refined research question could be: Is oral paracetamol effective in reducing pain following cardiac surgery for adult patients? A number of concepts for each element will need to be specified. There will also be a number of synonyms for these concepts ( Table 2 ).

Table 2 shows an example of concepts used to define a search strategy using the PICO statement. It is easy to see even with this dummy example that there are many concepts that require mapping and much thought required to capture ‘good’ search criteria. Consideration should be given to the various terms to describe the heart, such as cardiac, cardiothoracic, myocardial, myocardium, etc, and the different names used for drugs, such as the equivalent name used for paracetamol in other countries and regions, as well as the various brand names. Defining good search criteria is an important skill that requires a lot of practice. A high-quality review gives details of the search criteria that enables the reader to understand how the authors came up with the criteria. A specific, well-defined search criterion also aids in the reproducibility of a review.

Search criteria

Before the search for papers and other documents can begin it is important to explicitly define the eligibility criteria to determine whether a source is relevant to the review ( Hanley and Cutts, 2013 ). There are a number of database sources that are searched for medical/health literature including those shown in Table 3 .

The various databases can be searched using common Boolean operators to combine or exclude search terms (ie AND, OR, NOT) ( Figure 2 ).

Although most literature databases use similar operators, it is necessary to view the individual database guides, because there are key differences between some of them. Table 4 details some of the common operators and wildcards used in the databases for searching. When developing a search criteria, it is a good idea to check concepts against synonyms, as well as abbreviations, acronyms and plural and singular variations ( Cognetti et al, 2015 ). Reading some key papers in the area and paying attention to the key words they use and other terms used in the abstract, and looking through the reference lists/bibliographies of papers, can also help to ensure that you incorporate relevant terms. Medical Subject Headings (MeSH) that are used by the National Library of Medicine (NLM) ( https://www.nlm.nih.gov/mesh/meshhome.html) to provide hierarchical biomedical index terms for NLM databases (Medline and PubMed) should also be explored and included in relevant search strategies.

Searching the ‘grey literature’ is also an important factor in reducing publication bias. It is often the case that only studies with positive results and statistical significance are published. This creates a certain bias inherent in the published literature. This bias can, to some degree, be mitigated by the inclusion of results from the so-called grey literature, including unpublished work, abstracts, conference proceedings and PhD theses ( Higgins and Green, 2011 ; Bettany-Saltikov, 2012 ; Cognetti et al, 2015 ). Biases in a systematic review can lead to overestimating or underestimating the results ( Jahan et al, 2016 ).

An example search strategy from a published review looking at web use for the appraisal of physical health conditions can be seen in Box 2 . High-quality reviews usually detail which databases were searched and the number of items retrieved from each.

A balance between high recall and high precision is often required in order to produce the best results. An oversensitive search, or one prone to including too much noise, can mean missing important studies or producing too many search results ( Cognetti et al, 2015 ). Following a search, the exported citations can be added to citation management software (such as Mendeley or Endnote) and duplicates removed.

Title and abstract screening

Initial screening begins with the title and abstracts of articles being read and included or excluded from the review based on their relevance. This is usually carried out by at least two researchers to reduce bias ( Bashir and Conlon, 2018 ). After screening any discrepancies in agreement should be resolved by discussion, or by an additional researcher casting the deciding vote ( Bashir and Conlon, 2018 ). Statistics for inter-rater reliability exist and can be reported, such as percentage of agreement or Cohen's kappa ( Box 3 ) for two reviewers and Fleiss' kappa for more than two reviewers. Agreement can depend on the background and knowledge of the researchers and the clarity of the inclusion and exclusion criteria. This highlights the importance of providing clear, well-defined criteria for inclusion that are easy for other researchers to follow.

Full-text review

Following title and abstract screening, the remaining articles/sources are screened in the same way, but this time the full texts are read in their entirety and included or excluded based on their relevance. Reasons for exclusion are usually recorded and reported. Extraction of the specific details of the studies can begin once the final set of papers is determined.

Data extraction

At this stage, the full-text papers are read and compared against the inclusion criteria of the review. Data extraction sheets are forms that are created to extract specific data about a study (12 Jahan et al, 2016 ) and ensure that data are extracted in a uniform and structured manner. Extraction sheets can differ between quantitative and qualitative reviews. For quantitative reviews they normally include details of the study's population, design, sample size, intervention, comparisons and outcomes ( Bettany-Saltikov, 2012 ; Mueller et al, 2017 ).

Quality appraisal

The quality of the studies used in the review should also be appraised. Caldwell et al (2005) discussed the need for a health research evaluation framework that could be used to evaluate both qualitative and quantitative work. The framework produced uses features common to both research methodologies, as well as those that differ ( Caldwell et al, 2005 ; Dixon-Woods et al, 2006 ). Figure 3 details the research critique framework. Other quality appraisal methods do exist, such as those presented in Box 4 . Quality appraisal can also be used to weight the evidence from studies. For example, more emphasis can be placed on the results of large randomised controlled trials (RCT) than one with a small sample size. The quality of a review can also be used as a factor for exclusion and can be specified in inclusion/exclusion criteria. Quality appraisal is an important step that needs to be undertaken before conclusions about the body of evidence can be made ( Sambunjak and Franic, 2012 ). It is also important to note that there is a difference between the quality of the research carried out in the studies and the quality of how those studies were reported ( Sambunjak and Franic, 2012 ).

The quality appraisal is different for qualitative and quantitative studies. With quantitative studies this usually focuses on their internal and external validity, such as how well the study has been designed and analysed, and the generalisability of its findings. Qualitative work, on the other hand, is often evaluated in terms of trustworthiness and authenticity, as well as how transferable the findings may be ( Bettany-Saltikov, 2012 ; Bashir and Conlon, 2018 ; Siddaway et al, 2019 ).

Reporting a review (the PRISMA statement)

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) provides a reporting structure for systematic reviews/meta-analysis, and consists of a checklist and diagram ( Figure 4 ). The stages of identifying potential papers/sources, screening by title and abstract, determining eligibility and final inclusion are detailed with the number of articles included/excluded at each stage. PRISMA diagrams are often included in systematic reviews to detail the number of papers included at each of the four main stages (identification, screening, eligibility and inclusion) of the review.

Data synthesis

The combined results of the screened studies can be analysed qualitatively by grouping them together under themes and subthemes, often referred to as meta-synthesis or meta-ethnography ( Siddaway et al, 2019 ). Sometimes this is not done and a summary of the literature found is presented instead. When the findings are synthesised, they are usually grouped into themes that were derived by noting commonality among the studies included. Inductive (bottom-up) thematic analysis is frequently used for such purposes and works by identifying themes (essentially repeating patterns) in the data, and can include a set of higher-level and related subthemes (Braun and Clarke, 2012). Thomas and Harden (2008) provide examples of the use of thematic synthesis in systematic reviews, and there is an excellent introduction to thematic analysis by Braun and Clarke (2012).

The results of the review should contain details on the search strategy used (including search terms), the databases searched (and the number of items retrieved), summaries of the studies included and an overall synthesis of the results ( Bettany-Saltikov, 2012 ). Finally, conclusions should be made about the results and the limitations of the studies included ( Jahan et al, 2016 ). Another method for synthesising data in a systematic review is a meta-analysis.

Limitations of systematic reviews

Apart from the many advantages and benefits to carrying out systematic reviews highlighted throughout this article, there remain a number of disadvantages. These include the fact that not all stages of the review process are followed rigorously or even at all in some cases. This can lead to poor quality reviews that are difficult or impossible to replicate. There also exist some barriers to the use of evidence produced by reviews, including ( Wallace et al, 2012 ):

Lack of awareness and familiarity with reviews
Lack of access
Lack of direct usefulness/applicability.

Meta-analysis

When the methods used and the analysis are similar or the same, such as in some RCTs, the results can be synthesised using a statistical approach called meta-analysis and presented using summary visualisations such as forest plots (or blobbograms) ( Figure 5 ). This can be done only if the results can be combined in a meaningful way.

Meta-analysis can be carried out using common statistical and data science software, such as the cross-platform ‘R’ ( https://www.r-project.org), or by using standalone software, such as Review Manager (RevMan) produced by the Cochrane community ( https://tinyurl.com/revman-5), which is currently developing a cross-platform version RevMan Web.

Carrying out a systematic review is a time-consuming process, that on average takes between 6 and 18 months and requires skill from those involved. Ideally, several reviewers will work on a review to reduce bias. Experts such as librarians should be consulted and included where possible in review teams to leverage their expertise.

Systematic reviews should present the state of the art (most recent/up-to-date developments) concerning a specific topic and aim to be systematic and reproducible. Reproducibility is aided by transparent reporting of the various stages of a review using reporting frameworks such as PRISMA for standardisation. A high-quality review should present a summary of a specific topic to a high standard upon which other professionals can base subsequent care decisions that increase the quality of evidence-based clinical practice.

Systematic reviews remain one of the most trusted sources of high-quality information from which to make clinical decisions
Understanding the components of a review will help practitioners to better assess their quality
Many formal frameworks exist to help structure and report reviews, the use of which is recommended for reproducibility
Experts such as librarians can be included in the review team to help with the review process and improve its quality

CPD reflective questions

Where should high-quality qualitative research sit regarding the hierarchies of evidence?
What background and expertise should those conducting a systematic review have, and who should ideally be included in the team?
Consider to what extent inter-rater agreement is important in the screening process

The Sheridan Libraries

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How to Access Full Text
Background Information
Books, E-books, Dissertations
Articles, News, Who Cited This, More
Google Scholar and Google Books
PUBMED and EMBASE
Statistics -- United States
Statistics -- Worldwide
Avoiding Plagiarism
Citing Sources This link opens in a new window
Copyright This link opens in a new window
Evaluating Information This link opens in a new window
RefWorks Guide and Help This link opens in a new window
Epidemic Proportions
Environment and Your Health, AS 280.335, Spring 2024
Honors in Public Health, AS280.495, Fall 23-Spr 2024
Intro to Public Health, AS280.101, Spring 2024
Research Methods in Public Health, AS280.240, Spring 2024
Social+Behavioral Determinants of Health, AS280.355, Spring 2024
Feedback (for class use only)

Literature Reviews

Organizing/Synthesizing
Peer Review
Ulrich's -- One More Way To Find Peer-reviewed Papers

"Literature review," "systematic literature review," "integrative literature review" -- these are terms used in different disciplines for basically the same thing -- a rigorous examination of the scholarly literature about a topic (at different levels of rigor, and with some different emphases).

1. Our library's guide to Writing a Literature Review

2. Other helpful sites

Writing Center at UNC (Chapel Hill) -- A very good guide about lit reviews and how to write them
Literature Review: Synthesizing Multiple Sources (LSU, June 2011 but good; PDF) -- Planning, writing, and tips for revising your paper

3. Welch Library's list of the types of expert reviews

Doing a good job of organizing your information makes writing about it a lot easier.

You can organize your sources using a citation manager, such as refworks , or use a matrix (if you only have a few references):.

Use Google Sheets, Word, Excel, or whatever you prefer to create a table
The column headings should include the citation information, and the main points that you want to track, as shown

Synthesizing your information is not just summarizing it. Here are processes and examples about how to combine your sources into a good piece of writing:

Purdue OWL's Synthesizing Sources
Synthesizing Sources (California State University, Northridge)

Annotated Bibliography

An "annotation" is a note or comment. An "annotated bibliography" is a "list of citations to books, articles, and [other items]. Each citation is followed by a brief...descriptive and evaluative paragraph, [whose purpose is] to inform the reader of the relevance, accuracy, and quality of the sources cited."*

Sage Research Methods (database) --> Empirical Research and Writing (ebook) -- Chapter 3: Doing Pre-research
Purdue's OWL (Online Writing Lab) includes definitions and samples of annotations
Cornell's guide * to writing annotated bibliographies

* Thank you to Olin Library Reference, Research & Learning Services, Cornell University Library, Ithaca, NY, USA https://guides.library.cornell.edu/annotatedbibliography

What does "peer-reviewed" mean?

If an article has been peer-reviewed before being published, it means that the article has been read by other people in the same field of study ("peers").
The author's reviewers have commented on the article, not only noting typos and possible errors, but also giving a judgment about whether or not the article should be published by the journal to which it was submitted.

How do I find "peer-reviewed" materials?

Most of the the research articles in scholarly journals are peer-reviewed.
Many databases allow you to check a box that says "peer-reviewed," or to see which results in your list of results are from peer-reviewed sources. Some of the databases that provide this are Academic Search Ultimate, CINAHL, PsycINFO, and Sociological Abstracts.

What kinds of materials are not peer-reviewed?

open web pages
most newspapers, newsletters, and news items in journals
letters to the editor
press releases
columns and blogs
book reviews
anything in a popular magazine (e.g., Time, Newsweek, Glamour, Men's Health)

If a piece of information wasn't peer-reviewed, does that mean that I can't trust it at all?

No; sometimes you can. For example, the preprints submitted to well-known sites such as arXiv (mainly covering physics) and CiteSeerX (mainly covering computer science) are probably trustworthy, as are the databases and web pages produced by entities such as the National Library of Medicine, the Smithsonian Institution, and the American Cancer Society.

Is this paper peer-reviewed? Ulrichsweb will tell you.

1) On the library home page , choose "Articles and Databases" --> "Databases" --> Ulrichsweb

2) Put in the title of the JOURNAL (not the article), in quotation marks so all the words are next to each other

3) Mouse over the black icon, and you'll see that it means "refereed" (which means peer-reviewed, because it's been looked at by referees or reviewers). This journal is not peer-reviewed, because none of the formats have a black icon next to it:

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Searching the public health & medical literature more effectively: literature review help.

Getting Started
Articles: Searching PubMed This link opens in a new window
More Sources: Databases, Systematic Reviews, Grey Literature
Organize Citations & Search Strategies
Literature Review Help
Need More Help?

Writing Guides, Manuals, etc.

Literature Review Tips Handouts

Write about something you are passionate about!

About Literature Reviews (pdf)
Literature Review Workflow (pdf)
Search Tips/Search Operators
Quick Article Evaluation Worksheet (docx)
Tips for the Literature Review Workflow
Sample Outline for a Literature Review (docx)

Ten simple rules for writing a literature review . Pautasso M. PLoS Comput Biol. 2013;9(7):e1003149. doi:10.1371/journal.pcbi.1003149

Conducting the Literature Search . Chapter 4 of Chasan-Taber L. Writing Dissertation and Grant Proposals: Epidemiology, Preventive Medicine and Biostatistics. New York: Chapman and Hall/CRC, 2014.

A step-by-step guide to writing a research paper, from idea to full manuscript . Excellent and easy to follow blog post by Dr. Raul Pacheco-Vega.

Data Extraction

Data extraction answers the question “what do the studies tell us?”

At a minimum, consider the following when extracting data from the studies you are reviewing ( source ):

Only use the data elements relevant to your question;
Use a table, form, or tool (such as Covidence ) for data extraction;
Test your methods and tool for missing data elements, redundancy, consistency, clarity.

Here is a table of data elements to consider for your data extraction. (From University of York, Centre for Reviews and Dissemination).

Critical Reading

As you read articles, write notes. You may wish to create a table, answering these questions:

What is the hypothesis?
What is the method? Rigorous? Appropriate sample size? Results support conclusions?
What are the key findings?
How does this paper support/contradict other work?
How does it support/contradict your own approach?
How significant is this research? What is its special contribution?
Is this research repeating existing approaches or making a new contribution?
What are its strengths?
What are its weaknesses/limitations?

From: Kearns, H. & Finn, J. (2017) Supervising PhD Students: A Practical Guide and Toolkit . AU: Thinkwell, p. 103.

Submitting to a Journal? First Identify Journals That Publish on Your Topic

Through Scopus

Visit the Scopus database.
Search for recent articles on your research topic.
Above the results, click “Analyze search results."
Click in the "Documents per year by source" box.
On the left you will see the results listed by the number of articles published on your research topic per journal.

Through Web of Science

Visit the Web of Science database.
In the results, click "Analyze Results" on the right hand side.
From the drop-down menu near the top left, choose "Publication Titles."
Change the "Minimum record count (threshold)," if desired.
Scroll down for a table of results by journal title.
JANE (Journal/Author Name Estimator) Use JANE to help you discover and decide where to publish an article you have authored. Jane matches the abstract of your article to the articles in Medline to find the best matching journals (or authors, or articles).
Jot (Journal Targeter) Jot uses Jane and other data to determine journals likely to publish your article (based on title, abstract, references) against the impact metric of those journals. From Yale University.
EndNote Manuscript Matcher Using algorithms and data from the Web of Science and Journal Citation Reports, Manuscript Matcher identifies the most relevant and impactful journals to which one may wish to submit a manuscript. Access Manuscript Matcher via EndNote X9 or EndNote 20.
DOAJ (Directory of Open Access Journals) Journal Lookup Look up a journal title on DOAJ and find information on publication fees, aims and scope, instructions for authors, submission to publication time, copyright, and more.

Writing Help @UCB

Here is a short list of sources of writing help available to UC Berkeley students, staff, and faculty:

Purdue OWL Excellent collection of guides on writing, including citing/attribution, citation styles, grammar and punctuation, academic writing, and much more.
Berkeley Writing: College Writing Programs "Our philosophy includes small class size, careful attention to building your critical reading and thinking skills along with your writing, personalized attention, and a great deal of practice writing and revising." Website has a Writing Resources Database .
Graduate Writing Center, Berkeley Graduate Division Assists graduate students in the development of academic skills necessary to successfully complete their programs and prepare for future positions. Workshops and online consultations are offered on topics such as academic writing, grant writing, dissertation writing , thesis writing , editing, and preparing articles for publication, in addition to writing groups and individual consultations.
Nature Masterclass on Scientific Writing and Publishing For Postdocs, Visiting Scholars, and Visiting Student Researchers with active, approved appointments, and current UC Berkeley graduate students who are new to publishing or wish to refresh their skills. Part 1: Writing a Research Paper; Part 2: Publishing a Research Paper; Part 3: Writing and Publishing a Review Paper. Offered by Visiting Researcher Scholar and Postdoc Affairs (VSPA) program; complete this form to gain access.

Alternative Publishing Formats

Here is some information and tips on getting your research to a broader, or to a specialized, audience

Creating One-Page Reports One-page reports are a great way to provide a snapshot of a project’s activities and impact to stakeholders. Summarizing key facts in a format that is easily and quickly digestible engages the busy reader and can make your project stand out. From EvaluATE .
How to write an Op-ed (Webinar) Strategies on how to write sharp op-eds for broader consumption, one of the most important ways to ensure your analysis and research is shared in the public sphere. From the Institute for Research on Public Policy .
10 tips for commentary writers From UC Berkeley Media Relations’ 2017 Op-Ed writing workshop.
Journal of Science Policy and Governance JSPG publishes policy memos, op-eds, position papers, and similar items created by students.
Writing Persuasive Policy Briefs Presentation slides from a UCB Science Policy Group session.
3 Essential Steps to Share Research With Popular Audiences (Inside Higher Ed) How to broaden the reach and increase the impact of your academic writing. Popular writing isn’t a distraction from core research!

The Politics of Citation

"One of the feminist practices key to my teaching and research is a feminist practice of citation."

From The Digital Feminist Collective , this blog post emphasizes the power of citing.

"Acknowledging and establishing feminist genealogies is part of the work of producing more just forms of knowledge and intellectual practice."

Here's an exercise (docx) to help you in determining how inclusive you are when citing.

Additional Resources for Inclusive Citation Practices :

BIPOC Scientists Citation guide (Rockefeller Univ.).
Conducting Research through an Anti-Racism Lens (Univ. of Minnesota Libraries).
cleanBib (Code to probabilistically assign gender and race proportions of first/last authors pairs in bibliography entries).
Balanced Citer (Python script guesses the race and gender of the first and last authors for papers in your citation list and compares your list to expected distributions based on a model that accounts for paper characteristics).
Read Black women's work;
Integrate Black women into the CORE of your syllabus (in life & in the classroom);
Acknowledge Black women's intellectual production;
Make space for Black women to speak;
Give Black women the space and time to breathe.
CiteASista .
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Last Updated: Apr 25, 2024 2:35 PM
URL: https://guides.lib.berkeley.edu/publichealth/litsearch

University of Houston Libraries

Literature Reviews in the Health Sciences
Review Comparison Chart
Decision Tools
Systematic Review
Meta-Analysis
Scoping Review
Mapping Review
Integrative Review
Rapid Review
Realist Review
Umbrella Review
Review of Complex Interventions
Diagnostic Test Accuracy Review
Narrative Literature Reviews
Standards and Guidelines

Navigate the links below to jump to a specific section of the page:

When is a Scoping Review methodology appropriate?

Outline of stages, methods and guidance, examples of scoping reviews, supplementary resources.

According to Colquhoun et al. (2014) , a scoping review can be defined as: "a form of knowledge synthesis, which incorporate a range of study designs to comprehensively summarize and synthesize evidence with the aim of informing practice, programs, and policy and providing direction to future research priorities" (p.1291).

Characteristics

Answers a broad question
Scoping reviews serve the purpose of identifying the scope and extent of existing research on a topic
Similar to systematic reviews, scoping reviews follow a step-by-step process and aim to be transparent and replicable in its methods

When to Use It: A scoping review might be right for you if you are interested in:

Examining the extent, range, and nature of research activity
Determining the value of undertaking a full systematic review (e.g. Do any studies exist? Have systematic reviews already been conducted?)
Summarizing the disseminating research findings
Identifying gaps in an existing body of literature

The following stages of conducting a review of complex interventions are derived from Peters et al. (2015) and Levac et al. (2010) .

Timeframe: 12+ months, (same amount of time as a systematic review or longer)

*Varies beyond the type of review. Depends on many factors such as but not limited to: resources available, the quantity and quality of the literature, and the expertise or experience of reviewers" ( Grant & Booth, 2009 ).

Question: Answers broader and topic focused questions beyond those relating to the effectiveness of treatments or interventions. A priori review protocol is recommended.

Is your review question a complex intervention? Learn more about Reviews of Complex Interventions .

Sources and searches: Comprehensive search-may be limited by time/scope restraints, still aims to be thorough and repeatable of all literature. May involve multiple structured searches rather than a single structured search. This will produce more results than a systematic review. Must include a modified PRISMA flow diagram.

Selection: Based on inclusion/exclusion criteria, due to the iterative nature of a scoping review some changes may be necessary. May require more time spent screening articles due to the larger volume of results from broader questions.

Appraisal: Critical appraisal (optional), Risk of Bias assessment (optional) is not applicable for scoping reviews.

Synthesis: (Tabular with some narrative) The extraction of data for a scoping review may include a charting table or form but a formal synthesis of findings from individual studies and the generation of a 'summary of findings' (SOF) table is not required. Results may include a logical diagram or table or any descriptive form that aligns with the scope and objectives of the review. May incorporate a numerical summary and qualitative thematic analysis.

Consultation: (optional)

The following resources provide methods and guidance in the field of scoping reviews.

Methods & Guidance

Cochrane Training: Scoping reviews: what they are and how you can do them A series of videos presented by Dr Andrea C. Tricco and Kafayat Oboirien. Learn the about what a scoping review is, see examples, learn the steps involved, and common methods from Dr. Tricco. Oboirien presents her experiences of conducting a scoping review on strengthening clinical governance in low and middle income countries.
Current Best Practices for the Conduct of Scoping Reviews by Heather Colquhoun An overview on best practices when executing a scoping review.
Joanna Briggs Institute (JBI) Manual for Evidence Synthesis. Chapter 11: Scoping Reviews An extensive and detailed outline within the JBI Manual for Evidence Synthesis on how to properly conduct a scoping review.

Reporting Guideline

PRISMA for Scoping Reviews (PRISMA-ScR) Contains a 20-item checklist for proper reporting of a scoping review plus 2 optional items.
Håkonsen, S. J., Pedersen, P. U., Bjerrum, M., Bygholm, A., & Peters, M. (2018). Nursing minimum data sets for documenting nutritional care for adults in primary healthcare: a scoping review . JBI database of systematic reviews and implementation reports , 16 (1), 117–139. doi: 10.11124/JBISRIR-2017-003386
Kao, S. S., Peters, M., Dharmawardana, N., Stew, B., & Ooi, E. H. (2017). Scoping review of pediatric tonsillectomy quality of life assessment instruments . The Laryngoscope , 127 (10), 2399–2406. doi: 10.1002/lary.26522
Tricco, A. C., Zarin, W., Rios, P., Nincic, V., Khan, P. A., Ghassemi, M., Diaz, S., Pham, B., Straus, S. E., & Langlois, E. V. (2018). Engaging policy-makers, health system managers, and policy analysts in the knowledge synthesis process: a scoping review . Implementation science: IS , 13 (1), 31. doi: 10.1186/s13012-018-0717-x

Anderson, S., Allen, P., Peckham, S., & Goodwin, N. (2008). Asking the right questions: scoping studies in the commissioning of research on the organisation and delivery of health services . Health research policy and systems , 6 , 7. doi: 10.1186/1478-4505-6-7

Arksey, H., & O'Malley, L. (2005). Scoping studies: towards a methodological framework . International journal of social research methodology, 8 (1), 19-32. doi: 10.1080/1364557032000119616

Armstrong, R., Hall, B. J., Doyle, J., & Waters, E. (2011). Cochrane Update. 'Scoping the scope' of a cochrane review . Journal of public health (Oxford, England) , 33 (1), 147–150. doi: 10.1093/pubmed/fdr015

Colquhoun, H. (2016). Current best practices for the conducting of scoping reviews . Symposium Presentation - Impactful Biomedical Research: Achieving Quality and Transparency . https://www.equator-network.org/wp-content/uploads/2016/06/Gerstein-Library-scoping-reviews_May-12.pdf

Colquhoun, H. L., Levac, D., O'Brien, K. K., Straus, S., Tricco, A. C., Perrier, L., Kastner, M., & Moher, D. (2014). Scoping reviews: time for clarity in definition, methods, and reporting . Journal of clinical epidemiology , 67 (12), 1291–1294. doi: 10.1016/j.jclinepi.2014.03.013

Davis, K., Drey, N., & Gould, D. (2009). What are scoping studies? A review of the nursing literature . International journal of nursing studies , 46 (10), 1386–1400. doi: 10.1016/j.ijnurstu.2009.02.010

Khalil, H., Peters, M., Godfrey, C. M., McInerney, P., Soares, C. B., & Parker, D. (2016). An evidence-based approach to scoping reviews . Worldviews on evidence-based nursing , 13 (2), 118–123. doi: 10.1111/wvn.12144

Levac, D., Colquhoun, H., & O'Brien, K. K. (2010). Scoping studies: advancing the methodology . Implementation science: IS , 5 , 69. doi: 10.1186/1748-5908-5-69

Lockwood, C., Dos Santos, K. B., & Pap, R. (2019). Practical guidance for knowledge synthesis: scoping review methods . Asian nursing research , 13 (5), 287–294. doi: 10.1016/j.anr.2019.11.002

Morris, M., Boruff, J. T., & Gore, G. C. (2016). Scoping reviews: establishing the role of the librarian . Journal of the Medical Library Association: JMLA , 104 (4), 346–354. doi: 10.3163/1536-5050.104.4.020

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

O'Brien, K. K., Colquhoun, H., Levac, D., Baxter, L., Tricco, A. C., Straus, S., Wickerson, L., Nayar, A., Moher, D., & O'Malley, L. (2016). Advancing scoping study methodology: a web-based survey and consultation of perceptions on terminology, definition and methodological steps . BMC health services research , 16 , 305. doi: 10.1186/s12913-016-1579-z

Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015). Guidance for conducting systematic scoping reviews . International journal of evidence-based healthcare , 13 (3), 141–146. doi: 10.1097/XEB.0000000000000050

Peters, M. D. J., Godfrey, C., McInerney, P., Munn, Z., Tricco, A. C., & Khalil, H. (2020). Chapter 11: Scoping Reviews . In Aromataris, E. & Munn, Z. (Eds.), JBI Manual for Evidence Synthesis . Joanna Briggs Institute. doi: 10.46658/JBIMES-20-12

Peters, M., Marnie, C., Tricco, A. C., Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey, C. M., & Khalil, H. (2021). Updated methodological guidance for the conduct of scoping reviews . JBI evidence implementation , 19 (1), 3–10. doi: 10.1097/XEB.0000000000000277

Pham, M. T., Rajić, A., Greig, J. D., Sargeant, J. M., Papadopoulos, A., & McEwen, S. A. (2014). A scoping review of scoping reviews: advancing the approach and enhancing the consistency . Research synthesis methods , 5 (4), 371–385. doi: 10.1002/jrsm.1123

Tricco, A. C., Lillie, E., Zarin, W., O'Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., Lewin, S., … Straus, S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation . Annals of internal medicine , 169 (7), 467–473. doi: 10.7326/M18-0850

Tricco, A., Oboirien, K., Lotfi, T., & Sambunjak, D. (2017, August). Scoping reviews: what they are and how you can do them . Cochrane Training. https://training.cochrane.org/resource/scoping-reviews-what-they-are-and-how-you-can-do-them

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Next: Mapping Review >>

Other Names for a Scoping Review

Scoping Study
Systematic Scoping Review
Scoping Report
Scope of the Evidence
Rapid Scoping Review
Structured Literature Review
Scoping Project
Scoping Meta Review

Limitations of a Scoping Review

The following challenges of conducting a scoping review are derived from Grant & Booth (2009) , Peters et al. (2015) , and O'Brien (2016) .

