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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

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• Introduction

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

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What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Literature reviews, what is a literature review, learning more about how to do a literature review.

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

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

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What is a literature review? [with examples]

What is a literature review?

The purpose of a literature review, how to write a literature review, the format of a literature review, general formatting rules, the length of a literature review, literature review examples, frequently asked questions about literature reviews, related articles.

A literature review is an assessment of the sources in a chosen topic of research.

In a literature review, you’re expected to report on the existing scholarly conversation, without adding new contributions.

If you are currently writing one, you've come to the right place. In the following paragraphs, we will explain:

• the objective of a literature review
• how to write a literature review
• the basic format of a literature review

Tip: It’s not always mandatory to add a literature review in a paper. Theses and dissertations often include them, whereas research papers may not. Make sure to consult with your instructor for exact requirements.

The four main objectives of a literature review are:

• Studying the references of your research area
• Summarizing the main arguments
• Identifying current gaps, stances, and issues
• Presenting all of the above in a text

Ultimately, the main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

The format of a literature review is fairly standard. It includes an:

• introduction that briefly introduces the main topic
• body that includes the main discussion of the key arguments
• conclusion that highlights the gaps and issues of the literature

➡️ Take a look at our guide on how to write a literature review to learn more about how to structure a literature review.

First of all, a literature review should have its own labeled section. You should indicate clearly in the table of contents where the literature can be found, and you should label this section as “Literature Review.”

➡️ For more information on writing a thesis, visit our guide on how to structure a thesis .

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, it will be long. If your paper does not depend entirely on references, it will be short.

Take a look at these three theses featuring great literature reviews:

• School-Based Speech-Language Pathologist's Perceptions of Sensory Food Aversions in Children [ PDF , see page 20]
• Who's Writing What We Read: Authorship in Criminological Research [ PDF , see page 4]
• A Phenomenological Study of the Lived Experience of Online Instructors of Theological Reflection at Christian Institutions Accredited by the Association of Theological Schools [ PDF , see page 56]

Literature reviews are most commonly found in theses and dissertations. However, you find them in research papers as well.

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, then it will be long. If your paper does not depend entirely on references, then it will be short.

No. A literature review should have its own independent section. You should indicate clearly in the table of contents where the literature review can be found, and label this section as “Literature Review.”

The main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

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Introduction

Literature reviews take time. here is some general information to know before you start.  .

•  VIDEO -- This video is a great overview of the entire process.  (2020; North Carolina State University Libraries) --The transcript is included --This is for everyone; ignore the mention of "graduate students" --9.5 minutes, and every second is important  
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• NOT A RESEARCH ARTICLE -- A literature review follows a different style, format, and structure from a research article.  

Steps to Completing a Literature Review

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What is a literature review?

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

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

Why is it important?

A literature review is important because it:

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

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1. Choose a topic. Define your research question.

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

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

2. Decide on the scope of your review

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

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

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

Make a list of the databases you will search. 

Where to find databases:

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

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

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

Review the literature

Some questions to help you analyze the research:

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

Tips: 

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

• What is a Literature Review?
• What is NOT a Literature Review?
• Purposes of a Literature Review
• Types of Literature Reviews
• Literature Reviews vs. Systematic Reviews
• Systematic vs. Meta-Analysis

Literature Review  is a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works.

Also, we can define a literature review as the collected body of scholarly works related to a topic:

• Summarizes and analyzes previous research relevant to a topic
• Includes scholarly books and articles published in academic journals
• Can be an specific scholarly paper or a section in a research paper

The objective of a Literature Review is to find previous published scholarly works relevant to an specific topic

• Help gather ideas or information
• Keep up to date in current trends and findings
• Help develop new questions

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Helps focus your own research questions or problems
• Discovers relationships between research studies/ideas.
• Suggests unexplored ideas or populations
• Identifies major themes, concepts, and researchers on a topic.
• Tests assumptions; may help counter preconceived ideas and remove unconscious bias.
• Identifies critical gaps, points of disagreement, or potentially flawed methodology or theoretical approaches.
• Indicates potential directions for future research.

All content in this section is from Literature Review Research from Old Dominion University 

Keep in mind the following, a literature review is NOT:

Not an essay 

Not an annotated bibliography  in which you summarize each article that you have reviewed.  A literature review goes beyond basic summarizing to focus on the critical analysis of the reviewed works and their relationship to your research question.

Not a research paper   where you select resources to support one side of an issue versus another.  A lit review should explain and consider all sides of an argument in order to avoid bias, and areas of agreement and disagreement should be highlighted.

A literature review serves several purposes. For example, it

• provides thorough knowledge of previous studies; introduces seminal works.
• helps focus one’s own research topic.
• identifies a conceptual framework for one’s own research questions or problems; indicates potential directions for future research.
• suggests previously unused or underused methodologies, designs, quantitative and qualitative strategies.
• identifies gaps in previous studies; identifies flawed methodologies and/or theoretical approaches; avoids replication of mistakes.
• helps the researcher avoid repetition of earlier research.
• suggests unexplored populations.
• determines whether past studies agree or disagree; identifies controversy in the literature.
• tests assumptions; may help counter preconceived ideas and remove unconscious bias.

As Kennedy (2007) notes*, it is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the original studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally that become part of the lore of field. In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews.

Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are several approaches to how they can be done, depending upon the type of analysis underpinning your study. Listed below are definitions of types of literature reviews:

Argumentative Review      This form examines literature selectively in order to support or refute an argument, deeply imbedded assumption, or philosophical problem already established in the literature. The purpose is to develop a body of literature that establishes a contrarian viewpoint. Given the value-laden nature of some social science research [e.g., educational reform; immigration control], argumentative approaches to analyzing the literature can be a legitimate and important form of discourse. However, note that they can also introduce problems of bias when they are used to to make summary claims of the sort found in systematic reviews.

Integrative Review      Considered a form of research that reviews, critiques, and synthesizes representative literature on a topic in an integrated way such that new frameworks and perspectives on the topic are generated. The body of literature includes all studies that address related or identical hypotheses. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication.

Historical Review      Few things rest in isolation from historical precedent. Historical reviews are focused on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

Methodological Review      A review does not always focus on what someone said [content], but how they said it [method of analysis]. This approach provides a framework of understanding at different levels (i.e. those of theory, substantive fields, research approaches and data collection and analysis techniques), enables researchers to draw on a wide variety of knowledge ranging from the conceptual level to practical documents for use in fieldwork in the areas of ontological and epistemological consideration, quantitative and qualitative integration, sampling, interviewing, data collection and data analysis, and helps highlight many ethical issues which we should be aware of and consider as we go through our study.

Systematic Review      This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyse data from the studies that are included in the review. Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?"

Theoretical Review      The purpose of this form is to concretely examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review help establish what theories already exist, the relationships between them, to what degree the existing theories have been investigated, and to develop new hypotheses to be tested. Often this form is used to help establish a lack of appropriate theories or reveal that current theories are inadequate for explaining new or emerging research problems. The unit of analysis can focus on a theoretical concept or a whole theory or framework.

* Kennedy, Mary M. "Defining a Literature."  Educational Researcher  36 (April 2007): 139-147.

All content in this section is from The Literature Review created by Dr. Robert Larabee USC

Robinson, P. and Lowe, J. (2015),  Literature reviews vs systematic reviews.  Australian and New Zealand Journal of Public Health, 39: 103-103. doi: 10.1111/1753-6405.12393

What's in the name? The difference between a Systematic Review and a Literature Review, and why it matters . By Lynn Kysh from University of Southern California

Systematic review or meta-analysis?

A  systematic review  answers a defined research question by collecting and summarizing all empirical evidence that fits pre-specified eligibility criteria.

A  meta-analysis  is the use of statistical methods to summarize the results of these studies.

Systematic reviews, just like other research articles, can be of varying quality. They are a significant piece of work (the Centre for Reviews and Dissemination at York estimates that a team will take 9-24 months), and to be useful to other researchers and practitioners they should have:

• clearly stated objectives with pre-defined eligibility criteria for studies
• explicit, reproducible methodology
• a systematic search that attempts to identify all studies
• assessment of the validity of the findings of the included studies (e.g. risk of bias)
• systematic presentation, and synthesis, of the characteristics and findings of the included studies

Not all systematic reviews contain meta-analysis. 

Meta-analysis is the use of statistical methods to summarize the results of independent studies. By combining information from all relevant studies, meta-analysis can provide more precise estimates of the effects of health care than those derived from the individual studies included within a review.  More information on meta-analyses can be found in  Cochrane Handbook, Chapter 9 .

A meta-analysis goes beyond critique and integration and conducts secondary statistical analysis on the outcomes of similar studies.  It is a systematic review that uses quantitative methods to synthesize and summarize the results.

An advantage of a meta-analysis is the ability to be completely objective in evaluating research findings.  Not all topics, however, have sufficient research evidence to allow a meta-analysis to be conducted.  In that case, an integrative review is an appropriate strategy. 

Some of the content in this section is from Systematic reviews and meta-analyses: step by step guide created by Kate McAllister.

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As a student at VCU, VCU Libraries are here to help you succeed!  This guide offers an introduction to conducting a literature review and provides links to the resources and tools we offer.  To navigate, simply click the blue tabs to the left based on type of information you're needing.  

If ever you are in need of research assistance, don't hesitate to consult a specialist  based on your subject area.   

Please provide feedback on this guide at any point by emailing Kelsey Cheshire,  [email protected] . 

What is a Literature Review?

A literature review is an essential component of every research project. Literature reviews ask: What do we know, or not know, about this particular issue/ topic/ subject?  

How well you answer this question depends upon:

• the effectiveness of your search for information
• the quality & reliability of the sources you choose
• your ability to synthesize the sources you select

Literature reviews require “re-viewing” what credible scholars in the field have said, done, and found in order to help you:

• Identify what is currently known in your area of interest
• Establish an empirical/ theoretical/ foundation for your research
• Identify potential gaps in knowledge that you might fill
• Develop viable research questions and hypotheses
• Decide upon the scope of your research
• Demonstrate the importance of your research to the field

A literature review is not a descriptive summary of what you found. All works included in the review must be read, evaluated, and analyzed, and synthesized, meaning that relationships between the works must also be discussed.  

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What is a Literature Review?

So, what is a literature review .

"A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available or a set of summaries." - Quote from Taylor, D. (n.d)."The Literature Review: A Few Tips on Conducting it".

• Citation: "The Literature Review: A Few Tips on Conducting it"

What kinds of literature reviews are written?

Each field has a particular way to do reviews for academic research literature. In the social sciences and humanities the most common are:

• Narrative Reviews: The purpose of this type of review is to describe the current state of the research on a specific research topic and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weaknesses, and gaps are identified. The review ends with a conclusion section that summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.
• Book review essays/ Historiographical review essays : A type of literature review typical in History and related fields, e.g., Latin American studies. For example, the Latin American Research Review explains that the purpose of this type of review is to “(1) to familiarize readers with the subject, approach, arguments, and conclusions found in a group of books whose common focus is a historical period; a country or region within Latin America; or a practice, development, or issue of interest to specialists and others; (2) to locate these books within current scholarship, critical methodologies, and approaches; and (3) to probe the relation of these new books to previous work on the subject, especially canonical texts. Unlike individual book reviews, the cluster reviews found in LARR seek to address the state of the field or discipline and not solely the works at issue.” - LARR

What are the Goals of Creating a Literature Review?

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 
• Baumeister, R.F. & Leary, M.R. (1997). "Writing narrative literature reviews," Review of General Psychology , 1(3), 311-320.

When do you need to write a Literature Review?

• When writing a prospectus or a thesis/dissertation
• When writing a research paper
• When writing a grant proposal

In all these cases you need to dedicate a chapter in these works to showcase what has been written about your research topic and to point out how your own research will shed new light into a body of scholarship.

Where I can find examples of Literature Reviews?

Note:  In the humanities, even if they don't use the term "literature review", they may have a dedicated  chapter that reviewed the "critical bibliography" or they incorporated that review in the introduction or first chapter of the dissertation, book, or article.

• UCSB electronic theses and dissertations In partnership with the Graduate Division, the UC Santa Barbara Library is making available theses and dissertations produced by UCSB students. Currently included in ADRL are theses and dissertations that were originally filed electronically, starting in 2011. In future phases of ADRL, all theses and dissertations created by UCSB students may be digitized and made available.

Where to Find Standalone Literature Reviews

Literature reviews are also written as standalone articles as a way to survey a particular research topic in-depth. This type of literature review looks at a topic from a historical perspective to see how the understanding of the topic has changed over time. 

• Find e-Journals for Standalone Literature Reviews The best way to get familiar with and to learn how to write literature reviews is by reading them. You can use our Journal Search option to find journals that specialize in publishing literature reviews from major disciplines like anthropology, sociology, etc. Usually these titles are called, "Annual Review of [discipline name] OR [Discipline name] Review. This option works best if you know the title of the publication you are looking for. Below are some examples of these journals! more... less... Journal Search can be found by hovering over the link for Research on the library website.

Social Sciences

• Annual Review of Anthropology
• Annual Review of Political Science
• Annual Review of Sociology
• Ethnic Studies Review

Hard science and health sciences:

• Annual Review of Biomedical Data Science
• Annual Review of Materials Science
• Systematic Review From journal site: "The journal Systematic Reviews encompasses all aspects of the design, conduct, and reporting of systematic reviews" in the health sciences.
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Introduction to Literature Reviews

Introduction.

• Step One: Define
• Step Two: Research
• Step Three: Write
• Suggested Readings

A literature review is a written work that :

• Compiles significant research published on a topic by accredited scholars and researchers;
• —Surveys scholarly articles, books, dissertations, conference proceedings, and other sources;
• —Examines contrasting perspectives, theoretical approaches, methodologies, findings, results, conclusions.
• —Reviews critically, analyzes, and synthesizes existing research on a topic; and,
• Performs a thorough “re” view, “overview”, or “look again” of past and current works on a subject, issue, or theory.

From these analyses, the writer then offers an overview of the current status of a particular area of knowledge from both a practical and theoretical perspective.

Literature reviews are important because they are usually a  required  step in a thesis proposal (Master's or PhD). The proposal will not be well-supported without a literature review. Also, literature reviews are important because they help you learn important authors and ideas in your field. This is useful for your coursework and your writing. Knowing key authors also helps you become acquainted with other researchers in your field.

Look at this diagram and imagine that your research is the "something new." This shows how your research should relate to major works and other sources.

Olivia Whitfield | Graduate Reference Assistant | 2012-2015

• Next: Step One: Define >>
• Last Updated: Jun 28, 2023 5:49 PM
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Literature Review: What is a Literature Review?

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• Researching Your Topic
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A literature review is an in-depth critical analysis of published scholarly research related to a specific topic. Published scholarly research (the "literature") may include journal articles, books, book chapters, dissertations and thesis, or conference proceedings. 

A solid lit review must:

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

Why Conduct a Literature Review?

