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5 software tools to support your systematic review processes

By Dr. Mina Kalantar on 19-Jan-2021 13:01:01

Systematic reviews are a reassessment of scholarly literature to facilitate decision making. This methodical approach of re-evaluating evidence was initially applied in healthcare, to set policies, create guidelines and answer medical questions.

Systematic reviews are large, complex projects and, depending on the purpose, they can be quite expensive to conduct. A team of researchers, data analysts and experts from various fields may collaborate to review and examine incredibly large numbers of research articles for evidence synthesis. Depending on the spectrum, systematic reviews often take at least 6 months, and sometimes upwards of 18 months to complete.

The main principles of transparency and reproducibility require a pragmatic approach in the organisation of the required research activities and detailed documentation of the outcomes. As a result, many software tools have been developed to help researchers with some of the tedious tasks required as part of the systematic review process.

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The first generation of these software tools were produced to accommodate and manage collaborations, but gradually developed to help with screening literature and reporting outcomes. Some of these software packages were initially designed for medical and healthcare studies and have specific protocols and customised steps integrated for various types of systematic reviews. However, some are designed for general processing, and by extending the application of the systematic review approach to other fields, they are being increasingly adopted and used in software engineering, health-related nutrition, agriculture, environmental science, social sciences and education.

Software tools

There are various free and subscription-based tools to help with conducting a systematic review. Many of these tools are designed to assist with the key stages of the process, including title and abstract screening, data synthesis, and critical appraisal. Some are designed to facilitate the entire process of review, including protocol development, reporting of the outcomes and help with fast project completion.

As time goes on, more functions are being integrated into such software tools. Technological advancement has allowed for more sophisticated and user-friendly features, including visual graphics for pattern recognition and linking multiple concepts. The idea is to digitalise the cumbersome parts of the process to increase efficiency, thus allowing researchers to focus their time and efforts on assessing the rigorousness and robustness of the research articles.

This article introduces commonly used systematic review tools that are relevant to food research and related disciplines, which can be used in a similar context to the process in healthcare disciplines.

These reviews are based on IFIS' internal research, thus are unbiased and not affiliated with the companies.

This online platform is a core component of the Cochrane toolkit, supporting parts of the systematic review process, including title/abstract and full-text screening, documentation, and reporting.

The Covidence platform enables collaboration of the entire systematic reviews team and is suitable for researchers and students at all levels of experience.

From a user perspective, the interface is intuitive, and the citation screening is directed step-by-step through a well-defined workflow. Imports and exports are straightforward, with easy export options to Excel and CVS.

Access is free for Cochrane authors (a single reviewer), and Cochrane provides a free trial to other researchers in healthcare. Universities can also subscribe on an institutional basis.

Rayyan is a free and open access web-based platform funded by the Qatar Foundation, a non-profit organisation supporting education and community development initiative . Rayyan is used to screen and code literature through a systematic review process.

Unlike Covidence, Rayyan does not follow a standard SR workflow and simply helps with citation screening. It is accessible through a mobile application with compatibility for offline screening. The web-based platform is known for its accessible user interface, with easy and clear export options.

Function comparison of 5 software tools to support the systematic review process

Eppi-reviewer.

EPPI-Reviewer is a web-based software programme developed by the Evidence for Policy and Practice Information and Co-ordinating Centre  (EPPI) at the UCL Institute for Education, London .

It provides comprehensive functionalities for coding and screening. Users can create different levels of coding in a code set tool for clustering, screening, and administration of documents. EPPI-Reviewer allows direct search and import from PubMed. The import of search results from other databases is feasible in different formats. It stores, references, identifies and removes duplicates automatically. EPPI-Reviewer allows full-text screening, text mining, meta-analysis and the export of data into different types of reports.

There is no limit for concurrent use of the software and the number of articles being reviewed. Cochrane reviewers can access EPPI reviews using their Cochrane subscription details.

EPPI-Centre has other tools for facilitating the systematic review process, including coding guidelines and data management tools.

CADIMA is a free, online, open access review management tool, developed to facilitate research synthesis and structure documentation of the outcomes.

The Julius Institute and the Collaboration for Environmental Evidence established the software programme to support and guide users through the entire systematic review process, including protocol development, literature searching, study selection, critical appraisal, and documentation of the outcomes. The flexibility in choosing the steps also makes CADIMA suitable for conducting systematic mapping and rapid reviews.

CADIMA was initially developed for research questions in agriculture and environment but it is not limited to these, and as such, can be used for managing review processes in other disciplines. It enables users to export files and work offline.

The software allows for statistical analysis of the collated data using the R statistical software. Unlike EPPI-Reviewer, CADIMA does not have a built-in search engine to allow for searching in literature databases like PubMed.

DistillerSR

DistillerSR is an online software maintained by the Canadian company, Evidence Partners which specialises in literature review automation. DistillerSR provides a collaborative platform for every stage of literature review management. The framework is flexible and can accommodate literature reviews of different sizes. It is configurable to different data curation procedures, workflows and reporting standards. The platform integrates necessary features for screening, quality assessment, data extraction and reporting. The software uses Artificial Learning (AL)-enabled technologies in priority screening. It is to cut the screening process short by reranking the most relevant references nearer to the top. It can also use AL, as a second reviewer, in quality control checks of screened studies by human reviewers. DistillerSR is used to manage systematic reviews in various medical disciplines, surveillance, pharmacovigilance and public health reviews including food and nutrition topics. The software does not support statistical analyses. It provides configurable forms in standard formats for data extraction.

DistillerSR allows direct search and import of references from PubMed. It provides an add on feature called LitConnect which can be set to automatically import newly published references from data providers to keep reviews up to date during their progress.

The systematic review Toolbox is a web-based catalogue of various tools, including software packages which can assist with single or multiple tasks within the evidence synthesis process. Researchers can run a quick search or tailor a more sophisticated search by choosing their approach, budget, discipline, and preferred support features, to find the right tools for their research.

If you enjoyed this blog post, you may also be interested in our recently published blog post addressing the difference between a systematic review and a systematic literature review.

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All-in-one Literature Review Software

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MAXQDA The All-in-one Literature Review Software

MAXQDA is the best choice for a comprehensive literature review. It works with a wide range of data types and offers powerful tools for literature review, such as reference management, qualitative, vocabulary, text analysis tools, and more.

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Your analysis.

As your all-in-one literature review software, MAXQDA can be used to manage your entire research project. Easily import data from texts, interviews, focus groups, PDFs, web pages, spreadsheets, articles, e-books, and even social media data. Connect the reference management system of your choice with MAXQDA to easily import bibliographic data. Organize your data in groups, link relevant quotes to each other, keep track of your literature summaries, and share and compare work with your team members. Your project file stays flexible and you can expand and refine your category system as you go to suit your research.

Developed by and for researchers – since 1989

Having used several qualitative data analysis software programs, there is no doubt in my mind that MAXQDA has advantages over all the others. In addition to its remarkable analytical features for harnessing data, MAXQDA’s stellar customer service, online tutorials, and global learning community make it a user friendly and top-notch product.

Sally S. Cohen – NYU Rory Meyers College of Nursing

Literature Review is Faster and Smarter with MAXQDA

Easily import your literature review data

With a literature review software like MAXQDA, you can easily import bibliographic data from reference management programs for your literature review. MAXQDA can work with all reference management programs that can export their databases in RIS-format which is a standard format for bibliographic information. Like MAXQDA, these reference managers use project files, containing all collected bibliographic information, such as author, title, links to websites, keywords, abstracts, and other information. In addition, you can easily import the corresponding full texts. Upon import, all documents will be automatically pre-coded to facilitate your literature review at a later stage.

Capture your ideas while analyzing your literature

Great ideas will often occur to you while you’re doing your literature review. Using MAXQDA as your literature review software, you can create memos to store your ideas, such as research questions and objectives, or you can use memos for paraphrasing passages into your own words. By attaching memos like post-it notes to text passages, texts, document groups, images, audio/video clips, and of course codes, you can easily retrieve them at a later stage. Particularly useful for literature reviews are free memos written during the course of work from which passages can be copied and inserted into the final text.

Find concepts important to your generated literature review

When generating a literature review you might need to analyze a large amount of text. Luckily MAXQDA as the #1 literature review software offers Text Search tools that allow you to explore your documents without reading or coding them first. Automatically search for keywords (or dictionaries of keywords), such as important concepts for your literature review, and automatically code them with just a few clicks. Document variables that were automatically created during the import of your bibliographic information can be used for searching and retrieving certain text segments. MAXQDA’s powerful Coding Query allows you to analyze the combination of activated codes in different ways.

Aggregate your literature review

When conducting a literature review you can easily get lost. But with MAXQDA as your literature review software, you will never lose track of the bigger picture. Among other tools, MAXQDA’s overview and summary tables are especially useful for aggregating your literature review results. MAXQDA offers overview tables for almost everything, codes, memos, coded segments, links, and so on. With MAXQDA literature review tools you can create compressed summaries of sources that can be effectively compared and represented, and with just one click you can easily export your overview and summary tables and integrate them into your literature review report.

Powerful and easy-to-use literature review tools

Quantitative aspects can also be relevant when conducting a literature review analysis. Using MAXQDA as your literature review software enables you to employ a vast range of procedures for the quantitative evaluation of your material. You can sort sources according to document variables, compare amounts with frequency tables and charts, and much more. Make sure you don’t miss the word frequency tools of MAXQDA’s add-on module for quantitative content analysis. Included are tools for visual text exploration, content analysis, vocabulary analysis, dictionary-based analysis, and more that facilitate the quantitative analysis of terms and their semantic contexts.

Visualize your literature review

As an all-in-one literature review software, MAXQDA offers a variety of visual tools that are tailor-made for qualitative research and literature reviews. Create stunning visualizations to analyze your material. Of course, you can export your visualizations in various formats to enrich your literature review analysis report. Work with word clouds to explore the central themes of a text and key terms that are used, create charts to easily compare the occurrences of concepts and important keywords, or make use of the graphical representation possibilities of MAXMaps, which in particular permit the creation of concept maps. Thanks to the interactive connection between your visualizations with your MAXQDA data, you’ll never lose sight of the big picture.

AI Assist: literature review software meets AI

AI Assist – your virtual research assistant – supports your literature review with various tools. AI Assist simplifies your work by automatically analyzing and summarizing elements of your research project and by generating suggestions for subcodes. No matter which AI tool you use – you can customize your results to suit your needs.

Free tutorials and guides on literature review

MAXQDA offers a variety of free learning resources for literature review, making it easy for both beginners and advanced users to learn how to use the software. From free video tutorials and webinars to step-by-step guides and sample projects, these resources provide a wealth of information to help you understand the features and functionality of MAXQDA for literature review. For beginners, the software’s user-friendly interface and comprehensive help center make it easy to get started with your data analysis, while advanced users will appreciate the detailed guides and tutorials that cover more complex features and techniques. Whether you’re just starting out or are an experienced researcher, MAXQDA’s free learning resources will help you get the most out of your literature review.

Free MAXQDA Trial for Windows and Mac

Get your maxqda license, compare the features of maxqda and maxqda analytics pro, faq: literature review software.

Literature review software is a tool designed to help researchers efficiently manage and analyze the existing body of literature relevant to their research topic. MAXQDA, a versatile qualitative data analysis tool, can be instrumental in this process.

Literature review software, like MAXQDA, typically includes features such as data import and organization, coding and categorization, advanced search capabilities, data visualization tools, and collaboration features. These features facilitate the systematic review and analysis of relevant literature.

Literature review software, including MAXQDA, can assist in qualitative data interpretation by enabling researchers to organize, code, and categorize relevant literature. This organized data can then be analyzed to identify trends, patterns, and themes, helping researchers draw meaningful insights from the literature they’ve reviewed.

Yes, literature review software like MAXQDA is suitable for researchers of all levels of experience. It offers user-friendly interfaces and extensive support resources, making it accessible to beginners while providing advanced features that cater to the needs of experienced researchers.