Is not easier than a systematic review.
Is not faster than a systematic review; may take longer .
More citations to screen.
Different screening criteria/process than a systematic review.
Often leads to a broader, less defined search.
Requires multiple structured searches instead of one.
Increased emphasis for hand searching the literature.
May require larger teams because of larger volume of literature.
Inconsistency in the conduct of scoping reviews.

Medical Librarian

Last Updated: Sep 5, 2023 11:14 AM
URL: https://guides.lib.uh.edu/reviews

Open access
Published: 12 October 2020

A systematic literature review of researchers’ and healthcare professionals’ attitudes towards the secondary use and sharing of health administrative and clinical trial data

Elizabeth Hutchings ORCID: orcid.org/0000-0002-6030-954X 1 ,
Max Loomes ORCID: orcid.org/0000-0003-1042-0968 2 ,
Phyllis Butow ORCID: orcid.org/0000-0003-3562-6954 2 , 3 , 4 &
Frances M. Boyle ORCID: orcid.org/0000-0003-3798-1570 1 , 5

Systematic Reviews volume 9 , Article number: 240 ( 2020 ) Cite this article

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A systematic literature review of researchers and healthcare professionals’ attitudes towards the secondary use and sharing of health administrative and clinical trial data was conducted using electronic data searching. Eligible articles included those reporting qualitative or quantitative original research and published in English. No restrictions were placed on publication dates, study design, or disease setting. Two authors were involved in all stages of the review process; conflicts were resolved by consensus. Data was extracted independently using a pre-piloted data extraction template. Quality and bias were assessed using the QualSyst criteria for qualitative studies. Eighteen eligible articles were identified, and articles were categorised into four key themes: barriers, facilitators, access, and ownership; 14 subthemes were identified. While respondents were generally supportive of data sharing, concerns were expressed about access to data, data storage infrastructure, and consent. Perceptions of data ownership and acknowledgement, trust, and policy frameworks influenced sharing practice, as did age, discipline, professional focus, and world region. Young researchers were less willing to share data; they were willing to share in circumstances where they were acknowledged. While there is a general consensus that increased data sharing in health is beneficial to the wider scientific community, substantial barriers remain.

Systematic review registration

PROSPERO CRD42018110559

Peer Review reports

Healthcare systems generate large amounts of data; approximately 80 mB of data are generated per patient per year [ 1 ]. It is projected that this figure will continue to grow with an increasing reliance on technologies and diagnostic capabilities. Healthcare data provides an opportunity for secondary data analysis with the capacity to greatly influence medical research, service planning, and health policy.

There are many forms of data collected in the healthcare setting including administrative and clinical trial data which are the focus of this review. Administrative data collected during patients’ care in the primary, secondary, and tertiary settings can be analysed to identify systemic issues and service gaps, and used to inform improved health resourcing. Clinical trials play an essential role in furthering our understanding of disease, advancing new therapeutics, and developing improved supportive care interventions. However, clinical trials are expensive and can take several years to complete; a frequently quoted figure is that it takes 17 years for 14% of clinical research to benefit the patient [ 2 , 3 ].

Those who argue for increased data sharing in healthcare suggest that it may lead to improved treatment decisions based on all available information [ 4 , 5 ], improved identification of causes and clinical manifestations of disease [ 6 ], and provide increased research transparency [ 7 ]. In rare diseases, secondary data analysis may greatly accelerate the medical community’s understanding of the disease’s pathology and influence treatment.

Internationally, there are signs of movement towards greater transparency, particularly with regard to clinical research data. This change has been driven by governments [ 8 ], peak bodies [ 9 ], and clinician led initiatives [ 5 ]. One initiative led by the International Council of Medical Journal Editors (ICMJE) now requires a data sharing plan for all clinical research submitted for publication in a member scientific journal [ 9 ]. Further, international examples of data sharing can be seen in projects such as The Cancer Genome Atlas (TCGA) [ 10 ] dataset and the Surveillance, Epidemiology, and End Results (SEER) [ 11 ] database which have been used extensively for cancer research.

However, consent, data ownership, privacy, intellectual property rights, and potential for misinterpretation of data [ 12 ] remain areas of concern to individuals who are more circumspect about changing the data sharing norm. To date, there has been no published synthesis of views on data sharing from the perspectives of diverse professional stakeholders. Thus, we conducted a systematic review of the literature on the views of researchers and healthcare professionals regarding the sharing of health data.

This systematic literature review was part of a larger review of articles addressing data sharing, undertaken in accordance with the PRISMA statement for systematic reviews and meta-analysis [ 13 ]. The protocol was prospectively registered on PROSPERO ( www.crd.york.ac.uk /PROSPERO, CRD42018110559).

The following databases were searched: EMBASE/MEDLINE, Cochrane Library, PubMed, CINAHL, Informit Health Collection, PROSPERO Database of Systematic Reviews, PsycINFO, and ProQuest. The final search was conducted on 21 October 2018. No date restrictions were placed on the search; key search terms are listed in Table 1 . Papers were considered eligible if they: were published in English; were published in a peer review journal; reported original research, either qualitative or quantitative with any study design, related to data sharing in any disease setting; and included subjects over 18 years of age. Systematic literature reviews were included in the wider search but were not included in the results. Reference list and hand searching were undertaken to identify additional papers. Papers were considered ineligible if they focused on electronic health records, biobanking, or personal health records or were review articles, opinion pieces/articles/letters, editorials, or theses from masters or doctoral research. Duplicates were removed and title and abstract and full-text screening were undertaken using the Cochrane systematic literature review program Covidence [ 14 ]. Two authors were involved in all stages of the review process; conflicts were resolved by consensus.

Quality and bias were assessed at a study level using the QualSyst system for quantitative and qualitative studies as described by Kmet et al. [ 15 ]. A maximum score of 20 is assigned to articles of high quality and low bias; the final QualSyst score is a proportion of the total, with a possible score ranging from 0.0 to 1.0 [ 15 ].

Data extraction was undertaken using a pre-piloted form in Microsoft Office Excel. Data points included author, country and year of study, study design and methodology, health setting, and key themes and results. Where available, detailed information on research participants was extracted including age, sex, clinical/academic employment setting, publication and grant history, career stage, and world region.

Quantitative data were summarised using descriptive statistics. Synthesis of qualitative findings used a meta-ethnographic approach, in accordance with guidelines from Lockwood et al. [ 16 ].The main themes of each qualitative study were first identified and then combined, if relevant, into categories of commonality. Using a constant comparative approach, higher order themes and subthemes were developed. Quantitative data relevant to each theme were then incorporated. Using a framework analysis approach as described by Gale et al. [ 17 ], the perspectives of different professional groups (researchers, healthcare professionals, data custodians, and ethics committees) towards data sharing were identified. Where differences occurred, they are highlighted in the results. Similarly, where systematic differences according to other characteristics (such as age or years of experience), these are highlighted.

This search identified 4019 articles, of which 241 underwent full-text screening; 73 articles met the inclusion criteria for the larger review. Five systematic literature reviews were excluded as was one article which presented duplicate results; this left a total of 67 articles eligible for review. See Fig. 1 for the PRISMA diagram describing study screening.

PRIMSA flow diagram (attached)

This systematic literature review was originally developed to identify attitudes towards secondary use and sharing of health administrative and clinical trial data in breast cancer. However, as there was a paucity of material identified specifically related to this group, we present the multidisciplinary results of this search, and where possible highlight results specific to breast cancer, and cancer more generally. We believe that the material identified in this search is relevant and reflective of the wider attitudes towards data sharing within the scientific and medical communities and can be used to inform data sharing strategies in breast cancer.

Eighteen [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ] of the 67 articles addressed the perspectives of clinical and scientific researchers, data custodians, and ethics committees and were analysed for this paper (Table 2 ). The majority ( n = 16) of articles focused on the views of researchers and health professionals, [ 18 , 19 , 20 , 21 , 22 , 24 , 25 , 26 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ], only one article focused on data custodians [ 27 ] and ethics committees [ 23 ] respectively. Four articles [ 18 , 19 , 21 , 35 ] included a discussion on the attitudes of both researchers and healthcare professionals and patients; only results relating to researchers/clinicians are included in this analysis (Fig. 1 ).

Study design, location, and disciplines

Several study methodologies were used, including surveys ( n = 11) [ 24 , 25 , 26 , 27 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ], interviews and focus groups ( n = 6) [ 18 , 19 , 20 , 21 , 22 , 23 ], and mixed methods ( n = 1) [ 28 ]. Studies were conducted in a several countries and regions; a breakdown by country and study is available in Table 3 .

In addition to papers focusing on general health and sciences [ 18 , 21 , 22 , 24 , 25 , 26 , 29 , 30 , 31 , 32 , 33 , 34 ], two articles included views from both science and non-science disciplines [ 27 , 28 ]. Multiple sclerosis (MS) [ 19 ], mental health [ 35 ], and human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)/tuberculosis (TB) [ 20 ] were each the subject of one article.

Study quality

Results of the quality assessment are provided in Table 2 . QualSyst [15] scores ranged from 0.7 to 1.0 (possible range 0.0 to 1.0). While none were blinded studies, most provided clear information on respondent selection, data analysis methods, and justifiable study design and methodology.

Four key themes, barriers, facilitators, access, and ownership were identified; 14 subthemes were identified. A graphical representation of article themes is presented in Fig. 2 . Two articles reflect the perspective of research ethics committees [ 23 ] and data custodians [ 27 ]; concerns noted by these groups are similar to those highlighted by researchers and healthcare professionals.

Graphic representation of key themes and subthemes identified (attached)

Barriers and facilitators

Reasons for not sharing.

Eleven articles identified barriers to data sharing [ 20 , 22 , 24 , 25 , 27 , 29 , 30 , 31 , 32 , 33 , 34 ]. Concerns cited by respondents included other researchers taking their results [ 24 , 25 ], having data misinterpreted or misattributed [ 24 , 27 , 31 , 32 ], loss of opportunities to maximise intellectual property [ 24 , 25 , 27 ], and loss of publication opportunities [ 24 , 25 ] or funding [ 25 ]. Results of a qualitative study showed respondents emphasised the competitive value of research data and its capacity to advance an individual’s career [ 20 ] and the potential for competitive disadvantage with data sharing [ 22 ]. Systematic issues related to increased data sharing were noted in several articles where it was suggested the barriers are ‘deeply rooted in the practices and culture of the research process as well as the researchers themselves’ [ 33 ] (p. 1), and that scientific competition and a lack of incentive in academia to share data remain barriers to increased sharing [ 30 ].

Insufficient time, lack of funding, limited storage infrastructure, and lack of procedural standards were also noted as barriers [ 33 ]. Quantitative results demonstrated that the researchers did not have the right to make the data public or that there was no requirement to share by the study sponsor [ 33 ]. Maintaining the balance between investigator and funder interests and the protection of research subjects [ 31 ] were also cited as barriers. Concerns about privacy were noted in four articles [ 25 , 27 , 29 , 30 ]; one study indicated that clinical researchers were significantly more concerned with issues of privacy compared to scientific researchers [ 25 ]. The results of one qualitative study indicated that clinicians were more cautious than patients regarding the inclusion of personal information in a disease specific registry; the authors suggest this may be a result of potential for legal challenges in the setting of a lack of explicit consent and consistent guidelines [ 19 ]. Researchers, particularly clinical staff, indicated that they did not see sharing data in a repository as relevant to their work [ 29 ]

Trust was also identified as a barrier to greater data sharing [ 32 ]. Rathi et al. identified that researchers were likely to withhold data if they mistrusted the intent of the researcher requesting the information [ 32 ]. Ethical, moral, and legal issues were other potential barriers cited [ 19 , 22 ]. In one quantitative study, 74% of respondents ( N = 317) indicated that ensuring appropriate data use was a concern; other concerns included data not being appropriate for the requested purpose [ 32 ]. Concerns about data quality were also cited as a barrier to data reuse; some respondents suggested that there was a perceived negative association of data reuse among health scientists [ 30 ].

Reasons for sharing

Eleven articles [ 19 , 20 , 21 , 22 , 24 , 25 , 29 , 30 , 31 , 32 , 33 ] discussed the reasons identified by researchers and healthcare professionals for sharing health data; broadly the principle of data sharing was seen as a desirable norm [ 25 , 31 ]. Cited benefits included improvements to the delivery of care, communication and receipt of information, impacts on care and quality of life [ 19 ], contributing to the advancement of science [ 20 , 24 , 29 ], validating scientific outputs, reducing duplication of scientific effort and minimising research costs [ 20 ], and promoting open science [ 31 , 32 ]. Professional reasons for sharing data included academic benefit and recognition, networking and collaborative opportunities [ 20 , 24 , 29 , 31 ], and contributing to the visibility of their research [ 24 ]. Several articles noted the potential of shared data for enabling faster access to a wider pool of patients [ 21 ] for research, improved access to population data for longitudinal studies [ 22 ], and increased responsiveness to public health needs [ 20 ]. In one study, a small percentage of respondents indicated that there were no benefits from sharing their data [ 24 ].

Analysis of quantitative survey data indicated that the perceived usefulness of data was most strongly associated with reuse intention [ 30 ]. The lack of access to data generated by other researchers or institutions was seen as a major impediment to progress in science [ 33 ]. In a second study, quantitative data showed no significant differences in reasons for sharing by clinical trialists’ academic productivity, geographic location, trial funding source or size, or the journal in which the results were published [ 32 ]. Attitudes towards sharing in order to receive academic benefits or recognition differed significantly based on the respondent’s geographic location; those from Western Europe were more willing to share compared to respondents in the USA or Canada, and the rest of the world [ 32 ].

Views on sharing

Seven articles [ 19 , 20 , 21 , 29 , 31 , 33 , 34 ] discussed researchers’ and healthcare professionals’ views relating to sharing data, with a broad range of views noted. Two articles, both qualitative, discussed the role of national registries [ 21 ], and data repositories [ 31 ]. Generally, there was clear support for national research registers and an acceptance for their rationale [ 21 ], and some respondents believed that sharing de-identified data through data repositories should be required and that when requested, investigators should share data [ 31 ]. Sharing de-identified data for reasons beyond academic and public health benefit were cited as a concern [ 20 ]. Two quantitative studies noted a proportion of researchers who believed that data should not be made available [ 33 , 34 ]. Researchers also expressed differences in how shared data should be managed; the requirement for data to be ‘gate-kept’ was preferred by some, while others were happy to relinquish control of their data once curated or on release [ 20 ]. Quantitative results indicated that scientists were significantly more likely to rank data reuse as highly relevant to their work than clinicians [ 29 ], but not all scientists shared data equally or had the same views about data sharing or reuse [ 33 ]. Some respondents argued that not all data were equal and therefore should only be shared in certain circumstances. This was in direct contrast to other respondents who suggested that all data should be shared, all of the time [ 20 ].

Differences by age, background, discipline, professional focus, and world region

Differences in attitudes towards shared data were noted by age, professional focus, and world region [ 25 , 27 , 33 , 34 ]. Younger researchers, aged between 20–39 and 40–49 years, were less likely to share their data with others (39% and 38% respectively) compared to other age groups; respondents aged over 50 years of age were more willing (46%) to share [ 33 ]. Interestingly, while less willing to share, younger researchers also believed that the lack of access to data was a major impediment to science and their research [ 33 ]. Where younger researchers were able to place conditions on access to their data, rates of willingness to share were increased [ 33 ].

Respondents from the disciplines of education, medicine/health science, and psychology were more inclined than others to agree that their data should not be available for others to use in the first place [ 34 ]. However, results from one study indicated that researchers from the medical field and social sciences were less likely to share compared to other disciplines [ 33 ]. For example, results of a quantitative study showed that compared to biologists, who reported sharing 85% of their data, medical and social sciences reported sharing their data 65% and 58% percent of the time, respectively [ 33 ].

One of the primary reasons for controlling access to data, identified in a study of data custodians, was due to a desire to avoid data misuse; this was cited as a factor for all surveyed data repositories except those of an interdisciplinary nature [ 27 ]. Limiting access to certain types of research and ensuring attribution were not listed as a concern for sociology, humanities or interdisciplinary data collections [ 27 ]. Issues pertaining to privacy and sensitive data were only cited as concerns for data collections related to humanities, social sciences, and biology, ecology, and chemistry; concerns regarding intellectual property were also noted [ 27 ]. The disciplines of biology, ecology, and chemistry and social sciences had the most policy restrictions on the use of data held in their repositories [ 27 ].

Differences in data sharing practices were also noted by world region. Respondents not from North American and European countries were more willing to place their data on a central repository; however, they were also more likely to place conditions on the reuse of their data [ 33 , 34 ].

Experience of data sharing

The experience of data sharing among researchers was discussed in nine articles [ 20 , 24 , 25 , 26 , 28 , 29 , 30 , 31 , 32 , 33 ]. Data sharing arrangements were highly individual and ranged from ad hoc and informal processes to formal procedures enforced by institutional policies in the form of contractual agreements, with respondents indicating data sharing behaviour ranging from sharing no data to sharing all data [ 20 , 26 , 31 ]. Quantitative data from one study showed that researchers were more inclined to share data prior to publication with people that they knew compared to those they did not; post publication, these figures were similar between groups [ 24 ]. While many researchers were prepared to share data, results of a survey identified a preference of researchers to collect data themselves, followed by their team, or by close colleagues [ 26 ].

Differences in the stated rate of data sharing compared to the actual rate of sharing [ 25 ] were noted. In a large quantitative study ( N = 1329), nearly one third of respondents chose not to answer whether they make their data available to others; of those who responded to the question, 46% reported they do not make their data electronically available to others [ 33 ]. By discipline, differences in the rate of refusal to share were higher in chemistry compared to non-science disciplines such as sociology [ 25 ]. Respondents who were more academically productive (> 25 articles over the past 3 years) reported that they have or would withhold data to protect research subjects less frequently than those who were less academically productive or received industry funding [ 32 ].

Attitudes to sharing de-identified data via data repositories was discussed in two articles [ 29 , 31 ]. A majority of respondents in one study indicated that de-identified data should be shared via a repository and that it should be shared when requested. A lack of experience in uploading data to repositories was noted as a barrier [ 29 ]. When data was shared, most researchers included additional materials to support their data including materials such as metadata or a protocol description [ 29 ].

Two articles [ 28 , 30 ] focused on processes and variables associated with sharing. Factors such as norms, data infrastructure/organisational support, and research communities were identified as important factors in a researcher’s attitude towards data sharing [ 28 , 30 ]. A moderate correlation between data reuse and data sharing suggest that these two variables are not linked. Furthermore, sharing data compared to self-reported data reuse were also only moderately associated (Pearson’s correlation of 0.25 ( p ≤ 0.001)) [ 26 ].

Predictors of data sharing and norms

Two articles [ 26 , 30 ] discussed the role of social norms and an individual’s willingness to share health data. Perceived efficacy and efficiency of data reuse were strong predictors of data sharing [ 26 ] and the development of a ‘positive social norm towards data sharing support(s)[ed] researcher data reuse intention’ [ 30 ] (p. 400).

Policy framework

The establishment of clear policies and procedures to support data sharing was highlighted in two articles [ 22 , 28 ]. The presence of ambiguous data sharing policies was noted as a major limitation, particularly in primary care and the increased adoption of health informatics systems [ 22 ]. Policies that support an efficient exchange system allowing for the maximum amount of data sharing are preferred and may include incentives such as formal recognition and financial reimbursement; a framework for this is proposed in Fecher et al. [ 28 ].

Research funding

The requirement to share data funded by public monies was discussed in one article [ 25 ]. Some cases were reported of researchers refusing to share data funded by tax-payer funds; reasons for refusal included a potential reduction in future funding or publishing opportunities [ 25 ].

Access and ownership

Articles relating to access and ownership were grouped together and seven subthemes were identified.

Access, information systems, and metadata

Ten articles [ 19 , 20 , 21 , 22 , 26 , 27 , 29 , 33 , 34 , 35 ] discussed the themes of access, information systems, and the use of metadata. Ensuring privacy protections in a prospective manner was seen as important for data held in registries [ 19 ]. In the setting of mental health, researchers indicated that patients should have more choices for controlling access to shared registry data [ 35 ]. The use of guardianship committees [ 19 ] or gate-keepers [ 20 ] was seen as important in ensuring the security and access to data held in registries by some respondents; however, many suggested that a researcher should relinquish control of the data collection once curated or released, unless embargoed [ 20 ]. Reasons for maintaining control over registry data included ensuring attribution, restricting commercial research, protecting sensitive (non-personal) information, and limiting certain types of research [ 27 ]. Concerns about security and confidentiality were noted as important and assurances about these needed to be provided; accountability and transparency mechanisms also need to be included [ 21 ]. Many respondents believed that access to the registry data by pharmaceutical companies and marketing agencies was not considered appropriate [ 19 ].

Respondents to a survey from medicine and social sciences were less likely to agree to have all data included on a central repository with no restrictions [ 33 ]; notably, this was also reflected in the results of qualitative research which indicated that health professionals were more cautious than patients about the inclusion of personal data within a disease specific register [ 19 ].

While many researchers stated that they commonly shared data directly with other researchers, most did not have experience with uploading data to repositories [ 29 ]. Results from a survey indicated that younger respondents have more data access restrictions and thought that their data is easier to access significantly more than older respondents [ 34 ]. In the primary care setting, concerns were noted about the potential for practitioners to block patient involvement in a registry by refusing access to a patient’s personal data or by not giving permission for the data to be extracted from their clinical system [ 21 ]. There was also resistance in primary care towards health data amalgamation undertaken for an unspecified purpose [ 22 ]; respondents were not in favour of systems which included unwanted functionality (do not want/need), inadequate attributes (capability and receptivity) of the practice, or undesirable impact on the role of the general practitioner (autonomy, status, control, and workflow) [ 22 ].

Access to ‘comprehensive metadata (is needed) to support the correct interpretation of the data’ [ 26 ] (p. 4) at a later stage. When additional materials were shared, most researchers shared contextualising information or a description of the experimental protocol [ 29 ]. The use of metadata standards was not universal with some respondents using their own [ 33 ].

Several articles highlighted the impact of data curation on researchers’ time [ 20 , 21 , 22 , 29 , 33 ] or finances [ 24 , 28 , 29 , 33 , 34 ]; these were seen as potential barriers to increased registry adoption [ 21 ]. Tasks required for curation included preparing data for dissemination in a usable format and uploading data to repositories. The importance of ensuring that the data is accurately preserved for future reuse was highlighted; it must be presented in a retriable and auditable manner [ 20 ]. The amount of time required to curate data ranged from ‘no additional time’ to ‘greater than ten hours’ [ 29 ]. In one study, no clinical respondent had their data in a sharable format [ 29 ]. In the primary care setting, health information systems which promote sharing were not seen as being beneficial if they required standardisation of processes and/or sharing of clinical notes [ 22 ]. Further, spending time on non-medical issues in a time poor environment [ 22 ] was identified as a barrier. Six articles described the provision of funding or technical support to ensure data storage, maintenance, and the ability to provide access to data when requested. All noted a lack of funding and time as a barrier to increased sharing data [ 20 , 24 , 28 , 29 , 33 , 34 ].

Results of qualitative research indicated a range of views regarding consent mechanisms for future data use [ 18 , 19 , 20 , 23 , 35 ]. Consenting for future research can be complex given that the exact nature of the study will be unknown, and therefore some respondents suggested that a broad statement on future data uses be included [ 19 , 20 ] during the consent process. In contrast, other participants indicated that the current consent processes were too broad and do not reflect patient preferences sufficiently [ 35 ]. The importance of respecting the original consent in all future research was noted [ 20 ]. It was suggested that seeking additional consent for future data use may discourage participation in the original study [ 20 ]. Differences in views regarding the provision of detailed information about sharing individual level data was noted suggesting that the researchers wanted to exert some control over data they had collected [ 20 ]. An opt-out consent process was considered appropriate in some situations [ 18 ] but not all; some respondents suggested that consent to use a patient’s medical records was not required [ 18 ]. There was support by some researchers to provide patients with the option to ‘opt-in’ to different levels of involvement in a registry setting [ 19 ]. Providing patients more granular choices when controlling access to their medical data [ 35 ] was seen as important.

The attitudes of ethics and review boards ( N = 30) towards the use of medical records for research was discussed in one article [ 23 ]. While 38% indicated that no further consent would be required, 47% required participant consent, and 10% said that the requirement for consent would depend on how the potentially identifying variables would be managed [ 23 ]. External researcher access to medical record data was associated with a requirement for consent [ 23 ].

Acknowledgement

The importance of establishing mechanisms which acknowledge the use of shared data were discussed in four articles [ 27 , 29 , 33 , 34 ]. A significant proportion of respondents to a survey believed it was fair to use other researchers’ data if they acknowledged the originator and the funding body in all disseminated work or as a formal citation in published works [ 33 ]. Other mechanisms for acknowledging the data originator included opportunities to collaborate on the project, reciprocal data sharing agreements, allowing the originator to review or comment on results, but not approve derivative works, or the provision of a list of products making use of the data and co-authorship [ 33 , 34 ]. In the setting of controlled data collections, survey results indicated that ensuring attribution was a motivator for controlled access [ 27 ]. Over half of respondents in one survey believed it was fair to disseminate results based either in whole or part without the data provider’s approval [ 33 ]. No significant differences in mechanisms for acknowledgement were noted between clinical and scientific participants; mechanisms included co-authorship, recognition in the acknowledgement section of publications, and citation in the bibliography [ 29 ]. No consentient method for acknowledging shared data reuse was identified [ 29 ].

Data ownership was identified as a potential barrier to increased data sharing in academic research [ 28 ]. In the setting of control of data collections, survey respondents indicated that they wanted to maintain some control over the dataset, which is suggestive of researchers having a perceived ownership of their research data [ 28 ]. Examples of researchers extending ownership over their data include the right to publish first and the control of access to datasets [ 28 ]. Fecher et al. noted that the idea of data ownership by the researcher is not a position always supported legally; ‘the ownership and rights of use, privacy, contractual consent and copyright’ are subsumed [ 28 ] (p. 15). Rather data sharing is restricted by privacy law, which is applied to datasets containing data from individuals. The legal uncertainty about data ownership and the complexity of law can deter data sharing [ 28 ].

Promotion/professional criteria

The role of data sharing and its relation to promotion and professional criteria were discussed in two articles [ 24 , 28 ]. The requirement to share data is rarely a promotion or professional criterion, rather the systems are based on grants and publication history [ 24 , 28 ]. One study noted that while the traditional link between publication history and promotion remains, it is ‘likely that funders will continue to get sub-optimal returns on their investments, and that data will continue to be inefficiently utilised and disseminated’ [ 24 ] (p. 49).