• to distinguish what has been done from what needs to be done
• to discover important variables relevant to the topic
• to synthesize and gain new perspective
• to identify relationships between ideas and practices
• to establish the context of the topic
• to rationalize the significance of the problem
• to enhance and acquire subject vocabulary
• to understand the structure of the subject
• tp relate ideas and theory to applications
• to identify main methodologies and research techniques that have been used
• to place research in a historical context to show familiarity with state-of-art development

Questions to Consider

• What is the overarching question or problem your literature review seeks to address?
• How much familiarity do you already have with the field? Are you already familiar with common methodologies or professional vocabularies?
• What types of strategies or questions have others in your field pursued?
• How will you synthesize or summarize the information you gather?
• What do you or others perceive to be lacking in your field?
• Is your topic broad? How could it be narrowed?
• Can you articulate why your topic is important in your field?
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Literature review.

• What is a Literature Review?
• What is Its Purpose?
• 1. Select a Topic
• 2. Set the Topic in Context
• 3. Types of Information Sources
• 4. Use Information Sources
• 5. Get the Information
• 6. Organize / Manage the Information
• 7. Position the Literature Review
• 8. Write the Literature Review

A literature review is a comprehensive summary of previous research on a topic. The literature review surveys scholarly articles, books, and other sources relevant to a particular area of research.  The review should enumerate, describe, summarize, objectively evaluate and clarify this previous research.  It should give a theoretical base for the research and help you (the author) determine the nature of your research.  The literature review acknowledges the work of previous researchers, and in so doing, assures the reader that your work has been well conceived.  It is assumed that by mentioning a previous work in the field of study, that the author has read, evaluated, and assimiliated that work into the work at hand.

A literature review creates a "landscape" for the reader, giving her or him a full understanding of the developments in the field.  This landscape informs the reader that the author has indeed assimilated all (or the vast majority of) previous, significant works in the field into her or his research. 

 "In writing the literature review, the purpose is to convey to the reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. The literature review must be defined by a guiding concept (eg. your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries.( http://www.writing.utoronto.ca/advice/specific-types-of-writing/literature-review )

Recommended Reading

• Next: What is Its Purpose? >>
• Last Updated: Oct 2, 2023 12:34 PM

Enhancing Searching as Learning (SAL) with Generative Artificial Intelligence: A Literature Review

• Conference paper
• First Online: 01 June 2024
• Cite this conference paper

• Kok Khiang Lim   ORCID: orcid.org/0000-0002-7118-6864 8 &
• Chei Sian Lee   ORCID: orcid.org/0000-0003-0891-6526 8  

Part of the book series: Communications in Computer and Information Science ((CCIS,volume 2117))

Included in the following conference series:

• International Conference on Human-Computer Interaction

Searching as Learning (SAL), a learning process with potential knowledge gain during searches in a digital environment, is an emerging field in human-computer interaction research, especially with recent technological advancements in generative artificial intelligence (GenAI). According to SAL, the act of searching for the information itself can be a valuable learning experience. Many studies have investigated SAL’s learning perspective and facets supported by traditional search systems (e.g., web browsers), to access, search, and retrieve information to fulfill users’ learning intentions. However, the applications of GenAI, as well as their roles and disruption to the existing SAL process, are unclear. To address this gap, this study aims to shed light on the applicability of GenAI in enhancing the SAL process by conducting a systematic literature review.

First, we seek to define the concepts of ‘learning’ and ‘searching’ by examining the components of SAL in the literature and then detailing how SAL would have occurred. Next, the systematic literature review, guided by PRISMA, uses the PICO (Population, Intervention, Comparison, and Outcome) framework to develop searchable keywords and guide the literature review. Five major databases were searched, and literature that fulfilled the PICO’s criteria was included for review. Preliminary analysis shows that GenAI could improve and ease SAL human-computer interfaces that inevitably change the process and influence users’ learning behavior, such as how information is retrieved and consumed. Consequently, these opportunities posed concerns about information reliability, accuracy, and long-term effects on user behavior.

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Acknowledgments

This research is supported by the National Research Foundation, Singapore under its AI Singapore Programme (AISG Award No: AISG-GV-2023-013).

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Lim, K.K., Lee, C.S. (2024). Enhancing Searching as Learning (SAL) with Generative Artificial Intelligence: A Literature Review. In: Stephanidis, C., Antona, M., Ntoa, S., Salvendy, G. (eds) HCI International 2024 Posters. HCII 2024. Communications in Computer and Information Science, vol 2117. Springer, Cham. https://doi.org/10.1007/978-3-031-61953-3_17

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Understanding health behavior change by motivation and reward mechanisms: a review of the literature

The global rise of lifestyle-related chronic diseases has engendered growing interest among various stakeholders including policymakers, scientists, healthcare professionals, and patients, regarding the effective management of health behavior change and the development of interventions that facilitate lifestyle modification. Consequently, a plethora of health behavior change theories has been developed with the intention of elucidating the mechanisms underlying health behavior change and identifying key domains that enhance the likelihood of successful outcomes. Until now, only few studies have taken into account neurobiological correlates underlying health behavior change processes. Recent progress in the neuroscience of motivation and reward systems has provided further insights into the relevance of such domains. The aim of this contribution is to review the latest explanations of health behavior change initiation and maintenance based on novel insights into motivation and reward mechanisms. Based on a systematic literature search in PubMed, PsycInfo, and Google Scholar, four articles were reviewed. As a result, a description of motivation and reward systems (approach/wanting = pleasure; aversion/avoiding = relief; assertion/non-wanting = quiescence) and their role in health behavior change processes is presented. Three central findings are discussed: (1) motivation and reward processes allow to distinguish between goal-oriented and stimulus-driven behavior, (2) approach motivation is the key driver of the individual process of behavior change until a new behavior is maintained and assertion motivation takes over, (3) behavior change techniques can be clustered based on motivation and reward processes according to their functional mechanisms into facilitating (= providing external resources), boosting (= strengthening internal reflective resources) and nudging (= activating internal affective resources). The strengths and limitations of these advances for intervention planning are highlighted and an agenda for testing the models as well as future research is proposed.

1. Introduction

The prevalence of lifestyle-related chronic diseases has increased dramatically in the last decades. Chronic diseases were responsible for 71% of all deaths occurring worldwide in 2019 ( World Health Organisation [WHO], 2022a ), of which about one third are premature deaths, i.e., happening to people aged between 30 and 69 years ( World Health Organisation [WHO], 2022a ). Diseases of the circulatory system like stroke and ischaemic heart disease accounted for 30% of all deaths in 2019 in OECD countries, followed by cancer (24%), diseases of the respiratory system (10%) and diabetes (3%) ( Organisation for Economic Co-operation and Development [OECD], 2021 ). Individuals living with these conditions also face a major stress burden due to disability, in some cases already at young ages. Indeed, averaged across 26 OECD countries, more than one third of individuals aged 16 and over have been found to be living with longstanding illness or health problems ( Organisation for Economic Co-operation and Development [OECD], 2021 ). In addition, comorbidities (multimorbidity) as well as individual physical and emotional suffering frequently occur ( Stewart et al., 1989 ; Moussavi et al., 2007 ; de Ridder et al., 2008 ), reducing overall quality of life ( Maresova et al., 2019 ).

These numbers and trends can in part be traced back to rising rates of obesity, sedentary behavior and poor nutrition, as well as other metabolic risk factors for chronic diseases including tobacco use and harmful alcohol intake. In addition, as diseases and comorbidities accumulate in older age, countries’ aging populations further influence these numbers ( Zhou et al., 2016 ). Indeed, most countries in the world have experienced, and will experience great demographic transitions. It has been estimated that between 2015 and 2050, the number of individuals aged 60 years and older will nearly double from 12 to 22%, with two billion people aged above 60 years by 2050 ( World Health Organisation [WHO], 2022b ). At the same time, life expectancy has risen from 67.5 years in 2000 to 72.9 years in 2020 at the world’s average ( The World Bank, 2022 ). Based on these projections, it can be assumed that the total number of individuals with longstanding illnesses or health problems will continue to rise.

The treatment of chronic diseases is often lengthy and intense, and is frequently accompanied by a reduced ability to work ( Seuring et al., 2015 ). While this can reduce the quality of life in patients further ( Jing et al., 2018 ), it can also affect an individual’s household financial resources ( Seuring et al., 2015 ). In low income settings, tremendous costs for treatment can quickly drain savings ( World Health Organisation [WHO], 2022a ). This, in return, may perpetuate people’s conditions, as it has been found that poverty is closely linked with the prevalence of chronic diseases: vulnerable and socially disadvantaged people tend to get ill quicker and have lower life expectancy than people of higher social positions ( World Health Organisation [WHO], 2022a ). The main reasons for this phenomenon are that economically vulnerable individuals are at greater risk of being exposed to harmful products, such as tobacco, tend to have unhealthy diets, and, in some countries, cities or neighborhoods, have limited access to health services. In fact, the average life expectancy at birth of people with low income is 4.4 (women) to 8.6 (men) years lower than of people in the highest of five income groups ( Lampert et al., 2019 ).

These costs on individuals are accompanied by costs for the healthcare system and society as a whole. Health expenditure related to diabetes, for example, is at least 966 billion USD per year worldwide, which represents a 316% increase over the last 15 years ( International Diabetes Federation [IDF], 2021 ). In Germany, the cost burden for diabetes type 2 treatment has been calculated to be on average 1.8 times higher than for other diseases ( Ulrich et al., 2016 ). Multimorbidity typically incurs greater health care costs ( Rizzo et al., 2015 ), measured by the use of medication as well as emergency department presentations and hospital admissions ( Chan et al., 2002 ). For example, Schneider et al. (2009) found that older adults in the United States with three or more chronic conditions utilized on average 25 times more hospital bed-days and had on average 14.6 times more hospital admissions than older adults without any chronic condition. Furthermore, with one additional chronic condition in older adults, the health care utilization costs increase near exponentially ( Lehnert et al., 2011 ). In addition to these financial impacts, chronic conditions tend to dwell on non-tangible resources, e.g., through time and energy spent on disease management by the patient and family members ( Ellrodt et al., 1997 ; Korff et al., 1998 ; Wagner, 2000 ). These circumstances call for shifting the focus to health care measures that help to prevent and improve chronic conditions according to patient needs in a cost-effective way.

There is compelling evidence to suggest that lifestyle changes can significantly improve the conditions of chronic diseases. Studies have demonstrated the positive impact of increased exercise, healthier nutrition, reduced alcohol intake, smoking cessation, and relaxation techniques on a range of chronic conditions ( Ornish et al., 1990 ; Knowler et al., 2002 ; Savoye et al., 2007 ; Alert et al., 2013 ; Cramer et al., 2014 ; Morris et al., 2019 ). These health behaviors can decrease the major metabolic risk factors for chronic diseases and premature deaths, including blood pressure, blood glucose, blood lipids, and obesity ( World Health Organisation [WHO], 2022a ). Remarkably, the risk of developing type 2 diabetes is predominantly attributable to lifestyle-related factors rather than genetic risks ( Langenberg et al., 2014 ). Moreover, lifestyle changes could prevent up to 70% of strokes and cases of colon cancer, 80% of coronary heart diseases, and 90% of diabetes cases ( Willett, 2002 ). Such findings highlight the tremendous potential of lifestyle modification interventions for public health outcomes.

It is widely recognized that individuals encounter challenges when endeavoring to attain their lifestyle goals. This is not unexpected, given that lifestyle change necessitates a series of individual choices that often require postponement of immediate pleasure in favor of prospective long-term health gains (a.k.a. delayed gratification, present bias, hyperbolic discounting, etc., see Stroebe et al., 2008 , 2013 ; Hall and Fong, 2015 ). Despite these obvious difficulties, practitioners, politicians and stakeholders aim to engage patients in health behavior change ( Esch, 2018 ). How consistently individuals pursue health behavior changes depends largely on how well they can overcome their innate present bias and on their endowment with other resources, such as their knowledge about health behavior change consequences, their beliefs in their ability to succeed, their self-regulation skills, self-efficacy, internal locus of control, engagement and empowerment ( Cane et al., 2012 ; Cheng et al., 2016 ; Sheeran et al., 2016 ; Ludwig et al., 2020 ; Cardoso Barbosa et al., 2021 ). Hence, a thorough understanding of health behavior change and interventions to support health behavior change taking into account individuals’ resources are necessary.

Numerous health behavior change theories have been devised, with a primary emphasis on reflective resources and willpower ( Kwasnicka et al., 2016 ). However, there is a scarcity of research on domains that are supported by, or rooted in, neuroscientific evidence. Notably, recent advances in the neuroscience of motivation and reward systems have revealed new insights into the importance of such domains ( Michaelsen and Esch, 2021 , 2022 ).

The aim of this contribution is to provide an overview of the latest explanations of health behavior change initiation and maintenance based on novel insights to motivation and reward mechanisms. Based on a literature search in PubMed (22 hits), PsycInfo (39 hits), and Google Scholar using the term “motivation AND reward AND (‘behavior change’ OR ‘behavior modification’)” in titles and abstracts in January 2023, we identified four articles which discuss neurobiological mechanisms of reward and motivation in relation to health behavior change ( Letzen et al., 2019 ; Ludwig et al., 2020 ; Michaelsen and Esch, 2021 , 2022 ). These are integrated into the social psychological literature on behavior change, previously reviewed in Michaelsen and Esch (2021 , 2022) . The review is structured as follows: the next chapter presents a summary of behavior change theories as discussed in social and health psychology in order to provide thorough ground for the discussion of the role of motivation and reward processes in health behavior change. This is followed by a description of motivation and reward processes as recently discussed in neurobiological science. After this, three models are presented which take into account motivation and reward mechanisms in health behavior change and thereby combine the two strands of literature and present interesting avenues for future health behavior change intervention planning and implementation. A discussion of the review and future research is presented at the end of the article.

2. Behavior change theories in social and health psychology

A large number of theories aiming to explain health behavior change have been published in recent decades, most of them grounded in social and health psychology. These theories differ in the views of human nature they hold ( Bandura, 1989 ) as well as in what they consider to be the fundamental drivers of behavior and the resources necessary for behavior change.

Established theories are concerned with the determinants of and motives for initiation of behavior change, and some also take into account the domains that enhance the likelihood of maintaining a new behavior after initiation ( Kwasnicka et al., 2016 ). Among the leading theories are Bandura’s Social Cognitive Theory ( Bandura, 1989 ), Gollwitzer’s theory on Implementation Intentions ( Gollwitzer, 1999 ), and the Social Determination Theory by Ryan and Deci (2000) and Deci and Ryan (2008) . In Bandura’s Social Cognitive Theory, individuals are assumed to learn new behaviors not only through trial-and-error but also through copying the behavior of others. Based on the existence of role models, the performance of the new behavior is enhanced by outcome expectancies (individuals understand the potential outcomes of their behavior), self-efficacy (individuals believe that they can achieve their desired behavioral goal), and identification (individuals identify with certain aspects of the role model) ( Bandura, 1989 ). In Gollwitzer’s (1999) theory on Implementation Intentions, individuals are suggested to make plans for anticipated situations, in which their desired behavior is at risk. These plans (implementation intentions) are assumed to delegate the control of goal-directed responses over these critical situations when encountered. Another prominent behavior change theory has been published by Ryan and Deci (2000) and Deci and Ryan (2008) . According to their Self-Determination Theory, for behavior change to be successful, three basic psychological needs require fulfillment: autonomy (being the causal agent of one’s own life), competence (ability to master skills important to oneself) and relatedness (feeling connected to others). A number of other theories have each determined a small, inconsistent number of domains supposedly relevant for behavior change initiation.