Getting started with literature review software, such as MAXQDA, typically involves downloading and installing the software, importing your relevant literature, and exploring the available features. Many software providers offer tutorials and documentation to help users get started quickly.

For students, MAXQDA can be an excellent literature review software choice. Its user-friendly interface, comprehensive feature set, and educational discounts make it a valuable tool for students conducting literature reviews as part of their academic research.

MAXQDA is available for both Windows and Mac users, making it a suitable choice for Mac users looking for literature review software. It offers a consistent and feature-rich experience on Mac operating systems.

When it comes to literature review software, MAXQDA is widely regarded as one of the best choices. Its robust feature set, user-friendly interface, and versatility make it a top pick for researchers conducting literature reviews.

Yes, literature reviews can be conducted without software. However, using literature review software like MAXQDA can significantly streamline and enhance the process by providing tools for efficient data management, analysis, and visualization.

7 open source tools to make literature reviews easy

Opensource.com

A good literature review is critical for academic research in any field, whether it is for a research article, a critical review for coursework, or a dissertation. In a recent article, I presented detailed steps for doing  a literature review using open source software .

The following is a brief summary of seven free and open source software tools described in that article that will make your next literature review much easier.

1. GNU Linux

Most literature reviews are accomplished by graduate students working in research labs in universities. For absurd reasons, graduate students often have the worst computers on campus. They are often old, slow, and clunky Windows machines that have been discarded and recycled from the undergraduate computer labs. Installing a flavor of GNU Linux will breathe new life into these outdated PCs. There are more than 100 distributions , all of which can be downloaded and installed for free on computers. Most popular Linux distributions come with a "try-before-you-buy" feature. For example, with Ubuntu you can make a bootable USB stick that allows you to test-run the Ubuntu desktop experience without interfering in any way with your PC configuration. If you like the experience, you can use the stick to install Ubuntu on your machine permanently.

Linux distributions generally come with a free web browser, and the most popular is Firefox . Two Firefox plugins that are particularly useful for literature reviews are Unpaywall and Zotero. Keep reading to learn why.

3. Unpaywall

Often one of the hardest parts of a literature review is gaining access to the papers you want to read for your review. The unintended consequence of copyright restrictions and paywalls is it has narrowed access to the peer-reviewed literature to the point that even Harvard University is challenged to pay for it. Fortunately, there are a lot of open access articles—about a third of the literature is free (and the percentage is growing). Unpaywall is a Firefox plugin that enables researchers to click a green tab on the side of the browser and skip the paywall on millions of peer-reviewed journal articles. This makes finding accessible copies of articles much faster that searching each database individually. Unpaywall is fast, free, and legal, as it accesses many of the open access sites that I covered in my paper on using open source in lit reviews .

Formatting references is the most tedious of academic tasks. Zotero can save you from ever doing it again. It operates as an Android app, desktop program, and a Firefox plugin (which I recommend). It is a free, easy-to-use tool to help you collect, organize, cite, and share research. It replaces the functionality of proprietary packages such as RefWorks, Endnote, and Papers for zero cost. Zotero can auto-add bibliographic information directly from websites. In addition, it can scrape bibliographic data from PDF files. Notes can be easily added on each reference. Finally, and most importantly, it can import and export the bibliography databases in all publishers' various formats. With this feature, you can export bibliographic information to paste into a document editor for a paper or thesis—or even to a wiki for dynamic collaborative literature reviews (see tool #7 for more on the value of wikis in lit reviews).

5. LibreOffice

Your thesis or academic article can be written conventionally with the free office suite LibreOffice , which operates similarly to Microsoft's Office products but respects your freedom. Zotero has a word processor plugin to integrate directly with LibreOffice. LibreOffice is more than adequate for the vast majority of academic paper writing.

If LibreOffice is not enough for your layout needs, you can take your paper writing one step further with LaTeX , a high-quality typesetting system specifically designed for producing technical and scientific documentation. LaTeX is particularly useful if your writing has a lot of equations in it. Also, Zotero libraries can be directly exported to BibTeX files for use with LaTeX.

7. MediaWiki

If you want to leverage the open source way to get help with your literature review, you can facilitate a dynamic collaborative literature review . A wiki is a website that allows anyone to add, delete, or revise content directly using a web browser. MediaWiki is free software that enables you to set up your own wikis.

Researchers can (in decreasing order of complexity): 1) set up their own research group wiki with MediaWiki, 2) utilize wikis already established at their universities (e.g., Aalto University ), or 3) use wikis dedicated to areas that they research. For example, several university research groups that focus on sustainability (including mine ) use Appropedia , which is set up for collaborative solutions on sustainability, appropriate technology, poverty reduction, and permaculture.

Using a wiki makes it easy for anyone in the group to keep track of the status of and update literature reviews (both current and older or from other researchers). It also enables multiple members of the group to easily collaborate on a literature review asynchronously. Most importantly, it enables people outside the research group to help make a literature review more complete, accurate, and up-to-date.

Wrapping up

Free and open source software can cover the entire lit review toolchain, meaning there's no need for anyone to use proprietary solutions. Do you use other libre tools for making literature reviews or other academic work easier? Please let us know your favorites in the comments.

Related Content

10 Best Literature Review Tools for Researchers

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Boost your research game with these Best Literature Review Tools for Researchers! Uncover hidden gems, organize your findings, and ace your next research paper!

Conducting literature reviews poses challenges for researchers due to the overwhelming volume of information available and the lack of efficient methods to manage and analyze it.

Researchers struggle to identify key sources, extract relevant information, and maintain accuracy while manually conducting literature reviews. This leads to inefficiency, errors, and difficulty in identifying gaps or trends in existing literature.

Advancements in technology have resulted in a variety of literature review tools. These tools streamline the process, offering features like automated searching, filtering, citation management, and research data extraction. They save time, improve accuracy, and provide valuable insights for researchers. 

In this article, we present a curated list of the 10 best literature review tools, empowering researchers to make informed choices and revolutionize their systematic literature review process.

Table of Contents

Top 10 Literature Review Tools for Researchers: In A Nutshell (2023)

#1. semantic scholar – a free, ai-powered research tool for scientific literature.

Semantic Scholar is a cutting-edge literature review tool that researchers rely on for its comprehensive access to academic publications. With its advanced AI algorithms and extensive database, it simplifies the discovery of relevant research papers. 

By employing semantic analysis, users can explore scholarly articles based on context and meaning, making it a go-to resource for scholars across disciplines. 

Additionally, Semantic Scholar offers personalized recommendations and alerts, ensuring researchers stay updated with the latest developments. However, users should be cautious of potential limitations. 

Not all scholarly content may be indexed, and occasional false positives or inaccurate associations can occur. Furthermore, the tool primarily focuses on computer science and related fields, potentially limiting coverage in other disciplines. 

Researchers should be mindful of these considerations and supplement Semantic Scholar with other reputable resources for a comprehensive literature review. Despite these caveats, Semantic Scholar remains a valuable tool for streamlining research and staying informed.

#2. Elicit – Research assistant using language models like GPT-3

Elicit is a game-changing literature review tool that has gained popularity among researchers worldwide. With its user-friendly interface and extensive database of scholarly articles, it streamlines the research process, saving time and effort. 

The tool employs advanced algorithms to provide personalized recommendations, ensuring researchers discover the most relevant studies for their field. Elicit also promotes collaboration by enabling users to create shared folders and annotate articles.

However, users should be cautious when using Elicit. It is important to verify the credibility and accuracy of the sources found through the tool, as the database encompasses a wide range of publications. 

Additionally, occasional glitches in the search function have been reported, leading to incomplete or inaccurate results. While Elicit offers tremendous benefits, researchers should remain vigilant and cross-reference information to ensure a comprehensive literature review.

#3. Scite.Ai – Your personal research assistant

Scite.Ai is a popular literature review tool that revolutionizes the research process for scholars. With its innovative citation analysis feature, researchers can evaluate the credibility and impact of scientific articles, making informed decisions about their inclusion in their own work. 

By assessing the context in which citations are used, Scite.Ai ensures that the sources selected are reliable and of high quality, enabling researchers to establish a strong foundation for their research.

However, while Scite.Ai offers numerous advantages, there are a few aspects to be cautious about. As with any data-driven tool, occasional errors or inaccuracies may arise, necessitating researchers to cross-reference and verify results with other reputable sources. 

Moreover, Scite.Ai’s coverage may be limited in certain subject areas and languages, with a possibility of missing relevant studies, especially in niche fields or non-English publications. 

Therefore, researchers should supplement the use of Scite.Ai with additional resources to ensure comprehensive literature coverage and avoid any potential gaps in their research.

Rayyan offers the following paid plans:

• Monthly Plan: $20
• Yearly Plan: $12

#4. DistillerSR – Literature Review Software

DistillerSR is a powerful literature review tool trusted by researchers for its user-friendly interface and robust features. With its advanced search capabilities, researchers can quickly find relevant studies from multiple databases, saving time and effort. 

The tool offers comprehensive screening and data extraction functionalities, streamlining the review process and improving the reliability of findings. Real-time collaboration features also facilitate seamless teamwork among researchers.

While DistillerSR offers numerous advantages, there are a few considerations. Users should invest time in understanding the tool’s features and functionalities to maximize its potential. Additionally, the pricing structure may be a factor for individual researchers or small teams with limited budgets.

Despite occasional technical glitches reported by some users, the developers actively address these issues through updates and improvements, ensuring a better user experience. 

Overall, DistillerSR empowers researchers to navigate the vast sea of information, enhancing the quality and efficiency of literature reviews while fostering collaboration among research teams .

#5. Rayyan – AI Powered Tool for Systematic Literature Reviews

Rayyan is a powerful literature review tool that simplifies the research process for scholars and academics. With its user-friendly interface and efficient management features, Rayyan is highly regarded by researchers worldwide. 

It allows users to import and organize large volumes of scholarly articles, making it easier to identify relevant studies for their research projects. The tool also facilitates seamless collaboration among team members, enhancing productivity and streamlining the research workflow. 

However, it’s important to be aware of a few aspects. The free version of Rayyan has limitations, and upgrading to a premium subscription may be necessary for additional functionalities. 

Users should also be mindful of occasional technical glitches and compatibility issues, promptly reporting any problems. Despite these considerations, Rayyan remains a valuable asset for researchers, providing an effective solution for literature review tasks.

Rayyan offers both free and paid plans:

• Professional: $8.25/month
• Student: $4/month
• Pro Team: $8.25/month
• Team+: $24.99/month

#6. Consensus – Use AI to find you answers in scientific research

Consensus is a cutting-edge literature review tool that has become a go-to choice for researchers worldwide. Its intuitive interface and powerful capabilities make it a preferred tool for navigating and analyzing scholarly articles. 

With Consensus, researchers can save significant time by efficiently organizing and accessing relevant research material.People consider Consensus for several reasons. 

Its advanced search algorithms and filters help researchers sift through vast amounts of information, ensuring they focus on the most relevant articles. By streamlining the literature review process, Consensus allows researchers to extract valuable insights and accelerate their research progress.

However, there are a few factors to watch out for when using Consensus. As with any automated tool, researchers should exercise caution and independently verify the accuracy and relevance of the generated results. Complex or niche topics may present challenges, resulting in limited search results. Researchers should also supplement Consensus with manual searches to ensure comprehensive coverage of the literature.

Overall, Consensus is a valuable resource for researchers seeking to optimize their literature review process. By leveraging its features alongside critical thinking and manual searches, researchers can enhance the efficiency and effectiveness of their work, advancing their research endeavors to new heights.

Consensus offers both free and paid plans:

• Premium: $9.99/month
• Enterprise: Custom

#7. RAx – AI-powered reading assistant

Consensus is a revolutionary literature review tool that has transformed the research process for scholars worldwide. With its user-friendly interface and advanced features, it offers a vast database of academic publications across various disciplines, providing access to relevant and up-to-date literature. 