This systematic literature review highlights the ongoing complexity associated with increasing data sharing across the sciences. No additional literature meeting the inclusion criteria were identified in the period between the data search and the submission of this manuscript. Data gaps identified include a paucity of information specifically related to the attitudes of breast cancer researchers and health professionals towards the secondary use and sharing of health administrative and clinical trial data.

While the majority of respondents believed the principles of data sharing were sound, significant barriers remain: issues of consent, privacy, information security, and ownership were key themes throughout the literature. Data ownership and acknowledgement, trust, and policy frameworks influenced sharing practice, as did age, discipline, professional focus, and world region.

Addressing concerns of privacy, trust, and information security in a technologically changing and challenging landscape is complex. Ensuring the balance between privacy and sharing data for the greater good will require the formation of policy and procedures, which promote both these ideals.

Establishing clear consent mechanisms would provide greater clarity for all parties involved in the data sharing debate. Ensuring that appropriate consent for future research, including secondary data analysis and sharing and linking of datasets, is gained at the point of data collection, would continue to promote research transparency and provide healthcare professionals and researchers with knowledge that an individual is aware that their data may be used for other research purposes. The establishment of policy which supports and promotes the secondary use of data and data sharing will assist in the normalisation of this type of health research. With the increased promotion of data sharing and secondary data analysis as an established tool in health research, over time barriers to its use, including perceptions of ownership and concerns regarding privacy and consent, will decrease.

The importance of establishing clear and formal processes associated with acknowledging the use of shared data has been underscored in the results presented. Initiatives such as the Bioresource Research Impact Factor/Framework (BRIF) [ 36 ] and the Citation of BioResources in journal Articles (CoBRA) [ 37 ] have sought to formalise the process. However, increased academic recognition of sharing data for secondary analysis requires further development and the allocation of funding to ensure that collected data is in a usable, searchable, and retrievable format. Further, there needs to be a shift away from the traditional criteria of academic promotion, which includes research outputs, to one which is inclusive of a researcher’s data sharing history and the availability of their research dataset for secondary analysis.

The capacity to identify and use already collected data was identified as a barrier. Moves to make data findable, accessible, interoperable, and reusable (FAIR) have been promoted as a means to encourage greater accessibility to data in a systematic way [ 38 ]. The FAIR principles focus on data characteristics and should be interpreted alongside the collective benefit, authority to control, responsibility, and ethics (CARE) principles established by the Global Indigenous Data Alliance (GIDA) which a people and purpose orientated [ 39 ].

Limitations

The papers included in this study were limited to those indexed on major databases. Some literature on this topic may have been excluded if it was not identified during the grey literature and hand searching phases.

Implications

Results of this systematic literature review indicate that while there is broad agreement for the principles of data sharing in medical research, there remain disagreements about the infrastructure and procedures associated with the data sharing process. Additional work is therefore required on areas such as acknowledgement, curation, and data ownership.

While the literature confirms that there is overall support for data sharing in medical and scientific research, there remain significant barriers to its uptake. These include concerns about privacy, consent, information security, and data ownership.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

Bioresource Research Impact Factor/Framework

Collective benefit, authority to control, responsibility, and ethics

Citation of BioResources in journal Articles

Findable, accessible, interoperable, and reusable

Global Indigenous Data Alliance

Human immunodeficiency virus/acquired immunodeficiency

International Council of Medical Journal Editors

Multiple sclerosis

Surveillance, Epidemiology, and End Results

Tuberculosis

The Cancer Genome Atlas

Huesch MD, Mosher TJ. Using it or losing it? The case for data scientists inside health care. NEJM Catalyst. 2017.

Green LW. Closing the chasm between research and practice: evidence of and for change. Health Promot J Australia. 2014;25(1):25–9.

Article Google Scholar

Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510–20.

Article PubMed PubMed Central Google Scholar

Goldacre B. Are clinical trial data shared sufficiently today? No. Br Med J. 2013;347:f1880.

Goldacre B, Gray J. OpenTrials: towards a collaborative open database of all available information on all clinical trials. Trials. 2016;17(1):164.

Kostkova P, Brewer H, de Lusignan S, Fottrell E, Goldacre B, Hart G, et al. Who owns the data? Open data for healthcare. Front Public Health. 2016;4.

Elliott M. Seeing through the lies: innovation and the need for transparency. Gresham College Lecture Series; 23 November 2016; Museum of London. 2016.

European Medicines Agency. Publication and access to clinical-trial data. London: European Medicines Agency; 2013.

Google Scholar

Taichman DB, Backus J, Baethge C, Bauchner H, de Leeuw PW, Drazen JM, et al. Sharing clinical trial data: a proposal from the International Committee of Medical Journal Editors. J Am Med Assoc. 2016;315(5):467–8.

Article CAS Google Scholar

National Institue of Health (NIH). The Cancer Genome Atlas (TCGA): program overview United States of America: National Institue of Health (NIH); 2019 [Available from: https://cancergenome.nih.gov/abouttcga/overview ].

National Institue of Health (NIH). Surveillance, Epidemiology, and End Results (SEER) Program Washington: The Government of United States of Ameica; 2019 [Available from: https://seer.cancer.gov ].

Castellani J. Are clinical trial data shared sufficiently today? Yes. Br Med J. 2013;347:f1881.

Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097–e.

Veritas Health Innovation. Covidence systematic review software. Melbourne: Cochrane Collaboration; 2018.

Kmet LM, Cook LS, Lee RC. Standard quality assessment criteria for evaluating primary research papers from a variety of fields; 2004.

Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation. Int J Evidence Based Healthcare. 2015;13(3):179–87.

Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13(1):117.

Asai A, Ohnishi M, Nishigaki E, Sekimoto M, Fukuhara S, Fukui T. Attitudes of the Japanese public and doctors towards use of archived information and samples without informed consent: preliminary findings based on focus group interviews. BMC Medical Ethics. 2002;3(1):1.

Article PubMed Central Google Scholar

Baird W, Jackson R, Ford H, Evangelou N, Busby M, Bull P, et al. Holding personal information in a disease-specific register: the perspectives of people with multiple sclerosis and professionals on consent and access. J Med Ethics. 2009;35(2):92–6.

Article CAS PubMed Google Scholar

Denny SG, Silaigwana B, Wassenaar D, Bull S, Parker M. Developing ethical practices for public health research data sharing in South Africa: the views and experiences from a diverse sample of research stakeholders. J Empiric Res Human Res Ethics. 2015;10(3):290–301.

Grant A, Ure J, Nicolson DJ, Hanley J, Sheikh A, McKinstry B, et al. Acceptability and perceived barriers and facilitators to creating a national research register to enable 'direct to patient' enrolment into research: the Scottish Health Research register (SHARE). BMC Health Serv Res. 2013;13(1):422.

Knight J, Patrickson M, Gurd B. Understanding GP attitudes towards a data amalgamating health informatics system. Electron J Health Inform. 2008;3(2):12.

Willison DJ, Emerson C, Szala-Meneok KV, Gibson E, Schwartz L, Weisbaum KM, et al. Access to medical records for research purposes: varying perceptions across research ethics boards. J Med Ethics. 2008;34(4):308–14.

Bezuidenhout L, Chakauya E. Hidden concerns of sharing research data by low/middle-income country scientists. Glob Bioethics. 2018;29(1):39–54.

Ceci SJ. Scientists' attitudes toward data sharing. Sci Technol Human Values. 1988;13(1-2):45–52.

Curty RG, Crowston K, Specht A, Grant BW, Dalton ED. Attitudes and norms affecting scientists’ data reuse. PLoS One. 2017;12(12):e0189288.

Article PubMed PubMed Central CAS Google Scholar

Eschenfelder K, Johnson A. The limits of sharing: controlled data collections. Proc Am Soc Inf Sci Technol. 2011;48(1):1–10.

Fecher B, Friesike S, Hebing M. What drives academic data sharing? PLoS One. 2015;10(2):e0118053.

Federer LM, Lu Y-L, Joubert DJ, Welsh J, Brandys B. Biomedical data sharing and reuse: attitudes and practices of clinical and scientific research staff. PLoS One. 2015;10(6):e0129506.

Joo S, Kim S, Kim Y. An exploratory study of health scientists’ data reuse behaviors: examining attitudinal, social, and resource factors. Aslib J Inf Manag. 2017;69(4):389–407.

Rathi V, Dzara K, Gross CP, Hrynaszkiewicz I, Joffe S, Krumholz HM, et al. Sharing of clinical trial data among trialists: a cross sectional survey. Br Med J. 2012;345:e7570.

Rathi VK, Strait KM, Gross CP, Hrynaszkiewicz I, Joffe S, Krumholz HM, et al. Predictors of clinical trial data sharing: exploratory analysis of a cross-sectional survey. Trials. 2014;15(1):384.

Tenopir C, Allard S, Douglass K, Aydinoglu AU, Wu L, Read E, et al. Data sharing by scientists: practices and perceptions. PLoS One. 2011;6(6):e21101.

Article CAS PubMed PubMed Central Google Scholar

Tenopir C, Dalton ED, Allard S, Frame M, Pjesivac I, Birch B, et al. Changes in data sharing and data reuse practices and perceptions among scientists worldwide. PLoS One. 2015;10(8):e0134826.

Grando MA, Murcko A, Mahankali S, Saks M, Zent M, Chern D, et al. A study to elicit behavioral health patients' and providers' opinions on health records consent. J Law Med Ethics. 2017;45(2):238–59.

Howard HC, Mascalzoni D, Mabile L, Houeland G, Rial-Sebbag E, Cambon-Thomsen A. How to responsibly acknowledge research work in the era of big data and biobanks: ethical aspects of the bioresource research impact factor (BRIF). J Commun Genetics. 2018;9(2):169–76.

Bravo E, Calzolari A, De Castro P, Mabile L, Napolitani F, Rossi AM, et al. Developing a guideline to standardize the citation of bioresources in journal articles (CoBRA). BMC Med. 2015;13:33.

Boeckhout M, Zielhuis GA, Bredenoord AL. The FAIR guiding principles for data stewardship: fair enough? Eur J Human Genetics. 2018;26(7):931–6.

Global Indigenous Data Alliance (GIDA). CARE principles for indigenous data governance GIDA; 2019 [Available from: https://www.gida-global.org/care ].

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Acknowledgements

The authors would like to thank Ms. Ngaire Pettit-Young, Information First, Sydney, NSW, Australia, for her assistance in developing the search strategy.

This project was supported by the Sydney Vital, Translational Cancer Research, through a Cancer Institute NSW competitive grant. The views expressed herein are those of the authors and are not necessarily those of the Cancer Institute NSW. FB is supported in her academic role by the Friends of the Mater Foundation.

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EH, PB, and FB were responsible for developing the study concept and the development of the protocol. EH and ML were responsible for the data extraction and data analysis. FB and PB supervised this research. All authors participated in interpreting the findings and contributed the intellectual content of the manuscript. All authors have read and approved the manuscript.

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Hutchings, E., Loomes, M., Butow, P. et al. A systematic literature review of researchers’ and healthcare professionals’ attitudes towards the secondary use and sharing of health administrative and clinical trial data. Syst Rev 9 , 240 (2020). https://doi.org/10.1186/s13643-020-01485-5

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If you are doing a literature review as part of your capstone project, please see this document for guidance on format and structure.

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There are different types of literature reviews, for an overview on the differences between them please see this page . This page's main focus is systematic literature reviews -- please scroll down to find resources for doing scoping reviews .

At its most basic, a systematic review is a secondary study that summarizes research on a specific topic by means of explicit and rigorous methods. These are based on previously published works in the field and do not include new data or experiments.

Systematic reviews use a formal process to identify , select , appraise , analyze , and summarize the findings.

Try starting out by formulating and defining a clear, specific research question. The PICO Framework (standing for Population/problem, Intervention, Comparison and Outcome) is a guideline for focusing and answering health-related questions, and a well-formed clinical question covers these areas:

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A scoping review is a type of knowledge synthesis that uses a systematic and iterative approach to identify and synthesize an existing or emerging body of literature on a given topic. While there are several reasons for conducting a scoping review, the main reasons are to map the extent, range, and nature of the literature, as well as to determine possible gaps in the literature on a topic. Scoping reviews are not limited to peer-reviewed literature.

Mak S, Thomas A. Steps for Conducting a Scoping Review. J Grad Med Educ . 2022;14(5):565-567. doi:10.4300/JGME-D-22-00621.1

JBI Manual for Evidence Synthesis, Chapter 11: Scoping Reviews JBI, formerly known as the Joanna Briggs Institute, is an international research organization which develops and delivers evidence-based information, software, education and training.
PCC Question Outline The PCC Question outline helps frame the scoping review question and highlights important concepts for the literature search. From the Bernard Beck Medical Library at Washington U. St. Louis.
PRISMA-ScR This checklist contains 20 essential reporting items and 2 optional items to include when completing a scoping review.
Scoping Reviews: what they are & how you can do them Five videos featuring Dr Andrea C. Tricco presenting the definition of a scoping review, examples of scoping reviews, steps of the scoping review process, and methods used.
Scoping Review Guide SUNY Stony Brook University's Scoping Review Guide covers information you need to know to prepare for and conduct a scoping review.

Peters, M.D.J., Marnie, C., Colquhoun, H. et al. Scoping reviews: reinforcing and advancing the methodology and application. Syst Rev 10 , 263 (2021). https://doi.org/10.1186/s13643-021-01821-3

Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine . 2018;169(7):467-473. doi:10.7326/M18-0850

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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

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Not applicable.

Ethics approval

Maulik PK ,
Mascarenhas MN ,
Mathers CD , et al
World Health Organisation
Council for Intellectual Disability
Emerson E ,
Shogren KA ,
Wehmeyer ML ,
Reese RM , et al
Cordasco KM
Hallock JL ,
Jordens CFC ,
McGrath C , et al
Brenner LH ,
Brenner AT ,
United Nations Population Fund
Australian Commission on Safety and Quality in Health Care
The Joint Commission
Beauchamp TL ,
Childress JF
New South Wales Attorney General
United Nations General Assembly
Strnadová I ,
Loblinzk J ,
Scully JL , et al
MacPhail C ,
McKay K , et al
Keywood K ,
Fovargue S ,
Goldsmith L ,
Skirton H ,
Cash J , et al
Morris CD ,
Niederbuhl JM ,
Arscott K ,
Fisher CB ,
Davidson PW , et al
Giampieri M
Shamseer L ,
Clarke M , et al
McKenzie JE ,
Bossuyt PM , et al
Flemming K ,
McInnes E , et al
Appelbaum PS
↵ Covidence systematic review software . Melbourne, Australia ,
Proudfoot K
Papadopoulos I ,
Koulouglioti C ,
Lazzarino R , et al
Onwuegbuzie AJ
BMJ Best Practice
Guyatt GH ,
Vist GE , et al
Garcia-Lee B
Brimblecombe J , et al
Benson BA ,
Farmer CA , et al
Ferguson L ,
Graham YNH ,
Gerrard D ,
Laight S , et al
Huneke NTM ,
Halder N , et al
Ferguson M ,
Jarrett D ,
McGuire BE , et al
Woodward V ,
Jackson L , et al
Conboy-Hill S ,
Leafman J ,
Nehrenz GM , et al
Höglund B ,
Carlson T ,
English S , et al
Wiseman P ,
Walmsley J ,
Tilley E , et al
Khatkar HS , et al
Holland AJ , et al
Beauchamp TL
England National Health Service
National Health Service England
Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability

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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.

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Parenting style and child mental health at preschool age: evidence from rural China

Lei Wang 1 ,
Jing Tian 1 , 2 &
Scott Rozelle 3

BMC Psychiatry volume 24 , Article number: 314 ( 2024 ) Cite this article

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Mental health problems among children at preschool age are a common issue across the world. As shown in literature, a caregiver’s parenting style can play a critical role in child development. This study aims to examine the associations between a caregiver’s parenting style and the mental health problems (or not) of their child when he/she is at preschool age in rural China.

Participants were children, aged 49 to 65 months, and their primary caregivers. The primary caregivers of the sample children completed the Parenting Styles and Dimensions Questionnaire, Short Version, the Strengths and Difficulties Questionnaire, and a questionnaire that elicited their socio-demographic characteristics. The level of cognitive development of each sample child was assessed using the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition. Pearson correlation analysis, linear regression analysis, and multivariable regression analysis were used to analyze the data.

The prevalence of mental health problems among sample children at preschool age was high (31.6%). If a caregiver practices an authoritative parenting style, it was found to be negatively associated with the mental health problems of their child. In contrast, a caregiver’s authoritarian parenting style was positively associated with the mental health problems of their child. Compared to those in a subgroup of primary caregivers that used a combination of low authoritative and low authoritarian parenting style, primary caregivers that used a combination of high authoritarian and low authoritative or a combination of high authoritative and high authoritarian were found to have positive association with child health problems. A number of demographic characteristics were found to be associated with the adoption of different parenting styles.

Different parenting styles (including authoritative, authoritarian, and combination of authoritative and authoritarian) of the sample caregivers had different associations with the mental health problems of the sample children. Parenting programs that aim to improve the parenting styles (favoring authoritative parenting styles) should be promoted in an effort to improve the status of child mental health in rural China.

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Introduction

Mental health problems of young children have become a common public health issue worldwide in recent years [ 1 , 2 ]. In this paper, “mental health problems in early childhood” are those problems that involve normative issues of emotions, behavior and social interactions, which can be generally categorized into three broad categories: internalizing problems (e.g., depression, withdrawal, anxiety, somatization); externalizing problems (e.g., aggression, oppositional defiance, attention deficit, hyperactivity); and social problems (e.g., difficulties in socializing with others) [ 3 , 4 , 5 ]. A growing literature has indicated that the incidence and prevalence of mental health problems among preschool children is relatively high across the world [ 6 , 7 , 8 ]. Data from developed countries estimate that approximately 4–19% of preschool-aged children are experiencing mental health problems such as attention disorders, hyperactivity and/or emotional or behavioral problems [ 9 , 10 , 11 ].

In developing countries, the prevalence of mental health problems among preschool-aged children is even higher [ 12 , 13 , 14 ]. A study conducted in Brazil showed that 24% preschool-aged children were found to have mental health problems [ 12 ]. In South Africa, the prevalence of mental health problems among young children is much higher: 36.7% children aged 4–6 were identified to be abnormal in the state of mental health [ 14 ]. In the recent literature in China, researchers have started to examine the mental health problems among young children. Evidence has shown that child mental health problems at preschool age are prevalent in China, especially in rural areas [ 15 , 16 , 17 , 18 ]. Studies conducted in urban China have revealed that, approximately, 5–20% of preschool children are suffering from some type of mental health problems [ 19 , 20 , 21 ]. The rate of mental health problems among preschool children in rural China is even higher, up to 39% [ 17 , 18 ]. In a study by Li et al. (2021), around 70% of rural preschoolers were identified with at least one kind of mental health problems. Specifically, the rates of emotional problems, conduct problems, hyperactive/inattention problems, peer relationship problems, and prosocial behavioral problems were 39%, 27%, 23%, 12% and 26%, respectively [ 17 ].

In addition to the issues that the preschool children and their families experience during the preschool years, the literature also shows that mental health problems that occur when children are preschool age can have long-lasting negative effects on the children as they age, including problems such as poor levels of school readiness, psychological well-being and social relationships [ 22 , 23 , 24 ]. Untreated mental health problems at preschool age can lead to chronic mental disorders or more serious long-term behavioral problems, such as learning difficulties, school dropout, substance abuse, domestic violence, and even suicide [ 4 , 7 , 25 ]. Because of these longer-run possible consequences, it is thus critical to identify the mental health problems and conduct interventions that are able to solve mental health problems of children at preschool age [ 26 , 27 , 28 ].

Parenting style and child mental health

Since the strategies and approaches that caregivers use in their parenting activities when rearing their young children (e.g., 0 to 3 years old) have significant effects on child mental health outcomes, poor parenting styles have been identified as a primary risk factor of mental health problems among children [ 29 , 30 , 31 ]. As a central form of socialization that shapes the development of children, the family is a socio-cultural-economic arrangement that exerts significant influence on the behavior and character of children and thus parents play a considerable role in the development of children, especially during the early years of childhood [ 32 , 33 , 34 , 35 ]. In this sense, parenting styles can have important and lasting impacts on child development. Any inappropriate parenting styles such as physical punishments may lead to unwanted damaging effects on the mental health of children [ 32 , 36 , 37 ].

According to Baumrind (1967), caregivers do have choices as parenting styles can be divided into three categories: authoritative, authoritarian, and permissive. Authoritative parenting is characterized by high levels of warmth, responsiveness, encouragement of the autonomy of children, and democratic disciplinary strategies. In contrast, authoritarian caregivers often parent their children through physical coercion, verbal hostility, and punishment without explanation. Permissive parenting involves a combination of high warmth and acceptance and low expectations of the child as he/she is maturing [ 38 ]. Based on these categories, a scale, the Parenting Styles and Dimensions Questionnaire (PSDQ), was created to assess the style of parenting in the context of different cultural settings [ 39 ].

Research has found that different categories of parenting style measured by the PSDQ have shown different associations with the emergence of mental health problems of their children [ 31 , 40 , 41 ]. Specifically, an authoritative parenting style has been shown to have negative associations with the mental health problems of preschool children. In contrast, authoritarian and permissive parenting styles have been observed to be positively associated with mental health problem of children at preschool age. For example, a study of families in the United States demonstrated that, when compared to authoritarian and permissive parenting styles, adopting an authoritative parenting style was most predictive of fewer behavior problems of preschool children [ 31 ]. Another national cohort study conducted in the United Kingdom found that the attitudes of caregivers that adopted authoritarian style to discipline their children were associated with the occurrence of mental health problems of children at the age of 5 [ 41 ]. Research conducted by Hanafi & Thabet (2017) illustrated that, in the Gaza Strip, authoritative parenting style was negatively associated with mental health problems of preschool children. In contrast, children with authoritarian or permissive parenting style caregivers were more likely to have mental health problems [ 40 ].

Research also has investigated the reasons why different patterns of parenting styles have been shown to have different degrees of associations with the mental health problems of young children [ 31 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ]. Previous studies have shown that warm and responsive parenting behavior are consistently associated with developmental outcomes of early childhood, including mental health; in contrast, the children of parents that displayed low levels of warmth showed elevated levels of oppositional behavior [ 42 , 48 , 49 ]. Since authoritative parents care more about the feelings of their children, and give more encouragement to their children, this behavior not only provides psychological support but also autonomy in various activities; in short, children raised by authoritative parents can express their ideas freely and can create their own self-confidence and responsibility with less problematic behavior [ 36 , 46 , 47 , 49 ]. In contrast, authoritarian parents are not only often unresponsive to the needs of their children but also frequently are demanding. Parenting strategies, such as punishments, the use of forces and harshness are mostly used by authoritarian parents, and these actions often result in disobedient behavior, aggression, and restlessness of children, which can ultimately be detrimental to the mental health of children [ 43 , 45 , 48 , 49 ]. According to Baumrind (1967; 2013), permissive parents do not guide their children to regulate their behavior; instead, permissive parents tend to allow their children to make their decisions alone. Therefore, the children of parents that us a permissive style of parenting often become dependent and lack social responsibility, exhibiting either internalizing or externalizing behavior problems [ 32 , 38 , 40 , 49 ].

Previous studies have also revealed that certain demographic characteristics of children and households are associated with the adoption of different parenting styles [ 30 , 50 , 51 , 52 , 44 , 49 , 53 , 54 , 55 ]. When examining child characteristics, a strand of literature has explored the differences of parenting styles that are used with children of different gender [ 30 , 51 , 55 , 56 , 57 ]. The results of these studies show that parents tend to use authoritarian parenting style for boys more frequently and tend to use authoritative parenting style for girls. Other studies have also examined the associations between the number of children in a household and the parenting style that was adopted by the caregiver [ 44 , 54 ]. Comparing to families with only one child, parents are more likely to use authoritarian parenting styles than when they have more than one child. When examining household characteristics, previous studies have frequently focused on the association between parenting style and the socioeconomic status (SES) of the parents [ 50 , 52 , 53 ]. According to these studies, parents with higher levels of SES (e.g., higher levels of education and higher incomes) are more inclined to use authoritative parenting style. In contrast, parents with lower levels of SES are more likely to adopt authoritarian parenting style.

Parenting style and mental health of preschool children in China

Literature in China has also begun to investigate the sources of mental health problems among preschool children in China [ 15 , 58 , 59 ]. Similar to the findings of the literature on this topic outside of China, studies in China show that the type of parenting style used by the caregiver is one of the primary sources of the mental health problems of their children. For example, a study conducted in urban preschools of Guangzhou found that the adoption of authoritarian parenting style resulted in an increase in child mental health problems [ 15 ]. In contrast, the findings of another study conducted in a city located in the central region of China suggest that authoritative parenting style actually improved the mental health outcomes of preschool children [ 58 ].

The current study

Literature on parenting styles of parents in China have showed that more and more urban parents are adopting authoritative parenting style rather than relying on authoritarian parenting style as they are rearing their children—or at least are relying on more blended forms of authoritative/authoritarian parenting styles [ 60 , 61 , 62 , 63 , 64 , 65 ]. Importantly, however, to our knowledge there has never been a study on the adoption of parenting styles of caregivers that are raising preschool-aged children in rural China.

In addition, even though there have been studies on the association between parenting styles and mental health problems of preschool children in China, most of studies have been conducted with urban children and their parents [ 15 , 58 , 59 ]. Considering the great difference in child-rearing practices and the nature of child development between urban and rural areas, it is of great significance to understand the associations between parenting styles and the levels of mental health of children at preschool age in rural China. Examining the context of rural China is important because in studies of preschool children in rural China it has been found that rural China has much higher levels of mental health problems compared to their urban peers. As discussed previously, since mental health problems during early childhood can have long-lasting negative effects on children in many aspects, it is important to address the issue of high prevalence of mental health problems among preschool children in rural China. Since improving caregiver-child interactions can mitigate the mental health problems of children, understanding the associations between parenting styles and child mental health might encourage caregivers in rural China to adopt parenting strategies that improve the outcomes of child mental health. To the best of our knowledge, however, no related work with children at preschool age has been conducted in rural areas of China. The current study aims to fill this gap to the literature.

Given the absence of literature on parenting style and mental health of preschoolers in rural China, the current study uses data drawn from a longitudinal study to examine the association between different parenting styles and the levels of mental health of children at preschool age in rural China. To achieve this goal, the current study has four specific objectives. First, the study examines the state of parenting styles and mental health outcomes of children at preschool age in rural China. Second, the study investigates the associations between different parenting styles and the levels of mental health of rural children at preschool age. Third, the study explores the associations between different subgroups of combined parenting styles and mental health of preschool aged children in rural China. Finally, the study identifies some of the correlates—both child characteristics and household characteristics—of the adoption of different parenting styles.

The remainder of this paper is organized as follows. The next section describes the methods that we used. The third section presents the results of our analysis. The final two sections discuss the findings and conclude.

Participants

The data for the current study are drawn from a longitudinal study of children and households conducted in 11 nationally designated poverty counties in northwestern China. The selection of the sample for this longitudinal study was conducted in 2013 and followed a multistage clustering sampling design. First, all townships (n = 174) in the 11 study counties were included in the study. Next, we randomly selected two villages from each of the sample townships. In total, 351 villages were included. Finally, after excluding children with known diseases or disabilities, we selected all of the remaining children that were within the target age range (6–12 months) for inclusion in the longitudinal study. Overall, 1,802 children were enrolled into the study. After the sample selection, we conducted the baseline survey. In the following years, we followed up with the sample children and households several times after the initial baseline. In 2017, when the sample children were 49–65 months age, we conducted the most recent follow-up survey and tracked 1,459 children and their caregivers from 351 villages successfully. All the participants included in the current study completed a follow-up survey in 2017 (when the children were preschool age). Table 1 shows the demographic characteristics of children and households that were part of the 2017 survey.

