table of content for a research paper

Formatting Guides

APA Table of Contents Writing Guide (+ example)

Speech Topics
Basics of Essay Writing
Essay Topics
Other Essays
Main Academic Essays
Research Paper Topics
Basics of Research Paper Writing
Miscellaneous
Chicago/ Turabian
Data & Statistics
Methodology
Admission Writing Tips
Admission Advice
Other Guides
Student Life
Studying Tips
Understanding Plagiarism
Academic Writing Tips
Basics of Dissertation & Thesis Writing

Essay Guides
Research Paper Guides
Basics of Research Process
Admission Guides
Dissertation & Thesis Guides

Table of contents

Use our free Readability checker

Today we are going to learn how to make a proper APA table of contents. However, let’s start with some backstory to understand the formatting standards according to the latest APA 7th edition .

In an APA style paper , a table of contents is commonly used in longer research papers or dissertations to provide an organized outline of the document's structure. It helps to increase readability and navigation greatly. Even though a table of contents is not officially required by the APA guide, you may be asked by the instructor to include one. That’s why we compiled this guide on how to format a table of contents in APA style. Read our detailed instructions to arrange a contents page. Or you can always ask StudyCrumb to " write my paper for me " and get comprehensive help with your work, including assistance with formatting.

Table of Contents APA: Basics

In the present APA table of contents guide, we will show the most convenient and recommendable format for an APA paper. The first thing that you need to remember — it can not exceed two pages in size. So if the table is a must according to the instructor, you may have to exclude some section headings to fit in. It is good to optimize your paper with subheadings, but don’t get obsessed with it. Here are some of the major formatting rules according to APA Style:

Include at least 2 levels of headings — level 1 and level 2.
Use up to 5 levels of headings if it fits the structure.
Apply indents to highlight different levels of headings.
Locate it right after the abstract, before the intro part. (Read more information if you still wonder on how to write an abstract APA .)
Use a 12 pt Times New Roman font.
Keep the headings in the table left-aligned.
Capitalize all the headlines.
Make sure that margins from all sides are 1 inch long.

In all other regards, your formatting sticks to the plain text format. Don’t include any unnecessary formatting or highlighting. And don't be afraid to ask your instructor about it if you have any doubts or questions. At any time, you can buy essay quickly, remember about it.

APA Table of Contents Example

Nevertheless, there is nothing more representative than a proper APA table of contents sample. Pay attention to the length of indents for different heading levels. Check out our sample right below.

Note, there is no fixed standard for the length of indents that you make to highlight every level of headlines. Make sure that your headlines look readable and easy to distinguish.

Looking for annotated bibliography example APA ? We have got you covered! Open one more of our blogs.

How to Make APA Table of Contents in Word

Microsoft Word is the most likely software for formatting APA style tables of content. That’s why right now, we will learn how to generate automated ones. It is a very simple operation, and you only have to remember easy 3 steps:

Format the headings first
Apply an APA style format
Keep your table updated.

And now, look closer at each individual step, so it will be much easier to remember. So, let’s go! Buy APA format paper entirely from scratch if you have troubles at this point.

Format Your Headings

Before starting working with headings, make sure that all of them are in line with the general formatting style. Normally, the table of contents is generated after the text is finished and proofread. So don’t be in a hurry, even though the contents are located in the very beginning of the text. Make sure that your piece is flawless and doesn’t contain misspellings. Try an online typing test to hone your typing skills quickly. Formatting headings is easy — just highlight the heading first. Then, find a top panel featuring heading styles and make a right click on the one you want to choose. After it, select Please update Heading X to match selection. Do it with every heading that you have. Assign each one with Heading 1 — Heading 5 roles.

Create Table of Contents in APA Formats

One more step and our APA paper with table of contents is as good as ready. From the very beginning, type the page name, keep it centered and aligned to the top. Remember about 1-inch long indents. Make the heading bold to increase readability and navigation. Then choose the “ Table of Contents ” option from the “References” menu that is located on the top panel. In the new window, choose the number of heading levels that will be displayed. As you remember, you need at least 2 and not more than 5 levels of headings.

Keep Table of Contents Consistent

From this point, all the highlighted headings will be automatically synchronized with your table of contents. In case if you make changes to the actual heading, you may also change it in your list in one click. Just make a right click on it and choose the “Update Field” option. In Microsoft Word, you can choose to update either one element or all elements at a time. We recommend updating all the elements to keep your paper consistent and good-looking. Hiring a bibliography writer to work on your table of contents might be helpful as well.

We hope our blog explained all those formatting tricks in a most understandable way. Check out other articles if you have any other questions about academic writing. Good luck with your writing!

Whether it is an APA-style paper or an opinion essay, be sure it will be delivered timely and composed with skill and diligence. Check out the writing service and give yourself a little break from writing! Contact us when you are ready.

Emma Flores knows all about formatting standards. She shares with StudyCrumb readers tips on creating academic papers that will meet high-quality standards.

Frequently Asked Questions

1. is there a size limit for a table of contents in apa style.

Yes, your table of contents should not be bigger than two pages long. If it is larger, consider deleting it entirely or some of the headlines to fit in.

2. Where in the text is the table of contents located in APA style paper?

The table of contents is located after the Acknowledgment but before the Introduction paragraph.

3. How many heading levels is it required to have in a table of contents?

You need to include at least 2 levels and not more than 5 levels of headings. Just analyze the text and come up with the right format for your paper.

Have a language expert improve your writing

Run a free plagiarism check in 10 minutes, automatically generate references for free.

Knowledge Base
Dissertation
Dissertation Table of Contents in Word | Instructions & Examples

Dissertation Table of Contents in Word | Instructions & Examples

Published on 15 May 2022 by Tegan George .

The table of contents is where you list the chapters and major sections of your thesis, dissertation, or research paper, alongside their page numbers. A clear and well-formatted table of contents is essential, as it demonstrates to your reader that a quality paper will follow.

The table of contents (TOC) should be placed between the abstract and the introduction. The maximum length should be two pages. Depending on the nature of your thesis, dissertation, or paper, there are a few formatting options you can choose from.

Download Word doc Download Google doc

Instantly correct all language mistakes in your text

Be assured that you'll submit flawless writing. Upload your document to correct all your mistakes.

What to include in your table of contents, what not to include in your table of contents, creating a table of contents in microsoft word, table of contents examples, updating a table of contents in microsoft word, other lists in your thesis, dissertation, or research paper, frequently asked questions about the table of contents.

Depending on the length of your document, you can choose between a single-level, subdivided, or multi-level table of contents.

A single-level table of contents only includes ‘level 1’ headings, or chapters. This is the simplest option, but it may be too broad for a long document like a dissertation.
A subdivided table of contents includes chapters as well as ‘level 2’ headings, or sections. These show your reader what each chapter contains.
A multi-level table of contents also further divides sections into ‘level 3’ headings. This option can get messy quickly, so proceed with caution. Remember your table of contents should not be longer than 2 pages. A multi-level table is often a good choice for a shorter document like a research paper.

Examples of level 1 headings are Introduction, Literature Review, Methodology, and Bibliography. Subsections of each of these would be level 2 headings, further describing the contents of each chapter or large section. Any further subsections would be level 3.

In these introductory sections, less is often more. As you decide which sections to include, narrow it down to only the most essential.

Including appendices and tables

You should include all appendices in your table of contents. Whether or not you include tables and figures depends largely on how many there are in your document.

If there are more than three figures and tables, you might consider listing them on a separate page. Otherwise, you can include each one in the table of contents.

Theses and dissertations often have a separate list of figures and tables.
Research papers generally don’t have a separate list of figures and tables.

The only proofreading tool specialized in correcting academic writing

The academic proofreading tool has been trained on 1000s of academic texts and by native English editors. Making it the most accurate and reliable proofreading tool for students.

Correct my document today

All level 1 and level 2 headings should be included in your table of contents, with level 3 headings used very sparingly.

The following things should never be included in a table of contents:

Your acknowledgements page
Your abstract
The table of contents itself

The acknowledgements and abstract always precede the table of contents, so there’s no need to include them. This goes for any sections that precede the table of contents.

To automatically insert a table of contents in Microsoft Word, be sure to first apply the correct heading styles throughout the document, as shown below.

Choose which headings are heading 1 and which are heading 2 (or 3!
For example, if all level 1 headings should be Times New Roman, 12-point font, and bold, add this formatting to the first level 1 heading.
Highlight the level 1 heading.
Right-click the style that says ‘Heading 1’.
Select ‘Update Heading 1 to Match Selection’.
Allocate the formatting for each heading throughout your document by highlighting the heading in question and clicking the style you wish to apply.

Once that’s all set, follow these steps:

Add a title to your table of contents. Be sure to check if your citation style or university has guidelines for this.
Place your cursor where you would like your table of contents to go.
In the ‘References’ section at the top, locate the Table of Contents group.
Here, you can select which levels of headings you would like to include. You can also make manual adjustments to each level by clicking the Modify button.
When you are ready to insert the table of contents, click ‘OK’ and it will be automatically generated, as shown below.

The key features of a table of contents are:

Clear headings and subheadings
Corresponding page numbers

Check with your educational institution to see if they have any specific formatting or design requirements.

Prevent plagiarism, run a free check.

Write yourself a reminder to update your table of contents as one of your final tasks before submitting your dissertation or paper. It’s normal for your text to shift a bit as you input your final edits, and it’s crucial that your page numbers correspond correctly.

It’s easy to update your page numbers automatically in Microsoft Word. Simply right-click the table of contents and select ‘Update Field’. You can choose either to update page numbers only or to update all information in your table of contents.

In addition to a table of contents, you might also want to include a list of figures and tables, a list of abbreviations and a glossary in your thesis or dissertation. You can use the following guides to do so:

List of figures and tables
List of abbreviations

It is less common to include these lists in a research paper.

All level 1 and 2 headings should be included in your table of contents . That means the titles of your chapters and the main sections within them.

The contents should also include all appendices and the lists of tables and figures, if applicable, as well as your reference list .

Do not include the acknowledgements or abstract in the table of contents.

To automatically insert a table of contents in Microsoft Word, follow these steps:

Apply heading styles throughout the document.
In the references section in the ribbon, locate the Table of Contents group.
Click the arrow next to the Table of Contents icon and select Custom Table of Contents.
Select which levels of headings you would like to include in the table of contents.

Make sure to update your table of contents if you move text or change headings. To update, simply right click and select Update Field.

The table of contents in a thesis or dissertation always goes between your abstract and your introduction.

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the ‘Cite this Scribbr article’ button to automatically add the citation to our free Reference Generator.

George, T. (2022, May 15). Dissertation Table of Contents in Word | Instructions & Examples. Scribbr. Retrieved 15 April 2024, from https://www.scribbr.co.uk/thesis-dissertation/contents-page/

Is this article helpful?

Tegan George

Other students also liked, dissertation title page, how to write an abstract | steps & examples, thesis & dissertation acknowledgements | tips & examples.

How to Write a Table of Contents for Different Formats With Examples

11 December 2023

last updated

Rules that guide academic writing are specific to each paper format. However, some rules apply to all styles – APA, MLA, Chicago/Turabian, and Harvard. Basically, one of these rules is the inclusion of a Table of Contents (TOC) in an academic text, particularly long ones, like theses, dissertations, and research papers. When writing a TOC, students or researchers should observe some practices regardless of paper formats. Also, it includes writing the TOC on a new page after the title page, numbering the first-level and corresponding second-level headings, and indicating the page number of each entry. Hence, scholars need to learn how to write a table of contents in APA, MLA, Chicago/Turabian, and Harvard styles.

General Guidelines

When writing academic texts, such as theses, dissertations, and other research papers, students observe academic writing rules as applicable. Generally, the different paper formats – APA, MLA, Chicago/Turabian, and Harvard – have specific standards that students must follow in their writing. In this case, one of the rules is the inclusion of a Table of Contents (TOC) in the document. By definition, a TOC is a roadmap that scholars provide in their writing, outlining each portion of a paper. In other words, a TOC enables readers to locate specific information in documents or revisit favorite parts within written texts. Moreover, this part of academic papers provides readers with a preview of the paper’s contents.

For writing your paper, these links will be helpful:

Buy Research Paper
How to Write a Research Paper
How to Write a Research Proposal
How to Write a Term Paper
How to Write a Case Study

Difference Between a Table of Contents and an Outline

In essence, a TOC is a description of first-level headings (topics) and second-level headings (subtopics) within the paper’s body. For a longer document, writers may also include third-level titles to make the text palatable to read. Ideally, the length of papers determines the depth that authors go into detailing their writing in TOCs. Basically, this feature means that shorter texts may not require third-level headings. In contrast, an essay outline is a summary of the paper’s main ideas with a hierarchical or logical structuring of the content. Unlike a TOC that only lists headings and subheadings, outlines capture these headings and then describe the content briefly under each one. As such, an outline provides a more in-depth summary of essay papers compared to a TOC.

How to Write a Table of Contents in APA

When writing a TOC in the APA format , writers should capture all the headings in the paper – first-level, second-level, and even third-level. Besides this information, they should also include an abstract, references, and appendices. Notably, while a TOC in the APA style has an abstract, this section is not necessary for the other formats, like MLA, Chicago/Turabian, and Harvard. Hence, an example of a Table of Contents written in the APA format is indicated below:

How to Write a Table of Contents in MLA

Unlike papers written in the APA style, MLA papers do not require a Table of Contents unless they are long enough. In this case, documents, like theses, dissertations, and books written in the MLA format should have a TOC. Even where a TOC is necessary, there is no specific method that a writer should use when writing it. In turn, the structure of the TOC is left to the writer’s discretion. However, when students have to include a TOC in their papers, the information they capture should be much more than what would appear in the APA paper . Hence, an example of writing a Table of Contents in MLA format is:

In the case of writing a research paper, an example of a Table of Contents should be:

Example of a table of contents for a research paper in MLA

How to Write a Table of Contents in Chicago/Turabian

Like the MLA style, a Chicago/Turabian paper does not require writing a Table of Contents unless it is long enough. When a TOC is necessary, writers should capitalize on major headings. Additionally, authors do not need to add a row of periods (. . . . . . . .) between the heading entry and the page number. Moreover, the arrangement of the content should start with the first-level heading, then the second-level heading, and, finally, the third-level title, just like in the APA paper. In turn, all the information that precedes the introduction part should have lowercase Roman numerals. Also, the row of periods is only used for major headings. Hence, an example of writing a Table of Contents in a Chicago/Turabian paper is:

Example of a table of contents in Chicago/Turabian

How to Write a Table of Contents in Harvard

Like in the other formats, writing a Table of Contents in the Harvard style is captured by having the title “Table of Contents” at the center of the page, in the first line. Basically, it comes after the title page and captures all the sections and subsections of Harvard papers. In other words, writers must indicate first-level headings in a numbered list. Also, scholars should align titles to the left side and capitalize them. In turn, if there is a need to show second-level headings, authors should list them under corresponding first-level headings by using bullet points. However, it is essential for students not to disrupt the numbering of first-level headings. Moreover, writers should align second-level headings to the left side and indent them by half an inch and capitalize on this content. Hence, an example of writing a Table of Contents in a Harvard paper should appear as below:

Example of a table of contents in Harvard

A Table of Content (TOC) is an essential component of an academic paper , particularly for long documents, like theses, dissertations, and research papers. When students are writing a TOC, they should be careful to follow the applicable format’s rules and standards. Regardless of the format, writers should master the following tips when writing a TOC:

Write the TOC on a new page after the title page.
Indicate first-level headings of the document in a numbered list.
Indicate second-level headings under the corresponding first-level heading.
If applicable, indicate third-level headings under the corresponding second-level heading.
Write the page number for each heading.
Put the content in a two-column table.
Title the page with “Table of Contents.”

To Learn More, Read Relevant Articles

Mit essay prompts: free examples of writing assignments in 2024, how to cite a dictionary in mla 9: guidelines and examples.

University of Michigan Library
Research Guides

Microsoft Word for Dissertations

Table of Contents
Introduction, Template, & Resources
Formatting for All Readers
Applying a Style
Modifying a Style
Setting up a Heading 1 Example
Images, Charts, Other Objects
Footnotes, Endnotes, & Citations
Cross-References
Appendix Figures & Tables
List of Figures/Tables
Chapter and Section Numbering
Page Numbers
Landscape Pages
Combining Chapter Files
Commenting and Reviewing
The Two-inch Top Margin
Troubleshooting
Finalizing Without Styles
Preparing Your Final Document

Automatic Table of Contents

An automatic Table of Contents relies on Styles to keep track of page numbers and section titles for you automatically. Microsoft Word can scan your document and find everything in the Heading 1 style and put that on the first level of your table of contents, put any Heading 2’s on the second level of your table of contents, and so on.

If you want an automatic table of contents you need to apply the Heading 1 style to all of your chapter titles and front matter headings (like “Dedication” and “Acknowledgements”). All section headings within your chapters should use the Heading 2 style. All sub-section headings should use Heading 3 , etc....

If you have used Heading styles in your document, creating an automatic table of contents is easy.

Place your cursor where you want your table of contents to be.
On the References Ribbon, in the Table of Contents Group , click on the arrow next to the Table of Contents icon, and select Custom Table of Contents .
We suggest that you set each level (Chapters, sections, sub-sections, aka TOC 1, TOC 2, TOC 3) to be single-spaced, with 12 points of space afterwards. This makes each item in your ToC clump together if they're long enough to wrap to a second line, with the equivalent of a double space between each item, and makes the ToC easier to read and understand than if every line were double-spaced. See the video below for details.
If you want to change which headings appear in your Table of Contents, you can do so by changing the number in the Show levels: field. Select "1" to just include the major sections (Acknowledgements, List of Figures, Chapters, etc...). Select "4" to include Chapters, sections, sub-sections, and sub-sub-sections.
Click OK to insert your table of contents.

The table of contents is a snapshot of the headings and page numbers in your document, and does not automatically update itself as you make changes. At any time, you can update it by right-clicking on it and selecting Update field . Notice that once the table of contents is in your document, it will turn gray if you click on it. This just reminds you that it is a special field managed by Word, and is getting information from somewhere else.

Modifying the format of your Table of Contents

The video below shows how to make your Table of Contents a little easier to read by formatting the spacing between items in your Table of Contents. You may recognize the "Modify Style" window that appears, which can serve as a reminder that you can use this window to modify more than just paragraph settings. You can modify the indent distance, or font, or tab settings for your ToC, just the same as you may have modified it for Styles.

an image of the Modify Table of Contents window, where you can set Show Levels

By default, the Table of Contents tool creates the ToC by pulling in Headings 1 through 3. If you'd like to modify that -- to only show H1's, or to show Headings 1 through 4 -- then go to the References tab and select Custom Table of Contents . In the window that appears, set Show Levels to "1" to only show Heading 1's in the Table of Contents, or set it to "4" to show Headings 1 through 4.

Bonus tip for updating fields like the Table of Contents

You'll quickly realize that all of the automatic Lists and Tables need to be updated occasionally to reflect any changes you've made elsewhere in the document -- they do not dynamically update by themselves. Normally, this means going to each field, right-clicking on it and selecting "Update Field".

Alternatively, to update all fields throughout your document (Figure/Table numbers & Lists, cross-references, Table of Contents, etc...), just select "Print". This will cause Word to update everything in anticipation of printing. Once the print preview window appears, just cancel.

How to Effectively Create a Table of Contents for Your Research Paper?

Creating a table of contents (TOC) for a research paper might seem straightforward, but it’s a crucial part of your document that requires careful consideration. A well-organized TOC not only guides your readers through your paper but also reflects the depth and thoroughness of your research. So, how do you craft a TOC that enhances the readability and professionalism of your research paper?

Understanding the Basics of a Table of Contents

Before diving into the specifics, let’s understand what a TOC is. Essentially, it’s an organized listing of the chapters and major sections of your document. It’s like a roadmap, allowing readers to quickly navigate to sections that are most relevant to them. A clear, concise, and well-formatted TOC is more than just a list; it’s an integral part of your paper’s structure.

Step-by-Step Guide to Crafting Your TOC

Identify the Key Sections : Start by listing down all the chapters, sections, and significant sub-sections of your paper. This includes your introduction, literature review, methodology, results, discussion, and conclusion.
Use Consistent Formatting : Consistency is key in a TOC. Use the same font style and size as your main text, but you can bold or italicize the headings for emphasis. Remember, your TOC should be easy to read and navigate.
Leverage Word Processing Tools : Most word processors, like Microsoft Word, have built-in features to create a TOC automatically. Utilize these tools to ensure accuracy and ease of updating your TOC as your paper evolves.
Page Numbering : Each entry in your TOC should have a corresponding page number. This is crucial for guiding your readers directly to the content they’re interested in.
Update Regularly : As your research paper develops, so should your TOC. Regular updates ensure that the TOC accurately reflects the content of your paper.

While the basics of creating a TOC are universal, different research fields and styles might have specific requirements or preferences. For instance, APA style papers have particular guidelines for TOC formatting, including how to handle different levels of headings and page numbers. Here are some insights gathered from various online sources to help you tailor your TOC to your paper’s needs:

APA Style Specifics : If you’re writing in APA style, pay attention to how you format the different levels of headings in your TOC. The APA guidelines provide clear instructions on this, ensuring that your TOC aligns with the rest of your document’s formatting.
The Role of a TOC in Navigation : A TOC is more than just a list; it’s a navigational tool. It should provide a clear and concise overview of your paper’s structure, allowing readers to easily locate specific sections or topics.
Customizing Your TOC : Depending on your research paper’s complexity, you might want to customize your TOC. This could involve including or excluding certain elements, such as figures or tables, based on their relevance to your paper’s overall structure.
Automating Page Numbers : Modern word processors can automatically update page numbers in your TOC. This feature is incredibly useful, especially when you’re making significant edits to your paper that might affect its pagination.
Clarity and Readability : Above all, your TOC should be clear and easy to read. Avoid cluttering it with unnecessary details. Stick to the main sections and headings that provide a straightforward overview of your paper’s content.

Remember, your TOC is often one of the first elements your readers will interact with. Make it engaging and reflective of the depth of your research. Use it to showcase the organization and thoroughness of your work. A well-crafted TOC not only aids in navigation but also sets the tone for the rest of your paper. It’s an opportunity to make a strong first impression, indicating to your readers that your research is well-structured and thoughtfully presented.

To illustrate the importance of a well-structured TOC, consider the case of a complex research paper covering multiple interconnected topics. A clear TOC allows readers to easily navigate between these topics, understanding how they interrelate and contribute to the overall thesis of the paper. This not only enhances the reader’s experience but also underscores the researcher’s ability to organize complex information effectively.

Actionable Steps

For those looking to create their own TOC, here are some actionable steps:

Review Your Document’s Structure : Before creating your TOC, ensure that your document is well-organized with clearly defined sections and headings.
Utilize Built-in TOC Features : Use the TOC features of your word processor to automatically generate and update your TOC.
Customize According to Style Guides : If your paper must adhere to a specific style guide (like APA), customize your TOC to meet these requirements.
Regularly Update Your TOC : As your paper evolves, regularly update your TOC to reflect any changes in structure or page numbers.
Keep It Simple and Clear : Your TOC should be easy to navigate. Avoid overcomplicating it with too many sub-levels or unnecessary information.

How to Create the Best Table of Contents for a Dissertation

Published by Owen Ingram at August 12th, 2021 , Revised On September 20, 2023

“A table of contents is an essential part of any article, book, proceedings, essay , and paper with plenty of information. It requires providing the reader’s guidance about the position of the content.”

When preparing a dissertation , you may cram as much information into it as appropriate. The dissertation may be an extremely well-written one with a lot of valuable information to offer. Still, all that information could become perplexing if the reader cannot easily find the information.

The length of dissertations usually varies from a few pages to a few hundred pages, making it very difficult to find information that you may be after.

Instead of skimming through every page of the dissertation, there is a need for a guideline that directs the reader to the correct section of the dissertation and, more importantly, the correct page in the section.

Also read: The List of Figures and Tables in the Dissertation .

What is the Table of Contents in the Dissertation?

The table of contents is the section of a dissertation that guides each section of the dissertation paper’s contents.

Depending on the detail level in a table of contents, the most useful headings are listed to provide the reader concerning which page the said information may be found.

The table of contents is essentially a list found at the beginning of a dissertation , which contains names of the chapters, section titles and/or very brief descriptions, and page numbers indicated for each.

This allows the reader to look at the table of contents to locate the information needed from the dissertation. Having an effective table of contents is key to providing a seamless reading experience to the reader.

Here in this article, we will uncover every piece of information you need to know to write the dissertation’s abstract.

This article helps the readers on how to create the best table of contents for the dissertation. An important thing to note is that this guide discusses creating a table of contents in Microsoft Word.

Looking for dissertation help?

Researchprospect to the rescue then.

We have expert writers on our team who are skilled at helping students with dissertations across a variety of disciplines. Guaranteeing 100% satisfaction!

Styles for Dissertation Table of Contents

Making an effective table of contents starts with identifying headings and designating styles to those headings.

Using heading styles to format your headings can save a lot of time by automatically converting their formatting to the defined style and serves as a tool to identify the heading and its level, used later when creating a thesis table of contents .

Each heading style already has predefined sizes, fonts, colours, spacing, etc. but can be changed as per the user’s requirements. This also helps once all headings have been created and you intend to change the style of a certain type of heading.

All that is needed to change the style of a type of heading is automatically reflected on all headings that use the style.

Below is how the styles menu looks like;

To allocate a style to a heading, first select a heading and then click on one of the styles in the ‘Styles’ menu. Doing so converts the selected heading to the style that is selected in the Styles menu.

You can style a similar heading level in the same style by selecting each heading and then clicking on the style in the Style menu.

It is important to note that it greatly helps and saves time if you allocate styles systematically, i.e., you allocate the style as you write.

The styles are not limited to headings only but can be used for paragraphs and by selecting the whole paragraph and applying a style to it.

Changing Appearance of Pre-Defined Styles

To change the appearance of a style to one that suits you,

You would need to right-click on one of the styles to open a drop-down menu.