Using advanced algorithms and machine learning, Consensus delivers personalized recommendations, saving researchers time and effort in their literature search. 

However, researchers should be cautious of potential biases in the recommendation system and supplement their search with manual verification to ensure a comprehensive review. 

Additionally, occasional inaccuracies in metadata have been reported, making it essential for users to cross-reference information with reliable sources. Despite these considerations, Consensus remains an invaluable tool for enhancing the efficiency and quality of literature reviews.

RAx offers both free and paid plans. Currently offering 50% discounts as of July 2023:

• Premium: $6/month $3/month
• Premium with Copilot: $8/month $4/month

#8. Lateral – Advance your research with AI

“Lateral” is a revolutionary literature review tool trusted by researchers worldwide. With its user-friendly interface and powerful search capabilities, it simplifies the process of gathering and analyzing scholarly articles. 

By leveraging advanced algorithms and machine learning, Lateral saves researchers precious time by retrieving relevant articles and uncovering new connections between them, fostering interdisciplinary exploration.

While Lateral provides numerous benefits, users should exercise caution. It is advisable to cross-reference its findings with other sources to ensure a comprehensive review. 

Additionally, researchers must be mindful of potential biases introduced by the tool’s algorithms and should critically evaluate and interpret the results. 

Despite these considerations, Lateral remains an indispensable resource, empowering researchers to delve deeper into their fields of study and make valuable contributions to the academic community.

RAx offers both free and paid plans:

• Premium: $10.98
• Pro: $27.46

#9. Iris AI – Introducing the researcher workspace

Iris AI is an innovative literature review tool that has transformed the research process for academics and scholars. With its advanced artificial intelligence capabilities, Iris AI offers a seamless and efficient way to navigate through a vast array of academic papers and publications. 

Researchers are drawn to this tool because it saves valuable time by automating the tedious task of literature review and provides comprehensive coverage across multiple disciplines. 

Its intelligent recommendation system suggests related articles, enabling researchers to discover hidden connections and broaden their knowledge base. However, caution should be exercised while using Iris AI. 

While the tool excels at surfacing relevant papers, researchers should independently evaluate the quality and validity of the sources to ensure the reliability of their work. 

It’s important to note that Iris AI may occasionally miss niche or lesser-known publications, necessitating a supplementary search using traditional methods. 

Additionally, being an algorithm-based tool, there is a possibility of false positives or missed relevant articles due to the inherent limitations of automated text analysis. Nevertheless, Iris AI remains an invaluable asset for researchers, enhancing the quality and efficiency of their research endeavors.

Iris AI offers different pricing plans to cater to various user needs:

• Basic: Free
• Premium: Monthly ($82.41), Quarterly ($222.49), and Annual ($791.07)

#10. Scholarcy – Summarize your literature through AI

Scholarcy is a powerful literature review tool that helps researchers streamline their work. By employing advanced algorithms and natural language processing, it efficiently analyzes and summarizes academic papers, saving researchers valuable time. 

Scholarcy’s ability to extract key information and generate concise summaries makes it an attractive option for scholars looking to quickly grasp the main concepts and findings of multiple papers.

However, it is important to exercise caution when relying solely on Scholarcy. While it provides a useful starting point, engaging with the original research papers is crucial to ensure a comprehensive understanding. 

Scholarcy’s automated summarization may not capture the nuanced interpretations or contextual information presented in the full text. 

Researchers should also be aware that certain types of documents, particularly those with heavy mathematical or technical content, may pose challenges for the tool. 

Despite these considerations, Scholarcy remains a valuable resource for researchers seeking to enhance their literature review process and improve overall efficiency.

Scholarcy offer the following pricing plans:

• Browser Extension and Flashcards: Free 
• Personal Library: $9.99
• Academic Institution License: $8K+

Final Thoughts

In conclusion, conducting a comprehensive literature review is a crucial aspect of any research project, and the availability of reliable and efficient tools can greatly facilitate this process for researchers. This article has explored the top 10 literature review tools that have gained popularity among researchers.

Moreover, the rise of AI-powered tools like Iris.ai and Sci.ai promises to revolutionize the literature review process by automating various tasks and enhancing research efficiency. 

Ultimately, the choice of literature review tool depends on individual preferences and research needs, but the tools presented in this article serve as valuable resources to enhance the quality and productivity of research endeavors. 

Researchers are encouraged to explore and utilize these tools to stay at the forefront of knowledge in their respective fields and contribute to the advancement of science and academia.

Q1. What are literature review tools for researchers?

Literature review tools for researchers are software or online platforms designed to assist researchers in efficiently conducting literature reviews. These tools help researchers find, organize, analyze, and synthesize relevant academic papers and other sources of information.

Q2. What criteria should researchers consider when choosing literature review tools?

When choosing literature review tools, researchers should consider factors such as the tool’s search capabilities, database coverage, user interface, collaboration features, citation management, annotation and highlighting options, integration with reference management software, and data extraction capabilities. 

It’s also essential to consider the tool’s accessibility, cost, and technical support.

Q3. Are there any literature review tools specifically designed for systematic reviews or meta-analyses?

Yes, there are literature review tools that cater specifically to systematic reviews and meta-analyses, which involve a rigorous and structured approach to reviewing existing literature. These tools often provide features tailored to the specific needs of these methodologies, such as:

Screening and eligibility assessment: Systematic review tools typically offer functionalities for screening and assessing the eligibility of studies based on predefined inclusion and exclusion criteria. This streamlines the process of selecting relevant studies for analysis.

Data extraction and quality assessment: These tools often include templates and forms to facilitate data extraction from selected studies. Additionally, they may provide features for assessing the quality and risk of bias in individual studies.

Meta-analysis support: Some literature review tools include statistical analysis features that assist in conducting meta-analyses. These features can help calculate effect sizes, perform statistical tests, and generate forest plots or other visual representations of the meta-analytic results.

Reporting assistance: Many tools provide templates or frameworks for generating systematic review reports, ensuring compliance with established guidelines such as PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

Q4. Can literature review tools help with organizing and annotating collected references?

Yes, literature review tools often come equipped with features to help researchers organize and annotate collected references. Some common functionalities include:

Reference management: These tools enable researchers to import references from various sources, such as databases or PDF files, and store them in a central library. They typically allow you to create folders or tags to organize references based on themes or categories.

Annotation capabilities: Many tools provide options for adding annotations, comments, or tags to individual references or specific sections of research articles. This helps researchers keep track of important information, highlight key findings, or note potential connections between different sources.

Full-text search: Literature review tools often offer full-text search functionality, allowing you to search within the content of imported articles or documents. This can be particularly useful when you need to locate specific information or keywords across multiple references.

Integration with citation managers: Some literature review tools integrate with popular citation managers like Zotero, Mendeley, or EndNote, allowing seamless transfer of references and annotations between platforms.

By leveraging these features, researchers can streamline the organization and annotation of their collected references, making it easier to retrieve relevant information during the literature review process.

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Accelerate your research with the best systematic literature review tools

The ideal literature review tool helps you make sense of the most important insights in your research field. ATLAS.ti empowers researchers to perform powerful and collaborative analysis using the leading software for literature review.

Finalize your literature review faster with comfort

ATLAS.ti makes it easy to manage, organize, and analyze articles, PDFs, excerpts, and more for your projects. Conduct a deep systematic literature review and get the insights you need with a comprehensive toolset built specifically for your research projects.

Figure out the "why" behind your participant's motivations

Understand the behaviors and emotions that are driving your focus group participants. With ATLAS.ti, you can transform your raw data and turn it into qualitative insights you can learn from. Easily determine user intent in the same spot you're deciphering your overall focus group data.

Visualize your research findings like never before

We make it simple to present your analysis results with meaningful charts, networks, and diagrams. Instead of figuring out how to communicate the insights you just unlocked, we enable you to leverage easy-to-use visualizations that support your goals.

Everything you need to elevate your literature review

Import and organize literature data.

Import and analyze any type of text content – ATLAS.ti supports all standard text and transcription files such as Word and PDF.

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Utilize easy-to-learn workflows that save valuable time, such as auto coding, sentiment analysis, team collaboration, and more.

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Make efficiency a priority and let ATLAS.ti do your work with AI-powered research tools and features for faster results.

Visualize and present findings

With just a few clicks, you can create meaningful visualizations like charts, word clouds, tables, networks, among others for your literature data.

The faster way to make sense of your literature review. Try it for free, today.

A literature review analyzes the most current research within a research area. A literature review consists of published studies from many sources:

• Peer-reviewed academic publications
• Full-length books
• University bulletins
• Conference proceedings
• Dissertations and theses

Literature reviews allow researchers to:

• Summarize the state of the research
• Identify unexplored research inquiries
• Recommend practical applications
• Critique currently published research

Literature reviews are either standalone publications or part of a paper as background for an original research project. A literature review, as a section of a more extensive research article, summarizes the current state of the research to justify the primary research described in the paper.

For example, a researcher may have reviewed the literature on a new supplement's health benefits and concluded that more research needs to be conducted on those with a particular condition. This research gap warrants a study examining how this understudied population reacted to the supplement. Researchers need to establish this research gap through a literature review to persuade journal editors and reviewers of the value of their research.

Consider a literature review as a typical research publication presenting a study, its results, and the salient points scholars can infer from the study. The only significant difference with a literature review treats existing literature as the research data to collect and analyze. From that analysis, a literature review can suggest new inquiries to pursue.

Identify a focus

Similar to a typical study, a literature review should have a research question or questions that analysis can answer. This sort of inquiry typically targets a particular phenomenon, population, or even research method to examine how different studies have looked at the same thing differently. A literature review, then, should center the literature collection around that focus.

Collect and analyze the literature

With a focus in mind, a researcher can collect studies that provide relevant information for that focus. They can then analyze the collected studies by finding and identifying patterns or themes that occur frequently. This analysis allows the researcher to point out what the field has frequently explored or, on the other hand, overlooked.

Suggest implications

The literature review allows the researcher to argue a particular point through the evidence provided by the analysis. For example, suppose the analysis makes it apparent that the published research on people's sleep patterns has not adequately explored the connection between sleep and a particular factor (e.g., television-watching habits, indoor air quality). In that case, the researcher can argue that further study can address this research gap.

External requirements aside (e.g., many academic journals have a word limit of 6,000-8,000 words), a literature review as a standalone publication is as long as necessary to allow readers to understand the current state of the field. Even if it is just a section in a larger paper, a literature review is long enough to allow the researcher to justify the study that is the paper's focus.

Note that a literature review needs only to incorporate a representative number of studies relevant to the research inquiry. For term papers in university courses, 10 to 20 references might be appropriate for demonstrating analytical skills. Published literature reviews in peer-reviewed journals might have 40 to 50 references. One of the essential goals of a literature review is to persuade readers that you have analyzed a representative segment of the research you are reviewing.

Researchers can find published research from various online sources:

• Journal websites
• Research databases
• Search engines (Google Scholar, Semantic Scholar)
• Research repositories
• Social networking sites (Academia, ResearchGate)

Many journals make articles freely available under the term "open access," meaning that there are no restrictions to viewing and downloading such articles. Otherwise, collecting research articles from restricted journals usually requires access from an institution such as a university or a library.

Evidence of a rigorous literature review is more important than the word count or the number of articles that undergo data analysis. Especially when writing for a peer-reviewed journal, it is essential to consider how to demonstrate research rigor in your literature review to persuade reviewers of its scholarly value.

Select field-specific journals

The most significant research relevant to your field focuses on a narrow set of journals similar in aims and scope. Consider who the most prominent scholars in your field are and determine which journals publish their research or have them as editors or reviewers. Journals tend to look favorably on systematic reviews that include articles they have published.