In a systematic review on 100 behavior change maintenance theories, Kwasnicka et al. (2016) highlight a deficiency in theoretical elaboration regarding the process of maintenance after initial change present in the literature. Theories that are concerned with the behavior change maintenance describe several stages of a behavior change process and the resources necessary to progress from one stage to another. A widely used theory is the Transtheoretical Model ( Prochaska et al., 2008 ), according to which an individual’s change process starts at a precontemplation stage, and continues with the contemplation, planning, implementation, maintenance and termination stages. Similar processes have been suggested by other authors ( Weinstein and Sandman, 1992 , 2002 ; Gollwitzer, 1999 ; Rothman et al., 2004 ; Schwarzer et al., 2011 ). For example, Weinstein and Sandman (2002) emphasize the stage before precontemplation where individuals may be unaware of the issue (e.g., that change in diet could improve their health conditions) and Rothman et al.’s (2004) model adds a habit stage where individuals have automated the new behavior. Michaelsen and Esch (2021) have provided the first comprehensive synthesis of behavior change models, a flexible seven-stage behavior change process, which allows to systematically relate motivation and reward mechanisms to these stages. In their process, individuals may experience the stages unawareness, awareness, contemplation, planning, initiation, continued action, and maintenance. These stages are categorized into three phases of engagement, namely, non-engagement, motivational engagement, and executive engagement, in which individuals’ actions are driven by different types of motivation and reward processes ( Michaelsen and Esch, 2021 , 2022 ), as explained in more detail below.

3. Motivation and reward systems involved in behavior change processes

Michaelsen and Esch (2021) have described three types of motivational states (approach motivation, avoidance motivation, and assertion motivation) and their corresponding rewards (pleasure, relief, and quiescence) that seem to play key roles in health behavior change processes (see Figure 1 ).

Three types of motivation and reward. Esch (2022) ; copyright: ©2022 by the author (TE). Licensee MDPI, Basel, Switzerland.

3.1. Approach motivation

Approach motivation, also known as appetitive or incentive salience, is focused on stimuli or goals that are associated with positive and pleasurable experiences ( Bozarth, 1994 ; Esch and Stefano, 2004 ; Elliot et al., 2013 ). This type of motivation is linked to the wanting-system, reward expectation, performance, and action ( Esch, 2022 ). The attainment of a desired stimulus or goal typically produces a sense of pleasure or reward, which may or may not be noticeable depending on the intensity of the experience. The reward is not derived from the stimulus or goal itself, but from the psychological and neurobiological processes that occur when there is a positive anticipation and response to a stimulus or goal ( Berridge and Kringelbach, 2008 ; Schultz, 2015 ). While it is challenging to categorize experiences into specific types of motivational processes, it is generally agreed that individuals tend to assess stimuli as positive or negative ( Elliot et al., 2013 ). These assessments are frequently referred to as fundamental affective experiences and include emotions such as joy, pleasure, and excitement ( Schneirla, 1959 ; Cacioppo et al., 1999 ; Elliot et al., 2013 ; Lang and Bradley, 2013 ; Rolls, 2013 ). Therefore, the essence of approach motivation lies in the anticipation of obtaining a reward that is characterized by positive emotions.

The underlying physiological mechanisms of motivation occur in specific brain areas distinct from other sensory and cognitive areas ( Kringelbach, 2005 ; Esch, 2022 ). The approach motivation and reward system is commonly described as being embedded in the central nervous system (CNS), involves nerve cells that originate in the ventral tegmental area (VTA) and send projections to the frontal brain, specifically the nucleus accumbens (NAC), via the neurotransmitter dopamine ( Nestler, 2001 ; Nestler et al., 2001 ; Esch and Stefano, 2004 , 2010 ). The nucleus accumbens (NAC) plays a crucial role in the neural regulation of reward-seeking behavior by signaling the degree of effort necessary to acquire a reward and the desire to obtain it, thereby determining the appetitive motivational salience. Additionally, the ventral tegmental area-nucleus accumbens (VTA-NAC) pathway is responsible for measuring and regulating the rewarding aspects of an activity, transmitting pertinent information to other brain regions ( Esch and Stefano, 2004 ; Berridge, 2007 ; Smith et al., 2011 ; Esch, 2022 ). The magnitude of expected reward has been found to significantly influence the likelihood of an individual to retain and repeat a behavior ( Esch and Stefano, 2010 ). Furthermore, the hippocampus and amygdala have been identified as crucial components of the reward system, with the hippocampus serving as a gatekeeper for experiences to be recognized and stored in memory, while the amygdala assesses these experiences as either pleasurable or detrimental ( Esch and Stefano, 2004 ; Nestler and Malenka, 2004 ). The mesocortical dopamine pathway in the frontal cortex is also known to be involved in the evaluation of the “costs” and risks associated with the pursuit of rewards, ultimately shaping an individual’s behavioral response ( Esch and Stefano, 2010 ).

3.2. Avoidance motivation

The construct of avoidance motivation, also referred to as negatively-valenced fearful salience, pertains to the motivational system that drives the avoidance of punishment or potential harm, rather than the pursuit of reward. This type of motivation is intricately linked to the fight-flight-freeze response, which encompasses physiological and behavioral changes in response to perceived threat ( Bozarth, 1994 ; Esch and Stefano, 2004 ; Seymour et al., 2007 ; Esch, 2022 ). The phenomenon commonly known as avoidance behavior is typically evoked by an aversive or challenging stimulus, and elicits a motivated reaction of withdrawal, commonly manifested as the act of moving away from unpleasant conditions. It is noteworthy that avoidance behavior can be differentiated from punishment, which exerts a suppressing effect on the strength of the behavioral response (passive avoidance), and from negative reinforcement, which engenders an augmenting effect on the strength of the behavioral response (active avoidance) ( Schultz, 2015 ). In contrast to active reactions such as fighting or fleeing in response to a fear-inducing stimulus, there can also be the passive reactions of freezing ( Berridge, 2018 ). Emotions associated with avoidance motivation include anxiety, fear, and disgust ( Lang, 1995 ; Cacioppo et al., 1999 ; Watson et al., 1999 ; Elliot et al., 2013 ; Hirschberg and Manning, 2015 ; Esch, 2022 ).

Avoidance motivation is embedded in the stress system and involves increased sympathetic activity and the release of cortisol, adrenaline, opioids, and vasopressin ( Esch, 2022 ). This type of motivation is rooted in the lower limbic system, specifically the amygdala and hypothalamus. Upon the anticipation of an actual or imagined threat, two distinct pathways are instigated: one through the hypothalamus and pituitary gland, leading to the release of cortisol, and the other through the sympathetic nervous system, leading to the release of adrenaline ( Esch, 2022 ). The freeze reaction is also connected to the amygdala ( LeDoux, 1998 ). Successful avoidance can lead to relief, a positive, low-arousal emotion that can be experienced as relaxation or reward ( Levenson, 2011 ; Krisam et al., 2017 ; Esch, 2022 ). An incontrovertible interdependence between the approach and avoidance motivation systems exists, as akin brain regions are triggered during both relief and other positive affects ( Kim et al., 2007 ; Sangha, 2015 ).

3.3. Assertion motivation

The majority of research on motivation and reward does not differentiate between behavior driven by approach motivation and behavior driven by assertion motivation. In point of fact, these two categories of motivation are frequently confounded or amalgamated ( McCall and Singer, 2012 ), despite the divergent neurobiological mechanisms underlying them, their distinct loci in the brain, and their discrepant behavioral outcomes. Assertion motivation, or assertive salience, is linked to the “non-wanting” system and associated with inaction, acceptance, or contentment, homeostasis, and quiescence. It describes the motivation to maintain a certain condition or state ( McCall and Singer, 2012 ; Esch, 2022 ). Assertion motivation is different from approach motivation in terms of the emotions it evokes and the types of behavior it leads to McCall and Singer (2012) and Esch (2022) . Assertion motivation is associated with a lack of desire to change or move away from the current state, while approach motivation is associated with a desire to move toward something. Assertion motivation can be seen in instances where a person is content with their current situation, such as a newly habituated health behavior, and there is no inclination to change or move away from it.

Assertion motivation is linked to increased activity in the parasympathetic autonomous nervous system and is associated with neurotransmitters such as endogenous opiates, oxytocin, acetylcholine, serotonin, and endocannabinoids ( Esch, 2022 ). Brain areas involved in the activation of assertive motivation include the midbrain, vagus areas, cingulum, hippocampus, ventral striatum, hypothalamus, and pituitary gland ( Michaelsen and Esch, 2021 ). It is different from approach and avoidance motivation in terms of related affective qualities and behavioral outcomes and is not characterized by activation of dopaminergic activity.

4. Weaving together motivation and reward mechanisms with health behavior change theories

Weaving together psychological explanations of behavior change with neurobiological understandings of motivation and reward processes has produced three models explaining different aspects of behavior change. First, a model differentiating goal-directed and stimulus-driven behavior ( Michaelsen and Esch, 2021 ) will be explained. This is followed by the description of the Model of Engagement, that illustrates the role of the three types of motivation during a behavior change process ( Michaelsen and Esch, 2021 ). Finally, the behavior change resource model ( Michaelsen and Esch, 2022 ) that integrates the differentiation between goal-directed and stimulus-driven behavior with the Model of Engagement to explain the functional mechanisms of behavior change techniques is presented. The elaborations of Ludwig et al. (2020) concerning reward valuation and Letzen et al. (2019) on mesocorticolimbic function in behavior change are discussed within these sections.

4.1. Goal-directed and stimulus-driven behavior

Kwasnicka et al.’s (2016) systematic review revealed that existing health behavior change theories largely focus on cognitive resources deemed necessary for achieving behavior change. Their findings indicated that only 10% of the theories reviewed took into account the relevance of automatic responses to relevant cues or stimuli, which has been identified as a limitation to existing theories ( Van Cappellen et al., 2018 ). This is because the manifestation of health behaviors in daily life is often influenced by implicit emotions and non-cognitive motives, rather than reflective cognitive willpower, as various dual-process models have emphasized (e.g., Kahneman and Tversky, 1982 ; Strack and Deutsch, 2004 ; Hall and Fong, 2007 ; Marteau et al., 2012 ; Sheeran et al., 2013 ). Dual-process models of decision-making have been developed to differentiate between two regulatory systems in the brain: reflective (cognitive, conscious) and affective (impulsive, intuitive, automatic) antecedents of behavior ( Chaiken, 1980 ; Petty and Cacioppo, 2012 ). The reflective system is based on conscious deliberation and control, which requires subjective effort. It draws upon an individual’s knowledge of probabilities and values and is based on rules of language and logic. The key processes of the reflective system are volition and reasoning, which can be intentionally accessed. However, the reflective process is relatively slow ( Strack and Deutsch, 2004 ; Sheeran et al., 2013 ). The reflective system typically supersedes the automatic system, which is quicker and more effortless, and operates by utilizing stored associations acquired through experiences, responding to habits and impulses. Strack and Deutsch (2004) posit that the automatic system is a significant impulsive process that engenders activation, in which perceptual inputs stimulate elements in the associative memory, subsequently activating other related elements. This form of information processing is characterized by its rapidity and operation beyond conscious awareness, as noted in the extant literature ( Strack and Deutsch, 2004 ; Evans, 2010 ; Sheeran et al., 2013 ). While this view has garnered both commendation and condemnation from scholars ( Evans, 2018 ), it nevertheless represents a significant contribution to the comprehension of health behavior and behavior change. Furthermore, a widespread view stemming from dual-process models is that the more rapid component governs behavior.

In reference to dual-process models and the differentiation between controlled goals and autonomous goals (or unnoticed stimuli), Michaelsen and Esch (2021) present a neurobiologically informed model of stimulus-driven and goal-directed behavior. In stimulus-driven behavior, a stimulus activates automatic processes and leads to behavior without the individual having noticed the stimulus. Once a stimulus has undergone cognitive processing and been transformed into a goal, the ensuing behavior is referred to as goal-directed behavior. The authors posit that both varieties of stimuli are capable of inciting appetitive, aversive, or assertive salience by means of reward anticipation. In this way, motivational salience, or the ability to attract and hold attention, can lead to action and engagement without conscious thought or planning ( Ryan and Deci, 2000 ; Carver, 2009 ; Kruglanski et al., 2014 ; Berridge, 2018 ). Both unnoticed stimuli and those that are deliberately processed can result in the same actions and engagement. However, in goal-directed behavior, the individual is aware of their actions and is actively involved in the process, as noted by Michaelsen and Esch (2021) . Figure 2 illustrates the difference between stimulus-driven and goal-directed behavior in a simplified way.

Goal-directed and stimulus-driven behavior ( Michaelsen and Esch, 2021 ).

The model can be expanded by the theory proposed by Ludwig et al. (2020) , who propose an approach to achieve sustainable behavior change through a combination of theories and research on autonomous motivation, reinforcement learning and mindfulness. The authors argue that behavior change can occur through increased awareness of the reward value of specific actions, which drives future behavior, in addition to the commonly proposed “mental gap” mechanism. The stability of a behavior depends on changes in its reward value over time and the accessibility of more rewarding behaviors. The reward value of a behavior may depend on both external and internal factors, such as subjective experience and goal achievement. The authors suggest that bringing present-moment or mindful awareness to current behavior can update the reward value of habitual behaviors and lead to new learning. This approach involves direct, in-the-moment, curious awareness and is not reliant on reflective thought processes. An increased awareness about stimuli that engender change through increased reward value would shift individuals, in the above model, from stimulus-driven to goal-directed behavior.

4.2. Motivational engagement in behavior change processes

Based on the synthesis of multi-stage behavior change theories, Michaelsen and Esch (2021) have derived three different phases of engagement, based on the role of motivational processes involved during the stages of behavior change. During the first phase, called non-engagement phase, individuals are either unaware that behavior change may improve their health conditions, or they are aware but have no intention to change an aspect of their health behavior. During this phase, any motivational mechanisms are yet absent. Stimuli like new information about the health benefits of a certain behavior change may activate motivational processes so that individuals progress into the motivational engagement phase, which is comprised of the contemplation and planning stages.

The nature of the contemplative phase is contingent on the sort of motivational salience that is evoked by the stimulus. Should an individual be satisfied with their present state, assertive salience becomes operational. Here, the likelihood of perpetuating the present condition is linked to positive valence that instigates sensations of quiescence, stillness, and/or relaxation stemming from the discharge, such as that of endogenous opiates, oxytocin and related neurotransmitters, as well as parasympathetic activity. Such a state leads to a lack of behavioral activity, resulting in the cessation of the process of behavior change. In the event that an individual desires a change, either appetitive or aversive salience is elicited. When appetitive salience is activated, information undergoes processing by the mesocortical dopamine pathway in the frontal cortex, and a preference for a new behavior is set ( Esch and Stefano, 2010 ; Michaelsen and Esch, 2021 ). On the other hand, should aversive salience be activated, information is routed through the stress response pathways, namely, the hypothalamic-pituitary (-adrenal) axis and the (amygdalar-) sympathetic nervous system axis ( Esch and Stefano, 2010 ).