Select ‘Modify’ from the menu. This would display a window with various formatting and appearance options. You can select the most appropriate ones and click ‘OK.’ The change that you made to the style reflects on all headings or paragraphs that use this style.

Further changes can be made to headings, but using styles is an important step for creating the table of contents for the thesis. Once this step is completed, you can continue to create a thesis table of contents.

Also Read: What is Appendix in Dissertation?

Things to Consider when Making APA Style Table of Contents

The pages before the body of the dissertation, known as the ‘Prefatory Pages,’ should not have page numbers on them but should be numbered in the Roman Numerals instead as (i, ii, iii…).
Table of Contents and the Abstract pages are not to contain any numbers.
The remaining pages would carry the standard page numbers (1,2,3…).
The section titles and page numbers in the dissertation table of contents should have dotted lines between them.
All the Prefatory pages, Sections, Chapter Titles, Headings, Sub Headings, Reference Sections, and Appendices should be listed in the contents’ thesis table. If there are a limited number of Tables or Figures, they may be listed in the dissertation’s table contents.
If there are many figures, tables, symbols, or abbreviations, a List of Tables, List of Figures , List of Symbols, and List of Abbreviations should be made for easy navigation. These lists, however, should not be listed in the thesis table of contents.
The thesis/dissertation must be divided into sections even if it is not divided into chapters, with all sections being listed in the table of contents for the thesis.

Generating Dissertation Table of Contents

First, to generate the Table of Contents, start by entering a blank page after the pages you need the table of contents to follow.

To do so, click on the bottom of the page you want before the Table of Contents.
Open the ‘Insert’ tab and select ‘Page Break’.
This will create a page between the top and bottom sections of the Table of Contents area.

Generating-Table-of-Contents-for-Your-Dissertation

By the time you reach this section, you would have given each heading or sub-heading a dedicated style, distinguishing between different types of headings. Microsoft Word can automatically generate a Table of Contents, but the document, particularly the headings, needs to be formatted according to styles for this feature to work. You can assign different headings levels, different styles for Microsoft Word to recognize the level of heading.

How to Insert Table of Contents

Place the cursor where you want to place the Table of Contents on the page you added earlier.
On the ‘References’ tab, open the Table of Contents group. This would open a list of different Table of Contents designs and a table of contents sample.

You can select an option from the available Table of Contents or make a Custom Table of Contents. Although the available Table of Contents samples is appropriate, you may use a custom table of contents if it is more suitable to your needs. This allows you to modify different formatting options for the Table of Contents to satisfy your own

Updating the Table of Contents

As you proceed with editing your dissertation, the changes cause the page numbers and headings to vary. Often, people fail to incorporate those changes into the Table of Contents, which then effectively serves as an incorrect table and causes confusion.

It is thus important to update the changes into the table of contents as the final step once you have made all the necessary changes in the dissertation and are ready to print it.

These changes may alter the length of the thesis table of contents , which may also cause the dissertation’s formatting to be altered a little, so it is best to reformat it after updating the table of contents.

To update the table of contents,

Select ‘Update Table’ in the References tab.
This would open a dialogue box. Select ‘Update Entire Table’ to ensure that all changes are reflected in the contents table and not just the page numbers. This would display all changes and additions you have made to the document (Anon., 2017).

Using this guide, you should understand how to create the best table of contents for the dissertation. The use of a Table of Contents, while being important for most written work, is even more critical for dissertations, especially when the proper methodology of creating the table of contents is followed.

This includes the guidelines that must be considered to correctly format the table of contents so that it may be shaped so that it follows the norms and is effective at helping the reader navigate through the content of the dissertation.

The use of Microsoft Word’s Table of Contents generation feature has greatly helped people worldwide create, edit, and update the table of contents of their dissertations with ease.

Here in this article, we will uncover every piece of information you need to know how to write the dissertation’s abstract .

Are you in need of help with dissertation writing? At ResearchProspect, we have hundreds of Master’s and PhD qualified writers for all academic subjects, so you can get help with any aspect of your dissertation project. You can place your order for a proposal , full dissertation paper , or individual chapters .

Is it essential to add a table of content to the dissertation?

Yes, it is important to add a table of content in a dissertation .

How to make an effective table of contents for the dissertation?

How do I update the table of contents?

How do I format a table of contents in MLA style?

Note: This post relates to content in the eighth edition of the MLA Handbook . For up-to-date guidance, see the ninth edition of the MLA Handbook .

Tables of contents may be formatted in a number of ways. In our publications, we sometimes list chapter numbers before chapter titles and sometimes list the chapter titles alone. We also sometimes list section heads beneath the chapter titles. After each chapter or heading title, the page number on which the chapter or section begins is provided. The following show examples from three of the MLA’s books.

From Elizabeth Brookbank and H. Faye Christenberry’s MLA Guide to Undergraduate Research in Literature (Modern Language Association of America, 2019):

From Approaches to Teaching Bechdel’s Fun Home, edited by Judith Kegan Gardiner (Modern Language Association of America, 2018):

From the MLA Handbook , 8th ed. (Modern Language Association of America, 2016):

Need more information? Read about where to place a table of contents in your paper .

Foundations
Write Paper

Search form

Experiments
Anthropology
Self-Esteem
Social Anxiety

Research Paper >

Table of Contents Format

For Academic Papers

This table of contents is an essential part of writing a long academic paper, especially theoretical papers.

This article is a part of the guide:

Outline Examples
Example of a Paper
Write a Hypothesis
Introduction

Browse Full Outline

1 Write a Research Paper
2 Writing a Paper
3.1 Write an Outline
3.2 Outline Examples
4.1 Thesis Statement
4.2 Write a Hypothesis
5.2 Abstract
5.3 Introduction
5.4 Methods
5.5 Results
5.6 Discussion
5.7 Conclusion
5.8 Bibliography
6.1 Table of Contents
6.2 Acknowledgements
6.3 Appendix
7.1 In Text Citations
7.2 Footnotes
7.3.1 Floating Blocks
7.4 Example of a Paper
7.5 Example of a Paper 2
7.6.1 Citations
7.7.1 Writing Style
7.7.2 Citations
8.1.1 Sham Peer Review
8.1.2 Advantages
8.1.3 Disadvantages
8.2 Publication Bias
8.3.1 Journal Rejection
9.1 Article Writing
9.2 Ideas for Topics

It is usually not present in shorter research articles, since most empirical papers have similar structure .

A well laid out table of contents allows readers to easily navigate your paper and find the information that they need. Making a table of contents used to be a very long and complicated process, but the vast majority of word-processing programs, such as Microsoft WordTM and Open Office , do all of the hard work for you.

This saves hours of painstaking labor looking through your paper and makes sure that you have picked up on every subsection. If you have been using an outline as a basis for the paper, then you have a head start and the work on the table of contents formatting is already half done.

Whilst going into the exact details of how to make a table of contents in the program lies outside the scope of this article, the Help section included with the word-processing programs gives a useful series of tutorials and trouble-shooting guides.

That said, there are a few easy tips that you can adopt to make the whole process a little easier.

The Importance of Headings

In the word processing programs, there is the option of automatically creating headings and subheadings, using heading 1, heading 2, heading 3 etc on the formatting bar. You should make sure that you get into the habit of doing this as you write the paper, instead of manually changing the font size or using the bold format.

Once you have done this, you can click a button, and the program will do everything for you, laying out the table of contents formatting automatically, based upon all of the headings and subheadings.

In Word, to insert a table of contents, first ensure that the cursor is where you want the table of contents to appear. Once you are happy with this, click 'Insert' on the drop down menu, scroll down to 'Reference,' and then across to 'Index and Tables'.

Click on the 'Table of Contents' tab and you are ready to click OK and go. OpenOffice is a very similar process but, after clicking 'Insert,' you follow 'Indexes and Tables' and 'Indexes and Tables' again.

The table of contents should appear after the title page and after the abstract and keywords, if you use them. As with all academic papers, there may be slight variations from department to department and even from supervisor to supervisor.

Check the preferred table of contents format before you start writing the paper , because changing things retrospectively can be a little more time consuming.

Psychology 101
Flags and Countries
Capitals and Countries

Martyn Shuttleworth (Aug 27, 2009). Table of Contents Format. Retrieved Apr 17, 2024 from Explorable.com: https://explorable.com/table-of-contents-format

You Are Allowed To Copy The Text

The text in this article is licensed under the Creative Commons-License Attribution 4.0 International (CC BY 4.0) .

This means you're free to copy, share and adapt any parts (or all) of the text in the article, as long as you give appropriate credit and provide a link/reference to this page.

That is it. You don't need our permission to copy the article; just include a link/reference back to this page. You can use it freely (with some kind of link), and we're also okay with people reprinting in publications like books, blogs, newsletters, course-material, papers, wikipedia and presentations (with clear attribution).

Want to stay up to date follow us, check out the official book.

Learn how to construct, style and format an Academic paper and take your skills to the next level.

(also available as ebook )

Save this course for later

Don't have time for it all now? No problem, save it as a course and come back to it later.

Footer bottom

Subscribe to our RSS Feed
Like us on Facebook
Follow us on Twitter

The Plagiarism Checker Online For Your Academic Work

Start Plagiarism Check

Editing & Proofreading for Your Research Paper

Get it proofread now

Online Printing & Binding with Free Express Delivery

Configure binding now

Academic essay overview
The writing process
Structuring academic essays
Types of academic essays
Academic writing overview
Sentence structure
Academic writing process
Improving your academic writing
Titles and headings
APA style overview
APA citation & referencing
APA structure & sections
Citation & referencing
Structure and sections
APA examples overview
Commonly used citations
Other examples
British English vs. American English
Chicago style overview
Chicago citation & referencing
Chicago structure & sections
Chicago style examples
Citing sources overview
Citation format
Citation examples
College essay overview
Application
How to write a college essay
Types of college essays
Commonly confused words
Definitions
Dissertation overview
Dissertation structure & sections
Dissertation writing process
Graduate school overview
Application & admission
Study abroad
Master degree
Harvard referencing overview
Language rules overview
Grammatical rules & structures
Parts of speech
Punctuation
Methodology overview
Analyzing data
Experiments
Observations
Inductive vs. Deductive
Qualitative vs. Quantitative
Types of validity
Types of reliability
Sampling methods
Theories & Concepts
Types of research studies
Types of variables
MLA style overview
MLA examples
MLA citation & referencing
MLA structure & sections
Plagiarism overview
Plagiarism checker
Types of plagiarism
Printing production overview
Research bias overview
Types of research bias
Example sections
Types of research papers
Research process overview
Problem statement
Research proposal
Research topic
Statistics overview
Levels of measurment
Frequency distribution
Measures of central tendency
Measures of variability
Hypothesis testing
Parameters & test statistics
Types of distributions
Correlation
Effect size
Hypothesis testing assumptions
Types of ANOVAs
Types of chi-square
Statistical data
Statistical models
Spelling mistakes
Tips overview
Academic writing tips
Dissertation tips
Sources tips
Working with sources overview
Evaluating sources
Finding sources
Including sources
Types of sources

Your Step to Success

Plagiarism Check within 10min

Printing & Binding with 3D Live Preview

Example for Table of Contents

How do you like this article cancel reply.

Save my name, email, and website in this browser for the next time I comment.

Inhaltsverzeichnis

1 Definition
3 Examples for Your Thesis
4 Master’s Thesis Examples
5 Microsoft Word Tutorial
6 In a Nutshell

Definition

A table of contents example will help structure a long academic manuscript and a table of contents page is necessary for academic submission. The table of contents contains an organised listing of your manuscript’s chapters and sections with clearly marked (and accurate) page numbers. The aim of the table of contents is to allow the reader to flip easily to the section they require and to get a feel of your argument’s structure.

What comes first, table of contents or abstract?

If you are writing an academic paper, you have to take the order of your paper into account. Usually, the first sections of your thesis are the title page, cover page, acknowledgements and the abstract . After these pages, you place the table of contents. Be sure to check that all of the page numbers in your table of contents are correct.

What variations of table of content examples exist?

The table of contents can be displayed in the following formats:

Single level table of contents
Subdivided table of contents
Multi-level table of contents
Academic table of contents

You will find further details about what needs to be included inside of the table of contents on our blog.

Are references included in table of contents?

Yes. The references are included in the table of contents. You add them in as you would any other section of your thesis. Simply write the section in the table of contents with the corresponding page number. However, the acknowledgement for thesis and the abstract are usually not included in the table of contents. However, check with your institution as this could be dependent upon the formatting that you’re required to follow.

How can I make a table of contents in Microsoft Word?

On Microsoft Word, you will find the function to create a table of contents under the ‘references’ tab. Click on the tab and select ‘table of contents’. You can use one that has been designed by Microsoft Word, or you can create a custom one by yourself. Scroll down for a full tutorial on Microsoft Word and creating a table of contents.

Examples for Your Thesis

Below, you will find different examples for table of contents, including a

Single level table of contents example
Subdivided table of contents example
Multi-level table of contents example

We will also show you with an example how the table of contents for a bachelor’s thesis could look like, as well as for a master’s thesis.

Advice for creating a good table of contents: A good table of contents must be easy to read and formatted accurately, containing quick reference pages for all figures and illustrations. A table of contents example will help you structure your own thesis, but remember to make it relevant to your discipline. Table of contents example structures can be created for different disciplines, such as social sciences, humanities and engineering.

The type and length of a table of contents example will depend on the manuscript. Some thesis’ are short, containing just several chapters, whilst others (like a PhD thesis) are as lengthy as a book. This length will dictate the amount of detail that goes into forming a table of contents example page and the amount of “levels” (or subdivisions) in each chapter.

✓ Post a picture on Instagram
✓ Get the most likes on your picture
✓ Receive up to $300 cash back

Single Level Table of Contents Example

For shorter documents, a single level table of contents example can be used. This is a short and succinct table of contents example which utilises only single-level entries on sections or chapters. Remember, you’ll need to include properly formatted dots to lead the reader’s eye to the page number on the far right. The following table of contents example explores this basic structure:

Table-of-Contents-Example-Single-level-1

Subdivided Table of Contents E xample

A subdivided table of contents example is required for more lengthy papers, offering a subdivision of chapters and sections within chapters. These are more detailed and are recommended for higher-level dissertations like masters or PhD thesis’ (as well as some more detailed bachelor’s dissertations).

When formating subdivided table of contents example, ensure that chapters are listed in bold font and that subsections are not. It’s common (though not necessary) to denote each subsection by a number (1.1, etc.). You’ll also want to indent the subsections so that they can be read easily. The following table of contents example explores this structure:

Table-of-Contents-Example-Subdivided-table

Multi-level Table of Contents E xample

Adding additional levels to your table of contents is known as a multi-level table of contents example. These would be numbered onwards at 1.1.1, etc. Be aware that although you want to guide your reader through your manuscript, you should only highlight important areas of your manuscript, like sections and sub-sections, rather than random areas or thoughts in your manuscript. Creating too many levels will make your table of contents unnecessarily busy and too complex.

Academic Table of Contents

All of the above can be used as an academic table of contents example. Often, each separate heading in an academic work needs to be both numbered and labelled in accordance with your preferred reference style (consult your department). The following table of contents example sections will illustrate a table of contents example for a bachelor thesis and a table of contents example for a master thesis.

Table of Contents Example: Bachelor’s Thesis

A bachelor’s degree thesis has no set word or page limit nationwide and will depend entirely on your university or department’s guidelines. However, you can expect a thesis under 60 pages of length at between 10,000 – 15,000 words. As such, you won’t be expected to produce a long and detailed table of contents example with multiple levels and subsections. This is because your main body is more limited in terms of word count. At most, you may find yourself using a subdivided table of contents similar to the table of contents example above.

A bachelor’s thesis table of contents example may be structured like so:

Table-of-Contents-Example-Bachelor-Thesis-1

This table of contents example may change depending on your discipline and thesis structure, but note that a single-level structure will often suffice. Subdivided structures like the table of contents example listed earlier will only be necessary when writing several chapters, like in a Master’s thesis.

Master’s Thesis Examples

A master’s table of contents example is more complex than a bachelor’s thesis. This is because they average at about 80 pages with up to 40,000 words. Because this work is produced at a higher academic level, it normally includes a subdivision of chapters and subheadings, with a separate introduction and conclusion, as well as an abstract.

A table of contents example for a master’s thesis may then look something like this:

Microsoft Word Tutorial

Creating a table of contents page with Microsoft Word is simple.

In a Nutshell

All theses are different. Various departments and disciplines follow different structures and rules. The table of contents example pages here will help you in general to format your document, but remember to consult your university guidelines
Consistency and accuracy are the most important things to remember. You need the correct page number and the same layout for each chapter. It’s no good combining single-level table of contents with a multi-level table of contents
Simply put, bachelor’s thesis’ generally follow a single-level table of contents example unless otherwise specified
Postgraduate thesis’ like master and PhD-level work generally require a more detailed subdivision table of contents example. This is because they deal with both more complex arguments and more words
Remember to include all aspects of your thesis within the table of contents. Pre-thesis material needs to be listed in Roman numerals and you need to include all back-matter as well, such as References and Bibliography

We use cookies on our website. Some of them are essential, while others help us to improve this website and your experience.

External Media

Individual Privacy Preferences

Cookie Details Privacy Policy Imprint

Here you will find an overview of all cookies used. You can give your consent to whole categories or display further information and select certain cookies.

Accept all Save

Essential cookies enable basic functions and are necessary for the proper function of the website.

Show Cookie Information Hide Cookie Information

Statistics cookies collect information anonymously. This information helps us to understand how our visitors use our website.

Content from video platforms and social media platforms is blocked by default. If External Media cookies are accepted, access to those contents no longer requires manual consent.

Discoveries
Right Journal
Journal Metrics
Journal Fit
Abbreviation
In-Text Citations
Bibliographies
Writing an Article
Peer Review Types
Acknowledgements
Withdrawing a Paper
Form Letter
ISO, ANSI, CFR
Google Scholar
Journal Manuscript Editing
Research Manuscript Editing

Book Editing

Manuscript Editing Services

Medical Editing

Bioscience Editing
Physical Science Editing
PhD Thesis Editing Services
PhD Editing
Master’s Proofreading
Bachelor’s Editing
Dissertation Proofreading Services
Best Dissertation Proofreaders
Masters Dissertation Proofreading
PhD Proofreaders
Proofreading PhD Thesis Price
Journal Article Editing
Book Editing Service
Editing and Proofreading Services
Research Paper Editing
Medical Manuscript Editing
Academic Editing
Social Sciences Editing
Academic Proofreading
PhD Theses Editing
Dissertation Proofreading
Proofreading Rates UK
Medical Proofreading
PhD Proofreading Services UK
Academic Proofreading Services UK

Medical Editing Services

Life Science Editing
Biomedical Editing
Environmental Science Editing
Pharmaceutical Science Editing
Economics Editing
Psychology Editing
Sociology Editing
Archaeology Editing
History Paper Editing
Anthropology Editing
Law Paper Editing
Engineering Paper Editing
Technical Paper Editing
Philosophy Editing
PhD Dissertation Proofreading
Lektorat Englisch
Akademisches Lektorat
Lektorat Englisch Preise
Wissenschaftliches Lektorat
Lektorat Doktorarbeit

PhD Thesis Editing

Thesis Proofreading Services
PhD Thesis Proofreading
Proofreading Thesis Cost
Proofreading Thesis
Thesis Editing Services
Professional Thesis Editing
Thesis Editing Cost
Proofreading Dissertation
Dissertation Proofreading Cost
Dissertation Proofreader
Correção de Artigos Científicos
Correção de Trabalhos Academicos
Serviços de Correção de Inglês
Correção de Dissertação
Correção de Textos Precos
定額ネイティブチェック
Copy Editing
FREE Courses
Revision en Ingles
Revision de Textos en Ingles
Revision de Tesis
Revision Medica en Ingles
Revision de Tesis Precio
Revisão de Artigos Científicos
Revisão de Trabalhos Academicos
Serviços de Revisão de Inglês
Revisão de Dissertação
Revisão de Textos Precos
Corrección de Textos en Ingles
Corrección de Tesis
Corrección de Tesis Precio
Corrección Medica en Ingles
Corrector ingles

Select Page

How To Write a Table of Contents for Academic Papers

Posted by Rene Tetzner | Mar 17, 2021 | How To Get Published | 0 |

How To Write a Table of Contents for Academic Papers Although every author begins a writing project with the best of intentions and an ideal outline in mind, it often proves difficult to stick to one’s initial plans as the text begins to unfold and its complexities grow in number and depth. Sometimes a document quickly exceeds the word limits for a project, and at others certain important aspects are neglected or turn out a good deal shorter than intended. Drafting a working table of contents for your writing project can provide an excellent tool for keeping your discussion on track and your text within length requirements as you write.

A working table of contents should begin with a title. This title may change as you draft your text, but a working title will help you focus your thoughts as you devise the headings and plan the content for the main parts, chapters, sections and subsections that should be added beneath it. All headings, whether numbered or not, should be formatted in effective and consistent ways that distinguish section levels and clearly indicate the overall structure of the text. These headings can also be altered as your writing advances, but they will provide an effective outline of what you need to discuss and the order in which you think the main topics should be presented. At this initial stage, it is also a good idea to write under each heading a brief summary of or rough notes about what you hope to include in that part of the document, and you can continue to add, adjust and move material around within and among the sections as your table of contents and ultimately your text progresses. Reminders of how long (measured in words, paragraphs or pages) the entire text and each of its parts should ideally be may also prove helpful.

Once you have your annotated table of contents drafted, it will serve as an informative list of both content and order that can be productively consulted as you write. Assuming you construct your working table of contents as a computer file in the same program you intend to use for writing the entire document, you can also use the table of contents as a template for composing the text as a whole, replacing your rough notes under each heading with the formal text as you draft it. This practice lends an immediate physical presence to the guidance provided by your table of contents because you are literally working within that outline, which can be especially wise if you tend to run on or become distracted by new ideas as you write.

Finally, your working table of contents can become your final table of contents if one is required for your project. If you would like to use the working table of contents in this way and are also using it as a template, be sure to rename the file and save a separate copy before you begin adding the formal text of your document. Then you can simply delete your summaries and rough notes from the original table of contents to make your final one, leaving only the headings, to which you can add relevant page numbers as required.

You might be interested in Services offered by Proof-Reading-Service.com

Journal editing.

Journal article editing services

PhD thesis editing services

Scientific Editing

Manuscript editing.

Manuscript editing services

Expert Editing

Expert editing for all papers

Research Editing

Research paper editing services

Professional book editing services

Choosing the Right Journal

September 10, 2021

Example of a Quantitative Research Paper

September 4, 2021

What Is a Good H-Index Required for an Academic Position?

September 3, 2021

Acknowledgements Example for an Academic Research Paper

September 1, 2021

Our Recent Posts

Examples of Research Paper Topics in Different Study Areas

Our review ratings

Examples of Research Paper Topics in Different Study Areas Score: 98%
Dealing with Language Problems – Journal Editor’s Feedback Score: 95%
Making Good Use of a Professional Proofreader Score: 92%
How To Format Your Journal Paper Using Published Articles Score: 95%
Journal Rejection as Inspiration for a New Perspective Score: 95%

How to Create Table of Contents for Research Paper?

The table of contents is one of the most crucial components to include while writing a research paper, master’s thesis, or PhD dissertation.

Because it gives examiners a thorough and comprehensive list that they may use as a road map to go through each respective chapter, containing all relevant sections and subsections of material.

In this article, we will learn how to create table of contents for research paper? and learn what to include in table of contents with the help of examples and guide you how to create table of contents using Microsoft Word.

Table of Contents

What is Table of Contents?

A table of contents is a systematic list of the headings and subheadings within a research paper, along with their corresponding page numbers.

The chapters and significant sections of your thesis, dissertation, or research paper should be listed in the table of contents together with their corresponding page numbers. A clear, well-formatted table of contents is important because it shows the reader that a quality paper will follow.

The table of contents should be placed between the abstract and the introduction. The maximum length should be two pages. There are several formatting alternatives available depending on the type of your thesis, research paper or dissertation topic.

What to Include in Your Table of Contents?

Main Headings: Include the main sections or chapters of your research paper. These headings represent the major topics you will be addressing and should be descriptive enough to give readers an idea of the content covered in each section.
Subheadings: If your research paper is lengthy and consists of several subsections within each main heading, include subheadings in your table of contents. These subheadings provide a more detailed breakdown of the content and allow readers to locate specific information within a particular section.
Page Numbers: List the page numbers on which each heading and subheading can be found. This ensures that readers can quickly flip to the desired page and find the relevant information.

Your academic field and thesis length will determine how your table of contents is formatted. A methodical structure is used in some areas, such as the sciences, and includes suggested subheadings for methodology, data results, discussion, and conclusion.

On the other hand, humanities subjects are far more diverse. Regardless of the discipline you are working in, you must make an organized list of every chapter in the order that they occur, properly labelling the chapter subheadings.

Example: Table of Contents

The key features of a table of contents are:

Clear headings and subheadings
Corresponding page numbers

Check with your educational institution to see if they have any formatting or design requirements.

Table of Contents: Sample for a Short Dissertation

In a short dissertation, the table of contents serves as a roadmap for readers, outlining the main sections and subsections of the research paper.

It typically includes an introduction that sets the context, a literature review that analyzes existing scholarly works, a methodology section that describes the research design and data collection methods, a results and findings section that presents the research outcomes, and a conclusion that summarizes the key findings and implications.

Table of Contents: Sample for a PhD Dissertation

In a PhD dissertation, the table of contents provides a comprehensive overview of the entire research work. It encompasses various sections, starting with the title page and abstract, followed by acknowledgments and a detailed table of contents.

The contents include chapters such as introduction, literature review, methodology, results and findings, conclusion, and references. Additionally, there may be lists of figures and tables, as well as appendices containing supplementary materials.

This extensive table of contents helps readers navigate through the comprehensive research study and locate specific sections of interest.

Table of Contents: Sample for a PhD Dissertation

Creating a Table of Contents in Microsoft Word

Apply heading styles.

Assign appropriate heading styles (e.g., Heading 1, Heading 2, etc.) to the main headings and subheadings in your research paper. This can be done using the “Styles” feature in Microsoft Word’s “Home” tab.

