what is the importance of review of literature in research

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Why is it important to do a literature review in research?

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 “A substantive, thorough, sophisticated literature review is a precondition for doing substantive, thorough, sophisticated research”. Boote and Baile 2005

Authors of manuscripts treat writing a literature review as a routine work or a mere formality. But a seasoned one knows the purpose and importance of a well-written literature review.  Since it is one of the basic needs for researches at any level, they have to be done vigilantly. Only then the reader will know that the basics of research have not been neglected.

The aim of any literature review is to summarize and synthesize the arguments and ideas of existing knowledge in a particular field without adding any new contributions.   Being built on existing knowledge they help the researcher to even turn the wheels of the topic of research.  It is possible only with profound knowledge of what is wrong in the existing findings in detail to overpower them.  For other researches, the literature review gives the direction to be headed for its success. 

The common perception of literature review and reality:

As per the common belief, literature reviews are only a summary of the sources related to the research. And many authors of scientific manuscripts believe that they are only surveys of what are the researches are done on the chosen topic.  But on the contrary, it uses published information from pertinent and relevant sources like

• Scholarly books
• Scientific papers
• Latest studies in the field
• Established school of thoughts
• Relevant articles from renowned scientific journals

and many more for a field of study or theory or a particular problem to do the following:

• Summarize into a brief account of all information
• Synthesize the information by restructuring and reorganizing
• Critical evaluation of a concept or a school of thought or ideas
• Familiarize the authors to the extent of knowledge in the particular field
• Encapsulate
• Compare & contrast

By doing the above on the relevant information, it provides the reader of the scientific manuscript with the following for a better understanding of it:

• It establishes the authors’  in-depth understanding and knowledge of their field subject
• It gives the background of the research
• Portrays the scientific manuscript plan of examining the research result
• Illuminates on how the knowledge has changed within the field
• Highlights what has already been done in a particular field
• Information of the generally accepted facts, emerging and current state of the topic of research
• Identifies the research gap that is still unexplored or under-researched fields
• Demonstrates how the research fits within a larger field of study
• Provides an overview of the sources explored during the research of a particular topic

Importance of literature review in research:

The importance of literature review in scientific manuscripts can be condensed into an analytical feature to enable the multifold reach of its significance.  It adds value to the legitimacy of the research in many ways:

• Provides the interpretation of existing literature in light of updated developments in the field to help in establishing the consistency in knowledge and relevancy of existing materials
• It helps in calculating the impact of the latest information in the field by mapping their progress of knowledge.
• It brings out the dialects of contradictions between various thoughts within the field to establish facts
• The research gaps scrutinized initially are further explored to establish the latest facts of theories to add value to the field
• Indicates the current research place in the schema of a particular field
• Provides information for relevancy and coherency to check the research
• Apart from elucidating the continuance of knowledge, it also points out areas that require further investigation and thus aid as a starting point of any future research
• Justifies the research and sets up the research question
• Sets up a theoretical framework comprising the concepts and theories of the research upon which its success can be judged
• Helps to adopt a more appropriate methodology for the research by examining the strengths and weaknesses of existing research in the same field
• Increases the significance of the results by comparing it with the existing literature
• Provides a point of reference by writing the findings in the scientific manuscript
• Helps to get the due credit from the audience for having done the fact-finding and fact-checking mission in the scientific manuscripts
• The more the reference of relevant sources of it could increase more of its trustworthiness with the readers
• Helps to prevent plagiarism by tailoring and uniquely tweaking the scientific manuscript not to repeat other’s original idea
• By preventing plagiarism , it saves the scientific manuscript from rejection and thus also saves a lot of time and money
• Helps to evaluate, condense and synthesize gist in the author’s own words to sharpen the research focus
• Helps to compare and contrast to  show the originality and uniqueness of the research than that of the existing other researches
• Rationalizes the need for conducting the particular research in a specified field
• Helps to collect data accurately for allowing any new methodology of research than the existing ones
• Enables the readers of the manuscript to answer the following questions of its readers for its better chances for publication
• What do the researchers know?
• What do they not know?
• Is the scientific manuscript reliable and trustworthy?
• What are the knowledge gaps of the researcher?

22. It helps the readers to identify the following for further reading of the scientific manuscript:

• What has been already established, discredited and accepted in the particular field of research
• Areas of controversy and conflicts among different schools of thought
• Unsolved problems and issues in the connected field of research
• The emerging trends and approaches
• How the research extends, builds upon and leaves behind from the previous research

A profound literature review with many relevant sources of reference will enhance the chances of the scientific manuscript publication in renowned and reputed scientific journals .

References:

http://www.math.montana.edu/jobo/phdprep/phd6.pdf

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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

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

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

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

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

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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

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

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

Download Word doc Download Google doc

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

You can also use boolean operators to help narrow down your search.

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

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

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

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

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

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

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

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

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

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

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

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

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

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

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• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

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• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

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

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

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

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

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

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

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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• University of Texas Libraries

Literature Reviews

• What is a literature review?
• Steps in the Literature Review Process
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support

What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

Meryl Brodsky : Communication and Information Studies

Hannah Chapman Tripp : Biology, Neuroscience

Carolyn Cunningham : Human Development & Family Sciences, Psychology, Sociology

Larayne Dallas : Engineering

Janelle Hedstrom : Special Education, Curriculum & Instruction, Ed Leadership & Policy ​

Susan Macicak : Linguistics

Imelda Vetter : Dell Medical School

For help in other subject areas, please see the guide to library specialists by subject .

Periodically, UT Libraries runs a workshop covering the basics and library support for literature reviews. While we try to offer these once per academic year, we find providing the recording to be helpful to community members who have missed the session. Following is the most recent recording of the workshop, Conducting a Literature Review. To view the recording, a UT login is required.

• October 26, 2022 recording
• Last Updated: Oct 26, 2022 2:49 PM
• URL: https://guides.lib.utexas.edu/literaturereviews

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
• << Previous: Getting Started
• Next: How to Pick a Topic >>
• Last Updated: Sep 21, 2022 2:16 PM
• URL: https://guides.lib.uconn.edu/literaturereview

Libraries | Research Guides

Literature reviews, what is a literature review, learning more about how to do a literature review.

• Planning the Review
• The Research Question
• Choosing Where to Search
• Organizing the Review
• Writing the Review

A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

• Sage Research Methods Core Collection This link opens in a new window SAGE Research Methods supports research at all levels by providing material to guide users through every step of the research process. SAGE Research Methods is the ultimate methods library with more than 1000 books, reference works, journal articles, and instructional videos by world-leading academics from across the social sciences, including the largest collection of qualitative methods books available online from any scholarly publisher. – Publisher

• Next: Planning the Review >>
• Last Updated: Jan 17, 2024 10:05 AM
• URL: https://libguides.northwestern.edu/literaturereviews

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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

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What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

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1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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Conducting a literature review: why do a literature review, why do a literature review.

• How To Find "The Literature"
• Found it -- Now What?

Besides the obvious reason for students -- because it is assigned! -- a literature review helps you explore the research that has come before you, to see how your research question has (or has not) already been addressed.

You identify:

• core research in the field
• experts in the subject area
• methodology you may want to use (or avoid)
• gaps in knowledge -- or where your research would fit in

It Also Helps You:

• Publish and share your findings
• Justify requests for grants and other funding
• Identify best practices to inform practice
• Set wider context for a program evaluation
• Compile information to support community organizing

Great brief overview, from NCSU

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• Last Updated: Dec 8, 2023 10:11 AM
• URL: https://guides.lib.berkeley.edu/litreview

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

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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

• Quick Run-through
• Step 1 & 2

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

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

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

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

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

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

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

Download Word doc Download Google doc

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

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

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

For each publication, ask yourself:

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

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

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

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

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

Take notes and cite your sources

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

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

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

Prevent plagiarism, run a free check.

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

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

As you write, make sure to follow these tips:

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

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

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

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

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

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

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

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

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

Cite this Scribbr article

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McCombes, S. (2022, June 07). What is a Literature Review? | Guide, Template, & Examples. Scribbr. Retrieved 25 March 2024, from https://www.scribbr.co.uk/thesis-dissertation/literature-review/

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What is a literature review?

A literature review is a critical analysis of the literature related to your research topic. It evaluates and critiques the literature to establish a theoretical framework for your research topic and/or identify a gap in the existing research that your research will address.

A literature review is not a summary of the literature. You need to engage deeply and critically with the literature. Your literature review should show your understanding of the literature related to your research topic and lead to presenting a rationale for your research.

A literature review focuses on:

• the context of the topic
• key concepts, ideas, theories and methodologies
• key researchers, texts and seminal works
• major issues and debates
• identifying conflicting evidence
• the main questions that have been asked around the topic
• the organisation of knowledge on the topic
• definitions, particularly those that are contested
• showing how your research will advance scholarly knowledge (generally referred to as identifying the ‘gap’).

This module will guide you through the functions of a literature review; the typical process of conducting a literature review (including searching for literature and taking notes); structuring your literature review within your thesis and organising its internal ideas; and styling the language of your literature review.

The purposes of a literature review

A literature review serves two main purposes:

1) To show awareness of the present state of knowledge in a particular field, including:

• seminal authors
• the main empirical research
• theoretical positions
• controversies
• breakthroughs as well as links to other related areas of knowledge.

2) To provide a foundation for the author’s research. To do that, the literature review needs to:

• help the researcher define a hypothesis or a research question, and how answering the question will contribute to the body of knowledge;
• provide a rationale for investigating the problem and the selected methodology;
• provide a particular theoretical lens, support the argument, or identify gaps.

Before you engage further with this module, try the quiz below to see how much you already know about literature reviews.

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Literature Review in Research Writing

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Table of Contents

Research on research? If you find this idea rather peculiar, know that nowadays, with the huge amount of information produced daily all around the world, it is becoming more and more difficult to keep up to date with all of it. In addition to the sheer amount of research, there is also its origin. We are witnessing the economic and intellectual emergence of countries like China, Brazil, Turkey, and United Arab Emirates, for example, that are producing scholarly literature in their own languages. So, apart from the effort of gathering information, there must also be translators prepared to unify all of it in a single language to be the object of the literature survey. At Elsevier, our team of translators is ready to support researchers by delivering high-quality scientific translations , in several languages, to serve their research – no matter the topic.

What is a literature review?

A literature review is a study – or, more accurately, a survey – involving scholarly material, with the aim to discuss published information about a specific topic or research question. Therefore, to write a literature review, it is compulsory that you are a real expert in the object of study. The results and findings will be published and made available to the public, namely scientists working in the same area of research.

How to Write a Literature Review

First of all, don’t forget that writing a literature review is a great responsibility. It’s a document that is expected to be highly reliable, especially concerning its sources and findings. You have to feel intellectually comfortable in the area of study and highly proficient in the target language; misconceptions and errors do not have a place in a document as important as a literature review. In fact, you might want to consider text editing services, like those offered at Elsevier, to make sure your literature is following the highest standards of text quality. You want to make sure your literature review is memorable by its novelty and quality rather than language errors.

Writing a literature review requires expertise but also organization. We cannot teach you about your topic of research, but we can provide a few steps to guide you through conducting a literature review:

• Choose your topic or research question: It should not be too comprehensive or too limited. You have to complete your task within a feasible time frame.
• Set the scope: Define boundaries concerning the number of sources, time frame to be covered, geographical area, etc.
• Decide which databases you will use for your searches: In order to search the best viable sources for your literature review, use highly regarded, comprehensive databases to get a big picture of the literature related to your topic.
• Search, search, and search: Now you’ll start to investigate the research on your topic. It’s critical that you keep track of all the sources. Start by looking at research abstracts in detail to see if their respective studies relate to or are useful for your own work. Next, search for bibliographies and references that can help you broaden your list of resources. Choose the most relevant literature and remember to keep notes of their bibliographic references to be used later on.
• Review all the literature, appraising carefully it’s content: After reading the study’s abstract, pay attention to the rest of the content of the articles you deem the “most relevant.” Identify methodologies, the most important questions they address, if they are well-designed and executed, and if they are cited enough, etc.

If it’s the first time you’ve published a literature review, note that it is important to follow a special structure. Just like in a thesis, for example, it is expected that you have an introduction – giving the general idea of the central topic and organizational pattern – a body – which contains the actual discussion of the sources – and finally the conclusion or recommendations – where you bring forward whatever you have drawn from the reviewed literature. The conclusion may even suggest there are no agreeable findings and that the discussion should be continued.

Why are literature reviews important?

Literature reviews constantly feed new research, that constantly feeds literature reviews…and we could go on and on. The fact is, one acts like a force over the other and this is what makes science, as a global discipline, constantly develop and evolve. As a scientist, writing a literature review can be very beneficial to your career, and set you apart from the expert elite in your field of interest. But it also can be an overwhelming task, so don’t hesitate in contacting Elsevier for text editing services, either for profound edition or just a last revision. We guarantee the very highest standards. You can also save time by letting us suggest and make the necessary amendments to your manuscript, so that it fits the structural pattern of a literature review. Who knows how many worldwide researchers you will impact with your next perfectly written literature review.

Know more: How to Find a Gap in Research .

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Types of Literature Review — A Guide for Researchers

Table of Contents

Researchers often face challenges when choosing the appropriate type of literature review for their study. Regardless of the type of research design and the topic of a research problem , they encounter numerous queries, including:

What is the right type of literature review my study demands?

• How do we gather the data?
• How to conduct one?
• How reliable are the review findings?
• How do we employ them in our research? And the list goes on.

If you’re also dealing with such a hefty questionnaire, this article is of help. Read through this piece of guide to get an exhaustive understanding of the different types of literature reviews and their step-by-step methodologies along with a dash of pros and cons discussed.

Heading from scratch!

What is a Literature Review?

A literature review provides a comprehensive overview of existing knowledge on a particular topic, which is quintessential to any research project. Researchers employ various literature reviews based on their research goals and methodologies. The review process involves assembling, critically evaluating, and synthesizing existing scientific publications relevant to the research question at hand. It serves multiple purposes, including identifying gaps in existing literature, providing theoretical background, and supporting the rationale for a research study.

What is the importance of a Literature review in research?

Literature review in research serves several key purposes, including:

• Background of the study: Provides proper context for the research. It helps researchers understand the historical development, theoretical perspectives, and key debates related to their research topic.
• Identification of research gaps: By reviewing existing literature, researchers can identify gaps or inconsistencies in knowledge, paving the way for new research questions and hypotheses relevant to their study.
• Theoretical framework development: Facilitates the development of theoretical frameworks by cultivating diverse perspectives and empirical findings. It helps researchers refine their conceptualizations and theoretical models.
• Methodological guidance: Offers methodological guidance by highlighting the documented research methods and techniques used in previous studies. It assists researchers in selecting appropriate research designs, data collection methods, and analytical tools.
• Quality assurance and upholding academic integrity: Conducting a thorough literature review demonstrates the rigor and scholarly integrity of the research. It ensures that researchers are aware of relevant studies and can accurately attribute ideas and findings to their original sources.

Types of Literature Review

Literature review plays a crucial role in guiding the research process , from providing the background of the study to research dissemination and contributing to the synthesis of the latest theoretical literature review findings in academia.

However, not all types of literature reviews are the same; they vary in terms of methodology, approach, and purpose. Let's have a look at the various types of literature reviews to gain a deeper understanding of their applications.

1. Narrative Literature Review

A narrative literature review, also known as a traditional literature review, involves analyzing and summarizing existing literature without adhering to a structured methodology. It typically provides a descriptive overview of key concepts, theories, and relevant findings of the research topic.

Unlike other types of literature reviews, narrative reviews reinforce a more traditional approach, emphasizing the interpretation and discussion of the research findings rather than strict adherence to methodological review criteria. It helps researchers explore diverse perspectives and insights based on the research topic and acts as preliminary work for further investigation.

Steps to Conduct a Narrative Literature Review

Source:- https://www.researchgate.net/figure/Steps-of-writing-a-narrative-review_fig1_354466408

Define the research question or topic:

The first step in conducting a narrative literature review is to clearly define the research question or topic of interest. Defining the scope and purpose of the review includes — What specific aspect of the topic do you want to explore? What are the main objectives of the research? Refine your research question based on the specific area you want to explore.

Conduct a thorough literature search

Once the research question is defined, you can conduct a comprehensive literature search. Explore and use relevant databases and search engines like SciSpace Discover to identify credible and pertinent, scholarly articles and publications.

Select relevant studies

Before choosing the right set of studies, it’s vital to determine inclusion (studies that should possess the required factors) and exclusion criteria for the literature and then carefully select papers. For example — Which studies or sources will be included based on relevance, quality, and publication date?

*Important (applies to all the reviews): Inclusion criteria are the factors a study must include (For example: Include only peer-reviewed articles published between 2022-2023, etc.). Exclusion criteria are the factors that wouldn’t be required for your search strategy (Example: exclude irrelevant papers, preprints, written in non-English, etc.)

Critically analyze the literature

Once the relevant studies are shortlisted, evaluate the methodology, findings, and limitations of each source and jot down key themes, patterns, and contradictions. You can use efficient AI tools to conduct a thorough literature review and analyze all the required information.

Synthesize and integrate the findings

Now, you can weave together the reviewed studies, underscoring significant findings such that new frameworks, contrasting viewpoints, and identifying knowledge gaps.

Discussion and conclusion

This is an important step before crafting a narrative review — summarize the main findings of the review and discuss their implications in the relevant field. For example — What are the practical implications for practitioners? What are the directions for future research for them?

Write a cohesive narrative review

Organize the review into coherent sections and structure your review logically, guiding the reader through the research landscape and offering valuable insights. Use clear and concise language to convey key points effectively.

Structure of Narrative Literature Review

A well-structured, narrative analysis or literature review typically includes the following components:

• Introduction: Provides an overview of the topic, objectives of the study, and rationale for the review.
• Background: Highlights relevant background information and establish the context for the review.
• Main Body: Indexes the literature into thematic sections or categories, discussing key findings, methodologies, and theoretical frameworks.
• Discussion: Analyze and synthesize the findings of the reviewed studies, stressing similarities, differences, and any gaps in the literature.
• Conclusion: Summarizes the main findings of the review, identifies implications for future research, and offers concluding remarks.

Pros and Cons of Narrative Literature Review

• Flexibility in methodology and doesn’t necessarily rely on structured methodologies
• Follows traditional approach and provides valuable and contextualized insights
• Suitable for exploring complex or interdisciplinary topics. For example — Climate change and human health, Cybersecurity and privacy in the digital age, and more
• Subjectivity in data selection and interpretation
• Potential for bias in the review process
• Lack of rigor compared to systematic reviews

Example of Well-Executed Narrative Literature Reviews

Paper title:  Examining Moral Injury in Clinical Practice: A Narrative Literature Review

Source: SciSpace

While narrative reviews offer flexibility, academic integrity remains paramount. So, ensure proper citation of all sources and maintain a transparent and factual approach throughout your critical narrative review, itself.

2. Systematic Review

A systematic literature review is one of the comprehensive types of literature review that follows a structured approach to assembling, analyzing, and synthesizing existing research relevant to a particular topic or question. It involves clearly defined criteria for exploring and choosing studies, as well as rigorous methods for evaluating the quality of relevant studies.

It plays a prominent role in evidence-based practice and decision-making across various domains, including healthcare, social sciences, education, health sciences, and more. By systematically investigating available literature, researchers can identify gaps in knowledge, evaluate the strength of evidence, and report future research directions.

Steps to Conduct Systematic Reviews

Source:- https://www.researchgate.net/figure/Steps-of-Systematic-Literature-Review_fig1_321422320

Here are the key steps involved in conducting a systematic literature review

Formulate a clear and focused research question

Clearly define the research question or objective of the review. It helps to centralize the literature search strategy and determine inclusion criteria for relevant studies.

Develop a thorough literature search strategy

Design a comprehensive search strategy to identify relevant studies. It involves scrutinizing scientific databases and all relevant articles in journals. Plus, seek suggestions from domain experts and review reference lists of relevant review articles.

Screening and selecting studies

Employ predefined inclusion and exclusion criteria to systematically screen the identified studies. This screening process also typically involves multiple reviewers independently assessing the eligibility of each study.

Data extraction

Extract key information from selected studies using standardized forms or protocols. It includes study characteristics, methods, results, and conclusions.

Critical appraisal

Evaluate the methodological quality and potential biases of included studies. Various tools (BMC medical research methodology) and criteria can be implemented for critical evaluation depending on the study design and research quetions .

Data synthesis

Analyze and synthesize review findings from individual studies to draw encompassing conclusions or identify overarching patterns and explore heterogeneity among studies.

Interpretation and conclusion

Interpret the findings about the research question, considering the strengths and limitations of the research evidence. Draw conclusions and implications for further research.

The final step — Report writing

Craft a detailed report of the systematic literature review adhering to the established guidelines of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). This ensures transparency and reproducibility of the review process.

By following these steps, a systematic literature review aims to provide a comprehensive and unbiased summary of existing evidence, help make informed decisions, and advance knowledge in the respective domain or field.

Structure of a systematic literature review

A well-structured systematic literature review typically consists of the following sections:

• Introduction: Provides background information on the research topic, outlines the review objectives, and enunciates the scope of the study.
• Methodology: Describes the literature search strategy, selection criteria, data extraction process, and other methods used for data synthesis, extraction, or other data analysis..
• Results: Presents the review findings, including a summary of the incorporated studies and their key findings.
• Discussion: Interprets the findings in light of the review objectives, discusses their implications, and identifies limitations or promising areas for future research.
• Conclusion: Summarizes the main review findings and provides suggestions based on the evidence presented in depth meta analysis.

*Important (applies to all the reviews): Remember, the specific structure of your literature review may vary depending on your topic, research question, and intended audience. However, adhering to a clear and logical hierarchy ensures your review effectively analyses and synthesizes knowledge and contributes valuable insights for readers.

Pros and Cons of Systematic Literature Review

• Adopts rigorous and transparent methodology
• Minimizes bias and enhances the reliability of the study
• Provides evidence-based insights
• Time and resource-intensive
• High dependency on the quality of available literature (literature research strategy should be accurate)
• Potential for publication bias

Example of Well-Executed Systematic Literature Review

Paper title: Systematic Reviews: Understanding the Best Evidence For Clinical Decision-making in Health Care: Pros and Cons.

Read this detailed article on how to use AI tools to conduct a systematic review for your research!

3. Scoping Literature Review

A scoping literature review is a methodological review type of literature review that adopts an iterative approach to systematically map the existing literature on a particular topic or research area. It involves identifying, selecting, and synthesizing relevant papers to provide an overview of the size and scope of available evidence. Scoping reviews are broader in scope and include a diverse range of study designs and methodologies especially focused on health services research.

