importance of literature review process

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• v.8(3); 2016 Jul

The Literature Review: A Foundation for High-Quality Medical Education Research

a  These are subscription resources. Researchers should check with their librarian to determine their access rights.

Despite a surge in published scholarship in medical education 1 and rapid growth in journals that publish educational research, manuscript acceptance rates continue to fall. 2 Failure to conduct a thorough, accurate, and up-to-date literature review identifying an important problem and placing the study in context is consistently identified as one of the top reasons for rejection. 3 , 4 The purpose of this editorial is to provide a road map and practical recommendations for planning a literature review. By understanding the goals of a literature review and following a few basic processes, authors can enhance both the quality of their educational research and the likelihood of publication in the Journal of Graduate Medical Education ( JGME ) and in other journals.

The Literature Review Defined

In medical education, no organization has articulated a formal definition of a literature review for a research paper; thus, a literature review can take a number of forms. Depending on the type of article, target journal, and specific topic, these forms will vary in methodology, rigor, and depth. Several organizations have published guidelines for conducting an intensive literature search intended for formal systematic reviews, both broadly (eg, PRISMA) 5 and within medical education, 6 and there are excellent commentaries to guide authors of systematic reviews. 7 , 8

• A literature review forms the basis for high-quality medical education research and helps maximize relevance, originality, generalizability, and impact.
• A literature review provides context, informs methodology, maximizes innovation, avoids duplicative research, and ensures that professional standards are met.
• Literature reviews take time, are iterative, and should continue throughout the research process.
• Researchers should maximize the use of human resources (librarians, colleagues), search tools (databases/search engines), and existing literature (related articles).
• Keeping organized is critical.

Such work is outside the scope of this article, which focuses on literature reviews to inform reports of original medical education research. We define such a literature review as a synthetic review and summary of what is known and unknown regarding the topic of a scholarly body of work, including the current work's place within the existing knowledge . While this type of literature review may not require the intensive search processes mandated by systematic reviews, it merits a thoughtful and rigorous approach.

Purpose and Importance of the Literature Review

An understanding of the current literature is critical for all phases of a research study. Lingard 9 recently invoked the “journal-as-conversation” metaphor as a way of understanding how one's research fits into the larger medical education conversation. As she described it: “Imagine yourself joining a conversation at a social event. After you hang about eavesdropping to get the drift of what's being said (the conversational equivalent of the literature review), you join the conversation with a contribution that signals your shared interest in the topic, your knowledge of what's already been said, and your intention.” 9

The literature review helps any researcher “join the conversation” by providing context, informing methodology, identifying innovation, minimizing duplicative research, and ensuring that professional standards are met. Understanding the current literature also promotes scholarship, as proposed by Boyer, 10 by contributing to 5 of the 6 standards by which scholarly work should be evaluated. 11 Specifically, the review helps the researcher (1) articulate clear goals, (2) show evidence of adequate preparation, (3) select appropriate methods, (4) communicate relevant results, and (5) engage in reflective critique.

Failure to conduct a high-quality literature review is associated with several problems identified in the medical education literature, including studies that are repetitive, not grounded in theory, methodologically weak, and fail to expand knowledge beyond a single setting. 12 Indeed, medical education scholars complain that many studies repeat work already published and contribute little new knowledge—a likely cause of which is failure to conduct a proper literature review. 3 , 4

Likewise, studies that lack theoretical grounding or a conceptual framework make study design and interpretation difficult. 13 When theory is used in medical education studies, it is often invoked at a superficial level. As Norman 14 noted, when theory is used appropriately, it helps articulate variables that might be linked together and why, and it allows the researcher to make hypotheses and define a study's context and scope. Ultimately, a proper literature review is a first critical step toward identifying relevant conceptual frameworks.

Another problem is that many medical education studies are methodologically weak. 12 Good research requires trained investigators who can articulate relevant research questions, operationally define variables of interest, and choose the best method for specific research questions. Conducting a proper literature review helps both novice and experienced researchers select rigorous research methodologies.

Finally, many studies in medical education are “one-offs,” that is, single studies undertaken because the opportunity presented itself locally. Such studies frequently are not oriented toward progressive knowledge building and generalization to other settings. A firm grasp of the literature can encourage a programmatic approach to research.

Approaching the Literature Review

Considering these issues, journals have a responsibility to demand from authors a thoughtful synthesis of their study's position within the field, and it is the authors' responsibility to provide such a synthesis, based on a literature review. The aforementioned purposes of the literature review mandate that the review occurs throughout all phases of a study, from conception and design, to implementation and analysis, to manuscript preparation and submission.

Planning the literature review requires understanding of journal requirements, which vary greatly by journal ( table 1 ). Authors are advised to take note of common problems with reporting results of the literature review. Table 2 lists the most common problems that we have encountered as authors, reviewers, and editors.

Sample of Journals' Author Instructions for Literature Reviews Conducted as Part of Original Research Article a

Common Problem Areas for Reporting Literature Reviews in the Context of Scholarly Articles

Locating and Organizing the Literature

Three resources may facilitate identifying relevant literature: human resources, search tools, and related literature. As the process requires time, it is important to begin searching for literature early in the process (ie, the study design phase). Identifying and understanding relevant studies will increase the likelihood of designing a relevant, adaptable, generalizable, and novel study that is based on educational or learning theory and can maximize impact.

Human Resources

A medical librarian can help translate research interests into an effective search strategy, familiarize researchers with available information resources, provide information on organizing information, and introduce strategies for keeping current with emerging research. Often, librarians are also aware of research across their institutions and may be able to connect researchers with similar interests. Reaching out to colleagues for suggestions may help researchers quickly locate resources that would not otherwise be on their radar.

During this process, researchers will likely identify other researchers writing on aspects of their topic. Researchers should consider searching for the publications of these relevant researchers (see table 3 for search strategies). Additionally, institutional websites may include curriculum vitae of such relevant faculty with access to their entire publication record, including difficult to locate publications, such as book chapters, dissertations, and technical reports.

Strategies for Finding Related Researcher Publications in Databases and Search Engines

Search Tools and Related Literature

Researchers will locate the majority of needed information using databases and search engines. Excellent resources are available to guide researchers in the mechanics of literature searches. 15 , 16

Because medical education research draws on a variety of disciplines, researchers should include search tools with coverage beyond medicine (eg, psychology, nursing, education, and anthropology) and that cover several publication types, such as reports, standards, conference abstracts, and book chapters (see the box for several information resources). Many search tools include options for viewing citations of selected articles. Examining cited references provides additional articles for review and a sense of the influence of the selected article on its field.

Box Information Resources

• Web of Science a
• Education Resource Information Center (ERIC)
• Cumulative Index of Nursing & Allied Health (CINAHL) a
• Google Scholar

Once relevant articles are located, it is useful to mine those articles for additional citations. One strategy is to examine references of key articles, especially review articles, for relevant citations.

Getting Organized

As the aforementioned resources will likely provide a tremendous amount of information, organization is crucial. Researchers should determine which details are most important to their study (eg, participants, setting, methods, and outcomes) and generate a strategy for keeping those details organized and accessible. Increasingly, researchers utilize digital tools, such as Evernote, to capture such information, which enables accessibility across digital workspaces and search capabilities. Use of citation managers can also be helpful as they store citations and, in some cases, can generate bibliographies ( table 4 ).

Citation Managers

Knowing When to Say When

Researchers often ask how to know when they have located enough citations. Unfortunately, there is no magic or ideal number of citations to collect. One strategy for checking coverage of the literature is to inspect references of relevant articles. As researchers review references they will start noticing a repetition of the same articles with few new articles appearing. This can indicate that the researcher has covered the literature base on a particular topic.

Putting It All Together

In preparing to write a research paper, it is important to consider which citations to include and how they will inform the introduction and discussion sections. The “Instructions to Authors” for the targeted journal will often provide guidance on structuring the literature review (or introduction) and the number of total citations permitted for each article category. Reviewing articles of similar type published in the targeted journal can also provide guidance regarding structure and average lengths of the introduction and discussion sections.

When selecting references for the introduction consider those that illustrate core background theoretical and methodological concepts, as well as recent relevant studies. The introduction should be brief and present references not as a laundry list or narrative of available literature, but rather as a synthesized summary to provide context for the current study and to identify the gap in the literature that the study intends to fill. For the discussion, citations should be thoughtfully selected to compare and contrast the present study's findings with the current literature and to indicate how the present study moves the field forward.

To facilitate writing a literature review, journals are increasingly providing helpful features to guide authors. For example, the resources available through JGME include several articles on writing. 17 The journal Perspectives on Medical Education recently launched “The Writer's Craft,” which is intended to help medical educators improve their writing. Additionally, many institutions have writing centers that provide web-based materials on writing a literature review, and some even have writing coaches.

The literature review is a vital part of medical education research and should occur throughout the research process to help researchers design a strong study and effectively communicate study results and importance. To achieve these goals, researchers are advised to plan and execute the literature review carefully. The guidance in this editorial provides considerations and recommendations that may improve the quality of literature reviews.

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.

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

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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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• Steps in Conducting a Literature Review

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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• 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

• 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
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• Last Updated: Sep 21, 2022 2:16 PM
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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

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• Last Updated: Jan 17, 2024 10:05 AM
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A Guide to Literature Reviews

Importance of a good literature review.

• Conducting the Literature Review
• Structure and Writing Style
• Types of Literature Reviews
• Citation Management Software This link opens in a new window
• Acknowledgements

A literature review is not only a summary of key sources, but  has an organizational pattern which combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• Give a new interpretation of old material or combine new with old interpretations,
• Trace the intellectual progression of the field, including major debates,
• Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
• Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

The purpose of a literature review is to:

• Place each work in the context of its contribution to understanding the research problem being studied.
• Describe the relationship of each work to the others under consideration.
• Identify new ways to interpret prior research.
• Reveal any gaps that exist in the literature.
• Resolve conflicts amongst seemingly contradictory previous studies.
• Identify areas of prior scholarship to prevent duplication of effort.
• Point the way in fulfilling a need for additional research.
• Locate your own research within the context of existing literature [very important].
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• Research Process

Literature Review in Research Writing

• 4 minute read
• 421.9K views

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 .

Language Editing Services by Elsevier Author Services:

What is a Research Gap

• Manuscript Preparation

Types of Scientific Articles

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Writing a good review article

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Research Process :: Step by Step

• Introduction
• Select Topic
• Identify Keywords
• Background Information
• Develop Research Questions
• Refine Topic
• Search Strategy
• Popular Databases
• Evaluate Sources
• Types of Periodicals
• Reading Scholarly Articles
• Primary & Secondary Sources
• Organize / Take Notes
• Writing & Grammar Resources
• Annotated Bibliography
• Literature Review
• Citation Styles
• Paraphrasing
• Privacy / Confidentiality
• Research Process
• Selecting Your Topic
• Identifying Keywords
• Gathering Background Info
• Evaluating Sources

Organize the literature review into sections that present themes or identify trends, including relevant theory. You are not trying to list all the material published, but to synthesize and evaluate it according to the guiding concept of your thesis or research question.  