Creating a Table of Contents in Microsoft Word

Insert a Table of Contents

There may be a lot of space needed for a table of contents. A table of contents should be placed on a blank page towards the beginning of a document.

Where you wish to insert a Table of Contents, click in the document.
On the ribbon, click the References tab.
Then, select Table of Contents.
A collection of built-in styles appears. Choose one of these, look at additional tables of contents on Office.com, or design your own table of contents.
Select a table of contents style.

The table of contents is added, listing all of the headings in the document in outline order, as well as the page number on which each heading occurs.

Update the Table of Contents

Make a note to yourself to update your table of contents as one of your final tasks before submitting your dissertation or paper. As you enter your final revisions, it’s common for your text to slightly change, but it’s critical that your page numbers still match.

In Microsoft Word, it’s simple to update your page numbers automatically. Simply choose “Update Field” from the context menu when you right-click the contents page. You have the option of updating your table of contents entirely or just the page numbers.

Thesis Format – Templates and Samples

Table of contents.

Thesis Format

Thesis format refers to the structure and layout of a research thesis or dissertation. It typically includes several chapters, each of which focuses on a particular aspect of the research topic .

The exact format of a thesis can vary depending on the academic discipline and the institution, but some common elements include:

Introduction

Literature review, methodology.

The title page is the first page of a thesis that provides essential information about the document, such as the title, author’s name, degree program, university, and the date of submission. It is considered as an important component of a thesis as it gives the reader an initial impression of the document’s content and quality.

The typical contents of a title page in a thesis include:

The title of the thesis: It should be concise, informative, and accurately represent the main topic of the research.
Author’s name: This should be written in full and should be the same as it appears on official university records.
Degree program and department: This should specify the type of degree (e.g., Bachelor’s, Master’s, or Doctoral) and the field of study (e.g., Computer Science, Psychology, etc.).
University: The name of the university where the thesis is being submitted.
Date of submission : The month and year of submission of the thesis.
Other details that can be included on the title page include the name of the advisor, the name of the committee members, and any acknowledgments.

In terms of formatting, the title page should be centered horizontally and vertically on the page, with a consistent font size and style. The page margin for the title page should be at least 1 inch (2.54 cm) on all sides. Additionally, it is common practice to include the university logo or crest on the title page, and this should be placed appropriately.

Title of the Thesis in Title Case by Author’s Full Name in Title Case

A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Department Name at the University Name

Month Year of Submission

An abstract is a brief summary of a thesis or research paper that provides an overview of the main points, methodology, and findings of the study. It is typically placed at the beginning of the document, after the title page and before the introduction.

The purpose of an abstract is to provide readers with a quick and concise overview of the research paper or thesis. It should be written in a clear and concise language, and should not contain any jargon or technical terms that are not easily understood by the general public.

Here’s an example of an abstract for a thesis:

Title: The Impact of Social Media on Mental Health among Adolescents

This study examines the impact of social media on mental health among adolescents. The research utilized a survey methodology and collected data from a sample of 500 adolescents aged between 13 and 18 years. The findings reveal that social media has a significant impact on mental health among adolescents, with frequent use of social media associated with higher levels of anxiety, depression, and low self-esteem. The study concludes that there is a need for increased awareness and education on the risks associated with excessive use of social media, and recommends strategies for promoting healthy social media habits among adolescents.

In this example, the abstract provides a concise summary of the thesis by highlighting the main points, methodology, and findings of the study. It also provides a clear indication of the significance of the study and its implications for future research and practice.

A table of contents is an essential part of a thesis as it provides the reader with an overview of the entire document’s structure and organization.

Here’s an example of how a table of contents might look in a thesis:

TABLE OF CONTENTS

I. INTRODUCTION ……………………………………………………..1

A. Background of the Study………………………………………..1

B. Statement of the Problem……………………………………….2

C. Objectives of the Study………………………………………..3

D. Research Questions…………………………………………….4

E. Significance of the Study………………………………………5

F. Scope and Limitations………………………………………….6

G. Definition of Terms……………………………………………7

II. LITERATURE REVIEW. ………………………………………………8

A. Overview of the Literature……………………………………..8

B. Key Themes and Concepts………………………………………..9

C. Gaps in the Literature………………………………………..10

D. Theoretical Framework………………………………………….11

III. METHODOLOGY ……………………………………………………12

A. Research Design………………………………………………12

B. Participants and Sampling……………………………………..13

C. Data Collection Procedures…………………………………….14

D. Data Analysis Procedures………………………………………15

IV. RESULTS …………………………………………………………16

A. Descriptive Statistics…………………………………………16

B. Inferential Statistics…………………………………………17

V. DISCUSSION ………………………………………………………18

A. Interpretation of Results………………………………………18

B. Discussion of Finding s …………………………………………19

C. Implications of the Study………………………………………20

VI. CONCLUSION ………………………………………………………21

A. Summary of the Study…………………………………………..21

B. Limitations of the Study……………………………………….22

C. Recommendations for Future Research……………………………..23

REFERENCES …………………………………………………………….24

APPENDICES …………………………………………………………….26

As you can see, the table of contents is organized by chapters and sections. Each chapter and section is listed with its corresponding page number, making it easy for the reader to navigate the thesis.

The introduction is a critical part of a thesis as it provides an overview of the research problem, sets the context for the study, and outlines the research objectives and questions. The introduction is typically the first chapter of a thesis and serves as a roadmap for the reader.

Here’s an example of how an introduction in a thesis might look:

Introduction:

The prevalence of obesity has increased rapidly in recent decades, with more than one-third of adults in the United States being classified as obese. Obesity is associated with numerous adverse health outcomes, including cardiovascular disease, diabetes, and certain cancers. Despite significant efforts to address this issue, the rates of obesity continue to rise. The purpose of this study is to investigate the relationship between lifestyle behaviors and obesity in young adults.

The study will be conducted using a mixed-methods approach, with both qualitative and quantitative data collection methods. The research objectives are to:

Examine the relationship between lifestyle behaviors and obesity in young adults.
Identify the key lifestyle factors that contribute to obesity in young adults.
Evaluate the effectiveness of current interventions aimed at preventing and reducing obesity in young adults.

The research questions that will guide this study are:

What is the relationship between lifestyle behaviors and obesity in young adults?
Which lifestyle factors are most strongly associated with obesity in young adults?
How effective are current interventions aimed at preventing and reducing obesity in young adults?

By addressing these research questions, this study aims to contribute to the understanding of the factors that contribute to obesity in young adults and to inform the development of effective interventions to prevent and reduce obesity in this population.

A literature review is a critical analysis and evaluation of existing literature on a specific topic or research question. It is an essential part of any thesis, as it provides a comprehensive overview of the existing research on the topic and helps to establish the theoretical framework for the study. The literature review allows the researcher to identify gaps in the current research, highlight areas that need further exploration, and demonstrate the importance of their research question.

April 9, 2023:

A search on Google Scholar for “Effectiveness of Online Learning during the COVID-19 Pandemic” yielded 1,540 results. Upon reviewing the first few pages of results, it is evident that there is a significant amount of literature on the topic. A majority of the studies focus on the experiences and perspectives of students and educators during the transition to online learning due to the pandemic.

One recent study published in the Journal of Educational Technology & Society (Liu et al., 2023) found that students who were already familiar with online learning tools and platforms had an easier time adapting to online learning than those who were not. However, the study also found that students who were not familiar with online learning tools were able to adapt with proper support from their teachers and institutions.

Another study published in Computers & Education (Tang et al., 2023) compared the academic performance of students in online and traditional classroom settings during the pandemic. The study found that while there were no significant differences in the grades of students in the two settings, students in online classes reported higher levels of stress and lower levels of satisfaction with their learning experience.

Methodology in a thesis refers to the overall approach and systematic process that a researcher follows to collect and analyze data in order to answer their research question(s) or achieve their research objectives. It includes the research design, data collection methods, sampling techniques, data analysis procedures, and any other relevant procedures that the researcher uses to conduct their research.

For example, let’s consider a thesis on the impact of social media on mental health among teenagers. The methodology for this thesis might involve the following steps:

Research Design:

The researcher may choose to conduct a quantitative study using a survey questionnaire to collect data on social media usage and mental health among teenagers. Alternatively, they may conduct a qualitative study using focus group discussions or interviews to gain a deeper understanding of the experiences and perspectives of teenagers regarding social media and mental health.

Sampling Techniques:

The researcher may use random sampling to select a representative sample of teenagers from a specific geographic location or demographic group, or they may use purposive sampling to select participants who meet specific criteria such as age, gender, or mental health status.

Data Collection Methods:

The researcher may use an online survey tool to collect data on social media usage and mental health, or they may conduct face-to-face interviews or focus group discussions to gather qualitative data. They may also use existing data sources such as medical records or social media posts.

Data Analysis Procedures:

The researcher may use statistical analysis techniques such as regression analysis to examine the relationship between social media usage and mental health, or they may use thematic analysis to identify key themes and patterns in the qualitative data.

Ethical Considerations: The researcher must ensure that their research is conducted in an ethical manner, which may involve obtaining informed consent from participants, protecting their confidentiality, and ensuring that their rights and welfare are respected.

In a thesis, the “Results” section typically presents the findings of the research conducted by the author. This section typically includes both quantitative and qualitative data, such as statistical analyses, tables, figures, and other relevant data.

Here are some examples of how the “Results” section of a thesis might look:

Example 1: A quantitative study on the effects of exercise on cardiovascular health

In this study, the author conducts a randomized controlled trial to investigate the effects of exercise on cardiovascular health in a group of sedentary adults. The “Results” section might include tables showing the changes in blood pressure, cholesterol levels, and other relevant indicators in the exercise and control groups over the course of the study. The section might also include statistical analyses, such as t-tests or ANOVA, to demonstrate the significance of the results.

Example 2: A qualitative study on the experiences of immigrant families in a new country

In this study, the author conducts in-depth interviews with immigrant families to explore their experiences of adapting to a new country. The “Results” section might include quotes from the interviews that illustrate the participants’ experiences, as well as a thematic analysis that identifies common themes and patterns in the data. The section might also include a discussion of the implications of the findings for policy and practice.

A thesis discussion section is an opportunity for the author to present their interpretation and analysis of the research results. In this section, the author can provide their opinion on the findings, compare them with other literature, and suggest future research directions.

For example, let’s say the thesis topic is about the impact of social media on mental health. The author has conducted a survey among 500 individuals and has found that there is a significant correlation between excessive social media use and poor mental health.

In the discussion section, the author can start by summarizing the main findings and stating their interpretation of the results. For instance, the author may argue that excessive social media use is likely to cause mental health problems due to the pressure of constantly comparing oneself to others, fear of missing out, and cyberbullying.

Next, the author can compare their results with other studies and point out similarities and differences. They can also identify any limitations in their research design and suggest future directions for research.

For example, the author may point out that their study only measured social media use and mental health at one point in time, and it is unclear whether one caused the other or whether there are other confounding factors. Therefore, they may suggest longitudinal studies that follow individuals over time to better understand the causal relationship.

Writing a conclusion for a thesis is an essential part of the overall writing process. The conclusion should summarize the main points of the thesis and provide a sense of closure to the reader. It is also an opportunity to reflect on the research process and offer suggestions for further study.

Here is an example of a conclusion for a thesis:

After an extensive analysis of the data collected, it is evident that the implementation of a new curriculum has had a significant impact on student achievement. The findings suggest that the new curriculum has improved student performance in all subject areas, and this improvement is particularly notable in math and science. The results of this study provide empirical evidence to support the notion that curriculum reform can positively impact student learning outcomes.

In addition to the positive results, this study has also identified areas for future research. One limitation of the current study is that it only examines the short-term effects of the new curriculum. Future studies should explore the long-term effects of the new curriculum on student performance, as well as investigate the impact of the curriculum on students with different learning styles and abilities.

Overall, the findings of this study have important implications for educators and policymakers who are interested in improving student outcomes. The results of this study suggest that the implementation of a new curriculum can have a positive impact on student achievement, and it is recommended that schools and districts consider curriculum reform as a means of improving student learning outcomes.

References in a thesis typically follow a specific format depending on the citation style required by your academic institution or publisher.

Below are some examples of different citation styles and how to reference different types of sources in your thesis:

In-text citation format: (Author, Year)

Reference list format for a book: Author, A. A. (Year of publication). Title of work: Capital letter also for subtitle. Publisher.

Example: In-text citation: (Smith, 2010) Reference list entry: Smith, J. D. (2010). The art of writing a thesis. Cambridge University Press.

Reference list format for a journal article: Author, A. A., Author, B. B., & Author, C. C. (Year of publication). Title of article. Title of Journal, volume number(issue number), page range.

Example: In-text citation: (Brown, 2015) Reference list entry: Brown, E., Smith, J., & Johnson, L. (2015). The impact of social media on academic performance. Journal of Educational Psychology, 108(3), 393-407.

In-text citation format: (Author page number)

Works Cited list format for a book: Author. Title of Book. Publisher, Year of publication.

Example: In-text citation: (Smith 75) Works Cited entry: Smith, John D. The Art of Writing a Thesis. Cambridge University Press, 2010.

Works Cited list format for a journal article: Author(s). “Title of Article.” Title of Journal, volume number, issue number, date, pages.

Example: In-text citation: (Brown 394) Works Cited entry: Brown, Elizabeth, et al. “The Impact of Social Media on Academic Performance.” Journal of Educational Psychology, vol. 108, no. 3, 2015, pp. 393-407.

Chicago Style

In-text citation format: (Author year, page number)

Bibliography list format for a book: Author. Title of Book. Place of publication: Publisher, Year of publication.

Example: In-text citation: (Smith 2010, 75) Bibliography entry: Smith, John D. The Art of Writing a Thesis. Cambridge: Cambridge University Press, 2010.

Bibliography list format for a journal article: Author. “Title of Article.” Title of Journal volume number, no. issue number (date): page numbers.

Example: In-text citation: (Brown 2015, 394) Bibliography entry: Brown, Elizabeth, John Smith, and Laura Johnson. “The Impact of Social Media on Academic Performance.” Journal of Educational Psychology 108, no. 3 (2015): 393-407.

Reference list format for a book: [1] A. A. Author, Title of Book. City of Publisher, Abbrev. of State: Publisher, year.

Example: In-text citation: [1] Reference list entry: A. J. Smith, The Art of Writing a Thesis. New York, NY: Academic Press, 2010.

Reference list format for a journal article: [1] A. A. Author, “Title of Article,” Title of Journal, vol. x, no. x, pp. xxx-xxx, Month year.

Example: In-text citation: [1] Reference list entry: E. Brown, J. D. Smith, and L. Johnson, “The Impact of Social Media on Academic Performance,” Journal of Educational Psychology, vol. 108, no. 3, pp. 393-407, Mar. 2015.

An appendix in a thesis is a section that contains additional information that is not included in the main body of the document but is still relevant to the topic being discussed. It can include figures, tables, graphs, data sets, sample questionnaires, or any other supplementary material that supports your thesis.

Here is an example of how you can format appendices in your thesis:

Title page: The appendix should have a separate title page that lists the title, author’s name, the date, and the document type (i.e., thesis or dissertation). The title page should be numbered as the first page of the appendix section.
Table of contents: If you have more than one appendix, you should include a separate table of contents that lists each appendix and its page number. The table of contents should come after the title page.
Appendix sections: Each appendix should have its own section with a clear and concise title that describes the contents of the appendix. Each section should be numbered with Arabic numerals (e.g., Appendix 1, Appendix 2, etc.). The sections should be listed in the table of contents.
Formatting: The formatting of the appendices should be consistent with the rest of the thesis. This includes font size, font style, line spacing, and margins.
Example: Here is an example of what an appendix might look like in a thesis on the topic of climate change:

Appendix 1: Data Sources

This appendix includes a list of the primary data sources used in this thesis, including their URLs and a brief description of the data they provide.

Appendix 2: Survey Questionnaire

This appendix includes the survey questionnaire used to collect data from participants in the study.

Appendix 3: Additional Figures

This appendix includes additional figures that were not included in the main body of the thesis due to space limitations. These figures provide additional support for the findings presented in the thesis.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

Delimitations in Research – Types, Examples and...

Research Design – Types, Methods and Examples

Dissertation Methodology – Structure, Example...

What is a Hypothesis – Types, Examples and...

Dissertation – Format, Example and Template

Dissertation vs Thesis – Key Differences

Effective Use of Tables and Figures in Research Papers

Research papers are often based on copious amounts of data that can be summarized and easily read through tables and graphs. When writing a research paper , it is important for data to be presented to the reader in a visually appealing way. The data in figures and tables, however, should not be a repetition of the data found in the text. There are many ways of presenting data in tables and figures, governed by a few simple rules. An APA research paper and MLA research paper both require tables and figures, but the rules around them are different. When writing a research paper, the importance of tables and figures cannot be underestimated. How do you know if you need a table or figure? The rule of thumb is that if you cannot present your data in one or two sentences, then you need a table .

Using Tables

Tables are easily created using programs such as Excel. Tables and figures in scientific papers are wonderful ways of presenting data. Effective data presentation in research papers requires understanding your reader and the elements that comprise a table. Tables have several elements, including the legend, column titles, and body. As with academic writing, it is also just as important to structure tables so that readers can easily understand them. Tables that are disorganized or otherwise confusing will make the reader lose interest in your work.

Title: Tables should have a clear, descriptive title, which functions as the “topic sentence” of the table. The titles can be lengthy or short, depending on the discipline.
Column Titles: The goal of these title headings is to simplify the table. The reader’s attention moves from the title to the column title sequentially. A good set of column titles will allow the reader to quickly grasp what the table is about.
Table Body: This is the main area of the table where numerical or textual data is located. Construct your table so that elements read from up to down, and not across.

Related: Done organizing your research data effectively in tables? Check out this post on tips for citing tables in your manuscript now!

The placement of figures and tables should be at the center of the page. It should be properly referenced and ordered in the number that it appears in the text. In addition, tables should be set apart from the text. Text wrapping should not be used. Sometimes, tables and figures are presented after the references in selected journals.

Using Figures

Figures can take many forms, such as bar graphs, frequency histograms, scatterplots, drawings, maps, etc. When using figures in a research paper, always think of your reader. What is the easiest figure for your reader to understand? How can you present the data in the simplest and most effective way? For instance, a photograph may be the best choice if you want your reader to understand spatial relationships.

Figure Captions: Figures should be numbered and have descriptive titles or captions. The captions should be succinct enough to understand at the first glance. Captions are placed under the figure and are left justified.
Image: Choose an image that is simple and easily understandable. Consider the size, resolution, and the image’s overall visual attractiveness.
Additional Information: Illustrations in manuscripts are numbered separately from tables. Include any information that the reader needs to understand your figure, such as legends.

Common Errors in Research Papers

Effective data presentation in research papers requires understanding the common errors that make data presentation ineffective. These common mistakes include using the wrong type of figure for the data. For instance, using a scatterplot instead of a bar graph for showing levels of hydration is a mistake. Another common mistake is that some authors tend to italicize the table number. Remember, only the table title should be italicized . Another common mistake is failing to attribute the table. If the table/figure is from another source, simply put “ Note. Adapted from…” underneath the table. This should help avoid any issues with plagiarism.

Using tables and figures in research papers is essential for the paper’s readability. The reader is given a chance to understand data through visual content. When writing a research paper, these elements should be considered as part of good research writing. APA research papers, MLA research papers, and other manuscripts require visual content if the data is too complex or voluminous. The importance of tables and graphs is underscored by the main purpose of writing, and that is to be understood.

Frequently Asked Questions

"Consider the following points when creating figures for research papers: Determine purpose: Clarify the message or information to be conveyed. Choose figure type: Select the appropriate type for data representation. Prepare and organize data: Collect and arrange accurate and relevant data. Select software: Use suitable software for figure creation and editing. Design figure: Focus on clarity, labeling, and visual elements. Create the figure: Plot data or generate the figure using the chosen software. Label and annotate: Clearly identify and explain all elements in the figure. Review and revise: Verify accuracy, coherence, and alignment with the paper. Format and export: Adjust format to meet publication guidelines and export as suitable file."

"To create tables for a research paper, follow these steps: 1) Determine the purpose and information to be conveyed. 2) Plan the layout, including rows, columns, and headings. 3) Use spreadsheet software like Excel to design and format the table. 4) Input accurate data into cells, aligning it logically. 5) Include column and row headers for context. 6) Format the table for readability using consistent styles. 7) Add a descriptive title and caption to summarize and provide context. 8) Number and reference the table in the paper. 9) Review and revise for accuracy and clarity before finalizing."

"Including figures in a research paper enhances clarity and visual appeal. Follow these steps: Determine the need for figures based on data trends or to explain complex processes. Choose the right type of figure, such as graphs, charts, or images, to convey your message effectively. Create or obtain the figure, properly citing the source if needed. Number and caption each figure, providing concise and informative descriptions. Place figures logically in the paper and reference them in the text. Format and label figures clearly for better understanding. Provide detailed figure captions to aid comprehension. Cite the source for non-original figures or images. Review and revise figures for accuracy and consistency."

"Research papers use various types of tables to present data: Descriptive tables: Summarize main data characteristics, often presenting demographic information. Frequency tables: Display distribution of categorical variables, showing counts or percentages in different categories. Cross-tabulation tables: Explore relationships between categorical variables by presenting joint frequencies or percentages. Summary statistics tables: Present key statistics (mean, standard deviation, etc.) for numerical variables. Comparative tables: Compare different groups or conditions, displaying key statistics side by side. Correlation or regression tables: Display results of statistical analyses, such as coefficients and p-values. Longitudinal or time-series tables: Show data collected over multiple time points with columns for periods and rows for variables/subjects. Data matrix tables: Present raw data or matrices, common in experimental psychology or biology. Label tables clearly, include titles, and use footnotes or captions for explanations."

Enago is a very useful site. It covers nearly all topics of research writing and publishing in a simple, clear, attractive way. Though I’m a journal editor having much knowledge and training in these issues, I always find something new in this site. Thank you

“Thank You, your contents really help me :)”

Rate this article Cancel Reply

Your email address will not be published.

Enago Academy's Most Popular Articles

Reporting Research

Explanatory & Response Variable in Statistics — A quick guide for early career researchers!

Often researchers have a difficult time choosing the parameters and variables (like explanatory and response…

Manuscript Preparation
Publishing Research

How to Use Creative Data Visualization Techniques for Easy Comprehension of Qualitative Research

“A picture is worth a thousand words!”—an adage used so often stands true even whilst…

Figures & Tables

Effective Use of Statistics in Research – Methods and Tools for Data Analysis

Remember that impending feeling you get when you are asked to analyze your data! Now…

Old Webinars
Webinar Mobile App

SCI中稿技巧: 提升研究数据的说服力

如何寻找原创研究课题快速定位目标文献的有效搜索策略如何根据期刊指南准备手稿的对应部分论文手稿语言润色实用技巧分享，快速提高论文质量

Distill: A Journal With Interactive Images for Machine Learning Research

Research is a wide and extensive field of study. This field has welcomed a plethora…

Explanatory & Response Variable in Statistics — A quick guide for early career…

How to Create and Use Gantt Charts

Sign-up to read more

Subscribe for free to get unrestricted access to all our resources on research writing and academic publishing including:

2000+ blog articles
50+ Webinars
10+ Expert podcasts
50+ Infographics
10+ Checklists
Research Guides

We hate spam too. We promise to protect your privacy and never spam you.

I am looking for Editing/ Proofreading services for my manuscript Tentative date of next journal submission:

What should universities' stance be on AI tools in research and academic writing?

Generate accurate APA citations for free

Knowledge Base
APA Style 7th edition
How to format tables and figures in APA Style

APA Format for Tables and Figures | Annotated Examples

Published on November 5, 2020 by Jack Caulfield . Revised on January 17, 2024.

A table concisely presents information (often numbers) in rows and columns. A figure is any other image or illustration you include in your text—anything from a bar chart to a photograph.

Tables and figures differ in terms of how they convey information, but APA Style presents them in a similar format—preceded by a number and title, and followed by explanatory notes (if necessary).

Instantly correct all language mistakes in your text

Upload your document to correct all your mistakes in minutes

Apa table format, apa figure format, numbering and titling tables and figures, formatting table and figure notes, where to place tables and figures, referring to tables and figures in the text, frequently asked questions about apa tables and figures.

Tables will vary in size and structure depending on the data you’re presenting, but APA gives some general guidelines for their design. To correctly format an APA table, follow these rules:

Table number in bold above the table.
Brief title, in italics and title case, below the table number.
No vertical lines.
Horizontal lines only where necessary for clarity.
Clear, concise labels for column and row headings.
Numbers consistently formatted (e.g. with the same number of decimal places).
Any relevant notes below the table.

An example of a table formatted according to APA guidelines is shown below.

The table above uses only four lines: Those at the top and bottom, and those separating the main data from the column heads and the totals.

Create your tables using the tools built into your word processor. In Word, you can use the “ Insert table ” tool.

Prevent plagiarism. Run a free check.

Any images used within your text are called figures. Figures include data visualization graphics—e.g. graphs, diagrams, flowcharts—as well as things like photographs and artworks.

To correctly format an APA figure, follow these rules:

Figure number in bold above the figure.
Brief title, in italics and title case, under the figure number.
If necessary, clear labels and legends integrated into the image.
Any relevant notes below the figure.

An example of a figure formatted according to APA guidelines is shown below.

Keep the design of figures as simple as possible. Use colors only where necessary, not just to make the image look more appealing.

For text within the image itself, APA recommends using a sans serif font (e.g. Arial) with a size between 8 and 14 points.

For other figures, such as photographs, you won’t need a legend; the figure consists simply of the image itself, reproduced at an appropriate size and resolution.

Each table or figure is preceded by a number and title.

Tables and figures are each numbered separately, in the order they are referred to in your text. For example, the first table you refer to is Table 1; the fourth figure you refer to is Figure 4.

The title should clearly and straightforwardly describe the content of the table or figure. Omit articles to keep it concise.

The table or figure number appears on its own line, in bold, followed by the title on the following line, in italics and title case.