The main purpose of a scoping literature review is to examine the extent, range, and nature of existing studies on a topic, thereby identifying gaps in research, inconsistencies, and areas for further investigation. Additionally, scoping reviews can help researchers identify suitable methodologies and formulate clinical recommendations. They also act as the frameworks for future systematic reviews or primary research studies.

Scoping reviews are primarily focused on —

• Emerging or evolving topics — where the research landscape is still growing or budding. Example — Whole Systems Approaches to Diet and Healthy Weight: A Scoping Review of Reviews .
• Broad and complex topics : With a vast amount of existing literature.
• Scenarios where a systematic review is not feasible: Due to limited resources or time constraints.

Steps to Conduct a Scoping Literature Review

While Scoping reviews are not as rigorous as systematic reviews, however, they still follow a structured approach. Here are the steps:

Identify the research question: Define the broad topic you want to explore.

Identify Relevant Studies: Conduct a comprehensive search of relevant literature using appropriate databases, keywords, and search strategies.

Select studies to be included in the review: Based on the inclusion and exclusion criteria, determine the appropriate studies to be included in the review.

Data extraction and charting : Extract relevant information from selected studies, such as year, author, main results, study characteristics, key findings, and methodological approaches.  However, it varies depending on the research question.

Collate, summarize, and report the results: Analyze and summarize the extracted data to identify key themes and trends. Then, present the findings of the scoping review in a clear and structured manner, following established guidelines and frameworks .

Structure of a Scoping Literature Review

A scoping literature review typically follows a structured format similar to a systematic review. It includes the following sections:

• Introduction: Introduce the research topic and objectives of the review, providing the historical context, and rationale for the study.
• Methods : Describe the methods used to conduct the review, including search strategies, study selection criteria, and data extraction procedures.
• Results: Present the findings of the review, including key themes, concepts, and patterns identified in the literature review.
• Discussion: Examine the implications of the findings, including strengths, limitations, and areas for further examination.
• Conclusion: Recapitulate the main findings of the review and their implications for future research, policy, or practice.

Pros and Cons of Scoping Literature Review

• Provides a comprehensive overview of existing literature
• Helps to identify gaps and areas for further research
• Suitable for exploring broad or complex research questions
• Doesn’t provide the depth of analysis offered by systematic reviews
• Subject to researcher bias in study selection and data extraction
• Requires careful consideration of literature search strategies and inclusion criteria to ensure comprehensiveness and validity.

In short, a scoping review helps map the literature on developing or emerging topics and identifying gaps. It might be considered as a step before conducting another type of review, such as a systematic review. Basically, acts as a precursor for other literature reviews.

Example of a Well-Executed Scoping Literature Review

Paper title: Health Chatbots in Africa Literature: A Scoping Review

Check out the key differences between Systematic and Scoping reviews — Evaluating literature review: systematic vs. scoping reviews

4. Integrative Literature Review

Integrative Literature Review (ILR) is a type of literature review that proposes a distinctive way to analyze and synthesize existing literature on a specific topic, providing a thorough understanding of research and identifying potential gaps for future research.

Unlike a systematic review, which emphasizes quantitative studies and follows strict inclusion criteria, an ILR embraces a more pliable approach. It works beyond simply summarizing findings — it critically analyzes, integrates, and interprets research from various methodologies (qualitative, quantitative, mixed methods) to provide a deeper understanding of the research landscape. ILRs provide a holistic and systematic overview of existing research, integrating findings from various methodologies. ILRs are ideal for exploring intricate research issues, examining manifold perspectives, and developing new research questions.

Steps to Conduct an Integrative Literature Review

• Identify the research question: Clearly define the research question or topic of interest as formulating a clear and focused research question is critical to leading the entire review process.
• Literature search strategy: Employ systematic search techniques to locate relevant literature across various databases and sources.
• Evaluate the quality of the included studies : Critically assess the methodology, rigor, and validity of each study by applying inclusion and exclusion criteria to filter and select studies aligned with the research objectives.
• Data Extraction: Extract relevant data from selected studies using a structured approach.
• Synthesize the findings : Thoroughly analyze the selected literature, identify key themes, and synthesize findings to derive noteworthy insights.
• Critical appraisal: Critically evaluate the quality and validity of qualitative research and included studies by using BMC medical research methodology.
• Interpret and present your findings: Discuss the purpose and implications of your analysis, spotlighting key insights and limitations. Organize and present the findings coherently and systematically.

Structure of an Integrative Literature Review

• Introduction : Provide an overview of the research topic and the purpose of the integrative review.
• Methods: Describe the opted literature search strategy, selection criteria, and data extraction process.
• Results: Present the synthesized findings, including key themes, patterns, and contradictions.
• Discussion: Interpret the findings about the research question, emphasizing implications for theory, practice, and prospective research.
• Conclusion: Summarize the main findings, limitations, and contributions of the integrative review.

Pros and Cons of Integrative Literature Review

• Informs evidence-based practice and policy to the relevant stakeholders of the research.
• Contributes to theory development and methodological advancement, especially in the healthcare arena.
• Integrates diverse perspectives and findings
• Time-consuming process due to the extensive literature search and synthesis
• Requires advanced analytical and critical thinking skills
• Potential for bias in study selection and interpretation
• The quality of included studies may vary, affecting the validity of the review

Example of Integrative Literature Reviews

Paper Title: An Integrative Literature Review: The Dual Impact of Technological Tools on Health and Technostress Among Older Workers

5. Rapid Literature Review

A Rapid Literature Review (RLR) is the fastest type of literature review which makes use of a streamlined approach for synthesizing literature summaries, offering a quicker and more focused alternative to traditional systematic reviews. Despite employing identical research methods, it often simplifies or omits specific steps to expedite the process. It allows researchers to gain valuable insights into current research trends and identify key findings within a shorter timeframe, often ranging from a few days to a few weeks — unlike traditional literature reviews, which may take months or even years to complete.

When to Consider a Rapid Literature Review?

• When time impediments demand a swift summary of existing research
• For emerging topics where the latest literature requires quick evaluation
• To report pilot studies or preliminary research before embarking on a comprehensive systematic review

Steps to Conduct a Rapid Literature Review

• Define the research question or topic of interest. A well-defined question guides the search process and helps researchers focus on relevant studies.
• Determine key databases and sources of relevant literature to ensure comprehensive coverage.
• Develop literature search strategies using appropriate keywords and filters to fetch a pool of potential scientific articles.
• Screen search results based on predefined inclusion and exclusion criteria.
• Extract and summarize relevant information from the above-preferred studies.
• Synthesize findings to identify key themes, patterns, or gaps in the literature.
• Prepare a concise report or a summary of the RLR findings.

Structure of a Rapid Literature Review

An effective structure of an RLR typically includes the following sections:

• Introduction: Briefly introduce the research topic and objectives of the RLR.
• Methodology: Describe the search strategy, inclusion and exclusion criteria, and data extraction process.
• Results: Present a summary of the findings, including key themes or patterns identified.
• Discussion: Interpret the findings, discuss implications, and highlight any limitations or areas for further research
• Conclusion: Summarize the key findings and their implications for practice or future research

Pros and Cons of Rapid Literature Review

• RLRs can be completed quickly, authorizing timely decision-making
• RLRs are a cost-effective approach since they require fewer resources compared to traditional literature reviews
• Offers great accessibility as RLRs provide prompt access to synthesized evidence for stakeholders
• RLRs are flexible as they can be easily adapted for various research contexts and objectives
• RLR reports are limited and restricted, not as in-depth as systematic reviews, and do not provide comprehensive coverage of the literature compared to traditional reviews.
• Susceptible to bias because of the expedited nature of RLRs. It would increase the chance of overlooking relevant studies or biases in the selection process.
• Due to time constraints, RLR findings might not be robust enough as compared to systematic reviews.

Example of a Well-Executed Rapid Literature Review

Paper Title: What Is the Impact of ChatGPT on Education? A Rapid Review of the Literature

A Summary of Literature Review Types

Tools and resources for conducting different types of literature reviews, online scientific databases.

Platforms such as SciSpace , PubMed , Scopus , Elsevier , and Web of Science provide access to a vast array of scholarly literature, facilitating the search and data retrieval process.

Reference management software

Tools like SciSpace Citation Generator , EndNote, Zotero , and Mendeley assist researchers in organizing, annotating, and citing relevant literature, streamlining the review process altogether.

Automate Literature Review with AI tools

Automate the literature review process by using tools like SciSpace literature review which helps you compare and contrast multiple papers all on one screen in an easy-to-read matrix format. You can effortlessly analyze and interpret the review findings tailored to your study. It also supports the review in 75+ languages, making it more manageable even for non-English speakers.

Goes without saying — literature review plays a pivotal role in academic research to identify the current trends and provide insights to pave the way for future research endeavors. Different types of literature review has their own strengths and limitations, making them suitable for different research designs and contexts. Whether conducting a narrative review, systematic review, scoping review, integrative review, or rapid literature review, researchers must cautiously consider the objectives, resources, and the nature of the research topic.

If you’re currently working on a literature review and still adopting a manual and traditional approach, switch to the automated AI literature review workspace and transform your traditional literature review into a rapid one by extracting all the latest and relevant data for your research!

There you go!

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Why Is Literature Review Important? (3 Benefits Explained)

by  Antony W

January 21, 2023

Every research project needs a literature review. And while it’s one of the most challenging parts of the assignment, in part because of the intensity of the research involved, it’s by far the most important section of a research paper.

Many students fail to write comprehensive literature reviews because they see the assignment as a formality.

For the most part, they’ll vaguely create a list of existing studies and consider the assignment complete. But such an approach overlooks why a literature review is important.

We need to take a step back and look beyond the definition of a literature review.

In particular, the goal of this guide is to help you explore the significance of the review of the existing literature.

Once you understand the role that literature reviews play in research projects, you’ll give the assignment the full attention that it deserves.

Key Takeaways

Writing a literature review is important for the following reasons:

• It demonstrates that you understand the issue you’re investigating.
• A literature review allows you to develop a more theoretical framework for your research. 
• It justifies your research and shows the gaps present in the current literature.

Get Literature Review Writing Help

Do you find the workload involved in writing a literature review for your thesis, research paper, or standalone project overwhelming? We understand how involving the writing process can be, and we are here to help you with writing if you currently feel stuck.

You can hire a  professional literature review writer   from Help for Assessment to get the writing done for you. Whether you have a flexible deadline or the submission date for the literature is almost due, you can count on our team to help you get the paper done fast. 

What is a Literature Review?

A literature review is a study of the already existing research in a given area of study.

While it’s common in physical and social sciences, instructors may also request student to complete the assignment within the humanities space.

The review can be a standalone project or a part of an academic assignment.

If your professor or instructor asks you to write the review as a standalone project, your focus will be on exploring how a specific field of inquiry has developed over the course of time.

In the case where you have to include the review as part of your academic paper, the goal will be to set the background for the topic (or issue) you’re currently investigating.

How is Literature Review Different from an Essay?

In an education setting whether students are used to writing tons of essays every month, it’s likely for many to wonder whether an essay could be the same as a literature review.

While a literature review and an essay both require research before writing, there are a number of differences between them that you need to know.

Types of Literature Review

We’ll look at the significance of a literature review in a moment.

For now let’s look at the types of literature reviews that your instructor may ask you to write.

As of this writing, there are 6 types of reviews that you need to know about. These are:

1. Argumentative Review

Examines a literature review with the intention to support or refuse an argument, with the aim being to develop a body of literature that can establish a contrarian point of view.

2. Integrative Literature Review

This type of review critiques and synthesizes related literature to generate a new framework and perspective on a topic.

Researchers have to address identical and/or related hypotheses or research problems to comply with research standards with regards to replication, vigor, and clarity.

3. Historical Literature

The focus of the review is to examine research within a given period, and usually starts from the time a research problem or issue emerged.

Then, you have to trace its evolution throughout the suggested timeframe within the scholarship of that particular discipline.

4. Methodological Literature Review

The focus shifts from what someone said to how they ended up saying what they said.

Since the focus here is on the method of analysis, methodological reviews gives a better framework that help one to understand exactly how a researcher draws their conclusion from a wide range of knowledge.

5. Systematic Literature

A systematic review focuses on the existing evidence related to a specific research question.

You will need to use a pre-specified and standardized approach to identify, evaluate, and appraise research, not to mention collect, analyze, and report data collected from the review.

Understand that the goal of a systematic review is to evaluate, summarize, and document research that focuses on a specific (or clearly defined) research problem.

6. Theoretical Literature Review

Theoretical review focuses on examining theories that resulted from an issue, a concept, or a situation.

It’s through this type of review that a researcher can easily establish the kind of theories that already formulated, the degree to what researchers have investigated them, and the relationship between them.

It’s through theoretical review that one can develop new hypotheses for testing and can therefore help to determine what theories aren’t sufficient to explain emerging research problems.

Why Is Literature Review Important?

Now that you know the difference between an essay and a review as well as the different types of literature review, it’s important to look at why it’s important to examine existing literature in your research.

There are a number of reasons why instructors ask you to write a review , and they’re as follow:

1. Demonstrate a Clear Understanding of the Subject

Writing a literature review demonstrates that you have a clear understanding of the subject you’re investigating.

It also means that you can easily identify, evaluate, and summarize existing research that’s relevant to your work. 

2. Justify Your Research

There’s more to writing a research paper than just identifying topic and generating your research question from it.

You also have to go as far as to justify your research, and the only way to do that is by including a literature review in your work.

It’s important to understand that looking at past research is the only way to identify gaps that exist in the current literature.

That can go a long way to help fill in the gap by addressing them in your own research work.

3. Helps to Set a Resourceful Theoretical Framework

Because a research paper assignment builds up on the ideas of already existing research, doing a literature review can help you to set a resourceful theoretical framework on which to base your study.

The theoretical framework will include concepts and theories that you will base your research on. And keep in mind that it’s this framework that professors will use to judge the overall quality of your work. 

Frequently Asked Questions

1. what are the benefits of literature review in research.

A literature review in research allows you to discover exiting knowledge in your field and the boundaries and limitations that exists within that field.

Moreover, doing a review of existing literature helps you to understand the theories that drive an area of investigation, making it easy for you to place your research question  into proper context. 

2. What is the Effect of a Good Literature Review?

In addition to providing context, reducing research redundancy, and informing methodology, a well-written literature review can maximize relevance, enhance originality, and ensure professional standards in writing.

3. What is a Strength of a Literature Review?

The strength of a literature review is the ability to improve your information seeking skills and enhancing your knowledge about the topic under investigation.

As you can see, a review is quite a significant part of a research project, so you should treat it with the seriousness that it deserves.

At the end of the day, you want to create a good connection between you and your readers, and the best way to do that is to pack just as much value as you can in your literature review project.

About the author 

Antony W is a professional writer and coach at Help for Assessment. He spends countless hours every day researching and writing great content filled with expert advice on how to write engaging essays, research papers, and assignments.

Literature Review: Purpose of a Literature Review

• Literature Review
• Purpose of a Literature Review
• Work in Progress
• Compiling & Writing
• Books, Articles, & Web Pages
• Types of Literature Reviews
• Departmental Differences
• Citation Styles & Plagiarism
• Know the Difference! Systematic Review vs. Literature Review

The purpose of a literature review is to:

• Provide a foundation of knowledge on a topic
• Identify areas of prior scholarship to prevent duplication and give credit to other researchers
• Identify inconstancies: gaps in research, conflicts in previous studies, open questions left from other research
• Identify the need for additional research (justifying your research)
• Identify the relationship of works in the context of their contribution to the topic and other works
• Place your own research within the context of existing literature, making a case for why further study is needed.

Videos & Tutorials

VIDEO: What is the role of a literature review in research? What's it mean to "review" the literature? Get the big picture of what to expect as part of the process. This video is published under a Creative Commons 3.0 BY-NC-SA US license. License, credits, and contact information can be found here: https://www.lib.ncsu.edu/tutorials/litreview/

Elements in a Literature Review

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A Step-by-Step Guide to Writing a Stellar Literature Review (with Help from AI)

Table of contents

Aren’t all of us mini versions of Sherlock Holmes when browsing data and archives for a research piece? As we go through the process, a comprehensive literature review is an essential toolkit to make your research shine.

A literature review consists of scholarly sources that validate the content. Its primary objective is to offer a concise summary of the research and to let you explore relevant theories and methodologies. Through this review, you can identify gaps in the existing research and bridge them with your contribution. 

The real challenge is how to write an excellent literature review. Let’s learn.

What is the purpose of a literature review?

A literature review is an introduction to your research. It helps you put your perspective to the table, along with a summary of the theme.

What does my literature review communicate?

• Explanation of your research: how the information was collected, the research method, the justification of the chosen data sources, and an overview of the data analysis.
• Framework: the journey from where the concept began and how it is presented.
• Connects the previous and current research: 

It presents the broader scope of your research by connecting it to the existing data and debates and underlining how your content fits the prevailing studies. 

In an era of information overload, a literature review must be well-structured. 

Let’s learn all about the structure and style of a literature review that’ll help you strengthen your research.

Literature review– structure and style

Begin with a question and end it with the solution– the key to structuring a literature review. It resembles an essay’s format, with the first paragraph introducing the readers to the topic and the following explaining the research in-depth.

The conclusion reiterates the question and summarizes the overall insights of your research. There’s no word count restriction. —it depends on the type of research. For example, a dissertation demands lengthy work, whereas a short paper needs a few pages. 

In a literature review, maintaining high quality is vital, with a focus on academic writing style. Informal language should be avoided in favor of a more formal tone. 

The content avoids contractions, clearly differentiating between previous and current research through the use of past and present tense. Wordtune assists in establishing a formal tone, enhancing your work with pertinent suggestions. This AI-powered tool ensures your writing remains genuine, lucid, and engaging. 

The option of refining the tonality offers multiple possibilities for rephrasing a single sentence. Thus, pick the best and keep writing.

Get Wordtune for free > Get Wordtune for free >

Your friendly step-by-step guide to writing a literary review (with help from AI)

Do you find it challenging to begin the literature review? Don’t worry! We’re here to get you started with our step-by-step guide.

1. Narrow down the research scope

Simply begin with the question: What am I answering through my research?

Whether it’s cooking or painting, the real challenge is the prep-up for it rather than performing the task. Once you’re done, it smoothly progresses. Similarly, for your literature review, prepare the groundwork by narrowing down the research scope.

Browse and scoop out relevant data inclining well with your research. While you can’t cover every aspect of your research, pick a topic that isn’t too narrow nor too broad to keep your literature review well-balanced. 

2. Hunt relevant literature

The next question: Does this data align with the issue I’m trying to address?

As you review sources of information, hunt out the best ones. Determine which findings help in offering a focused insight on your topic. The best way to pick primary sources is to opt for the ones featured in reliable publications. You can also choose secondary sources from other researchers from a reasonable time frame and a relevant background.

For example, if your research focuses on the Historical Architecture of 18th-century Europe, the first-hand accounts and surveys from the past would hold more weight than the new-age publications. 

3. Observe the themes and patterns in sources

Next comes: What is the core viewpoint in most of the research? Has it stayed constant over time, or have the authors differed in their points of view?

Ensure to scoop out the essential aspects of what each source represents. Once you have collected all this information, combine it and add your interpretations at the end. This process is known as synthesis.

Synthesize ideas by combining arguments, findings and forming your new version.

4. Generate an outline

The next question: How can I organize my review effectively? When navigating multiple data sources, you must have noticed a structure throughout the research. Develop an outline to make the process easier. An outline is a skeletal format of the review, helping you connect the information more strategically.

Here are the three different ways to organize an outline– Chronologically, Thematically, or by Methodology.You can develop the outline chronologically, starting from the older sources and leading to the latest pieces. Another way of organizing is to thematically divide the sections and discuss each under the designated sub-heading.

You can even organize it per the research methods used by the respective authors. The choice of outline depends on the subject. For example, in the case of a science paper, you can divide the information into sections like introduction, types of equipment, method, procedure, findings, etc. In contrast, it’s best to present it in divisions based on timelines like Ancient, Middle Ages, Industrial revolutions, etc., for a history paper.

If you’re confused about how to structure the data, work with Wordtune. 

With the Generate with AI feature, you can mention your research topic and let Wordtune curate a comprehensive outline for your study.

Having a precise prompt is the key to getting the best results.

5. Start filling!

Your next question must be: Am I ready to compose all the parts of the literature review?

Once you’re ready with the basic outline and relevant sources, start filling in the data. Go for an introductory paragraph first to ensure your readers understand the topic and how you will present it. Ensure you clearly explain the section in the first sentence.

However, if beginning from the first paragraph seems intimidating, don’t worry! Add the main body content to the sub-headings, then jump to the introduction. 

Add headings wherever possible to make it more straightforward and guide your readers logically through different sources. Lastly, conclude your study by presenting a key takeaway and summarizing your findings. To make your task easier, work with Wordtune. It helps align your content with the desired tone and refine the structure.

6. Give attention to detail and edit

The last question: Am I satisfied with the language and content written in the literature review? Is it easy to understand?

Once you’re done writing the first draft of a literature review, it’s time to refine it. Take time between writing and reading the draft to ensure a fresh perspective. It makes it easier to spot errors when you disconnect from the content for some time. Start by looking at the document from a bird's eye to ensure the formatting and structure are in order. 

After reviewing the content format, you must thoroughly check your work for grammar, spelling, and punctuation. One of the best approaches to editing and proofreading is to use Wordtune . It helps simplify complex sentences, enhance the content quality, and gain prowess over the tonality.

The dos and don’ts of writing a literature review

Writing a stellar literature review requires following a few dos and don'ts. Just like Sherlock Holmes would never overlook a hint, you must pay attention to every minute detail while writing a perfect narrative. To help you write, below are some dos and don'ts to remember.

Composing a literature review demands a holistic research summary, each part exhibiting your understanding and approach. As you write the content, make sure to cover the following points:

• Keep a historical background of the field of research. Highlight the relevant relation between the old studies and your new research.
• Discuss the core issue, question, and debate of your topic.
• Theories lay the foundation of research. While you’re writing a literature review, make sure to add relevant concepts and ideas to support your statements.
• Another critical thing to keep in mind is to define complex terminologies. It helps the readers understand the content with better clarity. 

Examples of comprehensive literature reviews

Aren’t good examples the best way to understand a subject? Let’s look into a few examples of literature reviews and analyze what makes them well-written.

1. Critical Thinking and Transferability: A Review of the Literature (Gwendolyn Reece)

An overview of scholarly sources is included in the literature review, which explores critical thinking in American education. The introduction stating the subject’s importance makes it a winning literature review. Following the introduction is a well-defined purpose that highlights the importance of research.

As one keeps reading, there is more clarity on the pros and cons of the research. By dividing information into parts with relevant subheadings, the author breaks a lengthy literature review into manageable chunks, defining the overall structure.