The planning stage is defined by cognitive, goal-directed action (see Figure 3 ). In order to plan, the actions of thinking, reflecting, and evaluating are involved, and, neurobiologically, the upper limbic level. The cognitive task of planning is propelled by either appetitive or aversive motivational salience and may culminate in an intention, or a series of intentions (a plan). Michaelsen and Esch (2021) contend that, owing to its cognitive underpinnings, planning can only transpire in goal-directed behavioral processes, and not in stimulus-driven behavioral processes. They posit that both stages of motivational engagement can be bypassed if the presented stimulus and the evoked motivational salience go unnoticed (i.e., are stimulus-driven).

Model of Engagement ( Michaelsen and Esch, 2021 ).

The third engagement phase is called executive engagement and consists of the stages initiation, continued action and maintenance ( Michaelsen and Esch, 2021 ). According to the authors, initiation is the behavioral consequence of a response-outcome mechanism, whereby an individual actively reacts to the appetitive or aversive motivational salience that ensues from the encounter (and processing) of a stimulus. This reaction is propelled by the anticipation of pleasurable feelings (in the case of positive stimuli) or relief (in the case of negative stimuli). The appraisal of experiences as pleasurable or unpleasurable takes place within the endogenous reward system (such as the amygdala), which also encompasses the establishment of associations between an experience and other stimuli ( Michaelsen and Esch, 2021 ). Upon fulfillment of the expectation of a positive experience, said experience engenders a memory that, in turn, spawns an anticipation of a reward from the same activity, thereby enhancing the likelihood of the behavior being reiterated ( Van Cappellen et al., 2018 ). This phenomenon is referred to as reward responsiveness ( Carver and White, 1994 ).

The process of recording memories of experiences, which includes the context in which they occurred, such as the location, time, and social companionship, entails the involvement of the hippocampus ( Nestler, 2001 ; Nestler et al., 2001 ; Esch and Stefano, 2004 , 2010 ). This type of learning can lead to a reciprocal effect: as time passes, associations between positive affect and stimuli that predict it, and memories of it, may endow those stimuli with appetitive salience, making them more likely to capture attention in the future ( Fredrickson and Joiner, 2018 ; Van Cappellen et al., 2018 ). The phenomenon of learning encompasses two critical components, namely conditioning and expectation. In the context of stimulus-driven and goal-directed behavior, the experience of reward is not contingent on whether the stimulus was subjected to cognitive processing to be transformed into a goal. According to Michaelsen and Esch (2021) , the initiation of a new behavior through the activation of endogenous reward triggers a learning process, wherein the association between the new behavior and the experienced positive affect fosters reward expectancy, potentially resulting in continued action. The present study posits that the maintenance of response-outcome associations between pleasurable stimuli and their predictive cues is enhanced by sustained behavioral engagement. In this context, the authors assert that the probability of repetitive behavior, and consequently the degree of engagement therein, is contingent upon the magnitude of endogenous reward elicited by the new behavior ( Michaelsen and Esch, 2021 ). Following the repeated enactment of stimulus-driven or goal-directed behavioral actions, individuals ultimately transition into a maintenance stage, characterized by a sustained operant learning process that leads to habit formation ( Schultz, 2015 ). During this stage, the behavior is executed with regularity, and the assertive salience driven by the motivation and reward systems remains active, thereby strengthening the habitually performed action ( Michaelsen and Esch, 2021 ). The experience of quiescence, calm or contentment associated with the activation of the parasympathetic nervous system and other down-regulatory pathways serves as a powerful motivator for the maintenance of newly adopted behaviors. This state of contentment engenders a state of “non-wanting” with regard to further modifications of behavior ( Michaelsen and Esch, 2021 ). This Model of Engagement is presented in Figure 3 .

The findings can be integrated with the idea of Letzen et al. (2019) , who incorporate putative neurobiological mechanisms contributing to motivation for pain self-management into the Motivational Model for Pain Self-Management ( Jensen et al., 2003 ). The authors propose that an altered function in the mesocorticolimbic function would inhibit behavior change. The goal of this updated model is to determine whether potential neurobiological deficiencies contributing to poor motivation feed into observed non-adherence among patients with chronic pain. The authors hypothesize that mesocorticolimbic function subserves treatment-related learning history, contingency processing, and cost/benefit analysis, and individuals with mesocorticolimbic dysfunction will have lower perceived importance of symptom self-management and poorer self-efficacy for symptom self-management. They also suggest that magnitude of mesocorticolimbic dysfunction will correlate with reported treatment motivation, so that greater dysfunction is associated with poorer readiness for change, and that self-reported treatment motivation moderates the relationship between pre-treatment mesocorticolimbic function and adherence ( Letzen et al., 2019 ). The article also suggests that practice of a pain management strategy will be associated with mesocorticolimbic activity via reinforcement, and individuals with high reinforcement from this practice will have greater motivation for future practice, leading to better adherence ( Letzen et al., 2019 ). While the authors do not discuss pain management behavior as a process, by relating their hypothesis to the Model of Engagement, we can derive that mesocorticolimbic dysfunction would inhibit the progress to the stages contemplation, planning, initiation and/or continued action, and individuals with mesocorticolimbic dysfunction facing these stages within their health behavior change process would need specific support to progress.

4.3. The behavior change resource model

4.3.1. three types of behavior change resources.

The resources individuals need to progress from one health behavior change stage to another, as suggested in a number of health behavior change theories, have been summarized by Cane et al. (2012) , Kwasnicka et al. (2016) , and Carey et al. (2019) . Recently, the resources that facilitate changes in health behavior have been classified by Michaelsen and Esch (2022) into two broad categories, namely the socio-environmental resources external to the individual, and the bio-psychological resources that pertain to the internal state of the individual, with both types being characterized by changeable and non-changeable factors. While behavior change techniques (BCTs) cannot be leveraged to address non-changeable factors such as the weather, their utility is geared to targeting changeable resources ( Michaelsen and Esch, 2022 ).

Based on the distinction between reflective and affective aspects, Michaelsen and Esch (2022) have established a categorization of resources according to how these resources are accessed or generated in the brain. As such, resources are either external (socio-environmental), or internal (bio-psychological), whereby the latter can be either reflective or affective. Reflective resources are accessed, generated or refined through deliberate and effortful cognitive processing, including but not limited to goal-setting and behavioral regulation. In contrast, affective resources, such as emotions and their reinforcing valences, may be promptly elicited by environmental stimuli without the need for volitional engagement. External resources, such as environmental context and material resources, can be externally provided ( Michaelsen and Esch, 2022 ). These three types of changeable resources are depicted in Figure 4 .

Three types of changeable resources ( Michaelsen and Esch, 2022 ).

4.3.2. Behavior change techniques

Behavior change theories provide a foundation for developing effective behavior change techniques (BCTs) to support individuals in modifying their behaviors. Such theories have been employed in diverse ways, including the integration of social interactions based on Bandura’s (1989) Social Cognitive Theory, and assisting patients in generating implementation intentions, drawing on Gollwitzer’s (1999) theory on Implementation Intentions [see Bélanger-Gravel et al. (2013) for a meta-analysis of BCTs based on Gollwitzer’s (1999) theory on Implementation Intentions]. The extant literature has primarily focused on employing behavior change techniques (BCTs) that enhance cognitive resources, such as nutritional or psychological counseling ( Ball et al., 2013 ), or create situations that promote behavior modification, such as supervised walking groups ( Kassavou et al., 2013 ) or financial incentives ( Lee et al., 2019 ). However, these techniques often fail to account for patients’ individual differences in needs and circumstances ( Cecchini et al., 2010 ). The majority of interventions geared toward behavioral change tend to be financially costly and hence, not sustainable over a prolonged period of time or feasible to offer to a wide populace ( Forster et al., 2011 ). Some interventions have also yielded adverse side effects. For instance, monetary rewards for weight loss have been shown to be effective until the remuneration is obtained; however, subsequent weeks have reported higher odds of weight gain ( Paul-Ebhohimhen and Avenell, 2008 ). In contrast to BCTs that mainly, or solely, address cognitive, rational, or circumstantial/environmental resources and domains, modern BCTs primarily build on individual behavioral responses to various motivational stimuli, including affective components of a behavioral decision. Examples are the use of wearables (e.g., Piwek et al., 2016 ) and other digital innovations (e.g., Priesterroth et al., 2019 ) as well as reminders (e.g., Orr and King, 2015 ) among various forms of nudging. Nudging can be understood as shaping decision contexts in a way that encourages a particular behavior (e.g., Hansen and Jespersen, 2013 ) in a playful way through the activation of affective processes in the brain ( Michaelsen and Esch, 2022 ).

Despite a rapid growth in the implementation of interventions, most of these interventions are only successful in the short term, and often fail to demonstrate a significant improvement in the medium and long term (e.g., Marteau et al., 2012 ; International Diabetes Federation [IDF], 2013 ; Ulrich et al., 2016 ; Sainsbury et al., 2019 ). One reason for this may be the lack of comprehensive theories that allow developing successful BCTs. Another reason may be the insufficient use of theories in intervention development. In a scoping review pertaining to nudging interventions, it was discovered that only a quarter of the studies under review took into consideration the purported working mechanisms underlying the effectiveness of the intervention, while three-quarters focused solely on demonstrating its efficacy ( Szaszi et al., 2018 ). The working mechanisms, which involve the connections between BCTs and the targeted domains or resources, i.e., the specific BCT that addresses a particular resource, were elucidated upon by Carey et al. (2019) . A detailed list of resources relevant to behavior change initiation is presented by Michie et al. (2005) , who identified 112 behavior change theories and clustered the domains of behavior change mentioned therein into 12 categories. This Theoretical Domains Framework has been validated by Cane et al. (2012) , who extended the number of categories to 14 domains: “knowledge,” “skills,” “social/professional role and identity,” “beliefs about capabilities,” “optimism,” “beliefs about consequences,” “reinforcement,” “intentions,” “goals,” “memory,” “attention and decision processes,” “environmental context and resources,” “social influences,” “emotion,” and “self-regulation”. Kwasnicka et al. (2016) have summarized the domains that have been presented relevant for behavior change maintenance in their reviewed maintenance theories into five overarching categories; “maintenance motives,” “self-regulation,” “resources,” “habit,” and “environmental and social influences.” These inhibit significant overlaps with Cane et al.’s (2012) 14 domains. An analysis of these resources and the BCTs they are targeted by is presented by Michaelsen and Esch (2022) , as is further explained below.

4.3.3. Clustering BCTs

Based on the triad of behavior change resources, BCTs can be clustered according to how they address these resources and can thereby be described as the functional mechanisms of BCTs. In this way, Michaelsen and Esch (2022) derived three types of BCTs, namely those, that provide external resources (facilitating), those which strengthen internal reflective resources (boosting) and those that activate internal affective resources (nudging).

4.3.3.1. Facilitating

BCTs that focus on providing external resources enable individuals to engage in a desired behavior. These resources, which fall under categories such as “environmental context and resources” and “social influences” in the Theoretical Domains Framework ( Michie et al., 2005 ; Cane et al., 2012 ), can be provided by the individual, another person, or an organization. Illustrative of the aforementioned interventions are strategies that enhance the availability of healthy food alternatives within workplace canteens ( Geaney et al., 2013 ), incentivization programs that offer monetary rewards ( Petry et al., 2013 ), modification of the physical environment through initiatives such as the establishment of public fitness trails ( Cohen et al., 2012 ), and social support mechanisms including the facilitation of assisted walking groups ( Kassavou et al., 2013 ). These techniques can help facilitate behavior change, but the new behavior may not be sustained once the external resources are removed. However, when an individual has established a routine or habit of a specific new behavior, and their motivation to continue is strong, the end of the availability of the BCT may lead to a similar behavior that can be implemented independently of the original BCT. As an example, the termination of an organized walking group may prompt the participants to either sustain their walking activity on an individual basis or establish autonomous walking groups.

4.3.3.2. Boosting

Internal reflective resources can be addressed by involving cognitive processes. BCTs which target theses resources are called boosts. These enjoyable tasks foster the building up or strengthening of internal reflective resources that can support health behavior change. Examples are “beliefs about capabilities,” “beliefs about consequences,” “intentions,” “goals,” and “behavioral regulation” ( Cane et al., 2012 ). These types of interventions may include self-monitoring techniques, such as keeping a diary or practicing mindfulness ( Shomaker et al., 2019 ) to improve attention and awareness. Additionally, interventions like health education ( Gigerenzer et al., 2007 ) and nutritional counseling ( Ball et al., 2013 ) can increase an individual’s understanding of the consequences of their behavior and lead to a willingness to change. There are also other examples of boosting interventions (see, e.g., Grüne-Yanoff and Hertwig, 2016 ) that can similarly lead to an increased readiness to change and intentional implementation of a desired behavior ( Michaelsen and Esch, 2022 ). Having executed the desired behavior by means of one’s own effort, thus, leads to an experience of self-efficacy and the related positive affect. This in turn, can act as a reinforcement to pursue the behavior again. The generated effects potentially persist beyond the intervention, if those resources have become sufficiently strong or stable ( Hertwig and Grüne-Yanoff, 2017 ) and the reward, e.g., through the self-efficacy experience, has been sufficiently intense and therefore been stored in memory.

4.3.3.3. Nudging

Nudges are interventions that guide people toward a certain behavior without limiting their freedom of choice (e.g., Thaler and Sunstein, 2008 ; Alemanno and Sibony, 2015 ; Halpern and Sanders, 2016 ). This is achieved by manipulating aspects of the environment to create cues, stimuli, or triggers that make the desired behavior more appealing. Nudging activates the emotional aspects of decision-making, making the behavior more attractive, enjoyable and intrinsically rewarding, while still allowing individuals to make their own choices ( Michaelsen and Esch, 2021 , 2022 ). Nudging does not require cognitive skills or external resources, but it activates non-conscious or automatic resources to compensate for the lack of external or reflective resources needed for behavior change ( van Gestel et al., 2020 ). Felsen and Reiner (2015) provided a neuroscientific explanation of how nudges exert their effects based on diffusion-to-bound models. In diffusion-to-bound models, it is assumed that a decision is made within a decision space bounded by the available choices. A decision variable that is comprised of multiple factors that influence the decision including current sensory stimulation, stored memory about past experience, and the subjective value of each option, moves further or closer to each bound depending on the strength of these factors until one bound is reached and the corresponding decision is made ( Felsen and Reiner, 2015 ). Nudges can be considered to shift the decision variable toward the bound of the preferred choice, i.e., making the preferred choice more likely ( Felsen and Reiner, 2015 ).

In a systematic review, nudging interventions have been shown to lead to medium size effects in behavior change ( Mertens et al., 2022 ). Examples are variations in the manner of presenting food items ( Bucher et al., 2016 ; Broers et al., 2017 ; van Gestel et al., 2020 ), reminders or reinforcement-based learning schemes ( Orr and King, 2015 ; Yom-Tov et al., 2017 ), lotteries ( Volpp et al., 2008 ), and point systems ( Priesterroth et al., 2019 ), all of which serve to augment the expectation of rewards. The underlying premise is that the magnitude of the anticipated reward is positively correlated with the likelihood of remembering and repeating it ( Esch and Stefano, 2004 ). These nudges are believed to only have temporary effects on behavior, as the increased motivation from the nudge is not sustained once the nudge is removed. For example, a study that used point-of-decision prompts to encourage stair use in a university dormitory found that the effects were not sustained once the prompts were removed ( Howie and Young, 2011 ). However, with frequent repetition, the behavior being nudged may become a habit that continues even after the nudge is removed because of neurobiological learning processes ( Verplanken and Aarts, 1999 ; Lieberoth et al., 2018 ; van Rookhuijzen et al., 2021 ).