Where a table or figure needs further explanation, notes should be included immediately after it. These are not your analysis of the data presented; save that for the main text.

There are three kinds of notes: general , specific , and probability . Each type of note appears in a new paragraph, but multiple notes of the same kind all appear in one paragraph.

Only include the notes that are needed to understand the table or figure. It may be that it is clear in itself, and has no notes, or only probability notes; be as concise as possible.

General notes

General notes come first. They are preceded by the word “ Note ” in italics, followed by a period. They include any explanations that apply to the table or figure as a whole and a citation if it was adapted from another source, and they end with definitions of any abbreviations used.

Specific notes

Specific notes refer to specific points in the table or figure. Superscript letters (a, b, c …) appear at the relevant points in the table or figure and at the start of each note to indicate what they refer to. They are used when it’s necessary to comment on a specific data point or term.

Probability notes

Probability notes give p -values for the data in the table or figure. They correspond to asterisks (and/or other symbols) in the table or figure.

You have two options for the placement of tables and figures in APA Style:

Option 1: Place tables and figures throughout your text, shortly after the parts of the text that refer to them.
Option 2: Place them all together at the end of your text (after the reference list) to avoid breaking up the text.

If you place them throughout the text, note that each table or figure should only appear once. If you refer to the same table or figure more than once, don’t reproduce it each time—just place it after the paragraph in which it’s first discussed.

Align the table or figure with the text along the left margin. Leave a line break before and after the table or figure to clearly distinguish it from the main text, and place it on a new page if necessary to avoid splitting it across multiple pages.

If you place all your tables and figures at the end, you should have one table or figure on each page. Begin with all your tables, then place all your figures afterwards.

Avoid making redundant statements about your tables and figures in your text. When you write about data from tables and figures, it should be to highlight or analyze a particular data point or trend, not simply to restate what is already clearly shown in the table or figure:

As Table 1 shows, there are 115 boys in Grade 4, 130 in Grade 5, and 117 in Grade 6 …
Table 1 indicates a notable preponderance of boys in Grade 5. It is important to take this into account because …

Additionally, even if you have embedded your tables and figures in your text, refer to them by their numbers, not by their position relative to the text or by description:

The table below shows…
Table 1 shows…
As can be seen in the image on page 4…
As can be seen in Figure 3…
The photograph of a bald eagle is an example of…
Figure 1 is an example of…

In an APA Style paper , use a table or figure when it’s a clearer way to present important data than describing it in your main text. This is often the case when you need to communicate a large amount of information.

Before including a table or figure in your text, always reflect on whether it’s useful to your readers’ understanding:

Could this information be quickly summarized in the text instead?
Is it important to your arguments?
Does the table or figure require too much explanation to be efficient?

If the data you need to present only contains a few relevant numbers, try summarizing it in the text (potentially including full data in an appendix ). If describing the data makes your text overly long and difficult to read, a table or figure may be the best option.

APA doesn’t require you to include a list of tables or a list of figures . However, it is advisable to do so if your text is long enough to feature a table of contents and it includes a lot of tables and/or figures.

A list of tables and list of figures appear (in that order) after your table of contents , and are presented in a similar way.

If you adapt or reproduce a table or figure from another source, you should include that source in your APA reference list . You should also acknowledge the original source in the note or caption for the table or figure.

Tables and figures you created yourself, based on your own data, are not included in the reference list.

In most styles, the title page is used purely to provide information and doesn’t include any images. Ask your supervisor if you are allowed to include an image on the title page before doing so. If you do decide to include one, make sure to check whether you need permission from the creator of the image.

Include a note directly beneath the image acknowledging where it comes from, beginning with the word “ Note .” (italicized and followed by a period). Include a citation and copyright attribution . Don’t title, number, or label the image as a figure , since it doesn’t appear in your main text.

Cite this Scribbr article

If you want to cite this source, you can copy and paste the citation or click the “Cite this Scribbr article” button to automatically add the citation to our free Citation Generator.

Caulfield, J. (2024, January 17). APA Format for Tables and Figures | Annotated Examples. Scribbr. Retrieved April 15, 2024, from https://www.scribbr.com/apa-style/tables-and-figures/

Is this article helpful?

Jack Caulfield

Other students also liked, citing tables and figures from other sources in apa style, how to cite an image in apa style, how to write an apa results section, unlimited academic ai-proofreading.

✔ Document error-free in 5minutes ✔ Unlimited document corrections ✔ Specialized in correcting academic texts

Get science-backed answers as you write with Paperpal's Research feature

Paperpal’s New AI Research Finder Empowers Authors to Research, Write, Cite, All in One Place

Over 800,000 academic writers across 125 countries trust Paperpal’s comprehensive academic writing toolkit to save time and write more confidently. While the writing and editing process has become quick for our users, we identified a gap in the academic writing process, especially when researchers kick-start their writing process.

Our users use various AI research finders for different parts of the writing process – literature search, finding counter arguments, finding citations of papers that are credible and can back their arguments, etc. The entire process is not linear, and researchers need to actively keep their reading lists or library close by while they draft their paper. We also identified a need to enable users to lookup literature without switching tabs or tools while writing. Not only is this time-consuming and effort-intensive, but researchers could also lose writing momentum, which could cost them dearly when dealing with tight deadlines.

Recognizing this gap, Paperpal has introduced the Research feature, which provides science-backed answers to your questions as you write and lets you save references to your citation library. By integrating a robust AI research finder into its feature suite, Paperpal aims to accelerate the writing process and double your productivity.

Challenges in existing writing process
Paperpal’s AI research finder provides science-backed answers as you write
Research benefits: 5 ways Paperpal’s AI research finder can help you
How to use the new Research feature on Paperpal?
Crafting innovative solutions to transform your experience

Challenges in existing writing process

For academics, the process of crafting well-researched essays and research papers is both a necessity and a challenge. Students and researchers often find themselves navigating through a labyrinth of information to find citations of papers that are credible and can back their arguments.

They do literature search, conduct their research, and then sit down to write their essay or research paper. At this stage they often find an interesting new angle to explore, that requires another round of searching and reading to understand and ensure what you want to say is credible and grounded in published literature. This traditional academic research process involves browsing multiple platforms, shortlisting relevant sources, and verifying their credibility before referencing it in your own work.
The process is time-consuming process also requires a high level of expertise to distinguish between reliable and questionable content.
Furthermore, researchers often have to go deeper into topics and find counterpoints to add stronger arguments for their research, while writing their manuscripts.
Currently other AI research finder tools are inefficient as the long-drawn fragmented approach often disrupts writing flow, making the task more daunting and less efficient.
The research and writing process is even more difficult for those with English as a second language. A recent survey in PLOS revealed that those with low English proficiency took 91% longer to read papers published in English, and then 51% more time to write their manuscripts compared to native English speakers.

So can you really overcome these hurdles in your research and writing journey and streamline your path to success? Yes, with Paperpal by your side!

Paperpal’s AI research finder provides science-backed answers as you write

Paperpal’s new Research feature addresses these author challenges head-on by providing science-backed answers to research questions in easy-to-understand, summarized formats, as you write. With factual responses drawn from over 250 million research articles, authors can now enjoy verified citations and references seamlessly integrated into their writing environment. Academics no longer have to disrupt their writing momentum to figure out how to find references for research papers. You can browse the sources cited, and save relevant papers to your citation library, all without ever having to switch tabs.

By expanding its feature suite to now include the AI research finder, powered by R Discovery , Paperpal allows you to research, write, cite, edit, and ensure submission readiness all in one place, streamlining and ensuring an uninterrupted writing experience.

Research benefits: 5 ways Paperpal’s AI research finder can help you

Paperpal’s Research feature is a game-changer for academics who strive to deliver strong, well-researched content. It serves as a comprehensive reference finder, citation finder, and source finder, all rolled into one.

Here are 5 ways you can use Paperpal’s AI research finder to take your research journey to the next level:

Remove writer’s block and simplify the writing process : Use the AI research finder to ask questions and break down concepts into simple summarized responses, backed by references. You can also read full papers or save articles to your citation library to delve deeper into the topic later.
Maintain your writing momentum and flow: Paperpal allows you to write, edit, and now verify facts all in one place; researchers can ensure accuracy by using Research feature to ask questions and instantly check facts and concepts against verified sources, all in one place. 
Substantiate research arguments on the go: Paperpal’s source finder can be invaluable for those who want to quickly explore new ideas, when writing literature reviews for example. Asking and getting science-backed responses with references can help you elaborate on or strengthen arguments and substantiate your research effortlessly.  
Enhance cross-disciplinary research writing: Paperpal’s new Research feature is great for those working on cross-disciplinary research, who may need to understand concepts outside their own area of expertise or are looking for additional references to support their work.
Strengthen grant applications with facts: Grant writing can be challenging, with high competition for the same limited pool of resources. With Paperpal, academics can effortlessly write and refine grant applications and then strengthen them using supporting facts generated by the Research feature.

How to use the new Research feature on Paperpal ?

The benefits of Paperpal’s Research feature for the academic community are immense. It revolutionizes the way research is conducted, transforming a traditionally disjointed process into a cohesive and enjoyable experience. Authors can now focus more on developing their arguments and less on the mechanics of finding and verifying sources.

Here’s a quick step-by-step process to help you use Paperpal’s Research feature effectively:

1. Submit your query: Login to Paperpal , open a document and click on the Research tab. Type in your question to get accurate insights from over 250 million articles, with verified sources.

2. Review and save: Quickly scan the summarized response provided by the AI research finder to check for relevance, click to read references, and save any papers of interest to your citations library.

3. Cite references: Develop your ideas using these insights and cite relevant references to strengthen your text and deliver well-researched academic essays or papers.

It’s as simple as that! You’re all set to transform your writing with the best of research and writing support with the Paperpal AI research assistant.

Crafting innovative solutions to transform your experience

With the Research feature, Paperpal lives up to its aim to provide a one-stop solution for academic writing. Students and researchers can enjoy a truly uninterrupted writing experience, ensuring that their focus remains on creating compelling and well-researched content. And we are not stopping here. Paperpal is in the process of developing a citations generator and builder, promising to further empower authors by automating the citation process. Our commitment to enhancing academic writing continues to grow, with several innovative features lined up to revolutionize your research and writing process. Watch this space for more!

Paperpal is a comprehensive AI writing toolkit that helps students and researchers achieve 2x the writing in half the time. It leverages 21+ years of STM experience and insights from millions of research articles to provide in-depth academic writing, language editing, and submission readiness support to help you write better, faster.

Get accurate academic translations, rewriting support, grammar checks, vocabulary suggestions, and generative AI assistance that delivers human precision at machine speed. Try for free or upgrade to Paperpal Prime starting at US$19 a month to access premium features, including consistency, plagiarism, and 30+ submission readiness checks to help you succeed.

Experience the future of academic writing – Sign up to Paperpal and start writing for free!

What is Hedging in Academic Writing?

Why traditional editorial process needs an upgrade, you may also like, ai + human expertise – a paradigm shift..., how to use paperpal to generate emails &..., is it ethical to use ai-generated abstracts without..., how to avoid plagiarism when using generative ai..., what are journal guidelines on using generative ai..., types of plagiarism and 6 tips to avoid..., similarity checks: the author’s guide to plagiarism and..., quillbot review: features, pricing, and free alternatives, authorship in academia: ghost, guest, and gift authorship.

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

View all journals
Explore content
About the journal
Publish with us
Sign up for alerts

Volume 628 Issue 8007, 11 April 2024

Insects at risk.

The cover shows a green leafhopper ( Cicadella viridis ). Five papers in this week’s issue explore the environmental challenges now facing insect populations, with climate change emerging as a key factor whose influence has potentially been underestimated. Jörg Müller and colleagues analyse 27 years of insect biomass data to reveal that weather anomalies associated with climate change can affect insect biomass in the temperate zone. In a second paper, Melanie Kazenel and co-workers find that warming caused by climate change could pose a threat to bee diversity in the United States, and a paper by Guillaume Ghisbain and colleagues predicts significant reduction in suitable habitat for European bumblebee species owing to human-induced changes to the environment, including climate change. Another human effect is highlighted in a paper by Charlie Nicholson and co-workers , which looks at the negative effects of pesticide use on bumblebees in Europe. And a fifth paper by Roel van Klink and colleagues probes how declines in formerly abundant species can drive insect loss.

Cover image: Ralph Martin www.instagram.com/visualnature.de/

What happens when climate change and the mental-health crisis collide?

The warming planet is worsening mental illness and distress. Researchers need to work out the scale of the problem and how those who need assistance can be helped.

Rwanda 30 years on: understanding the horror of genocide

Researchers must support and elevate the voices of Rwanda’s scholars and survivors.

AI-fuelled election campaigns are here — where are the rules?

Political candidates are increasingly using AI-generated ‘softfakes’ to boost their campaigns. This raises deep ethical concerns.

Rumman Chowdhury

Research Highlights

Smallest known starquakes are detected with a subtle shift of colour.

An unusual technique picks up the slow vibration of a faint star.

Green space near home has an antidepressant effect

People who had the most vegetation near their residences were the least likely to report depression and anxiety.

Advanced CRISPR system fixes a deadly mutation in cells

Applying a ‘base editor’ allows cells to crank out increased levels of a vital metabolic enzyme.

Baseball-sized hail in Spain began with a heatwave at sea

Climate change is partly to blame for a storm that pounded Girona province with record-breaking hailstones.

News in Focus

Is ivf at risk in the us scientists fear for the fertility treatment’s future.

An Alabama court ruling that human embryos outside the uterus should be regarded as children has raised concerns among doctors and scientists.

Mariana Lenharo

How papers with doctored images can affect scientific reviews

Scientists compiling a review scan more than 1,000 papers and find troubling images in some 10%.

Sumeet Kulkarni

Climate change has slowed Earth’s rotation — and could affect how we keep time

The effect of melting polar ice could delay the need for a ‘leap second’ by three years.

Elizabeth Gibney

Journal editors are resigning en masse: what do these group exits achieve?

Editorial rebellions seem to be on the rise, as researchers seek more control over scholarly communication.

Katharine Sanderson

This super-Earth is the first planet confirmed to have a permanent dark side

Convincing evidence of 1:1 tidal locking had been absent until a new analysis of the exoplanet LHS 3844b.

Joseph Howlett

Right- or left-handed? Protein in embryo cells might help decide

Gene that codes for structural protein could determine the dominant side of the human brain.

Scientists made a six-legged mouse embryo — here’s why

A rodent with two extra limbs instead of genitals shows the crucial role of a gene pathway in determining the fate of a primordial structure.

Sara Reardon

mRNA drug offers hope for treating a devastating childhood disease

Drug trial results show that vaccines aren’t the only use for the mRNA technology behind the most widely used COVID-19 jabs.

Elie Dolgin

After the genocide: what scientists are learning from Rwanda

Thirty years after the genocide against the Tutsi in Rwanda, Nature met with researchers who are gaining insights that could help to prevent other atrocities and enable healing.

Nisha Gaind

The rise of eco-anxiety: scientists wake up to the mental-health toll of climate change

Researchers want to unpick how climate change affects mental health around the world — from lives that are disrupted by catastrophic weather to people who are anxious about the future.

Helen Pearson

Books & Arts

Book review, survival of the nicest: have we got evolution the wrong way round.

How humans, animals and even single-celled organisms cooperate to survive suggests there’s more to life than just competition, argues a cheering study of evolutionary biology.

Jonathan R. Goodman

The comings and goings of ants: how are social skills shaped in an ever-changing world?

A colourful study of the natural history of ants that takes in dry deserts and lush forests aims to show that sociality is shaped by, and changes with, the environment.

Seirian Sumner

AI can help to tailor drugs for Africa — but Africans should lead the way

Computational models that require very little data could transform biomedical and drug development research in Africa, as long as infrastructure, trained staff and secure databases are available.

Gemma Turon
Mathew Njoroge
Kelly Chibale

Correspondence

Declining postdoc numbers threaten the future of us life science.

Anastasia Gromova
Steven F. Grieco

How to break big tech’s stranglehold on AI in academia

Michał Woźniak
Paweł Ksieniewicz

Use fines from EU social-media act to fund research on adolescent mental health

Christian Montag
Benjamin Becker

Brazil’s postgraduate funding model is about rectifying past inequalities

Lucindo J. Quintans-Júnior

Ready or not, AI is coming to science education — and students have opinions

As educators debate whether it’s even possible to use AI safely in research and education, students are taking a role in shaping its responsible use.

Sarah Wells

Technology Feature

‘without these tools, i’d be lost’: how generative ai aids in accessibility.

A rush to place barriers around the use of artificial intelligence in academia could disproportionately affect those who stand to benefit most.

Amanda Heidt

Collection:

Where I Work

Digging in: last chance to save a native forest.

Dario Sandrini hikes, plants and digs to save a threatened and diminishing ecosystem.

James Mitchell Crow

News & Views

Nanoscale scythe cuts molecular tethers using mechanical forces.

Nanoscale systems that release small molecules have potential therapeutic and industrial uses, but can result in low numbers of molecules reaching their target. A release system triggered by mechanical force offers a fresh approach.

Iwona Nierengarten

Climate change predicted to exacerbate declines in bee populations

What effects will climate change have on insect communities? Analyses of data collected over decades robustly document consequences specific to bee populations, and this evidence might aid future conservation efforts.

Nicole E. Miller-Struttmann

Mammalian cells repress random DNA that yeast transcribes

In experiments dubbed the Random Genome Project, researchers have integrated DNA strands with random sequences into yeast and mouse cells to find the default transcriptional state of their genomes.

Sean R. Eddy

Melting ice solves leap-second problem — for now

Humans’ effect on the polar ice sheets is slowing Earth’s rotation, posing challenges for its alignment with the official time standard. Two researchers discuss the science behind the slowdown and the impact it has on timekeeping.

Patrizia Tavella
Jerry X. Mitrovica

Whittling down the bacterial subspecies that might drive colon cancer

Understanding the factors that drive formation of particular types of cancer can aid efforts to develop better diagnostics or treatments. The identification of a bacterial subspecies with a connection to colon cancer has clinical relevance.

Cynthia L. Sears
Jessica Queen
Cancer at Nature Portfolio

A massive galaxy that formed its stars at z ≈ 11

A massive galaxy observed with the JWST indicates that the bulk of its stars formed within the first 500 million years of the Universe.

Karl Glazebrook
Themiya Nanayakkara
Angel Chandro-Gomez

An optical tweezer array of ultracold polyatomic molecules

An optical tweezer array of individual polyatomic molecules is created, revealing the obvious state control in the tweezer array and enabling further research on polyatomic molecules with diverse spatial arrangements.

Nathaniel B. Vilas
Paige Robichaud
John M. Doyle

Direct observation of a magnetic-field-induced Wigner crystal

A magnetic-field-induced Wigner crystal in Bernal-stacked bilayer graphene was directly imaged using high-resolution scanning tunnelling microscopy and its structural properties as a function of electron density, magnetic field and temperature were examined.

Yen-Chen Tsui
Ali Yazdani

Phase-change memory via a phase-changeable self-confined nano-filament

We present a device that can reduce the phase-change memory reset current while maintaining a high on/off ratio, fast speed and small variations, representing advances for neuromorphic computing systems.

See-On Park
Seokman Hong
Shinhyun Choi

Dopant-additive synergism enhances perovskite solar modules

A synergistic dopant-additive combination strategy using methylammonium chloride as the dopant and a Lewis-basic ionic-liquid additive is shown to enable the fabrication of perovskite solar modules achieving record certified performance and long-term operational stability.

Mohammad Khaja Nazeeruddin

Triple-junction solar cells with cyanate in ultrawide-bandgap perovskites

Triple-junction solar cells with cyanate in ultrawide-bandgap perovskites exhibit enhanced defect formation energy and substantially decreased non-radiative recombination.

Shunchang Liu

Metal telluride nanosheets by scalable solid lithiation and exfoliation

Fast and scalable synthesis of a variety of transition metal telluride nanosheets by solid lithiation and hydrolysis is demonstrated and several interesting quantum phenomena were observed, such as quantum oscillations and giant magnetoresistance.

Liangzhu Zhang
Zixuan Yang
Hui-Ming Cheng

Force-controlled release of small molecules with a rotaxane actuator

A rotaxane-based mechanochemical system enables force-controlled release of multiple cargo molecules that are appended to its molecular axle.

Robert Nixon
Guillaume De Bo

Couple-close construction of polycyclic rings from diradicals

A couple-close approach used to build semisaturated ring systems from dual radical precursors allows sampling of regions of underexplored chemical space, leading to an annulation that can be used for late-stage functionalization of pharmaceutical scaffolds.

Christian J. Oswood
David W. C. MacMillan

A global timekeeping problem postponed by global warming

Increased melting of ice in Greenland and Antarctica, measured by satellite gravity, has decreased the angular velocity of Earth more rapidly than before and has already affected global timekeeping.

Duncan Carr Agnew

Projected decline in European bumblebee populations in the twenty-first century

A quantitative study of past, present and future ecological suitability of Europe for bumblebees finds that for 38–76% of species now considered non-threatened, suitable territory could decrease by at least 30% by 2061–2080.

Guillaume Ghisbain
Simon Dellicour
Progress towards the Sustainable Development Goals

Heat and desiccation tolerances predict bee abundance under climate change

A 16-year dataset of abundance patterns of a diverse assemblage of bees in New Mexico, USA predicts declines for many bee species and indicates that drought-tolerant taxa will prevail in a warming and drying climate.

Melanie R. Kazenel
Karen W. Wright
Jennifer A. Rudgers

Weather explains the decline and rise of insect biomass over 34 years

Insect biomass data covering 27 years were reanalysed using sample-specific information on weather conditions during sampling and weather anomalies during the insect life cycle, finding that biomass is driven by complex weather conditions.

Jörg Müller
Torsten Hothorn
Annette Menzel

Pesticide use negatively affects bumble bees across European landscapes

Results from 316 Bombus terrestris colonies at 106 agricultural sites across eight European countries find pesticides in bumble bee pollen to be associated with reduced colony performance, especially in areas of intensive agriculture.

Charlie C. Nicholson
Jessica Knapp
Maj Rundlöf

Disproportionate declines of formerly abundant species underlie insect loss

An analysis of more than 500 sites distributed worldwide finds that declines in the abundance of terrestrial insects are attributable mainly to decreases in species that were formerly abundant, rather than being the result of losses of rare species.

Roel van Klink
Diana E. Bowler
Jonathan M. Chase

Adaptive foraging behaviours in the Horn of Africa during Toba supereruption

The archaeological site Shinfa-Metema 1 in the lowlands of northwest Ethiopia provides early evidence of intensive riverine-based foraging aided by the likely adoption of the bow and arrow.

John Kappelman
Lawrence C. Todd
Sierra Yanny

Synthetic reversed sequences reveal default genomic states

Introduction of a long synthetic DNA into yeast genomic loci results in high default transcriptional activity in yeast but low activity in mouse, suggesting distinct default levels of genomic activity in these organisms.

Brendan R. Camellato
Jef D. Boeke

Neural signatures of natural behaviour in socializing macaques

Single-neuron and population activity in the macaque prefrontal and temporal cortex robustly encodes 24 species-typical behaviours, reciprocity in social interactions and social support.

Camille Testard
Sébastien Tremblay
Michael L. Platt

A patterned human neural tube model using microfluidic gradients

Newly developed microfluidic neural tube-like and forebrain-like structures based on human pluripotent stem cells can model pivotal aspects of neural patterning along both the rostral–caudal and dorsal–ventral axes.

Yung Su Kim
Jianping Fu

AIRE relies on Z-DNA to flag gene targets for thymic T cell tolerization

Z-DNA anchors the AIRE-mediated transcriptional program by enhancing the generation of double-stranded breaks and promoter poising.

Kushagra Bansal
Diane Mathis

Rapid unleashing of macrophage efferocytic capacity via transcriptional pause release

Macrophages are revealed to adopt a polymerase II pause/release process to effectively deal with ingested apoptotic corpses and for continuous efferocytosis.

Turan Tufan
Gamze Comertpay
Kodi S. Ravichandran

TRBC1-targeting antibody–drug conjugates for the treatment of T cell cancers

Anti-TRBC1 antibody–drug conjugates may offer a more potent T cell cancer therapy by bypassing the fratricide that may be limiting the efficacy of anti-TRBC1 CAR T cells in the clinical trial for patients with T cell cancers.

Tushar D. Nichakawade

A distinct Fusobacterium nucleatum clade dominates the colorectal cancer niche

A study reveals that Fusobacterium nucleatum subspecies animalis is bifurcated into two distinct clades, and shows that only one of these dominates the colorectal cancer niche, probably through increased colonization of the human gastrointestinal tract.

Martha Zepeda-Rivera
Samuel S. Minot
Christopher D. Johnston

Transcription–replication conflicts underlie sensitivity to PARP inhibitors

Poly(ADP-ribose) polymerase 1 (PARP1) functions together with TIMELESS and TIPIN to protect the replisome in early S phase from transcription–replication conflicts, and inhibiting PARP1 enzymatic activity may suffice for treatment efficacy in homologous recombination-deficient settings.

Michalis Petropoulos
Angeliki Karamichali
Thanos D. Halazonetis

Targeting DCAF5 suppresses SMARCB1 -mutant cancer by stabilizing SWI/SNF

DCAF5 has a quality-control function for SWI/SNF complexes and promotes the degradation of incompletely assembled SWI/SNF complexes in the absence of SMARCB1.

Sandi Radko-Juettner
Charles W. M. Roberts

Automated model building and protein identification in cryo-EM maps

ModelAngelo builds atomic models and identifies proteins with unknown sequences in cryo-EM maps.