What is a literature review?

A literature review is an account of what has been published on a topic by accredited scholars and researchers. Occasionally you will be asked to write one as a separate assignment, but more often it is part of the introduction to an essay, research report, or thesis. 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

A literature review must do these things:

• be organized around and related directly to the thesis or research question you are developing
• synthesize results into a summary of what is and is not known
• identify areas of controversy in the literature
• formulate questions that need further research

Ask yourself questions like these:

• What is the specific thesis, problem, or research question that my literature review helps to define?
• What type of literature review am I conducting? Am I looking at issues of theory? methodology? policy? quantitative research (e.g. on the effectiveness of a new procedure)? qualitative research (e.g., studies of loneliness among migrant workers)?
• What is the scope of my literature review? What types of publications am I using (e.g., journals, books, government documents, popular media)? What discipline am I working in (e.g., nursing psychology, sociology, medicine)?
• How good was my information seeking? Has my search been wide enough to ensure I've found all the relevant material? Has it been narrow enough to exclude irrelevant material? Is the number of sources I've used appropriate for the length of my paper?
• Have I critically analyzed the literature I use? Do I follow through a set of concepts and questions, comparing items to each other in the ways they deal with them? Instead of just listing and summarizing items, do I assess them, discussing strengths and weaknesses?
• Have I cited and discussed studies contrary to my perspective?
• Will the reader find my literature review relevant, appropriate, and useful?

Ask yourself questions like these about each book or article you include:

• Has the author formulated a problem/issue?
• Is it clearly defined? Is its significance (scope, severity, relevance) clearly established?
• Could the problem have been approached more effectively from another perspective?
• What is the author's research orientation (e.g., interpretive, critical science, combination)?
• What is the author's theoretical framework (e.g., psychological, developmental, feminist)?
• What is the relationship between the theoretical and research perspectives?
• Has the author evaluated the literature relevant to the problem/issue? Does the author include literature taking positions she or he does not agree with?
• In a research study, how good are the basic components of the study design (e.g., population, intervention, outcome)? How accurate and valid are the measurements? Is the analysis of the data accurate and relevant to the research question? Are the conclusions validly based upon the data and analysis?
• In material written for a popular readership, does the author use appeals to emotion, one-sided examples, or rhetorically-charged language and tone? Is there an objective basis to the reasoning, or is the author merely "proving" what he or she already believes?
• How does the author structure the argument? Can you "deconstruct" the flow of the argument to see whether or where it breaks down logically (e.g., in establishing cause-effect relationships)?
• In what ways does this book or article contribute to our understanding of the problem under study, and in what ways is it useful for practice? What are the strengths and limitations?
• How does this book or article relate to the specific thesis or question I am developing?

Text written by Dena Taylor, Health Sciences Writing Centre, University of Toronto

http://www.writing.utoronto.ca/advice/specific-types-of-writing/literature-review

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The Importance of Literature Reviews in Dissertations

1. Introduction to Literature Reviews in Dissertations

A literature review is a fundamental component of a dissertation. It enables the researcher to survey existing research related to their chosen topic and outline the principles of that particular field from which further investigation can be based. Literature reviews should include an analysis, synthesis, summarization and interpretation of current knowledge on the subject being studied.

• Analysis : A critical appraisal or examination of another scholar’s work in order to evaluate its relevance for your own study needs.
• Synthesis : Combining multiple viewpoints into one cohesive narrative while considering what may be missing from the various sources.

The purpose of analyzing the relevant literature is twofold: firstly, it allows you to create your own original argument by understanding how previous researchers have contributed to this specific area; secondly, it helps you identify any shortcomings or gaps in existing studies – areas where new knowledge could potentially be created through further research. As such, writing a thorough and accurate literature review is essential for producing good quality dissertations.

2. Examining the Significance of Literature Reviews

Exploring the Purpose of Literature Reviews A literature review is an analysis and evaluation of existing research findings on a topic. It serves several purposes in research-oriented writing, including providing context for related work, summarizing prior studies to form a basis for new research and synthesizing results from multiple sources into one unified interpretation. Writing a thorough and comprehensive literature review takes effort but ultimately aids researchers in deepening their understanding of the subject matter.

Organizing Existing Knowledge: The main purpose of conducting a literature review is to bring order out chaos within already existing knowledge or information on the chosen topic. By doing this task methodically and conscientiously, it becomes easier to spot areas that need more attention or where further investigation might be necessary while also avoiding errors by not overlooking important works all too common when performing ad hoc searches. Additionally, since most reviews focus on synthesis rather than quantitative aggregation across numerous detailed reports, they provide insight into trends over time as well as what future directions should entail such as upcoming technologies and changes in best practices.

• Researched information must be effectively organized.
• “Gaps” can easily be identified.

3. Benefits and Challenges of Conducting a Literature Review

The literature review process has multiple advantages and challenges in the research realm. This section provides a reflection on some of those benefits and issues.

• Develops an overview of current scholarly knowledge; identifies relationships among different fields and topics, potential gaps in knowledge, emerging trends or controversies.

4. Best Practices for Formulating an Effective Literary Review Structure

When formulating an effective literary review structure, it is important to have a clear plan in mind. First and foremost, summarise the key texts that you will be engaging with; this serves as a starting point for writing your review. It is helpful to adhere to certain best practices when establishing a structured approach.

• Focus on relevant works: Narrow down the list of literature by selecting those materials directly related to your study’s research questions or objectives.
• Develop distinct sections: Divide up different strands of inquiry into separate subsections so that each discussion may stand alone in its own right without losing coherence within the broader argument.
• Be critical in assessments: Evaluate strengths and weaknesses from both primary sources as well as past studies which seek out ways they can inform additional scholarship going forward.

5. Strategies for Locating Relevant Sources for Your Literary Review

Identifying Relevant Sources

The first step of conducting an effective literature review is to identify sources that are highly relevant to the research topic. This can be done through a variety of strategies, such as:

• Exploring bibliographies provided in existing articles.
• Researching potential authors and their research topics via databases or search engines.

These two methods can often lead you to further related studies and additional authors who have conducted work on the same topic. For example, exploring a study’s reference page may direct you to similar works written by different authors which provide complementary information.

Verifying Source Reliability

Once some sources have been identified for use, another important step is verifying whether these are reliable sources for your particular project. It is essential when researching academic fields that all materials used have undergone rigorous peer-review processes and meet certain academic standards; this helps maintain trustworthiness in all areas of academia. In addition, it’s also important to consider how current any source material might be – timeliness matters depending on the field being researched! Some considerations while evaluating reliability include asking questions such as:

6. Acknowledging Sources within your literary review

When writing a literature review, it is important to remember and give due credit to all sources that you have used in the compilation of your work. It is especially crucial when you are citing published material by other authors as these documents are protected under copyright law. Therefore, one must be sure to include proper acknowledgement of every source utilized.

• Inclusion of accurate referencing not only protects against infringement but also adds credibility and authority to your review.
• Be mindful that some publications may require specific formatting for citations; therefore familiarize yourself with them before beginning the project or refer back if any doubt arises

The use of Citations:

A citation provides information regarding the source so readers can easily identify it within their library collection or online database search results. To cite a particular author’s publication accurately , follow this correct format : Name ( date) , title , place where it was published . For instance : Smith (1984), “A Study on Literary Themes,” New York: Penguin Books

7. Concluding Remarks on the Importance of Completing a Thorough Literature Review

In conclusion, completing a thorough literature review is of paramount importance to any research endeavor. The primary aim of this type of review is to assess the existing studies related to the topic in order gain an understanding and identify knowledge gaps. As such, it provides new researchers with valuable insights including:

• Contextual information on how current theories are built.
• A better understanding of key terms and concepts.
• An assessment for potential methodological approaches.

What is Literature Review? Importance, Functions, Process,

• Post last modified: 13 August 2023
• Reading time: 12 mins read
• Post category: Research Methodology

What is Literature Review?

A literature review is a critical and comprehensive analysis of existing research, studies, articles, books, and other relevant sources on a specific topic or subject. It serves as a foundational step in the research process, helping researchers understand the current state of knowledge, identify gaps in the literature, and establish a context for their own study.

Table of Content

• 1 What is Literature Review?
• 2 Importance of a Literature Review
• 3 Functions of a Literature Review
• 4.1 Search the Existing Literature in Your Field of Interest
• 4.2 Review the Literature Obtained
• 4.3 Develop a Theoretical Framework
• 4.4 Write the Literature Review
• 5 How to Write a Literature Review
• 6 Types of Sources for Review

In most research reports or research papers, you will see that literature review is an essential element and it forms the basis for advancing knowledge, facilitates theory development, discovers new research areas and closes old ones. When researchers want to understand the management dilemma, they study various books, articles and all other available sources.

In the research reports, the researchers present a summary of their search, study and evaluation of the literature that is already available related to the research topic. When the researcher presents a summary of their study of present literature in addition to their analysis of how this literature is related to or essential for the current research report; then, this process is known as literature review.

For example, in a research paper titled ‘Attrition Analysis in a Leading Sales Organisation in India’, authored by Mamta Mohapatra (International Management Institute, New Delhi, India), Amisha Gupta (Birlasoft, New Delhi, India) and Nikita Lamba (Genpact, New Delhi, India), literature review is presented as follows:

Organisations and researchers usually conduct literature review in order to establish how their own research fits within the context of existing literature.

Apart from these, some other objectives of carrying out literature review are:

• Develop an understanding of how each source of literature helps in understanding the research problem
• Examine the interrelationships among different variables
• Find out ways to interpret earlier similar researches on the topic under study
• Rectify the conflicts that exist among previously conducted studies
• Get an idea regarding the required sample size
• Get an estimate of how much variance is there in the variables of interest
• Understand the type of relationship that exists among variables
• Determine the research method that can be used in the research

Importance of a Literature Review

There are various reasons for carrying out literature review. Majorly, literature review helps in:

• Assessing the current state and level of research on a given topic
• Identifying experts related to particular research
• Identifying questions that need further research and exploration
• Identifying what methodologies have been used in the related past studies and what methodology should be used in current research
• Justifying a proposed research methodology
• Indicating the originality and relevance of the given research problem
• Demonstrating the preparedness of a researcher to complete the research

Functions of a Literature Review

Some of the major functions of literature review are:

• Establishing a context for the research
• Demonstrating that the researcher has actually read related literature extensively and is aware of most theory and methodology related to the given research topic
• Providing a shape for the research under consideration
• Establishing a connection between what the researcher is proposing and what he has already read
• Demonstrating how the findings of researcher can be integrated with the already existing research findings.
• Revealing the differences or areas of gap between present and earlier research findings
• Improving researcher’s research methodology
• Expanding researcher’s knowledge base
• Ensuring that the researcher is carrying out new research that has not been carried out earlier

Process of a Literature Review

The second step in the research process is to carry out the review of already existing literature. Before engaging in literature review, the researcher must be clear as to what is the area and topic of research. There are four steps involved in the literature review process as shown in Figure:

Search the Existing Literature in Your Field of Interest

In the literature review process, the first step is to find out what research has already been done in the area that the researcher has chosen. This step involves preparing a list or bibliography of existing sources of relevant literature such as books, journals, abstracts of articles on your research topic, citation indices and digital libraries.