Incorporate recent research

Recently published studies have greater value in determining the gaps in the current state of research. Older research is likely to have encountered challenges and critiques that may render their findings outdated or refuted. What counts as recent differs by field; start by looking for research published within the last three years and gradually expand to older research when you need to collect more articles for your review.

Consider the quality of the research

Literature reviews are only as strong as the quality of the studies that the researcher collects. You can judge any particular study by many factors, including:

• the quality of the article's journal
• the article's research rigor
• the timeliness of the research

The critical point here is that you should consider more than just a study's findings or research outputs when including research in your literature review.

Narrow your research focus

Ideally, the articles you collect for your literature review have something in common, such as a research method or research context. For example, if you are conducting a literature review about teaching practices in high school contexts, it is best to narrow your literature search to studies focusing on high school. You should consider expanding your search to junior high school and university contexts only when there are not enough studies that match your focus.

You can create a project in ATLAS.ti for keeping track of your collected literature. ATLAS.ti allows you to view and analyze full text articles and PDF files in a single project. Within projects, you can use document groups to separate studies into different categories for easier and faster analysis.

For example, a researcher with a literature review that examines studies across different countries can create document groups labeled "United Kingdom," "Germany," and "United States," among others. A researcher can also use ATLAS.ti's global filters to narrow analysis to a particular set of studies and gain insights about a smaller set of literature.

ATLAS.ti allows you to search, code, and analyze text documents and PDF files. You can treat a set of research articles like other forms of qualitative data. The codes you apply to your literature collection allow for analysis through many powerful tools in ATLAS.ti:

• Code Co-Occurrence Explorer
• Code Co-Occurrence Table
• Code-Document Table

Other tools in ATLAS.ti employ machine learning to facilitate parts of the coding process for you. Some of our software tools that are effective for analyzing literature include:

• Named Entity Recognition
• Opinion Mining
• Sentiment Analysis

As long as your documents are text documents or text-enable PDF files, ATLAS.ti's automated tools can provide essential assistance in the data analysis process.

Distiller SR: Literature Review Software

Smarter reviews: trusted evidence.

Securely automate every stage of your literature review to produce evidence-based research faster, more accurately, and more

transparently at scale.

Software Built for Every Stage of a Literature Review

DistillerSR automates the management of literature collection, screening, and assessment using AI and intelligent workflows. From a systematic literature review to a rapid review to a living review, DistillerSR makes any project simpler to manage and configure to produce transparent, audit-ready, and compliant results.

Broader, Automated Literature Searches

Search more efficiently with DistillerSR’s integrations with data providers, such as PubMed, automatic review updates, and AI-powered duplicate detection and removal.

PubMed Integration

Automatic review updates.

Automatically import newly published references, always keeping literature reviews up-to-date with DistillerSR LitConnect .

Duplicate Detection

Detect and remove duplicate citations preventing skew and bias caused by studies included more than once.

Faster, More Effective Reference Screening

Reduce your screening burden by 60% with DistillerSR. Start working on later stages of your review sooner by finding relevant references faster and addressing conflicts more easily.

AI-Powered Screening

Conflict resolution.

Automatically identifies conflicts and disagreements between literature reviewers for easy resolution.

AI Quality Check

Increase the thoroughness of your literature review by having AI double-check your exclusion decisions and validate your categorization of records with the help of DistillerSR AI Classifiers software module.

Cost-Effective Access  to Full-Text Documents

Ensure your literature review is always up-to-date with DistillerSR’s direct connections to full-text data sources, all the while lowering overall subscription costs.

Ensure your review is always up-to-date with DistillerSR’s direct connections to full-text data sources, all the while lowering overall subscription costs.

Open Access Integrations

Automatically search for and upload full-text documents from PMC , and link directly to source material through DOI.org .

Copyright Compliant Bulk Search

Retrieve full-text articles for the lowest possible cost through Article Galaxy .

Ad-Hoc Document Retrieval

Leverage existing RightFind and Article Galaxy subscriptions, the open access Unpaywall plugin, and internal libraries to access copyright compliant documents.

Simple Yet Powerful Data-Extraction

Simplify data extraction through templates and configurable forms. Extract data easily with in-form validations and calculations, and easily capture repeating, complex data sets.

Cross-Review, Data Reuse

Prevent duplication of effort across your organization and reduce data extraction times with DistillerSR CuratorCR by easily reusing data across literature reviews.

Capturing Complex Output

Easily capture complex data, such as a variable number of time points across multiple studies in an easy-to-understand and ready-to-analyze way.

Smart Forms

Cut down on literature review data cleaning, data conversions, and effective measure calculations with input validation and built-in form calculations.

Automatic and Configurable Reporting

Customizable Reporting Engine

Build reports and schedule automated email updates to stakeholders. Integrate your data with third-party reporting applications and databases with DistillerSR API .

Auto-Generated Reports

Comprehensive audit-trail.

Automatically keeps track of every entry and decision providing transparency and reproducibility in your literature review.

Easy-to-use Literature Review Project Management

Facilitate project management throughout the literature review process with real-time user and project metric monitoring, reusable configurations, and granular user permissions.

Facilitate project management throughout the review process with real-time user and project metric monitoring, reusable configurations, and granular user permissions.

Real-Time User and Project Metrics

Monitor teams and literature review progress in real-time, improving management and quality oversight into projects.

Repeatable, Configurable Processes

Secure literature reviews.

Single sign-on (SSO) and fully configurable user roles and permissions simplify the literature reviewer experience while also ensuring data integrity and security .

I can’t think of a way to do reviews faster than with DistillerSR. Being able to monitor progress and collaborate with team members, no matter where they are located makes my life a lot easier.

DistillerSR Case Studies

Abbott Diagnostics

Maple Health Group

Congress of Neurological Surgeons

Distillersr frequently asked questions, what types of reviews can be done with distillersr systematic reviews, living reviews, rapid reviews, or clinical evaluation report (cer) literature reviews.

Literature reviews can be a very simple or highly complex process, and literature reviews can use a variety of methods for finding, assessing, and presenting evidence. We describe DistillerSR as a literature review software because it supports all types of reviews , from systematic reviews to rapid reviews, and from living reviews to CER literature reviews.

DistillerSR software is used by over 300 customers in many different industries to support their evidence generation initiatives, from guideline development to HEOR analysis to CERs to post-market surveillance (PMS) and pharmacovigilance.

What are some of DistillerSR’s capabilities that support conducting systematic reviews?

Systematic reviews are the gold standard of literature reviews that aim to identify and screen all evidence relating to a specific research question. DistillerSR facilitates systematic reviews through a configurable, transparent, reproducible process that makes it easy to view the provenance of every cell of data.

DistillerSR was originally designed to support systematic reviews. The software handles dual reviewer screening, conflict resolution, capturing exclusion reasons while you work, risk of bias assessments, duplicate detection, multiple database searches, and reporting templates such as PRISMA . DistillerSR can readily scale for systematic reviews of all sizes, supporting more than 700,000 references per project through a robust enterprise-grade technical architecture . Using software like DistillerSR makes conducting systematic reviews easier to manage and configure to produce transparent evidence-based research faster and more accurately.

How does DistillerSR support clinical evaluation reports (CERs) and performance evaluation reports (PERs) program management?

The new European Union Medical Device Regulation (EU-MDR) and In-Vitro Device Regulation (EU-IVDR) require medical device manufacturers to increase the frequency, traceability, and overall documentation for CERs in the MDR program or PERs in the IVDR counterpart. Literature review software is an ideal tool to help you comply with these regulations.

DistillerSR automates literature reviews to enable a more transparent, repeatable, and auditable process , enabling manufacturers to create and implement a standard framework for literature reviews. This framework for conducting literature reviews can then be incorporated into all CER and PER program management plans consistently across every product, division, and research group.

How can DistillerSR help rapid reviews?

DistillerSR AI is ideal to speed up the rapid review process without compromising on quality. The AI-powered screening enables you to find references faster by continuously reordering relevant references, resulting in accelerated screening. The AI can also double-check your exclusion decisions to ensure relevant references are not left out of the rapid review.

DistillerSR title screening functionality enables you to quickly perform title screening on large numbers of references.

Does DistillerSR support living reviews?

The short answer is yes. DistillerSR has multiple capabilities that automate living systematic reviews , such as automatically importing newly published references into your projects and notifying reviewers that there’s screening to do. You can also put reports on an automated schedule so you’re never caught off guard when important new data is collected.   These capabilities help ensure the latest research is included in your living systematic review and that your review is up-to-date. 

How can DistillerSR help ensure the accuracy of Literature and Systematic reviews?

The quality of systematic reviews is foundational to evidence-based research. However, quality may be compromised because systematic reviews – by their very nature – are often tedious and repetitive, and prone to human error. Tracking all review activity in systematic review software, like DistillerSR, and making it easy to trace the provenance of every cell of data, delivers total transparency and auditability into the systematic review process. DistillerSR enables reviewers to work on the same project simultaneously without the risk of duplicating work or overwriting each other’s results. Configurable workflow filters ensure that the right references are automatically assigned to the right reviewers, and DistillerSR’s cross-project dashboard allows reviewers to monitor to-do lists for all projects from one place.

Why should I add DistillerSR to my Literature and Systematic Review Toolbox and retire my current spreadsheet solution?

It’s estimated that 90% of spreadsheets contain formula errors and approximately 50% have material defects. These errors, coupled with the time and resources necessary to fix them, adversely impact the management of the systematic review process. DistillerSR software was specifically designed to address the challenges faced by systematic review authors, namely the ever-increasing volume of research to screen and extract, review bottlenecks, and regulatory requirements for auditability and transparency, as well as a tool for managing a remote global workforce. Efficiency, consistency, better collaboration, and quality control are just a few of the benefits you’ll get when you choose DistillerSR’s systematic review process over a manual spreadsheet tool for your reviews.

What is the role of AI in your systematic review process?

DistillerSR AI enables the automation of the logistic-heavy tasks involved in conducting a systematic literature review, such as finding references faster using AI to continuously reorder references based on relevance. Continuous AI Reprioritization uses machine learning to learn from the references you are including and excluding and automatically reorder the ones you have left to screen, putting the most pertinent references in front of you first. This means that you find included references much more quickly during the screening process. DistillerSR also uses classifiers , which use NLP to classify and process information in the systematic review.  DistillerSR can also increase the thoroughness of your systematic review by having AI double-check your exclusion decisions.

What about the security and scalability of systematic literature reviews done on DistillerSR?

DistillerSR builds security, scalability, and availability into everything we do, so you can focus on producing evidence-based research faster, more accurately, and more securely with our  systematic review software. We undergo an annual independent third-party audit and certify our products using the American Institute of Certified Public Accountants SOC 2 framework. In terms of scalability, systematic review projects in DistillerSR can easily handle a large number of references; some of our customers have over 700,000 references in their projects.

Do you offer any commitments on the frequency of new product and capability launches?

We pride ourselves on listening to and working with our customers to regularly introduce new capabilities that improve DistillerSR and the systematic review process. We plan on offering two major releases a year in addition to two minor feature enhancements. We notify customers in advance about upcoming releases, host webinars, develop tools and training to introduce the new capabilities, and provide extensive release notes for our reviewers.

I have a unique literature review protocol. Is your software configurable with my literature review data and process?

Configurability is one of the key foundations of DistillerSR software. In fact, with over 300 customers in many different industries, we have yet to see a literature review protocol that our software couldn’t handle. DistillerSR is a professional B2B SaaS company with an exceptional customer success team that will work with you to understand your unique requirements and systematic review process to get you started quickly. Our global support team is available 24/7 to help you.

Still unsure if DistillerSR will meet your systematic literature review requirements?

Adopting a new software is about more than just money. New software is also about commitment and trusting that the new platform will match your systematic review and scalability needs. We have resources to help you in your analysis and decision: check out the systematic review software checklist or the literature review software checklist .