Along with other studies and presented perspectives, the author also expresses her opinion. It is presented with minimal usage of ‘I,’ keeping it person-poised yet general. Toward the conclusion, the author again offers an overview of the study. A summary is further strengthened by presenting suggestions for future research as well. 

2. The Use of Technology in English Language Learning: A Literature Review

This literature review is thematically organized on how technology affects language acquisition. The study begins with an introduction to the topic with well-cited sources. It presents the views of different studies to help readers get a sense of different perspectives. After giving these perspectives, the author offers a personalized opinion.

One of the critical aspects that makes this a good literature review is a dedicated paragraph for definitions. It helps readers proceed further with a clear understanding of the crucial terminologies. There’s a comparison of the modern and previous studies and approaches to give an overall picture of the research.

Once the main body is composed, the author integrates recommendations for action-based tips. Thus, the literature review isn’t just summarizing the sources but offering actions relevant to the topics. Finally, the concluding paragraph has a brief overview with key takeaways.

Wordtune: your writing buddy!

A literature review demands the right balance of language and clarity. You must refine the content to achieve a formal tone and clear structure. Do you know what will help you the most? Wordtune !. 

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Peer Review in Scientific Publications: Benefits, Critiques, & A Survival Guide

Jacalyn kelly.

1 Clinical Biochemistry, Department of Pediatric Laboratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada

Tara Sadeghieh

Khosrow adeli.

2 Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada

3 Chair, Communications and Publications Division (CPD), International Federation for Sick Clinical Chemistry (IFCC), Milan, Italy

The authors declare no conflicts of interest regarding publication of this article.

Peer review has been defined as a process of subjecting an author’s scholarly work, research or ideas to the scrutiny of others who are experts in the same field. It functions to encourage authors to meet the accepted high standards of their discipline and to control the dissemination of research data to ensure that unwarranted claims, unacceptable interpretations or personal views are not published without prior expert review. Despite its wide-spread use by most journals, the peer review process has also been widely criticised due to the slowness of the process to publish new findings and due to perceived bias by the editors and/or reviewers. Within the scientific community, peer review has become an essential component of the academic writing process. It helps ensure that papers published in scientific journals answer meaningful research questions and draw accurate conclusions based on professionally executed experimentation. Submission of low quality manuscripts has become increasingly prevalent, and peer review acts as a filter to prevent this work from reaching the scientific community. The major advantage of a peer review process is that peer-reviewed articles provide a trusted form of scientific communication. Since scientific knowledge is cumulative and builds on itself, this trust is particularly important. Despite the positive impacts of peer review, critics argue that the peer review process stifles innovation in experimentation, and acts as a poor screen against plagiarism. Despite its downfalls, there has not yet been a foolproof system developed to take the place of peer review, however, researchers have been looking into electronic means of improving the peer review process. Unfortunately, the recent explosion in online only/electronic journals has led to mass publication of a large number of scientific articles with little or no peer review. This poses significant risk to advances in scientific knowledge and its future potential. The current article summarizes the peer review process, highlights the pros and cons associated with different types of peer review, and describes new methods for improving peer review.

WHAT IS PEER REVIEW AND WHAT IS ITS PURPOSE?

Peer Review is defined as “a process of subjecting an author’s scholarly work, research or ideas to the scrutiny of others who are experts in the same field” ( 1 ). Peer review is intended to serve two primary purposes. Firstly, it acts as a filter to ensure that only high quality research is published, especially in reputable journals, by determining the validity, significance and originality of the study. Secondly, peer review is intended to improve the quality of manuscripts that are deemed suitable for publication. Peer reviewers provide suggestions to authors on how to improve the quality of their manuscripts, and also identify any errors that need correcting before publication.

HISTORY OF PEER REVIEW

The concept of peer review was developed long before the scholarly journal. In fact, the peer review process is thought to have been used as a method of evaluating written work since ancient Greece ( 2 ). The peer review process was first described by a physician named Ishaq bin Ali al-Rahwi of Syria, who lived from 854-931 CE, in his book Ethics of the Physician ( 2 ). There, he stated that physicians must take notes describing the state of their patients’ medical conditions upon each visit. Following treatment, the notes were scrutinized by a local medical council to determine whether the physician had met the required standards of medical care. If the medical council deemed that the appropriate standards were not met, the physician in question could receive a lawsuit from the maltreated patient ( 2 ).

The invention of the printing press in 1453 allowed written documents to be distributed to the general public ( 3 ). At this time, it became more important to regulate the quality of the written material that became publicly available, and editing by peers increased in prevalence. In 1620, Francis Bacon wrote the work Novum Organum, where he described what eventually became known as the first universal method for generating and assessing new science ( 3 ). His work was instrumental in shaping the Scientific Method ( 3 ). In 1665, the French Journal des sçavans and the English Philosophical Transactions of the Royal Society were the first scientific journals to systematically publish research results ( 4 ). Philosophical Transactions of the Royal Society is thought to be the first journal to formalize the peer review process in 1665 ( 5 ), however, it is important to note that peer review was initially introduced to help editors decide which manuscripts to publish in their journals, and at that time it did not serve to ensure the validity of the research ( 6 ). It did not take long for the peer review process to evolve, and shortly thereafter papers were distributed to reviewers with the intent of authenticating the integrity of the research study before publication. The Royal Society of Edinburgh adhered to the following peer review process, published in their Medical Essays and Observations in 1731: “Memoirs sent by correspondence are distributed according to the subject matter to those members who are most versed in these matters. The report of their identity is not known to the author.” ( 7 ). The Royal Society of London adopted this review procedure in 1752 and developed the “Committee on Papers” to review manuscripts before they were published in Philosophical Transactions ( 6 ).

Peer review in the systematized and institutionalized form has developed immensely since the Second World War, at least partly due to the large increase in scientific research during this period ( 7 ). It is now used not only to ensure that a scientific manuscript is experimentally and ethically sound, but also to determine which papers sufficiently meet the journal’s standards of quality and originality before publication. Peer review is now standard practice by most credible scientific journals, and is an essential part of determining the credibility and quality of work submitted.

IMPACT OF THE PEER REVIEW PROCESS

Peer review has become the foundation of the scholarly publication system because it effectively subjects an author’s work to the scrutiny of other experts in the field. Thus, it encourages authors to strive to produce high quality research that will advance the field. Peer review also supports and maintains integrity and authenticity in the advancement of science. A scientific hypothesis or statement is generally not accepted by the academic community unless it has been published in a peer-reviewed journal ( 8 ). The Institute for Scientific Information ( ISI ) only considers journals that are peer-reviewed as candidates to receive Impact Factors. Peer review is a well-established process which has been a formal part of scientific communication for over 300 years.

OVERVIEW OF THE PEER REVIEW PROCESS

The peer review process begins when a scientist completes a research study and writes a manuscript that describes the purpose, experimental design, results, and conclusions of the study. The scientist then submits this paper to a suitable journal that specializes in a relevant research field, a step referred to as pre-submission. The editors of the journal will review the paper to ensure that the subject matter is in line with that of the journal, and that it fits with the editorial platform. Very few papers pass this initial evaluation. If the journal editors feel the paper sufficiently meets these requirements and is written by a credible source, they will send the paper to accomplished researchers in the field for a formal peer review. Peer reviewers are also known as referees (this process is summarized in Figure 1 ). The role of the editor is to select the most appropriate manuscripts for the journal, and to implement and monitor the peer review process. Editors must ensure that peer reviews are conducted fairly, and in an effective and timely manner. They must also ensure that there are no conflicts of interest involved in the peer review process.

Overview of the review process

When a reviewer is provided with a paper, he or she reads it carefully and scrutinizes it to evaluate the validity of the science, the quality of the experimental design, and the appropriateness of the methods used. The reviewer also assesses the significance of the research, and judges whether the work will contribute to advancement in the field by evaluating the importance of the findings, and determining the originality of the research. Additionally, reviewers identify any scientific errors and references that are missing or incorrect. Peer reviewers give recommendations to the editor regarding whether the paper should be accepted, rejected, or improved before publication in the journal. The editor will mediate author-referee discussion in order to clarify the priority of certain referee requests, suggest areas that can be strengthened, and overrule reviewer recommendations that are beyond the study’s scope ( 9 ). If the paper is accepted, as per suggestion by the peer reviewer, the paper goes into the production stage, where it is tweaked and formatted by the editors, and finally published in the scientific journal. An overview of the review process is presented in Figure 1 .

WHO CONDUCTS REVIEWS?

Peer reviews are conducted by scientific experts with specialized knowledge on the content of the manuscript, as well as by scientists with a more general knowledge base. Peer reviewers can be anyone who has competence and expertise in the subject areas that the journal covers. Reviewers can range from young and up-and-coming researchers to old masters in the field. Often, the young reviewers are the most responsive and deliver the best quality reviews, though this is not always the case. On average, a reviewer will conduct approximately eight reviews per year, according to a study on peer review by the Publishing Research Consortium (PRC) ( 7 ). Journals will often have a pool of reviewers with diverse backgrounds to allow for many different perspectives. They will also keep a rather large reviewer bank, so that reviewers do not get burnt out, overwhelmed or time constrained from reviewing multiple articles simultaneously.

WHY DO REVIEWERS REVIEW?

Referees are typically not paid to conduct peer reviews and the process takes considerable effort, so the question is raised as to what incentive referees have to review at all. Some feel an academic duty to perform reviews, and are of the mentality that if their peers are expected to review their papers, then they should review the work of their peers as well. Reviewers may also have personal contacts with editors, and may want to assist as much as possible. Others review to keep up-to-date with the latest developments in their field, and reading new scientific papers is an effective way to do so. Some scientists use peer review as an opportunity to advance their own research as it stimulates new ideas and allows them to read about new experimental techniques. Other reviewers are keen on building associations with prestigious journals and editors and becoming part of their community, as sometimes reviewers who show dedication to the journal are later hired as editors. Some scientists see peer review as a chance to become aware of the latest research before their peers, and thus be first to develop new insights from the material. Finally, in terms of career development, peer reviewing can be desirable as it is often noted on one’s resume or CV. Many institutions consider a researcher’s involvement in peer review when assessing their performance for promotions ( 11 ). Peer reviewing can also be an effective way for a scientist to show their superiors that they are committed to their scientific field ( 5 ).

ARE REVIEWERS KEEN TO REVIEW?

A 2009 international survey of 4000 peer reviewers conducted by the charity Sense About Science at the British Science Festival at the University of Surrey, found that 90% of reviewers were keen to peer review ( 12 ). One third of respondents to the survey said they were happy to review up to five papers per year, and an additional one third of respondents were happy to review up to ten.

HOW LONG DOES IT TAKE TO REVIEW ONE PAPER?

On average, it takes approximately six hours to review one paper ( 12 ), however, this number may vary greatly depending on the content of the paper and the nature of the peer reviewer. One in every 100 participants in the “Sense About Science” survey claims to have taken more than 100 hours to review their last paper ( 12 ).

HOW TO DETERMINE IF A JOURNAL IS PEER REVIEWED

Ulrichsweb is a directory that provides information on over 300,000 periodicals, including information regarding which journals are peer reviewed ( 13 ). After logging into the system using an institutional login (eg. from the University of Toronto), search terms, journal titles or ISSN numbers can be entered into the search bar. The database provides the title, publisher, and country of origin of the journal, and indicates whether the journal is still actively publishing. The black book symbol (labelled ‘refereed’) reveals that the journal is peer reviewed.

THE EVALUATION CRITERIA FOR PEER REVIEW OF SCIENTIFIC PAPERS

As previously mentioned, when a reviewer receives a scientific manuscript, he/she will first determine if the subject matter is well suited for the content of the journal. The reviewer will then consider whether the research question is important and original, a process which may be aided by a literature scan of review articles.

Scientific papers submitted for peer review usually follow a specific structure that begins with the title, followed by the abstract, introduction, methodology, results, discussion, conclusions, and references. The title must be descriptive and include the concept and organism investigated, and potentially the variable manipulated and the systems used in the study. The peer reviewer evaluates if the title is descriptive enough, and ensures that it is clear and concise. A study by the National Association of Realtors (NAR) published by the Oxford University Press in 2006 indicated that the title of a manuscript plays a significant role in determining reader interest, as 72% of respondents said they could usually judge whether an article will be of interest to them based on the title and the author, while 13% of respondents claimed to always be able to do so ( 14 ).

The abstract is a summary of the paper, which briefly mentions the background or purpose, methods, key results, and major conclusions of the study. The peer reviewer assesses whether the abstract is sufficiently informative and if the content of the abstract is consistent with the rest of the paper. The NAR study indicated that 40% of respondents could determine whether an article would be of interest to them based on the abstract alone 60-80% of the time, while 32% could judge an article based on the abstract 80-100% of the time ( 14 ). This demonstrates that the abstract alone is often used to assess the value of an article.

The introduction of a scientific paper presents the research question in the context of what is already known about the topic, in order to identify why the question being studied is of interest to the scientific community, and what gap in knowledge the study aims to fill ( 15 ). The introduction identifies the study’s purpose and scope, briefly describes the general methods of investigation, and outlines the hypothesis and predictions ( 15 ). The peer reviewer determines whether the introduction provides sufficient background information on the research topic, and ensures that the research question and hypothesis are clearly identifiable.

The methods section describes the experimental procedures, and explains why each experiment was conducted. The methods section also includes the equipment and reagents used in the investigation. The methods section should be detailed enough that it can be used it to repeat the experiment ( 15 ). Methods are written in the past tense and in the active voice. The peer reviewer assesses whether the appropriate methods were used to answer the research question, and if they were written with sufficient detail. If information is missing from the methods section, it is the peer reviewer’s job to identify what details need to be added.

The results section is where the outcomes of the experiment and trends in the data are explained without judgement, bias or interpretation ( 15 ). This section can include statistical tests performed on the data, as well as figures and tables in addition to the text. The peer reviewer ensures that the results are described with sufficient detail, and determines their credibility. Reviewers also confirm that the text is consistent with the information presented in tables and figures, and that all figures and tables included are important and relevant ( 15 ). The peer reviewer will also make sure that table and figure captions are appropriate both contextually and in length, and that tables and figures present the data accurately.

The discussion section is where the data is analyzed. Here, the results are interpreted and related to past studies ( 15 ). The discussion describes the meaning and significance of the results in terms of the research question and hypothesis, and states whether the hypothesis was supported or rejected. This section may also provide possible explanations for unusual results and suggestions for future research ( 15 ). The discussion should end with a conclusions section that summarizes the major findings of the investigation. The peer reviewer determines whether the discussion is clear and focused, and whether the conclusions are an appropriate interpretation of the results. Reviewers also ensure that the discussion addresses the limitations of the study, any anomalies in the results, the relationship of the study to previous research, and the theoretical implications and practical applications of the study.

The references are found at the end of the paper, and list all of the information sources cited in the text to describe the background, methods, and/or interpret results. Depending on the citation method used, the references are listed in alphabetical order according to author last name, or numbered according to the order in which they appear in the paper. The peer reviewer ensures that references are used appropriately, cited accurately, formatted correctly, and that none are missing.

Finally, the peer reviewer determines whether the paper is clearly written and if the content seems logical. After thoroughly reading through the entire manuscript, they determine whether it meets the journal’s standards for publication,

and whether it falls within the top 25% of papers in its field ( 16 ) to determine priority for publication. An overview of what a peer reviewer looks for when evaluating a manuscript, in order of importance, is presented in Figure 2 .

How a peer review evaluates a manuscript

To increase the chance of success in the peer review process, the author must ensure that the paper fully complies with the journal guidelines before submission. The author must also be open to criticism and suggested revisions, and learn from mistakes made in previous submissions.

ADVANTAGES AND DISADVANTAGES OF THE DIFFERENT TYPES OF PEER REVIEW

The peer review process is generally conducted in one of three ways: open review, single-blind review, or double-blind review. In an open review, both the author of the paper and the peer reviewer know one another’s identity. Alternatively, in single-blind review, the reviewer’s identity is kept private, but the author’s identity is revealed to the reviewer. In double-blind review, the identities of both the reviewer and author are kept anonymous. Open peer review is advantageous in that it prevents the reviewer from leaving malicious comments, being careless, or procrastinating completion of the review ( 2 ). It encourages reviewers to be open and honest without being disrespectful. Open reviewing also discourages plagiarism amongst authors ( 2 ). On the other hand, open peer review can also prevent reviewers from being honest for fear of developing bad rapport with the author. The reviewer may withhold or tone down their criticisms in order to be polite ( 2 ). This is especially true when younger reviewers are given a more esteemed author’s work, in which case the reviewer may be hesitant to provide criticism for fear that it will damper their relationship with a superior ( 2 ). According to the Sense About Science survey, editors find that completely open reviewing decreases the number of people willing to participate, and leads to reviews of little value ( 12 ). In the aforementioned study by the PRC, only 23% of authors surveyed had experience with open peer review ( 7 ).

Single-blind peer review is by far the most common. In the PRC study, 85% of authors surveyed had experience with single-blind peer review ( 7 ). This method is advantageous as the reviewer is more likely to provide honest feedback when their identity is concealed ( 2 ). This allows the reviewer to make independent decisions without the influence of the author ( 2 ). The main disadvantage of reviewer anonymity, however, is that reviewers who receive manuscripts on subjects similar to their own research may be tempted to delay completing the review in order to publish their own data first ( 2 ).

Double-blind peer review is advantageous as it prevents the reviewer from being biased against the author based on their country of origin or previous work ( 2 ). This allows the paper to be judged based on the quality of the content, rather than the reputation of the author. The Sense About Science survey indicates that 76% of researchers think double-blind peer review is a good idea ( 12 ), and the PRC survey indicates that 45% of authors have had experience with double-blind peer review ( 7 ). The disadvantage of double-blind peer review is that, especially in niche areas of research, it can sometimes be easy for the reviewer to determine the identity of the author based on writing style, subject matter or self-citation, and thus, impart bias ( 2 ).

Masking the author’s identity from peer reviewers, as is the case in double-blind review, is generally thought to minimize bias and maintain review quality. A study by Justice et al. in 1998 investigated whether masking author identity affected the quality of the review ( 17 ). One hundred and eighteen manuscripts were randomized; 26 were peer reviewed as normal, and 92 were moved into the ‘intervention’ arm, where editor quality assessments were completed for 77 manuscripts and author quality assessments were completed for 40 manuscripts ( 17 ). There was no perceived difference in quality between the masked and unmasked reviews. Additionally, the masking itself was often unsuccessful, especially with well-known authors ( 17 ). However, a previous study conducted by McNutt et al. had different results ( 18 ). In this case, blinding was successful 73% of the time, and they found that when author identity was masked, the quality of review was slightly higher ( 18 ). Although Justice et al. argued that this difference was too small to be consequential, their study targeted only biomedical journals, and the results cannot be generalized to journals of a different subject matter ( 17 ). Additionally, there were problems masking the identities of well-known authors, introducing a flaw in the methods. Regardless, Justice et al. concluded that masking author identity from reviewers may not improve review quality ( 17 ).

In addition to open, single-blind and double-blind peer review, there are two experimental forms of peer review. In some cases, following publication, papers may be subjected to post-publication peer review. As many papers are now published online, the scientific community has the opportunity to comment on these papers, engage in online discussions and post a formal review. For example, online publishers PLOS and BioMed Central have enabled scientists to post comments on published papers if they are registered users of the site ( 10 ). Philica is another journal launched with this experimental form of peer review. Only 8% of authors surveyed in the PRC study had experience with post-publication review ( 7 ). Another experimental form of peer review called Dynamic Peer Review has also emerged. Dynamic peer review is conducted on websites such as Naboj, which allow scientists to conduct peer reviews on articles in the preprint media ( 19 ). The peer review is conducted on repositories and is a continuous process, which allows the public to see both the article and the reviews as the article is being developed ( 19 ). Dynamic peer review helps prevent plagiarism as the scientific community will already be familiar with the work before the peer reviewed version appears in print ( 19 ). Dynamic review also reduces the time lag between manuscript submission and publishing. An example of a preprint server is the ‘arXiv’ developed by Paul Ginsparg in 1991, which is used primarily by physicists ( 19 ). These alternative forms of peer review are still un-established and experimental. Traditional peer review is time-tested and still highly utilized. All methods of peer review have their advantages and deficiencies, and all are prone to error.

PEER REVIEW OF OPEN ACCESS JOURNALS

Open access (OA) journals are becoming increasingly popular as they allow the potential for widespread distribution of publications in a timely manner ( 20 ). Nevertheless, there can be issues regarding the peer review process of open access journals. In a study published in Science in 2013, John Bohannon submitted 304 slightly different versions of a fictional scientific paper (written by a fake author, working out of a non-existent institution) to a selected group of OA journals. This study was performed in order to determine whether papers submitted to OA journals are properly reviewed before publication in comparison to subscription-based journals. The journals in this study were selected from the Directory of Open Access Journals (DOAJ) and Biall’s List, a list of journals which are potentially predatory, and all required a fee for publishing ( 21 ). Of the 304 journals, 157 accepted a fake paper, suggesting that acceptance was based on financial interest rather than the quality of article itself, while 98 journals promptly rejected the fakes ( 21 ). Although this study highlights useful information on the problems associated with lower quality publishers that do not have an effective peer review system in place, the article also generalizes the study results to all OA journals, which can be detrimental to the general perception of OA journals. There were two limitations of the study that made it impossible to accurately determine the relationship between peer review and OA journals: 1) there was no control group (subscription-based journals), and 2) the fake papers were sent to a non-randomized selection of journals, resulting in bias.

JOURNAL ACCEPTANCE RATES

Based on a recent survey, the average acceptance rate for papers submitted to scientific journals is about 50% ( 7 ). Twenty percent of the submitted manuscripts that are not accepted are rejected prior to review, and 30% are rejected following review ( 7 ). Of the 50% accepted, 41% are accepted with the condition of revision, while only 9% are accepted without the request for revision ( 7 ).

SATISFACTION WITH THE PEER REVIEW SYSTEM

Based on a recent survey by the PRC, 64% of academics are satisfied with the current system of peer review, and only 12% claimed to be ‘dissatisfied’ ( 7 ). The large majority, 85%, agreed with the statement that ‘scientific communication is greatly helped by peer review’ ( 7 ). There was a similarly high level of support (83%) for the idea that peer review ‘provides control in scientific communication’ ( 7 ).

HOW TO PEER REVIEW EFFECTIVELY

The following are ten tips on how to be an effective peer reviewer as indicated by Brian Lucey, an expert on the subject ( 22 ):

1) Be professional

Peer review is a mutual responsibility among fellow scientists, and scientists are expected, as part of the academic community, to take part in peer review. If one is to expect others to review their work, they should commit to reviewing the work of others as well, and put effort into it.

2) Be pleasant

If the paper is of low quality, suggest that it be rejected, but do not leave ad hominem comments. There is no benefit to being ruthless.