Review the Literature Obtained

After the researcher has identified related literature including journals, books, research papers, etc.; the next step is to study, evaluate and analyse the literature critically. This study of literature helps a researcher identify themes and issues related to the research topic.

An evaluation of literature helps in:

• Identifying the different theories and their criticism
• Identifying different methodologies used in different studies including their sample size, data used, measurement methods
• Assessing if the researcher’s theory is confirmed beyond doubt
• Preparing a list of different opinions of different researchers and researcher should also add his/her opinion about the validity of these different opinions

Develop a Theoretical Framework

Since carrying out literature review is a time-consuming activity but the researcher has to do it within a limited time. In order to do so, the researcher usually establishes a boundary and parameters for the research work. Also, the researcher must sort information obtained from all the sources of literature. For a researcher, the theoretical framework acts as a base on which he can further or extend his research. At times, the researchers may modify their research framework after analysing the available literature.

Write the Literature Review

The last step in literature review is to make a summary of all the literature that the researcher has studied and reviewed. Usually, writing a literature review starts with a write-up on the main theme of research followed by the important ideas on which the research would focus. After this, the all the major themes and sub-themes to be discussed are organised and related. This will help the researcher in structuring the literature review. The researcher should also identify and describe the theories and studies that are relevant for the study under consideration. The researcher should then list and describe all the gaps that are present in the current body of knowledge. In addition, the researcher may also explain the recent advances and trends in the given research field. To conclude, the researcher should compare and evaluate his findings on the basis of research assumptions, related research theories, hypotheses, applied research designs, variables selected and potential future work speculated by the researchers. Finally, the researcher must acknowledge, cite and quote all the sources that he/she has used in his research. One specific characteristic of literature review is that the researcher must ensure that he gives due credit to all people who have contributed in the research work.

How to Write a Literature Review

While writing the literature review, the researcher must adopt or adhere to certain strategies as follows:

• Establish a focus around the central theme and ideas of the research
• Describe what a reader can expect from the given research study
• Organise the literature research to include basic elements such as introduction, body and conclusions

Types of Sources for Review

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• Open access
• Published: 23 August 2022

Prognostic risk factors for moderate-to-severe exacerbations in patients with chronic obstructive pulmonary disease: a systematic literature review

• John R. Hurst 1 ,
• MeiLan K. Han 2 ,
• Barinder Singh 3 ,
• Sakshi Sharma 4 ,
• Gagandeep Kaur 3 ,
• Enrico de Nigris 5 ,
• Ulf Holmgren 6 &
• Mohd Kashif Siddiqui 3  

Respiratory Research volume  23 , Article number:  213 ( 2022 ) Cite this article

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Metrics details

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD exacerbations are associated with a worsening of lung function, increased disease burden, and mortality, and, therefore, preventing their occurrence is an important goal of COPD management. This review was conducted to identify the evidence base regarding risk factors and predictors of moderate-to-severe exacerbations in patients with COPD.

A literature review was performed in Embase, MEDLINE, MEDLINE In-Process, and the Cochrane Central Register of Controlled Trials (CENTRAL). Searches were conducted from January 2015 to July 2019. Eligible publications were peer-reviewed journal articles, published in English, that reported risk factors or predictors for the occurrence of moderate-to-severe exacerbations in adults age ≥ 40 years with a diagnosis of COPD.

The literature review identified 5112 references, of which 113 publications (reporting results for 76 studies) met the eligibility criteria and were included in the review. Among the 76 studies included, 61 were observational and 15 were randomized controlled clinical trials. Exacerbation history was the strongest predictor of future exacerbations, with 34 studies reporting a significant association between history of exacerbations and risk of future moderate or severe exacerbations. Other significant risk factors identified in multiple studies included disease severity or bronchodilator reversibility (39 studies), comorbidities (34 studies), higher symptom burden (17 studies), and higher blood eosinophil count (16 studies).

Conclusions

This systematic literature review identified several demographic and clinical characteristics that predict the future risk of COPD exacerbations. Prior exacerbation history was confirmed as the most important predictor of future exacerbations. These prognostic factors may help clinicians identify patients at high risk of exacerbations, which are a major driver of the global burden of COPD, including morbidity and mortality.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide [ 1 ]. Based upon disability-adjusted life-years, COPD ranked sixth out of 369 causes of global disease burden in 2019 [ 2 ]. COPD exacerbations are associated with a worsening of lung function, and increased disease burden and mortality (of those patients hospitalized for the first time with an exacerbation, > 20% die within 1 year of being discharged) [ 3 ]. Furthermore, patients with COPD consider exacerbations or hospitalization due to exacerbations to be the most important disease outcome, having a large impact on their lives [ 4 ]. Therefore, reducing the future risk of COPD exacerbations is a key goal of COPD management [ 5 ].

Being able to predict the level of risk for each patient allows clinicians to adapt treatment and patients to adjust their lifestyle (e.g., through a smoking cessation program) to prevent exacerbations [ 3 ]. As such, identifying high-risk patients using measurable risk factors and predictors that correlate with exacerbations is critical to reduce the burden of disease and prevent a cycle of decline encompassing irreversible lung damage, worsening quality of life (QoL), increasing disease burden, high healthcare costs, and early death.

Prior history of exacerbations is generally thought to be the best predictor of future exacerbations; however, there is a growing body of evidence suggesting other demographic and clinical characteristics, including symptom burden, airflow obstruction, comorbidities, and inflammatory biomarkers, also influence risk [ 6 , 7 , 8 , 9 ]. For example, in the prospective ECLIPSE observational study, the likelihood of patients experiencing an exacerbation within 1 year of follow-up increased significantly depending upon several factors, including prior exacerbation history, forced expiratory volume in 1 s (FEV 1 ), St. George’s Respiratory Questionnaire (SGRQ) score, gastroesophageal reflux, and white blood cell count [ 9 ].

Many studies have assessed predictors of COPD exacerbations across a variety of countries and patient populations. This systematic literature review (SLR) was conducted to identify and compile the evidence base regarding risk factors and predictors of moderate-to-severe exacerbations in patients with COPD.

• Systematic literature review

A comprehensive search strategy was designed to identify English-language studies published in peer-reviewed journals providing data on risk factors or predictors of moderate or severe exacerbations in adults aged ≥ 40 years with a diagnosis of COPD (sample size ≥ 100). The protocol is summarized in Table 1 and the search strategy is listed in Additional file 1 : Table S1. Key biomedical electronic literature databases were searched from January 2015 until July 2019. Other sources were identified via bibliographic searching of relevant systematic reviews.

Study selection process

Implementation and reporting followed the recommendations and standards of the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement [ 10 ]. An independent reviewer conducted the first screening based on titles and abstracts, and a second reviewer performed a quality check of the excluded evidence. A single independent reviewer also conducted the second screening based on full-text articles, with a quality check of excluded evidence performed by a second reviewer. Likewise, data tables of the included studies were generated by one reviewer, and another reviewer performed a quality check of extracted data. Where more than one publication was identified describing a single study or trial, data were compiled into a single entry in the data-extraction table to avoid double counting of patients and studies. One publication was designated as the ‘primary publication’ for the purposes of the SLR, based on the following criteria: most recently published evidence and/or the article that presented the majority of data (e.g., journal articles were preferred over conference abstracts; articles that reported results for the full population were preferred over later articles providing results of subpopulations). Other publications reporting results from the same study were designated as ‘linked publications’; any additional data in the linked publications that were not included in the primary publication were captured in the SLR. Conference abstracts were excluded from the SLR unless they were a ‘linked publication.’

Included studies

A total of 5112 references (Fig.  1 ) were identified from the database searches. In total, 76 studies from 113 publications were included in the review. Primary publications and ‘linked publications’ for each study are detailed in Additional file 1 : Table S2, and study characteristics are shown in Additional file 1 : Table S3. The studies included clinical trials, registry studies, cross-sectional studies, cohort studies, database studies, and case–control studies. All 76 included studies were published in peer-reviewed journals. Regarding study design, 61 of the studies were observational (34 retrospective observational studies, 19 prospective observational studies, four cross-sectional studies, two studies with both retrospective and prospective cohort data, one case–control study, and one with cross-sectional and longitudinal data) and 15 were randomized controlled clinical trials.

PRISMA flow diagram of studies through the systematic review process. CA conference abstract, CENTRAL Cochrane Central Register of Controlled Trials, PRISMA  Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Of the 76 studies, 16 were conducted in North America (13 studies in the USA, two in Canada, and one in Mexico); 26 were conducted in Europe (seven studies in Spain, four in the UK, three in Denmark, two studies each in Bulgaria, the Netherlands, and Switzerland, and one study each in Sweden, Serbia, Portugal, Greece, Germany, and France) and 17 were conducted in Asia (six studies in South Korea, four in China, three in Taiwan, two in Japan, and one study each in Singapore and Israel). One study each was conducted in Turkey and Australia. Fifteen studies were conducted across multiple countries.

The majority of the studies (n = 54) were conducted in a multicenter setting, while 22 studies were conducted in a single-center setting. The sample size among the included studies varied from 118 to 339,389 patients.

Patient characteristics

A total of 75 studies reported patient characteristics (Additional file 1 : Table S4). The mean age was reported in 65 studies and ranged from 58.0 to 75.2 years. The proportion of male patients ranged from 39.7 to 97.6%. The majority of included studies (85.3%) had a higher proportion of males than females.

Exacerbation history (as defined per each study) was reported in 18 of 76 included studies. The proportion of patients with no prior exacerbation was reported in ten studies (range, 0.1–79.5% of patients), one or fewer prior exacerbation in ten studies (range, 46–100%), one or more prior exacerbation in eight studies (range, 18.4–100%), and two or more prior exacerbations in 12 studies (range, 6.1–55.0%).

Prognostic factors of exacerbations

A summary of the risk factors and predictors reported across the included studies is provided in Tables 2 and 3 . The overall findings of the SLR are summarized in Figs. 2 and 3 .

