research methodology in english literature

Chapter Four: Theory, Methodologies, Methods, and Evidence

Research Methods

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This page discusses the following topics:

Research Goals

Research method types.

Before discussing research methods , we need to distinguish them from methodologies and research skills . Methodologies, linked to literary theories, are tools and lines of investigation: sets of practices and propositions about texts and the world. Researchers using Marxist literary criticism will adopt methodologies that look to material forces like labor, ownership, and technology to understand literature and its relationship to the world. They will also seek to understand authors not as inspired geniuses but as people whose lives and work are shaped by social forces.

Example: Critical Race Theory Methodologies

Critical Race Theory may use a variety of methodologies, including

Interest convergence: investigating whether marginalized groups only achieve progress when dominant groups benefit as well
Intersectional theory: investigating how multiple factors of advantage and disadvantage around race, gender, ethnicity, religion, etc. operate together in complex ways
Radical critique of the law: investigating how the law has historically been used to marginalize particular groups, such as black people, while recognizing that legal efforts are important to achieve emancipation and civil rights
Social constructivism: investigating how race is socially constructed (rather than biologically grounded)
Standpoint epistemology: investigating how knowledge relates to social position
Structural determinism: investigating how structures of thought and of organizations determine social outcomes

To identify appropriate methodologies, you will need to research your chosen theory and gather what methodologies are associated with it. For the most part, we can’t assume that there are “one size fits all” methodologies.

Research skills are about how you handle materials such as library search engines, citation management programs, special collections materials, and so on.

Research methods are about where and how you get answers to your research questions. Are you conducting interviews? Visiting archives? Doing close readings? Reviewing scholarship? You will need to choose which methods are most appropriate to use in your research and you need to gain some knowledge about how to use these methods. In other words, you need to do some research into research methods!

Your choice of research method depends on the kind of questions you are asking. For example, if you want to understand how an author progressed through several drafts to arrive at a final manuscript, you may need to do archival research. If you want to understand why a particular literary work became a bestseller, you may need to do audience research. If you want to know why a contemporary author wrote a particular work, you may need to do interviews. Usually literary research involves a combination of methods such as archival research , discourse analysis , and qualitative research methods.

Literary research methods tend to differ from research methods in the hard sciences (such as physics and chemistry). Science research must present results that are reproducible, while literary research rarely does (though it must still present evidence for its claims). Literary research often deals with questions of meaning, social conventions, representations of lived experience, and aesthetic effects; these are questions that reward dialogue and different perspectives rather than one great experiment that settles the issue. In literary research, we might get many valuable answers even though they are quite different from one another. Also in literary research, we usually have some room to speculate about answers, but our claims have to be plausible (believable) and our argument comprehensive (meaning we don’t overlook evidence that would alter our argument significantly if it were known).

A literary researcher might select the following:

Theory: Critical Race Theory

Methodology: Social Constructivism

Method: Scholarly

Skills: Search engines, citation management

Wendy Belcher, in Writing Your Journal Article in 12 Weeks , identifies two main approaches to understanding literary works: looking at a text by itself (associated with New Criticism ) and looking at texts as they connect to society (associated with Cultural Studies ). The goal of New Criticism is to bring the reader further into the text. The goal of Cultural Studies is to bring the reader into the network of discourses that surround and pass through the text. Other approaches, such as Ecocriticism, relate literary texts to the Sciences (as well as to the Humanities).

The New Critics, starting in the 1940s, focused on meaning within the text itself, using a method they called “ close reading .” The text itself becomes e vidence for a particular reading. Using this approach, you should summarize the literary work briefly and q uote particularly meaningful passages, being sure to introduce quotes and then interpret them (never let them stand alone). Make connections within the work; a sk “why” and “how” the various parts of the text relate to each other.

Cultural Studies critics see all texts as connected to society; the critic therefore has to connect a text to at least one political or social issue. How and why does the text reproduce particular knowledge systems (known as discourses) and how do these knowledge systems relate to issues of power within the society? Who speaks and when? Answering these questions helps your reader understand the text in context. Cultural contexts can include the treatment of gender (Feminist, Queer), class (Marxist), nationality, race, religion, or any other area of human society.

Other approaches, such as psychoanalytic literary criticism , look at literary texts to better understand human psychology. A psychoanalytic reading can focus on a character, the author, the reader, or on society in general. Ecocriticism look at human understandings of nature in literary texts.

We select our research methods based on the kinds of things we want to know. For example, we may be studying the relationship between literature and society, between author and text, or the status of a work in the literary canon. We may want to know about a work’s form, genre, or thematics. We may want to know about the audience’s reading and reception, or about methods for teaching literature in schools.

Below are a few research methods and their descriptions. You may need to consult with your instructor about which ones are most appropriate for your project. The first list covers methods most students use in their work. The second list covers methods more commonly used by advanced researchers. Even if you will not be using methods from this second list in your research project, you may read about these research methods in the scholarship you find.

Most commonly used undergraduate research methods:

Scholarship Methods: Studies the body of scholarship written about a particular author, literary work, historical period, literary movement, genre, theme, theory, or method.
Textual Analysis Methods: Used for close readings of literary texts, these methods also rely on literary theory and background information to support the reading.
Biographical Methods: Used to study the life of the author to better understand their work and times, these methods involve reading biographies and autobiographies about the author, and may also include research into private papers, correspondence, and interviews.
Discourse Analysis Methods: Studies language patterns to reveal ideology and social relations of power. This research involves the study of institutions, social groups, and social movements to understand how people in various settings use language to represent the world to themselves and others. Literary works may present complex mixtures of discourses which the characters (and readers) have to navigate.
Creative Writing Methods: A literary re-working of another literary text, creative writing research is used to better understand a literary work by investigating its language, formal structures, composition methods, themes, and so on. For instance, a creative research project may retell a story from a minor character’s perspective to reveal an alternative reading of events. To qualify as research, a creative research project is usually combined with a piece of theoretical writing that explains and justifies the work.

Methods used more often by advanced researchers:

Archival Methods: Usually involves trips to special collections where original papers are kept. In these archives are many unpublished materials such as diaries, letters, photographs, ledgers, and so on. These materials can offer us invaluable insight into the life of an author, the development of a literary work, or the society in which the author lived. There are at least three major archives of James Baldwin’s papers: The Smithsonian , Yale , and The New York Public Library . Descriptions of such materials are often available online, but the materials themselves are typically stored in boxes at the archive.
Computational Methods: Used for statistical analysis of texts such as studies of the popularity and meaning of particular words in literature over time.
Ethnographic Methods: Studies groups of people and their interactions with literary works, for instance in educational institutions, in reading groups (such as book clubs), and in fan networks. This approach may involve interviews and visits to places (including online communities) where people interact with literary works. Note: before you begin such work, you must have Institutional Review Board (IRB) approval “to protect the rights and welfare of human participants involved in research.”
Visual Methods: Studies the visual qualities of literary works. Some literary works, such as illuminated manuscripts, children’s literature, and graphic novels, present a complex interplay of text and image. Even works without illustrations can be studied for their use of typography, layout, and other visual features.

Regardless of the method(s) you choose, you will need to learn how to apply them to your work and how to carry them out successfully. For example, you should know that many archives do not allow you to bring pens (you can use pencils) and you may not be allowed to bring bags into the archives. You will need to keep a record of which documents you consult and their location (box number, etc.) in the archives. If you are unsure how to use a particular method, please consult a book about it. [1] Also, ask for the advice of trained researchers such as your instructor or a research librarian.

What research method(s) will you be using for your paper? Why did you make this method selection over other methods? If you haven’t made a selection yet, which methods are you considering?
What specific methodological approaches are you most interested in exploring in relation to the chosen literary work?
What is your plan for researching your method(s) and its major approaches?
What was the most important lesson you learned from this page? What point was confusing or difficult to understand?

Write your answers in a webcourse discussion page.

research methodology in english literature

Introduction to Research Methods: A Practical Guide for Anyone Undertaking a Research Project by Catherine, Dr. Dawson
Practical Research Methods: A User-Friendly Guide to Mastering Research Techniques and Projects by Catherine Dawson
Qualitative Inquiry and Research Design: Choosing Among Five Approaches by John W. Creswell Cheryl N. Poth
Qualitative Research Evaluation Methods: Integrating Theory and Practice by Michael Quinn Patton
Research Design: Qualitative, Quantitative, and Mixed Methods Approaches by John W. Creswell J. David Creswell
Research Methodology: A Step-by-Step Guide for Beginners by Ranjit Kumar
Research Methodology: Methods and Techniques by C.R. Kothari

Strategies for Conducting Literary Research Copyright © 2021 by Barry Mauer & John Venecek is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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MA English literature EL7308 RESEARCH METHODS MODULE HANDBOOK

2020, MA English literature EL7308 RESEARCH METHODS MODULE HANDBOOK

This module will enable students to hone the skills required to undertake research in literary studies and which are necessary to present the results of such research through writing and oral presentation. Students are encouraged to think about how to select appropriate methodologies from a range of possible choices, and consider how these methodologies can be used to shape the forms of research undertaken.

Research Methods for English Studies

Gabriele Griffin
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Language: English
Publisher: Edinburgh University Press
Copyright year: 2013
Audience: College/higher education;
Main content: 264
Keywords: Literary Studies
Published: September 13, 2013
ISBN: 9780748683444

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Theories and Methodologies

Theories and methodologies of english language and literature.

Description: These courses foreground theoretical approaches or methodological developments, including how they affect formal or historical topics. They explore how theories and methods such as Marxism, psychoanalysis, structuralism, phenomenology, reader reception, feminism, critical race theory or ethnography have influenced the production, practice or study of literature, language and culture in English.

Course Goals: While core courses may not achieve every goal, they will participate in the conversations represented in these goals as a central feature.

To be able to identify main concepts, premises/assumptions, and strengths/liabilities of a theoretical or methodological approach
To be able to compare and contrast what is distinct about different theoretical or methodological approaches
To understand the historical and political contexts and stakes of different theoretical or methodological approaches
To engage theory and method as a focus of analysis and research
To examine and develop theoretical or methodological strategies for producing and circulating texts and implementing findings within salient academic and/or public conversations
To explore how social groups or identities emerge through or participate in the production, significance, and reception of theories and methods

Course list for students who entered the major in Summer 2019 and later:

ENGL 302 Critical Practice (counts as a theory requirement for Creative Writing Students only)
ENGL 303 (History of Literary Criticism and Theory I)
ENGL 304 (History of Literary Criticism and Theory II)
ENGL 305 (Theories of the Imagination)
ENGL 306 (Introduction to Rhetoric)
ENGL 307 (Cultural Studies)
ENGL 308 (Marxism and Literary Theory)
ENGL 309 (Theories of Reading)
ENGL 367 (Gender Studies in Literature)
ENGL 369 (Research Methods in Language & Literature)
ENGL 370 (English Language Study)
ENGL 378 (Special Topics in Theories/Methods)
ENGL 470 (Theory and Practice of Teaching Literature)
ENGL 471 (Theory and Practice of Teaching Writing)

Note: students who've been accepted to the competitive-admission Creative Writing option in the major may count ENGL 302 toward this category.

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Research methods and resources: Language and Linguistics

Research Methods in English Literary Studies

Writing and presenting an academic paper

The purpose of this subject is to familiarise the student with the methods and resources used for research in English Literature. It is of a highly practical nature and aims to put her or him into contact with the tools necessary to carry out literary research. It stems from the fact that Literature does not exist as an autonomous entity but rather is found within a socio-political, cultural, ideological and aesthetic context which conditions its reception at different moments and in different places. To this aim, the student is introduced to the search for information resources in connection with different critical perspectives from which different literary genres can be analysed. Throughout the course, the student is familiarised with the bibliographical and electronic resources needed for literary research, including reference works, specific glossaries, consultation of catalogues from research libraries, use of databases of literary texts corresponding to different periods and genres, and periodicals relevant to different areas of specialisation.

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Språkvelger

Course - research methods in literature studies - litt3001, course-details-portlet, litt3001 - research methods in literature studies, examination arrangement.

Examination arrangement: Home examination Grade: Letter grades

Course content

This course will provide insight into central methodological issues within the field of literature studies. A primary goal is to give students an understanding of the diversity of methods that characterizes literary criticism. The course aims to train students in developing research questions and to assess the applicability and relevance of different research methods, thus providing them with the foundation for developing individual master's projects. The course will provide students with understanding of the connections between critical perspectives and methodological approaches.

Among others, the course will discuss the following topics:

- Methods for examining the relationship between literature and society, literature and history, author and text, and questions related to the literary canon

- Methods for examining the relationship between literature and form, genre and thematics

- Methods for examining the relationship between literature, reading and reception

- The use of physical and digital archives

- Methods for researching literature and education

Learning outcome

Candidates who have passed this course

have the knowledge to evaluate the applicability and relevance of different research methods in the research of others as well as in their own
can develop research questions in literature studies and at the same time describe what methods may be applicable to examine various problems
can discuss how different approaches to literature may result in different interpretations of the same text
are able to apply terms in, and knowledge of, literature studies in practical work with literature
are able to find and evaluate literary criticism

Learning methods and activities

Lectures/seminars. The course is taught in English or Norwegian. Students are expected to participate actively in the lectures/seminars for example by presentations, comments and other contributions. Students are required to use the course learning platform regularly.

Obligatory assignment: A written assignment in groups where students discuss different methodological choices in working with a literary text. An approved obligatory assignment is valid for 2 semesters (the semester in which the approval is given, plus the following semester).

Compulsory assignments

1 written assignment (in groups)

Further on evaluation

The course is assessed by a written home examination (approx. 4000 words, 5 days). The exam must be answered in Norwegian or English.

Recommended previous knowledge

Relevant undergraduate courses in literature.

Required previous knowledge

At least 7.5 credits (studiepoeng) of courses in literature at ENG2000-, FRA2000-, NORD2000-, or TYSK2000-level.

Course materials

A pensum consisting of 700-800 pages of articles/chapter excerpts focused on research methods, plus a limited selection of short literary texts. Curriculum/reading list will be made available at the beginning of the semester.