3) Read the invite

When emailing a scientist to ask them to conduct a peer review, the majority of journals will provide a link to either accept or reject. Do not respond to the email, respond to the link.

4) Be helpful

Suggest how the authors can overcome the shortcomings in their paper. A review should guide the author on what is good and what needs work from the reviewer’s perspective.

5) Be scientific

The peer reviewer plays the role of a scientific peer, not an editor for proofreading or decision-making. Don’t fill a review with comments on editorial and typographic issues. Instead, focus on adding value with scientific knowledge and commenting on the credibility of the research conducted and conclusions drawn. If the paper has a lot of typographical errors, suggest that it be professionally proof edited as part of the review.

6) Be timely

Stick to the timeline given when conducting a peer review. Editors track who is reviewing what and when and will know if someone is late on completing a review. It is important to be timely both out of respect for the journal and the author, as well as to not develop a reputation of being late for review deadlines.

7) Be realistic

The peer reviewer must be realistic about the work presented, the changes they suggest and their role. Peer reviewers may set the bar too high for the paper they are editing by proposing changes that are too ambitious and editors must override them.

8) Be empathetic

Ensure that the review is scientific, helpful and courteous. Be sensitive and respectful with word choice and tone in a review.

Remember that both specialists and generalists can provide valuable insight when peer reviewing. Editors will try to get both specialised and general reviewers for any particular paper to allow for different perspectives. If someone is asked to review, the editor has determined they have a valid and useful role to play, even if the paper is not in their area of expertise.

10) Be organised

A review requires structure and logical flow. A reviewer should proofread their review before submitting it for structural, grammatical and spelling errors as well as for clarity. Most publishers provide short guides on structuring a peer review on their website. Begin with an overview of the proposed improvements; then provide feedback on the paper structure, the quality of data sources and methods of investigation used, the logical flow of argument, and the validity of conclusions drawn. Then provide feedback on style, voice and lexical concerns, with suggestions on how to improve.

In addition, the American Physiology Society (APS) recommends in its Peer Review 101 Handout that peer reviewers should put themselves in both the editor’s and author’s shoes to ensure that they provide what both the editor and the author need and expect ( 11 ). To please the editor, the reviewer should ensure that the peer review is completed on time, and that it provides clear explanations to back up recommendations. To be helpful to the author, the reviewer must ensure that their feedback is constructive. It is suggested that the reviewer take time to think about the paper; they should read it once, wait at least a day, and then re-read it before writing the review ( 11 ). The APS also suggests that Graduate students and researchers pay attention to how peer reviewers edit their work, as well as to what edits they find helpful, in order to learn how to peer review effectively ( 11 ). Additionally, it is suggested that Graduate students practice reviewing by editing their peers’ papers and asking a faculty member for feedback on their efforts. It is recommended that young scientists offer to peer review as often as possible in order to become skilled at the process ( 11 ). The majority of students, fellows and trainees do not get formal training in peer review, but rather learn by observing their mentors. According to the APS, one acquires experience through networking and referrals, and should therefore try to strengthen relationships with journal editors by offering to review manuscripts ( 11 ). The APS also suggests that experienced reviewers provide constructive feedback to students and junior colleagues on their peer review efforts, and encourages them to peer review to demonstrate the importance of this process in improving science ( 11 ).

The peer reviewer should only comment on areas of the manuscript that they are knowledgeable about ( 23 ). If there is any section of the manuscript they feel they are not qualified to review, they should mention this in their comments and not provide further feedback on that section. The peer reviewer is not permitted to share any part of the manuscript with a colleague (even if they may be more knowledgeable in the subject matter) without first obtaining permission from the editor ( 23 ). If a peer reviewer comes across something they are unsure of in the paper, they can consult the literature to try and gain insight. It is important for scientists to remember that if a paper can be improved by the expertise of one of their colleagues, the journal must be informed of the colleague’s help, and approval must be obtained for their colleague to read the protected document. Additionally, the colleague must be identified in the confidential comments to the editor, in order to ensure that he/she is appropriately credited for any contributions ( 23 ). It is the job of the reviewer to make sure that the colleague assisting is aware of the confidentiality of the peer review process ( 23 ). Once the review is complete, the manuscript must be destroyed and cannot be saved electronically by the reviewers ( 23 ).

COMMON ERRORS IN SCIENTIFIC PAPERS

When performing a peer review, there are some common scientific errors to look out for. Most of these errors are violations of logic and common sense: these may include contradicting statements, unwarranted conclusions, suggestion of causation when there is only support for correlation, inappropriate extrapolation, circular reasoning, or pursuit of a trivial question ( 24 ). It is also common for authors to suggest that two variables are different because the effects of one variable are statistically significant while the effects of the other variable are not, rather than directly comparing the two variables ( 24 ). Authors sometimes oversee a confounding variable and do not control for it, or forget to include important details on how their experiments were controlled or the physical state of the organisms studied ( 24 ). Another common fault is the author’s failure to define terms or use words with precision, as these practices can mislead readers ( 24 ). Jargon and/or misused terms can be a serious problem in papers. Inaccurate statements about specific citations are also a common occurrence ( 24 ). Additionally, many studies produce knowledge that can be applied to areas of science outside the scope of the original study, therefore it is better for reviewers to look at the novelty of the idea, conclusions, data, and methodology, rather than scrutinize whether or not the paper answered the specific question at hand ( 24 ). Although it is important to recognize these points, when performing a review it is generally better practice for the peer reviewer to not focus on a checklist of things that could be wrong, but rather carefully identify the problems specific to each paper and continuously ask themselves if anything is missing ( 24 ). An extremely detailed description of how to conduct peer review effectively is presented in the paper How I Review an Original Scientific Article written by Frederic G. Hoppin, Jr. It can be accessed through the American Physiological Society website under the Peer Review Resources section.

CRITICISM OF PEER REVIEW

A major criticism of peer review is that there is little evidence that the process actually works, that it is actually an effective screen for good quality scientific work, and that it actually improves the quality of scientific literature. As a 2002 study published in the Journal of the American Medical Association concluded, ‘Editorial peer review, although widely used, is largely untested and its effects are uncertain’ ( 25 ). Critics also argue that peer review is not effective at detecting errors. Highlighting this point, an experiment by Godlee et al. published in the British Medical Journal (BMJ) inserted eight deliberate errors into a paper that was nearly ready for publication, and then sent the paper to 420 potential reviewers ( 7 ). Of the 420 reviewers that received the paper, 221 (53%) responded, the average number of errors spotted by reviewers was two, no reviewer spotted more than five errors, and 35 reviewers (16%) did not spot any.

Another criticism of peer review is that the process is not conducted thoroughly by scientific conferences with the goal of obtaining large numbers of submitted papers. Such conferences often accept any paper sent in, regardless of its credibility or the prevalence of errors, because the more papers they accept, the more money they can make from author registration fees ( 26 ). This misconduct was exposed in 2014 by three MIT graduate students by the names of Jeremy Stribling, Dan Aguayo and Maxwell Krohn, who developed a simple computer program called SCIgen that generates nonsense papers and presents them as scientific papers ( 26 ). Subsequently, a nonsense SCIgen paper submitted to a conference was promptly accepted. Nature recently reported that French researcher Cyril Labbé discovered that sixteen SCIgen nonsense papers had been used by the German academic publisher Springer ( 26 ). Over 100 nonsense papers generated by SCIgen were published by the US Institute of Electrical and Electronic Engineers (IEEE) ( 26 ). Both organisations have been working to remove the papers. Labbé developed a program to detect SCIgen papers and has made it freely available to ensure publishers and conference organizers do not accept nonsense work in the future. It is available at this link: http://scigendetect.on.imag.fr/main.php ( 26 ).

Additionally, peer review is often criticized for being unable to accurately detect plagiarism. However, many believe that detecting plagiarism cannot practically be included as a component of peer review. As explained by Alice Tuff, development manager at Sense About Science, ‘The vast majority of authors and reviewers think peer review should detect plagiarism (81%) but only a minority (38%) think it is capable. The academic time involved in detecting plagiarism through peer review would cause the system to grind to a halt’ ( 27 ). Publishing house Elsevier began developing electronic plagiarism tools with the help of journal editors in 2009 to help improve this issue ( 27 ).

It has also been argued that peer review has lowered research quality by limiting creativity amongst researchers. Proponents of this view claim that peer review has repressed scientists from pursuing innovative research ideas and bold research questions that have the potential to make major advances and paradigm shifts in the field, as they believe that this work will likely be rejected by their peers upon review ( 28 ). Indeed, in some cases peer review may result in rejection of innovative research, as some studies may not seem particularly strong initially, yet may be capable of yielding very interesting and useful developments when examined under different circumstances, or in the light of new information ( 28 ). Scientists that do not believe in peer review argue that the process stifles the development of ingenious ideas, and thus the release of fresh knowledge and new developments into the scientific community.

Another issue that peer review is criticized for, is that there are a limited number of people that are competent to conduct peer review compared to the vast number of papers that need reviewing. An enormous number of papers published (1.3 million papers in 23,750 journals in 2006), but the number of competent peer reviewers available could not have reviewed them all ( 29 ). Thus, people who lack the required expertise to analyze the quality of a research paper are conducting reviews, and weak papers are being accepted as a result. It is now possible to publish any paper in an obscure journal that claims to be peer-reviewed, though the paper or journal itself could be substandard ( 29 ). On a similar note, the US National Library of Medicine indexes 39 journals that specialize in alternative medicine, and though they all identify themselves as “peer-reviewed”, they rarely publish any high quality research ( 29 ). This highlights the fact that peer review of more controversial or specialized work is typically performed by people who are interested and hold similar views or opinions as the author, which can cause bias in their review. For instance, a paper on homeopathy is likely to be reviewed by fellow practicing homeopaths, and thus is likely to be accepted as credible, though other scientists may find the paper to be nonsense ( 29 ). In some cases, papers are initially published, but their credibility is challenged at a later date and they are subsequently retracted. Retraction Watch is a website dedicated to revealing papers that have been retracted after publishing, potentially due to improper peer review ( 30 ).

Additionally, despite its many positive outcomes, peer review is also criticized for being a delay to the dissemination of new knowledge into the scientific community, and as an unpaid-activity that takes scientists’ time away from activities that they would otherwise prioritize, such as research and teaching, for which they are paid ( 31 ). As described by Eva Amsen, Outreach Director for F1000Research, peer review was originally developed as a means of helping editors choose which papers to publish when journals had to limit the number of papers they could print in one issue ( 32 ). However, nowadays most journals are available online, either exclusively or in addition to print, and many journals have very limited printing runs ( 32 ). Since there are no longer page limits to journals, any good work can and should be published. Consequently, being selective for the purpose of saving space in a journal is no longer a valid excuse that peer reviewers can use to reject a paper ( 32 ). However, some reviewers have used this excuse when they have personal ulterior motives, such as getting their own research published first.

RECENT INITIATIVES TOWARDS IMPROVING PEER REVIEW

F1000Research was launched in January 2013 by Faculty of 1000 as an open access journal that immediately publishes papers (after an initial check to ensure that the paper is in fact produced by a scientist and has not been plagiarised), and then conducts transparent post-publication peer review ( 32 ). F1000Research aims to prevent delays in new science reaching the academic community that are caused by prolonged publication times ( 32 ). It also aims to make peer reviewing more fair by eliminating any anonymity, which prevents reviewers from delaying the completion of a review so they can publish their own similar work first ( 32 ). F1000Research offers completely open peer review, where everything is published, including the name of the reviewers, their review reports, and the editorial decision letters ( 32 ).

PeerJ was founded by Jason Hoyt and Peter Binfield in June 2012 as an open access, peer reviewed scholarly journal for the Biological and Medical Sciences ( 33 ). PeerJ selects articles to publish based only on scientific and methodological soundness, not on subjective determinants of ‘impact ’, ‘novelty’ or ‘interest’ ( 34 ). It works on a “lifetime publishing plan” model which charges scientists for publishing plans that give them lifetime rights to publish with PeerJ, rather than charging them per publication ( 34 ). PeerJ also encourages open peer review, and authors are given the option to post the full peer review history of their submission with their published article ( 34 ). PeerJ also offers a pre-print review service called PeerJ Pre-prints, in which paper drafts are reviewed before being sent to PeerJ to publish ( 34 ).

Rubriq is an independent peer review service designed by Shashi Mudunuri and Keith Collier to improve the peer review system ( 35 ). Rubriq is intended to decrease redundancy in the peer review process so that the time lost in redundant reviewing can be put back into research ( 35 ). According to Keith Collier, over 15 million hours are lost each year to redundant peer review, as papers get rejected from one journal and are subsequently submitted to a less prestigious journal where they are reviewed again ( 35 ). Authors often have to submit their manuscript to multiple journals, and are often rejected multiple times before they find the right match. This process could take months or even years ( 35 ). Rubriq makes peer review portable in order to help authors choose the journal that is best suited for their manuscript from the beginning, thus reducing the time before their paper is published ( 35 ). Rubriq operates under an author-pay model, in which the author pays a fee and their manuscript undergoes double-blind peer review by three expert academic reviewers using a standardized scorecard ( 35 ). The majority of the author’s fee goes towards a reviewer honorarium ( 35 ). The papers are also screened for plagiarism using iThenticate ( 35 ). Once the manuscript has been reviewed by the three experts, the most appropriate journal for submission is determined based on the topic and quality of the paper ( 35 ). The paper is returned to the author in 1-2 weeks with the Rubriq Report ( 35 ). The author can then submit their paper to the suggested journal with the Rubriq Report attached. The Rubriq Report will give the journal editors a much stronger incentive to consider the paper as it shows that three experts have recommended the paper to them ( 35 ). Rubriq also has its benefits for reviewers; the Rubriq scorecard gives structure to the peer review process, and thus makes it consistent and efficient, which decreases time and stress for the reviewer. Reviewers also receive feedback on their reviews and most significantly, they are compensated for their time ( 35 ). Journals also benefit, as they receive pre-screened papers, reducing the number of papers sent to their own reviewers, which often end up rejected ( 35 ). This can reduce reviewer fatigue, and allow only higher-quality articles to be sent to their peer reviewers ( 35 ).

According to Eva Amsen, peer review and scientific publishing are moving in a new direction, in which all papers will be posted online, and a post-publication peer review will take place that is independent of specific journal criteria and solely focused on improving paper quality ( 32 ). Journals will then choose papers that they find relevant based on the peer reviews and publish those papers as a collection ( 32 ). In this process, peer review and individual journals are uncoupled ( 32 ). In Keith Collier’s opinion, post-publication peer review is likely to become more prevalent as a complement to pre-publication peer review, but not as a replacement ( 35 ). Post-publication peer review will not serve to identify errors and fraud but will provide an additional measurement of impact ( 35 ). Collier also believes that as journals and publishers consolidate into larger systems, there will be stronger potential for “cascading” and shared peer review ( 35 ).

CONCLUDING REMARKS

Peer review has become fundamental in assisting editors in selecting credible, high quality, novel and interesting research papers to publish in scientific journals and to ensure the correction of any errors or issues present in submitted papers. Though the peer review process still has some flaws and deficiencies, a more suitable screening method for scientific papers has not yet been proposed or developed. Researchers have begun and must continue to look for means of addressing the current issues with peer review to ensure that it is a full-proof system that ensures only quality research papers are released into the scientific community.

• Open access
• Published: 09 January 2024

Recurrence of post-traumatic stress disorder: systematic review of definitions, prevalence and predictors

• Samantha K Brooks 1 &
• Neil Greenberg 1  

BMC Psychiatry volume  24 , Article number:  37 ( 2024 ) Cite this article

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Many people will experience a potentially traumatic event in their lifetime and a minority will go on to develop post-traumatic stress disorder (PTSD). A wealth of literature explores different trajectories of PTSD, focusing mostly on resilient, chronic, recovered and delayed-onset trajectories. Less is known about other potential trajectories such as recurring episodes of PTSD after initial recovery, and to date there has been no estimate of what percentage of those who initially recover from PTSD later go on to experience a recurrence. This systematic review aimed to synthesise existing literature to identify (i) how ‘recurrence’ of PTSD is defined in the literature; (ii) the prevalence of recurrent episodes of PTSD; and (iii) factors associated with recurrence.

A literature search of five electronic databases identified primary, quantitative studies relevant to the research aims. Reference lists of studies meeting pre-defined inclusion criteria were also hand-searched. Relevant data were extracted systematically from the included studies and results are reported narratively.

Searches identified 5,398 studies, and 35 were deemed relevant to the aims of the review. Results showed there is little consensus in the terminology or definitions used to refer to recurrence of PTSD. Because recurrence was defined and measured in different ways across the literature, and prevalence rates were reported in numerous different ways, it was not possible to perform meta-analysis to estimate the prevalence of recurrence. We also found no consistent evidence regarding predictors of PTSD recurrence.

A clear and consistent evidence-based definition of recurrence is urgently needed before the prevalence and predictors of recurrence can be truly understood.

Peer Review reports

Potentially traumatic events are common. Research suggests that over 70% of people will experience a potentially traumatic event (such as witnessing death or serious injury, automobile accident, life-threatening illness or injury, or violent encounter) in their lifetime [ 1 ]. Understandably, these events can be very distressing in the short-term and many people will experience acute post-traumatic symptoms in the immediate aftermath of a traumatic event, including intrusive symptoms (e.g. recurrent unwanted thoughts, nightmares); avoidance symptoms (e.g. emotional numbing, social withdrawing); hyperarousal (e.g. easily startled, feeling ‘on edge’); and physical symptoms (e.g. chest pain, dizziness) [ 2 ]. For the majority, these symptoms will decline naturally without intervention [ 3 ], typically within the first four weeks [ 2 ]. An important minority will find their symptoms persist for longer than a month. Those who continue to experience persistent re-experiencing of the traumatic event; avoidance of stimuli associated with the event; negative alterations in cognitions and mood and alterations in arousal and reactivity, causing clinical distress or functional impairment and not attributable to any other medical condition, are likely to be diagnosed with post-traumatic stress disorder (PTSD) [ 4 ]. Although only a minority of people who experience potentially traumatic events will go on to develop PTSD, it remains one of the most common mental disorders with lifetime prevalence estimated to be between 8% [ 5 ] and 12% [ 6 ]. PTSD is associated with reduced health-related quality of life and physical comorbidities, as well as major socio-economic costs [ 7 ].

The early 2000s saw a shift from studying PTSD itself as an outcome to studying change in symptoms as an outcome [ 8 ], with a wealth of studies using modelling approaches such as latent class growth analysis and latent growth mixture modelling to identify different trajectories of PTSD. Most of this literature identifies four trajectories, two of which are relatively stable trajectories ( chronic , a stable trajectory of post-traumatic stress symptoms, and resilient , a stable trajectory of healthy functioning after an adverse event), and two which display dynamic symptom patterns ( recovered , i.e. decreasing symptoms after an initial diagnosis of PTSD, and delayed-onset , i.e. increasing symptoms not meeting the diagnostic criteria for PTSD until potentially months or even years after traumatic exposure) [ 9 ]. Van de Schoot et al. [ 10 ] suggest that the two trajectories which typically occur less often (chronic and delayed-onset) are at risk of being overlooked by researchers or overwhelmed within the data by the larger trajectories. There may also be other less-researched or less-understood trajectories overlooked to an even greater extent. For example, one previous review [ 11 ] identified limited evidence of another, smaller trajectory referred to as a ‘relapsing’ or ‘recurring’ PTSD trajectory, in which individuals develop PTSD, are free from symptoms for long enough to be considered ‘recovered’, and then experience a recurrence of symptoms.

Recurrence is given relatively little attention in the PTSD literature, perhaps due to limitations of study methodologies and the complexities of studying recurrence. For example, Santiago et al. [ 11 ] note that few studies of PTSD follow participants for more than a year or with more than two assessments. Clearly, it would not be possible for researchers to identify recurrence of PTSD if data is only collected for two time-points: the only possible outcomes would be low symptom levels at each time-point (‘resilience’), high symptoms at each time-point (‘chronic’), or low level of symptoms at one time-point and a high level at the other (either ‘recovery’ or ‘delayed-onset’ depending on time-point at which symptoms were experienced). Additionally, studies which only follow up participants for a year or less are unlikely to clearly identify a recurrent trajectory of PTSD given the time needed to both recover and to experience a recurrent episode. The timing of PTSD assessment is also important: identification of PTSD recurrence relies on studies capturing the presence of symptoms during the recurrence, rather than before it occurs or after recurring symptoms have subsided. Therefore, it is perhaps unsurprising that the majority of the literature does not identify a ‘recurring’ trajectory of PTSD. Even studies which do identify recurrences often group these in with other trajectories: for example, Mota et al. [ 12 ] identified ‘recurrent’ cases of PTSD (individuals who had a lifetime diagnosis in 2002 and another post-2002 diagnosis reported in 2018), but grouped ‘persistent’ and ‘recurrent’ cases of PTSD together. Magruder et al. [ 13 ] identified a group of recurrent cases of PTSD – individuals who had lifetime PTSD pre-1992 but not a current diagnosis in 2002, who then had a diagnosis again in 2021, but these were grouped with ‘chronic’ cases. Karamustafalioglu et al. [ 14 ] simply include an ‘other’ group constituting both recurrent cases (individuals who met the criteria for PTSD diagnosis 1–3 months post-trauma and at the third follow-up 18–20 months post-trauma, but not at the second follow-up 6–10 months post-trauma) and others with delayed-onset PTSD which resolved. Boe et al. [ 15 ] identified a group of individuals with ‘reactivated’ PTSD who reported remission from PTSD in the first five years after the North Sea oil rig disaster of 1980 and a new episode at any point between 1985 and 2007. However, the authors suggest that there are blurred boundaries between delayed-onset and ‘reactivated’ PTSD, going on to include ‘possible delayed cases’ in their analysis of reactivated PTSD.

It is important to note that even the definitions of the more well-established trajectories of PTSD are not without their controversies. For example, Andrews et al. [ 16 ] point out the ambiguity in the criterion for delayed-onset PTSD, questioning whether ‘the onset of symptoms’ refers to any symptoms which might eventually lead to PTSD or only to full-blown PTSD itself. North et al. [ 17 ] comment on the ambiguities involved in the term remission (i.e. whether remission should be symptom-based or threshold-based) as well as the term onset (i.e. whether onset refers to first symptoms or first meeting diagnostic criteria). Definition of recovery also appears to differ from study to study, with some authors considering recovery to be symptom-based (i.e. no symptoms of the disorder remain) and others considering it to be threshold-based (i.e. some symptoms may remain, but they are beneath the diagnostic threshold) [ 18 ].