Risk factors for moderate-to-severe exacerbations in patients with COPD. Factors with > 30 supporting studies shown as large circles; factors with ≤ 30 supporting studies shown as small circles and should be interpreted cautiously. BDR bronchodilator reversibility, BMI body mass index, COPD chronic obstructive pulmonary disease, EOS eosinophil, QoL quality of life

Summary of risk factors for exacerbation events. a Treatment impact studies removed. BDR bronchodilator reversibility, BMI body mass index, COPD chronic obstructive pulmonary disease, EOS eosinophil, QoL quality of life

Exacerbation history within the past 12 months was the strongest predictor of future exacerbations. Across the studies assessing this predictor, 34 out of 35 studies (97.1%) reported a significant association between history of exacerbations and risk of future moderate-to-severe exacerbations (Table 3 ). Specifically, two or more exacerbations in the previous year or at least one hospitalization for COPD in the previous year were identified as reliable predictors of future moderate or severe exacerbations. Even one moderate exacerbation increased the risk of a future exacerbation, with the risk increasing further with each subsequent exacerbation (Fig.  4 ). A severe exacerbation was also found to increase the risk of subsequent exacerbation and hospitalization (Fig.  5 ). Patients experiencing one or more severe exacerbations were more likely to experience further severe exacerbations than moderate exacerbations [ 11 , 12 ]. In contrast, patients with a history of one or more moderate exacerbations were more likely to experience further moderate exacerbations than severe exacerbations [ 11 , 12 ].

Exacerbation history as a risk factor for moderate-to-severe exacerbations. Yun 2018 included two studies; the study from which data were extracted (COPDGene or ECLIPSE) is listed in parentheses. CI confidence interval, ES effect size

Exacerbation history as a risk factor for severe exacerbations. Where data have been extracted from a linked publication rather than the primary publication, the linked publication is listed in parentheses. CI confidence interval, ES , effect size

Overall, 35 studies assessed the association of comorbidities with the risk of exacerbation. All studies except one (97.1%) reported a positive association between comorbidities and the occurrence of moderate-to-severe exacerbations (Table 3 ). In addition to the presence of any comorbidity, specific comorbidities that were found to significantly increase the risk of moderate-to-severe exacerbations included anxiety and depression, cardiovascular comorbidities, gastroesophageal reflux disease/dyspepsia, and respiratory comorbidities (Fig.  6 ). Comorbidities that were significant risk factors for severe exacerbations included cardiovascular, musculoskeletal, and respiratory comorbidities, diabetes, and malignancy (Fig.  7 ). Overall, the strongest association between comorbidities and COPD readmissions in the emergency department was with cardiovascular disease. The degree of risk for both moderate-to-severe and severe exacerbations also increased with the number of comorbidities. A Dutch cohort study found that 88% of patients with COPD had at least one comorbidity, with hypertension (35%) and coronary heart disease (19%) being the most prevalent. In this cohort, the comorbidities with the greatest risk of frequent exacerbations were pulmonary cancer (odds ratio [OR] 1.85) and heart failure (OR 1.72) [ 7 ].

Comorbidities as risk factors for moderate-to-severe exacerbations. Yun 2018 included two studies; the study from which data were extracted (COPDGene or ECLIPSE) is listed in parentheses. Where data have been extracted from a linked publication rather than the primary publication, the linked publication is listed in parentheses. CI confidence interval, ES effect size, GERD gastroesophageal disease

Comorbidities as risk factors for severe exacerbations. Where data have been extracted from a linked publication rather than the primary publication, the linked publication is listed in parentheses. CI confidence interval, CKD , chronic kidney disease, ES effect size

The majority of studies assessing disease severity or bronchodilator reversibility (39/41; 95.1%) indicated a significant positive relation between risk of future exacerbations and greater disease severity, as assessed by greater lung function impairment (in terms of lower FEV 1 , FEV 1 /forced vital capacity ratio, or forced expiratory flow [25–75]/forced vital capacity ratio) or more severe Global Initiative for Chronic Obstructive Lung Disease (GOLD) class A − D, and a positive relationship between risk of future exacerbations and lack of bronchodilator reversibility (Table 3 , Figs. 8 and 9 ).

Disease severity as a risk factor for moderate-to-severe exacerbations. Yun 2018 included two studies; the study from which data were extracted (COPDGene or ECLIPSE) is listed in parentheses. Where data have been extracted from a linked publication rather than the primary publication, the linked publication is listed in parentheses. CI confidence interval, ES effect size, FEV 1 f orced expiratory volume in 1 s, FVC , forced vital capacity, GOLD Global Initiative for Obstructive Lung Disease, HR hazard ratio, OR odds ratio

Disease severity and BDR as risk factors for severe exacerbations. ACCP American College of Chest Physicians, ACOS Asthma-COPD overlap syndrome, ATS  American Thoracic Society, BDR bronchodilator reversibility, CI confidence interval, ERS  European Respiratory Society, ES effect size, FEV 1 forced expiratory volume in 1 s, FVC  forced vital capacity, GINA Global Initiative for Asthma, GOLD Global Initiative for Obstructive Lung Disease

Of 21 studies assessing the relationship between blood eosinophil count and exacerbations (Table 3 ), 16 reported estimates for the risk of moderate or severe exacerbations by eosinophil count. A positive association was observed between higher eosinophil count and a higher risk of moderate or severe exacerbations, particularly in patients not treated with an inhaled corticosteroid (ICS); however, five studies reported a significant positive association irrespective of intervention effects. The risk of moderate-to-severe exacerbations was observed to be positively associated with various definitions of higher eosinophil levels (absolute counts: ≥ 200, ≥ 300, ≥ 340, ≥ 400, and ≥ 500 cells/mm 3 ; % of blood eosinophil count: ≥ 2%, ≥ 3%, ≥ 4%, and ≥ 5%). Of note, one study found reduced efficacy of ICS in lowering moderate-to-severe exacerbation rates for current smokers versus former smokers at all eosinophil levels [ 13 ].

Of 12 studies assessing QoL scales, 11 (91.7%) studies reported a significant association between the worsening of QoL scores and the risk of future exacerbations (Table 3 ). Baseline SGRQ [ 14 , 15 ], Center for Epidemiologic Studies Depression Scale (for which increased scores may indicate impaired QoL) [ 16 ], and Clinical COPD Questionnaire [ 17 , 18 ] scores were found to be associated with future risk of moderate and/or severe COPD exacerbations. For symptom scores, six out of eight studies assessing the association between moderate-to-severe or severe exacerbations with COPD Assessment Test (CAT) scores reported a significant and positive relationship. Furthermore, the risk of moderate-to-severe exacerbations was found to be significantly higher in patients with higher CAT scores (≥ 10) [ 15 , 19 , 20 , 21 ], with one study demonstrating that a CAT score of 15 increased predictive ability for exacerbations compared with a score of 10 or more [ 18 ]. Among 15 studies that assessed the association of modified Medical Research Council (mMRC) scores with the risk of moderate-to-severe or severe exacerbation, 11 found that the risk of moderate-to-severe or severe exacerbations was significantly associated with higher mMRC scores (≥ 2) versus lower scores. Furthermore, morning and night symptoms (measured by Clinical COPD Questionnaire) were associated with poor health status and predicted future exacerbations [ 17 ].

Of 36 studies reporting the relationship between smoking status and moderate-to-severe or severe exacerbations, 22 studies (61.1%) reported a significant positive association (Table 3 ). Passive smoking was also significantly associated with an increased risk of severe exacerbations (OR 1.49) [ 20 ]. Of note, three studies reported a significantly lower rate of moderate-to-severe exacerbations in current smokers compared with former smokers [ 22 , 23 , 24 ].

A total of 14 studies assessed the association of body mass index (BMI) with the occurrence of frequent moderate-to-severe exacerbations in patients with COPD. Six out of 14 studies (42.9%) reported a significant negative association between exacerbations and BMI (Table 3 ). The risk of moderate and/or severe COPD exacerbations was highest among underweight patients compared with normal and overweight patients [ 23 , 25 , 26 , 27 , 28 ].

In the 29 studies reporting an association between age and moderate or severe exacerbations, more than half found an association of older age with an increased risk of moderate-to-severe exacerbations (58.6%; Table 3 ). Four of these studies noted a significant increase in the risk of moderate-to-severe or severe exacerbations for every 10-year increase in age [ 25 , 26 , 29 , 30 ]. However, 12 studies reported no significant association between age and moderate-to-severe or severe exacerbation risk.

Sixteen out of 33 studies investigating the impact of sex on exacerbation risk found a significant association (48.5%; Table 3 ). Among these, ten studies reported that female sex was associated with an increased risk of moderate-to-severe exacerbations, while six studies showed a higher exacerbation risk in males compared with females. There was some variation in findings by geographic location and exacerbation severity (Additional file 2 : Figs. S1 and S2). Notably, when assessing the risk of severe exacerbations, more studies found an association with male sex compared with female sex (6/13 studies vs 1/13 studies, respectively).

Both studies evaluating associations between exacerbations and environmental factors reported that colder temperature and exposure to major air pollution (NO 2 , O 3 , CO, and/or particulate matter ≤ 10 μm in diameter) increased hospital admissions due to severe exacerbations and moderate-to-severe exacerbation rates [ 31 , 32 ].

Four studies assessed the association of 6-min walk distance with the occurrence of frequent moderate-to-severe exacerbations (Table 3 ). One study (25.0%) found that shorter 6-min walk distance (representing low physical activity) was significantly associated with a shortened time to severe exacerbation, but the effect size was small (hazard ratio 0.99) [ 33 ].

Five out of six studies assessing the relationship between race or ethnicity and exacerbation risk reported significant associations (Table 3 ). Additionally, one study reported an association between geographic location in the US and exacerbations, with living in the Northeast region being the strongest predictor of severe COPD exacerbations versus living in the Midwest and South regions [ 34 ].

Overall, seven studies assessed the association of biomarkers with risk of future exacerbations (Table 3 ), with the majority identifying significant associations between inflammatory biomarkers and increased exacerbation risk, including higher C-reactive protein levels [ 8 , 35 ], fibrinogen levels [ 8 , 30 ], and white blood cell count [ 8 , 15 , 16 ].

This SLR has identified several demographic and clinical characteristics that predict the future risk of COPD exacerbations. Key factors associated with an increased risk of future moderate-to-severe exacerbations included a history of prior exacerbations, worse disease severity and bronchodilator reversibility, the presence of comorbidities, a higher eosinophil count, and older age (Fig.  2 ). These prognostic factors may help clinicians identify patients at high risk of exacerbations, which are a major driver of the burden of COPD, including morbidity and mortality [ 36 ].

Findings from this review summarize the existing evidence, validating the previously published literature [ 6 , 9 , 23 ] and suggesting that the best predictor of future exacerbations is a history of exacerbations in the prior year [ 8 , 11 , 12 , 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 26 , 29 , 34 , 35 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ]. In addition, the effect size generally increased with the number of prior exacerbations, with a stronger effect observed with prior severe versus moderate exacerbations. This effect was observed across regions, including in Europe and North America, and in several global studies. This relationship represents a vicious circle, whereby one exacerbation predisposes a patient to experience future exacerbations and leading to an ever-increasing disease burden, and emphasizes the importance of preventing the first exacerbation event through early, proactive exacerbation prevention. The finding that prior exacerbations tended to be associated with future exacerbations of the same severity suggests that the severity of the underlying disease may influence exacerbation severity. However, the validity of the traditional classification of exacerbation severity has recently been challenged [ 61 ], and further work is required to understand relationships with objective assessments of exacerbation severity.