4.3.4. Summary of the behavior change resource model

The classification of BCTs based on the behavior change resources they address, may be sufficient to define all existing BCTs and explain their functional mechanism. This means that any BCT, such as those listed in Michie et al. (2013) can be categorized as facilitating, boosting, or nudging. Michaelsen and Esch (2022) have defined resource-driven behavior change as a process that increases the likelihood of a preferred behavior by focusing on the resources needed for that particular behavior to occur. Resource-driven behavior change is accomplished via the implementation of one or a blend of three BCT types that provide external resources (facilitating), build up internal reflective resources (boosting) or activate internal affective resources (nudging). Upon achieving a certain level of efficacy, the BCTs can prompt the initiation or maintenance of a new behavior, which can subsequently yield a positive response (affect) as a reward. Such reward can serve as a cue or stimulus to augment resources, known as vantage resources ( Van Cappellen et al., 2018 ). Exemplifying this notion, a positive affect can function as a reinforcement, thereby acting as a subtle prompting mechanism (nudging), as the experience of a pleasurable affect is deemed vital in predicting the likelihood of subsequent behavioral engagement ( Michaelsen and Esch, 2022 ). Furthermore, successful implementation or repetition of the desired behavior can also reinforce other desirable cognitive and affective states, such as strengthening one’s belief in one’s own abilities (i.e., self-efficacy), which can serve as a boosting strategy. Neurobiologically, these emotional influences on reward experiences and subsequent decisions are mediated in the medial prefrontal cortex, as evidence from human and animal model studies indicates ( Euston et al., 2012 ). Therefore, the functional mechanisms of BCTs are not independent, but interrelated with neurobiological motivation and reward proceedings. Recognizing these multidirectional causal relationships, Michaelsen and Esch (2022) propose a new framework for understanding the functional mechanisms of BCTs, called the behavior change resource model (BCRM). The BCRM and its relation to the Model of Engagement is illustrated in Figure 5 .

Behavior change resource model and its relation to the Model of Engagement ( Michaelsen and Esch, 2021 , 2022 ).

5. Discussion

5.1. understanding health behavior change by motivation and reward mechanisms.

Despite being essential to enhance health, behavior change support is rarely covered by health care systems around the world ( Chauhan et al., 2017 ; Grabovac et al., 2019 ). It is therefore even more important to support the development of interventions, which are powerful in terms of efficiency and preservation of individuals’ autonomy in order to be applied in low-resource settings or independently of political decision-makers. Behavior change has been studied primarily from a social psychology perspective, focusing on cognitive, or reflective, resources and domains relevant to behavior change, including circumstantial/environmental aspects. Neurobiological advances in automatic functioning as well as motivation and reward systems, however, fit neatly into the discussion of how humans act and how behavior can be changed. Integrating motivation and reward mechanisms into the behavior change literature and presenting new models to understand behavior change potentially helps policy makers to identify the necessary and sufficient environmental, economic, and psychological conditions that make healthy choices possible and easy.

A framework with a similar purpose as the behavior change resource model is the behavior change wheel (BCW) ( Michie et al., 2011 ). The BCW is based on a review of 19 behavior change frameworks from various fields (e.g., health, environmental behavior). Its core is a “behavior system” with three essential conditions: capability, opportunity, and motivation. These three conditions can be interpreted as attributes of behavior change resources. They overlap slightly with the categorization of resources made by Michaelsen and Esch (2022) , in the sense that opportunity to behavior change is present when external resources are available, capability is fulfilled when the necessary internal reflective resources are strong enough, and motivation can be seen as an internal affective resource. In the BCW, motivation represents a psychological resource (referring to intrinsic vs. extrinsic motivation) and is not discussed or integrated in terms of its neurobiological underpinnings. In a second step, Michie et al. (2011) developed intervention functions, which are essentially a categorization of BCTs into nine groups: education, persuasion, incentivization, coercion, training, restriction, environmental restructuring, modeling and enablement. The three conditions are then linked to the intervention’s functions without a specific explanation of how the conditions relate to the interventions, i.e., their functional mechanisms are not explained.

5.2. Practical implications of the presented literature

The understanding of the role of motivational salience in health behavior change processes presented by the Model of Engagement could be applied to develop suitable cues and stimuli, e.g., nudges that direct people’s actions into their desired outcome. General examples are fruit placement experiments ( Wansink et al., 2011 ; Hansen et al., 2016 ) or goal formation through social comparison ( Custers and Aarts, 2005 , 2010 ). The findings can also be used in a more differentiated way. Considering the seven stages of the behavior change process, findings imply that different BCTs are required depending on where at the change process an individual is. At the unawareness stage, individuals are not aware that behavior change could contribute to their health status. Therefore, to move to the next stage, individuals require knowledge, insight or possibly a shift in health locus of control from external to more internal (i.e., perceiving the reward from one’s behavior as contingent on one’s own behavior, see Rotter, 1966 , or Cheng et al., 2016 for a meta-analysis on health locus of control and specific health behaviors). Knowledge can be provided, for example, through large-scale policy campaigns. Once an individual is aware that a change in behavior could positively affect their current or future health, a number of other resources may be required to spike interest in behavior change and to move into the motivational engagement phase. For example, hearing or reading about personal experiences from peers (e.g., friends, colleagues) could lead to goal formation. Thus, an individual could be incentivized to talk with peers about their health behavior goals and achievements. To move from the contemplation to the planning stage, information about various offers of health promotion courses could be beneficial. In general, the findings can be applied using these three steps:

• 1. Determining at which stage of their individual change process an individual is.
• 2. Identifying the resource(s) needed to reach the next relevant stage.
• 3. Selecting a BCT that targets the lacking, weak or inactive resource.

Step 1 can be done by applying motivational interviewing ( Rollnick and Miller, 1995 ) or the set of questions developed by Michie et al. (2005) . For step 2, the Theoretical Domains Framework by Cane et al. (2012) or any other framework that lists health behavior change resources, can be used. Once the lacking, weak or inactive resources for successful behavior change have been identified, one or more suitable BCTs can be selected and applied (step 3). Michaelsen and Esch (2022) provide guidance for the third step in their application guide of the BCRM. In this table, the potential target groups for each type of BCT, based on the seven-stage behavior change process described above, are explained and numerous examples for various settings and stakeholders are given. This can assist health/behavior therapists, intervention planners and patients in selecting appropriate measures to achieve the desired health behavior change.

From a public health perspective, the findings of the studies can also contribute to improve health literacy of specific patient groups, e.g., the chronically ill, or specific populations, such as vulnerable families, e.g., in low-income settings. By identifying the needs of these groups in relation to their health, knowing which type of motivation to foster and which resource to provide, strengthen, or activate with which measures, health behavior (e.g., diet) and disease management (e.g., regularly measuring blood sugar) can be improved. Thus, the findings can also be used in prevention and health promotion contexts and potentially help to close the gap in life expectancy between low- and high-income communities.

Furthermore, the findings have the potential to improve intervention effectiveness by better matching the goals of the intervention and the goals of the patients or individuals for whom they are developed. Interventions with a better fit promise better outcomes ( Michie and Prestwich, 2010 ; Prestwich et al., 2014 ; Beard et al., 2019 ; Carey et al., 2019 ) and could therefore be more cost-effective, thereby relying less on scarce financial resources of providers, such as health insurances, local governments, or states.

5.3. Avenues for future research

The results presented in this review are theoretical in nature and therefore require empirical verification. In addition, a number of aspects contained in the studies need to be explored further or discussed in more detail. Some of these points for future research are highlighted in the following.

First, for a number of research strands processed in this review, systematic rather than convenience literature searches could help to substantiate the claims made. While systematic literature searches have been conducted and reviews published on behavior change resources and BCTs (e.g., Cane et al., 2012 ; Prestwich et al., 2014 ; Kwasnicka et al., 2016 ), as well as on behavior change frameworks that served as a basis in the presented analyses (e.g., Kwasnicka et al., 2016 ; Carey et al., 2019 ), conducting new systematic searches and reviews could help to integrate the knowledge gained since the reviews were published. Especially the growing literature on single- or multi-system models (as alternatives to dual-process models) of behavior would benefit from a systematic overview and discussion of the advantages and disadvantages of the views published so far. On this basis, the BCRM potentially requires refinement. The literature on health promotion and behavior change is growing rapidly, so more up-to-date reviews could help to increase the granularity and accuracy of the findings. For example, a future systematic search of the behavior change resource literature could be done to map the resources identified in the literature to the three types of resources generated in this review. A comprehensive list of internal affective, internal reflective and external resources could be the result. This list could then be augmented by neurobiological analyses of the functional mechanisms proposed. In addition, a systematic search and analysis of empirically tested BCTs can result in a list and discussion of BCTs in the light of their functional mechanisms. Providing such lists would facilitate the application of the BCRM such that users could easily identify resources they need and the BCTs that help to address them.

Second, the Model of Engagement could be tested in the “real world” with patients, e.g., in primary care settings, through interviews that help patients to describe how they perceive their own behavior change process, at which stage they assume to be and what they require to move forwards. These descriptions are presumably very diverse and depend on patient characteristics, such as age, disease or cultural background. Qualitative interviews are potentially the right starting point for the development of a more general questionnaire to test the model in a larger population and with specific target groups.

Third, the BCRM, and aspects of it, is proposed based on several implicit hypotheses that need empirical verification. The first hypothesis is that it is possible to determine uniquely the stage in the behavior change process for each individual patient. This hypothesis could be tested through a new questionnaire that builds upon motivational interviewing ( Rollnick and Miller, 1995 ) or the set of questions developed by Michie et al. (2005) with specific reference to the stages developed in the Model of Engagement. The second hypothesis is that motivation and reward systems are required to process along the stages. This could be tested by interviewing individuals who have successfully progressed along their stage process with respect to their own description of their affective states (pleasure, relief, quiescence) that were present while progressing. The third hypothesis is that resources can uniquely be classified into internal affective, internal reflective and external resources. Neuroscientific methods such as brain imaging could be used to analyze the affective and motivational components associated with these resources and potentially involved in various BCTs. The fourth hypothesis is that certain BCTs influence resources through the three described functional mechanisms of facilitating, boosting, or nudging. Qualitative research methodologies may provide a means to expound upon the perceptions of individuals who have undergone specific interventions, in relation to the mechanisms that either support or impede their engagement in behavior change processes.

Future research should explore the specific functional mechanisms of BCTs in more detail. So far, the literature presents only a general understanding of the functional mechanisms of BCTs. The BCRM should be subject to further scrutiny by investigating the intricate affective processes that underlie nudging interventions, through the assessment of affective states before, during, and after decision-making. Gaining insight into the neurobiological mechanisms that underpin the three functional components of the BCRM, and their respective roles in determining motivational salience and reward intensity, would undoubtedly enhance the scientific knowledge base and prove invaluable in the development and implementation of future interventions in everyday settings.

Finally, the application process of the three steps with patients or communities could be accompanied by research on its applicability, feasibility and effectiveness to optimize the model and its features for future use.

6. Conclusion

Previous theories of health behavior change have overemphasized either cognitive, rational, or relational aspects, while largely neglecting the emotional-affective or motivational processes involved in behavior change. Recent literature has integrated neuroscientific evidence and evidence-informed models into the explanations of how health behavior can be changed, short-term and long-term. Thereby, classifications of behavior change resources and behavior change techniques have been developed and the mechanisms of behavior change techniques have been explained. All in all, the literature has potential to be enriched by more neuroscientific evidence, e.g., more details of the functional mechanisms of health behavior change techniques for particular behavior change resources. Other interesting avenues for future research have been described in this review.

Author contributions

MM was responsible for initial literature search, article screening, interpretation of the existing research, conducting the analysis, as well as writing, and critical revision of the manuscript. TE provided support from the idea through the conception and design of the review and also provided suggestions for revising the manuscript. Both authors contributed to the article and approved the submitted version.

Conflict of interest

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

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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• Systematic Review
• Open access
• Published: 30 May 2024

Patient experiences: a qualitative systematic review of chemotherapy adherence

• Amineh Rashidi 1 ,
• Susma Thapa 1 ,
• Wasana Sandamali Kahawaththa Palliya Guruge 1 &
• Shubhpreet Kaur 1  

BMC Cancer volume  24 , Article number:  658 ( 2024 ) Cite this article

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Adherence to chemotherapy treatment is recognized as a crucial health concern, especially in managing cancer patients. Chemotherapy presents challenges for patients, as it can lead to potential side effects that may adversely affect their mobility and overall function. Patients may sometimes neglect to communicate these side effects to health professionals, which can impact treatment management and leave their unresolved needs unaddressed. However, there is limited understanding of how patients’ experiences contribute to improving adherence to chemotherapy treatment and the provision of appropriate support. Therefore, gaining insights into patients’ experiences is crucial for enhancing the accompaniment and support provided during chemotherapy.

This review synthesizes qualitative literature on chemotherapy adherence within the context of patients’ experiences. Data were collected from Medline, Web of Science, CINAHL, PsychINFO, Embase, Scopus, and the Cochrane Library, systematically searched from 2006 to 2023. Keywords and MeSH terms were utilized to identify relevant research published in English. Thirteen articles were included in this review. Five key themes were synthesized from the findings, including positive outlook, receiving support, side effects, concerns about efficacy, and unmet information needs. The review underscores the importance for healthcare providers, particularly nurses, to focus on providing comprehensive information about chemotherapy treatment to patients. Adopting recommended strategies may assist patients in clinical practice settings in enhancing adherence to chemotherapy treatment and improving health outcomes for individuals living with cancer.

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Introduction

Cancer can affect anyone and is recognized as a chronic disease characterized by abnormal cell multiplication in the body [ 1 ]. While cancer is prevalent worldwide, approximately 70% of cancer-related deaths occur in low- to middle-income nations [ 1 ]. Disparities in cancer outcomes are primarily attributed to variations in the accessibility of comprehensive diagnosis and treatment among countries [ 1 , 2 ]. Cancer treatment comes in various forms; however, chemotherapy is the most widely used approach [ 3 ]. Patients undergoing chemotherapy experience both disease-related and treatment-related adverse effects, significantly impacting their quality of life [ 4 ]. Despite these challenges, many cancer patients adhere to treatment in the hope of survival [ 5 ]. However, some studies have shown that concerns about treatment efficacy may hinder treatment adherence [ 6 ]. Adherence is defined as “the extent to which a person’s behaviour aligns with the recommendations of healthcare providers“ [ 7 ]. Additionally, treatment adherence is influenced by the information provided by healthcare professionals following a cancer diagnosis [ 8 ]. Patient experiences suggest that the decision to adhere to treatment is often influenced by personal factors, with family support playing a crucial role [ 8 ]. Furthermore, providing adequate information about chemotherapy, including its benefits and consequences, can help individuals living with cancer gain a better understanding of the advantages associated with adhering to chemotherapy treatment [ 9 ].