Credit reductions

Blackboard - AUTUMN-2021

Version: 1 Credits: 7.5 SP Study level: Second degree level

Term no.: 1 Teaching semester: AUTUMN 2023

Language of instruction: Norwegian

Location: Trondheim

English Literature
French Literature
Comparative Literature
Scandinavian Language and Literature
Scandinavian Literature
German Literature

Department with academic responsibility Department of Language and Literature

Examination

Examination arrangement: home examination.

Release 2023-11-30

Submission 2023-12-05

Release 2024-03-04

Submission 2024-03-08

* The location (room) for a written examination is published 3 days before examination date. If more than one room is listed, you will find your room at Studentweb.

For more information regarding registration for examination and examination procedures, see "Innsida - Exams"

Reviewing the research methods literature: principles and strategies illustrated by a systematic overview of sampling in qualitative research

Stephen j. gentles.

1 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario Canada

4 CanChild Centre for Childhood Disability Research, McMaster University, 1400 Main Street West, IAHS 408, Hamilton, ON L8S 1C7 Canada

Cathy Charles

David b. nicholas.

2 Faculty of Social Work, University of Calgary, Alberta, Canada

Jenny Ploeg

3 School of Nursing, McMaster University, Hamilton, Ontario Canada

K. Ann McKibbon

Associated data.

The systematic methods overview used as a worked example in this article (Gentles SJ, Charles C, Ploeg J, McKibbon KA: Sampling in qualitative research: insights from an overview of the methods literature. The Qual Rep 2015, 20(11):1772-1789) is available from http://nsuworks.nova.edu/tqr/vol20/iss11/5 .

Overviews of methods are potentially useful means to increase clarity and enhance collective understanding of specific methods topics that may be characterized by ambiguity, inconsistency, or a lack of comprehensiveness. This type of review represents a distinct literature synthesis method, although to date, its methodology remains relatively undeveloped despite several aspects that demand unique review procedures. The purpose of this paper is to initiate discussion about what a rigorous systematic approach to reviews of methods, referred to here as systematic methods overviews , might look like by providing tentative suggestions for approaching specific challenges likely to be encountered. The guidance offered here was derived from experience conducting a systematic methods overview on the topic of sampling in qualitative research.

The guidance is organized into several principles that highlight specific objectives for this type of review given the common challenges that must be overcome to achieve them. Optional strategies for achieving each principle are also proposed, along with discussion of how they were successfully implemented in the overview on sampling. We describe seven paired principles and strategies that address the following aspects: delimiting the initial set of publications to consider, searching beyond standard bibliographic databases, searching without the availability of relevant metadata, selecting publications on purposeful conceptual grounds, defining concepts and other information to abstract iteratively, accounting for inconsistent terminology used to describe specific methods topics, and generating rigorous verifiable analytic interpretations. Since a broad aim in systematic methods overviews is to describe and interpret the relevant literature in qualitative terms, we suggest that iterative decision making at various stages of the review process, and a rigorous qualitative approach to analysis are necessary features of this review type.

Conclusions

We believe that the principles and strategies provided here will be useful to anyone choosing to undertake a systematic methods overview. This paper represents an initial effort to promote high quality critical evaluations of the literature regarding problematic methods topics, which have the potential to promote clearer, shared understandings, and accelerate advances in research methods. Further work is warranted to develop more definitive guidance.

Electronic supplementary material

The online version of this article (doi:10.1186/s13643-016-0343-0) contains supplementary material, which is available to authorized users.

While reviews of methods are not new, they represent a distinct review type whose methodology remains relatively under-addressed in the literature despite the clear implications for unique review procedures. One of few examples to describe it is a chapter containing reflections of two contributing authors in a book of 21 reviews on methodological topics compiled for the British National Health Service, Health Technology Assessment Program [ 1 ]. Notable is their observation of how the differences between the methods reviews and conventional quantitative systematic reviews, specifically attributable to their varying content and purpose, have implications for defining what qualifies as systematic. While the authors describe general aspects of “systematicity” (including rigorous application of a methodical search, abstraction, and analysis), they also describe a high degree of variation within the category of methods reviews itself and so offer little in the way of concrete guidance. In this paper, we present tentative concrete guidance, in the form of a preliminary set of proposed principles and optional strategies, for a rigorous systematic approach to reviewing and evaluating the literature on quantitative or qualitative methods topics. For purposes of this article, we have used the term systematic methods overview to emphasize the notion of a systematic approach to such reviews.

The conventional focus of rigorous literature reviews (i.e., review types for which systematic methods have been codified, including the various approaches to quantitative systematic reviews [ 2 – 4 ], and the numerous forms of qualitative and mixed methods literature synthesis [ 5 – 10 ]) is to synthesize empirical research findings from multiple studies. By contrast, the focus of overviews of methods, including the systematic approach we advocate, is to synthesize guidance on methods topics. The literature consulted for such reviews may include the methods literature, methods-relevant sections of empirical research reports, or both. Thus, this paper adds to previous work published in this journal—namely, recent preliminary guidance for conducting reviews of theory [ 11 ]—that has extended the application of systematic review methods to novel review types that are concerned with subject matter other than empirical research findings.

Published examples of methods overviews illustrate the varying objectives they can have. One objective is to establish methodological standards for appraisal purposes. For example, reviews of existing quality appraisal standards have been used to propose universal standards for appraising the quality of primary qualitative research [ 12 ] or evaluating qualitative research reports [ 13 ]. A second objective is to survey the methods-relevant sections of empirical research reports to establish current practices on methods use and reporting practices, which Moher and colleagues [ 14 ] recommend as a means for establishing the needs to be addressed in reporting guidelines (see, for example [ 15 , 16 ]). A third objective for a methods review is to offer clarity and enhance collective understanding regarding a specific methods topic that may be characterized by ambiguity, inconsistency, or a lack of comprehensiveness within the available methods literature. An example of this is a overview whose objective was to review the inconsistent definitions of intention-to-treat analysis (the methodologically preferred approach to analyze randomized controlled trial data) that have been offered in the methods literature and propose a solution for improving conceptual clarity [ 17 ]. Such reviews are warranted because students and researchers who must learn or apply research methods typically lack the time to systematically search, retrieve, review, and compare the available literature to develop a thorough and critical sense of the varied approaches regarding certain controversial or ambiguous methods topics.

While systematic methods overviews , as a review type, include both reviews of the methods literature and reviews of methods-relevant sections from empirical study reports, the guidance provided here is primarily applicable to reviews of the methods literature since it was derived from the experience of conducting such a review [ 18 ], described below. To our knowledge, there are no well-developed proposals on how to rigorously conduct such reviews. Such guidance would have the potential to improve the thoroughness and credibility of critical evaluations of the methods literature, which could increase their utility as a tool for generating understandings that advance research methods, both qualitative and quantitative. Our aim in this paper is thus to initiate discussion about what might constitute a rigorous approach to systematic methods overviews. While we hope to promote rigor in the conduct of systematic methods overviews wherever possible, we do not wish to suggest that all methods overviews need be conducted to the same standard. Rather, we believe that the level of rigor may need to be tailored pragmatically to the specific review objectives, which may not always justify the resource requirements of an intensive review process.

The example systematic methods overview on sampling in qualitative research

The principles and strategies we propose in this paper are derived from experience conducting a systematic methods overview on the topic of sampling in qualitative research [ 18 ]. The main objective of that methods overview was to bring clarity and deeper understanding of the prominent concepts related to sampling in qualitative research (purposeful sampling strategies, saturation, etc.). Specifically, we interpreted the available guidance, commenting on areas lacking clarity, consistency, or comprehensiveness (without proposing any recommendations on how to do sampling). This was achieved by a comparative and critical analysis of publications representing the most influential (i.e., highly cited) guidance across several methodological traditions in qualitative research.

The specific methods and procedures for the overview on sampling [ 18 ] from which our proposals are derived were developed both after soliciting initial input from local experts in qualitative research and an expert health librarian (KAM) and through ongoing careful deliberation throughout the review process. To summarize, in that review, we employed a transparent and rigorous approach to search the methods literature, selected publications for inclusion according to a purposeful and iterative process, abstracted textual data using structured abstraction forms, and analyzed (synthesized) the data using a systematic multi-step approach featuring abstraction of text, summary of information in matrices, and analytic comparisons.

For this article, we reflected on both the problems and challenges encountered at different stages of the review and our means for selecting justifiable procedures to deal with them. Several principles were then derived by considering the generic nature of these problems, while the generalizable aspects of the procedures used to address them formed the basis of optional strategies. Further details of the specific methods and procedures used in the overview on qualitative sampling are provided below to illustrate both the types of objectives and challenges that reviewers will likely need to consider and our approach to implementing each of the principles and strategies.

Organization of the guidance into principles and strategies

For the purposes of this article, principles are general statements outlining what we propose are important aims or considerations within a particular review process, given the unique objectives or challenges to be overcome with this type of review. These statements follow the general format, “considering the objective or challenge of X, we propose Y to be an important aim or consideration.” Strategies are optional and flexible approaches for implementing the previous principle outlined. Thus, generic challenges give rise to principles, which in turn give rise to strategies.

We organize the principles and strategies below into three sections corresponding to processes characteristic of most systematic literature synthesis approaches: literature identification and selection ; data abstraction from the publications selected for inclusion; and analysis , including critical appraisal and synthesis of the abstracted data. Within each section, we also describe the specific methodological decisions and procedures used in the overview on sampling in qualitative research [ 18 ] to illustrate how the principles and strategies for each review process were applied and implemented in a specific case. We expect this guidance and accompanying illustrations will be useful for anyone considering engaging in a methods overview, particularly those who may be familiar with conventional systematic review methods but may not yet appreciate some of the challenges specific to reviewing the methods literature.

Results and discussion

Literature identification and selection.

The identification and selection process includes search and retrieval of publications and the development and application of inclusion and exclusion criteria to select the publications that will be abstracted and analyzed in the final review. Literature identification and selection for overviews of the methods literature is challenging and potentially more resource-intensive than for most reviews of empirical research. This is true for several reasons that we describe below, alongside discussion of the potential solutions. Additionally, we suggest in this section how the selection procedures can be chosen to match the specific analytic approach used in methods overviews.

Delimiting a manageable set of publications

One aspect of methods overviews that can make identification and selection challenging is the fact that the universe of literature containing potentially relevant information regarding most methods-related topics is expansive and often unmanageably so. Reviewers are faced with two large categories of literature: the methods literature , where the possible publication types include journal articles, books, and book chapters; and the methods-relevant sections of empirical study reports , where the possible publication types include journal articles, monographs, books, theses, and conference proceedings. In our systematic overview of sampling in qualitative research, exhaustively searching (including retrieval and first-pass screening) all publication types across both categories of literature for information on a single methods-related topic was too burdensome to be feasible. The following proposed principle follows from the need to delimit a manageable set of literature for the review.

Principle #1:

Considering the broad universe of potentially relevant literature, we propose that an important objective early in the identification and selection stage is to delimit a manageable set of methods-relevant publications in accordance with the objectives of the methods overview.

Strategy #1:

To limit the set of methods-relevant publications that must be managed in the selection process, reviewers have the option to initially review only the methods literature, and exclude the methods-relevant sections of empirical study reports, provided this aligns with the review’s particular objectives.

We propose that reviewers are justified in choosing to select only the methods literature when the objective is to map out the range of recognized concepts relevant to a methods topic, to summarize the most authoritative or influential definitions or meanings for methods-related concepts, or to demonstrate a problematic lack of clarity regarding a widely established methods-related concept and potentially make recommendations for a preferred approach to the methods topic in question. For example, in the case of the methods overview on sampling [ 18 ], the primary aim was to define areas lacking in clarity for multiple widely established sampling-related topics. In the review on intention-to-treat in the context of missing outcome data [ 17 ], the authors identified a lack of clarity based on multiple inconsistent definitions in the literature and went on to recommend separating the issue of how to handle missing outcome data from the issue of whether an intention-to-treat analysis can be claimed.

In contrast to strategy #1, it may be appropriate to select the methods-relevant sections of empirical study reports when the objective is to illustrate how a methods concept is operationalized in research practice or reported by authors. For example, one could review all the publications in 2 years’ worth of issues of five high-impact field-related journals to answer questions about how researchers describe implementing a particular method or approach, or to quantify how consistently they define or report using it. Such reviews are often used to highlight gaps in the reporting practices regarding specific methods, which may be used to justify items to address in reporting guidelines (for example, [ 14 – 16 ]).

It is worth recognizing that other authors have advocated broader positions regarding the scope of literature to be considered in a review, expanding on our perspective. Suri [ 10 ] (who, like us, emphasizes how different sampling strategies are suitable for different literature synthesis objectives) has, for example, described a two-stage literature sampling procedure (pp. 96–97). First, reviewers use an initial approach to conduct a broad overview of the field—for reviews of methods topics, this would entail an initial review of the research methods literature. This is followed by a second more focused stage in which practical examples are purposefully selected—for methods reviews, this would involve sampling the empirical literature to illustrate key themes and variations. While this approach is seductive in its capacity to generate more in depth and interpretive analytic findings, some reviewers may consider it too resource-intensive to include the second step no matter how selective the purposeful sampling. In the overview on sampling where we stopped after the first stage [ 18 ], we discussed our selective focus on the methods literature as a limitation that left opportunities for further analysis of the literature. We explicitly recommended, for example, that theoretical sampling was a topic for which a future review of the methods sections of empirical reports was justified to answer specific questions identified in the primary review.

Ultimately, reviewers must make pragmatic decisions that balance resource considerations, combined with informed predictions about the depth and complexity of literature available on their topic, with the stated objectives of their review. The remaining principles and strategies apply primarily to overviews that include the methods literature, although some aspects may be relevant to reviews that include empirical study reports.