Parenting styles and dimensions Questionnaire-Short Version (PSDQ-Short Version)

We used the Parenting Styles and Dimensions Questionnaire-Short Version (PSDQ-Short Version) to measure the parenting styles of the primary caregivers of sample children [ 39 ]. The PSDQ-Short Version is a self-report questionnaire containing 36 items. The responses are given based on a 5-point Likert scale that ranges from never (1) to always (5). The PSDQ-Short Version includes three sub-scales of parenting style: authoritative, authoritarian, and permissive. Higher scores on each scale indicate that the respondent exhibits parenting behaviors that are more consistent with that particular parenting style. The translated Chinese version of the PSDQ-Short Version has been shown to have adequate internal consistency and reliability [ 64 , 66 , 67 , 68 ]. As several studies reported parents rarely use permissive parenting in China [ 62 , 64 ] and the permissive scale was not reliable among Chinese parents [ 60 , 65 , 69 ], our research team did not collect data on the items for a permissive parenting style. The present study, therefore, had two subscales—authoritative and authoritarian parenting styles, with a total of 27 items. Examples of the items are as follows: “I am responsive to my child’s feelings or needs.” “I take my child’s desire into account before asking my child to do something.” “I punish by taking privileges away from my child with little if any explanations.” The items were rated on a 5-points scale (1 = Never, 2 = Once in a while, 3 = About half of the time, 4 = Very often, 5 = Always). The subscale of the authoritative parenting style contains three dimensions with 15 items: Connection (Warmth and Support), Regulation (Reasoning or Induction), and Autonomy Granting (Democratic Participation). The subscale of authoritarian parenting style is comprised of three dimensions with 12 items: Physical Coercion, Verbal Hostility, and Non-Reasoning or Punitive. In the current study, the scale of PSDQ demonstrated good internal consistency. The Cronbach’s alpha was 0.77.

Strengths and Difficulties Questionnaire (SDQ)

The Strengths and Difficulties Questionnaire (SDQ) is a 25-item carer-reported instrument to assess mental health of children aged 2 to 17 [ 70 ]. For the current study, we used the Chinese version of SDQ that has been validated for the Chinese context [ 71 ]. Examples of the questions are: “Your child is helpful if someone is hurt, upset or felling ill.” “Your child often has temper tantrums or hot tempers.” “Your child has at least one good friend.” All items are scored on a three-point Likert scale (0 = not true, 1 = somewhat true, and 2 = certainly true). There are five subscales within the SDQ regarding three domains of mental health problems: Internalizing problems (including subscales of emotional symptoms and peer relationship problems); Externalizing problems (including subscales of conduct problems and hyperactivity problems); and Prosocial behaviors. Each subscale is further divided into three categories, namely, “normal,” “borderline,” and “abnormal” [ 71 ]. The cutoffs of the three categories for each subscale can be found in Appendix Table A1 . In the current study, children with scores either in the abnormal or borderline range on the total difficulties scale and individual subscales were classified having mental health problems. The scale of the SDQ showed good reliability for our sample. The Cronbach’s alpha was 0.68.

Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition (WPPSI-IV)

We used the Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition to assess the levels of cognitive development of the sample children (WPPSI-IV; [ 72 ]). The WPPSI-IV is comprised of 13 subtests that are incorporated together to form one Full-Scale Intelligence Quotient (FSIQ). The Chinese version of WPPSI-IV was adapted in 2010 and has subsequently been used in studies across China [ 73 , 74 ]. The WPPSI-IV is usually administered 1-on-1 by trained testers, using a standardized set of toys and detailed scoring sheets. In the current study, the Cronbach’s alpha for this scale was 0.91, indicating a high reliability. For the analysis of the current study, children with an FSIQ score below 85 (one standard deviation below the mean of 100) are considered to be developmentally delayed. According to the literature [ 75 , 76 , 77 ], in early childhood, the cognitive development of a child can promote the formation of his or her noncognitive development (including mental health). Because of this possibility of “skills begetting skills,” in the analyses of the current study, we controlled for the cognitive development of sample children (by including a measure of cognitive development as a control variable in the regression analysis).

Socio-demographic characteristics

A primary caregiver-reported questionnaire was used to collect data on child and household characteristics. The child characteristics that are in the survey include age in months, gender, whether the child had siblings, whether the child was left-behind (i.e., either parent migrated for work at the time of the survey), and whether the child attended preschool. Household characteristics included the identity of the primary caregiver (e.g., mother or grandmother), age of the primary caregiver (years), whether the primary caregiver had obtained at least a junior high school education, and a household assets index. The household assets index was constructed using polychoric principal component analysis based on the following information: whether a household had access to tap water, a toilet with running water, a water heater, a washing machine, a computer, the Internet, a refrigerator, air conditioning, a motorcycle or electronic bicycle, and/or an automobile.

The data collection was carried out by enumerators recruited from local universities in 2017. Prior to the field work, the enumerators underwent a formal, week-long training course, including 2.5 days of in-the-field training. During the data collection, enumerators visited each household of the sample children individually. Upon arriving at each household, the enumerators explained the goal and content of the survey and obtained consent from the primary caregivers for both their participation and that of the child of their family that was included in the current study. The enumerators then collected data on the PSDQ and the SDQ scales as well as the information on the socio-demographic characteristics by interviewing the primary caregivers. In addition, the WPPSI-IV was administered one-on-one to each child, using a standardized set of toys and a detailed scoring sheet.

Statistical analysis

All statistical analyses were conducted using STATA 16.0 Version. All statistical tests are two-sided. A P -value < 0.05 is considered statistically significant. Descriptive analyses are used to describe the sample characteristics. Continuous and categorical data are reported in the form of means (SD) and percentages. The frequencies and distributions of the status of the mental health of the sample children and parenting styles of primary caregivers are analyzed. Following two previous studies [ 78 , 79 ], we sorted the children in our sample into four groups with combinations of parenting styles using the medians of scores on the authoritative and authoritarian subscales. Bivariate correlation matrices using Pearson correlation analysis is performed to determine the simple correlation between child mental health, parenting styles and different socio-demographic characteristics. Linear regression analysis is used to examine the associations between parenting styles and mental health of children. Multivariable regression analyses are also used to investigate the determinants of different parenting styles.

Table 2 shows the prevalence of mental health problems of the sample children. In our sample, over 30.0% of children were found of being at risk of having mental health problems according to the total difficulties scale. In terms of the internalizing subscales, emotional problems were more prevalent among children (34.9%) than peer problems (6.8%). In contrast, in the subscales of externalizing problems, both conduct problems (40.1%) and hyperactivity problems had high levels of prevalence (24.5%). In addition, 20.8% of children had prosocial behavior problems.

The results in Table 3 indicate that the authoritative parenting style, both according to the total scores and the scores of each dimension, rated higher than those of the authoritarian parenting style among primary caregivers in our sample. The difference in the total scores of authoritative and authoritarian parenting styles was statistically significant ( p <.001), indicating that primary caregivers were more likely to conduct strategies related to authoritative parenting style than authoritarian parenting style.

The analysis using the Pearson correlations indicates that different parenting styles have different associations with the nature of the mental health of the sample children (Appendix Table A2 ). Regression analysis also shows that an authoritative parenting style was negatively associated with child mental health problems in the measurements of total difficulties, internalizing problems, and externalizing problems. The results also illustrate that an authoritative parenting style was positively associated with the measurement of prosocial behaviors. In contrast, an authoritarian parenting style was positively associated with child mental health problems as measured according to the scales of total difficulties, internalizing and externalizing problems. An authoritarian parenting style was negatively associated with prosocial behaviors (Table 4 ). Similar associations were also found between the subscales of each parenting styles and child mental health problems (Appendix Table A3 ). Specifically, all three subscales of the authoritative parenting style (i.e. Connection, Regulation and Autonomy granting) were significantly and negatively associated with the variables that measure: Total difficulties, Internalizing problems and Externalizing problems. In addition, all three subscales were significantly and positively associated with the variable measuring the Prosocial behavior of sample children. There is only one exception: the results show that the association between the Autonomy granting and the Internalizing problems was negative but insignificant. In regards to the three subscales of the authoritarian parenting style (i.e. Physical coercion, Verbal hostility, and Non-reasoning), positive and significant associations were found with the variables measuring Total difficulties, Internalizing problems and Externalizing problems. In addition, significant and negative associations between Physical coercion and the Prosocial behavior of children was also observed. However, no significant associations were found between the other two subscales of the authoritarian parenting style and the Prosocial behavior of children.

When the analysis sorted children into four groups of different combinations of “high” versus “low” values of the two parenting styles (Group 1: high authoritative, low authoritarian; Group 2: high authoritarian, low authoritative; Group 3: high authoritative, high authoritarian; and Group 4: low authoritative, low authoritarian) using ratings of primary caregivers from the authoritative and authoritarian parenting style scales, the share of each of the four groups was similar (around 25% for each) (Appendix Table A4 ). In the association analysis, we use Group 4 (low authoritative, low authoritarian) as the reference group. Results of the association analyses of the four groups with child mental health show that when compared to children in Group 4 (low authoritative, low authoritarian), children in Group 1 (high authoritative, low authoritarian) had significantly lower scores in the externalizing problems domain and higher scores in the domain of the prosocial behaviors (Table 5 ). No significant associations were found between Group 1 other two measurements of child mental health problems. In contrast, children in Group 2 (high authoritarian, low authoritative) had significantly higher scores in the scales that measured total difficulties, internalizing problems, and externalizing problems. No significant associations were found in the measurement of prosocial behaviors. Finally, children in Group 3 (high authoritative, high authoritarian) were found to have significantly higher scores in the scales that measured total difficulties, internalizing problems, and prosocial behaviors. However, no significant association was found in the measurement of externalizing problems.

When investigating the correlates of the authoritative and authoritarian parenting styles respectively (Table 6 ), a number of demographic characteristics of the sample children and sample households were found to be significant. The demographic characteristics that had significant correlations with the authoritative parenting style include whether the child cognitively delayed, educational level of primary caregiver, and household economic status. In contrast, many more demographic characteristics, such as child age, child gender, left-behind child, whether the child cognitively delayed, whether the mother is the primary caregiver, and household economic status, were found to have significant associations with the adoption of the authoritarian parenting style.

Considering the importance of identifying mental health problems of young children at preschool age (or issues involving the development of their social emotional abilities), this study first investigated the prevalence of mental health problems among preschool-aged children in rural China. The results of the current study show that the prevalence of child mental health problems is high in rural China, no matter whether it was measured by the total difficulties score of the SDQ scale, or by scores on the three domains of the SDQ scale (i.e. Internalizing problems, Externalizing problems, and Prosocial behavior problems). When looking at the literature, the prevalence in rural China appears to be higher than what has been found among preschoolers in developed countries [ 9 , 10 , 11 ]. When comparing the results of the sample children in this study to peers in other developing countries (including comparisons to children in urban China), the sample children of the current study still show relatively higher prevalence of mental health problems [ 12 , 14 , 15 ]. Importantly, these results are consistent with previous studies conducted in other areas of rural China [ 17 , 18 ]. One possible reason for the high prevalence of child mental health problems in rural China might be that there are many rural children are left-behind due to parental migration. Nearly one quarter (25%) of the children in the sample were left-behind children. According to previous studies, the absence of parents may have a negative impact on the mental health of the child [ 17 , 18 ]. Another potential reason lies in the fact that public health services are poor in rural China which might delay the detection and timely treatment of children with mental health problems. In this sense, actions that improve both the interactions between migrant parents and left-behind children and the public health system in rural China are encouraged. Otherwise, the prevalence of child mental health in rural China likely would persistently be high or become even higher.

Previous studies have provided evidence that suggests that parenting style is a potential risk factor of child mental health problems [ 29 , 30 , 31 ]. The current study reveals that although the primary caregivers of the children in the sample are more likely to be using authoritative parenting style (rather than authoritarian parenting style), when compared to urban studies carried out in China, the results of this study show that the use of strategies regarding the authoritative parenting style in our sample is significantly lower than in urban China [ 62 , 69 ]. In contrast, studies also show that the adoption of authoritarian parenting styles in rural China (as shown in this study) is higher than in urban China [ 60 , 61 , 62 , 63 , 64 , 65 ]. These findings indicate that rural caregivers appear to be increasingly influenced by their urban peers in the parenting styles due to the economic transition that China is undergoing, including trends in urbanization and rural-to-urban migration. However, continued disparities in many dimensions between rural and urban caregivers in China (e.g. economic status, educational levels, and values) are still barriers that are slowing down improvements in the adoption of parenting styles in rural families [ 17 , 18 , 69 ]. There is, thus, an urgent need to help rural families in China better understand the advantages of adopting an authoritative parenting style and the disadvantages of using an authoritarian parenting style. If this can be taught to rural caregivers, it is hoped that this will encourage those rural caregivers to interact with their young children more with authoritative parenting styles and less with authoritarian parenting styles.

Consistent with the literature, our study shows that the authoritative parenting style is negatively associated with the occurrence of mental health problems of children in terms of all dimensions of the SDQ scale, including Total difficulties; Internalizing problems; Externalizing problems; and Prosocial behavior problems [ 31 , 40 , 58 ]. As described by Baumrind (1966), children raised by authoritative caregivers grow up in an integrated environment of rules and freedom. Authoritative caregivers justify their actions and let the child take control of their own within fair boundaries. In such a democratic home environment, children are less likely to experience mental health problems [ 42 ]. Indeed, previous empirical studies also have provided evidence that authoritative parenting style can help prevent aggression and reduce peer problems among preschool children; in other words, an authoritative parenting style is negatively associated with internalizing, externalizing, and prosocial behavioral problems [ 40 , 43 , 46 , 47 ]. In search for reasons that might explain the associations between parenting style and the mental health of young children, according to Baumrind (1967), authoritative parenting style is more sensitive to the needs and skills of children since it is supposed to be based on warmth and support, induction and encouragement, reasoning or guiding, democratic participation, parental responsive attitudes, and proper control. The literature suggests that authoritative parenting style has been shown to be a protective factor for child mental health [ 31 , 58 ].

While the results in this study concur with the findings that show the negative association between authoritative parenting style and child mental health problems, the analysis also reveals the positive association between the authoritarian parenting style and child mental health problems. These findings regarding the mental health of children with caregivers that use authoritarian parenting styles also is in line with previous studies [ 15 , 31 , 41 , 58 ]. According to these studies, an authoritarian parenting style of caregiver, characterized by the lack of warmth and support, undermines the relationship of caregiver-child and causes the child either to exhibit overly submissive behavior that could lead to different types of internalizing problems, or to rebel against the caregiver in various forms of externalizing problems. In such scenarios, an authoritarian parenting style is often shown to be positively associated with child mental health problems. The literature demonstrates that the possible reasons for the effect of authoritarian parenting on child mental health involve the attempts of the caregiver to obtains control overall the child and this can lead to a rejection of the child’s activities, uses punishment and parental enforcement in parenting, and can ultimately leads to anxiety, fear, bewilderment, and dissatisfaction of children which in turn can induce internalizing problems and externalizing problems [ 38 , 41 , 57 ].

In rural China, primary caregivers (especially the grandparents of children), still influenced by Confucianism, tend to stick to traditional parenting strategies. They often place great stress on the parent-child hierarchy, demand respect and obedience from children, and impose more restrictions and disciplines rather than offering affective support [ 62 ]. All such interactive activities are more related to an authoritarian parenting style and less related to an authoritative parenting style, which in turn has often been associated with a negative impact on the mental health outcomes of rural children. To mitigate the severity of mental health problems among rural young children, the literature has begun to encourage caregivers to adopt strategies of authoritative parenting style in rural China.

In this period of transition of caregivers in rural China in their selection of parenting styles, more and more parents are beginning to use parenting strategies which combine elements of both authoritative and the authoritarian parenting styles [ 60 , 61 , 62 , 63 , 64 , 65 ]. Because of this, our study examines the associations between different subgroups of combined parenting styles and child mental health. When doing so the paper finds that different combinations of parenting styles can have different associations with child mental health problems. Although no previous study of the associations between the combinations of different parenting styles and child mental health has been conducted either in China or outside of China, our findings are consistent with the literature that have shown that the more an authoritative parenting style is used, the lower is the likelihood that a caregiver’s child will have mental health problems [ 31 , 62 ]. For example, when comparing children of caregivers that use combined parenting styles with low levels of both authoritative and authoritarian parenting styles (Group 4 in our sample), the children of caregivers that use combined parenting styles with high authoritative and low authoritarian (Group 1) are less likely to have externalizing problems and more likely to exhibit prosocial behavior. According to the literature, one possible mechanism might be that the parenting style used by caregivers in Group 1 are dominantly an authoritative strategy, which gives children more warmth which then decreases the possibility of oppositional behavior [ 48 ]. In contrast, our study also demonstrates that when caregivers use parenting styles that are more related to authoritarian, their children are more likely to have mental health problems [ 30 , 41 , 57 ]. The underlying reason of these findings might be that parenting styles that involve high levels of warmth, encouragement, support, and lower levels of control, enforcement and punishment are able to improve the atmosphere of the environment in which the child is raised, which in turn affects the overall social development and well-being of the child and ultimately results in lower incidence of mental health problems. If we use an example from the results from our sample, children of caregivers in Group 2 (high authoritarian, low authoritative) are more likely to have high levels of mental health problems. The reason for this may lie in the fact that the dominant parenting strategies of this pattern of combined parenting styles are more likely to be harsh and demanding, which has been shown to increase the likelihood of caregiver-child conflicts that is detrimental to the well-being of children [ 41 , 57 ]. Even for children of caregivers in Group 3 [high authoritative, high authoritarian), the benefits of the authoritative parenting style could be offsetting the negative effect of the authoritarian parenting style on the outcome of child mental health. These findings might be due to the fact that there is uncertainty of the home environment and this could make children suffer frustrations and struggles (since they are receiving mixed signals).

When investigating the determinants of the adoption of parenting styles, our study identified a number of socio-demographic characteristics, such as age, gender, and the cognitive development of the child, migration status of the parents, and the SES of the family, that are associated with the authoritative and authoritarian parenting styles. The findings in our study are consistent with previous studies that have found that certain demographic characteristics are often correlated with different parenting styles [ 30 , 51 , 53 , 69 ]. In terms of child characteristics, parents are reported to show more authoritarian parenting toward boys than girls in our study as well as in the literature [ 30 , 51 ]. While it is not shown in the paper empirically having such parental expectations on the gender differences, when comparing boys to girls, parents may be more likely to discipline boys (who often are more aggressive) using authoritarian parenting style rather than the authoritative parenting style [ 56 ]. Regarding the age of the child, the literature also has shown (as does our study) that younger children are expected to obey rules and norms more often than do older children. Therefore, the literature shows that parents are more likely to adopt the authoritarian parenting style when they are rearing older children [ 49 ].

Our findings also show that primary caregivers with higher levels of SES are more likely to adopt the authoritative parenting style. In contrast, primary caregivers with lower levels of SES are more likely to use parenting styles that are relatively more authoritarian. These findings are similar to those in previous studies that were conducted both in urban China and outside of China [ 50 , 52 , 53 ]. The underlying reason of the differences in the adoption of different parenting styles may lie in that more-educated primary caregivers, compared with less-educated peers, are more likely to understand the importance of inductive and rational parenting for child development and value authoritative parenting styles instead of authoritarian parenting styles. In addition, primary caregivers with lower SES often suffer from economic stress that may impede their ability to rear children in ways that are beneficial to children’s well-being. In contrast, primary caregivers with higher levels of SES do not experience such stress and tend to rely on strategies that are more in line with authoritative parenting styles [ 50 ].

In light of these findings, it can be suggested that parenting training programs that aim to improve the understanding of primary caregivers regarding choices of different parenting styles can be implemented in rural China. Rural communities should be encouraged to train caregivers to adopt more authoritative parenting styles instead of relying on traditional authoritarian styles through one-on-one parenting guidance, home-visiting services, community-based parenting training, or media-based promotional campaigns. Central and local governments also need to pay attention to ways that can allow them to improve public health services in rural China that will strengthen the capability of the public health system in rural China that will help local doctors and physicians and other health care actors to identify and treat mental health problems of preschool-aged children in an effective and timely fashion.

To the best of our knowledge, this study is the first study conducted in rural China to analyze the associations between parenting styles and mental health of preschool-aged children. Findings of this study offer important insights into the role that parenting style can play in the well-being of young children in rural settings, where children at preschool age have been found to have high prevalence of mental health problems. The study also fills the gap in the literature of the associations between different combinations of parenting styles (i.e., blends of authoritative and the authoritarian parenting styles) and the mental health problems of children that are preschool age. With increasing rates of adoption of combined parenting styles in China, findings of the current study help shed light on a series of new potential research questions that could be explored in this new area.

This study has three limitations. First, since the data used in the current study contained data from only one time period of the study, we can only interpret the results as being “associations” between parenting styles and child mental health, and we are unable to make casual conclusions of the impact of the parenting styles on child mental health due to lack of data on some of the key variables in earlier waves of the survey. Second, the mental health of children and parenting styles of primary caregivers are assessed by care-reported questionnaires, which might lead to inaccuracies in the responses (for a number of reasons) and thus might cause measurement bias. Since the two measurements (i.e. PSDQ and SDQ) have been used widely, many previous studies have also faced this same limitation. There is, thus, a need in this area that observational measures of parenting styles and mental health of children should be included in the data collection procedure. Future research should consider investigating the causality of parenting styles and child mental health as wells as conduct child-based questionnaire on child mental health. Third, since the sample observations in this study were selected from nationally designated poverty counties in northwestern China, we do not consider our results to be statistically representative of the entire country or other rural regions of China. Future studies should continue to expand on the current study by sampling populations from other rural areas in China.

This study shows that the prevalence of mental health problems among preschool-aged children is high in rural China. The significant and positive association between the authoritative parenting style and the mental health of children is found. In contrast, the authoritarian parenting style is significantly and negatively associated with the mental health of children. Similarly, the more likely it is that authoritative strategies appear in the combined parenting styles, the less likely it is that the child will have mental health problems. In contrast, the more likely it is that authoritarian activities appear in the combined parenting styles, the more likely it will be that the child has the mental health problems. Child age and gender, the status of parental migration, and the SES levels of families are the main determinants of the adoption of different parenting styles. The findings in this paper suggest that it is important to encourage primary caregivers of preschool-aged children to adopt the authoritative parenting styles, or at least use parenting strategies that are related to the authoritative styles, in order to promote child mental health in rural China.

Data availability

The data that support the findings of this study are available from the corresponding author upon request (email: [email protected]).

Abbreviations

Socioeconomic status

Parenting Styles and Dimensions Questionnaire

Strengths and Difficulties Questionnaire, WPPSI-IV: Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition

Full-Scale Intelligence Quotient

Colizzi M, Lasalvia A, Ruggeri M. Prevention and early intervention in youth mental health: is it time for a multidisciplinary and trans-diagnostic model for care? Int J Ment Health Syst. 2020;14(1):23.

Article PubMed PubMed Central Google Scholar

Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual Research Review: a meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56(3):345–65.

Article PubMed Google Scholar

Achenbach TM, Ivanova MY, Rescorla LA, Turner LV, Althoff RR. Internalizing/Externalizing problems: review and recommendations for clinical and Research Applications. J Am Acad Child Adolesc Psychiatry. 2016;55(8):647–56.

Bor W, Dean AJ, Najman J, Hayatbakhsh R. Are child and adolescent mental health problems increasing in the 21st century? A systematic review. Aust N Z J Psychiatry. 2014;48(7):606–16.

Sawyer MG, Arney FM, Baghurst PA, Clark JJ, Graetz BW, Kosky RJ, et al. The Mental Health of Young people in Australia: key findings from the child and adolescent component of the National Survey of Mental Health and Well-Being. Aust N Z J Psychiatry. 2001;35(6):806–14.

Article CAS PubMed Google Scholar

Charach A, Mohammadzadeh F, Belanger SA, Ma AE, Lipman EL, McLennan JD, et al. Identification of Preschool Children with Mental Health. J Can Acad Child Adolesc Psychiatry. 2020;29(2):76–105.

PubMed PubMed Central Google Scholar

Dougherty LR, Leppert KA, Merwin SM, Smith VC, Bufferd SJ, Kushner MR. Advances and directions in Preschool Mental Health Research. Child Dev Perspect. 2015;9(1):14–9.

Article Google Scholar

Vasileva M, Graf RK, Reinelt T, Petermann U, Petermann F. Research review: a meta-analysis of the international prevalence and comorbidity of mental disorders in children between 1 and 7 years. Child Psychol Psychiatry. 2021;62(4):372–81.

Elberling H, Linneberg A, Olsen EM, Goodman R, Skovgaard AM. The prevalence of SDQ-measured mental health problems at age 5–7 years and identification of predictors from birth to preschool age in a Danish birth cohort: the Copenhagen Child Cohort 2000. Eur Child Adolesc Psychiatry. 2010;19(9):725–35.

Klein AM, Otto Y, Fuchs S, Reibiger I, von Klitzing K. A prospective study of behavioral and emotional symptoms in preschoolers. Eur Child Adolesc Psychiatry. 2015;24(3):291–9.

Navarro JB, Fernández M, de la Osa N, Penelo E, Ezpeleta L. Warning signs of preschool victimization using the strengths and difficulties questionnaire: prevalence and individual and family risk factors. PLoS ONE. 2019;14(8):e0221580.

Article CAS PubMed PubMed Central Google Scholar

Anselmi L, Piccinini CA, Barros FC, Lopes RS. Psychosocial determinants of behaviour problems in Brazilian preschool children. J Child Psychol Psychiat. 2004;45(4):779–88.

Ma Chuan, Jiang L, Chu Lting, Zhang C, cao, Tian Y, Chen Jjin, et al. Mental health problems of preschool children during the COVID-19 home quarantine: a cross-sectional study in Shanghai, China. Front Psychol. 2022;13:1032244.

Mellins CA, Xu Q, Nestadt DF, Knox J, Kauchali S, Arpadi S, et al. Screening for Mental Health among Young South African children: the Use of the strengths and difficulties Questionnaire (SDQ). Glob Soc Welf. 2018;5(1):29–38.

Bao P, Jing J, Jin Y, Hu X, Liu B, Hu M. Trajectories and the influencing factors of behavior problems in preschool children: a longitudinal study in Guangzhou, China. BMC Psychiatry. 2016;16(1):178.

Guo Y, Zhang YQ, Wu CA, Yin XN, Zhang JY, Wu JB, et al. Bidirectional associations between parenting styles and conduct problems in Chinese preschool children: the Shenzhen Longhua Child Cohort Study. Psychol Health Med. 2021;27(9):2007–20.

Li S, Chen K, Liu C, Bi J, He Z, Luo R, et al. Dietary diversity and mental health in preschoolers in rural China. Public Health Nutr. 2021;24(7):1869–76.

Luo J, Zou J, Ji M, Yuan T, Sun M, Lin Q. Emotional and behavioral problems among 3- to 5-Year-Olds Left-behind children in Poor Rural areas of Hunan Province: a cross-sectional study. Int J Environ Res Public Health. 2019;16(21):4188.

Jing J, Yang C, Wang Y, Su X, Du Y. Impact of COVID-19 on Emotional and Behavioral Problems among Preschool Children: A Meta-analysis [Internet]. In Review; 2023 Aug [cited 2024 Jan 16]. Available from: https://www.researchsquare.com/article/rs-3204765/v1 .

Ren Y, Yao X, Liu Y, Liu S, Li X, Huang Q, et al. Outdoor air pollution pregnancy exposures are associated with behavioral problems in China’s preschoolers. Environ Sci Pollut Res. 2019;26(3):2397–408.

Article CAS Google Scholar

Zheng Y, Zheng X. Current state and recent developments of child psychiatry in China. Child Adolesc Psychiatry Ment Health. 2015;9(1):10.

Althoff RR, Verhulst FC, Rettew DC, Hudziak JJ, Van Der Ende J. Adult outcomes of Childhood Dysregulation: a 14-year follow-up study. J Am Acad Child Adolesc Psychiatry. 2010;49(11):1105–e11161.

Arslan İB, Lucassen N, van Lier PAC, de Haan AD, Prinzie P. Early childhood internalizing problems, externalizing problems and their co-occurrence and (mal)adaptive functioning in emerging adulthood: a 16-year follow-up study. Soc Psychiatry Psychiatr Epidemiol. 2021;56(2):193–206.