In addition to exacerbation history, disease severity and bronchodilator reversibility were also strong predictors for future exacerbations [ 8 , 14 , 16 , 18 , 19 , 20 , 22 , 23 , 24 , 26 , 28 , 29 , 33 , 37 , 40 , 43 , 44 , 45 , 46 , 48 , 50 , 51 , 52 , 56 , 59 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 ]. The association with disease severity was noted in studies that used GOLD disease stages 1–4 and those that used FEV 1 percent predicted and other lung function assessments as continuous variables. Again, this risk factor is self-perpetuating, as evidence shows that even a single moderate or severe exacerbation may almost double the rate of lung function decline [ 79 ]. Accordingly, disease severity and exacerbation history may be correlated. Margüello et al. concluded that the severity of COPD could be associated with a higher risk of exacerbations, but this effect was partly determined by the exacerbations suffered in the previous year [ 23 ]. It should be noted that FEV 1 is not recommended by GOLD for use as a predictor of exacerbation risk or mortality alone due to insufficient precision when used at the individual patient level [ 5 ].

Another factor that should be considered when assessing individual exacerbation risk is the presence of comorbidities [ 7 , 14 , 16 , 18 , 19 , 20 , 21 , 22 , 24 , 25 , 26 , 27 , 28 , 30 , 33 , 34 , 35 , 40 , 41 , 44 , 45 , 46 , 47 , 48 , 51 , 52 , 53 , 54 , 56 , 58 , 59 , 63 , 64 , 73 , 74 , 76 , 77 , 80 , 81 , 82 , 83 , 84 , 85 ]. Comorbidities are common in COPD, in part due to common risk factors (e.g., age, smoking, lifestyle factors) that also increase the risk of other chronic diseases [ 7 ]. Significant associations were observed between exacerbation risk and comorbidities, such as anxiety and depression, cardiovascular disease, diabetes, and respiratory comorbidities. As with prior exacerbations, the strength of the association increased with the number of comorbidities. Some comorbidities that were found to be associated with COPD exacerbations share a common biological mechanism of systemic inflammation, such as cardiovascular disease, diabetes, and depression [ 86 ]. Furthermore, other respiratory comorbidities, including asthma and bronchiectasis, involve inflammation of the airways [ 87 ]. In these patients, optimal management of comorbidities may reduce the risk of future COPD exacerbations (and improve QoL), although further research is needed to confirm the efficacy of this approach to exacerbation prevention. As cardiovascular conditions, including hypertension and coronary heart disease, are the most common comorbidities in people with COPD [ 7 ], reducing cardiovascular risk may be a key goal in reducing the occurrence of exacerbations. For other comorbidities, the mechanism for the association with exacerbation risk may be related to non-biological factors. For example, in depression, it has been suggested that the mechanism may relate to greater sensitivity to symptom changes or more frequent physician visits [ 88 ].

There is now a growing body of evidence reporting the relationship between blood eosinophil count and exacerbation risk [ 8 , 13 , 14 , 20 , 37 , 48 , 52 , 56 , 59 , 60 , 62 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 ]. Data from many large clinical trials (SUNSET [ 89 ], FLAME [ 96 ], WISDOM [ 98 ], IMPACT [ 13 ], TRISTAN [ 99 ], INSPIRE [ 99 ], KRONOS [ 91 ], TRIBUTE [ 48 ], TRILOGY [ 52 ], TRINITY [ 56 ]) have also shown relationships between treatment, eosinophil count, and exacerbation rates. Evidence shows that eosinophil count, along with other effect modifiers (e.g., exacerbation history), can be used to predict reductions in exacerbations with ICS treatment. Identifying patients most likely to respond to ICS should contribute to personalized medicine approaches to treat COPD. One challenge in drawing a strong conclusion from eosinophil counts is the choice of a cut-off value, with a variety of absolute and percentage values observed to be positively associated with the risk of moderate-to-severe exacerbations. The use of absolute counts may be more practical, as these are not affected by variations in other immune cell numbers; however, there is a lack of consensus on this point [ 100 ].

Across the studies examined, associations between sex and the risk of moderate and/or severe exacerbations were variable [ 14 , 16 , 18 , 20 , 21 , 22 , 23 , 24 , 26 , 27 , 28 , 29 , 37 , 40 , 42 , 44 , 45 , 46 , 47 , 48 , 51 , 52 , 56 , 58 , 59 , 63 , 73 , 74 , 77 , 80 , 83 , 84 , 85 ]. A greater number of studies showed an increased risk of exacerbations in females compared with males. In contrast, some studies failed to detect a relationship, suggesting that country-specific or cultural factors may play a role. A majority of the included studies evaluated more male patients than female patients; to further elucidate the relationship between sex and exacerbations, more studies in female patients are warranted. Over half of the studies that assessed the relationship between age and exacerbation risk found an association between increasing age and increasing risk of moderate-to-severe COPD exacerbations [ 14 , 16 , 18 , 20 , 21 , 22 , 23 , 24 , 26 , 27 , 28 , 29 , 33 , 40 , 42 , 44 , 45 , 47 , 51 , 52 , 54 , 56 , 63 , 73 , 74 , 77 , 80 , 83 , 85 ].

Our findings also suggested that patients with low BMI have greater risk of moderate and/or severe exacerbations. The mechanism underlying this increased risk in underweight patients is poorly understood; however, loss of lean body mass in patients with COPD may be related to ongoing systemic inflammation that impacts skeletal muscle mass [ 101 , 102 , 103 ].

A limitation of this SLR, that may have resulted in some studies with valid results being missed, was the exclusion of non-English-language studies and the limitation by date; however, the search strategy was otherwise broad, resulting in the review of a large number of studies. The majority of studies captured in this SLR were from Europe, North America, and Asia. The findings may therefore be less generalizable to patients in other regions, such as Africa or South America. Given that one study reported an association between geographic location within different regions of the US and exacerbations [ 34 ], it is plausible that risk of exacerbations may be impacted by global location. As no formal meta-analysis was planned, the assessments are based on a qualitative synthesis of studies. A majority of the included studies looked at exposures of certain factors (e.g., history of exacerbations) at baseline; however, some of these factors change over time, calling into question whether a more sophisticated statistical analysis should have been conducted in some cases to consider time-varying covariates. Our results can only inform on associations, not causation, and there are likely bidirectional relationships between many factors and exacerbation risk (e.g., health status). Finally, while our review of the literature captured a large number of prognostic factors, other variables such as genetic factors, lung microbiome composition, and changes in therapy over time have not been widely studied to date, but might also influence exacerbation frequency [ 104 ]. Further research is needed to assess the contribution of these factors to exacerbation risk.

This SLR captured publications up to July 2019. However, further studies have since been published that further support the prognostic factors identified here. For example, recent studies have reported an increased risk of exacerbations in patients with a history of exacerbations [ 105 ], comorbidities [ 106 ], poorer lung function (GOLD stage) [ 105 ], higher symptomatic burden [ 107 ], female sex [ 105 ], and lower BMI [ 106 , 108 ].

In summary, the literature assessing risk factors for moderate-to-severe COPD exacerbations shows that there are associations between several demographic and disease characteristics with COPD exacerbations, potentially allowing clinicians to identify patients most at risk of future exacerbations. Exacerbation history, comorbidities, and disease severity or bronchodilator reversibility were the factors most strongly associated with exacerbation risk, and should be considered in future research efforts to develop prognostic tools to estimate the likelihood of exacerbation occurrence. Importantly, many prognostic factors for exacerbations, such as symptom burden, QoL, and comorbidities, are modifiable with optimal pharmacologic and non-pharmacologic treatments or lifestyle modifications. Overall, the evidence suggests that, taken together, predicting and reducing exacerbation risk is an achievable goal in COPD.

Availability of data and materials

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

Abbreviations

Body mass index

COPD Assessment Test

Chronic obstructive pulmonary disease

Forced expiratory volume in 1 s

Global Initiative for Chronic Obstructive Lung Disease

Inhaled corticosteroid

Modified Medical Research Council

Quality of life

St. George’s Respiratory Questionnaire

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Acknowledgements

Medical writing support, under the direction of the authors, was provided by Julia King, PhD, and Sarah Piggott, MChem, CMC Connect, McCann Health Medical Communications, funded by AstraZeneca in accordance with Good Publication Practice (GPP3) guidelines [ 109 ].

This study was supported by AstraZeneca.

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The authors have made the following declaration about their contributions. JRH and MKH made substantial contributions to the interpretation of data; BS, SS, GK, and MKS made substantial contributions to the acquisition, analysis, and interpretation of data; EdN and UH made substantial contributions to the conception and design of the work and the interpretation of data. All authors contributed to drafting or critically revising the article, have approved the submitted version, and agree to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. All authors read and approved the final manuscript.

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JRH reports consulting fees from AstraZeneca; speaker fees from AstraZeneca, Chiesi, Pfizer, and Takeda; and travel support from GlaxoSmithKline and AstraZeneca. MKH reports assistance with conduction of this research and publication from AstraZeneca; personal fees from Aerogen, Altesa Biopharma, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, DevPro, GlaxoSmithKline, Integrity, Medscape, Merck, Mylan, NACE, Novartis, Polarean, Pulmonx, Regeneron, Sanofi, Teva, Verona, United Therapeutics, and UpToDate; either in kind research support or funds paid to the institution from the American Lung Association, AstraZeneca, Biodesix, Boehringer Ingelheim, the COPD Foundation, Gala Therapeutics, the NIH, Novartis, Nuvaira, Sanofi, and Sunovion; participation in Data Safety Monitoring Boards for Novartis and Medtronic with funds paid to the institution; and stock options from Altesa Biopharma and Meissa Vaccines. BS, GK, and MKS are former employees of Parexel International. SS is an employee of Parexel International, which was funded by AstraZeneca to conduct this analysis. EdN is a former employee of AstraZeneca and previously held stock and/or stock options in the company. UH is an employee of AstraZeneca and holds stock and/or stock options in the company.

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Additional file1: table s1..

Search strategies. Table S2. List of included studies with linked publications. Table S3. Study characteristics across the 76 included studies. Table S4. Clinical characteristics of the patients assessed across the included studies.

Additional file 2: Fig. S1.

Sex (male vs female) as a risk factor for moderate-to-severe exacerbations. Fig. S2. Sex (male vs female) as a risk factor for severe exacerbations.