Learn More About DistillerSR

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As a person who is an early researcher and identifies as dyslexic, I can say that having research articles laid out in the date vs cite graph format is much more approachable than looking at a standard database interface. I feel that the maps Litmaps offers lower the barrier of entry for researchers by giving them the connections between articles spaced out visually. This helps me orientate where a paper is in the history of a field. Thus, new researchers can look at one of Litmap's "seed maps" and have the same information as hours of digging through a database.

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YSN Doctoral Programs: Steps in Conducting a Literature Review

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• Steps in Conducting a Literature Review

What is a literature review?

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

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

Why is it important?

A literature review is important because it:

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

APA7 Style resources

APA Style Blog - for those harder to find answers

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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What is a Literature Review? How to Write It (with Examples)

A literature review is a critical analysis and synthesis of existing research on a particular topic. It provides an overview of the current state of knowledge, identifies gaps, and highlights key findings in the literature. 1 The purpose of a literature review is to situate your own research within the context of existing scholarship, demonstrating your understanding of the topic and showing how your work contributes to the ongoing conversation in the field. Learning how to write a literature review is a critical tool for successful research. Your ability to summarize and synthesize prior research pertaining to a certain topic demonstrates your grasp on the topic of study, and assists in the learning process. 

Table of Contents

• What is the purpose of literature review? 
• a. Habitat Loss and Species Extinction: 
• b. Range Shifts and Phenological Changes: 
• c. Ocean Acidification and Coral Reefs: 
• d. Adaptive Strategies and Conservation Efforts: 

How to write a good literature review 

• Choose a Topic and Define the Research Question: 
• Decide on the Scope of Your Review: 
• Select Databases for Searches: 
• Conduct Searches and Keep Track: 
• Review the Literature: 
• Organize and Write Your Literature Review: 
• How to write a literature review faster with Paperpal? 
• Frequently asked questions 

What is a literature review?

A well-conducted literature review demonstrates the researcher’s familiarity with the existing literature, establishes the context for their own research, and contributes to scholarly conversations on the topic. One of the purposes of a literature review is also to help researchers avoid duplicating previous work and ensure that their research is informed by and builds upon the existing body of knowledge.

What is the purpose of literature review?

A literature review serves several important purposes within academic and research contexts. Here are some key objectives and functions of a literature review: 2  

1. Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge. 

2. Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field. 

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3. Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research. 

4. Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered. 

5. Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research. 

6. Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature. 

Literature review example

Let’s delve deeper with a literature review example: Let’s say your literature review is about the impact of climate change on biodiversity. You might format your literature review into sections such as the effects of climate change on habitat loss and species extinction, phenological changes, and marine biodiversity. Each section would then summarize and analyze relevant studies in those areas, highlighting key findings and identifying gaps in the research. The review would conclude by emphasizing the need for further research on specific aspects of the relationship between climate change and biodiversity. The following literature review template provides a glimpse into the recommended literature review structure and content, demonstrating how research findings are organized around specific themes within a broader topic. 

Literature Review on Climate Change Impacts on Biodiversity:

Climate change is a global phenomenon with far-reaching consequences, including significant impacts on biodiversity. This literature review synthesizes key findings from various studies: 

a. Habitat Loss and Species Extinction:

Climate change-induced alterations in temperature and precipitation patterns contribute to habitat loss, affecting numerous species (Thomas et al., 2004). The review discusses how these changes increase the risk of extinction, particularly for species with specific habitat requirements. 

b. Range Shifts and Phenological Changes:

Observations of range shifts and changes in the timing of biological events (phenology) are documented in response to changing climatic conditions (Parmesan & Yohe, 2003). These shifts affect ecosystems and may lead to mismatches between species and their resources. 

c. Ocean Acidification and Coral Reefs:

The review explores the impact of climate change on marine biodiversity, emphasizing ocean acidification’s threat to coral reefs (Hoegh-Guldberg et al., 2007). Changes in pH levels negatively affect coral calcification, disrupting the delicate balance of marine ecosystems. 

d. Adaptive Strategies and Conservation Efforts:

Recognizing the urgency of the situation, the literature review discusses various adaptive strategies adopted by species and conservation efforts aimed at mitigating the impacts of climate change on biodiversity (Hannah et al., 2007). It emphasizes the importance of interdisciplinary approaches for effective conservation planning. 

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Writing a literature review involves summarizing and synthesizing existing research on a particular topic. A good literature review format should include the following elements. 

Introduction: The introduction sets the stage for your literature review, providing context and introducing the main focus of your review. 

• Opening Statement: Begin with a general statement about the broader topic and its significance in the field. 
• Scope and Purpose: Clearly define the scope of your literature review. Explain the specific research question or objective you aim to address. 
• Organizational Framework: Briefly outline the structure of your literature review, indicating how you will categorize and discuss the existing research. 
• Significance of the Study: Highlight why your literature review is important and how it contributes to the understanding of the chosen topic. 
• Thesis Statement: Conclude the introduction with a concise thesis statement that outlines the main argument or perspective you will develop in the body of the literature review. 

Body: The body of the literature review is where you provide a comprehensive analysis of existing literature, grouping studies based on themes, methodologies, or other relevant criteria. 

• Organize by Theme or Concept: Group studies that share common themes, concepts, or methodologies. Discuss each theme or concept in detail, summarizing key findings and identifying gaps or areas of disagreement. 
• Critical Analysis: Evaluate the strengths and weaknesses of each study. Discuss the methodologies used, the quality of evidence, and the overall contribution of each work to the understanding of the topic. 
• Synthesis of Findings: Synthesize the information from different studies to highlight trends, patterns, or areas of consensus in the literature. 
• Identification of Gaps: Discuss any gaps or limitations in the existing research and explain how your review contributes to filling these gaps. 
• Transition between Sections: Provide smooth transitions between different themes or concepts to maintain the flow of your literature review. 

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Conclusion: The conclusion of your literature review should summarize the main findings, highlight the contributions of the review, and suggest avenues for future research. 

• Summary of Key Findings: Recap the main findings from the literature and restate how they contribute to your research question or objective. 
• Contributions to the Field: Discuss the overall contribution of your literature review to the existing knowledge in the field. 
• Implications and Applications: Explore the practical implications of the findings and suggest how they might impact future research or practice. 
• Recommendations for Future Research: Identify areas that require further investigation and propose potential directions for future research in the field. 
• Final Thoughts: Conclude with a final reflection on the importance of your literature review and its relevance to the broader academic community. 

Conducting a literature review

Conducting a literature review is an essential step in research that involves reviewing and analyzing existing literature on a specific topic. It’s important to know how to do a literature review effectively, so here are the steps to follow: 1  

Choose a Topic and Define the Research Question:

• Select a topic that is relevant to your field of study. 
• Clearly define your research question or objective. Determine what specific aspect of the topic do you want to explore? 

Decide on the Scope of Your Review:

• Determine the timeframe for your literature review. Are you focusing on recent developments, or do you want a historical overview? 
• Consider the geographical scope. Is your review global, or are you focusing on a specific region? 
• Define the inclusion and exclusion criteria. What types of sources will you include? Are there specific types of studies or publications you will exclude? 

Select Databases for Searches:

• Identify relevant databases for your field. Examples include PubMed, IEEE Xplore, Scopus, Web of Science, and Google Scholar. 
• Consider searching in library catalogs, institutional repositories, and specialized databases related to your topic. 

Conduct Searches and Keep Track:

• Develop a systematic search strategy using keywords, Boolean operators (AND, OR, NOT), and other search techniques. 
• Record and document your search strategy for transparency and replicability. 
• Keep track of the articles, including publication details, abstracts, and links. Use citation management tools like EndNote, Zotero, or Mendeley to organize your references. 

Review the Literature:

• Evaluate the relevance and quality of each source. Consider the methodology, sample size, and results of studies. 
• Organize the literature by themes or key concepts. Identify patterns, trends, and gaps in the existing research. 
• Summarize key findings and arguments from each source. Compare and contrast different perspectives. 
• Identify areas where there is a consensus in the literature and where there are conflicting opinions. 
• Provide critical analysis and synthesis of the literature. What are the strengths and weaknesses of existing research? 

Organize and Write Your Literature Review:

• Literature review outline should be based on themes, chronological order, or methodological approaches. 
• Write a clear and coherent narrative that synthesizes the information gathered. 
• Use proper citations for each source and ensure consistency in your citation style (APA, MLA, Chicago, etc.). 
• Conclude your literature review by summarizing key findings, identifying gaps, and suggesting areas for future research. 

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How to write a literature review faster with Paperpal?

Paperpal, an AI writing assistant, integrates powerful academic search capabilities within its writing platform. With the Research feature, you get 100% factual insights, with citations backed by 250M+ verified research articles, directly within your writing interface with the option to save relevant references in your Citation Library. By eliminating the need to switch tabs to find answers to all your research questions, Paperpal saves time and helps you stay focused on your writing.   

Here’s how to use the Research feature:  

• Ask a question: Get started with a new document on paperpal.com. Click on the “Research” feature and type your question in plain English. Paperpal will scour over 250 million research articles, including conference papers and preprints, to provide you with accurate insights and citations. 
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• Cite with Confidence: Paperpal makes it easy to incorporate relevant citations and references into your writing, ensuring your arguments are well-supported by credible sources. This translates to a polished, well-researched literature review. 

The literature review sample and detailed advice on writing and conducting a review will help you produce a well-structured report. But remember that a good literature review is an ongoing process, and it may be necessary to revisit and update it as your research progresses. By combining effortless research with an easy citation process, Paperpal Research streamlines the literature review process and empowers you to write faster and with more confidence. Try Paperpal Research now and see for yourself.  

Frequently asked questions

A literature review is a critical and comprehensive analysis of existing literature (published and unpublished works) on a specific topic or research question and provides a synthesis of the current state of knowledge in a particular field. A well-conducted literature review is crucial for researchers to build upon existing knowledge, avoid duplication of efforts, and contribute to the advancement of their field. It also helps researchers situate their work within a broader context and facilitates the development of a sound theoretical and conceptual framework for their studies.

Literature review is a crucial component of research writing, providing a solid background for a research paper’s investigation. The aim is to keep professionals up to date by providing an understanding of ongoing developments within a specific field, including research methods, and experimental techniques used in that field, and present that knowledge in the form of a written report. Also, the depth and breadth of the literature review emphasizes the credibility of the scholar in his or her field.  

Before writing a literature review, it’s essential to undertake several preparatory steps to ensure that your review is well-researched, organized, and focused. This includes choosing a topic of general interest to you and doing exploratory research on that topic, writing an annotated bibliography, and noting major points, especially those that relate to the position you have taken on the topic. 

Literature reviews and academic research papers are essential components of scholarly work but serve different purposes within the academic realm. 3 A literature review aims to provide a foundation for understanding the current state of research on a particular topic, identify gaps or controversies, and lay the groundwork for future research. Therefore, it draws heavily from existing academic sources, including books, journal articles, and other scholarly publications. In contrast, an academic research paper aims to present new knowledge, contribute to the academic discourse, and advance the understanding of a specific research question. Therefore, it involves a mix of existing literature (in the introduction and literature review sections) and original data or findings obtained through research methods. 

Literature reviews are essential components of academic and research papers, and various strategies can be employed to conduct them effectively. If you want to know how to write a literature review for a research paper, here are four common approaches that are often used by researchers.  Chronological Review: This strategy involves organizing the literature based on the chronological order of publication. It helps to trace the development of a topic over time, showing how ideas, theories, and research have evolved.  Thematic Review: Thematic reviews focus on identifying and analyzing themes or topics that cut across different studies. Instead of organizing the literature chronologically, it is grouped by key themes or concepts, allowing for a comprehensive exploration of various aspects of the topic.  Methodological Review: This strategy involves organizing the literature based on the research methods employed in different studies. It helps to highlight the strengths and weaknesses of various methodologies and allows the reader to evaluate the reliability and validity of the research findings.  Theoretical Review: A theoretical review examines the literature based on the theoretical frameworks used in different studies. This approach helps to identify the key theories that have been applied to the topic and assess their contributions to the understanding of the subject.  It’s important to note that these strategies are not mutually exclusive, and a literature review may combine elements of more than one approach. The choice of strategy depends on the research question, the nature of the literature available, and the goals of the review. Additionally, other strategies, such as integrative reviews or systematic reviews, may be employed depending on the specific requirements of the research.