Kiarash Jamali
Sjors H. W. Scheres

Quick links

Explore articles by subject
Guide to authors
Editorial policies

This paper is in the following e-collection/theme issue:

Published on 15.4.2024 in Vol 8 (2024)

Clinical Decision Support System for Guidelines-Based Treatment of Gonococcal Infections, Screening for HIV, and Prescription of Pre-Exposure Prophylaxis: Design and Implementation Study

Authors of this article:

Original Paper

Saugat Karki 1 , MD, MS ;
Sarah Shaw 2 , MPH ;
Michael Lieberman 3, 4 , MD, MS ;
Alejandro Pérez 1 , MPH ;
Jonathan Pincus 5 , MD ;
Priya Jakhmola 6 , MBA, MS ;
Amrita Tailor 6 , MPH, PhD ;
Oyinkansola Bukky Ogunrinde 3 , MHSA ;
Danielle Sill 2 , MSPH ;
Shane Morgan 3 , MS ;
Miguel Alvarez 3 , MSEE ;
Jonathan Todd 3 , PhD ;
Dawn Smith 6 † , MD, MPH ;
Ninad Mishra 6 , MD, MSHI

1 Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States

2 Public Health Informatics Institute, Decatur, GA, United States

3 OCHIN, Portland, OR, United States

4 Oregon Health & Sciences University, Portland, OR, United States

5 Codman Square Health Center, Boston, MA, United States

6 Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, GA, United States

Corresponding Author:

Saugat Karki, MD, MS

Division of STD Prevention

Centers for Disease Control and Prevention

1600 Clifton Rd NE

Atlanta, GA, 30333

United States

Phone: 1 4047187483

Email: [email protected]

Background: The syndemic nature of gonococcal infections and HIV provides an opportunity to develop a synergistic intervention tool that could address the need for adequate treatment for gonorrhea, screen for HIV infections, and offer pre-exposure prophylaxis (PrEP) for persons who meet the criteria. By leveraging information available on electronic health records, a clinical decision support (CDS) system tool could fulfill this need and improve adherence to Centers for Disease Control and Prevention (CDC) treatment and screening guidelines for gonorrhea, HIV, and PrEP.

Objective: The goal of this study was to translate portions of CDC treatment guidelines for gonorrhea and relevant portions of HIV screening and prescribing PrEP that stem from a diagnosis of gonorrhea as an electronic health record–based CDS intervention. We also assessed whether this CDS solution worked in real-world clinic.

Methods: We developed 4 tools for this CDS intervention: a form for capturing sexual history information (SmartForm), rule-based alerts (best practice advisory), an enhanced sexually transmitted infection (STI) order set (SmartSet), and a documentation template (SmartText). A mixed methods pre-post design was used to measure the feasibility , use , and usability of the CDS solution. The study period was 12 weeks with a baseline patient sample of 12 weeks immediately prior to the intervention period for comparison. While the entire clinic had access to the CDS solution, we focused on a subset of clinicians who frequently engage in the screening and treatment of STIs within the clinical site under the name “X-Clinic.” We measured the use of the CDS solution within the population of patients who had either a confirmed gonococcal infection or an STI-related chief complaint. We conducted 4 midpoint surveys and 3 key informant interviews to quantify perception and impact of the CDS solution and solicit suggestions for potential future enhancements. The findings from qualitative data were determined using a combination of explorative and comparative analysis. Statistical analysis was conducted to compare the differences between patient populations in the baseline and intervention periods.

Results: Within the X-Clinic, the CDS alerted clinicians (as a best practice advisory) in one-tenth (348/3451, 10.08%) of clinical encounters. These 348 encounters represented 300 patients; SmartForms were opened for half of these patients (157/300, 52.33%) and was completed for most for them (147/300, 89.81%). STI test orders (SmartSet) were initiated by clinical providers in half of those patients (162/300, 54%). HIV screening was performed during about half of those patient encounters (191/348, 54.89%).

Conclusions: We successfully built and implemented multiple CDC treatment and screening guidelines into a single cohesive CDS solution. The CDS solution was integrated into the clinical workflow and had a high rate of use.

Introduction

Research has shown that a simultaneous, integrated approach to testing and other services targeting multiple diseases on the same population can be feasible and effective in improving accessibility and health outcomes among patients [ 1 ]. This integrated approach can be supported by point-of-care resources such as clinical decision support (CDS) system tools that can combine electronic patient health data and up-to-date guidelines and clinical protocols. This paper describes the usability phase of a study on the integration of a CDS tool for managing gonorrhea, screening for HIV, and identifying patients for HIV pre-exposure prophylaxis (PrEP) at Codman Square Clinic.

Gonorrhea, HIV, and PrEP

Gonorrhea was the second most commonly reported sexually transmitted infection (STI) in the United States in 2020, with a total of 677,769 cases reported to the Centers for Disease Control and Prevention (CDC) and has shown a 71.49% (395,216/677,769) increase since 2015 [ 2 ]. Among both men and women, untreated gonorrhea can cause serious and painful health problems, infertility, and in rare cases, even life-threatening conditions [ 3 - 7 ]. To mitigate these risks, annual screening is recommended for all sexually active women younger than 25 years and those at increased risk for infection. Timely diagnosis through routine screening and prompt, effective treatment—adhering to up-to-date CDC treatment guidelines—is paramount to both reducing gonorrhea and slowing down the threat of antimicrobial resistance [ 3 , 8 - 10 ].

HIV causes an infection that attacks the body’s immune system, specifically the cluster of differentiation antigen 4 T lymphocytes [ 11 , 12 ]. If left untreated, it can lead to AIDS, opportunistic infections, malignancies, and death [ 11 ]. HIV PrEP has been shown to reduce the risk of acquiring HIV infection [ 13 , 14 ]. As a result, the CDC has developed guidance for prescribing PrEP to individuals considered at high risk, and gonorrhea infection is identified as one of those risk factors [ 15 , 16 ].

Syndemic of STIs: Gonorrhea and HIV Infection

Patients with STIs have a 2- to 3-fold increased risk of having concomitant HIV infection compared to those without any STI [ 17 , 18 ]. Gonococcal infections, specifically, have also been associated with increased risk of HIV [ 18 - 23 ]. Gonococcal infections cause immune reactions that, among others, recruit cluster of differentiation antigen 4 cells, which can potentially enhance HIV in vivo replication and facilitate acquisition and transmission of HIV infection [ 20 , 24 - 26 ]. Previous studies have further advanced our understanding of this syndemic and describe the biological, behavioral, social, and structural determinants and their synergisms [ 20 , 22 , 25 ]. As a result, it has been a long-standing recommendation to screen patients diagnosed with STIs, including gonorrhea, for HIV [ 8 , 27 ].

This synergistic and potentially concomitant nature of gonorrhea and HIV and the overlap between gonorrhea treatment, HIV screening, and PrEP prescription present us with the opportunity to develop a CDC guidelines–based synergistic intervention tool that could target adequate treatment for gonococcal infections, screening for HIV based on risk factors associated with the diagnosis of gonorrhea, and PrEP prescription to relevant populations.

CDS Systems

CDS systems are computational tools that leverage information available in electronic health records (EHRs) to provide person-specific evidence-based information, intelligently filtered, and presented at appropriate times to help inform decisions regarding a patient’s care to improve patient outcomes and lead to higher quality care [ 28 - 31 ]. A systematic review of 160 articles representing 148 unique studies describing CDS implemented across diverse settings found that CDS interventions were efficacious on health care process outcomes, but data on clinical and economic outcomes were sparse [ 32 ]. The Community Preventive Services Task Force conducted a systematic review of 23 studies and reported that CDS increased HIV screening for both the general population and people at higher risk for HIV infections [ 33 ]. Based on the strong evidence of effectiveness, the Community Preventive Services Task Force has now recommended CDS to increase HIV screening [ 33 ]. The Sexually Transmitted Infections National Strategic Plan has also recommended increasing the implementation of CDS to support high-quality sexual health assessments, screen for STIs, integrated care models, and reduce adverse outcomes [ 34 ].

Gonorrhea treatment recommendations are updated regularly to represent the latest evidence to provide adequate treatment and curb the rise of antimicrobial resistance [ 3 , 8 ]. Keeping up to date with the latest guidelines could potentially pose a challenge to clinical providers, as evidenced with varying degrees of adherence to gonorrhea treatment guidelines [ 9 , 10 ]. Coupled with the synergistic nature of the infection with HIV [ 18 , 20 - 26 ], this presents an opportunity to develop a multifaceted CDS intervention to address the needs of the same patient population and improve clinical provider adherence to CDC guidelines on gonorrhea, HIV screening, and providing PrEP for HIV infection, when indicated.

The primary goal of this study was to translate portions of CDC treatment guidelines for gonorrhea and relevant portions of guidelines for HIV screening and PrEP prescribing, into EHR-based CDS interventions to aid clinicians’ adherence to these guidelines and improve respective patients’ health outcomes. CDC guidelines–based CDS tools for STIs have not been reported in published literature; similarly, 2 or more guidelines have not previously been cohesively built into a single CDS tool. A secondary goal was to assess whether the translated CDS solution worked in a real-world clinical workflow initiated by patients with a gonorrhea diagnosis.

Ethical Considerations

This project was designed and executed as a quality improvement project at OCHIN, the implementing partner, and therefore was not considered human subjects research, and institutional review board input was not obtained. The impact of the project was assessed using only aggregated deidentified data. All OCHIN members include language in their patient privacy notices stating that deidentified data may be used for research purposes. There was no compensation for human subjects’ research.

EHR Platform and Clinical Partner

We partnered with OCHIN, Inc, a nonprofit community-based health center–controlled network as the EHR provider [ 35 , 36 ]. We selected OCHIN’s Epic EHR [ 37 ] as it serves as the primary EHR to almost 1000 health care sites with 21,000 clinicians in 45 states who serve over 6 million patients [ 38 ]. OCHIN provides 1 instance of Epic consisting of enterprise-wide master patient index; patients have a single medical record across all clinics in the network, and all data are managed centrally.

Within the OCHIN network, we partnered with Codman Square Health Center, a Federally Qualified Health Center in Dorchester, Massachusetts, to pilot the CDS intervention [ 39 ]. We selected Codman Square Health Center as both patients with gonorrhea and HIV are regularly managed in their clinics and they have a well-established STI-reporting practice in place. Typically, they have over 115,000 client contacts per year.

Intervention Clinic

While all of Codman Square Health Center had access to the CDS solution, a subset of clinicians within the Internal Medicine clinic, specifically, were selected as the focus of the intervention. This subset of clinicians frequently engaged in the screening and treatment of STIs and provide care under the name “X-Clinic” to allow a level of discretion to the patients they serve. The X-Clinic clinicians were selected for the focus of the intervention due to the high rates of gonorrhea infection and the potential for use of the CDS solution during the pilot period. A clinical champion was identified to provide insight and encourage participation among staff along with 2 project leads, 1 representing the providers and 1 for support staff. While the CDS tool was available to the broader Codman Square Health Center, the X-clinic received targeted training and support to use the tool. This training and support were not extended to the rest of Codman Square Health Center.

CDS Solution Design

Study design.

An internal review by OCHIN, the implementing partner, determined this work as quality improvement and deemed that an institutional review board review was not necessary. A 12-week study period was planned, beginning August 31, 2021, and ending on November 23, 2021. A mixed methods pre-post design [ 40 ] was used to measure the feasibility , use , and usability of the CDS solution. During the time of the planned intervention, COVID-19 altered the typical pattern of patients seeking STI-related care [ 41 , 42 ]. As a result, we determined that the 12-week period immediately prior to the intervention period would be the most representative sample of baseline patient data.

Practice Coach Engagement

In addition to the direct training provided, the X-Clinic clinicians received targeted and continual support on the use of the CDS solution using the practice coaching methodology. This included supporting adaptive skills and learning to build capacity and capability for the care team to effectively use the CDS solution, explore change ideas, provide feedback to support the team’s progress as the team becomes more self-sufficient, and engage with iterative learning. Practice coaching (also known as practice facilitation) has been demonstrated to be effective in successfully implementing tools and new evidence into clinical practice [ 43 - 46 ]. A key part of the intervention design included a dedicated practice coach who regularly engaged with the clinical champion and project leads at the X-Clinic. The coach was part of the project team’s kick-off meeting, which included a warm welcome from the CDS solution developer, project orientation from the project manager, training by the trainer to demonstrate the solution, and an overview of the coaching engagement from the coach. The facilitation meetings were held biweekly for the duration of the project, and they typically included discussions about general assessment and feedback, use, perceived effectiveness, and clinical integration of the CDS solution. When available, CDS solution–related data were reviewed for discussion of key insights, opportunities for improvement, and when a need was identified, the practice coach engaged subject matter experts to provide added support and facilitated referrals for technical and application support.

CDS Solution Development

OCHIN Epic EHR [ 37 ] has native tools to develop CDS solutions in a variety of formats, each performing specific functions. For this CDS solution, we developed four tools: (1) a sexual history data capture form using “SmartForm” (Epic’s name for a method for capturing responses to questions in a structured format) and a patient questionnaire with the same questions that can be made available to the patient prior to the visit, (2) a “best practice advisory” (BPA; Epic’s name for rule-based alerts), (3) an enhanced STI order set—that included diagnoses as well as links to documentation templates—using “SmartSet” (Epic’s name for order sets), and (4) a documentation template using “SmartText” (Epic’s name for a method of notetaking that prompts clinician with standard information collected and presented during a visit).

We developed a CDS solution by integrating translated information from 3 separate CDC guidelines, specifically to guide clinicians to choose appropriate therapy for gonorrhea [ 3 , 8 ] and—as per the CDC’s guidelines to prevent or diagnose new HIV infections [ 47 - 49 ] and link those individuals considered at risk to relevant prevention and medical services [ 15 , 16 ]—prompt them to screen for HIV and consider PrEP, if patients met those criteria ( Figure 1 ). Health data standards were used wherever possible; ICD-10-CM ( International Classification of Diseases, Tenth Revision, Clinical Modification ) was used to evaluate the diagnosis of gonococcal infections.

The Sexual History SmartForm and corresponding patient questionnaire were developed to collect sexual history and STI-related symptoms from patients. The form and questionnaire were structured as point and click questions and answers for ease of use; patients had access to the questionnaire via MyChart [ 50 ] (Epic’s patient portal) prior to the visit ( Figure 1 , step 1; Table 1 ). At the beginning of the clinic visit, nurse navigators reviewed the information collected using the SmartForm and completed the questionnaire, if incomplete ( Figure 1 , step 2). Based on CDC’s guidelines [ 15 , 16 , 48 ], patients were considered to be at risk for HIV infection for the following criteria: (1) positive result or diagnosis for gonococcal infection in the last 6 months; (2) reason for visiting the clinic was related to STI; and (3) sexual risk behaviors, known partner with any STI, and if patient or partner using or sharing needles. If the patient’s response suggested a high risk for HIV infection, the SmartForm algorithm presented further questions to gauge awareness and interest for PrEP ( Table 1 ).

a STI: sexually transmitted infection.

b PrEP: pre-exposure prophylaxis.

c EHR: electronic health record.

For patients who (1) had a confirmed positive result for gonococcal infection in the last 14 days, (2) had a chief complaint related to gonorrhea (STI symptoms or concern; penile, urethral, rectal, or vaginal discharge and STI-related screening, testing, follow-up, or visit), or (3) were treated presumptively due to a partner with known gonococcal infection, a BPA would alert the clinical provider ( Figure 1 , step 3) to use the SmartSet to assist in providing standardized clinical care ( Figure 1 , step 4; Table 1 ). The SmartSet was designed to (1) recommend laboratory tests to screen for STI, including HIV, (2) provide PrEP prescription options, (3) present CDC guidelines–based recommendations for medication regimens as preferred options to treat gonococcal infections, and (4) provide a link to gonorrhea treatment guidelines for anything beyond uncomplicated gonorrhea and a link to the SmartText ( Figure 1 , step 5; Table 1 ). Opening the BPA did not necessarily mean that clinical providers selected diagnoses or ordered laboratory tests or medication directly from the SmartSet but merely that those options were made available for selection and action. Diagnoses, laboratory tests, and medication orders could also be entered for the patient outside of the SmartSet. The SmartText template was developed to prompt the clinical provider to document in a standardized manner ( Table 1 ). The SmartText included common heading for note taking, prepopulated STI-related laboratory results from the patient’s chart, and risk reduction suggestions.

Use of CDS Solution and Outcomes of Intervention

We evaluated CDS solution use and outcome metrics specifically for any person with confirmed case of gonorrhea or with an STI-related chief complaint. Data were collected on the demographics of the patient population to ensure appropriate comparison between the baseline and intervention populations, use metrics of CDS solutions by X-Clinic, and outcomes following the implementation of the CDS solution. To measure patient and disease characteristics for the baseline period (immediate 12-week period prior to the intervention period), a 1-time data extraction was performed ( Table 2 ). During the intervention period, quantitative data were extracted on a nightly basis.

a CDS: clinical decision support.

Clinical Provider Perspectives and Usability of the CDS Solution

We conducted 1 midpoint survey to confirm the use of CDS solution and identify any challenges faced by the clinical providers using the solution ( Table 2 ; Multimedia Appendix 1 ). Four end users—or clinical providers who used the CDS solution—completed the survey. We also conducted key informant interviews with 3 end users at the end of the pilot period to assess the usability of the CDS solution ( Multimedia Appendix 2 ). The CDS solution design encompassed multiple end user roles such as the SmartForm, which was anticipated to be completed by nurse navigators, and SmartSet, which was anticipated to be completed by clinical providers. We interviewed individuals who represented the various roles such as leadership, clinical provider, and nurse navigator perspectives. The purpose of the key informant interviews was to understand treatment and screening workflows prior to CDS solution implantation, perception, and impact of the CDS solution and solicit suggestions for potential future enhancements ( Table 2 ). We measured the use and usability of the CDS solution based on the clinical provider role to reveal how perception and familiarity with the CDS solution may have impacted use.

Data Analysis

We used quantitative and qualitative means to examine the feasibility of this guidelines-based CDS solution in a real-world clinical workflow, where 2 separate guidelines have been cohesively built into a single CDS tool solution, initiated by patients with a gonorrhea diagnosis. Quantitative data were used to describe the use metrics and outcomes post implementation of CDS solution and were summarized by descriptive statistics using counts and percentages. To assess usability of the CDS tool, qualitative data were systematically coded from interview transcripts, and findings were determined using a combination of explorative and comparative analysis to examine end user (clinical provider) perspectives.

Statistical analysis was conducted to compare the differences between patient populations in the baseline and intervention periods. For continuous variables, to test for a statistically significant difference among populations, a 2-sample t test was used. To test for a statistically significant association among outcomes, all categorical variables were tested using Pearson chi-square test, and if an expected count of 5 was not observed for a cell, Fisher exact test was used. If a statistically significant association was observed, odds ratios were calculated. All statistical analyses were conducted using SAS (version 9.4; SAS Institute).

Description of Patient Populations: Pre- and Post-CDS Intervention

During the intervention period, 12,048 patients were provided with clinical care in Codman Square Health Center and 37 were diagnosed with gonorrhea; similarly, 40 patients out of 11,269 were diagnosed with gonorrhea in the baseline period. The mean age of patients seen in the baseline and intervention periods was 37 (SD 21.46) years and 36 (SD 21.98) years, respectively ( P <.001). A 2-sample t test analysis of the age groups revealed that the intervention period included younger individuals compared to the baseline period and cannot be considered similar; however, the largest age group of 25-44 years old remained the same with 30.78% (3469/11,269) in the baseline period and 29.58% (3564/12,048) in the intervention period. Using Fisher exact test, it was determined that the patients in the baseline and intervention periods were comparable regarding gender ( P =.25). While ethnicity distribution was found to be similar ( P =.56) using Pearson chi-square test, baseline and intervention groups differed significantly by race ( χ 1 2 =4.36; P =.04). Nevertheless, the largest patient population served by Codman Square Health Center was Black or African American in both baseline (9040/11,269, 80.22%) and intervention (9565/12,048, 79.39%) periods.

Throughout Codman Square Health Center, the BPA was triggered 950 (4.07%) times. Within the X-Clinic specifically, the BPA was triggered in one-tenth of all the clinical encounters (348/3451, 10.08%); these 348 encounters represented 300 patients ( Figure 2 ). The SmartForm was opened for about half of the patients (157/300, 52.33%), and in instances when the SmartForm was opened, it was completed 89.81% (141/157) of the time ( Figure 2 ). Of note, while the BPA did not prompt the user to open the SmartForm, the patient cohort where the BPA presented was used for analysis as this represents the target population for this study. For those patients whose responses determined them as high-risk for HIV, further PrEP-related questions were asked ( Table 1 ). Some information about PrEP was known to 63.31% (88/139) of the patients who were asked that question; 6.62% (9/136) of patients reported having taken PrEP and 16.06% (22/137) patients showed interest in PrEP ( Figure 2 ).

Clinical providers could open SmartSet from the BPA ( Figure 1 , step 4), and this action was taken for about half of the patients (162/300, 54%) for whom BPA was presented. In the target population, the most common diagnosis was “Vulvovaginitis” ( ICD-10-CM : N76.0); it was assigned to 34 patients, 21 were assigned to patients for whom BPA was presented, and 13 were assigned where no BPA was presented ( Table 3 ). Diagnoses were assigned, and laboratories were ordered both from BPA-prompted SmartSet and outside of BPA without using the CDS solution ( Table 3 ). No patients were diagnosed with cervicitis but were diagnosed with urethritis, pharyngitis, and proctitis. The most ordered laboratory test was for HIV. More than half (191/348, 54.89%) of the encounters where a BPA was presented received these orders for HIV testing.

In the X-Clinic, SmartText note template was used in most of the clinical encounters (313/348, 89.9%), where the BPA presented. Clinical providers used SmartText extensively (2343/3103, 75.5%) even during encounters where the BPA did not trigger. The SmartText was accessible either through the SmartSet or a standard “quick button” in the documentation area. The clinical site continued to use the CDS tool beyond the study period.

a TMA: transcription-mediated amplification.

b BVS: blind vaginal swab.

c SDA: strand displacement amplification.

d IgG: immunoglobulin G.

e IgM: immunoglobulin M.

f RPR: rapid plasma reagin.

g ELISA: enzyme-linked immunosorbent assay.

Outcomes of Intervention

In the intervention period, among patients where a BPA was triggered, there were fewer patients with a diagnosis of gonococcal infections (33/750, 4.4%) as compared to the baseline period (41/649, 6.32%; Table 4 ). While roughly four-fifths (34/41, 82.93%) of these patients diagnosed with gonorrhea were prescribed antimicrobials for treating the infection, the difference in the number of patients treated in the intervention (26/33, 78.79%) and baseline periods were not statistically significant ( P= .65). Individuals in the intervention period had a 26% decrease in odds (odds ratio 0.74, CI: 0.60-0.91) of being screened for HIV (310/750, 41.33%) compared to the baseline period (317/649, 48.84%). PrEP was prescribed 2 times more to patients in the intervention period (12/750, 1.6%) compared to the baseline period (6/649, 0.92%); however, analysis revealed that these numbers not to be statistically significant ( P =.26).

a Any person with confirmed case of gonorrhea or with a sexually transmitted infection–related chief complaint.

Midpoint Survey

Most of the survey responders reported that the CDS solution was not intrusive to their clinical practice workflow (2/4, 50% strongly agreed; 1/4, 25% agreed; and 1/4, 25% was neutral). They also agreed (0/4, 0% strongly agreed; 3/4, 75% agreed; and 1/4, 25% was neutral) that the CDS solution was easy to navigate and provided sufficient time to use it during the patient consultation. They had neutral responses (0/4, 0% strongly agreed; 1/4, 25% agreed; and 3/4, 75% was neutral) about the CDS solution’s ability to present clear recommendations for treatment.

Key Informant Interviews

The interview revealed 3 major emerging themes. First, the interviewees opined that the CDS solution provided a faster and more standardized approach for capturing the sexual history and treating the patient and planned to keep using it after the pilot was complete. Second, while the CDS solution improved the efficiency and streamlined their existing processes, the interviewees did not change their treatment or screening recommendations based on the solution. Third, they also revealed that the full scope of the CDS solution was not clear to them and reported discovering components of the solution on their own that they were not aware were part of the CDS solution.

There were 3 key themes related to the features of the CDS solution. First, the BPAs alone would not prompt behavior change and use. Interviewees emphasized the importance of education of new guidelines and changes in the EHR tools from someone they know and trust and believed this would promote adherence from clinicians. Second, there were mixed reviews regarding the use of the logic that determined to present PrEP-related questions to some patients considered at high-risk for HIV. While 1 interviewee noted that the unique focus of X-Clinic to specifically address sexual health–related questions and conditions, all patients should be asked PrEP-related questions and noted confusion over the questions being presented to only some patients and not to other patients. Another interviewee indicated that this logic was helpful for colleagues who are less familiar with PrEP to highlight relevance in populations not typically targeted for PrEP, such as heterosexual patients. Third, there was a general sense that SmartSets were hard to navigate. Multiple interviewees commented that they were unable to find SmartSets without BPAs, and once in the SmartSet, it was not easy to leave and come back if an issue outside the scope of the SmartSet needed to be addressed, such as discussions regarding intrauterine devices in relation to gonococcal infections. One interviewee noted handwriting details to remember after completing a task within SmartSet.

Role-Based Use of CDS Solution

A patient may be seen by multiple providers from more than one provider type category. In the target population (750/12,048, 6.23%) described in Table 4 , 32 Doctors of Medicine and Doctors of Osteopathy (MD/DO) provided care for 281 patients and minimally used SmartForms (20/281, 7.12%) but completed most of them once opened (18/20, 90%); 26 advanced practice providers (APPs) provided care to 362 patients, used SmartForms for 20.99% (76/362) of patients, and 81.58% (62/76) completed most of them. In contrast, the “other” category, which included all other clinical staff such as case manager, dentist, laboratory technician, licensed practical nurse, medical assistants, midwives, and social workers, had the highest use, opening SmartForms for half of the patients they served (99/192, 51.56%) and completed most of the forms (83/99, 83.84%). Similarly, “other” category staff administered the highest number of PrEP-related questions, followed by APPs and MD/DOs administered very few. Providers classified as MD/DOs had 309 clinical encounters with 281 patients and opened SmartSets in half of the encounters (157/309, 50.81%) and those classified as APPs had 398 clinical encounters with 362 patients and opened SmartSets slightly lower than half of the encounters (180/398, 45.23%). “Other” staff opened SmartSets the least (82/126, 39.42%), with 10 staff who interacted with 192 patients in 208 encounters.