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Hurst, J.R., Han, M.K., Singh, B. et al. Prognostic risk factors for moderate-to-severe exacerbations in patients with chronic obstructive pulmonary disease: a systematic literature review. Respir Res 23 , 213 (2022). https://doi.org/10.1186/s12931-022-02123-5

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Active involvement in scientific research of persons living with dementia and long-term care users: a systematic review of existing methods with a specific focus on good practices, facilitators and barriers of involvement

• Janneke M. Groothuijse 1 , 2 ,
• Lisa S. van Tol 1 , 2 ,
• C. C. M. (Toos) Hoeksel-van Leeuwen 1 , 2 ,
• Johannes J. M. van Delden 3 ,
• Monique A. A. Caljouw 1 , 2 &
• Wilco P. Achterberg 1 , 2  

BMC Geriatrics volume  24 , Article number:  324 ( 2024 ) Cite this article

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Metrics details

Active involvement of persons living with dementia (PLWD) and long-term care (LTC) users in research is essential but less developed compared to other patient groups. However, their involvement in research is not only important but also feasible. This study aims to provide an overview of methods, facilitators, and barriers for involving PLWD and LTC users in scientific research.

A systematic literature search across 12 databases in December 2020 identified studies involving PLWD, LTC users, or their carers beyond research subjects and describing methods or models for involvement. Qualitative descriptions of involvement methods underwent a risk of bias assessment using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist 2018. A data collection sheet in Microsoft Excel and thematic analysis were used to synthesize the results.

The eighteen included studies delineated five core involvement methods spanning all research phases: advisory groups, formal and informal research team meetings, action groups, workshops, and co-conducting interviews. Additionally, two co-research models with PLWD and carers were found, while only two studies detailed LTC user involvement methods. Four distinct involvement roles were identified: consulting and advisory roles, co-analysts, co-researchers, and partners. The review also addressed barriers, facilitators, and good practices in the preparation, execution, and translation phases of research, emphasizing the importance of diversity, bias reduction, and resource allocation. Trust-building, clear roles, ongoing training, and inclusive support were highlighted.

Conclusions

Planning enough time for active involvement is important to ensure that researchers have time to build a trusting relationship and meet personal needs and preferences of PLWD, LTC users and carers. Researchers are advised not to presume the meaning of burden and to avoid a deficit perspective. A flexible or emergent design could aid involved persons’ ownership of the research process.

Trial registration

Prospero 2021: CRD42021253736.

Peer Review reports

In research characterized by active involvement, the target group plays a pivotal role in shaping research decisions and outcomes, directly impacting them. Involving patients in health research offers significant benefits [ 1 , 2 ]: it enhances participant recruitment [ 2 ], refines research questions [ 2 ], aligns study results with the target population [ 1 , 2 ], and promotes effective implementation of findings [ 1 ]. Active involvement of patients has also benefits for themselves, namely an enhanced understanding of research, building relationships, personal development, improved health and wellbeing, and enjoyment and satisfaction [ 3 , 4 ]. It gives them a sense of purpose and satisfaction through their tangible impact.

However, for long-term care (LTC) users and persons living with dementia (PLWD) active involvement in research is less developed than for other patient groups [ 5 , 6 ]. PLWD and LTC users share similar care needs, encompassing assistance with activities of daily living (ADLs), medication management, medical condition monitoring, and emotional support. Furthermore, a substantial portion of LTC users comprises individuals living with dementia [ 7 ]. Additionally, statistical data from the United States reveals that one in four older individuals is likely to reside in long-term care (LTC) facilities [ 8 ], and approximately forty to eighty percent of LTC residents in the United States, Japan, Australia, and England experience dementia or severe memory problems [ 7 , 9 ].

Due to these considerations, we have chosen to combine the target audiences of PLWD and LTC users in our systematic review. However, it's important to note that while there are potential advantages to combining these target groups, there may also be challenges. PLWD and LTC users may have varying needs, preferences, and experiences, including differences in care requirements driven by individual factors like the stage of dementia, coexisting conditions, and personal preferences. Therefore, it's imperative to conduct comprehensive research and involve these communities to ensure that involvement approaches are not only inclusive but also tailored to meet their specific requirements.

Given our ageing population and the intricate health challenges faced by PLWD and LTC users, including their vulnerability and shorter life expectancy in old age, it's crucial to establish effective research involvement methods. These individuals have unique needs and preferences that require attention. They possess a voice, and as researchers, it is our responsibility to not only listen to them but also actively involve them in the research process. Consequently, it is essential to identify means through which the voices of PLWD and LTC users can be effectively heard and ensure that their input is incorporated into research.

Fortunately, publication of studies on involvement of PLWD and LTC users in scientific research is slowly increasing [ 5 , 9 , 10 , 11 ]. A few reviews have described how PLWD and LTC users were involved [ 5 , 9 , 10 ]. However, with the increasing attention for involvement, the understanding of when involvement is meaningful grows and stricter requirements can be imposed to increase the quality of active involvement [ 12 , 13 ]. To our knowledge there is no up to date overview of involvement methods used with either or both PLWD and LTC users. Such an overview of involvement methods for PWLD and LTC users would provide a valuable, comprehensive resource encompassing various stages of the research cycle and different aspects of involvement. It would equip researchers with the necessary guidance to navigate the complexities of involving PLWD and LTC users in their research projects.

Recognizing the need to enhance the involvement of PLWD and LTC users in scientific research, this systematic review aims to construct a comprehensive overview of the multiple methodologies employed in previous studies, along with an examination of the facilitators and barriers of involvement. Our overarching goal is to promote inclusive and effective involvement practices within the research community. To achieve this objective, this review will address the following questions: (1) What kind of methods are used and how are these methods implemented to facilitate involvement of PLWD and LTC users in scientific research? (2) What are the facilitators and barriers encountered in previous research projects involving PLWD and LTC users?

Protocol and registration

The search and analysis methods were specified in advance in a protocol. The protocol is registered and published in the PROSPERO database with registration number CRD42021253736. The search and analysis methods are also described below more briefly.

Information sources, search strategy, and eligibility criteria

In preparation of the systematic literature search, key articles and reviews about involvement of PLWD and LTC users in research were screened to identify search terms. In addition, Thesaurus and MeSH terms were used to broaden the search. The search was conducted on December 10, 2020, across multiple databases: PubMed, Medline, Embase, Emcare, Web of Science, Cochrane Library, PsycINFO, Academic Search Premier, JSTOR, Social Services Abstracts, Sociological Abstracts, Psychology and Behavioral Sciences Collection. The search terms were entered in "phrases". The search strategy included synonymous and related terms for dementia, LTC user, involvement, research, method, and long-term care. The full search strategy is provided in supplement 1 .

After conducting the search, records underwent initial screening based on titles and abstracts. Selected reports were retrieved for full-text assessment, and studies were evaluated for eligibility based on several criteria. However, no restriction was made regarding publication date. First, to be included studies had to be written in English, German, French, or Dutch. Second, we only included original research studies. Third, studies were excluded when the target group or their representatives were not involved in research, but only participated as research subjects. Fourth, studies were excluded when not describing involvement in research. Therefore, studies concerning involvement in care, policy, or self-help groups were excluded. Fifth, the focus of this systematic review is on methods. Therefore, studies with a main focus on the results, evaluation, ethical issues, and impact of involvement in research were excluded. Additionally, we have not set specific inclusion or exclusion criteria based on study design since our primary focus is on involvement methodologies, regardless of the chosen research design. Sixth, the included studies had to concern the involvement in research of PLWD or adult LTC users, whether living in the community or in institutional settings, as well as informal caregivers or other representatives of these groups who may represent PLWD and LTC users facing limitations. Studies that involved LTC users that were children or ‘young adults’, or their representatives, were excluded. Studies were also excluded if they involved mental healthcare users if it remained unclear if the care that they received entailed more than only treatment from mental healthcare providers, but for example also assistance with ADL.

Terminology

For readability purposes, we use the abbreviation PLWD to refer to persons diagnosed with dementia, and we use the abbreviation LTC users to refer to persons receiving long-term care, at home or as residents living in nursing homes or other residential facilities. We use the term carers to refer to informal caregivers and other representatives of either PLWD or LTC users. As clear and consistent definitions regarding participatory research remains elusive [ 14 , 15 ], we formulated a broad working definition of involvement in research so as not to exclude any approach to participatory research. We defined involvement in research as “research carried out ‘with’ or ‘by’ the target group” [ 16 ], where the target group or their representatives take part in the governance or conduct of research and have some degree of ownership of the research [ 12 ]. It concerns involvement in research in which lived experienced experts work alongside research teams. We use the terms participation and participants, to refer to people being part of the research as study subjects.

Selection process, data-collection process, and data items

Titles and abstracts were independently screened by the first and second author (JG and LT). Only the studies that both reviewers agreed and met the inclusion criteria were included in the full-text screening process. Any uncertainty about whether the studies truly described a model or approach for involvement, was resolved by a quick screening of the full-text paper. The full-text screening process was then conducted according to the same procedure by JG and LT. Any disagreement was resolved by discussion until consensus was reached. If no agreement could be reached, a third researcher (MC) was consulted. References of the included studies were screened for any missing papers.

The following information was collected on a data collection sheet in Microsoft Excel: year and country of publication, topic, research aim, study design, living situation of involved persons (at home or institutionalized), description of involved persons, study participants (study subjects), theories and methods used, type/role(s) of involvement, research phase(s), recruitment, consent approach, study setting, structure of participatory activities, training, resources, facilitators, barriers, ethics, benefits, impact, and definition of involvement used.

JG independently extracted data from all included studies, the involved co-researcher (THL) independently extracted data from two studies, the second author (LT) from five. Differences in the analysis were discussed with the co-researcher (THL) and second author (LT) until consensus was reached. As only minor differences emerged, limited to the facilitator and barrier categories, data from the remaining studies was extracted by JG.

Risk of bias assessment

Every research article identified through the systematic review exclusively comprised qualitative descriptions of the involvement method(s) employed. Consequently, all articles underwent evaluation using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist 2018 [ 17 ], as opposed to the checklists intended for quantitative or mixed methods research. All included studies were independently assessed on quality by two reviewers (JG,LT) and any disagreement was resolved by discussion until consensus was reached. The CASP Qualitative Checklist consists of ten questions. The checklist does not provide suggestions on scoring, the first author designed a scoring system: zero points if no description was provided (‘no’), one point if a minimal description was provided (‘can’t tell’) and two points when the question was answered sufficiently (‘yes’). The second question of the checklist, “is a qualitative methodology appropriate”, was not applicable to the aims (i.e., to describe involvement) of the included studies and was therefore excluded. The tenth question was translated into a ‘yes’, ‘can’t tell’, or ‘no’ score to fit the scoring system. A maximum of eighteen points could be assigned.