The literature review format can vary depending on the specific publication guidelines. However, there are some common elements and structures that are often followed. Here is a general guideline for the format of a literature review:  Introduction:   Provide an overview of the topic.  Define the scope and purpose of the literature review.  State the research question or objective.  Body:   Organize the literature by themes, concepts, or chronology.  Critically analyze and evaluate each source.  Discuss the strengths and weaknesses of the studies.  Highlight any methodological limitations or biases.  Identify patterns, connections, or contradictions in the existing research.  Conclusion:   Summarize the key points discussed in the literature review.  Highlight the research gap.  Address the research question or objective stated in the introduction.  Highlight the contributions of the review and suggest directions for future research.

Both annotated bibliographies and literature reviews involve the examination of scholarly sources. While annotated bibliographies focus on individual sources with brief annotations, literature reviews provide a more in-depth, integrated, and comprehensive analysis of existing literature on a specific topic. The key differences are as follows: 

References 

• Denney, A. S., & Tewksbury, R. (2013). How to write a literature review.  Journal of criminal justice education ,  24 (2), 218-234. 
• Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Taylor & Francis. 
• Cantero, C. (2019). How to write a literature review.  San José State University Writing Center . 

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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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A literature review surveys prior research published in books, scholarly articles, and any other sources relevant to a particular issue, area of research, or theory, and by so doing, provides a description, summary, and critical evaluation of these works in relation to the research problem being investigated. Literature reviews are designed to provide an overview of sources you have used in researching a particular topic and to demonstrate to your readers how your research fits within existing scholarship about the topic.

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

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

Given this, the purpose of a literature review is to:

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

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

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 primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the 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 a number of approaches you could adopt depending upon the type of analysis underpinning your study.

Argumentative Review This form examines literature selectively in order to support or refute an argument, deeply embedded 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 make summary claims of the sort found in systematic reviews [see below].

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 or research problems. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication. This is the most common form of review in the social sciences.

Historical Review Few things rest in isolation from historical precedent. Historical literature reviews focus 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 [findings], but how they came about saying what they say [method of analysis]. Reviewing methods of analysis provides a framework of understanding at different levels [i.e. those of theory, substantive fields, research approaches, and data collection and analysis techniques], how researchers draw upon 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. This approach helps highlight ethical issues which you should be aware of and consider as you go through your own 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 analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . 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?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

Theoretical Review The purpose of this form is to examine the corpus of theory that has accumulated in regard to an issue, concept, theory, phenomena. The theoretical literature review helps to 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.

NOTE: Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

• An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
• Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most convincing or least convincing?
• Validity -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Basic Stages of Writing 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources would be appropriate to include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources in any way beyond evaluating how they relate to understanding the research problem? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read, such as required readings in the course syllabus, are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make the act of reviewing easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for recent books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] A thematic literature review is the most common approach to summarizing prior research in the social and behavioral sciences. Thematic reviews are organized around a topic or issue, rather than the progression of time, although the progression of time may still be incorporated into a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it would still be organized chronologically reflecting technological developments in media. The difference in this example between a "chronological" and a "thematic" approach is what is emphasized the most: themes related to the role of the Internet in presidential politics. Note that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point being made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. However, only include what is necessary for the reader to locate your study within the larger scholarship about the research problem.

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

• Current Situation : Information necessary to understand the current topic or focus of the literature review.
• Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
• History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
• Standards : Description of the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information, but that are not key to understanding the research problem, can be included in a list of further readings . Use Quotes Sparingly Some short quotes are appropriate if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, is not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for using your own words in reviewing the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work and the work of others. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

• Sources in your literature review do not clearly relate to the research problem;
• You do not take sufficient time to define and identify the most relevant sources to use in the literature review related to the research problem;
• Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
• Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• Does not describe the search procedures that were used in identifying the literature to review;
• Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
• Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout. Online Writing Center. Liberty University; Literature Reviews. The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation. vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It. University College Writing Centre. University of Toronto; Writing a Literature Review. Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

• How are they organizing their ideas?
• What methods have they used to study the problem?
• What theories have been used to explain, predict, or understand their research problem?
• What sources have they cited to support their conclusions?
• How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

• Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
• Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
• Search Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review [see next sub-tab]. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

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Literature Review Guide

The literature review, database search tips.

• Back to Research Help
• What is a Literature Review?
• Plan Your Literature Review
• Identify a Research Gap
• Define Your Research Question
• Search the Literature
• Analyze Your Research Results
• Manage Research Results
• Write the Literature Review

What is a Literature Review?  What is its purpose?

The purpose of a literature review is to offer a  comprehensive review of scholarly literature on a specific topic along with an  evaluation of the strengths and weaknesses of authors' arguments . In other words, you are summarizing research available on a certain topic and then drawing conclusions about researchers' findings. To make gathering research easier, be sure to start with a narrow/specific topic and then widen your topic if necessary.

A thorough literature review provides an accurate description of current knowledge on a topic and identifies areas for future research.  Are there gaps or areas that require further study and exploration? What opportunities are there for further research? What is missing from my collection of resources? Are more resources needed?

It is important to note that conclusions described in the literature you gather may contradict each other completely or in part.  Recognize that knowledge creation is collective and cumulative.  Current research is built upon past research findings and discoveries.  Research may bring previously accepted conclusions into question.  A literature review presents current knowledge on a topic and may point out various academic arguments within the discipline.

What a Literature Review is not

• A literature review is not an annotated bibliography .  An annotated bibliography provides a brief summary, analysis, and reflection of resources included in the bibliography.  Often it is not a systematic review of existing research on a specific subject.  That said, creating an annotated bibliography throughout your research process may be helpful in managing the resources discovered through your research.
• A literature review is not a research paper .  A research paper explores a topic and uses resources discovered through the research process to support a position on the topic.  In other words, research papers present one side of an issue.  A literature review explores all sides of the research topic and evaluates all positions and conclusions achieved through the scientific research process even though some conclusions may conflict partially or completely.

From the Online Library

SAGE Research Methods is a web-based research methods tool that covers quantitative, qualitative and mixed methods. Researchers can explore methods and concepts to help design research projects, understand a particular method or identify a new method, and write up research. Sage Research Methods focuses on methodology rather than disciplines, and is of potential use to researchers from the social sciences, health sciences and other research areas.

• Sage Research Methods Project Planner - Reviewing the Literature View the resources and videos for a step-by-step guide to performing a literature review.

The Literature Review: Step by Step

Follow this step-by-step process by using the related tabs in this Guide.

• Define your Research question
• Analyze the material you’ve found
• Manage the results of your research
• Write your Review

Getting Started

Consider the following questions as you develop your research topic, conduct your research, and begin evaluating the resources discovered in the research process:

• What is known about the subject?
• Are there any gaps in the knowledge of the subject?
• Have areas of further study been identified by other researchers that you may want to consider?
• Who are the significant research personalities in this area?
• Is there consensus about the topic?
• What aspects have generated significant debate on the topic?
• What methods or problems were identified by others studying in the field and how might they impact your research?
• What is the most productive methodology for your research based on the literature you have reviewed?
• What is the current status of research in this area?
• What sources of information or data were identified that might be useful to you?
• How detailed? Will it be a review of ALL relevant material or will the scope be limited to more recent material, e.g., the last five years.
• Are you focusing on methodological approaches; on theoretical issues; on qualitative or quantitative research?

What is Academic Literature?

What is the difference between popular and scholarly literature?

To better understand the differences between popular and scholarly articles, comparing characteristics and purpose of the publications where these articles appear is helpful.

Popular Article (Magazine)

• Articles are shorter and are written for the general public
• General interest topics or current events are covered
• Language is simple and easy to understand
• Source material is not cited
• Articles often include glossy photographs, graphics, or visuals
• Articles are written by the publication's staff of journalists
• Articles are edited and information is fact checked

Examples of magazines that contain popular articles:

Scholarly Article (Academic Journal)

• Articles are written by scholars and researchers for academics, professionals, and experts in the field
• Articles are longer and report original research findings
• Topics are narrower in focus and provide in-depth analysis
• Technical or scholarly language is used
• Source material is cited
• Charts and graphs illustrating research findings are included
• Many are  "peer reviewed"  meaning that panels of experts review articles submitted for publication to ensure that proper research methods were used and research findings are contributing something new to the field before selecting for publication.

Examples of academic journals that contain scholarly articles:

Define your research question

Selecting a research topic can be overwhelming.  Consider following these steps:

1.  Brainstorm  research topic ideas

      - Free write: Set a timer for five minutes and write down as many ideas as you can in the allotted time

      -  Mind-Map  to explore how ideas are related

2.  Prioritize  topics based on personal interest and curiosity

3.  Pre-research

      - Explore encyclopedias and reference books for background information on the topic

      - Perform a quick database or Google search on the topic to explore current issues. 

4.  Focus the topic  by evaluating how much information is available on the topic

         - Too much information?  Consider narrowing the topic by focusing on a specific issue 

         - Too little information?  Consider broadening the topic 

5.  Determine your purpose  by considering whether your research is attempting to:

         - further the research on this topic

         - fill a gap in the research

         - support existing knowledge with new evidence

         - take a new approach or direction

         - question or challenge existing knowledge

6.  Finalize your research question

NOTE:  Be aware that your initial research question may change as you conduct research on your topic.

Searching the Literature

Research on your topic should be conducted in the academic literature.  The  Rasmussen University Online Library contains subject-focused databases that contain the leading academic journals in your programmatic area.

Consult the  Using the Online Library video tutorials  for information about how to effectively search library databases.

Watch the video below for tips on how to create a search statement that will provide relevant results

Need help starting your research?  Make a  research appointment with a Rasmussen Librarian .

TIP:  Document as you research.  Begin building your references list using the citation managers in one of these resources:

• APA Academic Writer
• NoodleTools

Recommended programmatic databases include:

Data Science

Coverage includes computer engineering, computer theory & systems, research and development, and the social and professional implications of new technologies. Articles come from more than 1,900 academic journals, trade magazines, and professional publications.

Provides access to full-text peer-reviewed journals, transactions, magazines, conference proceedings, and published standards in the areas of electrical engineering, computer science, and electronics. It also provides access to the IEEE Standards Dictionary Online. Full-text available.

Computing, telecommunications, art, science and design databases from ProQuest.

Healthcare Management

Articles from scholarly business journals back as far as 1886 with content from all disciplines of business, including marketing, management, accounting, management information systems, production and operations management, finance, and economics. Contains 55 videos from the Harvard Faculty Seminar Series, on topics such as leadership, sustaining competitive advantage, and globalization. To access the videos, click "More" in the blue bar at the top. Select "Images/ Business Videos." Uncheck "Image Quick View Collection" to indicate you only wish to search for videos. Enter search terms.

Provides a truly comprehensive business research collection. The collection consists of the following databases and more: ABI/INFORM Complete, ProQuest Entrepreneurship, ProQuest Accounting & Tax, International Bibliography of Social Sciences (IBSS), ProQuest Asian Business and Reference, and Banking Information Source.

The definitive research tool for all areas of nursing and allied health literature. Geared towards the needs of nurses and medical professionals. Covers more than 750 journals from 1937 to present.

HPRC provides information on the creation, implementation and study of health care policy and the health care system. Topics covered include health care administration, economics, planning, law, quality control, ethics, and more.

PolicyMap is an online mapping site that provides data on demographics, real estate, health, jobs, and other areas across the U.S. Access and visualize data from Census and third-party records.