Searching beyond standard bibliographic databases

An important reality affecting identification and selection in overviews of the methods literature is the increased likelihood for relevant publications to be located in sources other than journal articles (which is usually not the case for overviews of empirical research, where journal articles generally represent the primary publication type). In the overview on sampling [ 18 ], out of 41 full-text publications retrieved and reviewed, only 4 were journal articles, while 37 were books or book chapters. Since many books and book chapters did not exist electronically, their full text had to be physically retrieved in hardcopy, while 11 publications were retrievable only through interlibrary loan or purchase request. The tasks associated with such retrieval are substantially more time-consuming than electronic retrieval. Since a substantial proportion of methods-related guidance may be located in publication types that are less comprehensively indexed in standard bibliographic databases, identification and retrieval thus become complicated processes.

Principle #2:

Considering that important sources of methods guidance can be located in non-journal publication types (e.g., books, book chapters) that tend to be poorly indexed in standard bibliographic databases, it is important to consider alternative search methods for identifying relevant publications to be further screened for inclusion.

Strategy #2:

To identify books, book chapters, and other non-journal publication types not thoroughly indexed in standard bibliographic databases, reviewers may choose to consult one or more of the following less standard sources: Google Scholar, publisher web sites, or expert opinion.

In the case of the overview on sampling in qualitative research [ 18 ], Google Scholar had two advantages over other standard bibliographic databases: it indexes and returns records of books and book chapters likely to contain guidance on qualitative research methods topics; and it has been validated as providing higher citation counts than ISI Web of Science (a producer of numerous bibliographic databases accessible through institutional subscription) for several non-biomedical disciplines including the social sciences where qualitative research methods are prominently used [ 19 – 21 ]. While we identified numerous useful publications by consulting experts, the author publication lists generated through Google Scholar searches were uniquely useful to identify more recent editions of methods books identified by experts.

Searching without relevant metadata

Determining what publications to select for inclusion in the overview on sampling [ 18 ] could only rarely be accomplished by reviewing the publication’s metadata. This was because for the many books and other non-journal type publications we identified as possibly relevant, the potential content of interest would be located in only a subsection of the publication. In this common scenario for reviews of the methods literature (as opposed to methods overviews that include empirical study reports), reviewers will often be unable to employ standard title, abstract, and keyword database searching or screening as a means for selecting publications.

Principle #3:

Considering that the presence of information about the topic of interest may not be indicated in the metadata for books and similar publication types, it is important to consider other means of identifying potentially useful publications for further screening.

Strategy #3:

One approach to identifying potentially useful books and similar publication types is to consider what classes of such publications (e.g., all methods manuals for a certain research approach) are likely to contain relevant content, then identify, retrieve, and review the full text of corresponding publications to determine whether they contain information on the topic of interest.

In the example of the overview on sampling in qualitative research [ 18 ], the topic of interest (sampling) was one of numerous topics covered in the general qualitative research methods manuals. Consequently, examples from this class of publications first had to be identified for retrieval according to non-keyword-dependent criteria. Thus, all methods manuals within the three research traditions reviewed (grounded theory, phenomenology, and case study) that might contain discussion of sampling were sought through Google Scholar and expert opinion, their full text obtained, and hand-searched for relevant content to determine eligibility. We used tables of contents and index sections of books to aid this hand searching.

Purposefully selecting literature on conceptual grounds

A final consideration in methods overviews relates to the type of analysis used to generate the review findings. Unlike quantitative systematic reviews where reviewers aim for accurate or unbiased quantitative estimates—something that requires identifying and selecting the literature exhaustively to obtain all relevant data available (i.e., a complete sample)—in methods overviews, reviewers must describe and interpret the relevant literature in qualitative terms to achieve review objectives. In other words, the aim in methods overviews is to seek coverage of the qualitative concepts relevant to the methods topic at hand. For example, in the overview of sampling in qualitative research [ 18 ], achieving review objectives entailed providing conceptual coverage of eight sampling-related topics that emerged as key domains. The following principle recognizes that literature sampling should therefore support generating qualitative conceptual data as the input to analysis.

Principle #4:

Since the analytic findings of a systematic methods overview are generated through qualitative description and interpretation of the literature on a specified topic, selection of the literature should be guided by a purposeful strategy designed to achieve adequate conceptual coverage (i.e., representing an appropriate degree of variation in relevant ideas) of the topic according to objectives of the review.

Strategy #4:

One strategy for choosing the purposeful approach to use in selecting the literature according to the review objectives is to consider whether those objectives imply exploring concepts either at a broad overview level, in which case combining maximum variation selection with a strategy that limits yield (e.g., critical case, politically important, or sampling for influence—described below) may be appropriate; or in depth, in which case purposeful approaches aimed at revealing innovative cases will likely be necessary.

In the methods overview on sampling, the implied scope was broad since we set out to review publications on sampling across three divergent qualitative research traditions—grounded theory, phenomenology, and case study—to facilitate making informative conceptual comparisons. Such an approach would be analogous to maximum variation sampling.

At the same time, the purpose of that review was to critically interrogate the clarity, consistency, and comprehensiveness of literature from these traditions that was “most likely to have widely influenced students’ and researchers’ ideas about sampling” (p. 1774) [ 18 ]. In other words, we explicitly set out to review and critique the most established and influential (and therefore dominant) literature, since this represents a common basis of knowledge among students and researchers seeking understanding or practical guidance on sampling in qualitative research. To achieve this objective, we purposefully sampled publications according to the criterion of influence , which we operationalized as how often an author or publication has been referenced in print or informal discourse. This second sampling approach also limited the literature we needed to consider within our broad scope review to a manageable amount.

To operationalize this strategy of sampling for influence , we sought to identify both the most influential authors within a qualitative research tradition (all of whose citations were subsequently screened) and the most influential publications on the topic of interest by non-influential authors. This involved a flexible approach that combined multiple indicators of influence to avoid the dilemma that any single indicator might provide inadequate coverage. These indicators included bibliometric data (h-index for author influence [ 22 ]; number of cites for publication influence), expert opinion, and cross-references in the literature (i.e., snowball sampling). As a final selection criterion, a publication was included only if it made an original contribution in terms of novel guidance regarding sampling or a related concept; thus, purely secondary sources were excluded. Publish or Perish software (Anne-Wil Harzing; available at http://www.harzing.com/resources/publish-or-perish ) was used to generate bibliometric data via the Google Scholar database. Figure 1 illustrates how identification and selection in the methods overview on sampling was a multi-faceted and iterative process. The authors selected as influential, and the publications selected for inclusion or exclusion are listed in Additional file 1 (Matrices 1, 2a, 2b).

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Literature identification and selection process used in the methods overview on sampling [ 18 ]

In summary, the strategies of seeking maximum variation and sampling for influence were employed in the sampling overview to meet the specific review objectives described. Reviewers will need to consider the full range of purposeful literature sampling approaches at their disposal in deciding what best matches the specific aims of their own reviews. Suri [ 10 ] has recently retooled Patton’s well-known typology of purposeful sampling strategies (originally intended for primary research) for application to literature synthesis, providing a useful resource in this respect.

Data abstraction

The purpose of data abstraction in rigorous literature reviews is to locate and record all data relevant to the topic of interest from the full text of included publications, making them available for subsequent analysis. Conventionally, a data abstraction form—consisting of numerous distinct conceptually defined fields to which corresponding information from the source publication is recorded—is developed and employed. There are several challenges, however, to the processes of developing the abstraction form and abstracting the data itself when conducting methods overviews, which we address here. Some of these problems and their solutions may be familiar to those who have conducted qualitative literature syntheses, which are similarly conceptual.

Iteratively defining conceptual information to abstract

In the overview on sampling [ 18 ], while we surveyed multiple sources beforehand to develop a list of concepts relevant for abstraction (e.g., purposeful sampling strategies, saturation, sample size), there was no way for us to anticipate some concepts prior to encountering them in the review process. Indeed, in many cases, reviewers are unable to determine the complete set of methods-related concepts that will be the focus of the final review a priori without having systematically reviewed the publications to be included. Thus, defining what information to abstract beforehand may not be feasible.

Principle #5:

Considering the potential impracticality of defining a complete set of relevant methods-related concepts from a body of literature one has not yet systematically read, selecting and defining fields for data abstraction must often be undertaken iteratively. Thus, concepts to be abstracted can be expected to grow and change as data abstraction proceeds.

Strategy #5:

Reviewers can develop an initial form or set of concepts for abstraction purposes according to standard methods (e.g., incorporating expert feedback, pilot testing) and remain attentive to the need to iteratively revise it as concepts are added or modified during the review. Reviewers should document revisions and return to re-abstract data from previously abstracted publications as the new data requirements are determined.

In the sampling overview [ 18 ], we developed and maintained the abstraction form in Microsoft Word. We derived the initial set of abstraction fields from our own knowledge of relevant sampling-related concepts, consultation with local experts, and reviewing a pilot sample of publications. Since the publications in this review included a large proportion of books, the abstraction process often began by flagging the broad sections within a publication containing topic-relevant information for detailed review to identify text to abstract. When reviewing flagged text, the reviewer occasionally encountered an unanticipated concept significant enough to warrant being added as a new field to the abstraction form. For example, a field was added to capture how authors described the timing of sampling decisions, whether before (a priori) or after (ongoing) starting data collection, or whether this was unclear. In these cases, we systematically documented the modification to the form and returned to previously abstracted publications to abstract any information that might be relevant to the new field.

The logic of this strategy is analogous to the logic used in a form of research synthesis called best fit framework synthesis (BFFS) [ 23 – 25 ]. In that method, reviewers initially code evidence using an a priori framework they have selected. When evidence cannot be accommodated by the selected framework, reviewers then develop new themes or concepts from which they construct a new expanded framework. Both the strategy proposed and the BFFS approach to research synthesis are notable for their rigorous and transparent means to adapt a final set of concepts to the content under review.

Accounting for inconsistent terminology

An important complication affecting the abstraction process in methods overviews is that the language used by authors to describe methods-related concepts can easily vary across publications. For example, authors from different qualitative research traditions often use different terms for similar methods-related concepts. Furthermore, as we found in the sampling overview [ 18 ], there may be cases where no identifiable term, phrase, or label for a methods-related concept is used at all, and a description of it is given instead. This can make searching the text for relevant concepts based on keywords unreliable.

Principle #6:

Since accepted terms may not be used consistently to refer to methods concepts, it is necessary to rely on the definitions for concepts, rather than keywords, to identify relevant information in the publication to abstract.

Strategy #6:

An effective means to systematically identify relevant information is to develop and iteratively adjust written definitions for key concepts (corresponding to abstraction fields) that are consistent with and as inclusive of as much of the literature reviewed as possible. Reviewers then seek information that matches these definitions (rather than keywords) when scanning a publication for relevant data to abstract.

In the abstraction process for the sampling overview [ 18 ], we noted the several concepts of interest to the review for which abstraction by keyword was particularly problematic due to inconsistent terminology across publications: sampling , purposeful sampling , sampling strategy , and saturation (for examples, see Additional file 1 , Matrices 3a, 3b, 4). We iteratively developed definitions for these concepts by abstracting text from publications that either provided an explicit definition or from which an implicit definition could be derived, which was recorded in fields dedicated to the concept’s definition. Using a method of constant comparison, we used text from definition fields to inform and modify a centrally maintained definition of the corresponding concept to optimize its fit and inclusiveness with the literature reviewed. Table 1 shows, as an example, the final definition constructed in this way for one of the central concepts of the review, qualitative sampling .

Final definition for qualitative sampling , including methodological tradition-specific variations

Developed after numerous iterations in the methods overview on sampling [ 18 ]

We applied iteratively developed definitions when making decisions about what specific text to abstract for an existing field, which allowed us to abstract concept-relevant data even if no recognized keyword was used. For example, this was the case for the sampling-related concept, saturation , where the relevant text available for abstraction in one publication [ 26 ]—“to continue to collect data until nothing new was being observed or recorded, no matter how long that takes”—was not accompanied by any term or label whatsoever.

This comparative analytic strategy (and our approach to analysis more broadly as described in strategy #7, below) is analogous to the process of reciprocal translation —a technique first introduced for meta-ethnography by Noblit and Hare [ 27 ] that has since been recognized as a common element in a variety of qualitative metasynthesis approaches [ 28 ]. Reciprocal translation, taken broadly, involves making sense of a study’s findings in terms of the findings of the other studies included in the review. In practice, it has been operationalized in different ways. Melendez-Torres and colleagues developed a typology from their review of the metasynthesis literature, describing four overlapping categories of specific operations undertaken in reciprocal translation: visual representation, key paper integration, data reduction and thematic extraction, and line-by-line coding [ 28 ]. The approaches suggested in both strategies #6 and #7, with their emphasis on constant comparison, appear to fall within the line-by-line coding category.

Generating credible and verifiable analytic interpretations

The analysis in a systematic methods overview must support its more general objective, which we suggested above is often to offer clarity and enhance collective understanding regarding a chosen methods topic. In our experience, this involves describing and interpreting the relevant literature in qualitative terms. Furthermore, any interpretative analysis required may entail reaching different levels of abstraction, depending on the more specific objectives of the review. For example, in the overview on sampling [ 18 ], we aimed to produce a comparative analysis of how multiple sampling-related topics were treated differently within and among different qualitative research traditions. To promote credibility of the review, however, not only should one seek a qualitative analytic approach that facilitates reaching varying levels of abstraction but that approach must also ensure that abstract interpretations are supported and justified by the source data and not solely the product of the analyst’s speculative thinking.

Principle #7:

Considering the qualitative nature of the analysis required in systematic methods overviews, it is important to select an analytic method whose interpretations can be verified as being consistent with the literature selected, regardless of the level of abstraction reached.

Strategy #7:

We suggest employing the constant comparative method of analysis [ 29 ] because it supports developing and verifying analytic links to the source data throughout progressively interpretive or abstract levels. In applying this approach, we advise a rigorous approach, documenting how supportive quotes or references to the original texts are carried forward in the successive steps of analysis to allow for easy verification.