Recognizing the importance of adhering to chemotherapy treatment and understanding the impact of individual experiences of chemotherapy adherence would aid in identifying determinants of adherence and non-adherence that are modifiable through effective interventions [ 10 ]. Recently, systematic reviews have focused on experiences and adherence in breast cancer [ 11 ], self-management of chemotherapy in cancer patients [ 12 ], and the influence of medication side effects on adherence [ 13 ]. However, these reviews were narrow in scope, and to date, no review has integrated the findings of qualitative studies designed to explore both positive and negative experiences regarding chemotherapy treatment adherence. This review aims to synthesize the qualitative literature on chemotherapy adherence within the context of patients’ experiences.

This review was conducted in accordance with the Joanna Briggs Institute [ 14 ] guidelines for systemic review involving meta-aggregation. This review was registered in PROSPERO (CRD42021270459).

Search methods

The searches for peer reviewed publications in English from January 2006-September 2023 were conducted by using keywords, medical subject headings (MeSH) terms and Boolean operators ‘AND’ and ‘OR’, which are presented in the table in Appendix 1 . The searches were performed in a systematic manner in core databases such including Embase, Medline, PsycINFO, CINAHL, Web of Science, Cochrane Library, Scopus and the Joanna Briggs Institute (JBI). The search strategy was developed from keywords and medical subject headings (MeSH) terms. Librarian’s support and advice were sought in forming of the search strategies.

Study selection and inclusion criteria

The systematic search was conducted on each database and all articles were exported to Endnote and duplicates records were removed. Then, title and abstract of the full text was screened by two independent reviewers against the inclusion criteria. For this review, populations were patients aged 18 and over with cancer, the phenomenon of interest was experiences on chemotherapy adherence and context was considered as hospitals, communities, rehabilitation centres, outpatient clinics, and residential aged care. All peer-reviewed qualitative study design were also considered for inclusion. Studies included in this review were classified as primary research, published in English since 2006, some intervention implemented to improve adherence to treatment. This review excluded any studies that related to with cancer and mental health condition, animal studies and grey literature.

Quality appraisal and data extraction

The JBI Qualitative Assessment and Review Instrument for qualitative studies was used to assess the methodological quality of the included studies, which was conducted by the primary and second reviewers independently. There was no disagreement between the reviews. The qualitative data on objectives, study population, context, study methods, and the phenomena of interest and findings form the included studies were extracted.

Data synthesis

The meta-aggregation approach was used to combine the results with similar meaning. The primary and secondary reviewers created categories based on the meanings and concept. These categories were supported by direct quotations from participants. The findings were assess based on three levels of evidence, including unequivocal, credible, and unsupported [ 15 , 16 ]. Findings with no quotation were not considered for synthesis in this review. The categories and findings were also discussed by the third and fourth reviewers until a consensus was reached. The review was approved by the Edith Cowan University Human Research Ethics Committee (2021–02896).

Study inclusion

A total of 4145 records were identified through a systematic search. Duplicates ( n  = 647) were excluded. Two independent reviewers conducted screening process. The remaining articles ( n  = 3498) were examined for title and abstract screening. Then, the full text screening conducted, yielded 13 articles to be included in the final synthesis see Appendix 2 .

Methodological quality of included studies

All included qualitative studies scored between 7 and 9, which is displayed in Appendix 3 . The congruity between the research methodology and the research question or objectives, followed by applying appropriate data collection and data analysis were observed in all included studies. Only one study [ 17 ] indicated the researcher’s statement regarding cultural or theoretical perspectives. Three studies [ 18 , 19 , 20 ] identified the influence of the researcher on the research and vice-versa.

Characteristics of included studies

Most of studies conducted semi-structured and in-depth interviews, one study used narrative stories [ 19 ], one study used focus group discussion [ 21 ], and one study combined focus group and interview [ 22 ] to collect data. All studies conducted outpatient’s clinic, community, or hospital settings [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. The study characteristics presented in Appendix 4 .

Review findings

Eighteen findings were extracted and synthesised into five categories: positive outlook, support, side effects, concern about efficacy and unmet information needs.

Positive outlook

Five studies discussed the link between positivity and hope and chemotherapy adherence [ 19 , 20 , 23 , 27 , 28 ]. Five studies commented that feeling positive and avoid the negativity and worry could encourage people to adhere in their mindset chemotherapy: “ I think the main thing for me was just keeping a positive attitude and not worrying, not letting myself worry about it ” [ 20 ]. Participants also considered the positive thoughts as a coping mechanism, that would help them to adhere and complete chemotherapy: “ I’m just real positive on how everything is going. I’m confident in the chemo, and I’m hoping to get out of her soon ” [ 23 ]. Viewing chemotherapy as part of their treatment regimen and having awareness of negative consequences of non-adherence to chemotherapy encouraged them to adhere chemotherapy: “ If I do not take medicine, I do not think I will be able to live ” [ 28 ]. Adhering chemotherapy was described as a survivor tool which helped people to control cancer-related symptoms: “ it is what is going to restore me. If it wasn’t this treatment, maybe I wasn’t here talking to you. So, I have to focus in what he is going to give me, life !” [ 27 ]. Similarly, people accepted the medical facts and prevent their life from worsening; “ without the treatment, it goes the wrong way. It is hard, but I have accepted it from the beginning, yes. This is how it is. I cannot do anything about it. Just have to accept it ” [ 19 ].

Finding from six studies contributed to this category [ 20 , 21 , 23 , 24 , 25 , 29 ]. Providing support from families and friends most important to the people. Receiving support from family members enhanced a sense responsibility towards their families, as they believed to survive for their family even if suffered: “ yes, I just thought that if something comes back again and I say no, then I have to look my family and friends in the eye and say I could have prevented it, perhaps. Now, if something comes back again, I can say I did everything I could. Cancer is bad enough without someone saying: It’s your own fault!!” [ 29 ]. Also, emotional support from family was described as important in helping and meeting their needs, and through facilitation helped people to adhere chemotherapy: “ people who genuinely mean the support that they’re giving […] just the pure joy on my daughter’s face for helping me. she was there day and night for me if I needed it, and that I think is the main thing not to have someone begrudgingly looking after you ” [ 20 ]. Another study discussed the role family, friends and social media as the best source of support during their treatment to adhere and continue “ I have tons of friends on Facebook, believe it or not, and it’s amazing how many people are supportive in that way, you know, just sending get-well wishes. I can’t imagine going through this like 10 years ago whenever stuff like that wasn’t around ” [ 23 ]. Receiving support from social workers was particularly helpful during chemotherapy in encouraging adherence to the chemotherapy: “ the social worker told me that love is courage. That was a huge encouragement, and I began to encourage myself ” [ 25 ].

Side effects

Findings from five studies informed this category [ 17 , 21 , 22 , 25 , 26 ]. Physical side effects were described by some as the most unpleasure experience: “ the side effects were very uncomfortable. I felt pain, fatigue, nausea, and dizziness that limited my daily activities. Sometimes, I was thinking about not keeping to my chemotherapy schedule due to those side effect ” [ 17 ]. The impact of side effects affected peoples’ ability to maintain their independence and self-care: “ I couldn’t walk because I didn’t have the energy, but I wouldn’t have dared to go out because the diarrhoea was so bad. Sometimes I couldn’t even get to the toilet; that’s very embarrassing because you feel like you’re a baby ” [ 26 ]. Some perceived that this resulted in being unable to perform independently: “ I was incredibly weak and then you still have to do things and you can’t manage it ” [ 22 ]. These side effect also decreased their quality of life “ I felt nauseated whenever I smelled food. I simply had no appetite when food was placed in front of me. I lost my sense of taste. Food had no taste anymore ” [ 25 ]. Although, the side effects impacted on patients´ leisure and free-time activities, they continued to undertake treatment: “ I had to give up doing the things I liked the most, such as going for walks or going to the beach. Routines, daily life in general were affected ” [ 21 ].

Concern about efficacy

Findings form four studies informed this category [ 17 , 18 , 24 , 28 ]. Although being concerned about the efficacy of the chemotherapy and whether or not chemotherapy treatment would be successful, one participant who undertook treatment described: “the efficacy is not so great. It is said to expect about 10% improvement, but I assume that it declines over time ” [ 28 ]. People were worried that such treatment could not cure their cancer and that their body suffered more due to the disease: “ I was really worried about my treatment effectiveness, and I will die shortly ” [ 17 ]. There were doubts expressed about remaining the cancer in the body after chemotherapy: “ there’s always sort of hidden worries in there that whilst they’re not actually taking the tumour away, then you’re wondering whether it’s getting bigger or what’s happening to it, whether it’s spreading or whatever, you know ” [ 24 ]. Uncertainty around the outcome of such treatment, or whether recovering from cancer or not was described as: “it makes you feel confused. You don’t know whether you are going to get better or else whether the illness is going to drag along further” [ 18 ].

Unmet information needs

Five studies contributed to this category [ 17 , 21 , 22 , 23 , 26 ]. The need for adequate information to assimilate information and provide more clarity when discussing complex information were described. Providing information from clinicians was described as minimal: “they explain everything to you and show you the statistics, then you’re supposed to take it all on-board. You could probably go a little bit slower with the different kinds of chemo and grappling with these statistics” [ 26 ]. People also used the internet search to gain information about their cancer or treatments, “I’ve done it (consult google), but I stopped right away because there’s so much information and you don’t know whether it’s true or not ” [ 21 ]. The need to receive from their clinicians to obtain clearer information was described as” I look a lot of stuff up online because it is not explained to me by the team here at the hospital ” [ 23 ]. Feeling overwhelmed with the volume of information could inhibit people to gain a better understanding of chemotherapy treatment and its relevant information: “ you don’t absorb everything that’s being said and an awful lot of information is given to you ” [ 22 ]. People stated that the need to know more information about their cancer, as they were never dared to ask from their clinicians: “ I am a low educated person and come from a rural area; I just follow the doctor’s advice for my health, and I do not dare to ask anything” [ 17 ].

The purpose of this review was to explore patient’s experiences about the chemotherapy adherence. After finalizing the searches, thirteen papers were included in this review that met the inclusion criteria.

The findings of the present review suggest that social support is a crucial element in people’s positive experiences of adhering to chemotherapy. Such support can lead to positive outcomes by providing consistent and timely assistance from family members or healthcare professionals, who play vital roles in maintaining chemotherapy adherence [ 30 ]. Consistent with our study, previous research has highlighted the significant role of family members in offering emotional and physical support, which helps individuals cope better with chemotherapy treatment [ 31 , 32 ]. However, while receiving support from family members reinforces individuals’ sense of responsibility in managing their treatment and their family, it also instils a desire to survive cancer and undergo chemotherapy. One study found that assuming self-responsibility empowers patients undergoing chemotherapy, as they feel a sense of control over their therapy and are less dependent on family members or healthcare professionals [ 33 ]. A qualitative systematic review reported that support from family members enables patients to become more proactive and effective in adhering to their treatment plan [ 34 ]. This review highlights the importance of maintaining a positive outlook and rational beliefs as essential components of chemotherapy adherence. Positive thinking helps individuals recognize their role in chemotherapy treatment and cope more effectively with their illness by accepting it as part of their treatment regimen and viewing it as a tool for survival. This finding is supported by previous studies indicating that positivity and positive affirmations play critical roles in helping individuals adapt to their reality and construct attitudes conducive to chemotherapy adherence [ 35 , 36 ]. Similarly, maintaining a positive mindset can foster more favourable thoughts regarding chemotherapy adherence, ultimately enhancing adherence and overall well-being [ 37 ].

This review identified side effects as a significant negative aspect of the chemotherapy experience, with individuals expressing concerns about how these side effects affected their ability to perform personal self-care tasks and maintain independent living in their daily lives. Previous studies have shown that participants with a history of chemotherapy drug side effects were less likely to adhere to their treatment regimen due to worsening symptoms, which increased the burden of medication side effects [ 38 , 39 ]. For instance, cancer patients who experienced minimal side effects from chemotherapy were at least 3.5 times more likely to adhere to their treatment plan compared to those who experienced side effects [ 40 ]. Despite experiencing side effects, patients were generally willing to accept and adhere to their treatment program, although one study in this review indicated that side effects made some patients unable to maintain treatment adherence. Side effects also decreased quality of life and imposed restrictions on lifestyle, as seen in another study where adverse effects limited individuals in fulfilling daily commitments and returning to normal levels of functioning [ 41 ]. Additionally, unmet needs regarding information on patients’ needs and expectations were common. Healthcare professionals were considered the most important source of information, followed by consultation with the internet. Providing information from healthcare professionals, particularly nurses, can support patients effectively and reinforce treatment adherence [ 42 , 43 ]. Chemotherapy patients often preferred to base their decisions on the recommendations of their care providers and required adequate information retention. Related studies have highlighted that unmet needs among cancer patients are known factors associated with chemotherapy adherence, emphasizing the importance of providing precise information and delivering it by healthcare professionals to improve adherence [ 44 , 45 ]. Doubts about the efficacy of chemotherapy treatment, as the disease may remain latent, were considered negative experiences. Despite these doubts, patients continued their treatment, echoing findings from a study where doubts regarding efficacy were identified as a main concern for chemotherapy adherence. Further research is needed to understand how doubts about treatment efficacy can still encourage patients to adhere to chemotherapy treatment.

Strengths and limitation

The strength of this review lies in its comprehensive search strategy across databases to select appropriate articles. Additionally, the use of JBI guidelines provided a comprehensive and rigorous methodological approach in conducting this review. However, the exclusion of non-English studies, quantitative studies, and studies involving adolescents and children may limit the generalizability of the findings. Furthermore, this review focuses solely on chemotherapy treatment and does not encompass other types of cancer treatment.

Conclusion and practical implications

Based on the discussion of the findings, it is evident that maintaining a positive mentality and receiving social support can enhance chemotherapy adherence. Conversely, experiencing treatment side effects, concerns about efficacy, and unmet information needs may lead to lower adherence. These findings present an opportunity for healthcare professionals, particularly nurses, to develop standardized approaches aimed at facilitating chemotherapy treatment adherence, with a focus on providing comprehensive information. By assessing patients’ needs, healthcare professionals can tailor approaches to promote chemotherapy adherence and improve the survival rates of people living with cancer. Raising awareness and providing education about cancer and chemotherapy treatment can enhance patients’ understanding of the disease and its treatment options. Utilizing videos and reading materials in outpatient clinics and pharmacy settings can broaden the reach of educational efforts. Policy makers and healthcare providers can collaborate to develop sustainable patient education models to optimize patient outcomes in the context of cancer care. A deeper understanding of individual processes related to chemotherapy adherence is necessary to plan the implementation of interventions effectively. Further research examining the experiences of both adherent and non-adherent patients is essential to gain a comprehensive understanding of this topic.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. on our submission system as well.