Human Resources

Articles from all subject areas gathered from more than 11,000 magazines, journals, books and reports. Subjects include astronomy, multicultural studies, humanities, geography, history, law, pharmaceutical sciences, women's studies, and more. Coverage from 1887 to present. Start your research here.

Cochrane gathers and summarizes the best evidence from research to help you make informed choices about treatments. Whether a doctor or nurse, patient, researcher or student, Cochrane evidence provides a tool to enhance your healthcare knowledge and decision making on topics ranging from allergies, blood disorders, and cancer, to mental health, pregnancy, urology, and wounds.

Health sciences, biology, science, and pharmaceutical information from ProQuest. Includes articles from scholarly, peer-reviewed journals, practical and professional development content from professional journals, and general interest articles from magazines and newspapers.

Joanna Briggs Institute Academic Collection contains evidence-based information from across the globe, including evidence summaries, systematic reviews, best practice guidelines, and more. Subjects include medical, nursing, and healthcare specialties.

Comprehensive source of full-text articles from more than 1,450 scholarly medical journals.

Articles from more than 35 nursing journals in full text, searchable as far back as 1995.

Analyzing Your Research Results

You have completed your research and discovered many, many academic articles on your topic.  The next step involves evaluating and organizing the literature found in the research process.

As you review, keep in mind that there are three types of research studies:

• Quantitative
• Qualitative 
• Mixed Methods

Consider these questions as you review the articles you have gathered through the research process:

1. Does the study relate to your topic?

2. Were sound research methods used in conducting the study?

3. Does the research design fit the research question? What variables were chosen? Was the sample size adequate?

4. What conclusions were drawn?  Do the authors point out areas for further research?

Reading Academic Literature

Academic journals publish the results of research studies performed by experts in an academic discipline.  Articles selected for publication go through a rigorous peer-review process.  This process includes a thorough evaluation of the research submitted for publication by journal editors and other experts or peers in the field.  Editors select articles based on specific criteria including the research methods used, whether the research contributes new findings to the field of study, and how the research fits within the scope of the academic journal.  Articles selected often go through a revision process prior to publication.

Most academic journal articles include the following sections:

• Abstract    (An executive summary of the study)
• Introduction  (Definition of the research question to be studied)
• Literature Review  (A summary of past research noting where gaps exist)
• Methods  (The research design including variables, sample size, measurements)
• Data   (Information gathered through the study often displayed in tables and charts)
• Results   (Conclusions reached at the end of the study)
• Conclusion   (Discussion of whether the study proved the thesis; may suggest opportunities for further research)
• Bibliography  (A list of works cited in the journal article)

TIP:  To begin selecting articles for your research, read the   highlighted sections   to determine whether the academic journal article includes information relevant to your research topic.

Step 1: Skim the article

When sorting through multiple articles discovered in the research process, skimming through these sections of the article will help you determine whether the article will be useful in your research.

1.  Article title   and subject headings assigned to the article

2.   Abstract

3.   Introduction

4.  Conclusion

If the article fits your information need, go back and  read the article thoroughly.

TIP:  Create a folder on your computer to save copies of articles you plan to use in your thesis or research project.  Use  NoodleTools  or  APA Academic Writer  to save APA references.

Step 2: Determine Your Purpose

Think about how you will evaluate the academic articles you find and how you will determine whether to include them in your research project.  Ask yourself the following questions to focus your search in the academic literature:

• ​Are you looking for an overview of a topic? an explanation of a specific concept, idea, or position?
• Are you exploring gaps in the research to identify a new area for academic study?
• Are you looking for research that supports or disagrees with your thesis or research question?
• Are you looking for examples of a research design and/or research methods you are considering for your own research project?

Step 3: Read Critically

Before reading the article, ask yourself the following:

• What is my research question?  What position am I trying to support?
• What do I already know about this topic?  What do I need to learn?
• How will I evaluate the article?  Author's reputation? Research design? Treatment of topic? 
• What are my biases about the topic?

As you read the article make note of the following:

• Who is the intended audience for this article?
• What is the author's purpose in writing this article?
• What is the main point?
• How was the main point proven or supported?  
• Were scientific methods used in conducting the research?
• Do you agree or disagree with the author? Why?
• How does this article compare or connect with other articles on the topic?
• Does the author recommend areas for further study?
• How does this article help to answer your research question?

Managing your Research

Tip:  Create APA references for resources as you discover them in the research process

Use APA Academic Writer or NoodleTools to generate citations and manage your resources.  Find information on how to use these resources in the Citation Tools Guide .

Writing the Literature Review

Once research has been completed, it is time to structure the literature review and begin summarizing and synthesizing information.  The following steps may help with this process:

• Chronological
• By research method used
• Explore contradictory or conflicting conclusions
• Read each study critically
• Critique methodology, processes, and conclusions
• Consider how the study relates to your topic

• Description of public health nursing nutrition assessment and interventions for home‐visited women. This article provides a nice review of the literature in the article introduction. You can see how the authors have used the existing literature to make a case for their research questions. more... less... Horning, M. L., Olsen, J. M., Lell, S., Thorson, D. R., & Monsen, K. A. (2018). Description of public health nursing nutrition assessment and interventions for home‐visited women. Public Health Nursing, 35(4), 317–326. https://doi.org/10.1111/phn.12410
• Improving Diabetes Self-Efficacy in the Hispanic Population Through Self-Management Education Doctoral papers are a good place to see how literature reviews can be done. You can learn where they searched, what search terms they used, and how they decided which articles were included. Notice how the literature review is organized around the three main themes that came out of the literature search. more... less... Robles, A. N. (2023). Improving diabetes self-efficacy in the hispanic population through self-management education (Order No. 30635901). Available from ProQuest Dissertations & Theses Global: The Sciences and Engineering Collection. https://www.proquest.com/dissertations-theses/improving-diabetes-self-efficacy-hispanic/docview/2853708553/se-2
• Exploring mediating effects between nursing leadership and patient safety from a person-centred perspective: A literature review Reading articles that publish the results of a systematic literature review is a great way to see in detail how a literature review is conducted. These articles provide an article matrix, which provides you an example of how you can document information about the articles you find in your own search. To see more examples, include "literature review" or "systematic review" as a search term. more... less... Wang, M., & Dewing, J. (2021). Exploring mediating effects between nursing leadership and patient safety from a person‐centred perspective: A literature review. Journal of Nursing Management, 29(5), 878–889. https://doi.org/10.1111/jonm.13226
• Boolean Operators
• Keywords vs. Subjects
• Creating a Search String
• Library databases are collections of resources that are searchable, including full-text articles, books, and encyclopedias.
• Searching library databases is different than searching Google. Best results are achieved when using Keywords linked with Boolean Operators . 
• Applying Limiters such as full-text, publication date, resource type, language, geographic location, and subject help to refine search results.
• Utilizing Phrases or Fields , in addition to an awareness of Stop Words , can focus your search and retrieve more useful results.
• Have questions? Ask a Librarian

Boolean Operators connect keywords or concepts logically to retrieve relevant articles, books, and other resources.  There are three Boolean Operators:

Using AND 

• Narrows search results
• Connects two or more keywords/concepts
• All keywords/concepts connected with "and" must be in an article or resource to appear in the search results list

Venn diagram of the AND connector

Example: The result list will include resources that include both keywords -- "distracted driving" and "texting" -- in the same article or resource, represented in the shaded area where the circles intersect (area shaded in purple).

• Broadens search results ("OR means more!")
• Connects two or more synonyms or related keywords/concepts
• Resources appearing in the results list will include any of the terms connected with the OR connector

Venn diagram of the OR connector

Example:  The result list will include resources that include the keyword "texting" OR the keyword "cell phone" (entire area shaded in blue); either is acceptable.

• Excludes keywords or concepts from the search
• Narrows results by removing resources that contain the keyword or term connected with the NOT connector
• Use sparingly

Venn diagram of the NOT connector

Example: The result list will include all resources that include the term "car" (green area) but will exclude any resource that includes the term "motorcycle" (purple area) even though the term car may be present in the resource.

A library database searches for keywords throughout the entire resource record including the full-text of the resource, subject headings, tags, bibliographic information, etc.

• Natural language words or short phrases that describe a concept or idea
• Can retrieve too few or irrelevant results due to full-text searching (What words would an author use to write about this topic?)
• Provide flexibility in a search
• Must consider synonyms or related terms to improve search results
• TIP: Build a Keyword List

Example:  The keyword list above was developed to find resources that discuss how texting while driving results in accidents.  Notice that there are synonyms (texting and "text messaging"), related terms ("cell phones" and texting), and spelling variations ("cell phone" and cellphone).  Using keywords when searching full text requires consideration of various words that express an idea or concept.

• Subject Headings
• Predetermined "controlled vocabulary" database editors apply to resources to describe topical coverage of content
• Can retrieve more precise search results because every article assigned that subject heading will be retrieved.
• Provide less flexibility in a search
• Can be combined with a keyword search to focus search results.
• TIP: Consult database subject heading list or subject headings assigned to relevant resources

Example 1: In EBSCO's Academic Search Complete, clicking on the "Subject Terms" tab provides access to the entire subject heading list used in the database.  It also allows a search for specific subject terms.

Example 2:  A subject term can be incorporated into a keyword search by clicking on the down arrow next to "Select a Field" and selecting "Subject Terms" from the dropdown list.  Also, notice how subject headings are listed below the resource title, providing another strategy for discovering subject headings used in the database.

When a search term is more than one word, enclose the phrase in quotation marks to retrieve more precise and accurate results.  Using quotation marks around a term will search it as a "chunk," searching for those particular words together in that order within the text of a resource. 

"cell phone"

"distracted driving"

"car accident"

TIP: In some databases, neglecting to enclose phrases in quotation marks will insert the AND Boolean connector between each word resulting in unintended search results.

Truncation provides an option to search for a root of a keyword in order to retrieve resources that include variations of that word.  This feature can be used to broaden search results, although some results may not be relevant.  To truncate a keyword, type an asterisk (*) following the root of the word.

For example:

Library databases provide a variety of tools to limit and refine search results.  Limiters provide the ability to limit search results to resources having specified characteristics including:

• Resource type
• Publication date
• Geographic location

In both the EBSCO and ProQuest databases, the limiting tools are located in the left panel of the results page.

                                                 EBSCO                                                     ProQuest

The short video below provides a demonstration of how to use limiters to refine a list of search results.

Each resource in a library database is stored in a record.  In addition to the full-text of the resources, searchable Fields are attached that typically include:

• Journal title
• Date of Publication

Incorporating Fields into your search can assist in focusing and refining search results by limiting the results to those resources that include specific information in a particular field.

In both EBSCO and ProQuest databases, selecting the Advanced Search option will allow Fields to be included in a search.

For example, in the Advanced Search option in EBSCO's Academic Search Complete database, clicking on the down arrow next to "Select a Field" provides a list of fields that can be searched within that database.  Select the field and enter the information in the text box to the left to use this feature.

Stop words are short, commonly used words--articles, prepositions, and pronouns-- that are automatically dropped from a search.  Typical stop words include:

In library databases, a stop word will not be searched even if it is included in a phrase enclosed in quotation marks.  In some instances, a word will be substituted for the stop word to allow for the other words in the phrase to be searched in proximity to one another within the text of the resource.

For example, if you searched company of America, your result list will include these variatons:

• company in America
• company of America
• company for America

Creating an Search String

This short video demonstrates how to create a search string -- keywords connected with Boolean operators -- to use in a library database search to retrieve relevant resources for any research assignment.

• Database Search Menu Template Use this search menu template to plan a database search.
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Substance Use Treatment Programs

Youth substance use treatment programs aim to reduce alcohol and illicit drug use, and the misuse of licit drugs, in youths who have been clinically diagnosed with a substance use problem. These programs differ from prevention programs, which aim to promote abstinence in youths to prevent their initial or escalating use. [1] Treatment programs can take a multitude of approaches, such as court-based, residential-based, and family-inclusive programs to help youth develop skills and knowledge to reduce substance use (Drake, 2012; Van Ryzin et al., 2016; Winters, Botzet, and Fahnhorst, 2011).