Principal Findings

We integrated translated information from 3 CDC guidelines into a single cohesive CDS solution. This included CDC’s treatment recommendations for gonococcal infections (for appropriate diagnosis, testing, and treatment for gonorrhea) and HIV screening recommendations and PrEP prescription recommendations that stem from the diagnosis of gonorrhea. This CDS solution was implemented at a federally qualified health center where it continued to be used after the intervention period. The CDS solution successfully collected relevant information about the patient, evaluated the patient information against the CDC guidelines to prompt adequate treatment for gonorrhea, and identified at-risk patients for further HIV screening and PrEP prescription. The quantitative data revealed high rates of use of the various tools developed for the CDS solution and demonstrated the feasibility of incorporating such multifaceted guidelines–based CDS solutions in real-world clinical settings.

During our usability testing, clinical providers used all components of the CDS solution, with varying degrees, based on their respective provider type or roles, and familiarity with the CDS solution. Providers classified as MD/DO and APP used the SmartSet more than “other” staff such as medical assistants and social workers and vice versa for the SmartForm that performed the initial screen for patients’ sexual history and PrEP awareness. In the X-Clinic, specifically, the BPA was presented in 10.08% (348/3451) of the encounters; clinicians reported that this was not intrusive and could be used as a benchmark to potentially reduce alert fatigue. The SmartSet was opened in about half of the times alerted by BPA, but fewer orders were directly entered from the SmartSet itself. This does not mean that patients did not receive care. Some insights offered by providers as plausible explanations include (1) clinicians reported benefiting from the reminder and served as a knowledge source even if they performed those actions outside of the SmartSet; (2) clinicians were not accustomed to using SmartSets and reported experiencing difficulties in locating it once they moved away from it during the clinical visit; (3) the BPA alert at the time when the patient record was initially opened may be too early to determine diagnosis, order laboratory tests, and prescribe treatment, delaying the timing of the BPA could be explored; and (4) clinicians had neutral responses when asked about CDS solution’s ability to present clear recommendations since SmartSet presented all treatment options with those aligned to the guidelines marked as “preferred” instead of targeted recommendations for a particular patient.

There was no significant difference between the baseline and intervention patient groups with respect to the treatment for gonococcal infections. It is important to note that X-Clinic is primarily focused on providing sexual health and STI-related care, and the providers were well versed with treatment recommendations, which could be an explanation for the lack of difference. The results also show that one-fifth of the patients in both baseline and intervention periods were not treated with antimicrobials during the visit. A likely explanation is that these patients were empirically treated elsewhere and were referred to X-Clinic for further follow-up, given their specialty in providing STI-related care. Fewer patients were screened for HIV during the intervention period compared to the baseline period. However, key informant interview participants anecdotally reported an increased interest regarding PrEP in less traditional populations, such as heterosexual women. While PrEP was prescribed to twice as many patients in the intervention period compared to the baseline period, this was not deemed statistically significant.

The widespread adoption of EHRs has provided us with the unique opportunity to leverage CDS approaches to automate and align clinical decisions such as identifying at-risk patients for further screening and providing adequate treatment with the latest guidelines. This becomes especially important in situations where clinical providers may not be familiar with the latest screening and treatment guidelines. Given the rise in resistance to antimicrobial treatment for gonorrhea, adherence to treatment guidelines is even more important. Further development of standards and tools and examination of workflows to implement useful guidelines-based CDS solutions with the ultimate goal of improving patient care are needed.

Limitations

The original design was based upon a 6-month intervention period. A longer pilot period would have allowed the opportunity for a larger data set of patients diagnosed with gonorrhea and potentially more compelling statistical correlations, along with additional time for the clinical staff to acclimate to the new solution.

For this phase of our work, it was important to test the feasibility of the guidelines-based CDS logic, measure the use of the CDS tools, and solicit feedback from end users regarding their experience using the CDS tool. Prioritizing these factors, we decided to leverage EHR-native but vendor-specific tools such as SmartForm, BPA, SmartSet, and SmartText. We factored that OCHIN, our partner organization has many clinics using their instance of Epic EHR across the United States [ 37 , 38 ], and any lessons learned could potentially be replicated and scaled to other interested clinical sites.

Since the focus of this work was to translate multiple CDC guidelines into a cohesive CDS solution, we selected a clinical site that was well versed in STI diagnosis and treatment with a track record of serving a large number of patients seeking sexual health and STI-related care. Due to the same reasons, this clinical setting may not be the best target of clinical providers to measure any potential outcomes of the CDS solution. The CDS solution would better serve clinical providers and settings, where there is less familiarity of treating patients with STIs.

In this study, we report the feasibility , use , and usability of the CDS solution; we did not measure the effectiveness of the intervention. We did not examine any change in clinical practice and its impact on clinical care or the long-term prevention outcomes in the patient population. As a result, we did not randomize the study and did not examine any potential confounding. Similarly, while we obtained quantitative and qualitative information from end users of various roles, the small sample size poses challenges to draw firm conclusion of usability at scale. Further examination of the CDS solution could be performed by manual chart review with an annotated gold standard measure.

Comparison With Prior Work

In the past, CDC guidelines–based CDS interventions have been designed to recommend appropriate immunizations [ 51 ], screening for alcohol use disorder [ 52 ], and screening for cervical cancer [ 53 ]. A United States Indian Health Services clinic implemented a chlamydia and HIV screening tool and observed increase in screening frequencies of both chlamydia and HIV; however, this was not strictly based on CDC guidelines [ 54 ]. Another study described the implementation of CDS tool to encourage appropriate prescription of azithromycin in primary care clinics with the aim to curb rise of antimicrobial resistance, but this study was not targeted toward STIs and was focused on bronchitis and upper respiratory tract infections [ 55 ]. To the best of our knowledge, no CDS tools have been implemented with the goal of improving adherence to guidelines for gonorrhea treatment, HIV screening, and HIV PrEP.

Conclusions

It is feasible to integrate multiple CDC guidelines into a single cohesive CDS solution. The CDS solution showed high rates of use, but given the short study period, we could not adequately measure realistic patient outcomes. The clinical site has opted to continue using the full scope of the CDS solution, and perhaps that decision is a measure of success.

Learning from this experience, we will be developing a standards-based EHR-agnostic CDS solution with a longer study period.

Acknowledgments

This project was supported by the Centers for Disease Control and Prevention (CDC) funding to the Task Force for Global Health under a cooperative agreement (NU38OT000316). The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the US CDC. Mention of company names or products does not imply endorsement by the CDC. The authors have not leveraged generative artificial intelligence in writing any portion of this manuscript. “Profile” symbol on Figure 1 is by Gregor Cresnar from The Noun Project “Platforms” symbol on Figure 1 is by IconPai from The Noun Project.

Data Availability

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Conflicts of Interest

None declared.

Midpoint survey instrument.

Key informant interview questions.

Gasbarrini N, Dubravić D, Combs L, Dišković A, Ankiersztejn-Bartczak M, Colaiaco F, et al. Increasing integrated testing in community settings through interventions for change, including the Spring European Testing Week. BMC Infect Dis. 2021;21(Suppl 2):874. [ FREE Full text ] [ CrossRef ] [ Medline ]
Sexually Transmitted Diseases Surveillance. Atlanta, GA. Centers for Disease Control and Prevention; 2020. URL: https://www.cdc.gov/std/statistics/2020/default.htm [accessed 2024-02-29]
Sexually transmitted infections treatment guideliens, 2021. Centers for Disease Control and Prevention. 2021. URL: https://www.cdc.gov/std/treatment-guidelines/gonorrhea-adults.htm [accessed 2022-09-15]
Kirkcaldy RD, Weston E, Segurado AC, Hughes G. Epidemiology of gonorrhoea: a global perspective. Sex Health. 2019;16(5):401-411. [ FREE Full text ] [ CrossRef ] [ Medline ]
Kreisel K, Torrone E, Bernstein K, Hong J, Gorwitz R. Prevalence of pelvic inflammatory disease in sexually experienced women of reproductive age—United States, 2013-2014. MMWR Morb Mortal Wkly Rep. 2017;66(3):80-83. [ FREE Full text ] [ CrossRef ] [ Medline ]
Kreisel KM, Llata E, Haderxhanaj L, Pearson WS, Tao G, Wiesenfeld HC, et al. The burden of and trends in pelvic inflammatory disease in the United States, 2006-2016. J Infect Dis. 2021;224(12 Suppl 2):S103-S112. [ FREE Full text ] [ CrossRef ] [ Medline ]
Antibiotic Resistance Threats in the United States 2019. Atlanta, GA. Centers for Disease Control and Prevention; 2019.
St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, Schlanger K, et al. Update to CDC's treatment guidelines for gonococcal infection, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(50):1911-1916. [ FREE Full text ] [ CrossRef ] [ Medline ]
Weston EJ, Workowski K, Torrone E, Weinstock H, Stenger MR. Adherence to CDC recommendations for the treatment of uncomplicated gonorrhea—STD surveillance network, United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(16):473-476. [ FREE Full text ] [ CrossRef ] [ Medline ]
Lechtenberg RJ, Samuel MC, Bernstein KT, Lahiff M, Olson N, Bauer HM. Variation in adherence to the treatment guidelines for Neisseria gonorrhoeae by clinical practice setting, California, 2009 to 2011. Sex Transm Dis. 2014;41(5):338-344. [ FREE Full text ] [ CrossRef ] [ Medline ]
HIV. Centers for Disease Control and Prevention. Atlanta, GA. URL: https://www.cdc.gov/hiv/basics/whatishiv.html [accessed 2022-09-19]
HIV/AIDS. World Health Organization. URL: https://www.who.int/health-topics/hiv-aids#tab=tab_1 [accessed 2022-09-19]
Baeten JM, Donnell D, Ndase P, Mugo NR, Campbell JD, Wangisi J, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med. 2012;367(5):399-410. [ FREE Full text ] [ CrossRef ] [ Medline ]
Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587-2599. [ FREE Full text ] [ CrossRef ] [ Medline ]
US Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States-2021 Update: A Clinical Practice Guideline. Atlanta, GA. Centers for Disease Control and Prevention; 2021.
US Public Health Service: Preexposure Prophylaxis for the Prevention of HIV Infection in the United States-2021 Update: Clinical Providers' Supplement. Atlanta, GA. Centers for Disease Control and Prevention; 2021.
Sexton J, Garnett G, Røttingen JA. Metaanalysis and metaregression in interpreting study variability in the impact of sexually transmitted diseases on susceptibility to HIV infection. Sex Transm Dis. 2005;32(6):351-357. [ FREE Full text ] [ CrossRef ] [ Medline ]
Kassler WJ, Zenilman JM, Erickson B, Fox R, Peterman TA, Hook EW. Seroconversion in patients attending sexually transmitted disease clinics. AIDS. 1994;8(3):351-355. [ CrossRef ] [ Medline ]
Bernstein KT, Marcus JL, Nieri G, Philip SS, Klausner JD. Rectal gonorrhea and chlamydia reinfection is associated with increased risk of HIV seroconversion. J Acquir Immune Defic Syndr. 2010;53(4):537-543. [ FREE Full text ] [ CrossRef ] [ Medline ]
Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect. 1999;75(1):3-17. [ FREE Full text ] [ CrossRef ] [ Medline ]
Zetola NM, Bernstein KT, Wong E, Louie B, Klausner JD. Exploring the relationship between sexually transmitted diseases and HIV acquisition by using different study designs. J Acquir Immune Defic Syndr. 2009;50(5):546-551. [ FREE Full text ] [ CrossRef ] [ Medline ]
Wasserheit JN. Epidemiological synergy. Interrelationships between human immunodeficiency virus infection and other sexually transmitted diseases. Sex Transm Dis. 1992;19(2):61-77. [ Medline ]
Stenger MR, Pathela P, Schumacher C, Burghardt N, Amiya R, Madera R, et al. Trends in HIV prevalence by self-report among MSM diagnosed and reported with gonorrhea in six United States jurisdictions from 2010 to 2019. AIDS. 2021;35(15):2523-2530. [ FREE Full text ] [ CrossRef ] [ Medline ]
Mayer KH, Venkatesh KK. Interactions of HIV, other sexually transmitted diseases, and genital tract inflammation facilitating local pathogen transmission and acquisition. Am J Reprod Immunol. 2011;65(3):308-316. [ FREE Full text ] [ CrossRef ] [ Medline ]
Bromberg DJ, Mayer KH, Altice FL. Identifying and managing infectious disease syndemics in patients with HIV. Curr Opin HIV AIDS. 2020;15(4):232-242. [ FREE Full text ] [ CrossRef ] [ Medline ]
Cohen MS, Hoffman IF, Royce RA, Kazembe P, Dyer JR, Daly CC, et al. Reduction of concentration of HIV-1 in semen after treatment of urethritis: implications for prevention of sexual transmission of HIV-1. AIDSCAP Malawi Research Group. Lancet. 1997;349(9069):1868-1873. [ CrossRef ] [ Medline ]
U.S. Preventive Services Task Force. Screening for HIV: recommendation statement. Am Fam Physician. 2005;72(11):2287-2292. [ FREE Full text ] [ Medline ]
Clinical decision support. The Office of the National Coordinator for Health Information Technology. URL: https://www.healthit.gov/topic/safety/clinical-decision-support [accessed 2022-09-19]
Clinical decision support. Agency for Healthcare Research and Quality. Rockville, MD.; 2019. URL: https://www.ahrq.gov/cpi/about/otherwebsites/clinical-decision-support/index.html [accessed 2022-09-19]
Dullabh P, Heaney-Huls K, Lobach DF, Hovey LS, Sandberg SF, Desai PJ, et al. The technical landscape for patient-centered CDS: progress, gaps, and challenges. J Am Med Inform Assoc. 2022;29(6):1101-1105. [ FREE Full text ] [ CrossRef ] [ Medline ]
Dullabh P, Sandberg SF, Heaney-Huls K, Hovey LS, Lobach DF, Boxwala A, et al. Challenges and opportunities for advancing patient-centered clinical decision support: findings from a horizon scan. J Am Med Inform Assoc. 2022;29(7):1233-1243. [ FREE Full text ] [ CrossRef ] [ Medline ]
Bright TJ, Wong A, Dhurjati R, Bristow E, Bastian L, Coeytaux RR, et al. Effect of clinical decision-support systems: a systematic review. Ann Intern Med. 2012;157(1):29-43. [ FREE Full text ] [ CrossRef ] [ Medline ]
HIV prevention: clinical decision support system to increase HIV screening. Community Preventive Services Task Force (CPSTF). 2020. URL: https://www.thecommunityguide.org/findings/hiv-prevention-clinical-decision-support-system-increase-hiv-screening.html [accessed 2024-02-28]
Sexually transmitted infections national strategic plan for the United States: 2021-2025. U.S. Department of Health and Human Services. Washington, DC.; 2020. URL: https://www.hhs.gov/sites/default/files/STI_NationalStrategicPlan_PublicComment_DRAFT.pdf [accessed 2024-02-28]
Devoe JE, Gold R, Spofford M, Chauvie S, Muench J, Turner A, et al. Developing a network of community health centers with a common electronic health record: description of the Safety Net West Practice-based Research Network (SNW-PBRN). J Am Board Fam Med. 2011;24(5):597-604. [ FREE Full text ] [ CrossRef ] [ Medline ]
Devoe JE, Sears A. The OCHIN community information network: bringing together community health centers, information technology, and data to support a patient-centered medical village. J Am Board Fam Med. 2013;26(3):271-278. [ FREE Full text ] [ CrossRef ] [ Medline ]
OCHIN Epic for ambulatory care: comprehensive EHR solutions to manage outpatient care and streamline clinical workflows. OCHIN. URL: https://ochin.org/hosted-epic-ehr [accessed 2022-08-25]
OCHIN. URL: https://ochin.org/ [accessed 2022-08-25]
Codman Square Health Center. URL: https://www.codman.org/ [accessed 2022-08-30]
Thiese MS. Observational and interventional study design types; an overview. Biochem Med (Zagreb). 2014;24(2):199-210. [ FREE Full text ] [ CrossRef ] [ Medline ]
Pagaoa M, Grey J, Torrone E, Kreisel K, Stenger M, Weinstock H. Trends in nationally notifiable sexually transmitted disease case reports during the US COVID-19 pandemic, january to december 2020. Sex Transm Dis. 2021;48(10):798-804. [ FREE Full text ] [ CrossRef ] [ Medline ]
Wright SS, Kreisel KM, Hitt JC, Pagaoa MA, Weinstock HS, Thorpe PG. Impact of the COVID-19 pandemic on centers for disease control and prevention-funded sexually transmitted disease programs. Sex Transm Dis. 2022;49(4):e61-e63. [ FREE Full text ] [ CrossRef ] [ Medline ]
Practice facilitation. Agency for Healthcare Research and Quality. Rockville, MD.; 2023. URL: https://www.ahrq.gov/evidencenow/practice-facilitation/index.html [accessed 2023-08-17]
Stange KC, Goodwin MA, Zyzanski SJ, Dietrich AJ. Sustainability of a practice-individualized preventive service delivery intervention. Am J Prev Med. 2003;25(4):296-300. [ FREE Full text ] [ CrossRef ] [ Medline ]
Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B, Titchen A. An exploration of the factors that influence the implementation of evidence into practice. J Clin Nurs. 2004;13(8):913-924. [ CrossRef ] [ Medline ]
Taveras EM, Marshall R, Kleinman KP, Gillman MW, Hacker K, Horan CM, et al. Comparative effectiveness of childhood obesity interventions in pediatric primary care: a cluster-randomized clinical trial. JAMA Pediatr. 2015;169(6):535-542. [ FREE Full text ] [ CrossRef ] [ Medline ]
Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17; quiz CE1-4. [ FREE Full text ] [ Medline ]
Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137. [ FREE Full text ] [ Medline ]
Seem DL, Lee I, Umscheid CA, Kuehnert MJ, United States Public Health Service. PHS guideline for reducing human immunodeficiency virus, hepatitis B virus, and hepatitis C virus transmission through organ transplantation. Public Health Rep. 2013;128(4):247-343. [ FREE Full text ] [ CrossRef ] [ Medline ]
MyChart. Epic Systems Corporation. URL: https://www.mychart.com/ [accessed 2022-08-30]
Shrader L, Myerburg S, Larson E. Clinical decision support for immunization uptake and use in immunization health information systems. Online J Public Health Inform. 2020;12(1):e10. [ FREE Full text ] [ CrossRef ] [ Medline ]
Electronic clinical decision support tools: safer patient care for opioid prescribing. Centers for Disease Control and Prevention. Atlanta, GA.; 2022. URL: https://www.cdc.gov/opioids/healthcare-admins/ehr/index.html [accessed 2022-09-19]
Saraiya M, Colbert J, Bhat GL, Almonte R, Winters DW, Sebastian S, et al. Computable guidelines and clinical decision support for cervical cancer screening and management to improve outcomes and health equity. J Womens Health (Larchmt). 2022;31(4):462-468. [ FREE Full text ] [ CrossRef ] [ Medline ]
Rudd S, Gemelas J, Reilley B, Leston J, Tulloch S. Integrating clinical decision support to increase HIV and chlamydia screening. Prev Med. 2013;57(6):908-909. [ CrossRef ] [ Medline ]
May A, Hester A, Quairoli K, Wong JR, Kandiah S. Impact of clinical decision support on azithromycin prescribing in primary care clinics. J Gen Intern Med. 2021;36(8):2267-2273. [ FREE Full text ] [ CrossRef ] [ Medline ]

Abbreviations

Edited by A Mavragani; submitted 22.09.23; peer-reviewed by J Hou, Y Zhang; comments to author 15.12.23; revised version received 02.02.24; accepted 21.02.24; published 15.04.24.

©Saugat Karki, Sarah Shaw, Michael Lieberman, Alejandro Pérez, Jonathan Pincus, Priya Jakhmola, Amrita Tailor, Oyinkansola Bukky Ogunrinde, Danielle Sill, Shane Morgan, Miguel Alvarez, Jonathan Todd, Dawn Smith, Ninad Mishra. Originally published in JMIR Formative Research (https://formative.jmir.org), 15.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

This paper is in the following e-collection/theme issue:

Published on 16.4.2024 in Vol 26 (2024)

User-Centered Development of a Patient Decision Aid for Choice of Early Abortion Method: Multi-Cycle Mixed Methods Study

Authors of this article:

Original Paper

Kate J Wahl 1 , MSc ;
Melissa Brooks 2 , MD ;
Logan Trenaman 3 , PhD ;
Kirsten Desjardins-Lorimer 4 , MD ;
Carolyn M Bell 4 , MD ;
Nazgul Chokmorova 4 , MD ;
Romy Segall 2 , BSc, MD ;
Janelle Syring 4 , MD ;
Aleyah Williams 1 , MPH ;
Linda C Li 5 , PhD ;
Wendy V Norman 4, 6 * , MD, MHSc ;
Sarah Munro 1, 3 * , PhD

1 Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada

2 Department of Obstetrics and Gynecology, Dalhousie University, Halifax, NS, Canada

3 Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States

4 Department of Family Practice, University of British Columbia, Vancouver, BC, Canada

5 Department of Physical Therapy, University of British Columbia, Vancouver, BC, Canada

6 Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom

*these authors contributed equally

Corresponding Author:

Kate J Wahl, MSc

Department of Obstetrics and Gynecology

University of British Columbia

4500 Oak Street

Vancouver, BC, V6H 3N1

Phone: 1 4165231923

Email: [email protected]

Background: People seeking abortion in early pregnancy have the choice between medication and procedural options for care. The choice is preference-sensitive—there is no clinically superior option and the choice depends on what matters most to the individual patient. Patient decision aids (PtDAs) are shared decision-making tools that support people in making informed, values-aligned health care choices.

Objective: We aimed to develop and evaluate the usability of a web-based PtDA for the Canadian context, where abortion care is publicly funded and available without legal restriction.

Methods: We used a systematic, user-centered design approach guided by principles of integrated knowledge translation. We first developed a prototype using available evidence for abortion seekers’ decisional needs and the risks, benefits, and consequences of each option. We then refined the prototype through think-aloud interviews with participants at risk of unintended pregnancy (“patient” participants). Interviews were audio-recorded and documented through field notes. Finally, we conducted a web-based survey of patients and health care professionals involved with abortion care, which included the System Usability Scale. We used content analysis to identify usability issues described in the field notes and open-ended survey questions, and descriptive statistics to summarize participant characteristics and close-ended survey responses.

Results: A total of 61 individuals participated in this study. Further, 11 patients participated in think-aloud interviews. Overall, the response to the PtDA was positive; however, the content analysis identified issues related to the design, language, and information about the process and experience of obtaining abortion care. In response, we adapted the PtDA into an interactive website and revised it to include consistent and plain language, additional information (eg, pain experience narratives), and links to additional resources on how to find an abortion health care professional. In total, 25 patients and 25 health care professionals completed the survey. The mean System Usability Scale score met the threshold for good usability among both patient and health care professional participants. Most participants felt that the PtDA was user-friendly (patients: n=25, 100%; health care professionals: n=22, 88%), was not missing information (patients: n=21, 84%; health care professionals: n=18, 72%), and that it was appropriate for patients to complete the PtDA before a consultation (patients: n=23, 92%; health care professionals: n=23, 92%). Open-ended responses focused on improving usability by reducing the length of the PtDA and making the website more mobile-friendly.

Conclusions: We systematically designed the PtDA to address an unmet need to support informed, values-aligned decision-making about the method of abortion. The design process responded to a need identified by potential users and addressed unique sensitivities related to reproductive health decision-making.

Introduction

In total, 1 in 3 pregnancy-capable people in Canada will have an abortion in their lifetimes, and most will seek care early in pregnancy [ 1 ]. Medication abortion (using the gold-standard mifepristone/misoprostol regimen) and procedural abortion are common, safe, and effective options for abortion care in the first trimester [ 2 , 3 ]. The choice between using medications and presenting to a facility for a procedure is a preference-sensitive decision; there is no clinically superior option and the choice depends on what matters most to the individual patient regarding the respective treatments and the features of those options [ 4 - 6 ].

The choice of method of abortion can involve a process of shared decision-making, in which the patient and health care professional share the best available evidence about options, and the patient is supported to consider those options and clarify an informed preference [ 7 ]. There are many types of interventions available to support shared decision-making, including interventions targeting health care professionals (eg, educational materials, meetings, outreach visits, audit and feedback, and reminders) and patients (eg, patient decision aids [PtDA], appointment preparation packages, empowerment sessions, printed materials, and shared decision-making education) [ 8 ]. Of these interventions, PtDAs are well-suited to address challenges to shared decision-making about the method of abortion, including limited patient knowledge, public misinformation about options, poor access to health care professionals with sufficient expertise, and apprehension about abortion counseling [ 9 ].

PtDAs are widely used interventions that support people in making informed, deliberate health care choices by explicitly describing the health problem and decision, providing information about each option, and clarifying patient values [ 10 ]. The results of the 2023 Cochrane systematic review of 209 randomized controlled trials indicate that, compared to usual care (eg, information pamphlets or webpages), the use of PtDAs results in increases in patient knowledge, expectations of benefits and harms, clarity about what matters most to them, and participation in making a decision [ 11 ]. Of the studies included in the systematic review, 1 tested the effect of a PtDA leaflet for method of abortion and found that patients eligible for both medication and procedural abortion who received the PtDA were more knowledgeable, and had lower risk perceptions and decisional conflict than those who were in the control group [ 12 ]. However, that PtDA was developed 20 years ago in the UK health system and was not publicly available. A recent environmental scan of PtDAs for a method of abortion found that other available options meet few of the criteria set by the International Patient Decision Aid Standards (IPDAS) collaboration and do not include language and content optimized for end users [ 9 , 13 ].