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First author (AR) and second author (ST) conceived the review and the second author oversight for all stages of the review provided by the second author. All authors (AR), (ST), (WG) and (SK) undertook the literature search. Data extraction, screening the included papers and quality appraisal were undertaken by all authors (AR), (ST), (WG) and (SK). First and second authors (AR) and (ST) analysed the data and wrote the first draft of the manuscript and revised the manuscript and all authors (AR), (ST), (WG) and (SK) approved the final version of the manuscript.

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The review was approved by the Edith Cowan University Human Research Ethics Committee (2021–02896). A proposal for the systematic review was assessed by the Edith Cowan University Human Research Ethics Committee and deemed not appropriate for full ethical review. However, a Data Management Plan (2021-02896-RASHIDI) was approved and monitored as part of this procedure. Raw data was extracted from the published manuscripts and authors could not identify individual participants during or after this process.

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Rashidi, A., Thapa, S., Kahawaththa Palliya Guruge, W. et al. Patient experiences: a qualitative systematic review of chemotherapy adherence. BMC Cancer 24 , 658 (2024). https://doi.org/10.1186/s12885-024-12353-z

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• Suwimol Prusmetikul 1 , 3 &
• Sarah Whitehorn 1  

BMC Medical Education volume  24 , Article number:  597 ( 2024 ) Cite this article

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Introduction

Solving disparities in assessments is crucial to a successful surgical training programme. The first step in levelling these inequalities is recognising in what contexts they occur, and what protected characteristics are potentially implicated.

This scoping review was based on Arksey & O’Malley’s guiding principles. OVID and Embase were used to identify articles, which were then screened by three reviewers.

From an initial 358 articles, 53 reported on the presence of differential attainment in postgraduate surgical assessments. The majority were quantitative studies (77.4%), using retrospective designs. 11.3% were qualitative. Differential attainment affects a varied range of protected characteristics. The characteristics most likely to be investigated were gender (85%), ethnicity (37%) and socioeconomic background (7.5%). Evidence of inequalities are present in many types of assessment, including: academic achievements, assessments of progression in training, workplace-based assessments, logs of surgical experience and tests of technical skills.

Attainment gaps have been demonstrated in many types of assessment, including supposedly “objective” written assessments and at revalidation. Further research is necessary to delineate the most effective methods to eliminate bias in higher surgical training. Surgical curriculum providers should be informed by the available literature on inequalities in surgical training, as well as other neighbouring specialties such as medicine or general practice, when designing assessments and considering how to mitigate for potential causes of differential attainment.

Peer Review reports

Diversity in the surgical workforce has been a hot topic for the last 10 years, increasing in traction following the BlackLivesMatter movement in 2016 [ 1 ]. In the UK this culminated in publication of the Kennedy report in 2021 [ 2 ]. Before this the focus was principally on gender imbalance in surgery, with the 2010 Surgical Workforce report only reporting gender percentages by speciality, with no comment on racial profile, sexuality distribution, disability occurrence, or socioeconomic background [ 3 ].

Gender is not the only protected characteristic deserving of equity in surgery; many groups find themselves at a disadvantage during postgraduate surgical examinations [ 4 ] and at revalidation [ 5 ]. This phenomenon is termed ‘differential attainment’ (DA), in which disparities in educational outcomes, progression rates, or achievements between groups with protected characteristics occur [ 4 ]. This may be due to the assessors’ subconscious bias, or a deficit in training and education before assessment.

One of the four pillars of medical ethics is “justice”, emphasising that healthcare should be provided in a fair, equitable, and ethical manner, benefiting all individuals and promoting the well-being of society as a whole. This applies not only to our patients but also to our colleagues; training should be provided in a fair, equitable, and ethical manner, benefiting all. By applying the principle of justice to surgical trainees, we can create an environment that is supportive, inclusive, and conducive to professional growth and well-being.

A diverse consultant body is crucial for providing high-quality healthcare to a diverse patient population. It has been shown that patients are happier when cared for by a doctor with the same ethnic background [ 6 ]. Takeshita et al. [ 6 ] proposed this is due to a greater likelihood of mutual understanding of cultural values, beliefs, and preferences and is therefore more likely to cultivate a trusting relationship, leading to accurate diagnosis, treatment adherence and improved patient understanding. As such, ensuring that all trainees are justly educated and assessed throughout their training may contribute to improving patient care by diversifying the consultant body.

Surgery is well known to have its own specific culture, language, and social rules which are unique even within the world of medicine [ 7 , 8 ]. Through training, graduates develop into surgeons, distinct from other physicians and practitioners [ 9 ]. As such, research conducted in other medical domains is not automatically applicable to surgery, and behavioural interventions focused on reducing or eliminating bias in training need to be tailored specifically to surgical settings.

Consequently, it’s important that the surgical community asks the questions:

Does DA exist in postgraduate surgical training, and to what extent?

Why does DA occur?

What groups or assessments are under-researched?

How can we apply this knowledge, or acquire new knowledge, to provide equity for trainees?

The following scoping review hopes to provide the surgical community with robust answers for future of surgical training.

Aims and research question

The aim of this scoping review is to understand the breadth of research about the presence of DA in postgraduate surgical education and to determine themes pertaining to causes of inequalities. A scoping review was chosen to provide a means to map the available literature, including published peer-reviewed primary research and grey literature.

Following the methodological framework set out by Arksey and O’Malley [ 10 ], our research was intended to characterise the literature addressing DA in HST, including Ophthalmology, Obstetrics & Gynaecology (O&G). We included literature from English-language speaking countries, including the UK and USA.

Search strategy

We used search terms tailored to our target population characteristics (e.g., gender, ethnicity), concept (i.e., DA) and context (i.e., assessment in postgraduate surgical education). Medline and Embase were searched with the assistance of a research librarian, with addition of synonyms. This was conducted in May 2023, and was exported to Microsoft Excel for further review. The reference lists of included articles were also searched to find any relevant data sources that had yet to be considered. In addition, to identify grey literature, a search was performed for the term “differential attainment” and “disparity” on the relevant stakeholders’ websites (See supplemental Table 1 for full listing). Stakeholders were included on the basis of their involvement in governance or training of surgical trainees.

Study selection

To start we excluded conference abstracts that were subsequently published as full papers to avoid duplications ( n  = 337). After an initial screen by title to exclude obviously irrelevant articles, articles were filtered to meet our inclusion and exclusion criteria (Table  1 ). The remaining articles ( n  = 47) were then reviewed in their entirety, with the addition of five reports found in grey literature. Following the screening process, 45 studies were recruited for scoping review (Fig.  1 ).

Charting the data

The extracted data included literature title, authors, year of publication, country of study, study design, population characteristic, case number, context, type of assessment, research question and main findings (Appendix 1). Extraction was performed initially by a single author and then subsequently by a second author to ensure thorough review. Group discussion was conducted in case of any disagreements. As charting occurred, papers were discovered within reference lists of included studies which were eligible for inclusion; these were assimilated into the data charting table and included in the data extraction ( n  = 8).

Collating, summarizing and reporting the results

The included studies were not formally assessed in their quality or risk of bias, consistent with a scoping review approach [ 10 ]. However, group discussion was conducted during charting to aid argumentation and identify themes and trends.

We conducted a descriptive numerical summary to describe the characteristics of included studies. Then thematic analysis was implemented to examine key details and organise the attainment quality and population characteristics based on their description. The coding of themes was an iterative process and involved discussion between authors, to identify and refine codes to group into themes.

We categorised the main themes as gender, ethnicity, country of graduation, individual and family background in education, socioeconomic background, age, and disability. The number of articles in each theme is demonstrated in Table  2 . Data was reviewed and organised into subtopics based on assessment types included: academic achievement (e.g., MRCS, FRCS), assessments for progression (e.g., ARCP), workplace-based assessment (e.g., EPA, feedback), surgical experience (e.g., case volume), and technical skills (e.g., visuo-spatial tasks).

PRISMA flow diagram

44 articles defined the number of included participants (89,399 participants in total; range of participants across individual studies 16–34,755). Two articles reported the number of included studies for their meta-analysis (18 and 63 included articles respectively). Two reports from grey literature did not define the number of participants they included in their analysis. The characteristics of the included articles are displayed in Table  2 .

Growth in published literature on differential attainment over the past 40 years

Academic achievement

In the American Board of Surgery Certifying Exam (ABSCE), Maker [ 11 ] found there to be no significant differences in terms of gender when comparing those who passed on their first attempt and those who did not in general surgery training, a finding supported by Ong et al. [ 12 ]. Pico et al. [ 13 ] reported that in Orthopaedic training, Orthopaedic In-Training Examination (OITE) and American Board of Orthopaedic Surgery (ABOS) Part 1 scores were similar between genders, but that female trainees took more attempts in order to pass. In the UK, two studies reported significantly lower Membership of the Royal College of Surgeons (MRCS) pass rates for female trainees compared to males [ 4 , 14 ]. However, Robinson et al. [ 15 ] presented no significant gender differences in MRCS success rates. A study assessing Fellowship of the Royal College of Surgeons (FRCS) examination results found no significant gender disparities in pass rates [ 16 ]. In MRCOG examination, no significant gender differences were found in Part 1 scores, but women had higher pass rates and scores in Part 2 [ 17 ].

Assessment for Progression

ARCP is the annual process of revalidation that UK doctors must perform to progress through training. A satisfactory progress outcome (“outcome 1”) allows trainees to advance through to the next training year, whereas non-satisfactory outcomes (“2–5”) suggest inadequate progress and recommends solutions, such as further time in training or being released from the training programme. Two studies reported that women received 60% more non-satisfactory outcomes than men [ 16 , 18 ]. In contrast, in O&G men had higher non-satisfactory ARCP outcomes without explicit reasons for this given [ 19 ].

Regarding Milestone evaluations based from the US Accreditation Council for Graduate Medical Education (ACGME), Anderson et al. [ 20 ] reported men had higher ratings of knowledge of diseases at postgraduate year 5 (PGY-5), while women had lower mean score achievements. This was similar to another study finding that men and women had similar competencies at PGY-1 to 3, and that it was only at PGY-5 that women were evaluated lower than men [ 21 ]. However, Kwasny et al. [ 22 ] found no difference in trainers’ ratings between genders, but women self-rated themselves lower. Salles et al. [ 23 ] demonstrated significant improvement in scoring in women following a value-affirmation intervention, while this intervention did not affect men.

Workplace-based Assessment

Galvin et al. [ 24 ] reported better evaluation scores from nurses for PGY-2 male trainees, while females received fewer positive and more negative comments. Gerull et al. [ 25 ] demonstrated men received compliments with superlatives or standout words, whereas women were more likely to receive compliments with mitigating phrases (e.g., excellent vs. quite competent).

Hayward et al. [ 26 ] investigated assessment of attributes of clinical performance (ethics, judgement, technical skills, knowledge and interpersonal skills) and found similar scoring between genders.

Several authors have studied autonomy given to trainees in theatre [ 27 , 28 , 29 , 30 , 31 ]. Two groups found no difference in level of granted autonomy between genders but that women rated lower perceived autonomy on self-evaluation [ 27 , 28 ]. Other studies found that assessors consistently gave female trainees lower autonomy ratings, but only in one paper was this replicated in lower performance scores [ 29 , 30 , 31 ].

Padilla et al. [ 32 ] reported no difference in entrustable professional activity assessment (EPA) levels between genders, yet women rated themselves much lower, which they regarded as evidence of imposter syndrome amongst female trainees. Cooney et al. [ 33 ] found that male trainers scored EPAs for women significantly lower than men, while female trainers rated both genders similarly. Conversely, Roshan et al. [ 34 ] found that male assessors were more positive in feedback comments to female trainees than male trainees, whereas they also found that comments from female assessors were comparable for each gender.

Surgical Experience

Gong et al. [ 35 ] found significantly fewer cataract operations were performed by women in ophthalmology residency programmes, which they suggested could be due to trainers being more likely to give cases to male trainees. Female trainees also participated in fewer robotic colorectal procedures, with less operative time on the robotic console afforded [ 36 ]. Similarly, a systematic review highlighted female trainees in various specialties performed fewer cases per week and potentially had limited access to training facilities [ 37 ]. Eruchalu et al. [ 38 ] found that female trainees performed fewer cases, that is, until gender parity was reached, after which case logs were equivalent.

Technical skills

Antonoff et al. [ 39 ] found higher scores for men in coronary anastomosis skills, with women receiving more “fail” assessments. Dill-Macky et al. [ 40 ] analysed laparoscopic skill assessment using blinded videos of trainees and unblinded assessments. While there was no difference in blinded scores between genders, when comparing blinded and unblinded scores individually, assessors were less likely to agree on the scores of women compared to men. However, another study about laparoscopic skills by Skjold-Ødegaard et al. [ 41 ] reported higher performance scores in female residents, particularly when rated by women. The lowest score was shown in male trainees rated by men. While some studies showed disparities in assessment, several studies reported no difference in technical skill assessments (arthroscopic, knot tying, and suturing skills) between genders [ 42 , 43 , 44 , 45 , 46 ].

Several studies investigated trainees’ abilities to complete isolated tasks associated with surgical skills. In laparoscopic tasks, men were initially more skilful in peg transfer and intracorporeal knot tying than women. Following training, the performance was not different between genders [ 47 ]. A study on microsurgical skills reported better initial visual-spatial and perceptual ability in men, while women had better fine motor psychomotor ability. However, these differences were not significant, and all trainees improved significantly after training [ 48 ]. A study by Milam et al. [ 49 ] revealed men performed better in mental rotation tasks and women outperformed in working memory. They hypothesised that female trainees would experience stereotype threat, fear of being reduced to a stereotype, which would impair their performance. They found no evidence of stereotype threat influencing female performance, disproving their hypothesis, a finding supported by Myers et al. [ 50 ].

Ethnicity and country of graduation

Most papers reported ethnicity and country of graduation concurrently, for example grouping trainees as White UK graduates (WUKG), Black and minority ethnicity UK graduates (BME UKG), and international medical graduates (IMG). Therefore, these areas will be addressed together in the following section.

When assessing the likelihood of passing American Board of Surgery (ABS) examinations on first attempt, Yeo et al. [ 51 ] found that White trainees were more likely than non-White. They found that the influence of ethnicity was more significant in the end-of-training certifying exam than in the start-of-training qualifying exam. This finding was corroborated in a study of both the OITE and ABOS certifying exam, suggesting widening inequalities during training [ 52 ].

Two UK-based studies reported significantly higher MRCS pass rates in White trainees compared to BMEs [ 4 , 14 ]. BMEs were less likely to pass MRCS Part A and B, though this was not true for Part A when variations in socioeconomic background were corrected for [ 14 ]. However, Robinson et al. [ 53 ] found no difference in MRCS pass rates based on ethnicity. Another study by Robinson et al. [ 15 ] demonstrated similar pass rates between WUKGs and BME UKGs, but IMGs had significantly lower pass rates than all UKGs. The FRCS pass rates of WUKGs, BME UKGs and IMGs were 76.9%, 52.9%, and 53.9%, respectively, though these percentages were not statistically significantly different [ 16 ].

There was no difference in MRCOG results based on ethnicity, but higher success rates were found in UKGs [ 19 ]. In FRCOphth, WUKGs had a pass rate of 70%, higher than other groups of trainees, with a pass rate of only 45% for White IMGs [ 52 ].