Narusyte J, Ropponen A, Alexanderson K, Svedberg P. Internalizing and externalizing problems in childhood and adolescence as predictors of work incapacity in young adulthood. Soc Psychiatry Psychiatr Epidemiol. 2017;52(9):1159–68.

Bornstein MH, Hahn CS, Haynes OM. Social competence, externalizing, and internalizing behavioral adjustment from early childhood through early adolescence: developmental cascades. Dev Psychopathol. 2010;22(4):717–35.

Conroy MA, Brown WH. Early identification, Prevention, and early intervention with Young children at risk for emotional or behavioral disorders: issues, trends, and a call for action. Behav Disorders. 2004;29(3):224–36.

Mesman J, Koot HM. Early Preschool predictors of Preadolescent Internalizing and Externalizing DSM-IV diagnoses. J AM Acad Child Psy. 2001;40(9):1029–36.

Njoroge WFM, Bernhart KP. Assessment of behavioral disorders in Preschool-aged children. Curr Psychiatry Rep. 2011;13(2):84–92.

Aunola K, Nurmi JE. The role of parenting styles in Children’s Problem Behavior: parenting styles in Children’s behavior. Child Dev. 2005;76(6):1144–59.

Braza P, Carreras R, Muñoz JM, Braza F, Azurmendi A, Pascual-Sagastizábal E, et al. Negative maternal and paternal parenting styles as predictors of children’s behavioral problems: moderating effects of the child’s sex. J Child Fam Stud. 2015;24(4):847–56.

Querido JG, Warner TD, Eyberg SM. Parenting styles and child behavior in African American families of Preschool Children. J Clin Child Adolesc. 2002;31(2):272–7.

Baumrind D. Effective parenting during the early adolescent transition. Family transitions. Routledge; 2013. pp. 111–63.

Clarke K, Cooper P, Creswell C. The parental overprotection scale: associations with child and parental anxiety. J Affect Disord. 2013;151(2):618–24.

Gar NS, Hudson JL, Rapee RM. Family factors and the development of anxiety disorders. Psychopathology and the family. Elsevier; 2005. pp. 125–45.

Kolip P, Lademann J. Family and health. Familie und Gesundheit In: Hurrelmann K, Razum O, editors[Handbook of health sciences] Handbuch Gesundheitswissenschaften Weinheim: Beltz Juventa. 2012;517–40.

Alizadeh S, Talib MBA, Abdullah R, Mansor M. Relationship between parenting style and children’s behavior problems. Asian Social Sci. 2011;7(12):195–200.

Azman Ö, Mauz E, Reitzle M, Geene R, Hölling H, Rattay P. Associations between parenting style and mental health in children and adolescents aged 11–17 years: results of the KiGGS cohort study (second follow-up). Children. 2021;8(8):672.

Baumrind D. Child care practices anteceding three patterns of preschool behavior. Genetic Psychol Monogr. 1967;37(4):887.

Google Scholar

Robinson CC, Mandleco B, Olsen SF, Hart CH. The parenting styles and dimensions questionnaire (PSDQ). In: Handbook of family measurement techniques. 2001. p. 319–21.

Hanafi H, Thabet AAM. The relationship between parenting styles and Mental Health problems among Preschool Children living in Gaza Strip. EC Psychol Psychiatry. 2017;7(7):347–57.

Thompson A, Hollis C, Richards D. Authoritarian parenting attitudes as a risk for conduct problems. Eur Child Adoles Psy. 2003;12(2):84–91.

Baumrind D. Effects of authoritative parental control on child behavior. Child Dev. 1966;37(4):887.

Choe DE, Olson SL, Sameroff AJ. The interplay of externalizing problems and physical and inductive discipline during childhood. Dev Psychol. 2013;49(11):2029–39.

Lin X, Liao Y, Li H. Parenting styles and social competence in Chinese preschoolers: a Moderated Mediation Model of Singleton and Self-regulation. Early Educ Dev. 2021;33(3):437–51.

Sahithya BR, Manohari SM, Vijaya R. Parenting styles and its impact on children– a cross cultural review with a focus on India. Mental Health Relig Cult. 2019;22(4):357–83.

Singh S. Parenting style in relation to children’s mental health and self-esteem: a review of literature. Indian J Health Wellbeing. 2017;8(12).

Yamagata S, Takahashi Y, Ozaki K, Fujisawa KK, Nonaka K, Ando J. Bidirectional influences between maternal parenting and children’s peer problems: a longitudinal monozygotic twin difference study. Dev Sci. 2013;16(2):249–59.

Roskam I, Stievenart M, Meunier JC, Noël MP. The development of children’s inhibition: does parenting matter? J Exp Child Psychol. 2014;122:166–82.

Saltalı ND, İmir HM. Parenting styles as a predictor of the Preschool Children’s Social Behaviours. PER. 2018;5(2):18–37.

Cobb-Clark DA, Salamanca N, Zhu A. Parenting Style as an Investment in Human Development. IZA Discussion Paper. 2019; No 9686.

Conrade G, Ho R. Differential parenting styles for fathers and mothers: Differential treatment for sons and daughters. Aust J Psycholo. 2001;53(1):29–35.

Fauziyah R, Salimo H, Murti B. Influence of psycho-socio-economic factors, parenting style, and Sibling Rivalry, on Mental and Emotional Development of Preschool Children in Sidoarjo District. J Maternal Child Health. 2017;02(03):233–44.

September SJ, Rich EG, Roman NV. The role of parenting styles and socio-economic status in parents’ knowledge of child development. Early Child Dev Care. 2016;186(7):1060–78.

Someya T, Uehara T, Kadowaki M, Tang SW, Takahashi S. Effects of gender difference and birth order on perceived parenting styles, measured by the EMBU scale, in Japanese two-sibling subjects. Psychiatry Clin Neurosci. 2000;54(1):77–81.

Vyas K, Bano S, Islamia J. Child’s gender and parenting styles. Delhi Psychiatry Journal. 2016;2(19).

McKee L, Erin Roland N, Coffelt AL, Olson R, Forehand C, Massari et al. Harsh Discipline and Child Problem behaviors: the roles of positive parenting and gender. J Fam Viol. 2007;(22):187–96.

Hosokawa R, Katsura T. Role of parenting style in children’s behavioral problems through the transition from Preschool to Elementary School according to gender in Japan. IJERPH. 2018;16(1):21.

Hu Q, Feng Q. Parenting style and prosocial behaviour among Chinese preschool children: a moderation model. Early Child Dev Care. 2022;192(9):1444–61.

Jia S, Wang L, Shi Y. Relationship between parenting and proactive Versus reactive aggression among Chinese Preschool Children. Arch Psychiatr Nurs. 2014;28(2):152–7.

Chan SM, Bowes J, Wyver S. Parenting style as a context for emotion socialization. Early Educ Dev. 2009;20(4):631–56.

Hu Z, Wu L. The influence of parental styles on Children’s peer Interaction ability in senior class of Kindergarten—By taking research examples of some kindergartens in B City of Anhui Province (in Chinese). J Shaanxi Xueqian Normal Univ. 2019;35(8):7–12.

Li X, Xie J. Parenting styles of Chinese families and children’s social-emotional and cognitive developmental outcomes. Eur Early Child Educ. 2017;25(4):637–50.

Way N, Okazaki S, Zhao J, Kim JJ, Chen X, Yoshikawa H, et al. Social and emotional parenting: Mothering in a changing Chinese society. Asian AM J Psychol. 2013;4(1):61–70.

Wu P, Robinson CC, Yang C, Hart CH, Olsen SF, Porter CL, et al. Similarities and differences in mothers’ parenting of preschoolers in China and the United States. Int J Behav Dev. 2002;26(6):481–91.

Xu Y, Farver JA, Zhang Z, Zeng Q, Yu L, Cai B. Mainland Chinese parenting styles and parent-child interaction. Int J Behav Dev. 2005;29(6):524–31.

Fan J, Chen BB. Parenting styles and coparenting in China: the role of parents and children’s sibling status. Curr Psychol. 2020;39(5):1505–12.

Tan TX, Camras LA, Deng H, Zhang M, Lu Z. Family stress, parenting styles, and behavioral adjustment in preschool-age adopted Chinese girls. Early Child Res Q. 2012;27(1):128–36.

Xia X. Parenting style and Chinese children’s school readiness outcomes: the moderating role of socioeconomic status. Child Youth Serv Rev. 2020;118:105381.

Ren L, Pope Edwards C. Pathways of influence: Chinese parents’ expectations, parenting styles, and child social competence. Early Child Dev Care. 2015;185(4):614–30.

Goodman R. Psychometric properties of the strengths and difficulties Questionnaire. J AM Acad Child Psy. 2001;40(11):1337–45.

Du Y, Kou J, Coghill D. The validity, reliability and normative scores of the parent, teacher and self report versions of the strengths and difficulties Questionnaire in China. Child Adolesc Psychiatry Ment Health. 2008;2(1):8.

Wechsler D. Wechsler preschool and primary scale of intelligence—fourth edition. The Psychological Corporation San Antonio, TX; 2012.

Chen HY, Chen YH, Liao YK, Chen HP, Lynn R. Dysgenic fertility for intelligence and education in Taiwan. Intelligence. 2017;63:29–32.

Wang L, Xian Y, Dill SE, Fang Z, Emmers D, Zhang S, et al. Parenting style and the cognitive development of preschool-aged children: evidence from rural China. J Exp Child Psychol. 2022;223:105490.

Attanasio O, Cattan S, Fitzsimons E, Meghir C, Rubio-Codina M. Estimating the production function for human capital: results from a randomized controlled trial in Colombia. Am Econ Rev. 2020;110(1):48–85.

Cunha F, Heckman J. The technology of skill formation. Am Econ Rev. 2007;97(2):31–47.

Cunha F, Heckman JJ. Formulating, identifying and estimating the technology of cognitive and noncognitive skill formation. J Hum Resour. 2008;43(4):738–82.

Zhang H, Qin X. The impact of the parenting style on the formation of adolescent human capital (in Chinese). J Finance Econ. 2019;45(02):46–58.

Winsler A, Madigan AL, Aquilino SA. Correspondence between maternal and paternal parenting styles in early childhood. Early Child Res Q. 2005;20(1):1–12.

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This study is funded by the China Scholarship Council (No. 202306870036).

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LW participated in designing the data collection instruments, performed and supervised data collection and analyses, drafted and revised the manuscript. JT analyzed and drafted the manuscript. SR conceptualized and designed the study, designed the data collection instruments, critically reviewed and edited the manuscript. All authors approved the final manuscript as submitted.

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Wang, L., Tian, J. & Rozelle, S. Parenting style and child mental health at preschool age: evidence from rural China. BMC Psychiatry 24 , 314 (2024). https://doi.org/10.1186/s12888-024-05707-1

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Professor, School of Nursing, Midwifery & Social Sciences, CQ University Brisbane, Australia

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Associate Professor, School of Social Sciences, Monash University, Australia

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Novice nursing researchers may increase the reliability of their results by employing a framework to guide them through the process of conducting an integrative review.

A literature review is a critical analysis of published research literature based on a specified topic ( Pluye et al., 2016 ). Literature reviews identify literature then examine its strengths and weaknesses to determine gaps in knowledge ( Pluye et al. 2016 ). Literature reviews are an integral aspect of research projects; indeed, many reviews constitute a publication in themselves ( Snyder, 2019 ). There are various types of literature reviews based largely on the type of literature sourced ( Cronin et al. 2008 ). These include systematic literature reviews, traditional, narrative and integrative literature reviews ( Snyder, 2019 ). Aveyard and Bradbury-Jones (2019) found more than 35 commonly used terms to describe literature reviews. Within healthcare, systematic literature reviews initially gained traction and widespread support because of their reproducibility and focus on arriving at evidence-based conclusions that could influence practice and policy development ( Boell and Cecez-Kecmanovic, 2015 ). Yet, it became apparent that healthcare-related treatment options needed to review broader spectrums of research for treatment options to be considered comprehensive, holistic and patient orientated ( Boell and Cecez-Kecmanovic, 2015 ). Stern et al. (2014) suggest that despite the focus in healthcare on quantitative research not all pertinent questions surrounding the provision of care can be answered from this approach. To devise solutions to multidimensional problems, all forms of trustworthy evidence need to be considered ( Stern et al. 2014 ).

Integrative reviews assimilate research data from various research designs to reach conclusions that are comprehensive and reliable ( Soares et al. 2014 ). For example, an integrative review considers both qualitative and quantitative research to reach its conclusions. This approach promotes the development of a comprehensive understanding of the topic from a synthesis of all forms of available evidence ( Russell, 2005 ; Torraco, 2005 ). The strengths of an integrative review include its capacity to analyse research literature, evaluate the quality of the evidence, identify knowledge gaps, amalgamate research from various research designs, generate research questions and develop theoretical frameworks ( Russell, 2005 ). Aveyard and Bradbury-Jones (2019) suggested that integrative reviews exhibit similar characteristics to systematic reviews and may therefore be regarded as rigorous.

Integrative reviews value both qualitative and quantitative research which are built upon differing epistemological paradigms. Both types of research are vital in developing the evidence base that guides healthcare provision ( Leppäkoski and Paavilainen, 2012 ). Therefore, integrative reviews may influence policy development as their conclusions have considered a broad range of appropriate literature ( Whittemore and Knafl, 2005 ). An integrative approach to evidence synthesis allows healthcare professionals to make better use of all available evidence and apply it to the clinical practice environment ( Souza et al. 2010 ). For example, Aveyard and Bradbury-Jones (2019) found in excess of 12 different types of reviews employed to guide healthcare practice. The healthcare profession requires both quantitative and qualitative forms of research to establish the robust evidence base that enables the provision of evidence-based patient-orientated healthcare.

Integrative reviews require a specific set of skills to identify and synthesise literature ( Boell and Cecez-Kecmanovic, 2010 ). There remains a paucity of literature that provides explicit guidance to novice nursing researchers on how to conduct an integrative review and importantly how to ensure the results and conclusions are both comprehensive and reliable. Furthermore, novice nursing researchers may receive little formal training to develop the skills required to generate a comprehensive integrative review ( Boote and Beile, 2005 ). Aveyard and Bradbury-Jones (2019) also emphasised the limited literature providing guidance surrounding integrative reviews. Therefore, novice nursing researchers need to rely on published guidance to assist them. In this regard this paper, using an integrative review conducted by the authors as a case study, aims to provide a framework for novice nursing researchers conducting integrative reviews.

Developing the framework

In conducting integrative reviews, the novice nursing researcher may need to employ a framework to ensure the findings are comprehensive and reliable ( Boell and Cecez-Kecmanovic, 2010 ; Snyder, 2019 ). A framework to guide novice nursing researchers in conducting integrative reviews has been adapted by the authors and will now be described and delineated. This framework used various published literature to guide its creation, namely works by Aveyard and Bradbury-Jones (2019) , Nelson (2014), Stern et al. (2014) , Whittemore and Knafl (2005) , Pluye et al. (2009) , Moher et al., (2009) and Attride-Stirling, (2001) . The suggested framework involves seven steps ( Figure 1 ).

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Integrative review framework ( Cooke et al. 2012 ; Riva et al. 2012 ).

Step 1: Write the review question

The review question acts as a foundation for an integrative study ( Riva et al. 2012 ). Yet, a review question may be difficult to articulate for the novice nursing researcher as it needs to consider multiple factors specifically, the population or sample, the interventions or area under investigation, the research design and outcomes and any benefit to the treatment ( Riva et al. 2012 ). A well-written review question aids the researcher to develop their research protocol/design and is of vital importance when writing an integrative review.

To articulate a review question there are numerous tools available to the novice nursing researcher to employ. These tools include variations on the PICOTs template (PICOT, PICO, PIO), and the Spider template. The PICOTs template is an established tool for structuring a research question. Yet, the SPIDER template has gained acceptance despite the need for further research to determine its applicability to multiple research contexts ( Cooke et al., 2012 ). Templates are recommended to aid the novice nursing researcher in effectively delineating and deconstructing the various elements within their review question. Delineation aids the researcher to refine the question and produce more targeted results within a literature search. In the case study, the review question was to: identify, evaluate and synthesise current knowledge and healthcare approaches to women presenting due to intimate partner violence (IPV) within emergency departments (ED). This review objective is delineated in the review question templates shown in Table 1 .

Comparison of elements involved with a PICOTS and SPIDER review question.

( Cooke et al. 2012 ; Riva et al. 2012 ).

Step 2: Determine the search strategy

In determining a search strategy, it is important for the novice nursing researcher to consider the databases employed, the search terms, the Boolean operators, the use of truncation and the use of subject headings. Furthermore, Nelson (2014) suggests that a detailed description of the search strategy should be included within integrative reviews to ensure readers are able to reproduce the results.

The databases employed within a search strategy need to consider the research aim and the scope of information contained within the database. Many databases vary in their coverage of specific journals and associated literature, such as conference proceedings ( Boell and Cecez-Kecmanovic, 2010 ). Therefore, the novice nursing researcher should consult several databases when conducting their searches. For example, search strategies within the healthcare field may utilise databases such as Cumulative Index to Nursing and Allied Healthcare Literature (CINAHL), Cochrane Library, Science Direct, ProQuest, Web of Science, Scopus and PsychInfo ( Cronin et al. 2008 ). These databases among others are largely considered appropriate repositories of reliable data that novice researchers may utilise when researching within healthcare. The date in which the searches are undertaken should be within the search strategy as searches undertaken after this date may generate increased results in line with the publication of further studies.

Utilising an established template to generate a research question allows for the delineation of key elements within the question as seen above. These key elements may assist the novice nursing researcher in determining the search terms they employ. Furthermore, keywords on published papers may provide the novice nursing researcher with alternative search terms, synonyms and introduce the researcher to key terminology employed within their field ( Boell and Cecez-Kecmanovic, 2010 ). For example, within the case study undertaken the search terms included among others: ‘domestic violence’, ‘domestic abuse’, ‘intimate partner violence and/or abuse’. To refine the search to the correct healthcare environment the terms ‘emergency department’ and/or ‘emergency room’ were employed. To link search terms, the researcher should consider their use of Boolean operators ‘And’ ‘Or’ and ‘Not’ and their use of truncation ( Cronin et al. 2008 ). Truncation is the shortening of words which in literature searches may increase the number of search results. Medical subject headings (MeSH) or general subject headings should be employed where appropriate and within this case study the headings included ‘nursing’, ‘domestic violence’ and ‘intimate partner violence’.

Inclusion and exclusion criteria allow the novice nursing researcher to reduce and refine the search parameters and locate the specific data they seek. Appropriate use of inclusion and exclusion criteria permits relevant data to be sourced as wider searches can produce a large amount of disparate data, whereas a search that is too narrow may result in the omission of significant findings ( Boell and Cecez-Kecmanovic, 2010 ). The novice nursing researcher needs to be aware that generating a large volume of search results may not necessarily result in relevant data being identified. Within integrative reviews there is potential for a large volume of data to be sourced and therefore time and resources required to complete the review need to be considered ( Heyvaert et al. 2017 ). The analysis and refining of a large volume of data can become a labour-intensive exercise for the novice nursing researcher ( Boell and Cecez-Kecmanovic, 2010 ).

Stern et al. (2014) suggest various elements that should be considered within inclusion/exclusion criteria:

the type of studies included;
the topic under exploration;
the outcomes;
publication language;
the time period; and
the methods employed.

The use of limiters or exclusion criteria are an effective method to manage the amount of time it takes to undertake searches and limit the volume of research generated. Yet, exclusion criteria may introduce biases in the search results and should therefore be used with caution and to produce specific outcomes by the novice nursing researcher ( Hammerstrøm et al. 2017 ).

Whittemore and Knafl (2005) suggest that randomised controlled trials, prospective and retrospective cohort studies, case control studies, cross sectional studies, systematic reviews and meta-analyses should all be included within the search strategy. Therefore, there are no biases based on the type of publication sourced ( Hammerstrøm et al. 2017 ).

There should be no restriction on the sample size within the studies recognising that qualitative studies generally have smaller sample sizes, and to capture the breadth of research available. There was no restriction on the date of publication within the case study as quality literature was limited. Scoping widely is an important strategy within integrative reviews to produce comprehensive results. A manual citation search of the reference list of all sourced papers was also undertaken by a member of the research team.

Literature may be excluded if those papers were published in a language foreign to the researcher with no accepted translation available. Though limiting papers based on translation availability may introduce some bias, this does ensure the review remains free from translational errors and cultural misinterpretations. In the case study, research conducted in developing countries with a markedly different healthcare service and significant resource limitations were excluded due to their lack of generalisability and clinical relevance; though this may have introduced a degree of location bias ( Nelson, 2014 ).

A peer review of the search strategy by an individual who specialises in research data searches such as a research librarian may be a viable method in which the novice healthcare researcher can ensure the search strategy is appropriate and able to generate the required data. One such tool that a novice nurse may employ is the Peer Review of the Search Strategy (PRESS) checklist. A peer review of the caste study was undertaken by a research librarian. All recommendations were incorporated into the search strategy which included removing a full text limiter, and changes to the Boolean and proximity operators.

After the search strategy has been implemented the researcher removes duplicate results and screened the retrieved publications based on their titles and abstracts. A second screening was then undertaken based on the full text of retrieved publications to remove papers that were irrelevant to the research question. Full text copies should then be obtained for critical appraisal employing validated methods.

Step 3: Critical appraisal of search results

The papers identified within the search strategy should undergo a critical appraisal to determine if they are appropriate and of sufficient quality to be included within the review. This should be conducted or reviewed by a second member of the research team, which occurred within this case study. Any discrepancies were discussed until consensus was achieved. A critical appraisal allows the novice healthcare researcher to appraise the relevance and trustworthiness of a study and, therefore, determine its applicability to their research (CASP, 2013). There are several established tools a novice nurse can employ in which to structure their critical appraisal. These include the Scoring System for Mixed-Methods Research and Mixed Studies Reviews developed by Pluye et al. (2009) and the Critical Appraisal Skills Programme (CASP, 2018) Checklists.

The review undertaken by the authors employed the scoring system for mixed-methods research and mixed-studies reviews developed by Pluye et al. (2009) . This scoring system was specifically designed for reviews employing studies from various research designs and therefore was utilised with ease ( Table 2 ).

The scoring system for mixed-methods research and mixed-studies reviews ( Pluye et al. 2009 ).

Using the CASP checklist aids the novice nursing researcher to examine the methodology of identified papers to establish validity. This critical appraisal tool contains 10 items. These items are yes or no questions that assist the researcher to determine (a) if the results of the paper are valid, (b) what the results are and (c) if it is relevant in the context of their study. For example, the checklist asks the researcher to consider the presence of a clear statement surrounding the aims of the research, and to consider why and how the research is important in regard to their topic (CASP, 2013). This checklist supports the nurse researcher to assess the validity, results and significance of research, and therefore appropriately decide on its inclusion within the review ( Krainovich-Miller et al., 2009 ).

Step 4: Summarise the search results

A summary of the results generated by literature searches is important to exemplify how comprehensive the literature is or conversely to identify if there are gaps in research. This summary should include the number of, and type of papers included within the review post limiters, screening and critical appraisal of search results. For example, within the review detailed throughout this paper the search strategy resulted in the inclusion of 25 qualitative and six quantitative papers ( Bakon et al. 2019 ). Many papers provide a summary of their search results visually in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram ( Boell and Cecez-Kecmanovic, 2015 ). PRISMA is a method of reporting that enables readers to assess the robustness of the results ( Leclercq et al. 2019 ; Moher et al. 2009 ). PRISMA promotes the transparency of the search process by delineating various items within the search process ( Leclercq et al. 2019 ; Moher et al. 2009 ). Researchers may decide how rigorously they follow this process yet should provide a rationale for any deviations ( Leclercq et al. 2019 ; Moher et al, 2009 ). Figure 2 is an example of the PRISMA flow diagram as it was applied within the case study.

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Example PRISMA flow diagram ( Bakon et al. 2019 ; Moher et al. 2009 ).

Step 5: Data extraction and reduction

Data can be extracted from the critically appraised papers identified through the search strategy employing extraction tables. Within the case study data were clearly delineated, as suggested by Boell and Cecez-Kecmanovic (2010) , into extraction or comparison tables ( Table 3 ). These tables specify the authors, the date of publication, year of publication, site where the research was conducted and the key findings. Setting out the data into tables facilitates the comparison of these variables and aids the researcher to determine the appropriateness of the papers’ inclusion or exclusion within the review ( Whittemore and Knafl, 2005 ).

Example of a data extraction table.

Step 6: Analysis

Thematic analysis is widely used in integrative research ( Attride-Stirling, 2001 ). In this section we will discuss the benefits of employing a structured approach to thematic analysis including the formation of a thematic network. A thematic network is a visual diagram or depiction of the themes displaying their interconnectivity. Thematic analysis with the development of a thematic network is a way of identifying themes at various levels and depicting the observed relationships and organisation of these themes ( Attride-Stirling, 2001 ). There are numerous methods and tools available in which to conduct a thematic analysis that may be of use to the novice healthcare researcher conducting an integrative review. The approach used in a thematic analysis is important though a cursory glance at many literature reviews will reveal that many authors do not delineate the methods they employ. This includes the thematic analysis approach suggested by Thomas and Harden (2008) and the approach to thematic networking suggested by Attride-Stirling (2001) .

Thomas and Harden (2008) espouse a three-step approach to thematic analysis which includes: (a) coding, (b) organisation of codes into descriptive themes, and (c) the amalgamation of descriptive themes into analytical themes. The benefit of this approach lies in its simplicity and the ease with which a novice nurse researcher can apply the required steps. In contrast, the benefit of the approach suggested by Attride-Stirling (2001) lies in its ability to move beyond analysis and generate a visual thematic network which facilitates a critical interpretation and synthesis of the data.

Thematic networks typically depict three levels: basic themes, organising themes and global themes ( Attride-Stirling, 2001 ). The thematic network can then be developed. A thematic network is a visual depiction that appears graphically as a web like design ( Attride-Stirling, 2001 ). Thematic networks emphasise the relationships and interconnectivity of the network. It is an illustrative tool that facilitates interpretation of the data ( Attride-Stirling, 2001 ).

The benefits of employing a thematic analysis and networking within integrative reviews is the flexibility inherent within the approach, which allows the novice nursing researcher to provide a comprehensive accounting of the data ( Nowell et al. 2017 ). Thematic analysis is also an easily grasped form of data analysis that is useful for exploring various perspectives on specific topics and highlighting knowledge gaps ( Nowell et al. 2017 ). Thematic analysis and networking is also useful as a method to summarise large or diversified data sets to produce insightful conclusions ( Attride-Stirling, 2001 ; Nowell et al. 2017 ). The ability to assimilate data from various seemingly disparate perspectives may be challenging for the novice nursing researcher conducting an integrative review yet this integration of data by thematic analysis and networking was is integral.

To ensure the trustworthiness of results, novice nursing researchers need to clearly articulate each stage within the chosen method of data analysis ( Attride-Stirling, 2001 ; Nowell et al. 2017 ). The method employed in data analysis needs to be precise and exhaustively delineated ( Attride-Stirling, 2001 ; Nowell et al. 2017 ). Attride-Stirling (2001) suggests six steps within her methods of thematic analysis and networking. These steps include:

code material;
identify themes;
construct thematic network;
describe and explore the thematic network;
summarise thematic network findings; and
interpret patterns to identify implications.

In employing the approach suggested by Attride-Stirling (2001) within the case study the coding of specific findings within the data permitted the development of various themes ( Table 4 ). Inclusion of both quantitative and qualitative findings within the themes facilitated integration of the data which identified patterns and generated insights into the current care provided to IPV victims within ED.

Coding and theme formation.

Step 7: Conclusions and implications

A conclusion is important to remind the reader why the research topic is important. The researcher can then follow advice by Higginbottom (2015) who suggests that in drawing and writing research conclusions the researcher has an opportunity to explain the significance of the findings. The researcher may also need to explain these conclusions in light of the study limitations and parameters. Higginbottom (2015) emphasises that a conclusion is not a summary or reiteration of the results but a section which details the broader implications of the research and translates this knowledge into a format that is of use to the reader. The implications of the review findings for healthcare practice, for healthcare education and research should be considered.