To date, several systematic reviews have been published which focus solely on only one PTSD trajectory. For example, previous reviews have focused on the delayed-onset trajectory [ 16 , 19 ]; the recovery trajectory [ 20 ]; and the resilient trajectory [ 21 ]. To date there has not been a literature review examining evidence of a recurrent trajectory of PTSD. Berge et al. [ 22 ] aimed to systematically review research on relapse in veterans but found no studies reporting actual rates of relapse or recurrence. Reviews have also explored the risk of relapse of various anxiety disorders, including PTSD, after discontinuation of antidepressants [ 23 ] and after cognitive behavioural therapy [ 24 ]. However, there have been no reviews attempting to quantify the risk of PTSD recurring, establish the predictors of recurrence, or quantify how much each predictive factor contributes to the risk of recurrence. The current review aimed to fill this gap in the literature by synthesising existing published data on how researchers define ‘recurrence’ of PTSD, recurrence rates of PTSD, and predictive factors of recurrence.

Having an appropriate understanding of recurrence is important as the concept needs to be properly understood in order to take steps to mitigate the risks of recurrent PTSD episodes. Mitigating the risk of PTSD recurring could benefit the health and wellbeing of trauma-exposed individuals and could reduce the socio-economic costs to the wider society [ 7 ]. The prevalence of recurrence is of particular importance to occupational medicine: regularly trauma-exposed organisations, for example, are often faced with decisions about when (and if) staff who have had and recovered from PTSD should return to the frontline duties. Understanding the risk of recurrent episodes may therefore have implications for those in charge of making such decisions. The present time is also a particularly relevant time to develop our understanding of recurrence of PTSD, as it is possible that the COVID-19 pandemic could contribute to recurrence. The pandemic has been declared a potential traumatic stressor, with research suggesting that COVID-19 survivors are at elevated risk of experiencing PTSD [ 25 ] and that PTSD symptoms may also develop due to quarantine [ 26 ], concerns about the health of loved ones, or economic loss as a result of the pandemic [ 27 ]. Hori et al. [ 28 ] suggest that the daily television updates regarding COVID-19 could trigger memories of surviving a previous traumatic situation, and exacerbate subthreshold PTSD symptoms. Therefore, experiencing the pandemic could potentially cause a recurrence of symptoms in people who have previously been diagnosed with PTSD.

The aim of this review was to collate literature which provides evidence of the lesser-studied ‘recurrent’ trajectory of PTSD and to identify: (i) the definitions of ‘recurrence’ used throughout the literature; (ii) prevalence of recurrence; and (iii) risk and protective factors for the recurrent trajectory of PTSD.

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [ 29 ]. Our population of interest were people who had been diagnosed with, recovered from, and experienced a recurrence of PTSD (as diagnosed by a clinician or validated PTSD assessment tool). For the aim relating to prevalence of recurrent episodes, studies needed to involve a suitable design allowing prevalence to be assessed: for example, studies involving a population of people who had recovered from PTSD, followed over time to show how many had a recurrent episode and how many did not. For the other aims (i.e., definitions of recurrence and factors associated with recurrence), a comparison group was not necessary.

Registering the review

A protocol for the current review was developed and registered with PROSPERO on March 9th 2023 (registration number CRD42023405752). The only deviation from the protocol was the addition of another quality appraisal tool, due to finding a study design (retrospective analysis of existing health data) which we had not anticipated.

Eligibility criteria

To be included in the review, studies needed to (1) be published in peer-reviewed journals, (2) be published in the English language, (3) use quantitative methodology, (4) use a standardised tool to assess PTSD and (5) present data on recurrence rates of PTSD and/or factors associated with PTSD recurrence. There were no limitations relating to publication date or location of the studies. Case studies were excluded but there were no other exclusion criteria relating to population size.

Data searching and screening

A systematic literature search was carried out to examine definitions, prevalence rates and predictors of PTSD recurrence. Four electronic databases (Embase, PsycInfo, Medline and Web of Science) were searched on 24th November 2022, using a combination of search terms relating to PTSD, recurrence, and prevalence/predictors which were combined using Boolean operators. The full list of search terms is presented in Appendix 1 . The US Department of Veterans Affairs National Center for Post-Traumatic Stress Disorder’s PTSDPubs database (formerly PILOTS) was searched separately on the same date using the individual terms ‘recurrence’ and ‘recurrent’ and limited to peer-reviewed articles. Reference lists of articles deemed to meet the inclusion criteria were also hand-searched.

All citations resulting from the literature searches were downloaded to an EndNote library where duplicates were removed. The titles of all citations were then screened for relevance to the review, with any clearly not relevant being excluded. Abstracts were then screened for eligibility and the full texts of all remaining citations after abstract screening were located and read in their entirety to identify studies meeting all inclusion criteria. The literature searches and screening were carried out by the first author. The two authors met regularly throughout the screening process to discuss any uncertainties about inclusion or exclusion until a decision was reached.

Data extraction

The first author carried out data extraction of all citations deemed to meet the inclusion criteria. Data were extracted to a Microsoft Excel spreadsheet with the following headings: authors, year of publication, country, study design, sampling method, inclusion/exclusion criteria, study population size, socio-demographic characteristics of participants, type of trauma exposure, time-points at which PTSD was assessed, tools for assessing PTSD, definitions of recovery and recurrence, whether any PTSD treatment was received, prevalence rates of recurrence, and factors examined as potential predictors of recurrence.

Data synthesis

For the first aim of the review (relating to definitions of recurrence), we designed a table to present data relating to how ‘recurrence’ was understood and defined in each study. The tools used to diagnose and measure PTSD symptoms in the first place are important in understanding how PTSD is defined, so first the assessment tools used in each study were extracted into the table. Given that we wanted to understand the length of time an individual needs to be free of PTSD in order to be considered ‘recovered’, for each study we also included the time-points of PTSD assessment in the table. Next, we included the definitions of recovery and recurrence from each study, explained narratively in the table. We also added information to this table to report whether participants had received PTSD treatment during each study, as some studies focusing on interventions used ‘response to treatment’ in their definitions of recovery. We compared the different definitions used within the studies to establish whether there was consensus within the literature around (i) whether recovery and recurrence are symptom-based or threshold-based and (ii) how long the recovery period between initial diagnosis and recurrent episodes needs to be in order to be considered recurrent rather than chronic PTSD.

The second aim related to prevalence of PTSD recurrence. Due to the various research designs and definitions of ‘recurrence’ in the literature, as well as the different ways in which prevalence was reported, meta-analytic techniques could not be used. Rather, we presented the prevalence data as it was reported in each study. This sometimes meant presenting the prevalence of PTSD recurrence within an entire trauma-exposed population, including those who never experienced PTSD at any time. Other times, this meant presenting the prevalence of PTSD within a population who all had PTSD at one time-point, and other times this meant presenting the prevalence of PTSD within a group who had recovered from PTSD.

Finally, in order to explore factors associated with PTSD recurrence, all variables considered as potential covariates were recorded individually for each study. Each potential predictive factor was descriptively reported in a table, and any found to be significantly associated with experiencing PTSD recurrence were bolded to differentiate between non-significant and significant findings. Factors are also described narratively within the results section. Insights from thematic analysis [ 30 ] were used to group similar data together. For example, data relating to gender or age as predictors of recurrence were coded ‘socio-demographic’ and discussed together within the results.

Quality appraisal

We appraised the quality of studies using National Institutes of Health (NIH) tools: either the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies or the Quality Assessment of Controlled Intervention Studies tool, depending on study design. Concurrent with other reviews [e.g. 31 ] we rated quality as ‘poor’ if studies scored 0–4/14, ‘fair’ if they scored 5–10/14 and ‘good’ if they scored 11–14/14. One study used retrospective analysis of existing health data, and for this study we used the MetaQAT Critical Appraisal Tool [ 32 ]. To keep the ratings consistent with our rating system for the studies appraised by NIH tools, we defined ‘poor’ quality as a score of 0–34%, ‘fair’ quality as a score of 35–72% and ‘good’ quality as a score of 78% or higher.

Literature searches yielded 5,398 citations of which 1,083 were duplicates. After title and abstract screening, 4,210 citations were excluded leaving 105 citations for full-text screening. After reading full texts of the remaining citations, 75 were excluded and an additional five studies were added after hand-searching reference lists. A total of 35 citations were included in the review [ 15 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 ]. Figure  1 illustrates the screening process in a PRISMA flow diagram.

PRISMA flow diagram of screening process

Table  1 provides an overview of key characteristics of all included studies. Studies originated from the United States of America (n = 13), Denmark (n = 5), Israel (n = 4), China (n = 4), Norway (n = 2), the United Kingdom (n = 2), Japan (n = 1), the Netherlands (n = 1), Switzerland (n = 1), and Turkey (n = 1). The remaining study included participants in multiple different countries across Europe and Asia. Study populations ranged from 35 to 7,918 and included military personnel (n = 15), civilian adults (n = 14), children or adolescents (n = 4) or a combination of military and civilian adults (n = 2). Only three studies were rated as ‘good’ quality; the majority were rated ‘fair’.

Definitions of recurrence

Table  2 reports, for each study, the tools used to assess PTSD; time-points at which PTSD was assessed; definitions of recovery and recurrence; and whether the participants received PTSD treatment or not.

Terminology

The first aim of the review was to explore how ‘recurrence’ is defined in the literature. We found no consensus in terms of how this is defined. In fact, the studies used a variety of different terms to describe the emergence of new PTSD episodes after initial ‘recovery’, including ‘recurrence’ [ 33 , 37 , 44 , 47 , 64 , 65 ]; ‘relapse’ [ 35 , 36 , 40 , 49 , 50 , 52 , 53 , 57 ]; ‘reactivation’ [ 15 , 60 , 62 ]; ‘exacerbation/reactivation’ [ 61 ]; ‘relieved-worsening PTSD’ [ 34 , 48 , 51 , 63 ]; ‘response-remit’ trajectory [ 54 ]; ‘fluctuating course’ [ 58 ]; ‘intermittent cases’ [ 43 ]; ‘delayed increase in symptoms’ [ 46 ]; and the ‘relapsing/remitting’ trajectory [ 42 , 55 ]. Many others simply described recurrence as ‘symptom increase’ [ 38 ], ‘initial declines followed by symptom increases’ [ 56 ] or ‘exacerbation of symptoms’ [ 41 , 60 ]. Some studies did not name the trajectory at all; rather, they presented tables or flow charts showing the number of participants with PTSD at each time-point, from which it was possible for us to identify a sub-group of participants who were described as having PTSD at one time-point, not having it at least one follow-up, and then having it again at subsequent time-points [ 39 , 59 ]. Similarly, Hansen et al. [ 45 ] identified and commented on a sub-group of participants who met the criteria for PTSD, did not meet the criteria at a subsequent time-point, and then met the criteria again later, but they did not give this a name.

Criteria for recurrence

Several studies defined recurrence (or equivalent terminology such as relapse) as meeting diagnostic criteria for PTSD at a follow-up time-point after an initial ‘recovery’ period where they did not meet the cut-off for PTSD [ 33 , 35 , 37 , 39 , 43 , 45 , 46 , 58 , 65 ]. Holliday et al. [ 47 ] referred to ‘clinically meaningful change in PTSD symptoms’, which was also assumed to refer to clinical cut-off scores. Markowitz et al. [ 52 ] based the definition of relapse on similarity to baseline scores. Sungur and Kaya [ 64 ] defined recovery and recurrence as being asymptomatic and then symptomatic again, but it is not clear whether this referred to clinical cut-offs. One study defined ‘reactivation’ of PTSD as meeting full diagnostic criteria or being a sub-syndromal case [ 15 ]. Others were more vague and did not mention cut-offs, instead referring to dramatic or steep symptom increases [ 34 , 38 , 56 , 63 ], fluctuating symptoms [ 42 , 55 ], returning to pre-treatment levels of PTSD [ 54 ], symptoms which ‘decreased somewhat and increased drastically’ [ 48 ], symptoms which ‘decreased to a low level and increased again’ [ 49 , 50 ] or ‘steadily worsening’ symptoms [ 36 ]. DenVelde et al. [ 41 ] simply asked participants to self-report whether they had ‘experienced remissions and exacerbations’. Martenyi et al. [ 53 ] had multiple definitions of relapse, including increases in scores on their PTSD measures or ‘the clinical judgement of the investigator’. Others labelled the trajectory but did not specify the parameters of their definitions [ 51 , 60 , 61 , 62 , 66 ]. One study [ 57 ] used ‘being hospitalised’ as a proxy measure of PTSD recurrence, although this way of defining recurrence would obviously not capture individuals who developed recurring symptoms which were not severe enough to warrant hospitalisation; additionally, no criteria for hospitalisation were described. Similarly, Davidson et al. [ 40 ] described ‘relapse’ as PTSD scores reverting back to baseline or worse, or experiencing an ‘untoward clinical event’ including suicidality, hospitalisation, or dropping out of the study due to feeling progress was not being made.

We found little consensus as to how long participants needed to be symptom-free (or have reduced symptoms) in order to be considered ‘recovered’ prior to recurrence. The majority of studies simply based their definitions on the time-points of the study, suggesting that recurrence was identified if participants had PTSD at baseline, did not have PTSD during at least one follow-up, and then had PTSD again at a later follow-up. The time-points of follow-ups ranged from weeks to months to years. Only four studies suggested specific timeframes: three studies claimed that participants needed to be ‘recovered’ for eight weeks in order for later reports of PTSD to count as ‘recurrence’ rather than symptom fluctuation [ 35 , 37 , 66 ] whereas Zanarini et al. [ 65 ] reported that participants needed to be not meeting the PTSD criteria for at least two years in order to be considered ‘recovered’. Similarly, most studies did not clarify a time-scale for how long symptoms needed to be experienced in order to be considered a ‘recurrence’. Most studies again simply based their diagnosis on the scores participants happened to report on the days they were assessed. Few studies specified a time-frame: three [ 35 , 43 , 65 ] suggested a duration of four consecutive weeks of meeting their criteria for PTSD, while Benítez et al. [ 37 ] suggested two weeks of symptoms was sufficient to identify a recurrent episode.

Prevalence of recurrence

The review’s second aim was to explore PTSD recurrence rates. Table  3 presents data on the prevalence of recurrence of PTSD for each study. The second column of Table  3 presents the data that is reported in the original studies. The findings reported in this column are not easily comparable because studies reported recurrence rates in different ways. Some reported the percentage of the entire trauma-exposed sample who experienced PTSD recurrence (column 3 of Table  3 ). Others reported the percentage of those with PTSD who experienced recurrence (column 4 of Table  3 ) and the remaining studies reported the percentage of those who recovered from PTSD who experienced recurrence (column 5 of Table  3 ). Three studies [ 44 , 47 , 57 ] did not report the prevalence of recurrence, but were still included in the review as they included definitions and/or predictors of recurrence. One study [ 60 ] deliberately chose a sample who had all experienced recurrence; therefore, recurrence prevalence data for this study was not recorded in Table  3 as it would, by design, be 100%.

Most studies (19/35) reported the prevalence of recurrence within the entire trauma-exposed population. We would therefore expect prevalence rates to be extremely small, given that the majority of trauma-exposed people will not develop PTSD in the first place [ 3 ], let alone have recurrent episodes. However, in several studies this was not the case. Prevalence of recurrence ranged from 0.2% (for a sub-set of participants who did not directly witness the disaster in question) [ 45 ] to 57% of 63 women newly-diagnosed with ovarian cancer [ 43 ]. The latter study was carried out over 27 weeks and identified ‘intermittent cases’ who had PTSD at one time-point, no PTSD at a later time-point, and then PTSD again later on. We note that 27 weeks is a fairly short period of time for both recovery and recurrence to occur, and it is therefore possible that the data reflects symptom fluctuations rather than true recovery or recurrence. Overall, the mean prevalence of recurrent PTSD in trauma-exposed populations was 13.1%, and the median was 3.8%.

Five studies presented the prevalence of recurrence within populations diagnosed with PTSD. We would expect these prevalence rates to be higher than the prevalence rates of recurrence within full trauma-exposed samples, as they are based on populations who developed PTSD only. The rates were 4.9% [ 39 ], 15.4% [ 66 ], 24.5% [ 36 ], 28% [ 46 ] and 49.6% [ 41 ]. Mean and median prevalence of recurrent PTSD were both 24.5%.

Seven studies presented data on the prevalence of recurrence within sub-sets of study populations who had recovered from PTSD; therefore, the only possible trajectories for these participants would be recurrence or maintenance of recovery. Recurrence rates ranged from 5.8% (for a sub-set of participants treated with fluoxetine) [ 53 ] to 50% (for a sub-group treated with a placebo) [ 40 ]. Mean prevalence of recurrent PTSD was 25.4% and the median was 22.2%.

The three studies rated highest in quality [ 34 , 47 , 55 ] did not report similar findings relating to prevalence. Holliday et al. [ 47 ] did not present prevalence data at all. Andersen et al. [ 34 ] reported that 2% of participants followed the ‘relieved-worsening’ trajectory, whereas Osenbach et al. [ 55 ] reported that 35% of participants followed the ‘relapsing-remitting’ trajectory. Notably, Andersen et al.’s [ 34 ] participants were military personnel, whilst Osenbach et al.’s [ 55 ] participants were civilian trauma survivors. For this reason, we decided to look separately at recurrence rates in military and civilian participants. We also decided to look separately at data on children as children’s experiences during and after potentially traumatic events are likely to be distinct from those of adults [ 67 ]. Table  4 presents the mean and median recurrence rates for different populations.

Prevalence of PTSD recurrence in military populations

Fifteen studies focused on military personnel and veterans, three of which did not provide prevalence data and one of which included only participants with PTSD recurrence. Military studies which presented rates of recurrence in trauma-exposed populations (rather than focusing on people diagnosed with PTSD only) typically found low prevalence of recurrence: seven studies found prevalence rates under 4% [ 34 , 48 , 51 , 54 , 61 , 62 ]. Another study found a prevalence rate of 6% [ 38 ]. The only higher prevalence rates were reported by Solomon & Mikulincer [ 59 ], who reported recurrence rates of 24.4% for those with combat stress reactions (people referred for psychiatric intervention during the war) and 13.2% for participants who participated in combat in the same units but without need for psychiatric intervention during the war. This study assessed participants over twenty years, which may explain its higher prevalence rate than the majority of studies which were completed within two-and-a-half years or less. However, the study period was shorter than the forty-seven years of Solomon et al.’s [ 62 ] study, which reported only a 1.6% rate of recurrence. It is unclear why Solomon and Mikulincer [ 59 ] found much higher rates of recurrence.

Two military studies reported recurrence rates for PTSD-populations. These were 24.5% [ 36 ] and 49.6% [ 41 ]. We note that all of Armenta et al.’s [ 36 ] participants had comorbid depression at baseline. We also note some concerns about the reliability of DenVelde et al.’s study [ 41 ], which was a retrospective study asking participants to give complete life-history data at one time-point only.

One military study reported on the prevalence of recurrence in a sub-group of participants who had recovered. Solomon et al. [ 62 ], who reported a prevalence rate of 1.6% (out of the entire trauma-exposed sample) over the first forty-two years of the study, found in a follow-up at forty-seven years that 16.7% of those who had initially recovered experienced recurrence of PTSD during the COVID-19 pandemic.

Prevalence of PTSD recurrence in civilian adult populations

Fourteen studies focused on civilian adults. Findings relating to recurrence prevalence in entire trauma-exposed samples were mixed. Two studies reported rates of under 5% [ 45 , 58 ] in survivors of a terrorist attack and an earthquake respectively. Sungur and Kaya [ 64 ] reported a recurrence rate of 8.9% in survivors of the Sivas disaster, a religious fundamentalist protest which resulted in civilian deaths. Higher rates of recurrence were reported for survivors of an oil rig disaster (18.8%) [ 15 ], survivors of an oil spill (32%) [ 56 ], acutely injured trauma survivors (35%) [ 55 ] and women recently diagnosed with ovarian cancer (57%) [ 43 ].

For populations of civilians with PTSD only, recurrence rates were 4.9% [ 39 ] (type of trauma not reported), 15.4% [ 66 ] (trauma type varied), and 28% [ 46 ] (participants severely injured in accidents). Four studies reported data on the prevalence of recurrence in populations who had previously recovered from PTSD. Reported rates were 14% [ 52 ] (trauma type varied), 29.5% [ 37 ] (trauma type varied), 34% [ 35 ] (trauma type not reported) and 40% [ 65 ] (trauma type varied).

Prevalence of PTSD recurrence in children

Four studies focused on recurrence in adolescents / children, with mixed findings. Fan et al. [ 42 ] found that 3.3% of 1,573 earthquake survivors experienced ‘relapsing/remitting’ PTSD. Liang et al. [ 49 , 50 ] found that 17.7% of 301 earthquake survivors experienced the ‘relapsing’ trajectory of PTSD. An et al. [ 33 ] found that 37% of 246 adolescents experienced ‘recurrent dysfunction’ after experiencing an earthquake.

Prevalence of PTSD recurrence in combined military and civilian populations

Finally, two studies included both military and civilian participants; both of these studies were trials comparing fluoxetine to placebo treatment in people with PTSD. Davidson et al. [ 40 ] found that half of the placebo group relapsed after recovery, compared to 22.2% of the fluoxetine group. Martenyi et al. [ 53 ] reported lower rates of ‘relapse’: 16.1% of the placebo group and 5.8% of the fluoxetine group. The latter study followed up participants after 36 months, while Davidson et al. [ 40 ] followed up participants for a year after treatment.

Predictors of PTSD recurrence

The third and final aim of the present review was to identify factors associated with PTSD recurrence. Firstly, we note that (as shown in Table  2 ), participants in a number of studies had received some type of intervention during the study period, which was typically not accounted for in analyses of predictors. Many other studies did not report whether participants received treatment or not. Having treatment, whether it be medication, therapy, or a combination, is likely to be an important factor influencing PTSD trajectory, given that there are evidence-based treatments for the condition [ 68 ], but this was typically not explored.

Table  5 shows the factors considered as predictors in each study, with significant associations presented in bold. The majority of included studies (22/35) explored at least one covariate; the remaining studies either did not explore covariates or combined recurrent trajectories with other trajectories in their analyses of predictors. Of those studies which did explore covariates of recurrence, we found little consensus.

Sociodemographic factors

Gender was considered as a potential covariate by six studies; one [ 33 ] found that recurrent PTSD was associated with female gender while five studies (including two based on the same data-set) [ 49 , 50 ] found no significant gender association [ 35 , 36 , 42 , 49 , 50 ]. None of the three studies testing age as a covariate found a significant association [ 35 , 36 , 57 ]. One study of school-aged children found that children in a higher grade (i.e. older in age) were more likely to experience PTSD recurrence [ 33 ], while three studies of two cohorts [ 42 , 49 , 50 ] found no significant association between recurrence and school grade. Three studies considered race as a covariate, finding no significant association between PTSD recurrence and race [ 36 , 44 , 55 ]. Other socio-demographic characteristics considered included number of children in the family [ 42 ], marital status and level of education [ 36 ], none of which were found to be associated with PTSD recurrence. For military participants, there were no significant differences in service branch, service component or pay grade between the recurrent and rapid recovery groups [ 36 ].