By gathering data from training programmes reporting little to no DA due to ethnicity, Roe et al. [ 54 ] were able to provide a list of factors they felt were protective against DA, such as having supportive supervisors and developing peer networks.

Assessment for progression

RCOphth [ 55 ] found higher rates of satisfactory ARCP outcomes for WUKGs compared to BME UKGs, followed by IMGs. RCOG [ 19 ] discovered higher rates of non-satisfactory ARCP outcomes from non-UK graduates, particularly amongst BMEs and those from the European Economic Area (EEA). Tiffin et al. [ 56 ] considered the difference in experience between UK graduates and UK nationals whose primary medical qualification was gained outside of the UK, and found that the latter were more likely to receive a non-satisfactory ARCP outcome, even when compared to non-UK nationals.

Woolf et al. [ 57 ] explored reasons behind DA by conducting interview studies with trainees. They investigated trainees’ perceptions of fairness in evaluation and found that trainees felt relationships developed with colleagues who gave feedback could affect ARCP results, and might be challenging for BME UKGs and IMGs who have less in common with their trainers.

Workplace-based assessment

Brooks et al. [ 58 ] surveyed the prevalence of microaggressions against Black orthopaedic surgeons during assessment and found 87% of participants experienced some level of racial discrimination during workplace-based performance feedback. Black women reported having more racially focused and devaluing statements from their seniors than men.

Surgical experience

Eruchalu et al. [ 38 ] found that white trainees performed more major surgical cases and more cases as a supervisor than did their BME counterparts.

Dill-Macky et al. [ 40 ] reported no significant difference in laparoscopic surgery assessments between ethnicities.

Individual and family background in education

Two studies [ 4 , 16 ] concentrated on educational background, considering factors such as parental occupation and attendance of a fee-paying school. MRCS part A pass rate was significantly higher for trainees for whom Medicine was their first Degree, those with university-educated parents, higher POLAR (Participation In Local Areas classification group) quintile, and those from fee-paying schools. Higher part B pass rate was associated with graduating from non-Graduate Entry Medicine programmes and parents with managerial or professional occupations [ 4 ]. Trainees with higher degrees were associated with an almost fivefold increase in FRCS success and seven times more scientific publications than their counterparts [ 16 ].

Socioeconomic background

Two studies used Index of Multiple Deprivation quintile, the official measure of relative deprivation in England based on geographical areas for grading socioeconomic level. The area was defined at the time of medical school application. Deprivation quintiles (DQ) were calculated, ranging from DQ1 (most deprived) to DQ5 (least deprived) [ 4 , 14 ].

Trainees with history of less deprivation were associated with higher MRCS part A pass rate. More success in part B was associated with history of no requirement for income support and less deprived areas [ 4 ]. Trainees from DQ1 and DQ2 had lower pass rates and higher number of attempts to pass [ 14 ]. A general trend of better outcomes in examination was found from O&G trainees in less deprived quintiles [ 19 ].

Trainees from DQ1 and DQ2 received significantly more non-satisfactory ARCP outcomes (24.4%) than DQ4 and DQ5 (14.2%) [ 14 ].

Trainees who graduated at age less than 29 years old were more likely to pass MRCS than their counterparts [ 4 ].

Authors [ 18 , 56 ] found that older trainees received more non-satisfactory ARCP outcomes. Likewise, there was higher percentage of non-satisfactory ARCP outcomes in O&G trainees aged over 45 compared with those aged 25–29 regardless of gender [ 19 ].

Trainees with disability had significantly lower pass rates in MRCS part A compared to candidates without disability. However, the difference was not significant for part B [ 59 ].

What have we learnt from the literature?

It is heartening to note the recent increase in interest in DA (27 studies in the last 4 years, compared to 26 in the preceding 40) (Fig.  2 ). The vast majority (77%) of studies are quantitative, based in the US or UK (89%), focus on gender (85%) and relate to clinical assessments (51%) rather than examination results. Therefore, the surgical community has invested primarily in researching the experience of women in the USA and UK.

Interestingly, a report by RCOG [ 19 ] showed that men were more likely to receive non-satisfactory ARCP outcomes than women, and a study by Rushd et al. [ 17 ] found that women were more likely to pass part 2 of MRCOG than men. This may be because within O&G men are the “out-group” (a social group or category characterised by marginalisation or exclusion by the dominant cultural group) as 75% of O&G trainees are female [ 60 ].

This contrasts with other specialities in which men are the in-group and women are seen to underperform. Outside of O&G, in comparison to men, women are less likely to pass MRCS [ 4 , 14 ], receive satisfactory ARCP outcome [ 16 , 18 ], or receive positive feedback [ 24 ], whilst not performing the same number of procedures as men [ 34 , 35 ]. This often leads to poor self-confidence in women [ 32 ], which can then worsen performance [ 21 ].

It proves difficult to comment on DA for many groups due to a lack of evidence. The current research suggests that being older, having a disability, graduate entry to medicine, low parental education, and living in a lower socioeconomic area at the time of entering medical school are all associated with lower MRCS pass rates. Being older and having a lower socioeconomic background are also associated with non-satisfactory ARCP outcomes, slowing progression through training.

These characteristics may provide a compounding negative effect – for example having a previous degree will automatically make a trainee older, and living in a lower socioeconomic area makes it more likely their parents will have a non-professional job and not hold a higher degree. When multiple protected characteristics interact to produce a compounded negative effect for a person, it is often referred to as “intersectional discrimination” or “intersectionality” [ 61 ]. This is a concept which remains underrepresented in the current literature.

The literature is not yet in agreement over the presence of DA due to ethnicity. There are many studies that report perceived discrimination, however the data for exam and clinical assessment outcomes is equivocal. This may be due to the fluctuating nature of in-groups and out-groups, and multiple intersecting characteristics. Despite this, the lived experience of BME surgeons should not be ignored and requires further investigation.

What are the gaps in the literature?

The overwhelming majority of literature exploring DA addresses issues of gender, ethnicity or country of medical qualification. Whilst bias related to these characteristics is crucial to recognise, studies into other protected characteristics are few and far between. The only paper on disability reported striking differences in attainment between disabled and non-disabled registrars [ 59 ]. There has also been increased awareness about neurodiversity amongst doctors and yet an exploration into the experience of neurodiverse surgeons and their progress through training has yet to be published [ 62 ].

The implications of being LGBTQ + in surgical training have not been recognised nor formally addressed in the literature. Promisingly, the experiences of LGBTQ + medical students have been recognised at an undergraduate level, so one can hope that this will be translated into postgraduate education [ 63 , 64 ]. While this is deeply entwined with experiences of gender discrimination, it is an important characteristic that the surgical community would benefit from addressing, along with disability. To a lesser extent, the effect of socioeconomic background and age have also been overlooked.

Characterising trainees for the purpose of research

Ethnicity is deeply personal, self-defined, and may change over time as personal identity evolves, and therefore arbitrarily grouping diverse ethnic backgrounds is unlikely to capture an accurate representation of experiences. There are levels of discrimination even within minority groups; colourism in India means dark-skinned Indians will experience more discrimination than light-skinned Indians, even from those within in their own ethnic group [ 65 ]. Therefore, although the studies included in the scoping review accepted self-definitions of ethnicity, this is likely not enough to fully capture the nuances of bias and discrimination present in society. For example, Ellis et al. [ 4 ] grouped participants as “White”, “Mixed”, “Asian”, “Black” and “Other”, however they could have also assigned a skin tone value such as the NIS Skin Colour Scale [ 66 ], thus providing more detail.

Ethnicity is more than genetic heritage; it is also cultural expression. The experience of an IMG in UK postgraduate training will differ from that of a UKG, an Indian UKG who grew up in India, and an Indian UKG who grew up in the UK. These are important distinctions which are noted in the literature (e.g. by Woolf et al., 2016 [ 57 ]) however some do not distinguish between ethnicity and graduate status [ 15 ] and none delve into an individual’s cultural expression (e.g., clothing choice) and how this affects the perception of their assessors.

Reasons for DA

Despite the recognition of inequalities in all specialties of surgery, there is a paucity of data explicitly addressing why DA occurs. Reasons behind the phenomenon must be explored to enable change and eliminate biases. Qualitative research is more attuned to capturing the complexities of DA through observation or interview-based studies. Currently most published data is quantitative, and relies on performance metrics to demonstrate the presence of DA while ignoring the causes. Promisingly, there are a gradually increasing number of qualitative, predominantly interview-based, studies (Fig.  2 ).

To create a map of DA in all its guises, an analysis of the themes reported to be contributory to its development is helpful. In our review of the literature, four themes have been identified:

Training culture

In higher surgical training, for there to be equality in outcomes, there needs to be equity in opportunities. Ellis et al. [ 4 ] recognised that variation in training experiences, such as accessibility of supportive peers and senior role models, can have implications on attainment. Trainees would benefit from targeted support at times of transition, such as induction or at examinations, and it may be that currently the needs of certain groups are being met before others, reinforcing differential attainment [ 4 ].

Experience of assessment

Most literature in DA relates to the presence (or lack of) an attainment gap in assessments, such as ARCP or MRCS. It is assumed that these assessments of trainee development are objective and free of bias, and indeed several authors have described a lack of bias in these high-stakes examinations (e.g., Ong et al., 2019 [ 12 ]; Robinson et al., 2019 [ 53 ]). However, in some populations, such as disabled trainees, there are differences in attainment [ 59 ]. This is demonstrated despite legislation requiring professional bodies to make reasonable adjustments to examinations for disabled candidates, such as additional time, text formatting amendments, or wheelchair-accessible venues [ 67 ]. Therefore it would be beneficial to investigate the implementation of these adjustments across higher surgical examinations and identify any deficits.

Social networks

Relationships between colleagues may influence DA in multiple ways. Several studies identified that a lack of a relatable and inspiring mentor may explain why female or BME doctors fail to excel in surgery [ 4 , 55 ]. Certain groups may receive preferential treatment due to their perceived familiarity to seniors [ 35 ]. Robinson et al. [ 15 ] recognised that peer-to-peer relationships were also implicated in professional development, and the lack thereof could lead to poor learning outcomes. Therefore, a non-discriminatory culture and inclusion of trainees within the social network of training is posited as beneficial.

Personal characteristics

Finally, personal factors directly related to protected characteristics have been suggested as a cause of DA. For example, IMGs may perform worse in examinations due to language barriers, and those from disadvantaged backgrounds may have less opportunity to attend expensive courses [ 14 , 16 ]. Although it is impossible to exclude these innate deficits from training, we may mitigate their influence by recognising their presence and providing solutions.

The causes of DA may also be grouped into three levels, as described by Regan de Bere et al. [ 68 ]: macro (the implications of high-level policy), meso (focusing on institutional or working environments) and micro (the influence of individual factors). This can intersect with the four themes identified above, as training culture can be enshrined at both an institutional and individual level, influencing decisions that relate to opportunities for trainees, or at a macro level, such as in the decisions made on nationwide recruitment processes. These three levels can be used to more deeply explore each of the four themes to enrich the discovery of causes of DA.

Discussions outside of surgery

Authors in General Practice (e.g., Unwin et al., 2019 [ 69 ]; Pattinson et al., 2019 [ 70 ]), postgraduate medical training (e.g., Andrews, Chartash, and Hay, 2021 [ 71 ]), and undergraduate medical education (e.g., Yeates et al., 2017 [ 72 ]; Woolf et al., 2013 [ 73 ]) have published more extensively in the aetiology of DA. A study by Hope et al. [ 74 ] evaluating the bias present in MRCP exams used differential item functioning to identify individual questions which demonstrated an attainment gap between male and female and Caucasian and non-Caucasian medical trainees. Conclusions drawn about MRCP Part 1 examinations may be generalisable to MRCS Part A or FRCOphth Part 1: they are all multiple-choice examinations testing applied basic science and usually taken within the first few years of postgraduate training. Therefore it is advisable that differential item functioning should also be applied to these examinations. However, it is possible that findings in some subspecialities may not be generalisable to others, as training environments can vary profoundly. The RCOphth [ 55 ] reported that in 2021, 53% of ophthalmic trainees identified as male, whereas in Orthopaedics 85% identified as male, suggesting different training environments [ 5 ]. It is useful to identify commonalities of DA between surgical specialties and in the wider scope of medical training.

Limitations of our paper

Firstly, whilst aiming to provide a review focussed on the experience of surgical trainees, four papers contained data about either non-surgical trainees or medical students. It is difficult to draw out the surgeons from this data and therefore it is possible that there are issues with generalisability. Furthermore, we did not consider the background of each paper’s authors, as their own lived experience of attainment gap could form the lens through which they commented on surgical education, colouring their interpretation. Despite intending to include as many protected characteristics as possible, inevitably there will be lived experiences missed. Lastly, the experience of surgical trainees outside of the English-speaking world were omitted. No studies were found that originated outside of Europe or North America and therefore the presence or characteristics of DA outside of this area cannot be assumed.

Experiences of inequality in surgical assessment are prevalent in all surgical subspecialities. In order to further investigate DA, researchers should ensure all protected characteristics are considered - and how these interact - to gain insight into intersectionality. Given the paucity of current evidence, particular focus should be given to the implications of disability, and specifically neurodiversity, in progress through training as they are yet to be explored in depth. In defining protected characteristics, future authors should be explicit and should avoid generalisation of cultural backgrounds to allow authentic appreciation of attainment gap. Few authors have considered the driving forces between bias in assessment and DA, and therefore qualitative studies should be prioritised to uncover causes for and protective factors against DA. Once these influences have been identified, educational designers can develop new assessment methods that ensure equity across surgical trainees.

Data availability

All data provided during this study are included in the supplementary information files.

Abbreviations

Accreditation Council for Graduate Medical Education

American Board of Orthopaedic Surgery

American Board of Surgery

American Board of Surgery Certifying Exam

Annual Review of Competence Progression

Black, Asian, and Minority Ethnicity

Council on Resident Education in Obstetrics and Gynecology

Differential Attainment

Deprivation Quintile

European Economic Area

Entrustable Professional Activities

Fellowship of The Royal College of Ophthalmologists

Fellow of the Royal College of Surgeons

General Medical Council

Higher Surgical Training

International Medical Graduate

In-Training Evaluation Report

Member of the Royal College of Obstetricians and Gynaecologists

Member of the Royal College of Physicians

Member of the Royal College of Surgeons

Obstetrics and Gynaecology

Orthopaedic In-Training Examination

Participation In Local Areas

Postgraduate Year

The Royal College of Ophthalmologists

The Royal College of Obstetricians and Gynaecologists

The Royal College of Surgeons of England

United Kingdom Graduate

White United Kingdom Graduate

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RJ, SP and SW conceived the study. RJ carried out the search. RJ, SP and SW reviewed and appraised articles. RJ, SP and SW extracted data and synthesized results from articles. RJ, SP and SW prepared the original draft of the manuscript. RJ and SP prepared Figs. 1 and 2. All authors reviewed and edited the manuscript and agreed to the final version.

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Jones, R.L., Prusmetikul, S. & Whitehorn, S. Differential attainment in assessment of postgraduate surgical trainees: a scoping review. BMC Med Educ 24 , 597 (2024). https://doi.org/10.1186/s12909-024-05580-2

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DOI : https://doi.org/10.1186/s12909-024-05580-2

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