Employing this structured and comprehensive framework within the case study the authors were able to determine that there remains a marked barrier in the provision of healthcare within the ED to women presenting with IPV-related injury. By employing an integrative approach multiple forms of literature were reviewed, and a considerable gap was identified. Therefore, further research may need to focus on the developing a structured healthcare protocol to aid ED clinicians to meet the needs of this vulnerable patient population.

Integrative reviews can be conducted with success when they follow a structured approach. This paper proposes a framework that novice nursing researchers can employ. Applying our stepped framework within an integrative review will strengthen the robustness of the study and facilitate its translation into policy and practice. This framework was employed by the authors to identify, evaluate and synthesise current knowledge and approaches of health professionals surrounding the care provision of women presenting due to IPV within emergency departments. The recommendations from the case study are currently being translated and implemented into the practice environment.

Key points for policy, practice and/or research

Integrative literature reviews are required within nursing to consider elements of care provision from a holistic perspective.
There is currently limited literature providing explicit guidance on how to undertake an integrative literature review.
Clear delineation of the integrative literature review process demonstrates how the knowledge base was understood, organised and analysed.
Nurse researchers may utilise this guidance to ensure the reliability of their integrative review.

Shannon Dhollande is a Lecturer, registered nurse and researcher. Her research explores the provision of emergency care to vulnerable populations.

Annabel Taylor is a Professorial Research Fellow at CQ University who with her background in social work explores methods of addressing gendered violence such as domestic violence.

Silke Meyer is an Associate Professor in Criminology and the Deputy Director of the Gender and Family Violence Prevention Centre at Monash University.

Mark Scott is an Emergency Medical Consultant with a track record in advancing emergency healthcare through implementation of evidence-based healthcare.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethics: Due to the nature of this article this article did not require ethical approval.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Shannon Dhollande https://orcid.org/0000-0003-3181-7606

Silke Meyer https://orcid.org/0000-0003-3964-042X

Attride-Stirling J. (2001) Thematic networks: An analytic tool for qualitative research . Qualitative Research 1 ( 3 ): 385–405. [ Google Scholar ]
Aveyard H, Bradbury-Jones C. (2019) An analysis of current practices in undertaking literature reviews in nursing: Findings from a focused mapping review and synthesis . BMC Medical Research Methodology 19 ( 1 ): 1–9. [ PMC free article ] [ PubMed ] [ Google Scholar ]
Bakon S, Taylor A, Meyer S, et al. (2019) The provision of emergency healthcare for women who experience intimate partner violence: Part 1 An integrative review . Emergency Nurse 27 : 19–25. [ PubMed ] [ Google Scholar ]
Boell S, Cecez-Kecmanovic D. (2010) Literature reviews and the Hermeneutic circle . Australian Academic & Research Libraries 41 ( 2 ): 129–144. [ Google Scholar ]
Boell S, Cecez-Kecmanovic D. (2015) On being systematic in literature reviews . Journal of Information Technology 30 : 161–173. [ Google Scholar ]
Boote D, Beile P. (2005) Scholars before researchers: On the centrality of the dissertation literature review in research preparation . Educational Researcher 34 ( 6 ): 3–15. [ Google Scholar ]
Cooke A, Smith D, Booth A. (2012) Beyond PICO: The SPIDER tool for qualitative evidence synthesis . Qualitative Health Research 22 ( 10 ): 1435–1443. [ PubMed ] [ Google Scholar ]
Critical Appraisal Skills Programme (CASP) (2018) CASP Checklists . casp-uk.net/casp-tools-checklists.
Cronin P, Ryan F, Coughlan M. (2008) Undertaking a literature review: A step by step approach . British Journal of Nursing 17 ( 1 ): 38–43. [ PubMed ] [ Google Scholar ]
Hammerstrøm K, Wade A, Jørgensen A, et al. (2017) Searching for relevant studie . In: Heyvaert M, Hannes K, Onghena P. (eds) Using Mixed Methods Research Synthesis for Literature Reviews , Thousand Oaks, CA: SAGE, pp. 69–112. [ Google Scholar ]
Heyvaert M, Maes B, Onghena P, et al. (2017) Introduction to MMRS literature reviews . In: Heyvaert M, Hannes K, Onghena P. (eds) Using Mixed Methods Research Synthesis for Literature Reviews , Thousand Oaks, CA: SAGE, pp. 1–22. [ Google Scholar ]
Higginbottom G. (2015) Drawing conclusions from your research . In: Higginbottom G, Liamputtong P. (eds) Participatory Qualitative Research Methodologies in Health , London: SAGE, pp. 80–89. [ Google Scholar ]
Krainovich-Miller B, Haber J, Yost J, et al. (2009) Evidence-based practice challenge: Teaching critical appraisal of systematic reviews and clinical practice guidelines to graduate students . Journal of Nursing Education 48 ( 4 ): 186–195. [ PubMed ] [ Google Scholar ]
Leclercq V, Beaudart C, Ajamieh S, et al. (2019) Meta-analyses indexed in PsycINFO had a better completeness of reporting when they mention PRISMA . Journal of Clinical Epidemiology 115 : 46–54. [ PubMed ] [ Google Scholar ]
Leppäkoski T, Paavilainen E. (2012) Triangulation as a method to create a preliminary model to identify and intervene in intimate partner violence . Applied Nursing Research 25 : 171–180. [ PubMed ] [ Google Scholar ]
Moher D, Liberati A, Tetzlaff J, et al. (2009) Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement . PLoS Med 6 ( 7 ): e1000097. [ PMC free article ] [ PubMed ] [ Google Scholar ]
Nelson H. (2014) Systematic Reviews to Answer Health Care Questions , Philadelphia, PA: Wolters Kluwer Health. [ Google Scholar ]
Nowell L, Norris J, White D, et al. (2017) Thematic analysis . International Journal of Qualitative Methods 16 ( 1 ): 1–13. [ Google Scholar ]
Pluye P, Gagnon M, Griffiths F, et al. (2009) A scoring system for appraising mixed methods research, and concomitantly appraising qualitative, quantitative and mixed methods primary studies in mixed studies reviews . International Journal of Nursing Studies 46 : 529–546. [ PubMed ] [ Google Scholar ]
Pluye P, Hong Q, Bush P, et al. (2016) Opening up the definition of systematic literature review: The plurality of worldviews, methodologies and methods for reviews and syntheses . Journal of Clinical Epidemiology 73 : 2–5. [ PubMed ] [ Google Scholar ]
Riva JJ, Malik KM, Burnie SJ, et al. (2012) What is your research question? An introduction to the PICOT format for clinicians . The Journal of the Canadian Chiropractic Association 56 ( 3 ): 167–171. [ PMC free article ] [ PubMed ] [ Google Scholar ]
Russell C. (2005) An overview of the integrative research review . Progress in Transplantation 15 ( 1 ): 8–13. [ PubMed ] [ Google Scholar ]
Snyder H. (2019) Literature review as a research methodology: An overview and guidelines . Journal of Business Research 104 : 333–339. [ Google Scholar ]
Soares C, Hoga L, Peduzzi M, et al. (2014) Integrative review: Concepts and methods used in nursing . Revista da Escola de Enfermagem da USP 48 ( 2 ): 335–345. [ PubMed ] [ Google Scholar ]
Souza M, Silva M, Carvalho R. (2010) Integrative review: What is it? How to do it? Einstein 8 ( 1 ): 102–106. [ PubMed ] [ Google Scholar ]
Stern C, Jordan Z, McArthur A. (2014) Developing the review question and inclusion criteria . American Journal of Nursing 114 ( 4 ): 53–56. [ PubMed ] [ Google Scholar ]
Thomas J, Harden A. (2008) Methods for the thematic synthesis of qualitative research in systematic reviews . BMC Medical Research Methodology 8 : 45. [ PMC free article ] [ PubMed ] [ Google Scholar ]
Torraco R. (2005) Writing integrative literature reviews: Guidelines and examples . Human Resource Development Review 4 ( 3 ): 356–367. [ Google Scholar ]
Whittemore R, Knafl K. (2005) The integrative review: Updated methodology . Journal of Advanced Nursing 52 ( 5 ): 546–553. [ PubMed ] [ Google Scholar ]

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

International Organisation for Migration (IOM). IOM Definition of Migrant. 2024. Available from: https://www.iom.int/about-migration .Cited 2024 Feb 8.

International Organisation for Migration United Nations. World Migration Report. 2022. Available from: available: https://worldmigrationreport.iom.int/wmr-2022-interactive/ .

The United Nations Refugee Angency. Refugee facts: What is a refugee? 2024. Available from: https://www.unrefugees.org/refugee-facts/what-is-a-refugee/ . Cited 2024 Feb 8.

Migration Data Portal. Migration data in Europe. 2023. Available from: https://www.migrationdataportal.org/regional-data-overview/europe#past-and-present-trends . Cited 2023 Aug 22.

International Centre for Migration Policy Development. Migration Outlook 2022 Twelve migration issues to look out for in 2022 Origins, key events and priorities for Europe. 2022. Available from: https://www.icmpd.org/file/download/56783/file/ICMPD%2520Migration%2520Outlook%25202022.pdf .

European Parliament. Exploring migration causes: why people migrate. 2023. Available from: https://www.europarl.europa.eu/news/en/headlines/world/20200624STO81906/exploring-migration-causes-why-people-migrate .

World Health Organisation. Strategic plan: Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region 2016–2022. 2016. Available from: https://www.who.int/publications/i/item/strategic-plan-strategy-and-action-plan-for-refugee-and-migrant-health-in-the-who-european-region-2016-2022 .

Graetz V, Rechel B, Groot W, Norredam M, Pavlova M. Utilization of health care services by migrants in Europe—a systematic literature review. Br Med Bull. 2017;121(1):5–18. Available from: https://www.academic.oup.com/bmb/article-lookup/doi/10.1093/bmb/ldw057 .

Article CAS PubMed Google Scholar

Hannigan A, O'Donnell P, O'Keeffe M, MacFarlane A. How do Variations in Definitions of “Migrant” and their Application Influence the Access of Migrants to Health Care Services? Copenhagen: WHO Regional Office for Europe; 2016. (Health Evidence Network Synthesis Report, No. 46.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK391032/ .

Rechel B, Mladovsky P, Ingleby D, Mackenbach JP, McKee M. Migration and health in an increasingly diverse Europe. Lancet. 2013;381(9873):1235–45. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140673612620868 .

Article PubMed Google Scholar

Giannoni M, Franzini L, Masiero G. Migrant integration policies and health inequalities in Europe. BMC Public Health. 2016;16(1):463. Available from: http://www.bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-3095-9 .

Article PubMed PubMed Central Google Scholar

Lebano A, Hamed S, Bradby H, Gil-Salmerón A, Durá-Ferrandis E, Garcés-Ferrer J, et al. Migrants’ and refugees’ health status and healthcare in Europe: a scoping literature review. BMC Public Health. 2020;20(1):1039. Available from: https://www.bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-08749-8 .

Cézard G, Finney N, Kulu H, Marshall A. Ethnic differences in self-assessed health in Scotland: The role of socio-economic status and migrant generation. Popul Space Place. 2022;28(3):e2403. Available from: https://onlinelibrary.wiley.com/doi/10.1002/psp.2403 .

Article Google Scholar

Anson J. The migrant mortality advantage: a 70 month follow-up of the brussels population. Eur J Popul. 2004;20(3):191–218.

World Health Organisation. Health of refugees and migrants. WHO European Region. 2018. Available from: https://www.who.int/publications/i/item/health-of-refugees-and-migrants---who-european-region-(2018) .

Mladovsky P. A framework for analysing migrant health policies in Europe. Health Policy (New York). 2009;93(1):55–63. Available from: https://www.linkinghub.elsevier.com/retrieve/pii/S0168851009001444 .

De Vito E, de Waure C, Specchia ML, Parente P, Azzolini E, Frisicale EM, et al. Are undocumented migrants’ entitlements and barriers to healthcare a public health challenge for the European Union? Public Health Rev. 2016;37(1):13. Available from: http://publichealthreviews.biomedcentral.com/articles/10.1186/s40985-016-0026-3 .

Katikireddi SV, Bhopal R, Quickfall JA. GPs need training and funding in caring for refugees and asylum seekers. BMJ. 2004;328(7442):770.1. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj.328.7442.770 .

Carballo M, Hargreaves S, Gudumac I, Maclean EC. Evolving migrant crisis in Europe: implications for health systems. Lancet Glob Heal. 2017;5(3):e252-253. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2214109X17300402 .

Juárez SP, Honkaniemi H, Dunlavy AC, Aldridge RW, Barreto ML, Katikireddi SV et al. Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis. Lancet Glob Heal. 2019;7(4):e420–35. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2214109X18305606 .

Nielsen SS, Krasnik A. Poorer self-perceived health among migrants and ethnic minorities versus the majority population in Europe: a systematic review. Int J Public Health. 2010;55(5):357–71. Available from: ( http://link.springer.com/10.1007/s00038-010-0145-4 ).

World Health Organsation. World report on the health of refugees and migrants. 2022. Available from: https://www.who.int/publications/i/item/9789240054462 .

Burns R, Zhang CX, Patel P, Eley I, Campos-Matos I, Aldridge RW. Migration health research in the United Kingdom: a scoping review. J Migr Heal. 2021;4:100061. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2666623521000283 .

Villarroel N, Hannigan A, Severoni S, Puthoopparambil S, MacFarlane A. Migrant health research in the Republic of Ireland: a scoping review. BMC Public Health. 2019;19(1):324. Available from: ( https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-6651-2 ).

Scottish Government. Demographic Change in Scotland. 2010. Available from: https://www.gov.scot/binaries/content/documents/govscot/publications/research-and-analysis/2010/11/demographic-change-scotland/documents/0108163-pdf/0108163-pdf/govscot%3Adocument/0108163.pdf .

National Records of Scotland. Projected Population of Scotland (Interim) 2020-based. 2022. Available from: https://www.nrscotland.gov.uk/files/statistics/population-projections/2020-based/pop-proj-2020-scot-nat-pub.pdf .

Scottish Government. Coronavirus (COVID-19) - experiences of vulnerable children, young people, and parents: research. 2021. Available from: https://www.gov.scot/publications/experiences-vulnerable-children-young-people-parents-during-covid-19-pandemic/ .

Scotland’s Census. Scotland’s Census: Ethnicity. 2011. Available from: https://www.scotlandscensus.gov.uk/census-results/at-a-glance/ethnicity/#:~:text=Scotland’spopulationwas96.0%25 .

Walsh D. The changing ethnic profiles of Glasgow and Scotland, and the implications for population health. 2017. Available from: https://www.gcph.co.uk/assets/0000/6255/The_changing_ethnic_profiles_of_Glasgow_and_Scotland.pdf .

National Records of Scotland. Migration Statistics Quarterly Summary for Scotland. 2021. Available from: https://www.nrscotland.gov.uk/files/statistics/migration/quarterly-summary/miration-statistics-quarterly-summary-february-2021.pdf .

The Scottish Ethnicity and Health Research Strategy Working Group. Health in our Multi-ethnic Scotland Future Research Priorities. 2009. Available from: https://www.healthscotland.scot/media/1842/health-in-our-multi-ethnic-scotland-full-report.pdf .

The Scottish Public Health Observatory. Ethnic minorities: defining ethnicity and race. 2023. Available from: https://www.scotpho.org.uk/population-groups/ethnic-minorities/defining-ethnicity-and-race/ . Cited 2023 Aug 22.

Krasnik A, Bhopal RS, Gruer L, Kumanyika SK. Advancing a unified, global effort to address health disadvantages associated with migration, ethnicity and race. Eur J Public Health. 2018;28(suppl_1). Available from: https://academic.oup.com/eurpub/article/doi/10.1093/eurpub/cky046/4956664 .

Bhopal R, Fischbacher C, Povey C, Chalmers J, Mueller G, Steiner M, et al. Cohort profile: scottish health and ethnicity linkage study of 4.65 million people exploring ethnic variations in disease in Scotland. Int J Epidemiol. 2011;40(5):1168–75. Available from: https://academic.oup.com/ije/article-lookup/doi/10.1093/ije/dyq118 .

Bhopal RS, Gruer L, Cezard G, Douglas A, Steiner MFC, Millard A, et al. Mortality, ethnicity, and country of birth on a national scale, 2001–2013: a retrospective cohort (Scottish Health and Ethnicity Linkage Study). Basu S, editor. Plos Med. 2018;15(3):e1002515. https://doi.org/10.1371/journal.pmed.1002515 . Basu S, editor.

Allik M, Brown D, Dundas R, Leyland AH. Differences in ill health and in socioeconomic inequalities in health by ethnic groups: a cross-sectional study using 2011 Scottish census. Ethn Health. 2022;27(1):190–208. https://doi.org/10.1080/13557858.2019.1643009 ( https://www.tandfonline.com/doi/full/ ).

Watkinson RE, Sutton M, Turner AJ. Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey. Lancet Public Hea. 2021;6(3):e145-154.

Fischbacher CM, Cezard G, Bhopal RS, Pearce J, Bansal N. Measures of socioeconomic position are not consistently associated with ethnic differences in cardiovascular disease in Scotland: methods from the Scottish Health and Ethnicity Linkage Study (SHELS). Int J Epidemiol. 2014;43(1):129–39. Available from: https://academic.oup.com/ije/article-lookup/doi/10.1093/ije/dyt237 .

Scottish Government. Characteristics of Recent and Established EEA and non-EEA migrants in Scotland: Analysis of the 2011 Census. 2015. Available from: https://www.gov.scot/publications/characteristics-recent-established-eea-non-eea-migrants-scotland-analysis-2011-census/ .

House of Lords Library. Refugees and asylum-seekers: UK policy. 2022. https://lordslibrary.parliament.uk/refugees-and-asylum-seekers-uk-policy/ .

British Medical Association. Refugee and asylum seeker patient health toolkit. Unique health challenges for refugees and asylum seekers. 2022. Available from: https://www.bma.org.uk/advice-and-support/ethics/refugees-overseas-visitors-and-vulnerable-migrants/refugee-and-asylum-seeker-patient-health-toolkit/unique-health-challenges-for-refugees-and-asylum-seekers .

Khalil H, Peters M, Godfrey CM, McInerney P, Soares CB, Parker D. An evidence-based approach to scoping reviews. Worldviews Evidence-Based Nurs. 2016;13(2):118–23. Available from: https://doi.org/10.1111/wvn.12144 .

Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5(1):69. Available from: ( http://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-5-69 ).

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.Available from: http://www.tandfonline.com/doi/abs/10.1080/1364557032000119616 ).

Kearns A, Whitley E, Egan M, Tabbner C, Tannahill C. Healthy migrants in an unhealthy city? The Effects of time on the health of migrants living in deprived areas of glasgow. J Int Migr Integr. 2017;18(3):675–98. Available from: http://link.springer.com/10.1007/s12134-016-0497-6 .

PubMed Google Scholar

Porqueddu T. Herbal medicines for diabetes control among Indian and Pakistani migrants with diabetes. Anthropol Med. 2017;24(1):17–31. Available from: https://www.tandfonline.com/doi/full/10.1080/13648470.2016.1249338 .

Roshan N. Supporting new communities: a qualitative study of health needs among asylum seekers and refugee communities in North Glasgow final report. 2005. Available from: https://www.stor.scot.nhs.uk/handle/11289/579930 .

Piacentini T, O’Donnell C, Phipps A, Jackson I, Stack N. Moving beyond the ‘language problem’: developing an understanding of the intersections of health, language and immigration status in interpreter-mediated health encounters. Lang Intercult Commun. 2019;19(3):256–71. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1353829214001233 .

Sime D. ‘I think that Polish doctors are better’: Newly arrived migrant children and their parents׳ experiences and views of health services in Scotland. Health Place. 2014;30:86–93. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1353829214001233 .

Steven K, Munoz S, Migrants, Matter. Report of a Peer Researched Project on EU Migrant Health in the Highlands of Scotland. University of the Highlands and Islands. 2016. Available from: https://www.spiritadvocacy.org.uk/assets/Birchwood-Highland-HUG-Migrants-Matter-study-2015-2016.pdf .

Anderson AS, Bush H, Lean M, Bradby H, Williams R, Lea E. Evolution of atherogenic diets in South Asian and Italian women after migration to a higher risk region. J Hum Nutr Diet. 2005;18(1):33–43. Available from: ( https://onlinelibrary.wiley.com/doi/10.1111/j.1365-277X.2004.00584.x ).

Isaacs A, Burns N, Macdonald S, O’Donnell CA. ‘I don’t think there’s anything I can do which can keep me healthy’: how the UK immigration and asylum system shapes the health and wellbeing of refugees and asylum seekers in Scotland. Crit Public Health. 2022;32(3):422–32. Available from: https://www.tandfonline.com/doi/full/10.1080/09581596.2020.1853058 .

Palattiyil G, Sidhva D. Caught in a web of multiple jeopardy: post-traumatic stress disorder and HIV-positive asylum seekers in Scotland. Clin Soc Work J. 2015;43(4):362–74. Available from: http://link.springer.com/10.1007/s10615-015-0542-5 ).

Abdulkadir J, Azzudin A, Buick A, Curtice L, Dzingisai M, Easton D, et al. What do you mean, I have a right to health? Participatory action research on health and human rights. 2016. Available from: https://strathprints.strath.ac.uk/58209/1/Abdulkadir_etal_IPPI_2016_What_do_you_mean_I_have_a_right_to_health.pdf .

Strang A, Quinn N. Integration or isolation? Mapping social connections and well-being amongst refugees in Glasgow. 2014. Available from: https://eresearch.qmu.ac.uk/bitstream/handle/20.500.12289/4139/eResearch%25204139.pdf?sequence=1&isAllowed=y .

Gorman DR, Bielecki K, Larson HJ, Willocks LJ, Craig J, Pollock KG. Comparing vaccination hesitancy in polish migrant parents who accept or refuse nasal flu vaccination for their children. Vaccine. 2020;38(13):2795–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0264410X20302255 .

Love J, Vertigans S, Domaszk E, Zdeb K, Love A, Sutton P. Health & ethnicity in Aberdeenshire: a study of Polish in-migrants; a report for the Scottish Health Council. 2007. Available from: https://rgu-repository.worktribe.com/output/247667 .

O’Donnell CA, Higgins M, Chauhan R, Mullen K. Asylum seekers’ expectations of and trust in general practice: a qualitative study. Br J Gen Pract. 2008;58(557):e1-11. Available from: https://bjgp.org/lookup/doi/10.3399/bjgp08X376104 .

Quinn N, Shirjeel S, Siebelt L, Donnelly R, Pietka E. An evaluation of the sanctuary community conversation programme to address mental health stigma with asylum seekers and refugees in Glasgow. 2011. Available from: https://www.healthscotland.com/uploads/documents/5584-SanctuaryCommunityConversationEvaluation.pdf .

Ager A. Community contact and mental health amongst socially isolated refugees in Edinburgh. J Refug Stud. 2002;15(1):71–80. Available from: https://academic.oup.com/jrs/article-lookup/doi/10.1093/jrs/15.1.71 .

Sim JA, Ulanika AA, Katikireddi SV, Gorman D. Out of two bad choices, I took the slightly better one’: Vaccination dilemmas for Scottish and Polish migrant women during the H1N1 influenza pandemic. Public Health. 2011;125(8):505–11. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0033350611001697 .

Zhao S, Patuano A. International Chinese Students in the UK: association between use of green spaces and lower stress levels. Sustainability. 2021;4(1):89. Available from: https://www.mdpi.com/2071-1050/14/1/89 .

Da Lomba S, Murray N. Women and Children First? Refused asylum seekers’ access to and experiences of maternity care in Glasgow. 2014. Available from: https://strathprints.strath.ac.uk/58655/1/Lomba_Murray_SRC_2014_Women_and_Children_First_Refused_Asylum_Seekers_Access_to_and_Experiences.pdf .

Sørbye IK, Vangen S, Juarez SP, Bolumar F, Morisaki N, Gissler M, et al. Birthweight of babies born to migrant mothers - What role do integration policies play? SSM - Popul Heal. 2019;9:100503. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2352827319301971 .

Teodorowski P, Woods R, Czarnecka M, Kennedy C. Brexit, acculturative stress and mental health among EU citizens in Scotland. Popul Space Place. 2021;27(6). Available from: https://onlinelibrary.wiley.com/doi/10.1002/psp.2436 .

Baillot H, Murray N, Connelly E, Howard N. Tackling Female Genital Mutilation in Scotland: A Scottish model of intervention. 2014. Available from: https://www.celcis.org/application/files/8116/2185/5421/Tackling_Female_Genital_Mutilation_-_A_Scottish_Model_of_Intervention.pdf .

Weishaar HB. Consequences of international migration: a qualitative study on stress among Polish migrant workers in Scotland. Public Health. 2008;122(11):1250–6. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0033350608000942 .

Weishaar HB. You have to be flexible—coping among polish migrant workers in Scotland. Health Place. 2010;16(5):820–7. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1353829210000432 .

Crowther S, Lau A. Migrant polish women overcoming communication challenges in scottish maternity services: a qualitative descriptive study. Midwifery. 2019;72:30–8. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0266613819300361 .

Fassetta G, Da Lomba S, Quinn N. A healthy start? Experiences of pregnant refugee and asylum seeking women in Scotland. 2016. Available from: https://www.redcross.org.uk/-/media/documents/about-us/research-publications/refugee-support/a-healthy-start-report.pdf .

Positive Action in Housing. 12 months since the Park Inn Tragedy in Glasgow, one in three hotel asylum seekers say their mental health has deteriorated. 2021. Available from: https://www.paih.org/one-in-three-glasgow-asylum-seekers-suffering-depression-and-anxiety .

Strang A. Refugee Peer Education for Health and Well-being. Evaluation Report. 2015. Available from: https://www.scottishrefugeecouncil.org.uk/wp-content/uploads/2019/10/Peer-Education-Evaluation-Report.pdf .

Strang A, Marsden R, Mignard E. The Holistic Integration Service: Learning and Evaluation Year 1. 2014. Available from: https://www.scottishrefugeecouncil.org.uk/wp-content/uploads/2019/10/Holistic-Integration-Service-year-1-evaluation-report.pdf .

British Red Cross. How will we survive? Steps to preventing destitution in the asylum system. 2021. Available from: https://www.redcross.org.uk/-/media/documents/about-us/how-will-we-survive-preventing-destitution-in-the-asylum-system.pdf .

Bhopal RS, Rafnsson SB, Agyemang C, Fagot-Campagna A, Giampaoli S, Hammar N, et al. Mortality from circulatory diseases by specific country of birth across six European countries: test of concept. Eur J Public Health. 2012;22(3):353–9. Available from: https://academic.oup.com/eurpub/article-lookup/doi/10.1093/eurpub/ckr062 .

Rafnsson SB, Bhopal RS, Agyemang C, Fagot-Campagna A, Harding S, Hammar N, et al. Sizable variations in circulatory disease mortality by region and country of birth in six European countries. Eur J Public Health. 2013;23(4):594–605. Available from: https://academic.oup.com/eurpub/article-lookup/doi/10.1093/eurpub/ckt023 ).

de Lima P, Masud Chaudhry M, Whelton R, Arshad R. A study of migrant workers in Grampian. 2007. Available from: . http://www.communitiesscotland.gov.uk/stellent/groups/public/%0Adocuments/webpages/pubcs_019731.pdff .

Ikram UZ, Mackenbach JP, Harding S, Rey G, Bhopal RS, Regidor E, et al. All-cause and cause-specific mortality of different migrant populations in Europe. Eur J Epidemiol. 2016;31(7):655–65. Available from: http://link.springer.com/10.1007/s10654-015-0083-9 .

de Brún T, De-Brún MO, van Weel-Baumgarten E, van Weel C, Dowrick C, Lionis C, et al. Guidelines and training initiatives that support communication in cross-cultural primary-care settings: appraising their implementability using Normalization Process Theory. Fam Pract. 2015;cmv022. Available from: https://academic.oup.com/fampra/article-lookup/doi/10.1093/fampra/cmv022 .