Psychiatric history

Seven studies considered psychiatric history and concurrent diagnoses as potential covariates of PTSD recurrence, again with mixed findings. Recurrence was not found to be associated with other anxiety syndromes [ 36 ], baseline levels of anxiety [ 54 ], depressive symptoms [ 55 ], baseline levels of depression [ 54 ] or psychiatric history [ 55 ]. Ansell et al. [ 35 ] found that diagnoses of a number of co-morbid mental health disorders such as major depressive disorder and personality disorders such as schizotypal personality disorder, avoidant personality disorder and borderline personality disorder were not associated with recurrence, but participants with a baseline diagnosis of obsessive-compulsive personality disorder were significantly less likely to experience PTSD recurrence. Conversely, Perconte et al. [ 57 ] found that those who experienced recurrence were significantly more likely to report obsessive-compulsive symptoms than those whose symptoms improved without recurrence. Sakuma et al. [ 58 ] found that pre-disaster treatment for mental illness was significantly associated with PTSD recurrence, but note that the results should be interpreted carefully due to the very small number of participants in the ‘fluctuating symptoms’ group who appeared to have experienced recurrent episodes. Perconte et al. [ 57 ] found that, versus the improved symptoms group, those with PTSD recurrence were more likely to report depression, anxiety, hostility, phobic anxiety, somaticism and psychoticism; however, previous psychiatric hospitalisations and pre-treatment ratings of global pathology on a psychiatric scale did not predict recurrence. Finally, Madsen et al. [ 51 ] found that suicidal ideation was significantly higher in the ‘relieved-worsening PTSD’ group than the ‘low-stable’ group and that suicidal ideation was in fact highest in the recurrent (termed ‘relieved-worsening’) group than any other. However, it should be noted that suicidality was not assessed at baseline in this study, therefore it is not clear whether suicidal ideation is a cause or a consequence of PTSD recurrence.

Physical health

Fewer studies considered physical health as a potential predictor of PTSD recurrence. One study found no association between recurrence and disabling injury/illness, somatic symptoms or bodily pain [ 36 ] and another found no association between recurrence and prior treatment for physical illness [ 57 ]. However, obesity was a significant predictor of PTSD recurrence [ 36 ]. In terms of health-related behaviours, Armenta et al. [ 36 ] found no association between PTSD recurrence and smoking status, alcohol problems or sleep duration. However, Perconte et al. [ 57 ] found that higher weekly alcohol intake both before and at termination of PTSD treatment predicted recurrence.

Cognitive ability

Only one study [ 63 ] explored cognitive ability as a potential covariate, finding that the participants who were in the recurrent (termed ‘relieved-worsening PTSD’) group had significantly lower cognitive ability scores than those in the ‘low-stable’ group.

Trauma history and pre-trauma experiences

The review also found mixed evidence for trauma history as a predictor of PTSD recurrence. Liang et al. [ 49 , 50 ] found no association between pre-disaster traumatic experience and PTSD recurrence. Armenta et al. [ 36 ] found no association between recurrence and childhood sexual abuse, childhood verbal abuse, childhood neglect, sexual assault, physical assault, or ‘other life events’, but did find that participants reporting a history of childhood physical abuse were significantly more likely to experience PTSD recurrence. Holliday et al. [ 47 ] found that veterans who had experienced military sexual trauma (MST) had greater initial reductions in PTSD symptoms than those who had not experienced MST, but also experienced a ‘modestly greater’ recurrence of symptoms than those without MST, although this difference did not appear to reach statistical significance. Zanarini et al. [ 65 ] found that the presence of childhood sexual abuse history did not significantly predict time-to-recurrence, but severity of childhood sexual abuse, adult rape history, combination of childhood sexual abuse history and adult rape history, and experiencing sexual assault during study follow-up were associated with less time-to-recurrence. Osofsky et al. [ 56 ] found that abuse, emotional abuse, domestic violence, and greater number of traumas experienced were associated with recurrence of PTSD, and Osenbach et al. [ 55 ] found that recurrent life stressors significantly increased the odds of membership in chronic, relapsing or recovery groups rather than the resilient group. For military participants, one study found combat deployment was significantly associated with recurrent PTSD [ 36 ] while others found combat exposure was not associated with recurrence [ 54 , 57 ]. Finally, Fan et al. [ 42 ] found that compared to the recovery group, relapsing participants experienced significantly fewer negative life events 6-months post-disaster, but significantly more such events at the 24-month follow-up.

Few other pre-trauma experiences were considered. An et al. [ 33 ] found that those with recurrent PTSD were significantly more likely to have experienced academic burnout than those in the recovery trajectory, although there was no difference between the recurrent and delayed trajectories.

Experiences during and immediately after the traumatic experience

The review also found mixed evidence for an association between peri-traumatic experiences and PTSD recurrence. The most consistent finding related to how stressful the traumatic experience was perceived to be at the time. For example, risk of recurrence was significantly higher in those with combat stress reactions [ 59 ] and in those with higher stress relating to the disaster they had experienced [ 56 ], as well as with greater trauma severity [ 49 , 50 ]. However, recurrence was not found to be associated with subjective fear during the event [ 33 ]; directly witnessing a disaster [ 42 ]; property loss during the event [ 33 , 42 ]; property damage [ 42 ]; displacement due to property damage [ 58 ]; near-death experience [ 58 ]; or having a family member injured, killed or missing [ 42 , 58 ].

There was some evidence that initial post-traumatic stress symptoms immediately after the traumatic event could predict PTSD trajectory. Liang et al. [ 49 , 50 ], in a study of PTSD in children from two schools affected by an earthquake, found that children from one of the two schools (‘School 2’) were significantly more likely to experience PTSD recurrence than children from the other school (‘School 1’). Further investigations revealed that after adjusting for immediate post-traumatic stress symptoms the school no longer predicted relapse; those from School 2 had significantly greater post-traumatic stress symptoms immediately after the disaster, which the authors suggest might be due to School 1 providing sufficient psychological services as well as having the same students and teachers before and after the earthquake (therefore perhaps greater social support available), whereas School 2 had insufficient psychological services and consisted of teachers and students from several different schools which could not be reconstructed after the earthquake.

One study [ 58 ] considered occupational-related covariates of PTSD recurrence for disaster recovery workers. They found that having mainly disaster-related occupational duties and lack of rest due to occupational duties were not associated with recurrence, but perceived poor workplace communication did predict recurrence.

Post-trauma experiences and symptoms

An et al. [ 33 ] found that, compared to the delayed PTSD trajectory, those who experienced recurrence were less likely to have experienced post-traumatic growth after the traumatic event; however, there were no differences in post-traumatic growth between the recurrent and recovery groups. Fan et al. [ 42 ] found that neither positive coping nor negative coping six months post-disaster were associated with PTSD recurrence. In a military study, Karstoft et al. [ 48 ] found that poor adjustment to civilian life (i.e. difficulties with community reintegration after deployment) was significantly higher for the recurrent (‘relieved-worsening PTSD’) group than all other groups. However, it is not clear whether poor adjustment was a cause or an effect of PTSD symptoms worsening after initial improvement.

Two studies explored specific cluster symptoms. Murphy and Smith [ 54 ] found PTSD recurrence was not predicted by the magnitude of re-experiencing, avoidance, or hyperarousal symptoms. Boe et al. [ 15 ] found that the number of intrusion and avoidance symptoms five-and-a-half months post-trauma did not predict recurrence, but the number of intrusion and avoidance symptoms both fourteen months and five years after the disaster did predict recurrence.

Social support

Only three studies directly considered social support as a potential covariate. Armenta et al. [ 36 ] found no association between social support and PTSD recurrence, and Perconte et al. [ 57 ] found that family support did not predict recurrence. Fan et al. [ 42 ] found that level of social support six months after experiencing an earthquake was not associated with PTSD recurrence, but those in the ‘relapsing’ group reported significantly less social support 24 months after the earthquake than those in the ‘recovery’ group.

PTSD treatment

Most of the studies investigating treatment for PTSD found that not receiving interventions, or discontinuing treatment, were associated with PTSD recurrence. For example, Osenbach et al. [ 55 ] found that those who received ‘usual care’ only were significantly more likely to experience recurrence than those who received interventions designed to reduce post-traumatic symptoms. Davidson et al. [ 40 ] found that those who received placebo treatment were significantly more likely to experience recurrence than those who received fluoxetine. Martenyi et al. [ 53 ] found that those who discontinued fluoxetine treatment were significantly more likely to experience recurrence, especially for those with combat-related PTSD. However, Perconte et al. [ 57 ] found that number of weeks enrolled in treatment and number of treatment sessions attended did not significantly affect risk of recurrence. In this study, though, being hospitalised at least once since the termination of treatment was used as a proxy measure of ‘recurrence’ and so the findings are arguably not truly representative of actual recurrent episodes of PTSD. Overall, our findings indicated some evidence that treatment helped to avoid recurrent episodes.

In this study, we systematically reviewed 35 studies to identify definitions and prevalence of recurrent PTSD and factors associated with recurrence. It is important to define and operationalise recurrence as the concept needs to be understood in order to make prevention efforts. The health-related, social and economic costs of PTSD can be substantial. PTSD negatively affects individuals’ emotional wellbeing and physical health [ 7 ], impedes social relationships [ 69 ], limits productivity at work and increases sickness absence [ 70 ]. The direct costs (e.g., medical care costs) and indirect costs (e.g., costs of unemployment or reduced productivity) of PTSD can create substantial economic burden [ 7 , 71 ]. Determining the predictors of recurrence of PTSD (which can only be properly understood if ‘recurrence’ itself has a clear definition) is important for prevention efforts: identifying those most at risk for recurrent episodes would allow for the subsequent investigation of ways of mitigating or preventing the risk. However, we found little consensus as to how recurrence is defined, mixed evidence on the prevalence of recurrence and inconsistent findings relating to predictors of recurrence. This lack of clarity about what relapse or recurrence is, and is not, is a major barrier to understanding this important topic.

In a previous review exploring PTSD recurrence in veterans, Berge et al. [ 22 ] acknowledge that there is no generally accepted or used definition of recovery relating to psychological trauma. The definition of recurrence used in their review was the return of symptoms following a period of complete recovery, representing the start of a new and separate episode . However, it is not clear what length of time is covered by ‘a period of complete recovery’ nor what ‘complete recovery’ means. How many days, weeks, or months does an individual need to be free of symptoms of PTSD in order to be considered truly recovered? Is ‘symptom-free’ the only definition of recovery, or is ‘not meeting the criteria for PTSD’ enough? Our own review revealed that there is little consensus as to what recurrence means and the parameters for its definition. Even the terminology used varied across studies, with ‘relapse’, ‘recurrence’, ‘reactivation’ and numerous other terms often used to describe what essentially appeared to be the same concept. There was no consensus as to how long an individual needed to be free of symptoms in order to be considered recovered, nor for how long symptoms needed to recur in order to be considered a recurrent episode. Most studies simply defined recurrence as a change in symptoms between assessments, meaning that whether or not an individual was defined as having a recurrent episode or not very much depended on the scores they reported at arbitrary time-points. Even minor symptom fluctuations could cause someone to change from being identified as a ‘case’ to ‘recovered’ and vice versa. Because PTSD tended to be examined using prospective studies where symptoms were assessed at predetermined assessment points, it is possible that individuals may have onsets of PTSD after one assessment and then remit before the next. With no retrospective assessment between time-points, it is difficult to assess the true prevalence of recurrence. Andrews et al. [ 16 ] make a similar point in relation to delayed onset PTSD, suggesting the absence of information about symptoms outside of the predetermined time-points of studies means that estimates of delayed onset PTSD may be unreliable.

The second aim of the review was to examine the prevalence of PTSD recurrence in existing literature. Given the numerous different ways of assessing PTSD, defining initial recovery and defining recurrence, as well as the differing time-points at which PTSD was assessed across studies, we suggest that the current data on recurrence prevalence is not especially meaningful. We found very different prevalence rates reported within the literature, with data suggesting that anywhere between 0.2% and 57% of trauma-exposed populations might experience recurrent episodes of PTSD. Some of the higher percentages we found seem greater than we would expect, given that only a minority of trauma-exposed people are likely to develop PTSD in the first place – let alone suffer from it, recover from it, and experience a recurrent episode. We would expect that studies carried out over a longer period of time would find higher recurrence rates, simply because in these studies there is more time for recurrent episodes to occur. However, the highest prevalence rate (57%) was found in a study which took place over only 27 weeks [ 43 ]; the authors labelled these participants as ‘intermittent cases’ and it appears likely that symptom fluctuation, rather than true recovery and recurrence, occurred in this study – and potentially many others. Additionally, studies did not typically control for exposure to subsequent trauma, meaning that ‘recurrences’ of PTSD identified may actually be new episodes, rather than a relapse. Further research studies, especially research involving assessments over a number of years, are needed to establish the true prevalence of recurrent PTSD which also needs to be clearly defined with an agreed time period between remission and relapse.

It has been proposed that recurrence rates might increase with old age. Murray [ 72 ] suggests that PTSD can be ‘reactivated’ in older age because physical illnesses become more common, which can reactivate traumatic memories; increased dependence on others due to ageing can reactivate feelings of helplessness; and loss of structure and identity caused by retirement can similarly reactivate traumatic symptoms. Other factors relating to ageing such as decline of cognitive function, difficulty controlling ruminations, reminiscing, and late-life stressors such as serious illness, surgical procedures and death of spouses, siblings or close friends can either directly remind the person of their previous traumatic experience(s) or can induce similar feelings of vulnerability [ 73 ]. Three studies of adults in this review did not find age predicted recurrence [ 35 , 36 , 57 ]; however, the populations trended young overall, with each of the three studies reporting the mean age of participants was under 40. We suggest, then, that more studies of older adults with lifetime PTSD are needed to establish whether this group are at increased risk of recurrence.

The third aim of this review was to understand factors associated with PTSD recurrence. Although a number of potential covariates were considered, most were not investigated by more than a few studies, and findings were varied and inconsistent. Of the covariates investigated by multiple studies, none were found to have significant associations with recurrence across all studies. It was therefore not possible to quantify the extent to which potential risk factors contribute to the risk of recurrence. One reason for the inconsistent findings might be the relatively small numbers of participants with recurrent PTSD in many of the studies. We note also that most studies did not consider either subsequent trauma or treatment impact in their analysis of predictors of recurrence.

We did not find strong evidence of an association between PTSD recurrence and comorbid psychiatric conditions. Recurrence of other mental health disorders, such as anxiety, is reportedly associated with comorbid psychiatric conditions including major depression, alcohol and substance use disorders [ 74 ]. Additionally, comorbid disorders have been found to be associated with an ‘unfavourable long-term course’ of PTSD [ 18 ]. However, in a review of predictors of developing PTSD, Brewin et al. [ 75 ] found that while psychiatric history was associated with development of PTSD, it was not a strong risk factor – factors operating during or after the traumatic exposure had greater effects than the pre-trauma factors. Many studies in this review found no evidence of a relationship between PTSD recurrence and other mental health conditions; in those that did find a relationship, it was not always clear whether the other conditions pre-dated the recurrent PTSD episode or not. Overall, the most consistent evidence we found indicated that recurrence of PTSD was associated with greater stress and traumatic response at the time of the traumatic experience.

We did not find evidence to suggest that trauma type may affect recurrence. Many studies examined PTSD trajectories after a single traumatic event. Those that did include participants who had experienced various different types of trauma did not consider trauma type as a potential predictor of recurrence. Given the wide variations in methodology, it was not appropriate for us to compare recurrence rates for different trauma types within the review. Future research should include participants who have experienced different types of trauma and should consider trauma type as a potential predictor of PTSD trajectory.

Only one study assessed PTSD during the COVID-19 pandemic, with Solomon et al. [ 62 ] reporting that 16.7% of initially-recovered participants experienced recurrence during the pandemic. However, it is not clear how many of this cohort may also have experienced recurrence before the pandemic, and without being able to make that comparison, we cannot ascertain the extent to which recurrence was exacerbated by the pandemic. Additionally, the percentage (16.7%) is similar to recurrence rates in several other, non-COVID studies. Ideally, future studies will present data on PTSD recurrence rates for one cohort at regular intervals, including data collected during or after the COVID-19 pandemic, to ascertain whether the pandemic did affect recurrence rates.

In their review, Steinert et al. [ 18 ] identified older age, higher education, greater trauma severity, higher baseline symptoms, more physical/functional impairments, and poorer social support as predictors of ‘unfavourable’ long-term course of PTSD. These were identified as predictors due to being reported in at least two studies within their review. The current review did not find consistent evidence that age, education, trauma severity, baseline symptoms, impairments or social support predicted recurrence – although age was only considered in studies of young people. We found some evidence from treatment studies that fluoxetine reduced the risk of recurrence, as did participation in an intervention involving a combination of motivational interviewing, behavioural activation and pharmacotherapy. It is therefore difficult to make recommendations relevant to occupational health, as we had hoped to do. Managers of trauma-exposed employees who have developed PTSD may have questions around whether recovered individuals can go back to frontline work, or whether they risk experiencing a recurrence of PTSD. Our findings tentatively suggest that recurrence might be relatively rare (rates of recurrence ranged from 0.2 − 57% in full trauma-exposed samples, mean 13.1%; 4.9 − 49.6% in PTSD-only subgroups, mean 24.5%; and 5.8 − 50% for recovered subgroups, mean 25.4%) but clearer definitions and assessments of recurrence are needed to substantiate that claim. As we found no consistent evidence of predictors of recurrence, it was therefore not possible to identify which sub-groups of people might be more likely to have their PTSD recur. We did find evidence from two studies that recurrence was more prevalent in groups of PTSD patients treated with placebos compared to PTSD patients treated with fluoxetine, suggesting that medication appears at least somewhat effective in reducing the risk of recurrence. However, we found no studies looking at the impact of first-line treatments on relapse (i.e. trauma-focused cognitive behavioural therapy [ 76 ] or eye movement desensitisation and reprocessing [ 77 , 78 ]) which is a major gap in the literature. Whilst more, high-quality studies are carried out, employers should ensure that workers get evidence-based treatments and have an occupational mental health assessment on completion of potentially traumatic work to provide an expert judgement, given that we cannot identify any clear risk factors from the literature.

The key limitation of the literature on PTSD recurrence is that it is not always easy to differentiate between recurrence and symptom fluctuation, and it is also difficult to know what ‘recovery’ truly means. It is not clear how many of the so-called ‘recovered’ participants within the reviewed studies may have been close to clinical thresholds for PTSD at the assessment points. Rather than moving from distinct ‘recovered’ to ‘recurrent episodes’, it may be that individuals only experienced small fluctuations in PTSD symptoms, moving them above and below the symptom thresholds. Indeed, the authors of several of the included studies remarked on the difficulties in identifying PTSD trajectories. In Boe et al.’s [ 15 ] study, clinical interviews were conducted by two clinical psychologists who were trained and supervised by an experienced clinician and trauma researcher and even these experienced individuals had difficulties identifying recurrence of PTSD, with one case being recategorised from ‘full-blown PTSD reactivation’ to ‘sub-syndromal reactivation’ after discussion between the researchers. Markowitz et al. [ 52 ] pointed out that, as they defined relapse as ‘loss of response (to treatment) status’, relapse might reflect barely crossing that threshold: indeed, more in-depth analysis of their six ‘relapsers’ showed that all but one still showed some, albeit more modest, treatment benefit relative to their baseline PTSD severity.

Sakuma et al. [ 58 ] discussed their finding of a ‘fluctuating’ trajectory (and lack of a delayed-onset trajectory), differing from the typical four trajectories widely accepted within the PTSD literature. They suggested the difference may be due to variations in the duration of study periods and characteristics of the study samples. The majority of studies which produce the typical four trajectories are conducted over short periods between a few months and two years [ 9 ], compared to the longer (54-month) period of Sakuma et al.’s [ 58 ] study: the trajectory commonly identified as ‘delayed onset’ could really be a fluctuating trajectory if examined over a longer period. Or, it could reflect a gradual accumulation of symptoms resulting in a delayed presentation of PTSD, rather than delayed onset.

The time-points of assessments could also affect reported prevalence rates. For example, Sungur & Kaya [ 64 ] pointed out that some of their ‘recurrent’ cases would have been considered ‘recovered’ if the study period had been shorter or if participants had not been reassessed at the particular time-points chosen. They also noted that symptoms across the entire participant population seemed to be higher at particular times during the study (namely, at the anniversary of the event and at the time of a disappointing result of a court hearing for compensation), suggesting that the nature and course of PTSD might be influenced by particular events which might trigger unwanted memories of the traumatic event. In the current review, most studies assessed participants for at least a year, but not all: five [ 38 , 39 , 43 , 52 , 53 ] followed participants for less than a year. Additionally, two studies [ 44 , 47 ] reported assessing participants pre-treatment and four months post-treatment but it was not clear how long treatment lasted.

We suggest that PTSD recurrence may not have been adequately assessed in many of the included studies. For example, Chopra et al. [ 39 ] described how, in order to minimise respondent burden, assessors were expected to stop inquiring about PTSD symptoms if participants were unlikely to meet the criteria and if they answered no to particular questions on the assessment tool. This could mean that some individuals who did have recurrent episodes of PTSD were not identified as they did not complete the full measures. Additionally, we found that a number of studies had very vague definitions of recurrence, such as ‘increasing symptoms’, where it was unclear what exactly this meant. Others used hospitalisation as a proxy measure for recurrence, or simply asked participants whether they perceived their symptoms had been exacerbated and in one case used the investigator’s own judgements as a way of determining recurrence. It is therefore likely that some recurrent cases may have been missed while others who never truly ‘recovered’ at all may have been reported to have experienced recurrence. Overall, the vague and inconsistent ways of assessing recurrence mean it is currently impossible to ascertain true recurrence rates within existing literature.

It is also possible that recurrent trajectories of PTSD appear in studies which do not identify them as such. For example, in Andrews et al.’s [ 16 ] review, the authors note that some cases of ‘delayed-onset PTSD’ in veterans of relatively old age with long intervals to first onset may in fact have had episodes of PTSD soon after their traumatic experiences which were undisclosed or forgotten. In other words, some cases of supposedly ‘delayed-onset’ PTSD might actually be recurrent cases. Andrews et al. [ 16 ] also point out that many of the studies included in their review of delayed-onset PTSD did not assess whether respondents could have had onsets of PTSD and then remitted before the next assessment point – which could lead to both over- and under-estimates of delayed-onset rates of PTSD. Indeed, the studies included in our own review tended to focus only on the scores at the various time-points and did not explore participants’ perceptions of symptom fluctuations outside of the time-points set by the study.