The analytic approach used in the methods overview on sampling [ 18 ] comprised four explicit steps, progressing in level of abstraction—data abstraction, matrices, narrative summaries, and final analytic conclusions (Fig. 2 ). While we have positioned data abstraction as the second stage of the generic review process (prior to Analysis), above, we also considered it as an initial step of analysis in the sampling overview for several reasons. First, it involved a process of constant comparisons and iterative decision-making about the fields to add or define during development and modification of the abstraction form, through which we established the range of concepts to be addressed in the review. At the same time, abstraction involved continuous analytic decisions about what textual quotes (ranging in size from short phrases to numerous paragraphs) to record in the fields thus created. This constant comparative process was analogous to open coding in which textual data from publications was compared to conceptual fields (equivalent to codes) or to other instances of data previously abstracted when constructing definitions to optimize their fit with the overall literature as described in strategy #6. Finally, in the data abstraction step, we also recorded our first interpretive thoughts in dedicated fields, providing initial material for the more abstract analytic steps.

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Summary of progressive steps of analysis used in the methods overview on sampling [ 18 ]

In the second step of the analysis, we constructed topic-specific matrices , or tables, by copying relevant quotes from abstraction forms into the appropriate cells of matrices (for the complete set of analytic matrices developed in the sampling review, see Additional file 1 (matrices 3 to 10)). Each matrix ranged from one to five pages; row headings, nested three-deep, identified the methodological tradition, author, and publication, respectively; and column headings identified the concepts, which corresponded to abstraction fields. Matrices thus allowed us to make further comparisons across methodological traditions, and between authors within a tradition. In the third step of analysis, we recorded our comparative observations as narrative summaries , in which we used illustrative quotes more sparingly. In the final step, we developed analytic conclusions based on the narrative summaries about the sampling-related concepts within each methodological tradition for which clarity, consistency, or comprehensiveness of the available guidance appeared to be lacking. Higher levels of analysis thus built logically from the lower levels, enabling us to easily verify analytic conclusions by tracing the support for claims by comparing the original text of publications reviewed.

Integrative versus interpretive methods overviews

The analytic product of systematic methods overviews is comparable to qualitative evidence syntheses, since both involve describing and interpreting the relevant literature in qualitative terms. Most qualitative synthesis approaches strive to produce new conceptual understandings that vary in level of interpretation. Dixon-Woods and colleagues [ 30 ] elaborate on a useful distinction, originating from Noblit and Hare [ 27 ], between integrative and interpretive reviews. Integrative reviews focus on summarizing available primary data and involve using largely secure and well defined concepts to do so; definitions are used from an early stage to specify categories for abstraction (or coding) of data, which in turn supports their aggregation; they do not seek as their primary focus to develop or specify new concepts, although they may achieve some theoretical or interpretive functions. For interpretive reviews, meanwhile, the main focus is to develop new concepts and theories that integrate them, with the implication that the concepts developed become fully defined towards the end of the analysis. These two forms are not completely distinct, and “every integrative synthesis will include elements of interpretation, and every interpretive synthesis will include elements of aggregation of data” [ 30 ].

The example methods overview on sampling [ 18 ] could be classified as predominantly integrative because its primary goal was to aggregate influential authors’ ideas on sampling-related concepts; there were also, however, elements of interpretive synthesis since it aimed to develop new ideas about where clarity in guidance on certain sampling-related topics is lacking, and definitions for some concepts were flexible and not fixed until late in the review. We suggest that most systematic methods overviews will be classifiable as predominantly integrative (aggregative). Nevertheless, more highly interpretive methods overviews are also quite possible—for example, when the review objective is to provide a highly critical analysis for the purpose of generating new methodological guidance. In such cases, reviewers may need to sample more deeply (see strategy #4), specifically by selecting empirical research reports (i.e., to go beyond dominant or influential ideas in the methods literature) that are likely to feature innovations or instructive lessons in employing a given method.

In this paper, we have outlined tentative guidance in the form of seven principles and strategies on how to conduct systematic methods overviews, a review type in which methods-relevant literature is systematically analyzed with the aim of offering clarity and enhancing collective understanding regarding a specific methods topic. Our proposals include strategies for delimiting the set of publications to consider, searching beyond standard bibliographic databases, searching without the availability of relevant metadata, selecting publications on purposeful conceptual grounds, defining concepts and other information to abstract iteratively, accounting for inconsistent terminology, and generating credible and verifiable analytic interpretations. We hope the suggestions proposed will be useful to others undertaking reviews on methods topics in future.

As far as we are aware, this is the first published source of concrete guidance for conducting this type of review. It is important to note that our primary objective was to initiate methodological discussion by stimulating reflection on what rigorous methods for this type of review should look like, leaving the development of more complete guidance to future work. While derived from the experience of reviewing a single qualitative methods topic, we believe the principles and strategies provided are generalizable to overviews of both qualitative and quantitative methods topics alike. However, it is expected that additional challenges and insights for conducting such reviews have yet to be defined. Thus, we propose that next steps for developing more definitive guidance should involve an attempt to collect and integrate other reviewers’ perspectives and experiences in conducting systematic methods overviews on a broad range of qualitative and quantitative methods topics. Formalized guidance and standards would improve the quality of future methods overviews, something we believe has important implications for advancing qualitative and quantitative methodology. When undertaken to a high standard, rigorous critical evaluations of the available methods guidance have significant potential to make implicit controversies explicit, and improve the clarity and precision of our understandings of problematic qualitative or quantitative methods issues.

A review process central to most types of rigorous reviews of empirical studies, which we did not explicitly address in a separate review step above, is quality appraisal . The reason we have not treated this as a separate step stems from the different objectives of the primary publications included in overviews of the methods literature (i.e., providing methodological guidance) compared to the primary publications included in the other established review types (i.e., reporting findings from single empirical studies). This is not to say that appraising quality of the methods literature is not an important concern for systematic methods overviews. Rather, appraisal is much more integral to (and difficult to separate from) the analysis step, in which we advocate appraising clarity, consistency, and comprehensiveness—the quality appraisal criteria that we suggest are appropriate for the methods literature. As a second important difference regarding appraisal, we currently advocate appraising the aforementioned aspects at the level of the literature in aggregate rather than at the level of individual publications. One reason for this is that methods guidance from individual publications generally builds on previous literature, and thus we feel that ahistorical judgments about comprehensiveness of single publications lack relevance and utility. Additionally, while different methods authors may express themselves less clearly than others, their guidance can nonetheless be highly influential and useful, and should therefore not be downgraded or ignored based on considerations of clarity—which raises questions about the alternative uses that quality appraisals of individual publications might have. Finally, legitimate variability in the perspectives that methods authors wish to emphasize, and the levels of generality at which they write about methods, makes critiquing individual publications based on the criterion of clarity a complex and potentially problematic endeavor that is beyond the scope of this paper to address. By appraising the current state of the literature at a holistic level, reviewers stand to identify important gaps in understanding that represent valuable opportunities for further methodological development.

To summarize, the principles and strategies provided here may be useful to those seeking to undertake their own systematic methods overview. Additional work is needed, however, to establish guidance that is comprehensive by comparing the experiences from conducting a variety of methods overviews on a range of methods topics. Efforts that further advance standards for systematic methods overviews have the potential to promote high-quality critical evaluations that produce conceptually clear and unified understandings of problematic methods topics, thereby accelerating the advance of research methodology.

Acknowledgements

Not applicable.

There was no funding for this work.

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Authors’ contributions.

SJG wrote the first draft of this article, with CC contributing to drafting. All authors contributed to revising the manuscript. All authors except CC (deceased) approved the final draft. SJG, CC, KAB, and JP were involved in developing methods for the systematic methods overview on sampling.

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Competing interests.

The authors declare that they have no competing interests.

Consent for publication

Ethics approval and consent to participate, additional file.

Submitted: Analysis_matrices. (DOC 330 kb)

Cathy Charles is deceased

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Access, acceptance and adherence to cancer prehabilitation: a mixed-methods systematic review

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Published: 06 May 2024

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Tessa Watts 1 ,
Nicholas Courtier 1 ,
Sarah Fry 1 ,
Nichola Gale 1 ,
Elizabeth Gillen 1 ,
Grace McCutchan 1 ,
Manasi Patil 1 ,
Tracy Rees 1 ,
Dominic Roche 1 ,
Sally Wheelwright 2 &
Jane Hopkinson 1

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The purpose of this systematic review is to better understand access to, acceptance of and adherence to cancer prehabilitation.

MEDLINE, CINAHL, PsychINFO, Embase, Physiotherapy Evidence Database, ProQuest Medical Library, Cochrane Library, Web of Science and grey literature were systematically searched for quantitative, qualitative and mixed-methods studies published in English between January 2017 and June 2023. Screening, data extraction and critical appraisal were conducted by two reviewers independently using Covidence™ systematic review software. Data were analysed and synthesised thematically to address the question ‘What do we know about access, acceptance and adherence to cancer prehabilitation, particularly among socially deprived and minority ethnic groups?’

The protocol is published on PROSPERO CRD42023403776

Searches identified 11,715 records, and 56 studies of variable methodological quality were included: 32 quantitative, 15 qualitative and nine mixed-methods. Analysis identified facilitators and barriers at individual and structural levels, and with interpersonal connections important for prehabilitation access, acceptance and adherence. No study reported analysis of facilitators and barriers to prehabilitation specific to people from ethnic minority communities. One study described health literacy as a barrier to access for people from socioeconomically deprived communities.

Conclusions

There is limited empirical research of barriers and facilitators to inform improvement in equity of access to cancer prehabilitation.

Implications for Cancer Survivors

To enhance the inclusivity of cancer prehabilitation, adjustments may be needed to accommodate individual characteristics and attention given to structural factors, such as staff training. Interpersonal connections are proposed as a fundamental ingredient for successful prehabilitation.

Prehabilitation in the lung cancer pathway: a scoping review

Research Priorities in Prehabilitation for Patients Undergoing Cancer Surgery: An International Delphi Study

From Theory to Practice: An International Approach to Establishing Prehabilitation Programmes

Avoid common mistakes on your manuscript.

Introduction

Prehabilitation is a core component of supportive care for health and well-being during cancer survivorship. It aims to improve cancer treatment outcomes and long-term health by preparing people awaiting cancer treatments, not only surgery, through support for physical activity, nutrition and emotional well-being either alone or in combination, and from the point of diagnosis [ 1 ]. Growing international evidence indicates that, in specific cancers, engagement with either uni or multimodal prehabilitation interventions can improve individuals’ pre-treatment functional capacity [ 2 , 3 ], reduce treatment-related complications [ 4 , 5 , 6 ], ease anxiety [ 7 ] and enhance post-treatment recovery [ 8 , 9 ]. As the evidence base develops and momentum for prehabilitation grows, the need to embed prehabilitation as the standard of care across different cancers has been recognised [ 10 , 11 , 12 ]. In some regions, multimodal prehabilitation is now offered as the standard of care in certain cancers, particularly lung [ 13 ] and colorectal [ 14 ].

Internationally, there are persistent health disparities following cancer treatment. Treatment and survival outcomes are poor among people from socioeconomically deprived communities and some minority ethnic groups compared to socioeconomically advantaged and majority groups [ 15 , 16 , 17 ]. To ease the overall social and economic impact of cancer on individuals and society, and to reduce the societal and healthcare costs of suboptimal treatment outcomes, it is important to identify the facilitators of and barriers to individuals’ engagement with interventions. People from socioeconomically deprived communities and some minority ethnic groups are known to be underserved in prehabilitation interventions [ 1 , 18 ]. Accordingly, to better understand reasons for informed action, this mixed-methods systematic review aims to identify, critically appraise and synthesise international empirical evidence of the facilitators of and barriers to access, acceptance and adherence of cancer prehabilitation. For this review, prehabilitation is defined as proactive and preventative for all cancer treatments (not only surgery and including neoadjuvant) and includes interventions to support physical activity, nutritional intake or psychological well-being, alone or together, carried out at any time before a course of treatment begins.

Review question

What is known about access, acceptance and adherence to cancer prehabilitation, particularly among socially deprived and minority ethnic groups?

The systematic review was informed by the Joanna Briggs Institute (JBI) mixed-methods systematic reviews (MMSR) methodology [ 19 ]. A convergent, integrated approach to data synthesis and integration was adopted [ 19 , 20 ]. The review was registered in PROSPERO CRD42023403776) on 3 March 2023 and is reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines [ 21 ]. Ethical approval was not required.

Database searches

In collaboration with a specialist health service systematic review librarian, the search strategy was developed using medical subject headings (MeSH) and keywords including and relating to cancer, prehabilitation, inequity, inequality, socioeconomic deprivation, ethnic groups and health services accessibility, and then tested and refined. The electronic databases Ovid SP MEDLINE, CINAHL via EBSCO host, PsycINFO, Ovid SP EMBASE, Ovid Emcare, Allied and Complementary Medicine (AMED), Physiotherapy Evidence Database (PEDRo) and Cochrane Central were systematically searched by EG for studies published in English between January 2017 and May 2023. The search strategy was tailored for each database and detailed in online resource (Supplementary information 1 ). Supplementary searches of grey literature using the Overton, Dimensions and Proquest dissertation and theses databases (PQDT), and relevant organisational websites were conducted. Reference lists of papers retrieved for full review were scrutinised for potentially useful papers not identified through the database searches.

Selection criteria

The PICO framework was used to guide inclusion criteria on population (P), Intervention (I), comparators (C) and outcomes (O) and context (Co). It enabled identification of primary qualitative, quantitative and mixed-methods research studies about prehabilitation, published in peer-reviewed journals. Eligibility criteria were used during study selection to screen this body of literature for empirical data about barriers and facilitators of prehabilitation. Non-empirical, opinion pieces, theoretical and methodological articles, reviews and editorials were excluded, as were studies involving children, adolescents and focusing on end-of-life care.

Study selection

All search results were stored in Endnote™. Following deduplication, results were imported into Covidence™ systematic review management software. For study selection, standardised systematic review methods [ 22 ] were used. All project team members were involved in study screening and selection. Firstly, two reviewers independently screened all returned titles and abstracts. Based on eligibility and relevance, these were sifted into ‘yes’, ‘no’ or ‘maybe’ categories. Disagreements were resolved by a third reviewer. Where a definite decision could not be made, full text was retrieved and assessed. Secondly, full text of all potentially relevant abstracts was retrieved and independently assessed for inclusion by two reviewers against the eligibility criteria. Arbitration by an independent reviewer in the event of disagreement was not required at this stage. Reasons for exclusion at full text review were recorded.