Synthesis methods

Tables were used to summarize the findings and to acquire an overview of (1) the kinds of methods used to enable involvement of PLWD, LTC users, or carers in scientific research, and (2) the facilitators and barriers for involving this target group in scientific research. As to the first research aim, the headings of the first two tables are based on the Guidance for Reporting Involvement of Patients and the Public, long form version 2 (GRIPP2-LF) [ 18 ]. Because our systematic review focusses on methods, only the topics belonging to sections two, three, and four were included. Following Shippee et al., three main research phases were distinguished: preparation, execution, and translation [ 19 ]. Furthermore, the following fields were added to the GRIPP2-LF: First author, year of publication, country of study, setting of involvement, frequency of meetings, and a summary description of activities.

Concerning the second research aim, the extracted facilitators, barriers, and good practices were imported per study in ATLAS.ti for qualitative data analysis. Following the method for thematic synthesis of qualitative studies in systematic reviews [ 20 ], all imported barriers, facilitators and good practices were inductively coded staying 'close' to the results of the original studies, which resulted in 50 initial codes. After multiple rounds of pile sorting [ 21 ], based on similarities and differences and discussions in the research team, this long code list was grouped into a total of 27 categories, which were thereafter subsequently organized into 14 descriptive themes within the three research phases (preparation, execution, translation).

Study selection and characteristics

The Prisma Flow Diagram was used to summarize the study selection process [ 22 ]. In the full text screening, 72 of the 93 remaining studies were excluded because they were not original research articles (n = 5), not about involvement (n = 8), not about involvement in a research project (n = 1), they did not describe a model or method for involvement (n = 34), or they were not about PLWD or LTC users (n = 24). The search resulted in 18 publications eligible for analysis (Fig.  1 ).

Preferred Reporting items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram

Table 1 presents the general study characteristics. Two studies explicitly aimed to develop a model for involvement or good practice, and both focus on co-research either with PLWD [ 23 ] or their carers [ 13 ]. The other sixteen provide a description of the involvement of PLWD [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ] or LTC users in their research projects [ 35 , 36 , 37 , 38 , 39 ].

Quality assessment

Table 1 presents the CASP-score per study [ 17 ]. Five scored 16 to 18 points [ 13 , 28 , 29 , 32 , 35 ], indicating high quality with robust methods, clear aims, and strong data analysis. Eleven scored 12 to 15 [ 23 , 24 , 26 , 30 , 32 , 33 , 34 , 36 , 37 , 38 , 39 ], showing generally strong methodologies but with some limitations. Two scored 9 or lower [ 25 , 27 ], signifying significant methodological and analytical shortcomings. Notably, these low-scoring studies were short articles lacking clear recommendations for involvement in research.

Design and implementation of involvement

Phases and methods of involvement.

Table 2 describes the involvement methods used for and the implementation of involvement in research. The included studies jointly presented methods for involvement in the three main research phases [ 19 ]. Regarding the preparation phase, which involves the preparatory work for the study, only three studies provided detailed descriptions of the methods employed [ 26 , 30 , 32 ]. The execution phase, encompassing the actual conduct of the research, was most frequently discussed [ 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. Five studies addressed the translation phase [ 13 , 25 , 31 , 36 , 37 ], where the focus shifts to translating research findings into actionable outcomes.

The eighteen studies introduced a variety of involvement methods, categorizable into five groups: 1) advisory groups, 2) research team meetings (both formal and informal), 3) action groups, 4) workshops, and 5) co-research in interviews. In five studies, individuals including PLWD, LTCF residents, carers, and health professionals participated in advisory/reference groups [ 25 , 26 , 27 , 32 ], working groups [ 27 ], and panels [ 28 ]. These groups offered valuable feedback on research aspects, spanning protocols, design, questionnaires, and implementation of research. Meetings occurred at varying frequencies - monthly, quarterly, or biannually.

Two studies exemplify diverse research collaboration settings. One involving older individuals within an academic research team of five [ 37 ], and another featuring a doctoral student and a co-researcher conducting informal monthly discussions at a local coffee shop [ 31 ]. Brown et al. sought to minimize power differentials and enhance inclusivity [ 37 ], while Mann and Hung focused on benefiting people with dementia and challenging negative discourse on dementia [ 31 ].

An additional five studies employed methods involving frequent meetings, including action [ 35 , 39 ], inquiry [ 23 ], and discussion groups [ 29 , 36 ] In these groups, involved persons with lived experience contributed to developing a shared vision and community improvements, such as enhancing the mealtime experience in care facilities [ 35 ].

Seven studies involved individuals through workshops, often conducted over one or two sessions. These workshops contributed to generating recommendations [ 37 ], informing future e-health designs [ 29 , 30 ], and ensuring diverse perspectives and lived experiences were included in data analysis [ 13 , 24 , 32 , 33 ]. In three studies, representatives worked as co-researchers in interviews, drawing on personal experiences to enhance the interview process, making it more dementia-appropriate and enriching data collection [ 13 , 32 , 34 ]. Finally, one study involved representatives in the recruitment and conduct of interviews [ 38 ].

People involved

The number of persons involved varied from a single co-researcher [ 31 ] to 34 panel individuals providing feedback on their experiences in a clinical trial [ 28 ]. Thirteen studies focussed on PLWD: eleven involved PLWD themselves [ 23 , 24 , 25 , 26 , 27 , 29 , 30 , 31 , 32 , 33 , 34 ], one exclusively focused on caregivers [ 13 ], and another one involved people without or with mild cognitive impairment, who participated in a study examining the risks of developing Alzheimer's disease [ 28 ]. Although not all articles provided descriptions of the dementia stage, available information indicated that individuals involved typically fell within the early to mid-stages of dementia [ 29 , 30 , 32 , 33 , 34 ]. Next to PLWD and carers, two studies additionally involved organizational or advocacy representatives [ 25 , 27 ]. The other five studies concerned older adults living in a LTC facility. Two of them involved older residents themselves [ 35 , 39 ], the other three carers, older community/client representatives or health care practitioners [ 36 , 37 , 38 ].

Roles and level of involvement

Four general roles could be identified. First, consultation and advisory roles were held by PLWD and carers [ 25 , 26 , 27 , 28 , 29 , 30 , 32 ], where involved persons share knowledge and experiences to make suggestions [ 32 ], but the research team retained formal decision-making power [ 25 ]. Second, PLWD were involved as co-analysts in data analysis [ 24 , 32 , 33 ]. Co-analysts influence data analysis, but the decision-making power remained with academic researchers [ 24 ]. Third, in six studies the co-researcher role was part of the research design in which involved persons and researchers steer and conduct research together [ 13 , 23 , 31 , 32 , 34 , 36 ]. Finally, two studies partnered with LTC residents [ 35 , 39 ], with residents at the core of the group, and positioned as experts by experience [ 39 ]. Residents had the decision-making authority regarding how to improve life in LTC facilities [ 35 ].

Models for involvement in research

Only two studies designed a model for co-research with PLWD [ 23 ] or their carers [ 13 ] across all research phases. These models underscored the importance of iterative training for co-researchers [ 13 , 23 ] and academic researchers [ 23 ]. Furthermore, these studies advocate involving co-researchers early on in the research process [ 13 ] and in steering committees [ 23 ]. Co-researchers can be involved in designing research materials [ 23 ], conducting interviews [ 13 , 23 ], analysing data [ 13 ], and co-disseminating findings [ 13 , 23 ]. Additionally, one study stressed involving PLWD in identifying (future) research priorities [ 23 ].

Barriers, facilitators, and good practices in research phases

Preparation phase.

Table 3 describes the barriers, facilitators, and good practices per main research phase. Lack of diversity in ethnicity and stages of dementia in the recruitment of involved persons is mentioned as a recurring barrier [ 26 , 28 , 32 , 33 ]. The exclusion of people with cognitive impairments is partly due to gatekeepers’ and recruiters’ bias towards cognitively healthy people [ 28 , 32 ]. It is stressed that researchers should refrain from making assumptions about the abilities of PLWD and ask the person what he/she is willing to do [ 31 ]. It is considered good practice to involve people regardless of cognitive abilities [ 23 ], based on skills, various personal characteristics [ 13 ] and, if possible, relevant prior experience [ 38 ].

Many studies stress the importance of building a mutual trusting relationship between involved persons and academic researchers [ 13 , 23 , 31 , 33 , 34 , 37 ]. A good relationship is believed to break down social barriers [ 37 ], foster freedom of expression [ 33 ], and thereby avoiding tokenistic involvement [ 13 ]. In addition, spending time with these persons is important to become familiar with an individual’s strengths and limitations [ 31 ].

Opting for naturally evolving involvement roles was mentioned as a barrier, as this may result in conflicting expectations and irrelevant tasks [ 37 ]. A clear role description and clarification of tasks is key to balancing potentially different expectations of the involved persons and researchers [ 26 , 28 , 29 , 32 , 38 ]. When designing a role for involvement in research, good practices dictate taking into account personal skills, preferences, development goals, and motivation for involvement [ 13 , 32 ]. This role should ideally be designed in collaboration with involved persons [ 13 , 32 ].

The perception of providing training to involved persons is ambivalent. Studies cited that training should not aim to transform them into “pseudo-scientist” [ 32 , 37 ] and that it raises the costs for involvement [ 28 ]. However, multiple scholars emphasize the importance of providing iterative training to facilitate meaningful involvement and development opportunities [ 13 , 23 , 28 , 31 , 32 , 33 , 36 , 37 ]. Training can empower involved persons to engage in the research process equally and with confidence, with the skills to fulfil their role [ 13 , 33 , 38 ]. However, the implementation of training may present a potential conflict with the fundamental principle of valuing experiential knowledge [ 37 ] and should avoid the objective of transforming co-researchers into 'expert' researchers [ 32 ]. Academic researchers should also be offered training on how to facilitate meaningful involvement [ 13 , 23 , 28 , 31 ].

Limited time and resources were mentioned as barriers to involvement that can delay the research process [ 13 , 33 , 36 , 39 ], restrict the involvement [ 28 ] and hinder the implementation of developed ideas [ 39 ]. Financial compensation for involvement is encouraged [ 25 , 26 , 27 , 32 ], as it acknowledges the contribution of involved persons [ 13 ]. Thus, meaningful involvement in research requires adequate funding and infrastructure to support the involvement activities [ 13 , 28 , 33 , 37 ].

Execution phase

The use of academic jargon and rapid paced discussions [ 13 , 37 ], power differentials, and the dominant discourse in biomedical research on what is considered “good science” can limit the impact of involvement [ 13 , 24 , 32 , 36 , 37 ]. Facilitating researchers should reflect on power differentials [ 35 ] and how decision-making power is shared [ 31 ]. Other facilitating factors are making a glossary of terms used and planning separate meetings for “technical topics” [ 37 ]. In addition, an emergent research design [ 35 ] or a design with flexible elements [ 28 ] can increase ownership in the research project and provide space for involvement to inform the research agenda [ 28 , 35 ]. This requires academic researchers to value experiential knowledge and to have an open mind towards the evolving research process [ 13 , 23 , 31 ].