Consequently, no PtDAs for method of abortion were available in Canada at the time of this study. This was a critical gap for both patients and health care professionals as, in 2017, mifepristone/misoprostol medication abortion came to the market, offering a new method of choice for people seeking abortion in the first trimester [ 14 ]. Unlike most jurisdictions, in Canada medication abortion is typically prescribed in primary care and dispensed in community pharmacies. Offering a PtDA in preparation for a brief primary care consultation allows the person seeking abortion more time to digest new information, consider their preferences, be ready to discuss their options, and make a quality decision.

In this context, we identified a need for a high-quality and publicly available PtDA to support people in making an informed choice about the method of abortion that reflects what is most important to them. Concurrently, our team was working in collaboration with knowledge users (health care professionals, patients, and health system decision makers) who were part of a larger project to investigate the implementation of mifepristone in Canada [ 15 , 16 ]. We, therefore, aimed to develop and evaluate the usability of a web-based PtDA for the Canadian context, where abortion care is publicly funded and available without legal restriction.

Study Design

We performed a mixed methods user-centered development and evaluation study informed by principles of integrated knowledge translation. Integrated knowledge translation is an approach to collaborative research in which researchers and knowledge users work together to identify a problem, conduct research as equal partners to address that problem, and coproduce research products that aim to impact health service delivery [ 17 ]. We selected this approach to increase the likelihood that our end PtDAs would be relevant, useable, and used for patients and health care professionals in Canada [ 17 ]. The need for a PtDA was identified through engagement with health care professionals. In 2017, they highlighted the need for patients to be supported in choosing between procedural care—which historically represented more than 90% of abortions in Canada [ 18 ]—and the newly available medication option [ 19 , 20 ]. This need was reaffirmed in 2022 by the Canadian federal health agency, Health Canada, which circulated a request for proposals to generate “evidence-based, culturally-relevant information aimed at supporting people in their reproductive decision-making and in accessing abortion services as needed” [ 21 ].

We operationalized integrated knowledge translation principles in a user-centered design process. User-centered design “grounds the characteristics of an innovation in information about the individuals who use that innovation, with a goal of maximizing ‘usability in context’” [ 22 ]. In PtDA development, user-centered design involves iteratively understanding users, developing and refining a prototype, and observing user interaction with the prototype [ 23 , 24 ]. Like integrated knowledge translation, this approach is predicated on the assumption that involving users throughout the process increases the relevance of the PtDA and the likelihood of successful implementation [ 24 ].

Our design process included the following steps ( Figure 1 ): identification of evidence about abortion patients’ decisional needs and the attributes of medication and procedural abortion that matter most from a patient perspective; development of a paper-based prototype; usability testing via think-aloud interviews with potential end users; refinement of the PtDA prototype into an interactive website; usability testing via a survey with potential end users and abortion health care professionals; and final revisions before launching the PtDA for real-world testing. Our systematic process was informed by user-centered methods for PtDA development [ 23 , 24 ], guidance from the IPDAS collaboration [ 25 - 27 ], and the Standards for Universal Reporting of Patient Decision Aid Evaluation checklist [ 10 ].

Our multidisciplinary team included experts in shared decision-making (SM and LT), a PhD student in patient-oriented knowledge translation (KJW), experts in integrated knowledge translation with health care professionals and policy makers (WVN and SM), clinical experts in abortion counseling and care (WVN and MB), a medical undergraduate student (RS), a research project coordinator (AW), and family medicine residents (KD-L, CMB, NC, and JS) who had an interest in abortion care. Additionally, a panel of experts external to the development process reviewed the PtDA for clinical accuracy following each revision of the prototype. These experts included coauthors of the national Society for Obstetricians and Gynaecologists of Canada (SOGC) clinical practice guidelines for abortion care in Canada. They were invited to this project because of their knowledge of first-trimester abortion care as well as their ability to support the implementation of the PtDA in guidelines and routine clinical practice.

Ethical Considerations

The research was approved by the University of British Columbia Children’s and Women’s Research Ethics Board (H16-01006) and the Nova Scotia Health Research Ethics Board (1027637). In each round of testing, participants received a CAD $20 (US $14.75) Amazon gift card by email for their participation.

Preliminary Work: Identification of Evidence

We identified the decisional needs of people seeking early abortion care using a 2018 systematic review of reasons for choosing an abortion method [ 28 ], an additional search that identified 1 study conducted in Canada following the 2017 availability of mifepristone/misoprostol medication abortion [ 29 ], and the SOGC clinical practice guidelines [ 2 , 3 ]. The review identified several key factors that matter most for patient choice of early abortion method: perceived simplicity and “naturalness,” fear of complication or bleeding , fear of anesthesia or surgery , timing of the procedure , and chance of sedation . The additional Canadian study found that the time required to complete the abortion and side effects were important factors. According to the SOGC clinical practice guidelines, the key information that should be communicated to the patient are gestational age limits and the risk of complications with increasing gestational age [ 2 , 3 ]. The guidelines also indicate that wait times , travel times , and cost considerations may be important in a person’s choice of abortion method and should be addressed [ 2 , 3 ].

We compiled a long list of attributes for our expert panel and then consolidated and refined the attribute list through each stage of the prototype evaluation. For evidence of how these factors differed for medication and procedural abortion, we drew primarily from the SOGC clinical practice guidelines for abortion [ 2 , 3 ]. For cost considerations, we described the range of federal, provincial, and population-specific programs that provide free coverage of abortion care for people in Canada.

Step 1: Developing the Prototype

Our goal was to produce an interactive, web-based PtDA that would be widely accessible to people seeking an abortion in Canada by leveraging the widespread use of digital health information, especially among reproductive-aged people [ 30 ]. Our first prototype was based on a previously identified paper-based question-and-answer comparison grid that presented evidence-based information about the medication and procedural options [ 9 , 31 ]. We calculated readability by inputting the plain text of the paper-based prototype into a Simple Measure of Gobbledygook (SMOG) Index calculator [ 32 ].

We made 2 intentional deviations from common practices in PtDA development [ 33 ]. First, we did not include an “opt-out” or “do nothing” option, which would describe the natural course of pregnancy. We chose to exclude this option to ensure clarity for users regarding the decision point; specifically, our decision point of interest was the method of abortion, not the choice to terminate or continue a pregnancy. Second, we characterized attributes of the options as key points rather than positive and negative features to avoid imposing value judgments onto subjective features (eg, having the abortion take place at home may be beneficial for some people but may be a deterrent for others).

Step 2: Usability Testing of the Prototype

We first conducted usability testing involving think-aloud interviews with patient participants to assess the paper-based prototype. Inclusion criteria included people aged 18-49 years assigned-female-at-birth who resided in Canada and could speak and read English. In January 2020, we recruited participants for the first round of think-aloud interviews [ 34 ] via email and poster advertising circulated to (1) a network of parent research advisors who were convened to guide a broader program of research about pregnancy and childbirth in British Columbia, Canada, and (2) a clinic providing surgical abortion care in Nova Scotia, Canada, as well as snowball sampling with participants. We purposively sought to advertise this study with these populations to ensure variation in age, ethnicity, level of education, parity, and abortion experience. Interested individuals reviewed this study information form and provided consent to participate, before scheduling an interview. The interviewer asked participants to think aloud as they navigated the prototype, for example describing what they liked or disliked, missing information, or lack of clarity. The interviewer noted the participant’s feedback on a copy of the prototype during the interview. Finally, the participant responded to questions adapted from the System Usability Scale [ 35 ], a measure designed to collect subjective ratings of a product’s usability, and completed a brief demographic questionnaire. The interviews were conducted via videoconferencing and were audio recorded. We deidentified the qualitative data and assigned each participant a unique identifier. Then, the interviewer listened to the recording and revised their field notes with additional information including relevant quotes.

For the analysis of think-aloud interviews, we used inductive content analysis to describe the usability and acceptability of different elements of the PtDA [ 36 ]. Further, 3 family medicine residents (KD-L, CMB, and NC) under guidance from a senior coauthor (SM) completed open coding to develop a list of initial categories, which we grouped under higher-order headings. We then organized these results in a table to illustrate usability issues (categories), illustrative participant quotes, and modifications to make. We then used the results of interviews to adapt the prototype into a web-based format, which we tested via further think-aloud interviews and a survey with people capable of becoming pregnant and health care professionals involved with abortion care.

Step 3: Usability Testing of the Website

For the web-based format, we used DecideApp PtDA open-source software, which provides a sustainable solution to the problems of low quality and high maintenance costs faced by web-based PtDAs by allowing developers to host, maintain, and update their tools at no cost. This software has been user-tested and can be accessed by phone, tablet, or computer [ 37 , 38 ]. It organizes a PtDA into 6 sections: Introduction, About Me, My Values, My Choice, Review, and Next Steps. In the My Values section, an interactive values clarification exercise allows users to rank and make trade-offs between attributes of the options. The final pages provide an opportunity for users to make a choice, complete a knowledge self-assessment, and consider the next steps to access their chosen method.

From July to August 2020, we recruited patient and health care professional participants using Twitter and the email list of the Canadian Abortion Providers Support platform, respectively. Participants received an email with a link to the PtDA and were redirected to the survey once they had navigated through the PtDA. As above, inclusion criteria included people aged 18-49 years assigned as female-at-birth who resided in Canada. Among health care professionals, we included eligible prescribers who may not have previously engaged in abortion care (family physicians, residents, nurse practitioners, and midwives), and allied health professionals and stakeholders who provide or support abortion care, who practiced in Canada. All participants had to speak and read English.

The survey included 3 sections: usability, implementation, and participant characteristics. The usability section consisted of the System Usability Scale [ 35 ], and purpose-built questions about what participants liked and disliked about the PtDA. The implementation section included open- and close-ended questions about how the PtDA compares to other resources and when it could be implemented in the care pathway. Patient participants also completed the Control Preference Scale, a validated measure used to determine their preferred role in decision-making (active, collaborative, or passive) [ 39 ]. Data on participant characteristics included gender, abortion experience (patient participants), and abortion practice (health care professional participants). We deidentified the qualitative data and assigned each participant a unique identifier. For the analysis of survey data, we characterized close-ended responses using descriptive statistics, and, following the analysis procedures described in Step 2 in the Methods section, used inductive content analysis of open-ended responses to generate categories associated with usability and implementation [ 36 ]. In 2021, we made minor revisions to the website based on the results of usability testing and published the PtDA for use in routine clinical care.

In the following sections, we outline the results of the development process including the results of the think-aloud interviews and survey, as well as the final decision aid prototype.

Our initial prototype, a paper-based question-and-answer comparison grid, presented evidence-based information comparing medication and procedural abortion. The first version of the prototype also included a second medication abortion regimen involving off-label use of methotrexate, however, we removed this option following a review by the clinical expert panel who advised us that there is very infrequent use of this regimen in Canada in comparison to the gold standard medication abortion option, mifepristone. Other changes at this stage involved clarifying the scope of practice (health care professionals other than gynecologists can perform a procedural abortion), abortion practice (gestational age limit and how the medication is taken), the abortion experience (what to expect in terms of bleeding), and risk (removing information about second- and third-trimester abortion). The updated prototype was finalized by a scientist (SM) and trainee (KJW) with expertise in PtDA development. The prototype (see Multimedia Appendix 1 ) was ultimately 4 pages long and described 18 attributes of each option framed as Frequently Asked Questions, including abortion eligibility (How far along in pregnancy can I be?), duration (How long does it take?), and side effects (How much will I bleed?). The SMOG grade level was 8.4.

Participant Characteristics

We included 11 participants in think-aloud interviews between January and July 2020, including 7 recruited through a parent research advisory network and 4 individuals who had recently attended an abortion clinic. The mean interview duration was 36 minutes (SD 6 minutes). The participants ranged in age from 31 to 37 years. All had been pregnant and 8 out of 11 (73%) participants had a personal experience of abortion (4 participants who had recently attended an abortion clinic and 4 participants from the parent research advisory who disclosed their experience during the interview). The characteristics of the sample are reported in Table 1 .

Overall, participants had a positive view of the paper-based, comparison grid PtDA. In total, 1 participant who had recently sought an abortion said, “I think this is great and super helpful. It would’ve been awesome to have had access to this right away … I don’t think there’s really anything missing from here that I was Googling about” (DA010). The only participant who expressed antichoice views indicated that the PtDA would be helpful to someone seeking to terminate a pregnancy (DA001). Another participant said, “[The PtDA] is not biased, it’s not like you’re going to die. It’s a fact, you know the facts and then you decide whether you want it or not. A lot of people feel it’s so shameful and judgmental, but this is very straightforward. I like it.” (DA002). Several participants stated they felt more informed and knowledgeable about the options.

In response to questions adapted from the System Usability Scale, all 11 participants agreed that the PtDA was easy to use, that most people could learn to use it quickly, and that they felt very confident using the prototype, and disagreed that it was awkward to use. In total, 8 (73%) participants agreed with the statement that the components of the PtDA were well-integrated. A majority of participants disagreed with the statements that the website was unnecessarily complex (n=8, 73%), that they would need the support of an expert to use it (n=8, 73%), that it was too inconsistent (n=9, 82%), and that they would need to learn a lot before using it (n=8, 73%). Further, 2 (18%) participants agreed with the statements that the PtDA was unnecessarily complex and that they would need to learn a lot before using it. Furthermore, 1 (9%) participant agreed with the statement that the PtDA was too inconsistent.

Through inductive analysis of think-aloud interviews, we identified 4 key usability categories: design, language, process, and experience.

Participants liked the side-by-side comparison layout, appreciated the summary of key points to remember, and said that overall, the presented information was clear. For example, 1 participant reflected, “I think it’s very clear ... it’s very simplistic, people will understand the left-hand column is for medical abortion and the right-hand column is for surgical.” (DA005) Some participants raised concerns about the aesthetics of the PtDA, difficulties recalling the headers across multiple pages, and the overall length of the PtDA.

Participants sought to clarify language at several points in the PtDA. Common feedback was that the gestational age limit for the medication and the procedure should be clarified. Participants also pointed out inconsistent use of language (eg, doctor and health care professional) and medical jargon.

Several participants were surprised to learn that family doctors could provide abortion care. Others noted that information about the duration—including travel time—and number of appointments for both medication and procedural abortion could be improved. In addition to clarifying the abortion process, several participants suggested including additional information and resources to help identify an abortion health care professional, understand when to seek help for abortion-related complications, and access emotional support. It was also important to participants that financial impacts (eg, hospital parking and menstrual pads) were included for each option.

Participants provided insight into the description of the physical, psychological, and other consequences associated with the abortion medication and procedure. Participants who had both types of abortion care felt that the description of pain that “may be worse than a period” was inaccurate. Other participants indicated that information about perceived and real risks was distressing or felt out of place, such as correcting myths about future fertility or breast cancer. Some participants indicated that patient stories would be valuable saying, for example, “I think what might be nice to help with the decision-making process is reading stories of people’s experiences” (DA006).

Modifications Made

Changes made based on these findings are described in Table 2 . Key user-centered modifications included transitioning to a web-based format with a consistent color scheme, clarifying who the PtDA is for (for typical pregnancies up to 10 weeks), adding information about telemedicine to reflect guidelines for the provision of abortion during pandemics, and developing brief first-person qualitative descriptions of the pain intensity for each option.

Through analysis of the interviews and consultation with our panel of clinical experts, we also identified that, among the 18 initial attributes in our prototype, 7 had the most relative importance to patients in choosing between medication and procedural abortion. These attributes also represented important differences between each option which forced participants to consider the trade-offs they were willing to make. Thus we moved all other potential attributes into an information section (My Options) that supported the user to gain knowledge before clarifying what mattered most to them by considering the differences between options (My Values).

a PtDA: patient decision aid.

b SOGC: Society of Obstetricians and Gynaecologists of Canada.

Description of the PtDA

As shown in Figure 2 , the revised version of the PtDA resulting from our systematic process is an interactive website. Initially, the title was My Body, My Choice ; however, this was changed to avoid association with antivaccine campaigns that co-opted this reproductive rights slogan. The new title, It’s My Choice or C’est Mon Choix , was selected for its easy use in English and French. The PtDA leads the user through 6 sections:

The Introduction section provides the user with information about the decision and the PtDA, as well as grids comparing positive and negative features of the abortion pill and procedure, including their chance of benefits (eg, effectiveness), harms (eg, complications), and other relevant factors (eg, number of appointments and cost).
The About Me section asks the user to identify any contraindications to the methods. It then prompts users to consider their privacy needs and gives examples of how this relates to each option (eg, the abortion pill can be explained to others as a miscarriage; procedural care can be completed quickly).
The My Values section includes a values clarification exercise, in which the user selects and weights (on a 0-100 scale) the relative importance of at least three of 7 decisional attributes: avoiding pain, avoiding bleeding, having the abortion at home, having an experience that feels like a miscarriage, having fewer appointments, less time off for recovery, and having a companion during the abortion.
The My Choice section highlights 1 option, based on the attribute weights the user assigned in the My Values section. For instance, if a user strongly preferred to avoid bleeding and have fewer appointments, the software would suggest that a procedural abortion would be a better match. For a user who preferred having the abortion at home and having a companion present, the software would suggest that a medication abortion would be a better match. The user selects the option they prefer.
The Review section asks the user to complete the 4-item SURE (Sure of Myself, Understand Information, Risk-Benefit Ratio, Encouragement) screening test [ 41 ], and advises them to talk with an expert if they answer “no” to any of the questions. This section also includes information phone lines to ensure that users can seek confidential, accurate, and nonjudgmental support.
Lastly, in the Next Steps section, users see a summary of their choice and the features that matter most to them, instructions for how to save the results, keep the results private, and find an abortion health care professional. Each section of the PtDA includes a “Leave” button in case users need to navigate away from the website quickly.

We calculated readability by inputting the plain text of the web-based PtDA into a SMOG Index calculator [ 32 ], which assessed the reading level of the web-based PtDA as grade 9.2.

To ensure users’ trust in the information as accurate and unbiased we provided a data declaration on the landing page: “the clinical information presented in this decision aid comes from Society of Obstetricians and Gynaecologists best practice guidelines.” On the landing page, we also specify “This website was developed by researchers at the University of British Columbia and Dalhousie University. This tool is not supported or connected to any pharmaceutical company.”

A total of 50 participants, including 25 patients and 25 health care professionals, reviewed the PtDA website and completed the survey between January and March 2021. The majority of patient (n=23, 92%) and health care professional (n=23, 92%) participants identified as cisgender women. Among patient participants, 16% (n=4) reported one or more previous abortions in various clinical settings. More than half (n=16, 64%) of health care professionals offered care in private medical offices, with other locations including sexual health clinics, community health centers, and youth clinics. Many health care professionals were family physicians (n=11, 44%), and other common types were nurse practitioners (n=7, 28%) and midwives (n=3, 12%). The mean proportion of the clinical practice of each health care professional devoted to abortion care was 18% (SD 13%). Most health care professional respondents (n=18, 72%) were involved with the provision of medication, but not procedural, abortion care. The characteristics of patient and health care professional participants are reported in Table 3 .

a In total, 4 participants reported a history of abortion care, representing 6 abortion procedures.

b Not available.

The mean System Usability Score met the threshold for good usability among both patient (mean 85.7, SD 8.6) and health care professional (mean 80, SD 12) participants, although some health care professionals agreed with the statement, “I found the website to be unnecessarily complex,” (see Multimedia Appendix 3 for the full distribution of responses from patient and health care professionals). All 25 patients and 22 out of 25 (88%) health care professional respondents indicated that the user-friendliness of the PtDA was good or the best imaginable. When asked what they liked most about the PtDA, both participant groups described the ease of use, comparison of options, and the explicit values clarification exercise. When asked what they liked least about the PtDA, several health care professionals and some patients pointed out that it was difficult to use on a cell phone. A summary of usability results is presented in Table 4 .

In total, 21 (84%) patients and 18 (72%) health care professionals felt that the PtDA was not missing any information needed to decide about the method of abortion in early pregnancy. While acknowledging that it is “hard to balance being easy to read/understand while including enough accurate clinical information,” several health care professionals and some patients indicated that the PtDA was too long and repetitive. Among the 4 (16%) patient participants who felt information was missing, the most common suggestion was a tool for locating an abortion health care professional. The 7 (28%) health care professionals who felt information was missing primarily made suggestions about the medical information included in the PtDA (eg, listing midwives as health care professionals with abortion care in scope of practice and the appropriateness of gender-inclusive terminology) and the accessibility of information for various language and cultural groups.

a Not available.

Implementation

Participants viewed the PtDA as a positive addition to current resources. Patients with a history of abortion care described looking for the information on the internet and speaking with friends, family members, and health care professionals. Compared with these sources of information, many patients liked the credibility and anonymity of the PtDA, whereas some disliked that it was less personal than a conversation. Further, 18 (72%) health care professional participants said that the PtDA would add to or replace the resources they currently use in practice. Compared with these other resources, health care professionals liked that the PtDA could be explored by patients independently and that it would support them in thinking about the option that was best for them. The disadvantages of the PtDA compared with existing resources were the length—which health care professionals felt would make it difficult to use in a clinical interaction—and the lack of localized information. In total, 23 each (92%) of patient and health care professional participants felt that they would use the PtDA before a consultation.

Principal Results

We designed a web-based, interactive PtDA for the choice of method of abortion in early pregnancy [ 42 ], taking a user-centered approach that involved usability testing with 36 patients and 25 health care professionals. Both patient and health care professional participants indicated that the PtDA had good usability and would be a valuable resource for decision-making. This PtDA fills a critical need to support the autonomy of patients and shared decision-making with their health care professional related to the preference-sensitive choice of method of abortion.

Comparison With Prior Work

A 2017 systematic review and environmental scan found that existing PtDAs for the method of abortion are of suboptimal quality [ 9 ]. Of the 50 PtDAs identified, all but one were created without expertise in decision aid design (eg, abortion services, reproductive health organizations, and consumer health information organizations); however, the development process for this UK-based pamphlet-style PtDA was not reported. The remaining PtDAs were noninteractive websites, smartphone apps, and PDFs that were not tested with users. The authors found that the information about methods of abortion was presented in a disorganized, inconsistent, and unequal way. Subsequent work has found that existing PtDAs emphasize medical (versus social, emotional, and practical) attributes, do not include values clarification, and can be biased to persuade users of a certain method [ 13 ].

To address some of the challenges identified in the literature, we systematically structured and designed elements of the PtDA following newly proposed IPDAS criteria (eg, showing positive and negative features with equal detail) [ 33 ]. We included an explicit values-clarification exercise, which a recent meta-analysis found to decrease decisional conflict and values-incongruent choices [ 43 ].

We based the decision aid on comprehensive and up-to-date scientific evidence related to the effectiveness and safety of medication abortion and procedural abortion; however, less evidence was available for nonmedical attributes. For example, many existing PtDAs incorrectly frame privacy as a “factual advantage” of medication abortion [ 13 ]. To address this, we included privacy in the About Me section as something that means “different things to different people.” Similarly, evidence suggests that patients who do not feel appropriately informed about the pain associated with their method of abortion are less satisfied with their choice [ 44 , 45 ]; and the degree of pain experienced varies across options and among individuals. Following the suggestion of patient participants to include stories and recognizing that evidence for the inclusion of narratives in PtDAs is emerging [ 46 ], we elected to develop brief first-person qualitative descriptions of the pain experience. The inclusion of narratives in PtDAs may be effective in supporting patients to avoid surprise and regret, to minimize affective forecasting errors, and to “visualize” their health condition or treatment experience [ 46 ]. Guided by the narrative immersion model, our goal was to provide a “real-world preview” of the pain experience [ 47 ].

In addition to integrating user perspectives on the optimal tone, content, and format of the PtDA, user testing provided evidence to inform the future implementation of the PtDA. A clear barrier to the completion of the PtDA during the clinical encounter from the health care professional perspective was its length, supporting the finding of a recent rapid realist review, which theorized that health care professionals are less likely to use long or otherwise complex PtDAs that are difficult to integrate into routine practice [ 48 ]. However, 46 out of 50 (92%) participants endorsed the use of the PtDA by the patient alone before the initial consultation, which was aligned with the patient participant’s preference to take an active role in making the final decision about their method of abortion as well as the best practice of early, pre-encounter distribution of PtDAs [ 48 ].

A unique feature of this PtDA was that it resulted from a broader program of integrated knowledge translation designed to support access to medication abortion once mifepristone became available in Canada in 2017. Guided by the principle that including knowledge users in research yields results that are more relevant and useful [ 49 ], we developed the PtDA in response to a knowledge user need, involved health care professional users as partners in our research process, including as coauthors, and integrated feedback from the expert panel. This parallels a theory of PtDA implementation that proposes that early involvement of health care professionals in PtDA development “creates a sense of ownership, increases buy-in, helps to legitimize content, and ensures the PtDA (content and delivery) is consistent with current practice” thereby increasing the likelihood of PtDA integration into routine clinical settings [ 48 ].

Viewed through an integrated knowledge translation lens, our findings point toward future areas of work to support access to abortion in Canada. Several patient participants indicated a need for tools to identify health care professionals who offer abortion care. Some shared that their primary health care professionals did not offer medication abortion despite it being within their scope of practice, and instead referred them to an abortion clinic for methods of counseling and care. We addressed this challenge in the PtDA by including links to available resources, such as confidential phone lines that link patients to health care professionals in their region. On the website we also indicated that patient users could ask their primary care providers whether they provide abortion care; however, we acknowledge that this may place the patient in a vulnerable position if their health care professional is uncomfortable with, or unable to, provide this service for any reason. Future work should investigate opportunities to shorten the pathway to this time-sensitive care, including how to support patients who use the decision aid to act on their informed preference for the method of abortion. This work may involve developing a tool for patients to talk to their primary care provider about prescribing medication abortion.