Quality assessment

Two reviewers independently assessed the quality of included studies via Covidence ™ using the Mixed Methods Appraisal Tool (MMAT) version 18 [ 23 ]. The MMAT was constructed specifically for quality appraisal in mixed studies reviews and is widely used [ 23 , 24 ]. Within a single tool, Version 18 of the MMAT can be used to appraise the methodological quality of five broad categories of study design, namely qualitative, randomised controlled trials, non-randomised, quantitative descriptive and mixed methods studies. The MMAT comprises two screening questions to establish whether or not the quality appraisal should proceed and 25 core questions: five criteria which mostly relate to the appropriateness of study design and approaches to sampling, data collection and analysis relevant to each of the five study designs [ 23 ]. Each criterion is assessed as being met (Yes) or not (No). There is also scope to indicate uncertainty. A third reviewer independently moderated all quality assessments for accuracy.

Data extraction

Two reviewers independently extracted data systematically via Covidence™ using an adapted, piloted JBI mixed-methods data extraction form. Information extracted included study author, aim, year and country of publication, setting, intervention type, design, sample, data collection, analysis, data relating to prehabilitation facilitators and barriers and, as relevant, data on intervention for support of access, acceptance or adherence to prehabilitation. A third reviewer cross-checked the data extraction tables independently for accuracy and completeness.

Data synthesis and integration

All extracted findings were imported into Microsoft Excel. Quantitative data were ‘qualitised’ into textual descriptions of quantitative results to enable assimilation with qualitative data [ 25 ]. To analyse and synthesise all findings, thematic synthesis [ 26 , 27 ] was used. Thematic analysis is an established process involving the identification and development of patterns and analytic themes in primary research data. Two reviewers coded the findings and then grouped related codes into preliminary descriptive themes which captured patterns across the data describing barriers to and facilitators of cancer prehabilitation [ 26 ]. Preliminary themes were discussed with a third reviewer. Themes were then further combined and synthesised to generate three overarching analytical themes relative to the review question [ 26 ].

Figure 1 shows the PRISMA flow chart of search results. Following the first and second round screening, 56 papers published between 2017 and 2023 were included: 33 quantitative; 14 qualitative and nine mixed methods.

PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources. *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/

A synopsis of study characteristics and the quality appraisal outcomes is found in Table 1 . Brief narrative summaries of the included papers’ findings of relevance to the review question, namely access, acceptance and adherence of prehabilitation interventions, are provided in the online supplementary information (supplementary information 2 ).

Study characteristics

Of the 32 quantitative studies reviewed, there were eight randomised controlled trials, two single-arm multi-centre trials, seven cohort studies and one cross-sectional survey. Others were pilot ( n = 3), feasibility ( n = 7), observational ( n = 1) and prevalence ( n = 1) studies, with one non-randomised trial and one audit. Qualitative studies ( n = 15) mainly used a broad qualitative approach ( n = 12), one used phenomenology, one participatory action research and one used a cross-sectional survey. Nine studies used mixed methods.

Study populations

The majority of included studies were conducted in Europe ( n = 33) (UK ( n = 19), Netherlands ( n = 4), Denmark ( n = 3), Spain ( n = 1), France ( n =1), Portugal ( n = 1), Belgium ( n = 1), Slovenia ( n = 1), Norway ( n = 1) and Sweden ( n = 1)). Eleven were conducted in North America (Canada ( n = 8), United States ( n =3)), and eight were from Australia. The remaining studies were from Japan ( n = 1) and China ( n =1), and two studies were conducted across two countries, Australia and New Zealand and the UK and Norway. Studies focused on prehabilitation in different settings including hospitals ( n = 12), local communities (including universities and local gymnasiums), individuals’ homes ( n = 14) and outdoors ( n = 1). Ten studies reported a hybrid, home and hospital approach to prehabilitation, whilst digital prehabilitation was reported in nine studies. Fifty-three studies were conducted in a range of cancers. Of these, 41 reported data for a single cancer site: colorectal ( n = 11); gastrointestinal ( n = 9); lung ( n = 7); haematology ( n= 4); breast ( n = 3); head and neck ( n =2); bladder ( n = 2) prostate ( n =1) and a range of abdominal surgeries ( n = 3). In 12 studies, cancer sites were pooled. Three studies focused on healthcare professionals ( n = 2) and key stakeholders ( n = 1).

Methodological quality

There was considerable variation in the methodological quality of the 56 studies included. Twelve studies, 10 qualitative and two quantitative, satisfied all the MMAT criteria [ 23 ]. Fourteen studies, nine mixed methods, two qualitative and three quantitative, satisfied just one or two criteria. Thus, data were extracted from a body of literature where one-fifth (21%) of publications were about research of the highest quality, defined as having met 100% of the MMAT criteria [ 23 ]. Detailed results of the MMAT quality assessments are found in supplementary information (supplementary information 3 ).

Thematic synthesis

The thematic synthesis identified three cross-cutting analytic themes. As illustrated in Figure 2 , these themes reflected individual, structural and interpersonal facilitators of and barriers to access, acceptability and adherence of cancer prehabilitation:

Overarching themes

Theme 1 The influence of individual drivers of cancer prehabilitation engagement

Theme 2 Providing acceptable cancer prehabilitation service and interventions

Theme 3 Interpersonal support – the unifying golden thread

Interpersonal support was the unifying golden thread as it facilitated the fit between the individual and the structural for access to, acceptance of and adherence to prehabilitation.

Theme 1. The influence of individual drivers of cancer prehabilitation engagement

Factors at the level of the individual were found to shape prehabilitation access, acceptance and adherence. These included perceived need and benefits, motivations, health status and everyday practicalities.

The perceived need for and potential benefits of prehabilitation

A key stimulus for accessing and adhering to cancer prehabilitation was a belief that engagement might confer benefit. Influences included clinicians’ prehabilitation endorsement and encouragement [ 12 , 13 , 42 , 52 , 55 , 59 , 60 , 65 , 66 , 71 ], positive prior personal experiences of routine physical activities [ 60 , 69 , 70 , 77 ] and weight loss programmes [ 77 ], other patients’ support [ 12 , 71 ] and the perceived need to improve personal fitness [ 60 , 63 ]. Some participants in UK-based studies believed they had a social responsibility to engage in prehabilitation [ 63 , 64 ] as enhanced fitness would benefit healthcare services financially [ 12 , 64 ].

The money, the cost per night in the hospital, goodness knows how much that costs and the follow-up with all the doctors, the dieticians and everyone else behind (….). It’s (prehabilitation) saving the NHS thousands and thousands of pounds of money ([ 64 ] p.4).

Several studies indicated some individuals perceived prehabilitation to be beneficial in that interventions provided a welcome distraction from their illness and situation [ 64 , 72 , 74 ]. Benefit was understood in terms of being psychologically and physically prepared for cancer treatments, potentially enhancing post-treatment recovery and survival [ 12 , 55 , 60 , 63 , 64 , 66 , 67 , 68 , 70 , 71 , 74 ].

I benefited a lot from it because it caught me in that time just after diagnosis when things were pretty scary and pretty awful and I felt like it was one of the key pieces of my plan for positivity during this whole thing, because it was setting a tone for recovery ([ 74 ] p. 8)

Yet, it was also clear that some individuals were disinterested in engaging with prehabilitation [ 56 , 58 , 66 , 74 , 80 ]. Some studies suggested a connection between imminent surgery and patients’ perceptions of little benefit of prehabilitation in the short timescales [ 47 , 54 , 63 , 69 , 77 , 79 ]. Some individuals felt that making additional hospital visits for prehabilitation was onerous [ 54 ]. Others were unaccustomed to or did not want to exercise [ 36 , 70 ] or perceived exercise as demanding [ 41 ], particularly when combined with cancer treatment [ 51 ]. Some considered their existing fitness levels [ 61 , 63 ] and diet [ 61 ] sufficient. A sense of low perceived benefit of or need for prehabilitation meant it was considered a low priority [ 36 ].

Personal motivators

A cancer diagnosis [ 71 , 77 ] conjoined with the desire to improve fitness [ 63 , 64 , 72 ], survive surgery [ 63 , 64 ] and to be present for and enjoy their families [ 64 ] were influential motivators for individuals’ proactively effecting lifestyle change and thus engagement with prehabilitation. Having accessed prehabilitation, exercise logs and diaries [ 64 , 68 , 74 ], personal goal setting [ 61 , 64 , 71 ], progress self-monitoring [ 61 , 64 , 68 , 71 , 77 ], activity tracking and objective feedback [ 56 , 60 ] motivated individuals to maintain participation. They inspired them to remain on track, enabled them to realise their progress, build self-efficacy for prehabilitation adherence [ 60 , 70 , 73 , 76 , 77 ] and, through a process of cognitive reframing, regain a sense of control [ 71 ].

Now I have a feeling of control over my body . . . I don’t want cancer to define me. [ 71 ]

Nonetheless, one study reported that motivation to access prehabilitation may be negatively affected by low levels of health literacy, which is associated with socioeconomic deprivation [ 46 ]. Furthermore, sustaining motivation to continue prehabilitation could be challenging [ 43 , 45 , 58 , 64 , 70 , 74 ], especially when faced with unanticipated setbacks such as delayed surgery [ 57 ] or insufficient peer support [ 64 ].

The enduring problems of health limitations

Individuals’ physical and psychological health status influenced prehabilitation access and adherence, particularly when there was a perception of insufficient on-going professional [ 61 , 72 , 73 ] and family support [ 31 ], and interventions were located away from home. Pancreatic cancer [ 33 ] adversely affected individuals’ access to prehabilitation. Furthermore, physical health problems limited some individuals’ ability to travel and thus access hospital-based prehabilitation [ 54 , 59 , 71 ]. Symptoms experienced and perceived health status influenced individuals’ prehabilitation adherence. Reported adherence barriers included physical symptoms [ 61 , 67 , 70 , 72 , 73 , 81 ] such as fatigue [ 45 , 50 , 57 , 70 , 73 ], pain [ 40 , 45 , 57 , 59 , 70 , 71 , 73 ], digestive problems [ 30 , 35 , 39 , 47 , 55 , 67 ] and feeling unwell [ 40 , 43 , 64 , 79 ]. In addition, functional limitations [ 63 , 70 ] associated with comorbidities [ 31 , 37 , 40 , 49 , 51 , 57 , 64 , 70 , 77 ], disease status [ 37 , 41 ], pre-surgery neoadjuvant treatments [ 37 , 53 , 64 , 70 , 81 ] and mental health problems [ 35 , 39 ] were all reported to negatively affect individuals’ ability to engage with and adhere to prehabilitation, particularly in terms of physical activities.

Several studies reported that psychological distress had a negative effect on prehabilitation access and adherence [ 59 , 61 , 70 , 73 ]. Described by a participant in one study [ 63 ] as ‘dark moments’, as anxiety and stress were often connected with attending hospitals [ 71 ]. In addition, several studies reported that individuals felt overwhelmed, both generally [ 42 , 57 , 74 ] and emotionally [ 12 , 70 ], in advance of their treatments. Information overload [ 62 ] and competing personal matters which required their attention pre-treatment [ 70 , 80 ] contributed to the sense of feeling overwhelmed.

The challenges of everyday life

Across studies, insufficient time for prehabilitation was frequently reported [ 40 , 50 , 51 , 55 , 58 , 66 , 71 , 72 , 74 , 77 , 78 ]. Some individuals described competing priorities in the short space of time between diagnosis and treatment [ 49 , 57 , 59 , 70 , 79 ]. This was partly due to putting affairs in order, prioritising family time [ 61 ] or treatments being scheduled earlier than originally planned [ 35 , 54 , 55 ]. Others were constrained by their employment [ 51 , 70 , 73 , 80 ] and family responsibilities, including caring for other family members [ 55 , 58 , 70 ]. Additional barriers to prehabilitation engagement included geographical distance to hospitals delivering prehabilitation [ 28 , 32 , 41 , 51 , 54 , 57 , 63 , 74 ]; transport difficulties [ 29 , 49 , 51 , 54 , 58 , 60 , 66 , 79 ] and associated financial costs [ 51 , 66 , 71 ]; inclement weather, particularly in relation to prehabilitation with outdoor exercise components [ 45 , 57 , 64 , 70 , 73 , 74 ]; low digital literacy [ 34 , 42 , 76 ]; restricted or limited access to and problems with technology [ 42 , 56 , 76 , 80 ], notably broadband [ 45 , 79 ] and experiencing physical discomfort with exercise equipment [ 60 , 64 ].

Theme 2. Providing acceptable cancer prehabilitation service and interventions

The prehabilitation environment, mode of delivery (which might be technological) and the perceived utility of interventions were important facilitators of access [ 34 , 48 , 57 , 66 , 71 , 75 , 80 ] and adherence [ 36 , 45 , 48 , 61 ] and influenced acceptance [ 36 , 52 , 61 , 64 , 69 , 71 , 77 , 80 , 81 ].

The value of home-based prehabilitation

Home-based prehabilitation interventions with remote professional supervision and support were accepted for their convenience [ 38 , 74 ], capacity to motivate [ 38 , 61 , 64 , 73 ] and build self-efficacy [ 40 , 61 , 64 , 73 ] and perceived benefit [ 40 , 69 , 74 ]. Specifically, individuals reported that home-based prehabilitation enabled them to integrate interventions into their everyday lives [ 61 , 64 ]. Exercising in the safe, private, space of home was enjoyable [ 36 , 66 ], could help with overcoming self-consciousness and engendered a sense of control [ 61 , 64 ].