Limitations

There are a number of limitations of the literature reviewed. Many did not collect data on whether participants had undergone any intervention or not, and those that did tended not to include this as a potential confounding variable. The majority of studies did not assess whether participants experienced additional potentially traumatic experiences between PTSD assessments. Many did not define the parameters of ‘recovery’ and ‘recurrence’ and it is not clear whether recurrent episodes identified were truly recurrent episodes or merely symptom fluctuations. Many did not collect data on whether or not participants received any treatment for PTSD between data collection time-points, and many of those which did ask participants whether they had received any treatment did not distinguish between types of treatment. It is therefore unclear if, and how many, participants in many studies received any evidence-based PTSD treatment or not. Additionally, the majority of studies did not collect data on the time period of any treatment received. Some studies had extremely long gaps (e.g., decades) between assessments which could mean that recurrences were missed.

There are also limitations of the review process itself. Firstly, the screening, data extraction and quality appraisal were carried out by one author. Although decisions about exclusion or inclusion were discussed with the second author, it would have been preferable to have multiple screeners. We limited the review to English-language studies only, meaning that important studies published in other languages would have been missed. We included only studies which identified ‘recurrent episodes’ (or equivalent terminology e.g. relapse, reactivation); studies which identified no recurrent trajectory were not reviewed. It may be that these studies did not include a sufficient number of assessments to pick up on recurrent episodes, but it may also be that no participants in these studies experienced recurrence and therefore the true prevalence of recurrence may be lower than this review suggests.

Conclusions and implications

The main conclusion that can be drawn from the current review is that, moving forward, better clarity and consensus regarding the definition and identification of recurrent PTSD are urgently needed. Berge et al. [ 22 ] suggest that consistent definitions of relapse-related terms, supported by empirical research, are required in order to make studies of PTSD trajectories more robust. The findings of this review support this suggestion. Experts in the field should agree on an appropriate definition of recurrence (i.e. symptom-based or threshold-based) and should agree how long an individual needs to be ‘better’ for in order to be considered recovered as well as how long an individual needs to experience symptoms for in order to be considered as having a recurrent episode. Recurrence is arguably better-defined for recurrent depressive disorder, with the ICD-11 stating that recurrence is characterised by a history of depressive episodes separated by at least several months without significant mood disturbance [ 79 ]. However, further clarity is still needed. How many months is ‘several’? What are ‘significant’ symptoms? Still, we suggest this might be a useful starting point for a working definition of recurrent PTSD: a history of episodes of PTSD separated by at least several (i.e., three) months without significant (i.e., meeting diagnostic criteria) PTSD symptoms . However, further research is necessary to clarify whether these parameters (i.e. three months as a time period, symptom thresholds as a diagnostic tool) are the most appropriate to use. Using consistent terminology within the literature would make it easier to researchers in the future to understand true prevalence rates of PTSD recurrence and to compare them across studies. Further research allowing for the identification of recurrent PTSD episodes is needed. We believe the gold standard for assessing PTSD and properly identifying its trajectories, including recurrent trajectories, would be using the Clinician Administered PTSD Scale (CAPS) [ 80 ], or other validated questionnaires, at multiple specific time points over a long period of time. Figure  2 summarises the findings of the review and the proposed next steps based on our findings.

Summary of review and suggested next steps

It is important to understand recurrence in order to take steps towards reducing the risk of PTSD recurring. However, due to the inconsistent findings relating to predictors of recurrence, it is difficult to draw conclusions about the best ways of preventing or minimising recurrence. We suggest that ensuring that people who develop PTSD are provided with timely, evidence-based treatments is a logical first step [ 68 ]. Second, awareness of ‘early warning sign’ symptoms and ‘triggers’ might be useful, as well as awareness of effective coping strategies and how to access support. That is, if people with PTSD are able to recognise when they are struggling more and acknowledge that they need to be proactive in ensuring symptoms do not develop into full-blown PTSD again, they may be able to draw on their coping skills or reach out for formal or informal support when a recurrent episode seems imminent and may be able to stave off the recurrent episode. We also suggest that reframing the re-emergence of symptoms in a more positive way might be useful: instead of feeling defeated that symptoms have recurred, people could remind themselves that they have recovered once and therefore know that they are capable of doing so again. Within organisational settings, it is also important to foster an environment in which people who have any mental health condition, including PTSD, feel confident that asking for help will not lead to stigmatisation or increase the likelihood of inappropriate job loss. It may also be helpful to incorporate relapse prevention, understanding ‘warning signs’ of recurrent episodes and positive reframing into PTSD treatment programmes.

Data availability

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

Abbreviations

Clinician-Administered PTSD Scale

Military sexual trauma

National Institutes for Health

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Post-Traumatic Stress Disorder

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Brooks, S.K., Greenberg, N. Recurrence of post-traumatic stress disorder: systematic review of definitions, prevalence and predictors. BMC Psychiatry 24 , 37 (2024). https://doi.org/10.1186/s12888-023-05460-x

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In recent years, the Water-Energy-Food (WEF) nexus has gained significant attention in global research. Spatial inequality in water-energy-food security (WEF) and its impact on public health and how this is affected by climate change remains a grand adaptation challenge. South Africa is extremely vulnerable and exposed to the impacts of climate change due to its socio-economic and environmental context. While alternative nexus types have garnered interest, this paper pioneers an extension of the conventional WEF framework to encompass health, giving rise to the Water-Energy-Food-Health (WEF-H) nexus. Despite a plethora of WEF nexus studies focused on South Africa, a substantial knowledge gap persists due to the lack of a comprehensive overview of the enablers and barriers to realizing the WEF-H nexus. South Africa boasts diverse policies related to water, energy, food, and health; however, their alignment remains an ongoing challenge. This study seeks to bridge this critical gap by conducting an exhaustive review of existing literature. Its primary aim is to delve into the intricate mechanisms that either facilitate or impede the actualization of the WEF-H nexus in South Africa. By synthesizing insights from a wide array of literature sources, this research strives to illuminate the challenges and opportunities stemming from the integration of health considerations into the established WEF nexus framework. This exploration holds immense significance, not only for unraveling the multifaceted interactions between these pivotal sectors but also for guiding policy development and decision-making processes in South Africa towards a more holistic and sustainable approach to resource management.

1 Introduction

Despite three decades of democracy, South Africa still struggles with the legacy of apartheid, including extreme inequality across racial and regional lines ( Klug, 2021 ), widening gulfs between the rich and poor ( Naidoo, 2005 ; Sibanda and Batisai, 2021 ) compounded with increased frequency of climate-induced hazards. The 1994 transition to majority rule in South Africa aimed to reduce socio-economic inequality, expand basic services, and embrace human rights principles as the foundation of constitutional solutions ( Klug, 2021 ). Access to water, food, health, and energy services are basic human rights, but the struggle for these rights continues to echo the popular struggles of the apartheid era. The South African government is committed to eliminating poverty and reducing inequality by 2030, as set out in its key national policy documents, e.g., National Development Plan 2030 ( NPC, 2011 ) and National Climate Change Response Policy (NCCRP) ( DEA, 2011 ) as well as the international agenda for Sustainable Development Goals (SDGs) to which the government has subscribed. Despite the government’s valiant efforts, many South Africans continue to face socio-economic challenges and the ramifications of climate change ( Naidoo, 2005 ; Sibanda and Batisai, 2021 ). This reality is particularly pronounced among the country’s black African population.

Like many developing countries, South Africa faces the challenge of balancing economic growth with environmental sustainability, what Simpson coined “reconciling growth with planetary boundaries” ( Simpson and Jewitt, 2019 ). This means developing the economy in a way that is equitable, inclusive, and does not irreversibly damage renewable resources or fail to realize the full potential of non-renewable resources. However, South Africa’s political economy has tended to prioritise an economic approach that transfers problems to a wide range of sectors. For example, mining rights often trump conservation of strategic water resource areas, agriculture lands and even human health considerations. As a result, tensions are growing between the increasing demand for, and use of natural resources (e.g., water, land, and energy) to support development and the availability and quality of those resources.

Coupled with its developmental challenges, the country is also water-stressed, with climate change ( Nhamo et al., 2020 ) further compounding existing socio-economic challenges. Escalating food prices ( Simpson and Jewitt, 2019 ) are leaving a large portion of the population highly food insecure, unable to meet their basic nutritional needs. Even more urgent and complex is the issue of the ailing energy system. Eskom, the national power utility has failed to meet the energy demand resulting in frequent power outages ( Baker and Phillips, 2019 ; International Energy Agency, 2022 ) and increased rationing of the available energy ( Lawrence, 2020 ).

South Africa has many policies related to water, food, and energy, which aim to make these sectors more sustainable. However, many stakeholders are increasingly recognizing the importance of managing the complex interactions between water, energy and food (WEF). The WEF nexus, an approach that considers these three sectors together, has been suggested as a governance solution to complex resource management challenges ( Srigiri and Dombrowsky, 2022 ). This paper examines the implementation of the WEF-H nexus in a country case study, with a focus on the key bottlenecks and enablers. The paper acknowledges that more than a decade after the introduction of the WEF Nexus as a governance ( Keskinen et al., 2016 ), analytical ( Nhamo et al., 2020 ) and ideological tool, the transition from “nexus thinking” to “nexus doing” remains essential to foster appropriate policy development, effective decision-making and practical implementation, in the context of water, energy, food, and health interlinkages.

The paper explores developments in the WEF-H nexus through an extensive literature review, unpacking its complexity and challenges within the South African context, and examining the key ingredients for successful implementation.

2 Understanding the nexus concept

The term “nexus” is central to the WEF-H Nexus, and it refers to a polycentric approach to problem solving ( Srigiri and Dombrowsky, 2022 ). As such, the nexus concept is a useful framework ( Keskinen et al., 2016 ) for action that brings together multiple actors and institutions at different levels of governance to address complex challenges. It is both an analytical tool and a discourse centred on the theory of polycentricity ( Thiel, 2016 ) and polycentric governance ( Ostrom, 2010 ) which means that power and decision-making are distributed across multiple centres.

In simpler terms, a nexus approach is a systems-based way of thinking about complex problems by considering how different sectors are connected and how decisions made in one sector can impact on others. This may be especially useful for identifying the inter-relatedness and interdependencies between sectors when making decisions about projects, strategies, policies and investment options in complex socio-environmental systems ( DeLaurentis and Callaway, 2004 ). It aims to integrate research, management and governance across sectors and scales. The nexus approach assumes that there are biophysical and environmental limits to the degree to which resources can be exploited or pollutants can be absorbed, and that exceeding these limits will have potentially catastrophic impacts, either now or in the future.

Moreover, it is understood that there are complex feedbacks within and between sectors ( Mutanga et al., 2016 ), often resulting in non-linear responses, and tipping points beyond which systems cannot easily recover ( Cabrera et al., 2008 ). The nexus approach allows for a more holistic understanding of (un-)intended consequences of policies, technologies and practices whilst highlighting areas of opportunity for further exploration ( Trist, 1981 ; Mutanga et al., 2016 ). It aims to enhance resource-use efficiency (resource-use getting more from less) and political cohesion by reducing resource trade-offs and increasing synergies. The nexus concept needs to be interdisciplinary and transdisciplinary, accepting a plurality of views ( Geels, 2004 ). It is also participatory, requiring stakeholders to engage with researchers in jointly deriving potential solutions. Given the above dimensions, resource-use remains clear that no single definition can be used to define nexus and its applications, it remains an evolving concept. What is clear though is that it forms the basis within which the WEF nexus is defined and understood.

3 The water-energy-food-health (WEF-H) nexus approach

The Water-Energy-Food-Health (WEF-H) Nexus is a complex concept with no single agreed-upon definition or framework. It is often used to describe the interconnectedness of these four sectors, and how challenges in one sector can have cascading impacts on the others ( Rasul and Sharma, 2016 ). The number of sectors included in the Nexus can vary, depending on the discipline or perspective and can sometimes add additional lenses such as livelihoods, ecosystems, and climate change ( Keskinen et al., 2016 ). For example, those in the water sector may refer to the Nexus as WEF, while those in the energy sector may refer to it as EWF. The agriculture sector may define it as FEW, and the health sector may add the ‘H’ ( Nhamo et al., 2020 ). This lack of common understanding can make it difficult to collaborate and develop effective policies and solutions.

Despite the lack of consensus on a definition, the WEF-H Nexus is a useful concept for understanding the complex challenges facing our world. It can be used as an analytical tool, a conceptual framework, or a discourse ( Keskinen et al., 2016 ). Instead of passively acknowledging the existence of the WEF-H nexus, this paper argues that it is a critical driver of resilience in both our economy and society. Recognizing its interconnectedness demands proactive measures – not just awareness, but concrete policies and actions. By effectively managing this complex system, we can harness its synergies and mitigate challenges, ensuring the WEF-H nexus becomes a potent force for resilience in the face of interconnected water, energy, food, and health concerns.

Nexus studies equip us with the knowledge and tools to tackle complex challenges head-on. By delving into resource efficiency, institutional dynamics, and policy integration, they provide a roadmap for action through methods like integrated models and stakeholder engagement. The WEF-H nexus is not just a concept; it's a powerful framework for shaping a sustainable future.

For example, it enables consideration of ways to:

i. Address energy security without impacting further on food or water resources.

ii. Improve water security without increasing the energy burden of water management.

iii. Create a more circular system by integrating food production with water and energy utilization. Wastewater can be treated and reused for irrigation, renewable energy can power agricultural processes, and food waste can be converted into biofuels or compost.

iv. Encourage sustainable food production practices that prioritize nutrient-rich crops and diversified diets which can contribute to improved public health and reduced malnutrition.

v. Create new green jobs in renewable energy, resource recovery, and precision agriculture, thereby meeting job creation ambitions in a sluggish agricultural economy without overextending water and energy resources.

The four most important interfaces in the water-energy-food-health (WEF-H) nexus are:

• Water which plays a vital role in both food and energy production, and for sustaining the ecosystems that support agriculture and other economic activities that are critical for food security.

• Energy, which is required for food production (especially irrigation) and for water supply, including the extraction, purification, and distribution of water.

• The role of food production as a consumer of land, energy, and water as well as their interlinkage with health.

• Health which is an intrinsic component of the WEF-H nexus, as the wellbeing of individuals is intricately linked to the quality and availability of water, the energy required for sustenance, and the nutritional aspects of food production. Recognition of the interconnections between addressing the challenges and opportunities within this interconnected system.

Agriculture, which is responsible for growing food, is a major user of water (more than 70% of all water use globally) and energy ( Rasul and Sharma, 2016 ). Agriculture and food production also affect the water sector through land degradation, changes in runoff, and disruption of groundwater discharge (Shinde, 2017). Recognizing the intricate connections within the Water-Energy-Food-Health (WEF-H) nexus is paramount. Health, as a crucial facet of this nexus, is intricately linked to the availability and quality of water, the energy required for sustenance, and the nutritional aspects of food production. A holistic understanding of these interdependencies is essential for comprehensive and sustainable management within the WEF-H nexus.

4 Taxonomy of nexus approaches

According to Bian & Liu, (2021) , there are four globally recognized nexus types:

• Water-energy: This nexus focuses on the interconnectedness of water and energy systems. For example, energy production often requires large amounts of water for cooling, while water distribution and treatment require energy ( Wilson et al., 2021 ).

• Water-food: This nexus focuses on the connections between water resources and agriculture. Agriculture, particularly irrigation, is a major consumer of water resources. Consequently, fluctuations in water availability directly impact food production.

• Water-energy-food: This nexus adopts a holistic approach, bringing together the three core elements of water, energy, and food. It underscores the need for integrated planning and management, recognizing the interconnectedness and interdependence of these essential domains.

• Water-energy and climate: In this context, the nexus signifies the interplay between water, energy, and climate factors. It acknowledges the substantial influence of climate change on water resources, energy production, and food security. For instance, altered precipitation patterns can disrupt water availability, and extreme weather events have the potential to damage energy infrastructure and disrupt food supply chains. The discussion aims to clarify that the nexus represents the combination of these sectors, emphasizing the importance of a comprehensive understanding and strategic planning within the broader WEF-H context.

In recent years, additional nexus types have emerged:

• The Water-energy-food-ecosystems (WEFE) nexus: This nexus recognizes the pivotal role of ecosystems in shaping and sustaining the interconnections among water, energy, and food systems. Ecosystems provide indispensable services, including clean water, pollination, climate regulation, and biodiversity, which underpin the functionality of water, energy, and food systems ( De Roo et al., 2021 ). The WEFE nexus highlights the profound interdependence between ecosystems and the essential sectors of water, energy, and food. It emphasises the need for holistic, integrated resource management approaches that recognize the intrinsic value of ecosystems in sustaining human wellbeing and promoting environmental resilience.

• Nuwayhid and Mohtar, 2022 contends that Water-Energy-Food-Health (WEF-H) nexus is a comprehensive framework that explores the intricate relationships between water resources, energy production, food systems, and public health. Unlike the WEFE which advances ecosystems as a critical physical component this nexus advances the health wellbeing. Equally it recognizes that changes in one domain can have significant impacts on the others though with an inherent interlinkage between physical components and human wellbeing. For instance, water is crucial for human survival and agricultural production, while energy is essential for water treatment and food processing. Similarly, food quality and availability directly affect public health. This approach underscores the need for integrated, sustainable strategies in resource management and policymaking, emphasizing that decisions in one sector can have far-reaching consequences for the others. By embracing the WEF-H nexus, stakeholders can better address complex challenges related to resource scarcity, environmental sustainability, and community wellbeing through collaborative and innovative solutions refer to ( Figure 1 ).

• Another nexus type, the water-energy-food-biodiversity-health (WEFBH) nexus, encompasses the complex interdependencies between water utilization, energy generation, food supply chains, and environmental and public health ( Hirwa et al., 2021 ).

Figure 1 . WEF-H nexus adaptation framework.

The interrelationships between the nexuses are illustrated in Figure 1 . Essentially the framework for WEF-H Nexus not only captures the traditional WEF but encapsulates the health dimension as an equal sectoral lens to the nexus thus providing a holistic dimension. Policy framing is broadened to include issues around “healthy water,” “sustainable energy for health,” and “nutritious food for wellbeing.” Health metrics can be tracked alongside traditional WEF indicators to monitor the Nexus’s impact on health and identify areas needing improvement. Moreover, the nexus adaptation framework recognizes that the nexus is influenced by several exogenous factors including the impact of climate change, the policy sphere, institutional mechanisms as well as the financial mechanisms all of which have an inherent effect on each of the sectors identified in this nexus.

Building on the foundation of previous nexus typologies that excluded health, the Water-Energy-Food-Health (WEF-H) nexus is a powerful tool at the socio-political level. It can alleviate tensions caused by poor coordination among non-state actors and inadequate service provision by the state. The WEF-H nexus also presents a unique opportunity to shift the focus from governance challenges to community empowerment, fostering self-reliance and sustainability. This empowerment includes showcasing alternative livelihood possibilities.

Furthermore, the WEF-H nexus has the potential to bridge the gap created by inequitable partnerships, whether rooted in gender, wealth disparities, racial divides, educational levels, or social statuses which have become pervasive in South African society. The nexus approach can contribute to what we term “societal hope,” instilling a profound belief within communities that they can chart a course away from hopelessness, even in the face of governance inefficiencies and limited access to opportunities. The principles thereof illustrated in Figure 1 include environmental stewardship which advocates for investment in sustaining ecosystems services, social equity, resource use efficiency as well as the integrative perspective. These principles provide a foundation for merging effective pathways for successful implementation of NEXUS.

The adaptability of the Water-Energy-Food-Health (WEF-H) nexus, in contrast to other aspects of the economy, lies in its capacity to cater to communities with varying levels of knowledge and information. Unlike traditional economic frameworks, the WEF-H nexus is inherently versatile, offering a more inclusive approach that accommodates diverse communities. This adaptability stems from its comprehensive consideration of interconnected elements, allowing for nuanced solutions that address the complex and dynamic challenges present in the realms of water, energy, food, and health. By embracing a holistic perspective and fostering collaboration among stakeholders, including academics, civil society organizations, the private sector, government bodies, and international partners, the WEF-H nexus creates a platform that encourages innovation and technological advancements across multiple sectors and scales.

The WEF-H nexus holds the most promise for regions facing significant development gaps or struggling with complex socio-economic issues. It offers a powerful, unified approach to tackling these challenges and unlocking new opportunities. We characterize the opportunity presented by the WEF-H nexus as “extraordinary” due to its unique capacity to simultaneously address multiple facets of development challenges. The extraordinary nature lies in the nexus’s holistic approach, integrating water, energy, food, and health considerations. This all-encompassing strategy allows for comprehensive and interconnected solutions, offering a more effective and sustainable response to the complex socio-economic challenges and developmental hurdles that regions may face. The extraordinary nature of this opportunity is underscored by the potential for transformative and inclusive development outcomes, some of which are illustrated on Figure 1 as sustainable adaptation outcomes.

5 Key characteristics of the water-energy-food-health (WEF-H) nexus approach

The WEF-H nexus approach is inherently accessible and requires no demystification. It is conceptually straightforward and designed to be inclusive, catering to individuals of all backgrounds and levels of expertise. Recognizing that, for the general public, concepts such as the WEF nexus and the WEF-H nexus may benefit from some explanation, we emphasize the fundamental nature of this approach. It relates to some of the most essential human needs: water, energy, food, and health. In this paper, we have identified ten salient characteristics that are recognized by many scholars and in the literature on the WEF-H nexus, aiming to enhance clarity and promote a more inclusive understanding:

a. Multi-sectoral focus : The WEF-H approach unites a diverse range of stakeholders around a common set of goals, providing a platform for intentional and focused interaction. This cross-sectional coordination promotes convergence of perspectives and facilitates collaborative solutions.

b. Interconnectedness : WEF-H nexus broadens the understanding of interlinkages ( Simpson and Jewitt, 2019 ) recognizing the interdependencies ( Leck et al., 2015 ) between sectors i.e., water, food, and energy.

c. Social embeddedness. Beyond the physical/environmental connections of the nexus approach is the ability to recognize the social interactions among actors which may be referred to as social embeddedness interactions ( Srigiri and Dombrowsky, 2022 ). WEF thus considers the political and cognitive factors that are central to policy change within sectors ( Weitz et al., 2017 ).

d. Complexity : The multifaceted nature and interactions between and within different subsystems ( Mutanga et al., 2016 ) create complex dimensions that must be addressed. As a result, there is no one-size-fits-all model to deal with WEF-related issues ( Simpson and Jewitt, 2019 ). Instead, time-bound and place-bound solutions are encouraged.

e. Governance modes : Scholars studying the WEF nexus agree that integrative coordination across sectors, actors and levels of governance is essential, given the interconnected nature of the nexus ( Welsch et al., 2015 ). It is important to note that the WEF-H nexus approach does not seek to replace focus and attention on actions (planning, investments, implementation, etc.) related to related to water, energy, food and health. Rather, it aims to break down the siloed approach to managing these resources and promote coherent and balanced planning and implementation.

f. Holistic Approach : WEF-H nexus is a holistic approach that is consistent with well-established analytical frameworks such as Institutional analysis and development (IAD) framework ( Ostrom, 2010 ) value chain analysis ( Villamayor-Tomas et al., 2015 ), network of adjacent action situations (NAAS) ( Srigiri and Dombrowsky, 2022 ), multi-criteria decision-making models (MCDM) ( Kumar et al., 2017 ), Integrative Model ( Nhamo et al., 2020 ), as well as systems dynamics models ( Wen et al., 2022 ). All these tools share a common structure for solving complex decision and planning problems, but their application and impact vary across sectors.

g. Implementation : WEF-H nexus implementation is not an event, rather, it is a process that requires access to information about on-going plans and activities to ensure building-on and complementing those activities.