García-Medrano S, Panhofer H. Improving migrant well-being: spontaneous movement as a way to increase the creativity, spontaneity and welfare of migrants in Glasgow. Body Mov Danc Psychother. 2020;15(3):189–203. Available from: https://www.tandfonline.com/doi/full/10.1080/17432979.2020.1767208 .

Jamil NA, Gray SR, Fraser WD, Fielding S, Macdonald HM. The relationship between vitamin D status and muscle strength in young healthy adults from sunny climate countries currently living in the northeast of Scotland. Osteoporos Int. 2017;28(4):1433–43. Available from: http://link.springer.com/10.1007/s00198-016-3901-3 .

Kaneoka M, Spence W. The cultural context of sexual and reproductive health support: an exploration of sexual and reproductive health literacy among female Asylum Seekers and Refugees in Glasgow. Int J Migr Heal Soc Care. 2019;16(1):46–64. Available from: https://www.emerald.com/insight/content/doi/10.1108/IJMHSC-01-2019-0002/full/html .

O’Donnell CA, Higgins M, Chauhan R, Mullen K. They think we’re OK and we know we’re not. A qualitative study of asylum seekers’ access, knowledge and views to health care in the UK. BMC Health Serv Res. 2007;7(1):75. Available from: https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-7-75 .

Cooper M, Harding S, Mullen K, O’Donnell C. ‘A chronic disease is a disease which keeps coming back … it is like the flu’: chronic disease risk perception and explanatory models among French- and Swahili-speaking African migrants. Ethn Health. 2012;17(6):597–613. Available from: http://www.tandfonline.com/doi/abs/10.1080/13557858.2012.740003 .

Ezika EA. An exploration of smoking behavior of african male immigrants living in glasgow. Tob Use Insights. 2014;7:TUI .S13262. Available from: http://journals.sagepub.com/doi/10.4137/TUI.S13262 .

Karadzhov D, White R. Between the whispers of the devil and the revelation of the word : christian clergy’s mental health literacy and pastoral support for BME congregants. J Spiritual Ment Heal. 2020;22(2):147–72. Available from: https://www.tandfonline.com/doi/full/10.1080/19349637.2018.1537755 ).

Yakubu BD, Simkhada P, van Teijlingen E, Eboh W. Sexual health information and uptake of sexual health services by African women in Scotland: a pilot study. Int J Heal Promot Educ. 2010;48(3):79–84. Available from: http://www.tandfonline.com/doi/abs/10.1080/14635240.2010.10708186 .

Goff J, Kay K, Lima M, Shallangwa S, We All Have A. Different Consciousness About It: Exploring the Sexual Health Needs of People From African Communities in Scotland. 2021. Available from: https://www.waverleycare.org/wp-content/uploads/2023/05/We_All_Have_Different_Consciousness_About_It_Report.pdf .

Bielecki K, Craig J, Willocks LJ, Pollock KG, Gorman DR. Impact of an influenza information pamphlet on vaccination uptake among Polish pupils in Edinburgh, Scotland and the role of social media in parental decision making. BMC Public Health. 2020;20(1):1381. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09481-z .

Article CAS PubMed PubMed Central Google Scholar

Gorman DR, Bielecki K, Willocks LJ, Pollock KG. A qualitative study of vaccination behaviour amongst female Polish migrants in Edinburgh, Scotland. Vaccine. 2019;37(20):2741–7. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0264410X19304220 .

Bak-Klimek A, Karatzias T, Elliott L, MacLean R. The determinants of well-being among polish economic immigrants. Testing the sustainable happiness model in migrant population. J Happiness Stud. 2018;19(6):1565–88. Available from: http://link.springer.com/10.1007/s10902-017-9877-7 .

Cheung NF. The cultural and social meanings of childbearing for Chinese and Scottish women in Scotland. Midwifery. 2002;18(4):279–95. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0266613802903281 .

Papadaki A, Scott J. The impact on eating habits of temporary translocation from a Mediterranean to a Northern European environment. Eur J Clin Nutr. 2002;56(5):455–61. Available from: https://www.nature.com/articles/1601337 .

McCann A, Mackie P. Improving the Health of Migrants to Scotland: An update for Scottish Directors of Public Health. 2016. Available from: https://www.scotphn.net/wp-content/uploads/2016/04/2016_03_23-Migrant-Health-Report-FINAL-1.pdf .

Ahmed A, Cameron S, Dickson C, Mountain K. Arabic-speaking students’ primary care experiences in Scotland. Community Pract J Community Pract Heal Visit Assoc. 2010;83(2):23–6.

Google Scholar

Bray J, Gorman D, Dundas K, Sim J. Obstetric care of New European migrants in Scotland: an audit of antenatal care, obstetric outcomes and communication. Scott Med J. 2010;55(3):26–31. Available from: ( http://journals.sagepub.com/doi/10.1258/rsmsmj.55.3.26 .

Cheung NF. Choice and control as experienced by Chinese and Scottish childbearing women in Scotland. Midwifery. 2002;18(3):200–13. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0266613802903153 .

Spence W, Zhu L. Perceptions of smoking cessation among Glasgow’s Chinese community. Tob Prev Cessat. 2017;3(October). Available from: http://www.journalssystem.com/tpc/Perceptions-of-smoking-cessation-among-Glasgow-s-Chinese-community,77942,0,2.html .

Gorman DR, Katikireddi SV, Morris C, Chalmers JWT, Sim J, Szamotulska K, et al. Ethnic variation in maternity care: a comparison of Polish and Scottish women delivering in Scotland 2004–2009. Public Health. 2014;128(3):262–7. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0033350613003910 .

Gorman DR, Porteous LA. Influences on Polish migrants’ breast screening uptake in Lothian, Scotland. Public Health. 2018;158:86–92. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0033350617304018 .

Hogg R, de Kok B, Netto G, Hanley J, Haycock-Stuart E. Supporting Pakistani and Chinese families with young children: perspectives of mothers and health visitors. Child Care Health Dev. 2015;41(3):416–23. Available from: https://onlinelibrary.wiley.com/doi/10.1111/cch.12154 .

Kearns A, Whitley E. Health, Wellbeing and Social Inclusion of Migrants in North Glasgow. 2010. Available from: https://www.gowellonline.com/assets/0000/0521/Health_Wellbeing_and_Social_Inclusion_of_Migrants_in_North_Glasgow.pdf .

Poole L, Adamson K. Report on the Situation of the Roma Community in Govanhill, Glasgow. 2008. Available from: https://www.bemis.org.uk/resources/gt/scotland/reportonthesituationoftheromacommunityingovanhill,Glasgow.pdf .

Schofield L, Walsh D, Feng Z, Buchanan D, Dibben C, Fischbacher C, et al. Does ethnic diversity explain intra-UK variation in mortality? A longitudinal cohort study. BMJ Open. 2019;9(3):e024563. Available from: https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2018-024563 .

Unger HW, McCallum AD, Ukachukwu V, McGoldrick C, Perrow K, Latin G, et al. Imported malaria in Scotland – an overview of surveillance, reporting and trends. Travel Med Infect Dis. 2011;9(6):289–97. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1477893911001074 .

Young I, Flowers P, McDaid LM. Barriers to uptake and use of pre-exposure prophylaxis (PrEP) among communities most affected by HIV in the UK: findings from a qualitative study in Scotland. BMJ Open. 2014;4(11):e005717. Available from: https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2014-005717 .

Young I, Flowers P, McDaid LM. Key factors in the acceptability of treatment as prevention (TasP) in Scotland: a qualitative study with communities affected by HIV. Sex Transm Infect. 2015;91(4):269–74. Available from: https://sti.bmj.com/lookup/doi/10.1136/sextrans-2014-051711 .

Bhopal R, Cm FI, Teiner SM, Halmers CJ, Ovey PC, Amieson J. Ethnicity and health in Scotland: Can we fill the information gap ? A demonstration project focusing on coronary heart disease and linkage of census and health records. Ethics. 2005. Available from: http://www.cphs.mvm.ed.ac.uk/docs/Retrocodingfinalreport.pdf .

Cezard GI, Bhopal RS, Ward HJT, Bansal N, Bhala N. Ethnic variations in upper gastrointestinal hospitalizations and deaths: the Scottish Health and Ethnicity Linkage Study. Eur J Public Health. 2016;26(2):254–60. Available from: https://academic.oup.com/eurpub/article-lookup/doi/10.1093/eurpub/ckv182 .

Christie-de Jong F, Kotzur M, Amiri R, Ling J, Mooney JD, Robb KA. Qualitative evaluation of a codesigned faith-based intervention for muslim women in Scotland to encourage uptake of breast, colorectal and cervical cancer screening. BMJ Open. 2022;12(5):e058739. Available from: https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2021-058739 .

Cree VE, Sidhva D. Children and HIV in Scotland: findings from a cross-sector needs assessment of children and young people infected and affected by HIV in Scotland. Br J Soc Work. 2011;41(8):1586–603. Available from: https://academic.oup.com/bjsw/article-lookup/doi/10.1093/bjsw/bcr036 .

Gallimore A, Irshad T, Cooper M, Cameron S. Influence of culture, religion and experience on the decision of Pakistani women in Lothian, Scotland to use postnatal contraception: a qualitative study. BMJ Sex Reprod Heal. 2021;47(1):43–8. Available from: https://jfprhc.bmj.com/lookup/doi/10.1136/bmjsrh-2019-200497 .

Gruer LD, Cézard GI, Wallace LA, Hutchinson SJ, Douglas AF, Buchanan D, et al. Complex differences in infection rates between ethnic groups in Scotland: a retrospective, national census-linked cohort study of 1.65 million cases. J Public Health (Bangkok). 2022;44(1):60–9. Available from: https://academic.oup.com/jpubhealth/article/44/1/60/6106111 .

Article CAS Google Scholar

Bhala N, Cézard G, Ward HJT, Bansal N, Bhopal R. Ethnic variations in liver- and alcohol-related disease hospitalisations and mortality: the Scottish health and ethnicity linkage study. Alcohol Alcohol. 2016;51(5):593–601. Available from: https://academic.oup.com/alcalc/article-lookup/doi/10.1093/alcalc/agw018 .

Pollock KG, McDonald E, Smith-Palmer A, Johnston F, Ahmed S. Tuberculosis in healthcare workers, Scotland. Scott Med J. 2017;62(3):101–3. Available from: http://journals.sagepub.com/doi/10.1177/0036933017727963 .

Gruer LD, Millard AD, Williams LJ, Bhopal RS, Katikireddi SV, Cézard GI, et al. Differences in all-cause hospitalisation by ethnic group: a data linkage cohort study of 4.62 million people in Scotland, 2001–2013. Public Health. 2018;161:5–11. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0033350618301501 .

Jackson C, Bedford H, Cheater FM, Condon L, Emslie C, Ireland L, et al. Needles, Jabs and Jags: a qualitative exploration of barriers and facilitators to child and adult immunisation uptake among Gypsies, Travellers and Roma. BMC Public Health. 2017;17(1):254. Available from: http://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4178-y .

John JR, Curry G, Cunningham-Burley S. Exploring ethnic minority women’s experiences of maternity care during the SARS-CoV-2 pandemic: a qualitative study. BMJ Open. 2021;11(9):e050666. Available from: https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2021-050666 .

Lawton J, Ahmad N, Hanna L, Douglas M, Hallowell N. Diabetes service provision: a qualitative study of the experiences and views of Pakistani and Indian patients with Type 2 diabetes. Diabet Med. 2006;23(9):1003–7. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2006.01922.x .

Livingston MR, Shaw LE, Codere G, Goldberg DJ. Human immunodeficiency virus acquired heterosexually abroad: expert panel assessment of the indigenous/nonindigenous to the united kingdom status of cases. J Travel Med. 2006;12(1):19–25. Available from: https://academic.oup.com/jtm/article-lookup/doi/10.2310/7060.2005.00005 .

Nelson M, Patton A, Robb K, Weller D, Sheikh A, Ragupathy K, et al. Experiences of cervical screening participation and non-participation in women from minority ethnic populations in Scotland. Heal Expect. 2021;24(4):1459–72. Available from: https://onlinelibrary.wiley.com/doi/10.1111/hex.13287 .

Noble G, Okpo E, Tonna I, Fielding S. Factors associated with late HIV diagnosis in North-East Scotland: a six-year retrospective study. Public Health. 2016;139:36–43. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0033350616301020 .

Gillespie M. Trapped: Destitution and Asylum in Scotland. 2012. Available from: http://www.rst.org.uk/wp-content/uploads/2012/11/Trapped-destitution-and-asylum-summary-final-compressed-pictures.pdf .

Hopkins P, Hill M. The needs and strengths of unaccompanied asylum-seeking children and young people in Scotland. Child Fam Soc Work. 2010;15(4):399–408. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1365-2206.2010.00687.x .

Marsden R, Harris C. “We started life again”: Integration experiences of refugee families reuniting in Glasgow. 2015. Available from: https://www.refworld.org/docid/560cde294.html .

Martzoukou K, Burnett S. Exploring the everyday life information needs and the socio-cultural adaptation barriers of Syrian refugees in Scotland. J Doc. 2018;74(5):1104–32. Available from: https://www.emerald.com/insight/content/doi/10.1108/JD-10-2017-0142/full/html .

McKenna R. From pillar to post: Destitution among people refused asylum in Scotland. 2019; Available from: https://www.rst.org.uk/wp-content/uploads/2019/03/From-Pillar-to-Post-Feb-2019.pdf .

Independent Commission of Inquiry. Failings in the provision of care to New Scots during the Covid pandemic: Part 2. 2022. Available from: https://static1.squarespace.com/static/62af1289a666c80e00b17253/t/636b9190408f81778746eaa7/1667994032702/AIS+Phase+2+Report+Full.pdf .

Trevena P, Gawlewicz A, Wright S. Addressing the needs of Scotland’s migrant and minority ethnic populations under Covid-19: lessons for the future. 2022. Available from: https://migrantessentialworkers.com/wp-content/uploads/2022/11/SC-Migrant-C19-Innovations.pdf .

Oduntan O, Ruthven I. The information needs matrix: a navigational guide for refugee integration. Inf Process Manag. 2019;56(3):791–808. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0306457318306939 .

Sime D, Fox R, Migrant C. Social capital and access to services post-migration: transitions, negotiations and complex agencies. Child Soc. 2015;29(6):524–34. Available from: https://onlinelibrary.wiley.com/doi/10.1111/chso.12092 .

Strang A, Baillot H, Mignard E. Insights into integration pathways. New Scots and the Holistic Integration Service. A report drawing on year two of the Holistic Integration Service. 2015. Available from: https://scottishrefugeecouncil.org.uk/wp-content/uploads/2019/10/Holistic-Integration-Service-Year-2-report.pdf .

Weir KEA, Wilson SJ, Gorman DR. The Syrian vulnerable person resettlement programme: evaluation of Edinburgh’s reception arrangements. J Public Health (Bangkok). 2018;40(3):451–60. Available from: https://academic.oup.com/jpubhealth/article/40/3/451/4600209 .

Hammond CN. Scots 2- Engagement analysis of the New Scot Refugee Integration Strategy 2018–2022. 2018. Available from: https://www.gov.scot/binaries/content/documents/govscot/publications/research-and-analysis/2018/06/news-scots-2-engagement-analysis-new-scots-refugee-integration-strategy/documents/00537019-pdf/00537019-pdf/govscot%3Adocument/00537019.pdf .

Blake Stevenson. A8 Nationals in Glasgow. 2007. Available from: http://crosshillandgovanhill.org.uk/grindocs/A8NationalsinGlasgow.pdf .

Ajetunmobi O, Whyte B, Chalmers J, Fleming M, Stockton D, Wood R. Informing the ‘early years’ agenda in Scotland: understanding infant feeding patterns using linked datasets. J Epidemiol Community Health. 2014;68(1):83–92. Available from: https://jech.bmj.com/lookup/doi/10.1136/jech-2013-202718 .

Laidlaw K, Wang D, Coelho C, Power M. Attitudes to ageing and expectations for filial piety across Chinese and British cultures: a pilot exploratory evaluation. Aging Ment Health. 2010;14(3):283–92. Available from: http://www.tandfonline.com/doi/abs/10.1080/13607860903483060 .

Marsden R, Aldegheri E, Khan A, Lowe M, Strang A, Salinas E, et al. “What’s going on?” A study into destitution and poverty faced by asylum seekers and refugees in Scotland. 2005. Available from: http://www.rst.org.uk/wp-content/uploads/2012/11/Whats_going_on_A_study.pdf .

Quinn N. Participatory action research with asylum seekers and refugees experiencing stigma and discrimination: the experience from Scotland. Disabil Soc. 2014;29(1):58–70. Available from: http://www.tandfonline.com/doi/abs/10.1080/09687599.2013.769863 .

British Red Cross, Refugee Survival Trust. How will we survive? Steps to preventing destitution in the asylum system. 2021. Available from: https://mcusercontent.com/c17c136fc126588cb51e5471d/files/a35dd0e1-d785-f962-6a41-01e928493775/DASS_Research_Report_2021.pdf .

O’Donnell R, Angus K, McCulloch P, Amos A, Greaves L, Semple S. Fathers’ views and experiences of creating a smoke-free home: a scoping review. Int J Environ Res Public Health. 2019;16(24):5164. Available from: https://www.mdpi.com/1660-4601/16/24/5164 .

Sweileh WM, Wickramage K, Pottie K, Hui C, Roberts B, Sawalha AF, et al. Bibliometric analysis of global migration health research in peer-reviewed literature (2000–2016). BMC Public Health. 2018;18(1):777. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5689-x .

Wren K. Supporting asylum seekers and refugees in glasgow: the role of multi-agency networks. J Refug Stud. 2007;20(3):391–413. Available from: https://academic.oup.com/jrs/article-lookup/doi/10.1093/jrs/fem006 .

UK Government Home Office. A Fairer Asylum Accommodation System. 2022. Available from: https://www.emcouncils.gov.uk/write/Migration/Asylum_Dispersal_Factsheet_PDF.pdf .

Scottish Refugee Council. Scotland’s Welcome: an analysis of community support for refugee integration. 2020. Available from https://scottishrefugeecouncil.org.uk/wp-content/uploads/2021/01/Community-support-analysis-2020.pdf .

Sturge G, UK Parliament House of Commons Library Asylum statistics Research Briefing. 2023. Available from: https://commonslibrary.parliament.uk/research-briefings/sn01403/#:~:text=IntheyearendingJune,ofimmigrantstotheUK .

The Migration Observatory. Where do migrants live in the UK? The Migration Observatory at the University of Oxford. 2022. Available from: https://migrationobservatory.ox.ac.uk/resources/briefings/where-do-migrants-live-in-the-uk .

Pavli A, Maltezou H. Health problems of newly arrived migrants and refugees in Europe. J Travel Med. 2017;24(4). Available from: http://academic.oup.com/jtm/article/doi/10.1093/jtm/tax016/3095987/Health-problems-of-newly-arrived-migrants-and .

Humphris R, Bradby H. Health Status of Refugees and Asylum Seekers in Europe. In: Oxford Research Encyclopedia of Global Public Health. Oxford University Press; 2017. Available from: https://oxfordre.com/publichealth/view/10.1093/acrefore/9780190632366.001.0001/acrefore-9780190632366-e-8 .

Bradby H, Humphris R, Newall D, Phillimore J. Public Health Aspects of Migrant Health: A Review of the Evidence on Health Status for Refugees and Asylum Seekers in the European Region. (Health Evidence Network Synthesis Report, No. 44.) ANNEX 2, DEFINITIONS OF REFUGEES, ASYLUM SEEKERS AND MIGRANTS IN THE LITERATURE. Copenhagen: Eerat; 2015. Available from: https://www.ncbi.nlm.nih.gov/books/NBK379415/ .

Gerritsen AAM, Bramsen I, Devillé W, van Willigen LHM, Hovens JE, van der Ploeg HM. Physical and mental health of Afghan, Iranian and Somali asylum seekers and refugees living in the Netherlands. Soc Psychiatry Psychiatr Epidemiol. 2006;41(1):18–26. Available from: http://link.springer.com/10.1007/s00127-005-0003-5 .

Laue J, Diaz E, Eriksen L, Risør T. Migration health research in Norway: a scoping review. Scand J Public Health. 2023;51(3):381–90. Available from: http://journals.sagepub.com/doi/10.1177/14034948211032494 .

Scottish Refugee Council. Ukraine response one year on. 2023. Available from: https://scottishrefugeecouncil.org.uk/ukraine-response-one-year-on/ . Cited 2023 Aug 26.

Woodward A, Howard N, Wolffers I. Health and access to care for undocumented migrants living in the European Union: a scoping review. Health Policy Plan. 2014;29(7):818–30. Available from: https://academic.oup.com/heapol/article-lookup/doi/10.1093/heapol/czt061 .

Simon J, Kiss N, Laszewska A, Mayer S. Public health aspects of migrant health: a review of the evidence on health status for labour migrants in the European Region. Health Evidence Network Synthesis Report 43. 2015. Available from: http://www.epgencms.europarl.europa.eu/cmsdata/upload/114f16b6-1667-44ab-802b-a5a83dd50af0/WHO-HEN-Report-A5-1-Labour-FINAL_EN.pdf .

Scottish Government. Seasonal migrant workers in Scottish agriculture: research report. 2023. Available from: https://www.gov.scot/publications/seasonal-migrant-workers-scottish-agriculture/pages/10/ .

Scottish Government. New Scots: refugee integration strategy 2018–2022. 2018. Available from: https://www.gov.scot/publications/new-scots-refugee-integration-strategy-2018-2022/pages/11/ .

Oliva A, Palavra V, Caloun J. Refugees in Scotland: understanding the policy domain. 2016. Available from: https://www.academia.edu/34097718/REFUGEES_IN_SCOTLAND_UNDERSTANDING_THE_POLICY_DOMAIN .

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. Available from: https://www.acpjournals.org/doi/10.7326/M18-0850 .

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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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KA, RO and GP finalised the study design collectively. GP conducted the searches, analysis and write up, with support from KA and RO. All three authors read and approved the manuscript prior to submission.

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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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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.

Boud D, Molloy E. Rethinking models of feedback for learning: The challenge of design. Assess Eval High Educ. 2013;38:698–712.

Article Google Scholar

Henderson M, Ajjawi R, Boud D, Molloy E. Identifying feedback that has impact. In: The Impact of Feedback in Higher Education. Springer International Publishing: Cham; 2019. p. 15–34.

Chapter Google Scholar

Winstone N, Carless D. Designing effective feedback processes in higher education: A learning-focused approach. 1st ed. New York: Routledge; 2020.

Google Scholar

Ajjawi R, Boud D. Assessment & Evaluation in Higher Education Researching feedback dialogue: an interactional analysis approach. 2015. https://doi.org/10.1080/02602938.2015.1102863 .

Carless D. Feedback loops and the longer-term: towards feedback spirals. Assess Eval High Educ. 2019;44:705–14.

Sadler DR. Formative assessment and the design of instructional systems. Instr Sci. 1989;18:119–44.

Hattie J, Timperley H. The Power of Feedback The Meaning of Feedback. Rev Educ Res. 2007;77:81–112.

Zarrinabadi N, Rezazadeh M. Why only feedback? Including feed up and feed forward improves nonlinguistic aspects of L2 writing. Language Teaching Research. 2023;27(3):575–92.

Fisher D, Frey N. Feed up, back, forward. Educ Leadersh. 2009;67:20–5.

Reimann A, Sadler I, Sambell K. What’s in a word? Practices associated with ‘feedforward’ in higher education. Assessment evaluation in higher education. 2019;44:1279–90.

Esterhazy R. Re-conceptualizing Feedback Through a Sociocultural Lens. In: Henderson M, Ajjawi R, Boud D, Molloy E, editors. The Impact of Feedback in Higher Education. Cham: Palgrave Macmillan; 2019. https://doi.org/10.1007/978-3-030-25112-3_5 .

Bransen D, Govaerts MJB, Sluijsmans DMA, Driessen EW. Beyond the self: The role of co-regulation in medical students’ self-regulated learning. Med Educ. 2020;54:234–41.

Ramani S, Könings KD, Ginsburg S, Van Der Vleuten CP. Feedback Redefined: Principles and Practice. J Gen Intern Med. 2019;34:744–53.

Atkinson A, Watling CJ, Brand PL. Feedback and coaching. Eur J Pediatr. 2022;181(2):441–6.

Suhoyo Y, Schonrock-Adema J, Emilia O, Kuks JBM, Cohen-Schotanus JA. Clinical workplace learning: perceived learning value of individual and group feedback in a collectivistic culture. BMC Med Educ. 2018;18:79.

Bowen L, Marshall M, Murdoch-Eaton D. Medical Student Perceptions of Feedback and Feedback Behaviors Within the Context of the “Educational Alliance.” Acad Med. 2017;92:1303–12.

Bok HGJ, Teunissen PW, Spruijt A, Fokkema JPI, van Beukelen P, Jaarsma DADC, et al. Clarifying students’ feedback-seeking behaviour in clinical clerkships. Med Educ. 2013;47:282–91.

Al-Kadri HM, Al-Kadi MT, Van Der Vleuten CPM. Workplace-based assessment and students’ approaches to learning: A qualitative inquiry. Med Teach. 2013;35(SUPPL):1.

Dennis AA, Foy MJ, Monrouxe LV, Rees CE. Exploring trainer and trainee emotional talk in narratives about workplace-based feedback processes. Adv Health Sci Educ. 2018;23:75–93.

Watling C, LaDonna KA, Lingard L, Voyer S, Hatala R. ‘Sometimes the work just needs to be done’: socio-cultural influences on direct observation in medical training. Med Educ. 2016;50:1054–64.

Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for Learners in Medical Education: What is Known? A Scoping Review Academic Medicine. 2017;92:1346–54.

Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19–32.

Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med. 2018;169:467–73.

Colquhoun HL, Levac D, O’brien KK, Straus S, Tricco AC, Perrier L, et al. Scoping reviews: time for clarity in definition methods and reporting. J Clin Epidemiol. 2014;67:1291–4.

StArt - State of Art through Systematic Review. 2013.

Levac D, Colquhoun H, O’Brien KK. Scoping studies: Advancing the methodology. Implementation Science. 2010;5:1–9.

Peters MDJ, BPharm CMGHK, Parker PMD, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid Based Healthc. 2015;13:141–6.

Bing-You R, Varaklis K, Hayes V, Trowbridge R, Kemp H, McKelvy D, et al. The Feedback Tango: An Integrative Review and Analysis of the Content of the Teacher-Learner Feedback Exchange. Acad Med. 2018;93:657–63.

Ossenberg C, Henderson A, Mitchell M. What attributes guide best practice for effective feedback? A scoping review. Adv Health Sci Educ. 2019;24:383–401.

Spooner M, Duane C, Uygur J, Smyth E, Marron B, Murphy PJ, et al. Self -regulatory learning theory as a lens on how undergraduate and postgraduate learners respond to feedback: A BEME scoping review: BEME Guide No. 66. Med Teach. 2022;44:3–18.

Long S, Rodriguez C, St-Onge C, Tellier PP, Torabi N, Young M. Factors affecting perceived credibility of assessment in medical education: A scoping review. Adv Health Sci Educ. 2022;27:229–62.

Bing-You R, Hayes V, Varaklis K, Trowbridge R, Kemp H, McKelvy D. Feedback for Learners in Medical Education: What is Known? A Scoping Review: Lippincott Williams and Wilkins; 2017.

Schopper H, Rosenbaum M, Axelson R. “I wish someone watched me interview:” medical student insight into observation and feedback as a method for teaching communication skills during the clinical years. BMC Med Educ. 2016;16:286.

Crommelinck M, Anseel F. Understanding and encouraging feedback-seeking behaviour: a literature review. Med Educ. 2013;47:232–41.

Adamson E, Kinga L, Foy L, McLeodb M, Traynor J, Watson W, et al. Feedback in clinical practice: Enhancing the students’ experience through action research. Nurse Educ Pract. 2018;31:48–53.

Al-Mously N, Nabil NM, Al-Babtain SA, et al. Undergraduate medical students’ perceptions on the quality of feedback received during clinical rotations. Med Teach. 2014;36(Supplement 1):S17-23.