I couldn’t go to the gym any longer. I can’t very well be running out to the toilet the whole time. So, I had to find something else, so it was that [static bike at home]. ([ 61 ] p. 206) …I don’t want to do it [prehabilitation] in a hospital because I think it then becomes really competitive. And people are, like, if they can’t do it, they feel…. They would feel like, ‘Oh, I’m not strong enough…’ you know what I mean. It might depress them. Whereas if you do it in the house, you can do it at your own pace, there’s nobody watching over you and everything. [ 64 ]

Home-based prehabilitation interventions were important facilitators of access [ 48 , 66 ] and adherence [ 36 , 48 , 61 ]. The provision of portable exercise equipment such as resistance bands enabled sustained adherence, particularly when individuals were temporarily away from home [ 74 ]. Some individuals welcomed the freedom and flexibility of home-based prehabilitation [ 72 ]. Yet despite being provided with resources to monitor [ 34 , 42 , 52 , 64 , 66 , 76 ], supplement and continue physical activity at home [ 48 , 63 , 66 , 74 , 77 ], insufficient in-person healthcare professional engagement and encouragement could mean adherence was often difficult to monitor [ 69 , 81 ] and sustained intervention adherence could be challenging [ 28 , 63 , 64 ] and afforded a low priority by individuals [ 61 , 72 , 73 ].

There had to be real pressure, there really had! And then if suddenly they were not around (the health professionals), then I’m not sure I’d finish it. That’s how I am. You have to keep an eye on me. [ 72 ]

Navigating the technological space of tele-prehabilitation

Sometimes referred to as ‘tele’ or ‘digital’-prehabilitation, technology-based uni and multimodal home-based prehabilitation capitalised on internet and/or telephone communication services and was delivered using smartphones, videos, wearable technology, tablets, mobile applications, video platforms and secure video conferencing [ 34 , 36 , 42 , 45 , 56 , 70 , 71 , 76 , 80 ]. In terms of acceptability, individuals perceived home-based, tele-prehabilitation programmes as accessible, particularly during the SARS-CoV-2 pandemic [ 34 , 71 , 80 ]:

Having prehabilitation outside of the hospital setting made things easier. I wasn’t feeling good with the pain and couldn’t travel too far. Could also do it in my own time ([ 71 ] p. 646)

Home-based tele-rehabilitation was also perceived as motivating [ 36 , 45 , 56 , 76 ], conferred benefit [ 34 , 36 , 45 , 56 , 80 ], particularly when personalised [ 34 , 45 , 56 , 71 ] and reduced transport-associated costs [ 80 ].

Sustained tele-prehabilitation engagement was aided by the provision of smartphones [ 56 , 76 ], tablets with relevant applications and content downloaded [ 34 ], training watches [ 34 , 56 , 76 ], supplementary information and alternate web browser pathways for those without access to or with low digital literacy [ 42 ] and integrated digital training and support during the intervention’s implementation [ 34 , 36 , 42 ].

I would not have been able to endure the treatments and the surgery thereafter had it not been for the continuous support I was receiving through the digital platform. [ 34 ]

Reported barriers were primarily intervention specific. They included technical [ 45 , 80 ] and device connectivity issues [ 34 , 76 ], broadband and website interface problems, particularly for individuals unaccustomed to using technology [ 45 ]. Negative views of mobile mindfulness apps [ 56 ] and equipment aesthetics [ 76 ] were also described.

The perceived utility of prehabilitation interventions

Interventions that were perceived as being accessible in terms of their user-friendliness [ 34 , 56 , 74 , 76 ] and appropriately designed to meet individuals’ needs, preferences and capabilities in terms of their structure [ 40 , 52 , 60 , 68 , 74 , 77 , 78 ], notably coherence [ 36 , 38 , 45 , 75 , 76 ] and components [ 38 , 54 , 55 , 64 , 69 , 74 ], including nutritional supplements [ 44 , 54 , 55 , 67 ], enhanced acceptability. The acceptability of prehabilitation interventions was reflected in the expressions of gratitude [ 12 ] and the positive ways in which interventions were variously described by individuals in some studies [ 12 , 38 , 58 , 64 , 74 ] as ‘excellent’, ‘very good’, ‘great’, ‘brilliant’, ‘hugely beneficial’ and ‘fun’. Some would even recommend home-based prehabilitation to people preparing for cancer treatments [ 52 , 63 , 68 , 74 ]. However, one study [ 42 ] reported that unfamiliarity with the English language had a negative impact on access, whilst in another study [ 56 ], individuals reported adhering to protein targets challenging.

At an individual level, the availability [ 61 ] and extent of integrated healthcare professional supervision and support was perceived to enable intervention access [ 75 ] and adherence [ 42 , 60 , 61 , 64 , 66 , 68 , 69 , 74 , 78 ], particularly when this was personalised [ 34 , 45 , 56 , 65 , 68 , 71 , 78 ]. Unpalatable nutritional interventions had a negative effect on intervention adherence [ 30 , 50 ], and it was reported that inspiratory muscle training devices could be difficult for individuals to use [ 38 ].

Healthcare professionals reported organisational barriers to implementation, and thus individuals’ access to, acceptance of and adherence with prehabilitation. These barriers included workforce capacity limitations [ 12 , 65 , 75 , 79 , 81 ], including insufficient embedded specialist prehabilitation professionals [ 69 , 81 ], delayed or insufficient referral to prehabilitation [ 33 , 44 , 63 ], disconnect in cross-boundary systematic service delivery and communication [ 12 , 28 , 75 , 81 ], inadequate funding [ 12 , 65 , 79 , 81 ] and awareness of local prehabilitation provision, uncertainty regarding what constitutes prehabilitation among some healthcare professionals [ 28 , 79 , 81 ] and space and time constraints [ 69 , 81 ] together with insufficient equipment [ 28 ] in hospital settings to deliver interventions [ 81 ].

Theme 3. Interpersonal support: the unifying golden thread

Across the studies reviewed, the unifying golden thread was interpersonal support, for this was an important, valued enabler of prehabilitation access [ 64 ] acceptance and adherence. It was reported that interpersonal support was derived from family and friends [ 12 , 45 , 60 , 61 , 64 , 70 , 73 ], prehabilitation healthcare professionals [ 42 , 51 , 55 , 60 , 61 , 63 , 64 , 66 , 69 , 71 , 75 , 78 ], prehabilitation peers [ 51 , 59 ], volunteers [ 79 ] and in-person and online peer support groups [ 71 , 79 ]. When embedded within interventions, a network of interpersonal support helped to sustain prehabilitation adherence, particularly in relation to physical activity [ 59 , 60 , 68 , 72 , 79 ]. During what could be challenging times, the interpersonal support experienced during prehabilitation enhanced interventions’ acceptability [ 52 , 60 , 63 , 68 ].

The active involvement of family during physical activities such as walking and exercise routines was reported to generate a sense of companionship, encouragement and motivational and psychological support [ 34 , 60 , 61 , 64 , 70 , 71 , 77 ]. In these ways, prehabilitation interventions with embedded family support enhanced their acceptability [ 52 ].

My wife did the same ones with me so there were two of us doing the same stuff. We did the walks together. Then we would both do the exercises. So that was good company. [ 64 ]

Findings reported in one study [ 31 ] indicated that living alone could have a negative effect on prehabilitation adherence.

The acceptability of prehabilitation interventions was enhanced by relevant healthcare professionals’ supportive dialogue in the shape of information, personalised encouragement, validation and timely, constructive feedback on individuals’ engagement, progress and performance [ 69 , 77 ], signposting to other support services [ 63 ] and broader emotional support [ 77 ]. In addition to sustaining prehabilitation behaviours through collaboration, activation and motivational support [ 60 , 61 , 71 , 72 , 77 , 78 ], healthcare professionals’ presence instilled a sense of trust [ 71 ], comfort [ 51 ] and safety [ 38 , 62 , 63 ] and reduced feelings of social isolation [ 71 ]. The need for and importance of supportive dialogue with healthcare professionals during prehabilitation was identified by participants in one study investigating individuals’ experiences of multimodal prehabilitation delivered via a leaflet and with no embedded healthcare professional support [ 73 ].

I have only been a number. Like I was a garden shovel with a barcode that you scanned at the cash register. There is no one who thinks about what this means for one’s self-understanding–- just to be regarded as a disease [...] There is no one asking about the human being behind it. It is insane [ 73 ]

For some participants, peer support in the shape of information sharing was beneficial and enabled prehabilitation access [ 63 , 71 ]. Integrated group or one to one peer support was reported to enhance an intervention’s acceptability [ 12 , 63 ]. In part, this was because individuals did not always want to engage their families, and peer support reduced their sense of isolation [ 71 ]. Peer support was reported to be beneficial in terms of interaction with others in a similar situation, thereby lending individuals’ social, emotional and motivational support, enabling them to remain on track with their prehabilitation programme [ 51 , 59 , 64 , 66 , 71 ].

Exercising in a group motivates. Let new patients exercise with other patients who are further along and have more experience exercising. They (experienced patients) can then tell them, Yes, you will get muscle aches, but they will subside too. [ 59 ]

It was clear from some studies that the absence of peer support in prehabilitation interventions was lamented [ 64 , 71 ], with some participants exercising agency and accessing online patient forums to derive required support [ 71 ].

This review reports findings from across the globe regarding facilitators of and barriers to access, acceptance and adherence of cancer prehabilitation. The findings draw attention to cross-cutting themes at individual and structural levels and interpersonal factors that connect the levels. As illuminated in Fig. 2 , the multifaceted facilitators and barriers underscore the complexity of cancer prehabilitation access, acceptance and adherence.

This review found interpersonal connections, support either directly obtained from peers, family, healthcare professionals or via digital connectivity, can facilitate a fit between the individual factors and structural factors that affect engagement with prehabilitation. Examples include encouragement from a spouse willing to engage in a recommended physical activity with the patient, practical help with digital technology, peer support during group prehabilitation and health professional supervision. Support through these interpersonal connections may be a core ingredient for successful access, acceptance and adherence. This proposition should now be explored and tested. There may be sub-groups with need or preference for certain sources of interpersonal support. Our review was designed to find out ‘what is known about access, acceptance and adherence to cancer prehabilitation, particularly among socially deprived and minority ethnic groups’ because of the known benefits from prehab for post treatment recovery [ 8 , 9 ]. It found no empirically based analysis of prehabilitation access, acceptance or adherence by people from these groups.

The individual and structural context

This review revealed individual factors enabling or impeding prehabilitation access, acceptance and adherence include personal beliefs and understandings about potential harms or benefits; motivations, for example finding enjoyment in participation; health status and everyday practicalities such as time and transport availability. Structural factors identified included the availability of knowledgeable and supportive health professionals and/or people affected by cancer’ service organisation, such as the availability of a prehabilitation multidisciplinary team and the place and space of service delivery, for example, if it was available in the community.

Individual and structural level factors affecting access to cancer treatment and care are widely reported [ 82 , 83 , 84 , 85 ]. Some are proposed to be modifiable for improved health outcomes in groups at risk of poor health because of poverty and/or discrimination based on age, race, ethnicity or gender [ 84 ]. The findings of the review are consistent with this wider literature on service access, acceptance and adherence. It is notable that although our search was designed to identify all literature about access, acceptance and adherence to cancer prehabilitation from 2017 to 2023, we found no analysis of structural differences. The differential experience of people from structurally vulnerable groups, for example, those who are socioeconomically deprived or from minority communities, had not been considered. Yet, evidence indicates that cancer rehabilitation services are underutilised by people from socioeconomically deprived communities [ 86 , 87 ] and ethnic minorities [ 88 ]. We also know patient engagement with prehabilitation is variable [ 89 ], and third sector organisations claim people from socioeconomically deprived communities, which include people from some ethnic minorities, are underserved by prehabilitation services [ 1 ]. Exploration and understanding of difference in prehabilitation experiences across social groups is needed if support for access, acceptance and adherence is to achieve equity in health outcomes.

Interpersonal connections linking individual experience and structural context

This review identified that it was people, namely peers, family members and friends, who, through their support, influenced the extent to which individual and structural level factors were obstacles or enablers of prehabilitation. In the relational space between individual experience and the infrastructure in place to enable prehabilitation, these people were supportive actors, influencing individuals’ access to, acceptance of and adherence to prehabilitation.

International studies have revealed that interpersonal support is related to mental and physical health. Low perceived social support has been shown to be associated with mental and physical health problems [ 90 ]. In the USA, a high level of perceived social support was found more likely in women and young people and low level of perceived social support more likely for those living in poverty [ 90 ]. Loneliness has been proposed the mediating factor between socioeconomic status and health in a Norwegian population-based study of people aged over 40 years [ 91 ]. Two explanations were suggested. Firstly, people with few social contacts have low levels of physical activity. Secondly, people with poor physical or emotional health are more likely to have low self-esteem and self-efficacy in self-care, which is associated with less successful occupational career and low socioeconomic status and thus fewer social contact resources to manage health [ 91 ].

This review supports an argument that interpersonal connections can be important for prehabilitation access, acceptance and adherence. It found evidence of relationships with family, peers and cancer care staff influencing access to, acceptance of, and adherence to prehabilitation. Perceived social support may have a key role in successful prehabilitation. This proposition should be further explored, paying attention to the known relationship between social support and socioeconomic status in other contexts and the potential for this to be an explanation of any observed difference in access across socioeconomic groups.

Technology as interpersonal connection?

An interesting finding is of data showing some people find web-based resources and/or online help to satisfy their prehabilitation information and support needs. These people experienced interpersonal connection through technology. An online survey among 1037 adults (18+) in the UK found that 80% of those with a long-term condition used technology for managing their health, a majority for seeking information whilst a third used wearable technology or apps. Those most likely to use technologies were younger and/or of high socioeconomic status, leading the authors to caution completely digital approaches because of the potential to exclude some groups from the care they need [ 92 ]. Arguably, technology may provide a partial solution to enabling successful prehabilitation.