6 Barriers/bottlenecks for implementing nexus

The WEF-H is anchored in prioritizing the management of the four interconnected resources (water, energy, food, and health) in a sustainable way. However, implementing this nexus comes with different barriers and bottlenecks that hinder progress (detailed below and in Table 1 ).

Table 1 . Identified bottlenecks drawn from literature and recommendations for implementing WEF-H Nexus.

South Africa currently lacks a singular policy document that explicitly addresses the Water-Energy-Food-Health (WEF-H) nexus. This does not necessarily imply a lack of commitment but reflects the intricate task of navigating trade-offs and resource constraints. This, position reflects the broader global context where numerous nations are yet to formulate comprehensive policies on the WEF-H nexus. In many instances, the implementation of WEF-H activities remains imbalanced, with sectors such as water, energy, food, and health often managed in a sectoral or “silo” approach ( Nhamo et al., 2018 ). Despite the acknowledgment of the WEF-H nexus approach, these sectors frequently treat resources independently, guided by institutional structures ( Adom et al., 2022 ). The reluctance to enforce integrative policies is a complex challenge influenced by trade-offs embedded across sectors, particularly in resource-limited countries. South Africa, being a water-scarce nation, has ambitious plans to transition from coal-based to renewable energy, including hydropower ( Pegels, 2010 ; Ololade et al., 2017 ). This puts pressure on the water sector which has to prioritise maintaining the supply of its limited water resource to water provision, energy generation and agricultural production (the latter has a very high-water consumption factor of 62% due to irrigation ( Adom et al., 2022 ).

The reluctance to enforce integrative policies, driven by trade-offs across sectors in resource-limited countries like South Africa, poses significant challenges. As a water-scarce nation with ambitious plans for transitioning to renewable energy, the pressure on the water sector is pronounced ( Rasul and Sharma, 2016 ).

Global climate change, and climate variability exacerbates the challenges of WEF-nexus in South Africa. Increasing aridity has a direct knock-on effect on food security ( Schreiner and Baleta, 2015 ; Mabhaudhi et al., 2016 ), leading to hunger and a decline in the supply of nutritious food ( Wlokas, 2008 ). Extreme weather events such as floods and heat waves also cause health issues such as food and waterborne diseases and heat stroke ( Mabhaudhi et al., 2019 ) and exacerbates land degradation, especially of agricultural lands ( Wlokas, 2008 ).

Water and land are key natural resources that are already under pressure from competing interests. Climate change exacerbates these challenges, as it increases the demand for resources. In regions where land and water are limited, an upsurge in multi-service projects aiming to tackle food insecurity and promote clean energy could exacerbate competition for these vital resources.

The lack of dedicated funding to provide integrated solutions is another reason why the sectoral approach persists, as the implementation of the nexus requires significant investment. The current funding landscape in South Africa prioritizes individual WEF sectors, with cross-sectoral funding streams being scarce ( Mabhaudhi et al., 2018 ). This siloed approach creates several challenges among which includes:

• Competing priorities: Crises like the COVID-19 pandemic necessitate diverting limited resources to immediate needs like health and hunger alleviation ( Wlokas, 2008 ; Mabhaudhi et al., 2019 ). This can exacerbate other critical issues like energy insecurity and poverty, further hindering progress on the WEF-H nexus.

• Limited impact: Sector-specific funding often fails to account for the interconnected nature of the WEF-H nexus, hindering the development of holistic solutions that address multiple challenges simultaneously.

The implementation of the WEF-H nexus requires innovative technologies and robust data, yet South Africa faces significant limitations:

• Data scarcity and comparability: Data availability is limited, and existing data often suffers from inconsistencies in spatial scales and temporal trends, hindering effective analysis and planning.

• Technological lag: Access to and expertise in innovative technologies like smart agriculture and early warning systems is limited, impeding the development of solutions to address challenges like climate change and disease outbreaks.

• Amid unpredictable extreme weather events and the prevalence of diseases, there is also a lack of innovative technologies tailored to alleviate the resultant impacts imposed by these events. Even though they come at a hefty cost, technologies such as smart agriculture (to alleviate a 15% decline in agricultural yields by 2050 if global warming increased by 2°C ( Mabhaudhi et al., 2019 )), early warming or detection systems and cutting edge health facilities are a necessity for an integrated response. Another bottleneck in this is that these innovative and sophisticated technologies require, trained personnel to operate them, which is still a scarce skill in the country.

Lack of functional, effective, efficient, and equitable partnerships or collaborations to drive implementation is another barrier. The implementation of the WEF-H nexus requires partnerships as individual experts rarely have expertise across all its dimensions. All this comes with effective communication across all relevant stakeholders including communities, technicians and government officials to promote dialogue among partners towards balancing the decision-making process. At the moment there is ambiguity regarding the roles of communities and relevant stakeholders in the implementation of the nexus framework (D. Naidoo et al., 2021 ). Some of the stakeholders are also in need of capacity development and awareness which hinders collaboration and results in a lack of stakeholder involvement in the nexus framework ( Adom et al., 2022 ). For instance, about 73% of the participants in an interview study agreed that there are major gaps within stakeholder engagement in the nexus ( Adom et al., 2022 ).

The WEF-H nexus faces the challenge of navigating complex political and socio-cultural landscapes, where historical biases towards isolated sectors hinder balanced implementation. Achieving consensus across spheres and sectors requires addressing these challenges and fostering equitable development.

By design, the implementation of the WEF-H programme ideally requires a long period of time. It is possible that while implementing the WEF-H programme, the breadth and coverage of activities of WEF-H approach lend themselves to unintended delays that derail achievement of outcomes and impact. Pressured by the short terms in government, politicians and decision-makers may face pressure to show immediate results to meet political or economic agendas. This can lead to biased prioritization of short-term goals at the expense of the more comprehensive long-term goals of the nexus. Developing and revising policies to effectively enforce the WEF-H nexus demands meticulous consideration of numerous factors, inherently leading to a time-intensive process.

Getting the private sector to actively contribute to the implementation of the WEF-H nexus is another bottleneck. The focus of the private sector is profit. ‘What is in it for us’ has been the dominant and acceptable main focus of the private sector. The private sector is risk averse. Waiting for, encouraging, or coercing the government to absorb the inherent transactional risks has been one of the approaches that the private has used to minimize their exposure and ensure their profitability and sustainability. Despite these basic attributes of the private sector, it is evident that most sections of the private sector are looking for opportunities where they can make a positive societal impact. The WEF-H nexus provides such an opportunity. This leaves us with the question: Why has the private sector not seized the opportunities to implement the WEF-H nexus, especially in communities wherein they operate? Is it likely that there are actions inherent in the implementation of the WEF-H nexus that are laden with risks that the private sector is not willing to absorb?

7 Enablers for implementing the WEF-H nexus

Several ingredients for transitioning from “nexus thinking” to “nexus doing” are required for a successful implementation of the WEF-H nexus. This approach holds immense potential to provide lucrative opportunities for South Africa. This paper adapts the scaling framework and classify the nexus under a three-pronged scaling principles system consisting of (i) scaling up, (ii) scaling deep, and (iii) scaling out as illustrated in Figure 2 . Scaling up focusses on enabling factors that are policy and institutionally oriented, while scaling deep focus on culture and beliefs and scaling out centers on factors impacting greater numbers, the replication and dissemination of information on the WEF-H nexus. This results in an increased number of people or communities impacted. Lastly, scaling deep looks at enabling factors impacting on the cultural roots including aspects such as changing relationships, culture, and beliefs.

Figure 2 . Nexus enabling principles.

For this procedural and transformative transition to happen, several enabling factors have been identified in the literature which foster the adoption and implementation of the WEF-H nexus. The first factor identified is the investment in Capacity Development. To unlock the full potential of the WEF-H nexus, robust capacity development initiatives are required across stakeholders, encompassing government agencies, researchers, and local communities ( Chibarabada et al., 2022 ). These initiatives should encompass comprehensive training programs and knowledge-sharing platforms aimed at enhancing the understanding of nexus interlinkages. By equipping stakeholders with the necessary skills and insights, we empower them to make informed decisions that align with the holistic goals of the WEF-H nexus, thus catalyzing its effectiveness ( Ramos et al., 2022 ). Local communities can also benefit from educational programs on sustainable water and energy practices, alongside leadership development workshops to empower them to participate in decision-making processes.

Secondly, mobilization of finance is also an imperative factor when it comes to the WEF-H nexus implementation. Securing finances is pivotal to translating the WEF-H nexus from theory into impactful practice, regardless of the chosen institutional approach ( Hejnowicz et al., 2022 ). Southern Africa has witnessed a surge in research projects and publications concerning the nexus since 2013 ( Naidoo et al., 2021 ). For instance, the Southern African Development Community-European Union (SADC-EU) nexus dialogue-funded project has been instrumental in driving the WEF nexus from abstract research to tangible action across southern Africa. This initiative has led to the organization of numerous workshops, symposia, and science-policy dialogues within the region. Such financial commitments not only facilitate research and data generation but also provide the necessary resources for practical interventions and policy implementations that promote the sustainable integration of water, energy, food, and health systems.

Decision Support Systems and Frameworks are also a necessary ingredient. The development of robust decision support systems and frameworks is paramount in navigating the complex terrain of the WEF-H nexus ( Nhamo et al., 2020 ). These technological tools serve as indispensable guides for systematic analysis of intricate nexus linkages, enabling policymakers to scrutinize diverse scenarios and their potential ramifications on water, energy, food, and health systems. Decision support systems are the linchpin of informed and effective decision-making within the multifaceted landscape of the WEF-H nexus, fostering data-driven, evidence-based solutions that optimize resource allocation, minimize vulnerabilities, and bolster resilience across these interconnected sectors.

Innovative Policy Frameworks have also been identified as one of the enabling factors ( Naidoo et al., 2021 ). The dynamic nature of the WEF-H nexus necessitates adaptive and forward-thinking policy frameworks capable of accommodating its complexity. These policies should transcend sectoral boundaries, encouraging seamless integration and collaboration while emphasizing sustainability and resilience. The shared resources within the SADC region highlight the importance of harmonizing existing policies and linking them, as illustrated by the Revised Regional Indicative Strategic Development Plan. Such initiatives promote holistic resource management, acknowledge the interdependence of different sectors, and pave the way for comprehensive, cross-cutting policies that effectively address the WEF-H nexus’s challenges.

Regional Cooperation is also an important enabling factor that has been identified within the literature ( Decoppet et al., 2023 ) . Recognizing that environmental and resource challenges often transcend national borders, robust regional cooperation is essential. Collaborative efforts between South Africa and neighboring countries can effectively address shared WEF-H nexus issues, enhancing stability and mutual benefits while ensuring harmonized resource management. Given the overarching nature of environmental and resource challenges, regional cooperation may serve as a fundamental pillar in addressing the complexities of the WEF-H nexus. The SADC regional integration framework (Saurombe, 2010) could transcend beyond trade to include developmental trajectories that have a bearing on WEF-H nexus. South Africa’s geographical proximity to neighboring countries accentuates the necessity for collaborative endeavors. By forging strategic partnerships and alliances with neighboring nations, South Africa and other member states can collectively tackle shared WEF-H nexus challenges that transcend political borders. Such collaborative efforts foster stability, mutual benefit, and regional cohesion. Whether it is addressing transboundary water management, cross-border energy initiatives, harmonizing agricultural practices, or jointly responding to health crises, regional cooperation can yield synergistic solutions that are more effective and sustainable than isolated efforts within national boundaries. Additionally, regional cooperation can lead to enhanced resilience in the face of resource-related uncertainties and bolster collective capacity for responding to emerging WEF-H nexus issues.

Political will is another important enabling factor that fosters the adoption and implementation of the WEF-H nexus. A bedrock of strong political will is fundamental to prioritize the WEF-H nexus and commit to sustainable resource management and public health. Such commitment provides the foundation for integrated policies and action plans that genuinely address the nexus’s intricate challenges. A robust and unwavering political will stands as the cornerstone of meaningful progress within the WEF-H nexus. National leaders hold the key to prioritizing this integrated approach, committing to sustainable resource management, and safeguarding public health. Their dedication paves the way for the development and implementation of comprehensive policies and action plans that genuinely confront the intricate challenges posed by the nexus. It sends a resounding message that these issues are of paramount importance, transcending political cycles and short-term interests, and underscoring a commitment to the long-term wellbeing of both the environment and the populace.

Another necessary ingredient noted in the literature is the clear demarcation of WEF-H operational boundaries: Defining distinct operational boundaries for WEF-H initiatives is crucial as it ensures that roles, responsibilities, and accountabilities are well-understood, preventing overlaps or gaps in resource management, and fostering efficient and effective governance. This not only prevents wasteful overlaps and dangerous gaps in resource management but also fosters efficient and effective governance. By delineating the boundaries of action and influence, stakeholders can coordinate their efforts more effectively, resulting in streamlined operations and more impactful outcomes.

360-Degree stakeholder engagement that leaves no one behind is also another important enabling factor. This underscores the principle of inclusivity’s paramount importance is recognized. Engaging all stakeholders, including marginalized communities, is essential for equitable resource allocation and access ( Bruns et al., 2022 ; Hejnowicz et al., 2022 ). Such comprehensive engagement ensures that diverse perspectives and needs are considered. Engaging all stakeholders, without exception, is not only a moral imperative but also a strategic necessity. This comprehensive involvement ensures that the benefits and burdens of resource management are equitably distributed. Marginalized communities, often disproportionately affected by environmental and health challenges, must have their voices heard and their needs addressed. Inclusivity makes the WEF-H nexus genuinely holistic, drawing on a wealth of perspectives and insights to inform more equitable and effective policies and actions. To operationalize this approach, we propose several pathways for engaging all relevant stakeholders in the WEF-H nexus. Firstly, the establishment of inclusive platforms, such as community forums and online portals, can facilitate ongoing communication and collaboration. Secondly, targeted outreach and awareness campaigns can ensure that marginalized communities are actively involved. Thirdly, leveraging technology, such as mobile applications and social media, can enhance accessibility and engagement. Additionally, incorporating participatory approaches, like co-design sessions and citizen science initiatives, fosters a sense of ownership among stakeholders.

Unlocking the full potential of the WEF-H Nexus, demands breaking down siloed governance. Effective collaboration among government departments, private sector entities, civil society organizations, and academia creates a fertile ground for innovation which enables the sharing of knowledge, identify synergies, and address challenges holistically ( Lazaro et al., 2022 ). Imagine a fertile ecosystem where engineers, farmers, policymakers, and community leaders, all contribute to cross-pollination of ideas. This is the power of a multidisciplinary approach to the WEF-H nexus, where collaboration sparks innovation and ensures no facet is overlooked. From policy blueprints to grassroots implementation, every strand contributes to a more comprehensive and impactful solution, ultimately leading to more sustainable and equitable outcomes for food, water, energy, and health.

Establishment of open access databases and encouraging data sharing can also positively impact on the adoption and the implementation of the WEF-H nexus. Data transparency and sharing are cornerstones of the WEF-H nexus approach. Open access databases facilitate the exchange of information, supporting evidence-based decision-making and research that can drive sustainable resource management and public health improvements ( Mabhaudhi et al., 2021 ). Open access databases facilitate the seamless exchange of information among stakeholders, underpinning evidence-based decision-making, and research. With access to comprehensive and up-to-date data, policymakers and researchers can identify trends, track progress, and make informed choices that drive sustainable resource management and improvements in public health.

Innovative Technology is another enabling factor positively impacting on the adoption and implementation of the WEF-H nexus. Examples of these cutting-edge technologies include, but are not limited to, precision agriculture techniques that optimize water use, the integration of renewable energy sources to power nexus-related activities, and advanced health monitoring systems. Embracing cutting-edge technology within the WEF-H nexus enhances monitoring, data collection, and resource management. This includes the adoption of technologies that promote efficient water use, harness renewable energy sources, advance sustainable agriculture practices, and facilitate health monitoring, thereby driving innovation and progress across the nexus. Embracing cutting-edge technology is a catalyst for progress across the WEF-H nexus. By harnessing innovative solutions, stakeholders can drive meaningful change. Technology enhances monitoring, data collection, and resource management, leading to more efficient and sustainable practices that benefit both the environment and public health. It also fosters a culture of innovation, inspiring continuous progress within the nexus.

8 Conclusion

The exploration of water-energy-food-health (WEF-H) remains key in broadening our understanding of the nexus complexity. This article contributes to the body of knowledge which reveals a paradigm-shifting approach to addressing the intricate interdependencies among these critical sectors. Integration of the health dimension goes beyond conventional WEF frameworks, as it introduces a comprehensive understanding of human wellbeing and resilience. The study contribute to the ongoing discourse surrounding the WEF nexus demonstrating the advantages of linking the health sector. By synthesizing insights from various disciplines, our work advances the understanding of how health interplays with water, energy, and food dynamics. This contribution positions the WEF-H nexus as an innovative solution to complex global challenges. To realize its full potential, there is a need for dedicated champions who can not only navigate the enablers and barriers outlined in this study but also translate concepts into actionable plans and sustainable programs. The success of the WEF-H nexus requires collaborative efforts from governments, stakeholders, and communities, providing a unique and impactful framework for addressing the multifaceted challenges at the intersection of water, energy, food, and health. South Africa, like many nations, aspires to build capable governance, but the complexity of the WEF-H nexus approach may strain government resources. The nexus approach acknowledges the existence of various policies, plans, systems, and programs, but also recognizes that their impact can be amplified when integrated into a cohesive implementation framework from the outset. This should not discourage governments to invest resources in the nexus approach but highlights the inherent challenges in aligning governance structures with its holistic nature.

While the Water-Energy-Food-Health (WEF-H) nexus presents a promising solution to urgent global challenges, its successful implementation necessitates meticulous planning, dedicated champions, and strategic governance. Recognizing the need for a nuanced approach, our paper emphasizes the imperative of capacity development, cross-sectoral collaboration, and the formulation of integrated governance frameworks. These elements are not merely suggested but they could be integral components that address the complexities involved. By strategically integrating these aspects into the implementation process, we ensure that the WEF-H nexus may be closer to reaching its full potential without imposing undue burdens on existing systems. Throughout the paper, we have enhanced the discussion, providing earlier argumentation to articulate the critical role of capacity development and integrated governance, thereby reinforcing the foundation for our proposed strategies.

In conclusion the WEF-H nexus presents an extraordinary opportunity to break the mold of traditional development paradigms. Its unprecedented focus on interconnectedness allows us to address multifaceted challenges from water scarcity, energy and food security to health disparities in a truly comprehensive manner. This holistic approach promises not just incremental progress, but a paradigm shift towards sustainable and equitable development.

Author contributions

SSM: Conceptualization, Writing–original draft, Writing–review and editing, Funding acquisition, Investigation, Project administration. BKM: Writing–review and editing, Funding acquisition, Project administration, Supervision. SM: Writing–review and editing. MSM: Writing–review and editing. FVS: Writing–review and editing. TL: Writing–review and editing. SN: Writing–review and editing. TT: Writing–review and editing. JJ: Writing–review and editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. The author(s) acknowledge that the financial support for the research, authorship and publication of this article was received from the Department of Science and Innovation (DSI) through a CSIR Parliamentary Grant (P1EGC02).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

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Keywords: WEF-H nexus, South Africa, enablers, barriers, policy alignment, sustainability

Citation: Mutanga SS, Mantlana BK, Mudavanhu S, Muthige MS, Skhosana FV, Lumsden T, Naidoo S, Thambiran T and John J (2024) Implementation of water energy food-health nexus in a climate constrained world: a review for South Africa. Front. Environ. Sci. 12:1307972. doi: 10.3389/fenvs.2024.1307972

Received: 06 October 2023; Accepted: 14 March 2024; Published: 25 March 2024.

Reviewed by:

Copyright © 2024 Mutanga, Mantlana, Mudavanhu, Muthige, Skhosana, Lumsden, Naidoo, Thambiran and John. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Shingirirai S. Mutanga, [email protected]

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Victim feedback: a literature review report by the cps social research team, executive summary.

To ensure that any potential future victim feedback developments within the CPS are built on an appropriate evidence base, this literature review aims to: develop a broad understanding of what feedback mechanisms are currently available to victims across the CJS; determine good practice by examining appropriate comparator agencies; and assess the extant literature on engaging with seldom heard groups.

The review found that whilst surveys appeared to be the most popular method of data collection, both at a national and local level, qualitative methods were also common, and most organisations used more than one approach to gather information on service user experience. Complex organisations comprising of several smaller divisions and/or localities also appear to manage the challenge of designing and delivering national feedback mechanisms by using one of four broad approaches: a top-down approach where the organisation designs and manages a centralised service user feedback mechanism; a semi devolved approach where a national feedback mechanism is designed centrally but managed locally; a fully devolved approach where individual localities are encouraged to create and manage their own mechanism; and, finally, a blended approach, where the organisation has a number of separate feedback mechanisms and uses a combination of the above in their delivery.

Although there are already a sizable number of victim-specific feedback mechanisms within the UK, both at a national and local level, the evidence suggests that some victim groups may not be well-accounted for by current practices. For example, the experiences of children, those with mental health problems, and those that are victims of some crimes against the person (such as domestic violence), may be missing or under-represented due to additional safeguarding concerns or access and inclusion barriers. Whilst the evidence suggests that strategies for engaging seldom heard groups should be developed according to the distinct circumstances and characteristics of each group, three common themes emerged when examining best practice regardless of the group’s particular characteristics and could perhaps be considered core engagement tenets. These were: building trust, using appropriate and accessible communication, and having a flexible approach.

The full report (PDF document, 1mb, 109 pages) is available on request - please email [email protected] .

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