Strengths and Limitations

Several factors affect the interpretation of our work. Although potential patient users participated in the iterative development process, the patient perspective was not represented in a formal advisory panel in the same way that the health care professional experts were. Participant characteristics collected for the think-aloud interviews demonstrated that our patient sample did not include people with lower education attainment, for whom the grade level and length of the PtDA could present a barrier [ 50 ]. Any transfer of the PtDA to jurisdictions outside Canada must consider how legal, regulatory, and other contextual factors affect the choice of the method of abortion. Since this study was completed, we have explored additional strategies to address these concerns, including additional user testing with people from equity-deserving groups, drop-down menus to adjust the level of detail, further plain language editing, and videos illustrating core content. Since the focus of this study was usability, we did not assess PtDA effectiveness, including impact on knowledge, decisional conflict, choice predisposition and decision, or concordance; however, a randomized controlled trial currently underway will measure the impact of the PtDA on these outcomes in a clinical setting. Finally, our integrated knowledge translation approach added to the robustness of our study by ensuring that health care professionals and patients were equal partners in the research process. One impact of this partnered approach is that our team has received funding support from Health Canada to implement the website on a national scale for people across Canada considering their abortion options [ 51 ].

Conclusions

The PtDA provides people choosing a method of early abortion and their health care professionals with a resource to understand methods of abortion available in the Canadian context and support to make a values-aligned choice. We designed the PtDA using a systematic approach that included both patient and health care professional participants to help ensure its relevance and usability. Our future work will seek to evaluate the implementation of the PtDA in clinical settings, create alternate formats to enhance accessibility, and develop a sustainable update policy. We will also continue to advance access to abortion care in Canada with our broader integrated knowledge translation program of research.

Acknowledgments

The authors thank the participants for contributing their time and expertise to the design of this tool. Family medicine residents CMB, NC, KD-L, and JS were supported by Sue Harris grants, Department of Family Practice, University of British Columbia. KJW was supported by the Vanier Scholar Award (2020-23). SM was supported by a Michael Smith Health Research BC Scholar Award (18270). WVN was supported by a Canadian Institutes of Health Research and Public Health Agency of Canada Chair in Applied Public Health Research (2014-2024, CPP-329455-107837). All grants underwent external peer review for scientific quality. The funders played no role in the design of this study, data collection, analysis, interpretation, or preparation of this paper.

Data Availability

Our ethics approval has specified the primary data is not available.

Authors' Contributions

KJW, SM, and MB conceived of and designed this study. CMB, NC, and KD-L led interview data collection, analysis, and interpretation with input from SM. RS and JS led survey data collection, analysis, and interpretation with input from SM and MB. AW, LCL, and WVN contributed to the synthesis and interpretation of results. KJW, SM, and LT wrote the first draft of this paper, and all authors contributed to this paper’s revisions and approved the final version.

Conflicts of Interest

None declared.

Patient decision aid prototype.

Raw data for pain narratives.

Full distribution of System Usability Scale scores for patients and providers.

Norman WV. Induced abortion in Canada 1974-2005: trends over the first generation with legal access. Contraception. 2012;85(2):185-191. [ CrossRef ] [ Medline ]
Costescu D, Guilbert E, Bernardin J, Black A, Dunn S, Fitzsimmons B, et al. Medical abortion. J Obstet Gynaecol Can. 2016;38(4):366-389. [ CrossRef ] [ Medline ]
Costescu D, Guilbert É. No. 360-induced abortion: surgical abortion and second trimester medical methods. J Obstet Gynaecol Can. 2018;40(6):750-783. [ CrossRef ] [ Medline ]
Wennberg JE. Unwarranted variations in healthcare delivery: implications for academic medical centres. BMJ. 2002;325(7370):961-964. [ FREE Full text ] [ CrossRef ] [ Medline ]
Elwyn G, Frosch D, Rollnick S. Dual equipoise shared decision making: definitions for decision and behaviour support interventions. Implement Sci. 2009;4:75. [ FREE Full text ] [ CrossRef ] [ Medline ]
Sepucha KR, Mulley AG. A practical approach to measuring the quality of preference-sensitive decisions. In: Edwards A, Elwyn G, editors. Shared Decision-Making in Health Care: Achieving Evidence-based Patient Choice. Oxford. Oxford University Press; 2009;151-156.
Elwyn G, Laitner S, Coulter A, Walker E, Watson P, Thomson R. Implementing shared decision making in the NHS. BMJ. 2010;341:c5146. [ FREE Full text ] [ CrossRef ] [ Medline ]
Légaré F, Adekpedjou R, Stacey D, Turcotte S, Kryworuchko J, Graham ID, et al. Interventions for increasing the use of shared decision making by healthcare professionals. Cochrane Database Syst Rev. 2018;7(7):CD006732. [ FREE Full text ] [ CrossRef ] [ Medline ]
Donnelly KZ, Elwyn G, Thompson R. Quantity over quality-findings from a systematic review and environmental scan of patient decision aids on early abortion methods. Health Expect. 2018;21(1):316-326. [ FREE Full text ] [ CrossRef ] [ Medline ]
Sepucha KR, Abhyankar P, Hoffman AS, Bekker HL, LeBlanc A, Levin CA, et al. Standards for Universal Reporting of Patient Decision Aid Evaluation studies: the development of SUNDAE checklist. BMJ Qual Saf. 2018;27(5):380-388. [ FREE Full text ] [ CrossRef ] [ Medline ]
Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2024;1(1):CD001431. [ CrossRef ] [ Medline ]
Wong SSM, Thornton JG, Gbolade B, Bekker HL. A randomised controlled trial of a decision-aid leaflet to facilitate women's choice between pregnancy termination methods. BJOG. 2006;113(6):688-694. [ CrossRef ] [ Medline ]
Donnelly KZ, Elwyn G, Theiler R, Thompson R. Promoting or undermining quality decision making? A qualitative content analysis of patient decision aids comparing surgical and medication abortion. Womens Health Issues. 2019;29(5):414-423. [ CrossRef ] [ Medline ]
Grant K. Long-awaited abortion pill Mifegymiso makes Canadian debut. The Globe and Mail. 2017. URL: https://www.theglobeandmail.com/news/national/long-awaited-abortion-pill-mifegymiso-rolls-out-in-canada/article33695167/?ref=http://www.theglobeandmail.com& [accessed 2023-04-03]
Norman WV, Munro S, Brooks M, Devane C, Guilbert E, Renner R, et al. Could implementation of mifepristone address Canada's urban-rural abortion access disparity: a mixed-methods implementation study protocol. BMJ Open. 2019;9(4):e028443. [ FREE Full text ] [ CrossRef ] [ Medline ]
Munro SB, Dunn S, Guilbert ER, Norman WV. Advancing reproductive health through policy-engaged research in abortion care. Semin Reprod Med. 2022;40(5-06):268-276. [ CrossRef ] [ Medline ]
Dunn SI, Bhati DK, Reszel J, Kothari A, McCutcheon C, Graham ID. Understanding how and under what circumstances integrated knowledge translation works for people engaged in collaborative research: metasynthesis of IKTRN casebooks. JBI Evid Implement. 2023;21(3):277-293. [ FREE Full text ] [ CrossRef ] [ Medline ]
Norman WV, Guilbert ER, Okpaleke C, Hayden AS, Lichtenberg ES, Paul M, et al. Abortion health services in Canada: results of a 2012 national survey. Can Fam Physician. 2016;62(4):e209-e217. [ FREE Full text ] [ Medline ]
Munro S, Guilbert E, Wagner MS, Wilcox ES, Devane C, Dunn S, et al. Perspectives among canadian physicians on factors influencing implementation of mifepristone medical abortion: a national qualitative study. Ann Fam Med. 2020;18(5):413-421. [ FREE Full text ] [ CrossRef ] [ Medline ]
Munro S, Wahl K, Soon JA, Guilbert E, Wilcox ES, Leduc-Robert G, et al. Pharmacist dispensing of the abortion pill in Canada: diffusion of innovation meets integrated knowledge translation. Implement Sci. 2021;16(1):76. [ FREE Full text ] [ CrossRef ] [ Medline ]
Health care policy and strategies program. Call for proposals: funding opportunities for sexual and reproductive health. Health Canada. URL: https://www.canada.ca/en/health-canada/programs/health-care-policy-strategies-program.html [accessed 2024-03-14]
Dopp AR, Parisi KE, Munson SA, Lyon AR. A glossary of user-centered design strategies for implementation experts. Transl Behav Med. 2019;9(6):1057-1064. [ FREE Full text ] [ CrossRef ] [ Medline ]
Vaisson G, Provencher T, Dugas M, Trottier ME, Dansokho SC, Colquhoun H, et al. User involvement in the design and development of patient decision aids and other personal health tools: a systematic review. Med Decis Making. 2021;41(3):261-274. [ FREE Full text ] [ CrossRef ] [ Medline ]
Witteman HO, Maki KG, Vaisson G, Finderup J, Lewis KB, Steffensen KD, et al. Systematic development of patient decision aids: an update from the IPDAS collaboration. Med Decis Making. 2021;41(7):736-754. [ FREE Full text ] [ CrossRef ] [ Medline ]
Joseph-Williams N, Newcombe R, Politi M, Durand MA, Sivell S, Stacey D, et al. Toward minimum standards for certifying patient decision aids: a modified Delphi consensus process. Med Decis Making. 2014;34(6):699-710. [ CrossRef ] [ Medline ]
Stacey D, Volk RJ, IPDAS Evidence Update Leads (Hilary Bekker, Karina Dahl Steffensen, Tammy C. Hoffmann, Kirsten McCaffery, Rachel Thompson, Richard Thomson, Lyndal Trevena, Trudy van der Weijden, and Holly Witteman). The International Patient Decision Aid Standards (IPDAS) collaboration: evidence update 2.0. Med Decis Making. 2021;41(7):729-733. [ FREE Full text ] [ CrossRef ] [ Medline ]
Hoffman AS, Volk RJ, Saarimaki A, Stirling C, Li LC, Härter M, et al. Delivering patient decision aids on the internet: definitions, theories, current evidence, and emerging research areas. BMC Med Inform Decis Mak. 2013;13(Suppl 2):S13. [ FREE Full text ] [ CrossRef ] [ Medline ]
Kanstrup C, Mäkelä M, Graungaard AH. Women's reasons for choosing abortion method: a systematic literature review. Scand J Public Health. 2018;46(8):835-845. [ CrossRef ] [ Medline ]
Murray ME, Casson M, Pudwell J, Waddington A. Patients' motivation for surgical versus medical abortion. J Obstet Gynaecol Can. 2019;41(9):1325-1329. [ CrossRef ] [ Medline ]
Kummervold PE, Chronaki CE, Lausen B, Prokosch HU, Rasmussen J, Santana S, et al. eHealth trends in Europe 2005-2007: a population-based survey. J Med Internet Res. 2008;10(4):e42. [ FREE Full text ] [ CrossRef ] [ Medline ]
Early abortion options. Reproductive Health Access Project. 2022. URL: https://www.reproductiveaccess.org/resource/early-abortion-options/ [accessed 2019-03-24]
Readability Formulas: free readability assessment tools to help you write for your readers. URL: https://readabilityformulas.com/ [accessed 2022-12-15]
Martin RW, Andersen SB, O'Brien MA, Bravo P, Hoffmann T, Olling K, et al. Providing balanced information about options in patient decision aids: an update from the International Patient Decision Aid Standards. Med Decis Making. 2021;41(7):780-800. [ FREE Full text ] [ CrossRef ] [ Medline ]
Lundgrén-Laine H, Salanterä S. Think-aloud technique and protocol analysis in clinical decision-making research. Qual Health Res. 2010;20(4):565-575. [ CrossRef ] [ Medline ]
Bangor A, Kortum PT, Miller JT. An empirical evaluation of the system usability scale. Int J Hum Comput Interact. 2008;24(6):574-594. [ CrossRef ]
Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107-115. [ CrossRef ] [ Medline ]
Bansback N, Li LC, Lynd L, Bryan S. Development and preliminary user testing of the DCIDA (Dynamic Computer Interactive Decision Application) for 'nudging' patients towards high quality decisions. BMC Med Inform Decis Mak. 2014;14:62. [ FREE Full text ] [ CrossRef ] [ Medline ]
Trenaman L, Munro S, Almeida F, Ayas N, Hicklin J, Bansback N. Development of a patient decision aid prototype for adults with obstructive sleep apnea. Sleep Breath. 2016;20(2):653-661. [ CrossRef ] [ Medline ]
Degner LF, Sloan JA, Venkatesh P. The control preferences scale. Can J Nurs Res. 1997;29(3):21-43. [ Medline ]
Patev AJ, Hood KB. Towards a better understanding of abortion misinformation in the USA: a review of the literature. Cult Health Sex. 2021;23(3):285-300. [ CrossRef ] [ Medline ]
Légaré F, Kearing S, Clay K, Gagnon S, D'Amours D, Rousseau M, et al. Are you SURE?: Assessing patient decisional conflict with a 4-item screening test. Can Fam Physician. 2010;56(8):e308-e314. [ FREE Full text ] [ Medline ]
The Society of Obstetricians and Gynaecologists of Canada. URL: https://www.sexandu.ca/its-my-choice/ [accessed 2024-03-30]
Witteman HO, Ndjaboue R, Vaisson G, Dansokho SC, Arnold B, Bridges JFP, et al. Clarifying values: an updated and expanded systematic review and meta-analysis. Med Decis Making. 2021;41(7):801-820. [ FREE Full text ] [ CrossRef ] [ Medline ]
Cavet S, Fiala C, Scemama A, Partouche H. Assessment of pain during medical abortion with home use of misoprostol. Eur J Contracept Reprod Health Care. 2017;22(3):207-211. [ CrossRef ] [ Medline ]
Baraitser P, Free C, Norman WV, Lewandowska M, Meiksin R, Palmer MJ, et al. Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review. BMJ Open. 2022;12(11):e066650. [ FREE Full text ] [ CrossRef ] [ Medline ]
Shaffer VA, Brodney S, Gavaruzzi T, Zisman-Ilani Y, Munro S, Smith SK, et al. Do personal stories make patient decision aids more effective? An update from the International Patient Decision Aids Standards. Med Decis Making. 2021;41(7):897-906. [ FREE Full text ] [ CrossRef ] [ Medline ]
Shaffer VA, Focella ES, Hathaway A, Scherer LD, Zikmund-Fisher BJ. On the usefulness of narratives: an interdisciplinary review and theoretical model. Ann Behav Med. 2018;52(5):429-442. [ FREE Full text ] [ CrossRef ] [ Medline ]
Joseph-Williams N, Abhyankar P, Boland L, Bravo P, Brenner AT, Brodney S, et al. What works in implementing patient decision aids in routine clinical settings? A rapid realist review and update from the International Patient Decision Aid Standards collaboration. Med Decis Making. 2021;41(7):907-937. [ FREE Full text ] [ CrossRef ] [ Medline ]
Guide to knowledge translation planning at CIHR: integrated and end-of-grant approaches. Government of Canada, Canadian Institutes of Health Research. 2012. URL: http://www.cihr-irsc.gc.ca/e/45321.html [accessed 2018-10-08]
Muscat DM, Smith J, Mac O, Cadet T, Giguere A, Housten AJ, et al. Addressing health literacy in patient decision aids: an update from the International Patient Decision Aid Standards. Med Decis Making. 2021;41(7):848-869. [ FREE Full text ] [ CrossRef ] [ Medline ]
The CART access project. Contraception and Abortion Research Team (CART-GRAC). 2024. URL: https://cart-grac.ubc.ca/the-cart-access-project-2/ [accessed 2024-01-28]

Abbreviations

Edited by T Leung; submitted 07.05.23; peer-reviewed by G Sebastian, R French, B Zikmund-Fisher; comments to author 11.01.24; revised version received 23.02.24; accepted 25.02.24; published 16.04.24.

©Kate J Wahl, Melissa Brooks, Logan Trenaman, Kirsten Desjardins-Lorimer, Carolyn M Bell, Nazgul Chokmorova, Romy Segall, Janelle Syring, Aleyah Williams, Linda C Li, Wendy V Norman, Sarah Munro. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 16.04.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

IMAGES

20 Table of Contents Templates and Examples ᐅ TemplateLab
sample table of contents for research paper in 2020
Free Free Table of Contents Example Template
Mla Format Table Of Contents Example
Research Paper Table of Contents Template in Google Docs, Word
Table of Content

VIDEO

How to insert automatic table of contents
How to Make Table of Contents for Review Paper ?
computer insert system table
11/18 CREATE REFERENCE AND TABLE OF CONTENTS in Microsoft Word 2019/365
Equations in Tables
Modern Tabel design☝🏻☝🏻 metal table design ideas

COMMENTS

How to Make a Table of Contents, With Examples
Just like in Word, it's easy to make a table of contents in Google Docs. Click on Insert in the top horizontal menu and then Table of Contents at the bottom of the dropdown menu. You will then have three options: Plain Text: a standard table of contents design. Dotted: a table of contents with dotted leader lines.
APA Table of Contents Writing Guide (+ Example)
Create Table of Contents in APA Formats. One more step and our APA paper with table of contents is as good as ready. From the very beginning, type the page name, keep it centered and aligned to the top. Remember about 1-inch long indents. Make the heading bold to increase readability and navigation.
Dissertation Table of Contents in Word
A multi-level table of contents also further divides sections into 'level 3' headings. This option can get messy quickly, so proceed with caution. Remember your table of contents should not be longer than 2 pages. A multi-level table is often a good choice for a shorter document like a research paper.
How to Write a Table of Contents for Different Formats With Examples
A Table of Content (TOC) is an essential component of an academic paper, particularly for long documents, like theses, dissertations, and research papers. When students are writing a TOC, they should be careful to follow the applicable format's rules and standards.
Table of Contents
An automatic Table of Contents relies on Styles to keep track of page numbers and section titles for you automatically. Microsoft Word can scan your document and find everything in the Heading 1 style and put that on the first level of your table of contents, put any Heading 2's on the second level of your table of contents, and so on.. If you want an automatic table of contents you need to ...
How to Effectively Create a Table of Contents for Your Research Paper
A table of contents in a research paper serves as a structured guide, allowing readers to easily navigate and locate specific sections or chapters. It provides an overview of the paper's organization and helps in understanding the flow of information.
How do I create a table of contents?
To automatically insert a table of contents in Microsoft Word, follow these steps: Apply heading styles throughout the document. In the references section in the ribbon, locate the Table of Contents group. Click the arrow next to the Table of Contents icon and select Custom Table of Contents.
How to Create the Best Table of Contents for a Dissertation
First, to generate the Table of Contents, start by entering a blank page after the pages you need the table of contents to follow. To do so, click on the bottom of the page you want before the Table of Contents. Open the 'Insert' tab and select 'Page Break'.
How do I format a table of contents in MLA style?
Tables of contents may be formatted in a number of ways. In our publications, we sometimes list chapter numbers before chapter titles and sometimes list the chapter titles alone. We also sometimes list section heads beneath the chapter titles. After each chapter or heading title, the page number on which the chapter or section begins is provided.
How to Create a Structured Research Paper Outline
A decimal outline is similar in format to the alphanumeric outline, but with a different numbering system: 1, 1.1, 1.2, etc. Text is written as short notes rather than full sentences. Example: 1 Body paragraph one. 1.1 First point. 1.1.1 Sub-point of first point. 1.1.2 Sub-point of first point.
Table of Contents
However, if your written report, research paper, or other longer work is more than five pages, it is helpful to include a table of contents showing the page number where each specific section is ...
Table of Contents Format for Research Papers?
Once you are happy with this, click 'Insert' on the drop down menu, scroll down to 'Reference,' and then across to 'Index and Tables'. Click on the 'Table of Contents' tab and you are ready to click OK and go. OpenOffice is a very similar process but, after clicking 'Insert,' you follow 'Indexes and Tables' and 'Indexes and Tables' again.
Example for Table of Contents
A table of contents example will help structure a long academic manuscript and a table of contents page is necessary for academic submission. The table of contents contains an organised listing of your manuscript's chapters and sections with clearly marked (and accurate) page numbers. The aim of the table of contents is to allow the reader to ...
How To Write a Table of Contents for Academic Papers
A working table of contents should begin with a title. This title may change as you draft your text, but a working title will help you focus your thoughts as you devise the headings and plan the content for the main parts, chapters, sections and subsections that should be added beneath it. All headings, whether numbered or not, should be ...
Research Paper
Definition: Research Paper is a written document that presents the author's original research, analysis, and interpretation of a specific topic or issue. It is typically based on Empirical Evidence, and may involve qualitative or quantitative research methods, or a combination of both. The purpose of a research paper is to contribute new ...
Figure and Table Lists
To do this, follow these steps: Navigate to the References tab, and click "Insert Caption," which you can find in the Captions group. Give your caption a name. In the Label list, you can select the label that best describes your figure or table, or make your own by selecting "New Label.". Next, you can insert the list of tables and ...
Research Paper Format
Research paper format is an essential aspect of academic writing that plays a crucial role in the communication of research findings.The format of a research paper depends on various factors such as the discipline, style guide, and purpose of the research. It includes guidelines for the structure, citation style, referencing, and other elements of the paper that contribute to its overall ...
How to Create Table of Contents for Research Paper?
Where you wish to insert a Table of Contents, click in the document. On the ribbon, click the References tab. Then, select Table of Contents. A collection of built-in styles appears. Choose one of these, look at additional tables of contents on Office.com, or design your own table of contents. Select a table of contents style.
How to create a table of contents for a research paper
Once you have created a table of contents, you can insert it into your research paper by following these steps:1. Open your research paper in Microsoft Word....
Thesis Format
The table of contents should come after the title page. Appendix sections: Each appendix should have its own section with a clear and concise title that describes the contents of the appendix. Each section should be numbered with Arabic numerals (e.g., Appendix 1, Appendix 2, etc.). The sections should be listed in the table of contents.
Effective Use of Tables and Figures in Research Papers
The reader is given a chance to understand data through visual content. When writing a research paper, these elements should be considered as part of good research writing. APA research papers, MLA research papers, and other manuscripts require visual content if the data is too complex or voluminous. ... Number and reference the table in the ...
APA Format for Tables and Figures
Tables and figures are each numbered separately, in the order they are referred to in your text. For example, the first table you refer to is Table 1; the fourth figure you refer to is Figure 4. The title should clearly and straightforwardly describe the content of the table or figure. Omit articles to keep it concise.
How to Create a Table of Contents
Tips on how to create a table of contents in MS WordPlease don't forget to subscribe.. Thanks! =) #TableofContents#MSWord
Writing a Research Paper Introduction (with 3 Examples)
1-) Start with a Catchy Hook. Your first sentence is one of the factors that most influence a reader's decision to read your paper. This sentence determines the tone of your paper and attracts the reader's attention. For this reason, we recommend that you start your introduction paragraph with a strong and catchy hook sentence.
Paperpal's New AI Research Finder Empowers Authors to Research, Write
By integrating a robust AI research finder into its feature suite, Paperpal aims to accelerate the writing process and double your productivity. Table of Contents. Challenges in existing writing process ; Paperpal's AI research finder provides science-backed answers as you write ; Research benefits: 5 ways Paperpal's AI research finder can ...
Volume 628 Issue 8007, 11 April 2024
Insects at risk. The cover shows a green leafhopper (Cicadella viridis). Five papers in this week's issue explore the environmental challenges now facing insect populations, with climate change ...
JMIR Formative Research
Background: The syndemic nature of gonococcal infections and HIV provides an opportunity to develop a synergistic intervention tool that could address the need for adequate treatment for gonorrhea, screen for HIV infections, and offer pre-exposure prophylaxis (PrEP) for persons who meet the criteria. By leveraging information available on electronic health records, a clinical decision support ...
Journal of Medical Internet Research
We used content analysis to identify usability issues described in the field notes and open-ended survey questions, and descriptive statistics to summarize participant characteristics and close-ended survey responses. Results: A total of 61 individuals participated in this study. Further, 11 patients participated in think-aloud interviews.

APA Table of Contents Writing Guide (+ example)

Table of Contents APA: Basics

APA Table of Contents Example

How to Make APA Table of Contents in Word

Format Your Headings

Create Table of Contents in APA Formats

Keep Table of Contents Consistent

You may also like

Frequently Asked Questions

2. Where in the text is the table of contents located in APA style paper?

3. How many heading levels is it required to have in a table of contents?

Have a language expert improve your writing

Dissertation Table of Contents in Word | Instructions & Examples

Instantly correct all language mistakes in your text

Table of contents

Including appendices and tables

The only proofreading tool specialized in correcting academic writing

Prevent plagiarism, run a free check.

Cite this Scribbr article

Is this article helpful?

Tegan George

How to Write a Table of Contents for Different Formats With Examples

General Guidelines

Difference Between a Table of Contents and an Outline

How to Write a Table of Contents in APA

How to Write a Table of Contents in MLA

How to Write a Table of Contents in Chicago/Turabian

How to Write a Table of Contents in Harvard

To Learn More, Read Relevant Articles

Microsoft Word for Dissertations

Automatic Table of Contents

Modifying the format of your Table of Contents

Bonus tip for updating fields like the Table of Contents

How to Effectively Create a Table of Contents for Your Research Paper?

Understanding the Basics of a Table of Contents

Step-by-Step Guide to Crafting Your TOC

Actionable Steps

Related Questions and Answers from “Table of Contents Research Paper”

How to Create the Best Table of Contents for a Dissertation

What is the Table of Contents in the Dissertation?

Looking for dissertation help?

Styles for Dissertation Table of Contents

Changing Appearance of Pre-Defined Styles

Things to Consider when Making APA Style Table of Contents

Generating Dissertation Table of Contents

How to Insert Table of Contents

Updating the Table of Contents

Is it essential to add a table of content to the dissertation?

How to make an effective table of contents for the dissertation?

How do I update the table of contents?

How do I format a table of contents in MLA style?

Search form

For Academic Papers

This article is a part of the guide:

Browse Full Outline

The Importance of Headings

You Are Allowed To Copy The Text

Related articles

Save this course for later

Footer bottom

Your Step to Success

Example for Table of Contents

Definition

What comes first, table of contents or abstract?

What variations of table of content examples exist?

Are references included in table of contents?

How can I make a table of contents in Microsoft Word?

Examples for Your Thesis

Single Level Table of Contents Example

Subdivided Table of Contents E xample

Multi-level Table of Contents E xample

Academic Table of Contents

Table of Contents Example: Bachelor’s Thesis

Master’s Thesis Examples

Microsoft Word Tutorial

In a Nutshell

Book Editing

Medical Editing

PhD Thesis Editing

How To Write a Table of Contents for Academic Papers