What this review adds

Our finding of structural and individual level factors affecting access to, acceptance of and adherence to prehabilitation is consistent with Levesque et al.’s [ 93 ] socioecological model of access to health services. Levesque et al.’s [ 93 ] model sets out access as a process with five dimensions of accessibility (approachability; acceptability; availability and accommodation; affordability; appropriateness) and five corresponding abilities of populations (ability to perceive; ability to seek; ability to reach; ability to pay; ability to engage). The model enables attention to social, service organisation and person-centred factors that influence access. However, the model does not address the relational dimensions derived from our data analysis, i.e. how person-centred and structural factors interrelate for better or poorer service access. Based on our findings, an important ingredient for improving access to prehabilitation may be attention to what happens in the relational space connecting these factors. Voorhees et al. [ 94 ] interpreted findings of participatory research about access to general practice and claimed it is the human abilities of workforce and clients that are an important yet absent consideration in Levesque’s model. They argued that staff training and support for human interaction were needed. We agree. In addition, and based on our analysis, we also consider important the network of interactions between patient and others. Understanding the nature and mechanisms of these interactions may be important for health equity in prehabilitation.

Strengths and limitations

A strength of this review is that established, rigorous systematic review processes were followed to identify and select relevant peer-reviewed literature. Methods and thematic synthesis procedures were reported explicitly, providing an audit trail for dependability. To maximise study identification, the detailed and comprehensive search strategy was developed with the assistance of an expert information specialist, and the review was conducted by a multidisciplinary team with a minimum of two reviewers engaged in the screening and extracting process. Searches were limited from 2017 to 2023 and published in the English language. By limiting the search dates in this way, we have ensured that the evidence assessed has context and relevance to current policy and practices. This systematic review, as a result, provides an overarching picture and holistic understanding of access, acceptance and adherence to cancer prehabilitation. However, this review is not without its limitations. It is possible that some potentially useful studies, notably those not published in the English language have been omitted. Furthermore, we did not take account of study quality in our analysis. To reduce the risk of selection bias, studies were included irrespective of their methodological quality assessment. However, this means that some low quality evidence has been included, and this is a limitation to the credibility of the analysis. Nevertheless, there is some consistency between studies and across international healthcare settings. This does indicate a level of trustworthiness in the review findings. The review was of mixed cancer sites. Cancer site along with its symptoms and treatment-related problems may affect access, acceptance and adherence to prehabilitation. As the body of literature about engagement with prehabilitation grows, further work will be warranted to investigate cancer site–specific factors affecting inclusion in prehabilitation.

ThQueryere is limited empirical study of barriers and facilitators to inform improvement in equity of access to cancer prehabilitation. To enhance the inclusivity of cancer prehabilitation, adjustments may be needed to accommodate individual preferences and characteristics, such as comorbidity, and attention given to structural factors, such as staff training. Based on our findings, we propose interpersonal connections as a fundamental core ingredient for facilitation of prehabilitation access, acceptance and adherence.

Systematic review registration

This systematic review was registered in PROSPERO (CRD42023403776)

Data Availability

All data generated for this review are included in the manuscript and/or the supplementary files.

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T.W. and JH wrote the main manuscript. E.G. Designed and tested the search strategy, ran all the searches and prepared supplementary file 1 E.G. and TW prepared figure 1 JH prepared figure 2 All authors contributed to study selection, quality assessment and data extraction TW and MP prepared supplementary file 2 TW prepared supplementary file 3 TW, MP and JH analysed data. All authors reviewed the manuscript.

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Published: 13 May 2024

Sexual and reproductive health implementation research in humanitarian contexts: a scoping review

Alexandra Norton 1 &
Hannah Tappis 2

Reproductive Health volume 21 , Article number: 64 ( 2024 ) Cite this article

Metrics details

Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on appropriate methods and analytical frameworks is limited.

A scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Peer-reviewed papers published from 2013 to 2022 were identified through relevant systematic reviews and a literature search of Pubmed, Embase, PsycInfo, CINAHL and Global Health databases. Papers that presented primary quantitative or qualitative data pertaining to a sexual and reproductive health intervention in a humanitarian setting were included.

Seven thousand thirty-six unique records were screened for inclusion, and 69 papers met inclusion criteria. Of these, six papers explicitly described the use of an implementation research framework, three citing use of the Consolidated Framework for Implementation Research. Three additional papers referenced other types of frameworks used in their evaluation. Factors cited across all included studies as helping the intervention in their presence or hindering in their absence were synthesized into the following Consolidated Framework for Implementation Research domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process.

This review found a wide range of methodologies and only six of 69 studies using an implementation research framework, highlighting an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

Plain English summary

Three hundred thirty-nine million people globally were in need of humanitarian assistance in 2023, and meeting the health needs of crisis-affected populations is a growing challenge. One in four people living in humanitarian contexts are women and girls of reproductive age, and provision of sexual and reproductive health care is considered to be essential within a humanitarian response. Implementation research can help to better understand how real-world contexts affect health improvement efforts. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on how best to do so is limited. This scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Of 69 papers that met inclusion criteria for the review, six of them explicitly described the use of an implementation research framework. Three used the Consolidated Framework for Implementation Research, a theory-based framework that can guide implementation research. Three additional papers referenced other types of frameworks used in their evaluation. This review summarizes how factors relevant to different aspects of implementation within the included papers could have been organized using the Consolidated Framework for Implementation Research. The findings from this review highlight an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

Peer Review reports

Over the past few decades, the field of public health implementation research (IR) has grown as a means by which the real-world conditions affecting health improvement efforts can be better understood. Peters et al. put forward the following broad definition of IR for health: “IR is the scientific inquiry into questions concerning implementation – the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions)” [ 1 ].

As IR emphasizes real-world circumstances, the context within which a health intervention is delivered is a core consideration. However, much IR implemented to date has focused on higher-resource settings, with many proposed frameworks developed with particular utility for a higher-income setting [ 2 ]. In recognition of IR’s potential to increase evidence across a range of settings, there have been numerous reviews of the use of IR in lower-resource settings as well as calls for broader use [ 3 , 4 ]. There have also been more focused efforts to modify various approaches and frameworks to strengthen the relevance of IR to low- and middle-income country settings (LMICs), such as the work by Means et al. to adapt a specific IR framework for increased utility in LMICs [ 2 ].

Within LMIC settings, the centrality of context to a health intervention’s impact is of particular relevance in humanitarian settings, which present a set of distinct implementation challenges [ 5 ]. Humanitarian responses to crisis situations operate with limited resources, under potential security concerns, and often under pressure to relieve acute suffering and need [ 6 ]. Given these factors, successful implementation of a particular health intervention may require different qualities than those that optimize intervention impact under more stable circumstances [ 7 ]. Despite increasing recognition of the need for expanded evidence of health interventions in humanitarian settings, the evidence base remains limited [ 8 ]. Furthermore, despite its potential utility, there is not standardized guidance on IR in humanitarian settings, nor are there widely endorsed recommendations for the frameworks best suited to analyze implementation in these settings.

Sexual and reproductive health (SRH) is a core aspect of the health sector response in humanitarian settings [ 9 ]. Yet, progress in addressing SRH needs has lagged far behind other services because of challenges related to culture and ideology, financing constraints, lack of data and competing priorities [ 10 ]. The Minimum Initial Service Package (MISP) for SRH in Crisis Situations is the international standard for the minimum set of SRH services that should be implemented in all crisis situations [ 11 ]. However, as in other areas of health, there is need for expanded evidence for planning and implementation of SRH interventions in humanitarian settings. Recent systematic reviews of SRH in humanitarian settings have focused on the effectiveness of interventions and service delivery strategies, as well as factors affecting utilization, but have not detailed whether IR frameworks were used [ 12 , 13 , 14 , 15 ]. There have also been recent reviews examining IR frameworks used in various settings and research areas, but none have explicitly focused on humanitarian settings [ 2 , 16 ].

Given the need for an expanded evidence base for SRH interventions in humanitarian settings and the potential for IR to be used to expand the available evidence, a scoping review was undertaken. This scoping review sought to identify IR approaches that have been used in the last ten years to evaluate SRH interventions in humanitarian settings.

This review also sought to shed light on whether there is a need for a common framework to guide research design, analysis, and reporting for SRH interventions in humanitarian settings and if so, if there are any established frameworks already in use that would be fit-for-purpose or could be tailored to meet this need.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews was utilized to guide the elements of this review [ 17 ]. The review protocol was retrospectively registered with the Open Science Framework ( https://osf.io/b5qtz ).

Search strategy

A two-fold search strategy was undertaken for this review, which covered the last 10 years (2013–2022). First, recent systematic reviews pertaining to research or evaluation of SRH interventions in humanitarian settings were identified through keyword searches on PubMed and Google Scholar. Four relevant systematic reviews were identified [ 12 , 13 , 14 , 15 ] Table 1 .

Second, a literature search mirroring these reviews was conducted to identify relevant papers published since the completion of searches for the most recent review (April 2017). Additional file 1 includes the search terms that were used in the literature search [see Additional file 1 ].

The literature search was conducted for papers published from April 2017 to December 2022 in the databases that were searched in one or more of the systematic reviews: PubMed, Embase, PsycInfo, CINAHL and Global Health. Searches were completed in January 2023 Table 2 .

Two reviewers screened each identified study for alignment with inclusion criteria. Studies in the four systematic reviews identified were considered potentially eligible if published during the last 10 years. These papers then underwent full-text review to confirm satisfaction of all inclusion criteria, as inclusion criteria were similar but not fully aligned across the four reviews.

Literature search results were exported into a citation manager (Covidence), duplicates were removed, and a step-wise screening process for inclusion was applied. First, all papers underwent title and abstract screening. The remaining papers after abstract screening then underwent full-text review to confirm satisfaction of all inclusion criteria. Title and abstract screening as well as full-text review was conducted independently by both authors; disagreements after full-text review were resolved by consensus.

Data extraction and synthesis

The following content areas were summarized in Microsoft Excel for each paper that met inclusion criteria: publication details including author, year, country, setting [rural, urban, camp, settlement], population [refugees, internally displaced persons, general crisis-affected], crisis type [armed conflict, natural disaster], crisis stage [acute, chronic], study design, research methods, SRH intervention, and intervention target population [specific beneficiaries of the intervention within the broader population]; the use of an IR framework; details regarding the IR framework, how it was used, and any rationale given for the framework used; factors cited as impacting SRH interventions, either positively or negatively; and other key findings deemed relevant to this review.

As the focus of this review was on the approach taken for SRH intervention research and evaluation, the quality of the studies themselves was not assessed.

Twenty papers underwent full-text review due to their inclusion in one or more of the four systematic reviews and meeting publication date inclusion criteria. The literature search identified 7,016 unique papers. After full-text screening, 69 met all inclusion criteria and were included in the review. Figure 1 illustrates the search strategy and screening process.

Flow chart of paper identification

Papers published in each of the 10 years of the review timeframe (2013–2022) were included. 29% of the papers originated from the first five years of the time frame considered for this review, with the remaining 71% papers coming from the second half. Characteristics of included publications, including geographic location, type of humanitarian crisis, and type of SRH intervention, are presented in Table 3 .

A wide range of study designs and methods were used across the papers, with both qualitative and quantitative studies well represented. Twenty-six papers were quantitative evaluations [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ], 17 were qualitative [ 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ], and 26 used mixed methods [ 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 ]. Within the quantitative evaluations, 15 were observational, while five were quasi-experimental, five were randomized controlled trials, and one was an economic evaluation. Study designs as classified by the authors of this review are summarized in Table 4 .

Six papers (9%) explicitly cited use of an IR framework. Three of these papers utilized the Consolidated Framework for Implementation Research (CFIR) [ 51 , 65 , 70 ]. The CFIR is a commonly used determinant framework that—in its originally proposed form in 2009—is comprised of five domains, each of which has constructs to further categorize factors that impact implementation. The CFIR domains were identified as core content areas influencing the effectiveness of implementation, and the constructs within each domain are intended to provide a range of options for researchers to select from to “guide diagnostic assessments of implementation context, evaluate implementation progress, and help explain findings.” [ 87 ] To allow for consistent terminology throughout this review, the original 2009 CFIR domains and constructs are used.

Guan et al. conducted a mixed methods study to assess the feasibility and effectiveness of a neonatal hepatitis B immunization program in a conflict-affected rural region of Myanmar. Guan et al. report mapping data onto the CFIR as a secondary analysis step. They describe that “CFIR was used as a comprehensive meta-theoretical framework to examine the implementation of the Hepatitis B Virus vaccination program,” and implementation themes from multiple study data sources (interviews, observations, examination of monitoring materials) were mapped onto CFIR constructs. They report their results in two phases – Pre-implementation training and community education, and Implementation – with both anchored in themes that they had mapped onto CFIR domains and constructs. All but six constructs were included in their analysis, with a majority summarized in a table and key themes explored further in the narrative text. They specify that most concerns were identified within the Outer Setting and Process domains, while elements identified within the Inner Setting domain provided strength to the intervention and helped mitigate against barriers [ 70 ].