Bates J, Konkin J, Suddards C, Dobson S, Pratt D. Student perceptions of assessment and feedback in longitudinal integrated clerkships. Med Educ. 2013;47:362–74.

Bennett AJ, Goldenhar LM, Stanford K. Utilization of a Formative Evaluation Card in a Psychiatry Clerkship. Acad Psychiatry. 2006;30:319–24.

Bok HG, Jaarsma DA, Spruijt A, Van Beukelen P, Van Der Vleuten CP, Teunissen PW, et al. Feedback-giving behaviour in performance evaluations during clinical clerkships. Med Teach. 2016;38:88–95.

Bok HG, Teunissen PW, Spruijt A, Fokkema JP, van Beukelen P, Jaarsma DA, et al. Clarifying students’ feedback-seeking behaviour in clinical clerkships. Med Educ. 2013;47:282–91.

Calleja P, Harvey T, Fox A, Carmichael M, et al. Feedback and clinical practice improvement: A tool to assist workplace supervisors and students. Nurse Educ Pract. 2016;17:167–73.

Carey EG, Wu C, Hur ES, Hasday SJ, Rosculet NP, Kemp MT, et al. Evaluation of Feedback Systems for the Third-Year Surgical Clerkship. J Surg Educ. 2017;74:787–93.

Daelmans HE, Overmeer RM, Van der Hem-Stokroos HH, Scherpbier AJ, Stehouwer CD, van der Vleuten CP. In-training assessment: qualitative study of effects on supervision and feedback in an undergraduate clinical rotation. Medical education. 2006;40(1):51–8.

DeWitt D, Carline J, Paauw D, Pangaro L. Pilot study of a ’RIME’-based tool for giving feedback in a multi-specialty longitudinal clerkship. Med Educ. 2008;42:1205–9.

Dolan BM, O’Brien CL, Green MM. Including Entrustment Language in an Assessment Form May Improve Constructive Feedback for Student Clinical Skills. Med Sci Educ. 2017;27:461–4.

Duijn CC, Welink LS, Mandoki M, Ten Cate OT, Kremer WD, Bok HG. Am I ready for it? Students’ perceptions of meaningful feedback on entrustable professional activities. Perspectives on medical education. 2017;6:256–64.

Elnicki DM, Zalenski D. Integrating medical students’ goals, self-assessment and preceptor feedback in an ambulatory clerkship. Teach Learn Med. 2013;25:285–91.

Embo MP, Driessen EW, Valcke M, Van der Vleuten CP. Assessment and feedback to facilitate self-directed learning in clinical practice of Midwifery students. Medical teacher. 2010;32(7):e263-9.

Eva KW, Armson H, Holmboe E, Lockyer J, Loney E, Mann K, et al. Factors influencing responsiveness to feedback: On the interplay between fear, confidence, and reasoning processes. Adv Health Sci Educ. 2012;17:15–26.

Farrell L, Bourgeois-Law G, Ajjawi R, Regehr G. An autoethnographic exploration of the use of goal oriented feedback to enhance brief clinical teaching encounters. Adv Health Sci Educ. 2017;22:91–104.

Fernando N, Cleland J, McKenzie H, Cassar K. Identifying the factors that determine feedback given to undergraduate medical students following formative mini-CEX assessments. Med Educ. 2008;42:89–95.

Garino A. Ready, willing and able: a model to explain successful use of feedback. Adv Health Sci Educ. 2020;25:337–61.

Garner MS, Gusberg RJ, Kim AW. The positive effect of immediate feedback on medical student education during the surgical clerkship. J Surg Educ. 2014;71:391–7.

Bing-You R, Hayes V, Palka T, Ford M, Trowbridge R. The Art (and Artifice) of Seeking Feedback: Clerkship Students’ Approaches to Asking for Feedback. Acad Med. 2018;93:1218–26.

Haffling AC, Beckman A, Edgren G. Structured feedback to undergraduate medical students: 3 years’ experience of an assessment tool. Medical teacher. 2011;33(7):e349-57.

Harrison CJ, Könings KD, Dannefer EF, Schuwirth LWTT, Wass V, van der Vleuten CPMM. Factors influencing students’ receptivity to formative feedback emerging from different assessment cultures. Perspect Med Educ. 2016;5:276–84.

Harrison CJ, Könings KD, Schuwirth LW, Wass V, Van der Vleuten CP, Konings KD, et al. Changing the culture of assessment: the dominance of the summative assessment paradigm. BMC medical education. 2017;17:1–4.

Harvey P, Radomski N, O’Connor D. Written feedback and continuity of learning in a geographically distributed medical education program. Medical teacher. 2013;35(12):1009–13.

Hochberg M, Berman R, Ogilvie J, Yingling S, Lee S, Pusic M, et al. Midclerkship feedback in the surgical clerkship: the “Professionalism, Reporting, Interpreting, Managing, Educating, and Procedural Skills” application utilizing learner self-assessment. Am J Surg. 2017;213:212–6.

Holmboe ES, Yepes M, Williams F, Huot SJ. Feedback and the mini clinical evaluation exercise. Journal of general internal medicine. 2004;19(5):558–61.

Tai JHM, Canny BJ, Haines TP, Molloy EK. The role of peer-assisted learning in building evaluative judgement: opportunities in clinical medical education. Adv Health Sci Educ. 2016;21:659–76.

Johnson CE, Keating JL, Molloy EK. Psychological safety in feedback: What does it look like and how can educators work with learners to foster it? Med Educ. 2020;54:559–70.

Joshi A, Generalla J, Thompson B, Haidet P. Facilitating the Feedback Process on a Clinical Clerkship Using a Smartphone Application. Acad Psychiatry. 2017;41:651–5.

Kiger ME, Riley C, Stolfi A, Morrison S, Burke A, Lockspeiser T. Use of Individualized Learning Plans to Facilitate Feedback Among Medical Students. Teach Learn Med. 2020;32:399–409.

Kogan J, Shea J. Implementing feedback cards in core clerkships. Med Educ. 2008;42:1071–9.

Lefroy J, Walters B, Molyneux A, Smithson S. Can learning from workplace feedback be enhanced by reflective writing? A realist evaluation in UK undergraduate medical education. Educ Prim Care. 2021;32:326–35.

McGinness HT, Caldwell PHY, Gunasekera H, Scott KM. ‘Every Human Interaction Requires a Bit of Give and Take’: Medical Students’ Approaches to Pursuing Feedback in the Clinical Setting. Teach Learn Med. 2022. https://doi.org/10.1080/10401334.2022.2084401 .

Noble C, Billett S, Armit L, Collier L, Hilder J, Sly C, et al. ``It’s yours to take{’’}: generating learner feedback literacy in the workplace. Adv Health Sci Educ. 2020;25:55–74.

Ogburn T, Espey E. The R-I-M-E method for evaluation of medical students on an obstetrics and gynecology clerkship. Am J Obstet Gynecol. 2003;189:666–9.

Po O, Reznik M, Greenberg L. Improving a medical student feedback with a clinical encounter card. Ambul Pediatr. 2007;7:449–52.

Parkes J, Abercrombie S, McCarty T, Parkes J, Abercrombie S, McCarty T. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ. 2013;18:397–407.

Paukert JL, Richards ML, Olney C. An encounter card system for increasing feedback to students. Am J Surg. 2002;183:300–4.

Rassos J, Melvin LJ, Panisko D, Kulasegaram K, Kuper A. Unearthing Faculty and Trainee Perspectives of Feedback in Internal Medicine: the Oral Case Presentation as a Model. J Gen Intern Med. 2019;34:2107–13.

Rizan C, Elsey C, Lemon T, Grant A, Monrouxe L. Feedback in action within bedside teaching encounters: a video ethnographic study. Med Educ. 2014;48:902–20.

Robertson AC, Fowler LC. Medical student perceptions of learner-initiated feedback using a mobile web application. Journal of medical education and curricular development. 2017;4:2382120517746384.

Scheidt PC, Lazoritz S, Ebbeling WL, Figelman AR, Moessner HF, Singer JE. Evaluation of system providing feedback to students on videotaped patient encounters. J Med Educ. 1986;61(7):585–90.

Sokol-Hessner L, Shea J, Kogan J. The open-ended comment space for action plans on core clerkship students’ encounter cards: what gets written? Acad Med. 2010;85:S110–4.

Sox CM, Dell M, Phillipi CA, Cabral HJ, Vargas G, Lewin LO. Feedback on oral presentations during pediatric clerkships: a randomized controlled trial. Pediatrics. 2014;134:965–71.

Spickard A, Gigante J, Stein G, Denny JC. Automatic capture of student notes to augment mentor feedback and student performance on patient write-ups. J Gen Intern Med. 2008;23:979–84.

Suhoyo Y, Van Hell EA, Kerdijk W, Emilia O, Schönrock-Adema J, Kuks JB, et al. nfluence of feedback characteristics on perceived learning value of feedback in clerkships: does culture matter? BMC medical education. 2017;17:1–7.

Torre DM, Simpson D, Sebastian JL, Elnicki DM. Learning/feedback activities and high-quality teaching: perceptions of third-year medical students during an inpatient rotation. Acad Med. 2005;80:950–4.

Urquhart LM, Ker JS, Rees CE. Exploring the influence of context on feedback at medical school: a video-ethnography study. Adv Health Sci Educ. 2018;23:159–86.

Watling C, Driessen E, van der Vleuten C, Lingard L. Learning culture and feedback: an international study of medical athletes and musicians. Med Educ. 2014;48:713–23.

Watling C, Driessen E, van der Vleuten C, Vanstone M, Lingard L. Beyond individualism: Professional culture and its influence on feedback. Med Educ. 2013;47:585–94.

Soemantri D, Dodds A, Mccoll G. Examining the nature of feedback within the Mini Clinical Evaluation Exercise (Mini-CEX): an analysis of 1427 Mini-CEX assessment forms. GMS J Med Educ. 2018;35:Doc47.

Van De Ridder JMMM, Stokking KM, McGaghie WC, ten Cate OTJ, van der Ridder JM, Stokking KM, et al. What is feedback in clinical education? Med Educ. 2008;42:189–97.

van de Ridder JMMM, McGaghie WC, Stokking KM, ten Cate OTJJ. Variables that affect the process and outcome of feedback, relevant for medical training: a meta-review. Med Educ. 2015;49:658–73.

Boud D. Feedback: ensuring that it leads to enhanced learning. Clin Teach. 2015. https://doi.org/10.1111/tct.12345 .

Brehaut J, Colquhoun H, Eva K, Carrol K, Sales A, Michie S, et al. Practice feedback interventions: 15 suggestions for optimizing effectiveness. Ann Intern Med. 2016;164:435–41.

Ende J. Feedback in clinical medical education. J Am Med Assoc. 1983;250:777–81.

Cantillon P, Sargeant J. Giving feedback in clinical settings. Br Med J. 2008;337(7681):1292–4.

Norcini J, Burch V. Workplace-based assessment as an educational tool: AMEE Guide No. 31. Med Teach. 2007;29:855–71.

Watling CJ, Ginsburg S. Assessment, feedback and the alchemy of learning. Med Educ. 2019;53:76–85.

van der Vleuten CPM, Schuwirth LWT, Driessen EW, Dijkstra J, Tigelaar D, Baartman LKJ, et al. A model for programmatic assessment fit for purpose. Med Teach. 2012;34:205–14.

Schuwirth LWT, der Vleuten CPM. Programmatic assessment: from assessment of learning to assessment for learning. Med Teach. 2011;33:478–85.

Schut S, Driessen E, van Tartwijk J, van der Vleuten C, Heeneman S. Stakes in the eye of the beholder: an international study of learners’ perceptions within programmatic assessment. Med Educ. 2018;52:654–63.

Henderson M, Boud D, Molloy E, Dawson P, Phillips M, Ryan T, Mahoney MP. Feedback for learning. Closing the assessment loop. Framework for effective learning. Canberra, Australia: Australian Government, Department for Education and Training; 2018.

Heeneman S, Pool AO, Schuwirth LWT, van der Vleuten CPM, Driessen EW, Oudkerk A, et al. The impact of programmatic assessment on student learning: theory versus practice. Med Educ. 2015;49:487–98.

Lefroy J, Watling C, Teunissen P, Brand P, Watling C. Guidelines: the do’s, don’ts and don’t knows of feedback for clinical education. Perspect Med Educ. 2015;4:284–99.

Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34:787–91.

Telio S, Ajjawi R, Regehr G. The, “Educational Alliance” as a Framework for Reconceptualizing Feedback in Medical Education. Acad Med. 2015;90:609–14.

Lockyer J, Armson H, Könings KD, Lee-Krueger RC, des Ordons AR, Ramani S, et al. In-the-Moment Feedback and Coaching: Improving R2C2 for a New Context. J Grad Med Educ. 2020;12:27–35.

Black P, Wiliam D. Developing the theory of formative assessment. Educ Assess Eval Account. 2009;21:5–31.

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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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The Courage to Follow the Evidence on Transgender Care

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By David Brooks

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Hilary Cass is the kind of hero the world needs today. She has entered one of the most toxic debates in our culture: how the medical community should respond to the growing numbers of young people who seek gender transition through medical treatments, including puberty blockers and hormone therapies. This month, after more than three years of research, Cass, a pediatrician, produced a report , commissioned by the National Health Service in England, that is remarkable for its empathy for people on all sides of this issue, for its humility in the face of complex social trends we don’t understand and for its intellectual integrity as we try to figure out which treatments actually work to serve those patients who are in distress. With incredible courage, she shows that careful scholarship can cut through debates that have been marked by vituperation and intimidation and possibly reset them on more rational grounds.

Cass, a past president of Britain’s Royal College of Pediatrics and Child Health, is clear about the mission of her report: “This review is not about defining what it means to be trans, nor is it about undermining the validity of trans identities, challenging the right of people to express themselves or rolling back on people’s rights to health care. It is about what the health care approach should be, and how best to help the growing number of children and young people who are looking for support from the N.H.S. in relation to their gender identity.”

This issue begins with a mystery. For reasons that are not clear, the number of adolescents who have sought to medically change their sex has been skyrocketing in recent years, though the overall number remains very small. For reasons that are also not clear, adolescents who were assigned female at birth are driving this trend, whereas before the late 2000s, it was mostly adolescents who were assigned male at birth who sought these treatments.

Doctors and researchers have proposed various theories to try to explain these trends. One is that greater social acceptance of trans people has enabled people to seek these therapies. Another is that teenagers are being influenced by the popularity of searching and experimenting around identity. A third is that the rise of teen mental health issues may be contributing to gender dysphoria. In her report, Cass is skeptical of broad generalizations in the absence of clear evidence; these are individual children and adolescents who take their own routes to who they are.

Some activists and medical practitioners on the left have come to see the surge in requests for medical transitioning as a piece of the new civil rights issue of our time — offering recognition to people of all gender identities. Transition through medical interventions was embraced by providers in the United States and Europe after a pair of small Dutch studies showed that such treatment improved patients’ well-being. But a 2022 Reuters investigation found that some American clinics were quite aggressive with treatment: None of the 18 U.S. clinics that Reuters looked at performed long assessments on their patients, and some prescribed puberty blockers on the first visit.

Unfortunately, some researchers who questioned the Dutch approach were viciously attacked. This year, Sallie Baxendale, a professor of clinical neuropsychology at the University College London, published a review of studies looking at the impact of puberty blockers on brain development and concluded that “critical questions” about the therapy remain unanswered. She was immediately attacked. She recently told The Guardian, “I’ve been accused of being an anti-trans activist, and that now comes up on Google and is never going to go away.”

As Cass writes in her report, “The toxicity of the debate is exceptional.” She continues, “There are few other areas of health care where professionals are so afraid to openly discuss their views, where people are vilified on social media and where name-calling echoes the worst bullying behavior.”

Cass focused on Britain, but her description of the intellectual and political climate is just as applicable to the U.S., where brutality on the left has been matched by brutality on the right, with crude legislation that doesn’t acknowledge the well-being of the young people in question. In 24 states Republicans have passed laws banning these therapies, sometimes threatening doctors with prison time if they prescribe the treatment they think is best for their patients.

The battle lines on this issue are an extreme case, but they are not unfamiliar. On issue after issue, zealous minorities bully and intimidate the reasonable majority. Often, those who see nuance decide it’s best to just keep their heads down. The rage-filled minority rules.

Cass showed enormous courage in walking into this maelstrom. She did it in the face of practitioners who refused to cooperate and thus denied her information that could have helped inform her report. As an editorial in The BMJ puts it, “Despite encouragement from N.H.S. England,” the “necessary cooperation” was not forthcoming. “Professionals withholding data from a national inquiry seems hard to imagine, but it is what happened.”

Cass’s report does not contain even a hint of rancor, just a generous open-mindedness and empathy for all involved. Time and again in her report, she returns to the young people and the parents directly involved, on all sides of the issue. She clearly spent a lot of time meeting with them. She writes, “One of the great pleasures of the review has been getting to meet and talk to so many interesting people.”

The report’s greatest strength is its epistemic humility. Cass is continually asking, “What do we really know?” She is carefully examining the various studies — which are high quality, which are not. She is down in the academic weeds.

She notes that the quality of the research in this field is poor. The current treatments are “built on shaky foundations,” she writes in The BMJ. Practitioners have raced ahead with therapies when we don’t know what the effects will be. As Cass tells The BMJ, “I can’t think of another area of pediatric care where we give young people a potentially irreversible treatment and have no idea what happens to them in adulthood.”

She writes in her report, “The option to provide masculinizing/feminizing hormones from age 16 is available, but the review would recommend extreme caution.” She does not issue a blanket, one-size-fits-all recommendation, but her core conclusion is this: “For most young people, a medical pathway will not be the best way to manage their gender-related distress.” She realizes that this conclusion will not please many of the young people she has come to know, but this is where the evidence has taken her.

You can agree or disagree with this or that part of the report, and maybe the evidence will look different in 10 years, but I ask you to examine the integrity with which Cass did her work in such a treacherous environment.

In 1877 a British philosopher and mathematician named William Kingdon Clifford published an essay called “ The Ethics of Belief .” In it he argued that if a shipowner ignored evidence that his craft had problems and sent the ship to sea having convinced himself it was safe, then of course we would blame him if the ship went down and all aboard were lost. To have a belief is to bear responsibility, and one thus has a moral responsibility to dig arduously into the evidence, avoid ideological thinking and take into account self-serving biases. “It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence,” Clifford wrote. A belief, he continued, is a public possession. If too many people believe things without evidence, “the danger to society is not merely that it should believe wrong things, though that is great enough; but that it should become credulous, and lose the habit of testing things and inquiring into them; for then it must sink back into savagery.”

Since the Trump years, this habit of not consulting the evidence has become the underlying crisis in so many realms. People segregate into intellectually cohesive teams, which are always dumber than intellectually diverse teams. Issues are settled by intimidation, not evidence. Our natural human tendency is to be too confident in our knowledge, too quick to ignore contrary evidence. But these days it has become acceptable to luxuriate in those epistemic shortcomings, not to struggle against them. See, for example, the modern Republican Party.

Recently it’s been encouraging to see cases in which the evidence has won out. Many universities have acknowledged that the SAT is a better predictor of college success than high school grades and have reinstated it. Some corporations have come to understand that while diversity, equity and inclusion are essential goals, the current programs often empirically fail to serve those goals and need to be reformed. I’m hoping that Hilary Cass is modeling a kind of behavior that will be replicated across academia, in the other professions and across the body politic more generally and thus save us from spiraling into an epistemological doom loop.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

Follow the New York Times Opinion section on Facebook , Instagram , TikTok , WhatsApp , X and Threads .

David Brooks has been a columnist with The Times since 2003. He is the author, most recently, of “How to Know a Person: The Art of Seeing Others Deeply and Being Deeply Seen.” @ nytdavidbrooks

COMMENTS

Literature Reviews
Literature Review & Systematic Review Steps. Develop a Focused Question; Scope the Literature (Initial Search) Refine & Expand the Search; ... Download a sample template of a health sciences review matrix (GoogleSheets) Steps modified from: Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach.
Reviewing the literature
This may require a comprehensive literature review: this article aims to outline the approaches and stages required and provides a working example of a published review. Literature reviews aim to answer focused questions to: inform professionals and patients of the best available evidence when making healthcare decisions; influence policy; and ...
Further reading & examples
Examples of literature reviews; Articles on literature reviews; Family needs and involvement in the intensive care unit: a literature review ... Brown, D. (2004). A literature review exploring how healthcare professionals contribute to the assessment and control of postoperative pain in older people. Journal of Clinical Nursing, 13(6b), 74-90 ...
Writing a Literature Review
Run a few sample database searches to make sure your research question is not too broad or too narrow. If possible, discuss your topic with your professor. 2. Determine the scope of your review. The scope of your review will be determined by your professor during your program. Check your assignment requirements for parameters for the Literature ...
How to Write a Literature Review
Examples of literature reviews. Step 1 - Search for relevant literature. Step 2 - Evaluate and select sources. Step 3 - Identify themes, debates, and gaps. Step 4 - Outline your literature review's structure. Step 5 - Write your literature review.
PDF Doing a Literature Review in Health
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A practical guide to data analysis in general literature reviews
This article is a practical guide to conducting data analysis in general literature reviews. The general literature review is a synthesis and analysis of published research on a relevant clinical issue, and is a common format for academic theses at the bachelor's and master's levels in nursing, physiotherapy, occupational therapy, public health and other related fields.
Performing a literature review
Literature reviews are most commonly performed to help answer a particular question. While you are at medical school, there will usually be some choice regarding the area you are going to review. Once you have identified a subject area for review, the next step is to formulate a specific research question. This is arguably the most important ...
Writing a literature review
Writing a literature review requires a range of skills to gather, sort, evaluate and summarise peer-reviewed published data into a relevant and informative unbiased narrative. Digital access to research papers, academic texts, review articles, reference databases and public data sets are all sources of information that are available to enrich ...
Conducting a Literature Review in Health Research: Basics of the
Background: Literature reviews play a significant role in healthcare practice. There are different types of reviews available depending on the nature of the research question and the extent of ...
The Literature Review: A Foundation for High-Quality Medical Education
Purpose and Importance of the Literature Review. An understanding of the current literature is critical for all phases of a research study. Lingard 9 recently invoked the "journal-as-conversation" metaphor as a way of understanding how one's research fits into the larger medical education conversation. As she described it: "Imagine yourself joining a conversation at a social event.
PDF Reviewing the literature
structured review of the literature. Health Expect 2015;18:452-74. Table 1 An example of rapid evidence assessment review Stages Example Background Living with a child with a long-term condition is challenging because of illness-specific demands. A critical evaluation of research exploring parents' experiences of living with a child with a ...
How to Conduct a Literature Review (Health Sciences and Beyond)
The other pages in this guide will cover some basic steps to consider when conducting a traditional health sciences literature review. See below for a quick look at some of the more popular types of literature reviews. For additional information on a variety of review methods, the following article provides an excellent overview. Grant MJ, Booth A.
Carrying out systematic literature reviews: an introduction
Abstract. Systematic reviews provide a synthesis of evidence for a specific topic of interest, summarising the results of multiple studies to aid in clinical decisions and resource allocation. They remain among the best forms of evidence, and reduce the bias inherent in other methods. A solid understanding of the systematic review process can ...
Conducting a Literature Review for Health Sciences
A literature review is an essential part of a research project. It discusses previous research on a topic. Some reasons to conduct a literature review include: To understand what is currently known about a topic. How does the research you propose to undertake fit into a larger picture. To offer an overview of significant literature published on ...
Guides: Public Health: Literature Reviews + Annotating
Literature Reviews. "Literature review," "systematic literature review," "integrative literature review" -- these are terms used in different disciplines for basically the same thing -- a rigorous examination of the scholarly literature about a topic (at different levels of rigor, and with some different emphases). 1.
Systematically Reviewing the Literature: Building the Evidence for
Systematic reviews that summarize the available information on a topic are an important part of evidence-based health care. There are both research and non-research reasons for undertaking a literature review. It is important to systematically review the literature when one would like to justify the need for a study, to update personal ...
Literature Review Help
Doing a Literature Review in Health and Social Care: ... Chapters match the stages of a literature review, from start to finish. Useful examples and key questions will help to keep the reader on track. With this book as your guide, developing a literature review need not be a daunting or overwhelming task." Dr Merryl E Harvey, Senior Academic ...
Scoping Review
According to Colquhoun et al. (2014), a scoping review can be defined as: "a form of knowledge synthesis, which incorporate a range of study designs to comprehensively summarize and synthesize evidence with the aim of informing practice, programs, and policy and providing direction to future research priorities" (p.1291). Characteristics.
Ten Simple Rules for Writing a Literature Review
Literature reviews are in great demand in most scientific fields. Their need stems from the ever-increasing output of scientific publications .For example, compared to 1991, in 2008 three, eight, and forty times more papers were indexed in Web of Science on malaria, obesity, and biodiversity, respectively .Given such mountains of papers, scientists cannot be expected to examine in detail every ...
A systematic literature review of researchers' and healthcare
Abstract A systematic literature review of researchers and healthcare professionals' attitudes towards the secondary use and sharing of health administrative and clinical trial data was conducted using electronic data searching. Eligible articles included those reporting qualitative or quantitative original research and published in English. No restrictions were placed on publication dates ...
Public Health: Literature Reviews
A scoping review is a type of knowledge synthesis that uses a systematic and iterative approach to identify and synthesize an existing or emerging body of literature on a given topic. While there are several reasons for conducting a scoping review, the main reasons are to map the extent, range, and nature of the literature, as well as to ...
Routine versus prompted clinical debriefing: aligning aims, mechanisms
Implementation of routine and prompted CD. Paxino et al present a comprehensive review of the existing literature of CD practices, and propose the new categories of routine and prompted CD. This useful distinction helps us appreciate that these types of CD differ not only in terms of the 'When' but also the 'Why' regarding the aims of the debrief—to learn and/or to manage emotional ...
Equitable and accessible informed healthcare consent process for people
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Parenting style and child mental health at preschool age: evidence from
Background Mental health problems among children at preschool age are a common issue across the world. As shown in literature, a caregiver's parenting style can play a critical role in child development. This study aims to examine the associations between a caregiver's parenting style and the mental health problems (or not) of their child when he/she is at preschool age in rural China ...
Full article: Organizational culture: a systematic review
Among these review methods, we preferred the structured review method to properly understand OC, identify trends, and draw any gaps in the existing literature. This strategy is advantageous because it enables the reviewer to recognize and emphasize the theories and structures frequently applied in OC research (Kunisch et al., Citation 2015 ).
Conducting integrative reviews: a guide for novice nursing researchers
Step 1: Write the review question. The review question acts as a foundation for an integrative study (Riva et al. 2012).Yet, a review question may be difficult to articulate for the novice nursing researcher as it needs to consider multiple factors specifically, the population or sample, the interventions or area under investigation, the research design and outcomes and any benefit to the ...
A scoping review of academic and grey literature on migrant health
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 ...
Designing feedback processes in the workplace-based learning of
A scoping review was conducted using the five-step methodological framework proposed by Arksey and O'Malley (2005) [], intertwined with the PRISMA checklist extension for scoping reviews to provide reporting guidance for this specific type of knowledge synthesis [].Scoping reviews allow us to study the literature without restricting the methodological quality of the studies found ...
Opinion
1334. By David Brooks. Opinion Columnist. Hilary Cass is the kind of hero the world needs today. She has entered one of the most toxic debates in our culture: how the medical community should ...

Health (Nursing, Medicine, Allied Health)

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Systematic Literature Reviews: Steps & Resources

Literature Review & Systematic Review Steps

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Literature Reviews

"Literature review," "systematic literature review," "integrative literature review" -- these are terms used in different disciplines for basically the same thing -- a rigorous examination of the scholarly literature about a topic (at different levels of rigor, and with some different emphases).

Doing a good job of organizing your information makes writing about it a lot easier.

Synthesizing your information is not just summarizing it. Here are processes and examples about how to combine your sources into a good piece of writing:

Annotated Bibliography

What does "peer-reviewed" mean?

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A systematic literature review of researchers’ and healthcare professionals’ attitudes towards the secondary use and sharing of health administrative and clinical trial data

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