Furthermore, managing the involvement process and ensuring equity in the collaboration [ 13 , 32 , 33 ], facilitating researchers must encourage involved persons to voice their perspectives. This means that they sometimes need to be convinced that they are experts of lived experience [ 32 , 33 , 36 , 37 , 39 ]. To enable involvement of PLWD, the use of visual and creative tools to prompt memories can be considered [ 24 , 30 , 33 , 34 ], as well as flexibility in relation to time frames and planning regular breaks to avoid too fast a pace for people who may tire easily [ 24 , 25 , 29 , 30 ].

Involvement can be experienced as stressful [ 13 , 32 , 38 ] and caring responsibilities may interfere [ 26 ]. Tailored [ 29 ] physical and emotional support should therefore be offered [ 13 , 23 , 38 ] without making assumptions about the meaning of burden [ 30 , 31 ]. Moreover, being the only PLWD involved in an advisory group was experienced as intimidating [ 25 ] and, ideally, a larger team of PLWD is involved to mitigate responsibilities [ 37 ]. PLWD having a focal point of contact [ 28 , 37 ] and involving nurses or other staff with experience working with PLWD and their carers [ 29 , 30 ] are mentioned as being beneficial. Some stress the importance of involving carers when engaging with PLWD in research [ 25 , 29 , 30 ].

To avoid an overload of information that is shared with the involved persons, tailoring information-sharing formats to individual preferences and abilities is essential to make communication effective [ 27 , 37 ].

Translation

Two studies indicated a need for more robust evaluation measures to assess the effect of involvement [ 28 , 33 ]. Reflection and evaluation of the involvement serves to improve the collaboration and to foster introspective learning [ 13 , 23 , 26 , 31 ]. The included studies evaluated involvement through the use of reflective diaries [ 13 ] or a template [ 38 ] with open-ended questions [ 33 ].

Two studies postulate that findings should benefit and be accessible to PLWD [ 23 , 31 ]. The use of creative tools not only enables involvement of PLWD, but can also increase accessibility of research findings and expand the present representation of PLWD [ 23 ].

The 18 included studies presented multiple methods for involvement in all three research phases. We found five types of involvement: advisory groups, (formal and informal) research team meetings, action groups, workshops, and co-conducting interviews. Only two studies described methods for involvement of LTC users in research. Involved persons were most often involved in consulting and advisory roles, but also as co-analysts, co-researchers, and partners. Involved persons’ roles can evolve and change over time. Especially as involved persons grow into their role, and gain confidence and knowledge of the specific research project, a more active role with shared responsibilities can become part of the research project. In addition, multiple involvement roles can be used throughout the research depending on the research phase.

Compared to the five types of involvement that we identified, other literature reviews about involvement methods for LTC users and PLWD in research also described advisory groups [ 10 ] and workshops [ 5 , 11 ], and methods that were similar to research team meetings (drop-in sessions and meetings [ 11 ]). Methods for action research (action groups) and co-conducting research (interviews) were not included by these other review studies. In addition to our findings, these other reviews also described as involvement methods interviews and focus groups [ 5 , 10 ] surveys [ 10 ], reader consultation [ 11 ]. Those types of methods were excluded from our study, because our definition of involvement is more strict; collecting opinions is not involvement per se, but sometimes only study participation. Moreover, compared to these previous reviews we set a high standard for transparency about the participation methods and the level of detail at which they are described.

Engaging the target group in research, particularly when collaborating with PLWD, LTC users, and carers, involves navigating unforeseen challenges [ 40 ]. This requires academic researchers to carefully balance academic research goals and expectations, and the expectations, personal circumstances and development goals related to the involved person. The aim is to maximize involvement while being attentive to the individual’s needs and avoiding a deficit perspective. Effective communication should be established, promoting respect, equality, and regular feedback between all stakeholders, including individuals living with dementia and LTCF staff. Building a mutual trusting relationship between involved persons and academic researchers through social interaction and clear communication is key to overcome barriers and ensure meaningful involvement. Inclusivity and empowerment, along with fostering an environment where diverse voices are heard, are crucial for the success of involvement in research. Our results are in line with a recent study concerning the experiences of frail older persons with involvement in research, confirming the importance of avoiding stereotypic views of ageing and frailty, building a trusting relationship, and being sensitive to older persons’ preferences and needs [ 41 ].

Furthermore, our results show that training academic researchers and involved persons is essential to develop the skills to facilitate involvement and to fulfil their role with confidence, respectively. Whilst the need for training is acknowledged by others [ 41 , 42 ], there are legitimate objections to the idea of training involved persons, as the professionalization underpinning the concept of training is at odds with voicing a lay perspective [ 43 , 44 ]. Furthermore, it is argued that experiential knowledge is compromised when training is structured according to the dominant professional epistemology of objectivity [ 45 ]. Therefore, training of involved persons should not focus on what researchers think they ought to know, but on what they want to learn [ 41 ].

Academic culture was frequently mentioned as a barrier to meaningful involvement. This result resonates with the wider debate related to involvement in health research which is concerned about active or “authentic involvement” being replaced with the appropriation of the patient voice as an add-on to conventional research designs [ 12 , 46 ]. It is argued that such tokenistic involvement limits the involved persons’ ability to shape research outcomes [ 46 ]. To reduce tokenism requires a culture shift [ 13 ]. We believe that due to the strict definition of involvement and high transparency standard used in this review, tokenistic approaches were excluded. This may set an example for how to stimulate making this culture shift.

Furthermore, the importance of practical aspects such as funding and, by extension, the availability of time should not be underestimated. Adequate funding is necessary for compensation of involvement, but also to ensure that researchers have ample time to plan involvement activities and provide personalized support for PLWD, LTC residents and their carers. Funding bodies increasingly require involvement of the public to be part of research proposals. Yet, support in terms of financial compensation and time for the implementation of involvement in research is rarely part of funding grants [ 42 ]. In addition, whereas an emergent design could aid the impact of involvement, funders often require a pre-set research proposal in which individual components are already fixed [ 5 , 47 ]. This indicates that not only do academic researchers and culture need to change, academic systems also need to be modified in order to facilitate and nurture meaningful involvement [ 47 ].

Strengths and limitations

A key strength of this review is the inclusion of over ten scientific databases, with a reach beyond the conventional biomedical science databases often consulted in systematic reviews. Besides, we believe that we have overcome the inconsistent use of terminology of involvement in research by including also other terms used, such as participation and engagement, in our search strategy. However, there was also inconsistency in length of publications and precision of the explanation of the process of involvement. E.g., involvement in the execution phase was often elaborated on, contributions to the research proposal and co-authoring research findings were only stated and not described. This presented challenges for data extraction and analysis, as it was not always possible to identify how the target group was involved. Involvement in these research phases is therefore not fully represented in this review.

The included studies in this review, the majority of which are of high quality, provide methods for involvement of PLWD and LTC users in research and they do not explicitly attend to the effectiveness or impact of the method for involvement used. Therefore, a limitation of this review is that it cannot make any statements regarding the effectiveness of the involvement methods included. Moreover, our target population was broad, although PLWD and LTC users are largely overlapping in their care needs and share important features, this may have led to heterogeneous results. In future research, it would be interesting to interpret potential differences between involvement of PLWD, LTC users, and their carers. However, as we expected, the amount of literature included in our analyses was too limited to do so. Furthermore, whereas the broad target group is a limitation it is also a strength of our review. Limiting our search to specifically persons living in LTC facilities would have provided limited methods for involvement of persons living with dementia. Our broad target groups enabled us to learn from research projects in which people living with early staged dementia are directly involved from which we can draw lessons on the involvement of people with more advanced stages of dementia and persons living with cognitive problems who live within LTC facilities.

Since January 2021 quite some research has been published about the importance of involvement in research. Although we had quickly screened for new methods, we realise that we may have missed some involvement methods in the past years. There will be a need for a search update in the future.

Implications for future research

Our review shows that a flexible and emergent design may help to increase involved persons' influence on and ownership in the research process. However, not all research objectives may be suitable for the implementation of an emergent design. Future research should therefore examine how aspects of a flexible emergent design can be integrated in, e.g., clinical research without compromising the validity of research outcomes.

Alzheimer Europe has called for the direct involvement of persons living with dementia in research [ 48 ]. In addition, Swarbrick et al. (this review) advise to involve persons regardless of their cognitive abilities [ 23 ]. These statements question the involvement of proxies, such as carers, professional caregivers and others involved in the care of PLWD. While PLWD and persons with other cognitive problems constitute a significant group within residential and nursing homes [ 7 ], none of the studies included in this review have provided methods to directly involve persons with more advanced stages of dementia. This raises the question if research methods should be adapted to allow those with more advanced stages of dementia to be involved themselves or if, concerning the progressive nature of the disease, it is more appropriate to involve proxies. And secondly who should these proxies be? Those that care for and live with persons with an advanced stage of dementia, or for example a person living with an early stage of dementia to represent the voices of persons with more advanced stages of dementia [ 31 ]?

Future research should adopt our example for stricter requirements for involvement and transparency about the involvement methods used. This will reduce tokenistic involvement and further promote the culture shift towards meaningful involvement. In addition, future research should assess the impact of the involvement methods that are described in this review. One of the first instruments that that may be used to do so in varying healthcare settings is the Public and Patient Engagement Evaluation Tool (PPEET) [ 49 ]. Moreover, scholars in this review stress, and we agree with this, that future research is needed on the involvement of persons with more advanced stages of dementia to ensure their voices are not excluded from research [ 33 , 34 ].

This review provides an overview of the existing methods used to actively involve PLWD, LTC users, and carers in scientific research. Our findings show that their involvement is feasible throughout all research phases. We have identified five different methods for involvement, four different roles, and two models for co-research. Our results suggest that planning enough time for involving PLWD, LTC users, and carers in research, is important to ensure that researchers have time to build a trusting relationship and meet their personal needs and preferences. In addition, researchers are advised not to presume the meaning of burden and to avoid a deficit perspective. A flexible or emergent design could aid involved persons’ ownership in the research process.

Availability of data and materials

The full search strategy is provided in supplement 1 . The data extraction form can be provided by the corresponding author on reasonable request.

Abbreviations

Critical Appraisal Skills Programme

Guidance for Reporting Involvement of Patients and the Public, long form version 2

• Long-term care

Persons living with dementia

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Acknowledgements

We thank Jan W. Schoones, information specialist Directorate of Research Policy (formerly: Walaeus Library, Leiden University Medical Centre, Leiden, the Netherlands), for helping with the search.

This systematic review received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Groothuijse, J.M., van Tol, L.S., Leeuwen, C.C.M.(.Hv. et al. Active involvement in scientific research of persons living with dementia and long-term care users: a systematic review of existing methods with a specific focus on good practices, facilitators and barriers of involvement. BMC Geriatr 24 , 324 (2024). https://doi.org/10.1186/s12877-024-04877-7

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