Sarker et al. conducted a qualitative study to assess provision of maternal, newborn and child health services to Rohingya refugees residing in camps in Cox’s Bazar, Bangladesh. They cite using CFIR as a guide for thematic analysis, applying it after a process of inductive and deductive coding to index these codes into the CFIR domains. They utilized three of the five CFIR domains (Outer Setting, Inner Setting, and Process), stating that the remaining two domains (Intervention Characteristics and Characteristics of Individuals) were not relevant to their analysis. They then proposed two additional CFIR domains, Context and Security, for use in humanitarian contexts. In contrast to Guan et al., CFIR constructs are not used nor mentioned by Sarker et al., with content under each domain instead synthesized as challenges and potential solutions. Regarding the CFIR, Sarker et al. write, “The CFIR guided us for interpretative coding and creating the challenges and possible solutions into groups for further clarification of the issues related to program delivery in a humanitarian crisis setting.” [ 51 ]

Sami et al. conducted a mixed methods case study to assess the implementation of a package of neonatal interventions at health facilities within refugee and internally displaced persons camps in South Sudan. They reference use of the CFIR earlier in the study than Sarker et al., basing their guides for semi-structured focus group discussions on the CFIR framework. They similarly reference a general use of the CFIR framework as they conducted thematic analysis. Constructs are referenced once, but they do not specify whether their application of the CFIR framework included use of domains, constructs, or both. This may be in part because they then applied an additional framework, the World Health Organization (WHO) Health System Framework, to present their findings. They describe a nested approach to their use of these frameworks: “Exploring these [CFIR] constructs within the WHO Health Systems Framework can identify specific entry points to improve the implementation of newborn interventions at critical health system building blocks.” [ 65 ]

Three papers cite use of different IR frameworks. Bolan et al. utilized the Theoretical Domains Framework in their mixed methods feasibility study and pilot cluster randomized trial evaluating pilot use of the Safe Delivery App by maternal and newborn health workers providing basic emergency obstetric and newborn care in facilities in the conflict-affected Maniema province of the Democratic Republic of the Congo (DRC). They used the Theroetical Domains Framework in designing interview questions, and further used it as the coding framework for their analysis. Similar to the CFIR, the Theoretical Domains Framework is a determinant framework that consists of domains, each of which then includes constructs. Bolan et al. utilized the Theoretical Domains Framework at the construct level in interview question development and at the domain level in their analysis, mapping interview responses to eight of the 14 domains [ 83 ]. Berg et al. report using an “exploratory design guided by the principles of an evaluation framework” developed by the Medical Research Council to analyze the implementation process, mechanisms of impact, and outcomes of a three-pillar training intervention to improve maternal and neonatal healthcare in the conflict-affected South Kivu province of the DRC [ 67 , 88 ]. Select components of this evaluation framework were used to guide deductive analysis of focus group discussions and in-depth interviews [ 67 ]. In their study of health workers’ knowledge and attitudes toward newborn health interventions in South Sudan, before and after training and supply provision, Sami et al. report use of the Conceptual Framework of the Role of Attitudes in Evidence-Based Practice Implementation in their analysis process. The framework was used to group codes following initial inductive coding analysis of in-depth interviews [ 72 ].

Three other papers cite use of specific frameworks in their intervention evaluation [ 19 , 44 , 76 ]. As a characteristic of IR is the use of an explicit framework to guide the research, the use of the frameworks in these three papers meets the intention of IR and serves the purpose that an IR framework would have in strengthening the analytical rigor. Castle et al. cite use of their program’s theory of change as a framework for a mixed methods evaluation of the provision of family planning services and more specifically uptake of long-acting reversible contraception use in the DRC. They describe use of the theory of change to “enhance effectiveness of [long-acting reversible contraception] access and uptake.” [ 76 ] Thommesen et al. cite use of the AAAQ (Availability, Accessibility, Acceptability and Quality) framework in their qualitative study assessing midwifery services provided to pregnant women in Afghanistan. This framework is focused on the “underlying elements needed for attainment of optimum standard of health care,” but the authors used it in this paper to evaluate facilitators and barriers to women accessing midwifery services [ 44 ]. Jarrett et al. cite use of the Centers for Disease Control and Prevention’s (CDC) Guidelines for Evaluating Public Health Surveillance Systems to explore the characteristics of a population mobility, mortality and birth surveillance system in South Kivu, DRC. Use of these CDC guidelines is cited as one of four study objectives, and commentary is included in the Results section pertaining to each criteria within these guidelines, although more detail regarding use of these guidelines or the authors’ experience with their use in the study is not provided [ 19 ].

Overall, 22 of the 69 papers either explicitly or implicitly identified IR as relevant to their work. Nineteen papers include a focus on feasibility (seven of which did not otherwise identify the importance of exploring questions concerning implementation), touching on a common outcome of interest in implementation research [ 89 ].

While a majority of papers did not explicitly or implicitly use an IR framework to evaluate their SRH intervention of focus, most identified factors that facilitated implementation when they were present or served as a barrier when absent. Sixty cite factors that served as facilitators and 49 cite factors that served as barriers, with just three not citing either. Fifty-nine distinct factors were identified across the papers.

Three of the six studies that explicitly used an IR framework used the CFIR, and the CFIR is the only IR framework that was used by multiple studies. As previously mentioned, Means et al. put forth an adaptation of the CFIR to increase its relevance in LMIC settings, proposing a sixth domain (Characteristics of Systems) and 11 additional constructs [ 2 ]. Using the expanded domains and constructs as proposed by Means et al., the 59 factors cited by papers in this review were thematically grouped into the six domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process. Within each domain, alignment with CFIR constructs was assessed for, and alignment was found with 29 constructs: eight of Means et al.’s 11 constructs, and 21 of the 39 standard CFIR constructs. Three factors did not align with any construct (all fitting within the Outer Setting domain), and 14 aligned with a construct label but not the associated definition. Table 5 synthesizes the mapping of factors affecting SRH intervention implementation to CFIR domains and constructs, with the construct appearing in italics if it is considered to align with that factor by label but not by definition.

Table 6 lists the CFIR constructs that were not found to have alignment with any factor cited by the papers in this review.

This scoping review sought to assess how IR frameworks have been used to bolster the evidence base for SRH interventions in humanitarian settings, and it revealed that IR frameworks, or an explicit IR approach, are rarely used. All four of the systematic reviews identified with a focus on SRH in humanitarian settings articulate the need for more research examining the effectiveness of SRH interventions in humanitarian settings, with two specifically citing a need for implementation research/science [ 12 , 13 ]. The distribution of papers across the timeframe included in this review does suggest that more research on SRH interventions for crisis-affected populations is taking place, as a majority of relevant papers were published in the second half of the review period. The papers included a wide range of methodologies, which reflect the differing research questions and contexts being evaluated. However, it also invites the question of whether there should be more standardization of outcomes measured or frameworks used to guide analysis and to facilitate increased comparison, synthesis and application across settings.

Three of the six papers that used an IR framework utilized the CFIR. Guan et al. used the CFIR at both a domain and construct level, Sarker et al. used the CFIR at the domain level, and Sami et al. did not specify which CFIR elements were used in informing the focus group discussion guide [ 51 , 65 , 70 ]. It is challenging to draw strong conclusions about the applicability of CFIR in humanitarian settings based on the minimal use of CFIR and IR frameworks within the papers reviewed, although Guan et al. provides a helpful model for how analysis can be structured around CFIR domains and constructs. It is worth considering that the minimal use of IR frameworks, and more specifically CFIR constructs, could be in part because that level of prescriptive categorization does not allow for enough fluidity in humanitarian settings. It also raises questions about the appropriate degree of standardization to pursue for research done in these settings.

The mapping of factors affecting SRH intervention implementation provides an example of how a modified CFIR framework could be used for IR in humanitarian contexts. This mapping exercise found factors that mapped to all five of the original CFIR domains as well as the sixth domain proposed by Means et al. All factors fit well within the definition for the selected domain, indicating an appropriate degree of fit between these existing domains and the factors identified as impacting SRH interventions in humanitarian settings. On a construct level, however, the findings were more variable, with one-quarter of factors not fully aligning with any construct. Furthermore, over 40% of the CFIR constructs (including the additional constructs from Means et al.) were not found to align with any factors cited by the papers in this review, also demonstrating some disconnect between the parameters posed by the CFIR constructs and the factors cited as relevant in a humanitarian context.

It is worth noting that while the CFIR as proposed in 2009 was used in this assessment, as well as in the included papers which used the CFIR, an update was published in 2022. Following a review of CFIR use since its publication, the authors provide updates to construct names and definitions to “make the framework more applicable across a range of innovations and settings.” New constructs and subconstructs were also added, for a total of 48 constructs and 19 subconstructs across the five domains [ 90 ]. A CFIR Outcomes Addendum was also published in 2022, based on recommendations for the CFIR to add outcomes and intended to be used as a complement to the CFIR determinants framework [ 91 ]. These expansions to the CFIR framework may improve applicability of the CFIR in humanitarian settings. Several constructs added to the Outer Setting domain could be of particular utility – critical incidents, local attitudes, and local conditions, each of which could help account for unique challenges faced in contexts of crisis. Sub-constructs added within the Inner Setting domain that seek to clarify structural characteristics and available resources would also be of high utility based on mapping of the factors identified in this review to the original CFIR constructs. As outcomes were not formally included in the CFIR until the 2022 addendum, a separate assessment of implementation outcomes was not undertaken in this review. However, analysis of the factors cited by papers in this review as affecting implementation was derived from the full text of the papers and thus captures content relevant to implementation determinants that is contained within the outcomes.

Given the demonstrated need for additional flexibility within an IR framework for humanitarian contexts, while not a focus of this review, it is worth considering whether a different framework could provide a better fit than the CFIR. Other frameworks have differing points of emphasis that would create different opportunities for flexibility but that do not seem to resolve the challenges experienced in applying the CFIR to a humanitarian context. As one example, the EPIS (Exploration, Preparation, Implementation, Sustainment) Framework considers the impact of inner and outer context on each of four implementation phases; while the constructs within this framework are broader than the CFIR, an emphasis on the intervention characteristics is missing, a domain where stronger alignment within the CFIR is also needed [ 92 ]. Alternatively, the PRISM (Practical, Robust Implementation and Sustainability Model) framework is a determinant and evaluation framework that adds consideration of context factors to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) outcomes framework. It has a stronger emphasis on intervention aspects, with sub-domains to account for both organization and patient perspectives within the intervention. While PRISM does include aspects of context, external environment considerations are less robust and intentionally less comprehensive in scope, which would not provide the degree of alignment possible between the Characteristics of Systems and Outer Setting CFIR domains for the considerations unique to humanitarian environments [ 93 ].

Reflecting on their experience with the CFIR, Sarker et al. indicate that it can be a “great asset” in both evaluating current work and developing future interventions. They also encourage future research of humanitarian health interventions to utilize the CFIR [ 51 ]. The other papers that used the CFIR do not specifically reflect on their experience utilizing it, referring more generally to having felt that it was a useful tool [ 65 , 70 ]. On their use of an evaluation framework, Berg et al. reflected that it lent useful structure and helped to identify aspects affecting implementation that otherwise would have gone un-noticed [ 67 ]. The remaining studies that utilized an IR framework did not specifically comment on their experience with its use [ 72 , 83 ]. While a formal IR framework was not engaged by other studies, a number cite a desire for IR to contribute further detail to their findings [ 21 , 37 ].

In their recommendations for strengthening the evidence base for humanitarian health interventions, Ager et al. speak to the need for “methodologic innovation” to develop methodologies with particular applicability in humanitarian settings [ 7 ]. As IR is not yet routinized for SRH interventions, this could be opportune timing for the use of a standardized IR framework to gauge its utility. Using an IR framework to assess factors influencing implementation of the MISP in initial stages of a humanitarian response, and interventions to support more comprehensive SRH service delivery in protracted crises, could lend further rigor and standardization to SRH evaluations, as well as inform strategies to improve MISP implementation over time. Based on categorizing factors identified by these papers as relevant for intervention evaluation, there does seem to be utility to a modified CFIR approach. Given the paucity of formal IR framework use within SRH literature, it would be worth conducting similar scoping exercises to assess for explicit use of IR frameworks within the evidence base for other health service delivery areas in humanitarian settings. In the interim, the recommended approach from this review for future IR on humanitarian health interventions would be a modified CFIR approach with domain-level standardization and flexibility for constructs that may standardize over time with more use. This would enable use of a common analytical framework and vocabulary at the domain level for stakeholders to describe interventions and the factors influencing the effectiveness of implementation, with constructs available to use and customize as most appropriate for specific contexts and interventions.

This review had a number of limitations. As this was a scoping review and a two-part search strategy was used, the papers summarized here may not be comprehensive of those written pertaining to SRH interventions over the past 10 years. Papers from 2013 to 2017 that would have met this scoping review’s inclusion criteria may have been omitted due to being excluded from the systematic reviews. The review was limited to papers available in English. Furthermore, this review did not assess the quality of the papers included or seek to assess the methodology used beyond examination of the use of an IR framework. It does, however, serve as a first step in assessing the extent to which calls for implementation research have been addressed, and identify entry points for strengthening the science and practice of SRH research in humanitarian settings.

With one in 23 people worldwide in need of humanitarian assistance, and financing required for response plans at an all-time high, the need for evidence to guide resource allocation and programming for SRH in humanitarian settings is as important as ever [ 94 ]. Recent research agenda setting initiatives and strategies to advance health in humanitarian settings call for increased investment in implementation research—with priorities ranging from research on effective strategies for expanding access to a full range of contraceptive options to integrating mental health and psychosocial support into SRH programming to capturing accurate and actionable data on maternal and perinatal mortality in a wide range of acute and protracted emergency contexts [ 95 , 96 ]. To truly advance guidance in these areas, implementation research will need to be conducted across diverse humanitarian settings, with clear and consistent documentation of both intervention characteristics and outcomes, as well as contextual and programmatic factors affecting implementation.

Conclusions

Implementation research has potential to increase impact of health interventions particularly in crisis-affected settings where flexibility, adaptability and context-responsive approaches are highlighted as cornerstones of effective programming. There remains significant opportunity for standardization of research in the humanitarian space, with one such opportunity occurring through increased utilization of IR frameworks such as a modified CFIR approach. Investing in more robust sexual and reproductive health research in humanitarian contexts can enrich insights available to guide programming and increase transferability of learning across settings.

Availability of data and materials

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

Abbreviations

Availability, Accessibility, Acceptability and Quality

Centers for Disease Control and Prevention

Consolidated Framework for Implementation Research

Democratic Republic of the Congo

Exploration, Preparation, Implementation, Sustainment

Implementation research

Low and middle income country

Minimum Initial Service Package

Practical, Robust Implementation and Sustainability Model

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Reach, Effectiveness, Adoption, Implementation, Maintenance

Sexual and reproductive health

World Health Organization

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. Literature search terms: Exact search terms used in literature search, with additional detail on the methodology to determine search terms and definitions used for each component of the search

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Reviewing the research methods literature: principles and strategies illustrated by a systematic overview of sampling in qualitative research

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Searching beyond standard bibliographic databases

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Searching without relevant metadata

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Purposefully selecting literature on conceptual grounds

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