Substance use disorder in youth is a prevalent problem. An estimated 2.8 percent (712,000) of youths ages 12 to 17 experienced an alcohol use disorder in the past year, and 6.3 percent (1.6 million) of youths ages 12 to 17 experienced a substance use disorder in the past year (SAMSHA, 2021). However, the rate of utilization of substance use treatment programs is low. According to a study by Haughwout and colleagues (2016), fewer than 12 percent of youths who have a substance use disorder participate in treatment.

This literature review focuses on substance use disorder among youths under 18 and on the utilization of substance use treatment programs. The review describes the scope of substance use among youth, the theoretical base of substance-use treatment programs, risk factors that can lead to substance use disorders, protective factors that can buffer against substance use disorders, various types of treatment programs and outcome evidence, limitations to treatment programs, and the research currently available.

[1] For more information, see the Model Programs Guide literature review on Substance Use Prevention Programs .

Scope of the Problem

Overview of substance use disorders.

Among youth in the United States, it is estimated that 8 percent will experience an alcohol use disorder, and 2 percent to 3 percent will experience an illicit drug use disorder before turning 18 Merikangas et al., 2010; Swendsen et al., 2012; SAMSHA, 2011). Several surveys collect information on youths' self-reported use of alcohol and their use of illicit [1] and licit [2] drugs. These self-reported data are then used to calculate the prevalence rates of youth substance use (such as 30-day prevalence in alcohol use or past-year use of narcotics). However, few surveys collect information specifically regarding the prevalence of substance use disorders in youth. Substance use disorder is a diagnosable condition of ongoing and habitual use, and is distinct from substance use, which refers to episodes of occasional use. Most of the information provided below on prevalence rates of youth substance use disorders (and specific disorders such as alcohol use disorder) come from one survey, the National Survey on Drug Use and Health ( NSDUH ), which is the most comprehensive and up-to-date federal survey.

The NSDUH is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) and collects national and state-level data annually from all 50 states and the District of Columbia. In 2020, more than 36,000 people ages 12 and older were surveyed, including 6,337 interviews conducted with youths ages 12 to 17. Findings pertaining to substance use disorders—including alcohol use disorder, illicit drug use disorder, and more-specific disorders resulting from marijuana, cocaine, heroin, prescription pain reliever, or opioid use—are presented in an annual report.

In general, rates of substance use disorder among youth have declined and leveled off since the first decade of the 2000s. Specifically, among 12- to 17-year-olds, past-year alcohol use disorder declined from 5.9 percent (or 1.5 million youths) in 2002 to 1.7 percent (or 414,000 youths) in 2019. Within the same age group, 3.4 percent (or 894,000 youths) had a past-year illicit drug use disorder in 2019, which was higher than estimates in 2017 and 2018, but similar to estimates in 2015 and 2016. [3

In 2020 the NSDUH used the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM–5 ) criteria to assess substance use disorder. The DSM-5 is the most current diagnostic tool published by the American Psychiatric Association (APA), and it serves as the principal authority for psychiatric diagnoses. Previous surveys used the DSM–4 criteria, meaning that the 2020 findings cannot be easily compared with previous years. In 2020, respondents were identified as having a substance use disorder if they met two or more of the following criteria in a 12-month period: 

• Consuming the substance in larger amounts or over a longer period of time than intended.
• Desiring to cut back on or stop use of the substance but being unsuccessful in these attempts.
• Spending a significant amount of time obtaining, using, or recovering from using the substance.
• Experiencing cravings and urges to use the substance.
• Failing to meet school, home, or work obligations because of substance use.
• Continuing to use the substance despite problems it has caused.
• Giving up important social, occupational, or recreational activities because of substance use.
• Continuing to use substances, even in situations where it is physically dangerous.
• Continuing to use substances, despite having physical or psychological problems that may have been caused or made worse by the substance.
• Needing more of the substance to achieve the desired effect (increased tolerance).
• Development of withdrawal symptoms, which can be relieved by taking more of the substance.

Using these criteria, it was estimated that 6.3 percent (1.6 million) of youths ages 12 to 17 experienced a substance use disorder in the past year (SAMHSA, 2021).

Alcohol Use Disorder

Alcohol is the most commonly used drug among youth (NIAAA, 2022). According to the 2020 NSDUH, 8.2 percent of youths reported using alcohol in the past month, 4.1 percent reported binge alcohol use, and 0.6 percent reported heavy alcohol use [4] in the past month (SAMHSA, 2021). However, while any alcohol use by youths is problematic, not all youths who drink alcohol meet the criteria for an alcohol use disorder.

The NSDUH identified respondents as having alcohol use disorder if they had used alcohol on 6 or more days in the past 12 months and if they also met two or more of the DSM–5 criteria for alcohol use disorder. The criteria for alcohol use disorder are as follows:

• Used alcohol in larger amounts or for a longer time period than intended.
• Had a persistent desire or made unsuccessful attempts to cut down on alcohol use.
• Spent a great deal of time in activities to obtain, use, or recover from alcohol use.
• Felt a craving or strong desire to use alcohol.
• Engaged in recurrent alcohol use resulting in failure to fulfill major role obligations at work, school, or home.
• Continued to use alcohol despite social or interpersonal problems caused by the effects of alcohol.
• Gave up or reduced important social, occupational, or recreational activities because of alcohol use.
• Continued to use alcohol in physically hazardous situations.
• Continued to use alcohol despite physical or psychological problems caused by alcohol use.
• Developed tolerance (i.e., needed to use alcohol more than before to get desired effects or noticing that the same amount of alcohol had less effect than before.
• Experienced a required number of withdrawal symptoms after cutting back or stopping alcohol use.

Based on these requirements, the NSDUH estimated that 2.8 percent (712,000) of youths ages 12 to 17 experienced alcohol use disorder in the past year.

Illicit Drug Use Disorder

Many youths experiment with illicit drugs, in addition to alcohol. In 2020, 13.8 percent of youths who responded to the NSDUH indicated past-year illicit drug use (SAMHSA, 2021). However, not all youths who engage in illicit drug use will meet the criteria for an illicit drug use disorder.

The NSDUH identified respondents as having an illicit drug use disorder if they met the DSM–5 substance use disorder criteria (described above under Overview of Substance Use Disorders) for one or more of the following illicit drugs: marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine, or prescription psychotherapeutic drugs (stimulants, tranquilizers or sedatives, and pain relievers). For respondents whose drug use concentrated on a certain substance, specific disorders (such as marijuana use disorder, opioid use disorder, prescription pain reliever use disorder, cocaine use disorder, and heroin use disorder) were included.

In 2020, using past-year use rates among 12- to 17-year-olds, the NSDUH (SAMHSA, 2021) estimated that 4.9 percent (1.4 million youths) met criteria for at least one illicit drug use disorder. Specifically:

• 4.1 percent (1 million youths) met criteria for marijuana use disorder.
• 0.3 percent (80,000 youths) met criteria for opioid use disorder.
• 0.3 percent (80,000 youths) met criteria for prescription pain reliever use disorder.
• 0.1 percent (28,000 youths) met criteria for cocaine use disorder.
• Estimates for heroin use disorder could not be calculated with sufficient precision.

Co-Occurring Mental Health Disorders and Substance Use Disorders Among Youth

Youth substance use and mental health problems are commonly experienced simultaneously; an estimated 60 percent to 75 percent of youths with substance use disorders also have a co-occurring mental health disorder (Torrens et al., 2012; Burkstein and Horner, 2010; Chan, Dennis, and Funk, 2008; Turner et al., 2004; Hoffman et al., 2004). Common co-occurring mental health problems include conduct disorder, Attention Deficit Hyperactivity Disorder (ADHD), mood disorders, and trauma-related disorders (Burkstein and Horner, 2010).

Youths may turn to alcohol or drugs to help alleviate symptoms associated with mental health disorders, such as hopelessness, anxiety, irritability, or negative thoughts. However, substance use can have the opposite effect, which can lead to exacerbating and/or worsening these symptoms (Ramo et al., 2005). As a result, co-occurring disorders are associated with more-severe substance use disorder symptoms (Chan, Dennis, and Funk, 2008; Wise, Cuffe, and Fischer, 2001).

Research on co-occurring substance use disorder and mental health disorders in youth has largely focused on mood disorders, or mental health disorders that largely affect one’s emotional state such as depression and anxiety. Youths who have experienced a major depressive episode (MDE) are twice as likely to engage in alcohol or illicit drug use, compared with youths who have not experienced one (SAMHSA, 2021). Using DSM–5 criteria, youths were identified as having experienced an MDE if in the past year if 1) they had at least one period of 2 weeks or longer when, for most of the day nearly every day, they felt depressed or lost interest or pleasure in daily activities, and 2) they also had problems with sleeping, eating, energy, concentration, or self-worth or had recurrent thoughts of death or recurrent suicidal ideation. In 2020, 2.7 percent of adolescents surveyed (644,000 people) experienced a substance use disorder and a major depressive episode in the same year (SAMHSA, 2021). The 2020 NSDUH examined rates of substance use disorder in youths who experienced MDE in the past year. Based on these criteria, an estimated 2.7 percent (644,000) of youths ages 12 to 17 experienced both MDE and substance use disorder in the past year (SAMHSA, 2021).

Overall Key Findings

Findings from the NSDUH showed that 2.8 percent of youths ages 12 to 17 met the criteria for alcohol use disorder and 4.9 percent met the criteria for at least one illicit drug use disorder. T he most common type of illicit drug use disorder was marijuana use disorder (4.1 percent), with well under 1 percent of youths experiencing opioid, prescription pain reliever, or cocaine use disorder. The NSDUH also found that 2.7 percent of youths experienced both a substance use disorder and a major depressive episode. Yet, substance use treatment use remained low among youths who met the criteria for substance use disorder and therefore demonstrated a need for treatment (SAMHSA, 2021).

Differences in Substance Use Disorder by Gender

While many studies have described the differences between adult men and women in the prevalence of substance use disorders (e.g., Vasilenko, Evans–Polce, and Lanza, 2017), and some research have focused on the differences between adolescent boys and girls in substance use and initiation (e.g., Johnston et al., 2020), there is limited research on the difference in the prevalence of substance use disorders between adolescent boys and girls (Aarons et al., 2001; Gau et al., 2007; McHugh et al., 2018). For example, a study of prevalence of adolescent substance use disorders among youth ages 13 to 18 across five sectors of care (e.g., juvenile justice system, mental health system, child welfare) found that rates of substance use disorder were higher among males (Aarons et al., 2001). Also, a study from Taiwan found that boys were more likely than girls to develop substance use disorders in adolescence (Gau et al., 2007). Studies of older youth (ages 16 to 25) have found that documented opioid use disorder was higher for males than females (Bagley et al., 2021). However, several sources find that there is more gender parity in problematic substance use in adolescence than in adulthood (e.g., Young et al., 2002; McHugh et al., 2018) and that the differences by gender that had existed in the past have been getting smaller.

[1] Illicit drugs include marijuana (in 40 states), opioids (e.g., heroin), certain stimulants (e.g., methamphetamine, cocaine), hallucinogens (e.g., LSD), and dissociative drugs (e.g., PCP) [NIDA, 2020].

[2] Licit drugs include alcohol, nicotine (e.g., cigarettes), marijuana (as of 2022, in Alaska, California, Colorado, the District of Columbia, Maine, Massachusetts, Michigan, Nevada, Oregon, and Washington), certain stimulants (e.g., coffee), medicines used for illnesses, over-the-counter drugs used as directed, and prescription medicines used by the person to whom the drugs were prescribed (NIDA, 2020).

[3] The 2015 NSDUH was the first year during which estimates were provided for any illicit drug use disorder among youths. Previous years collected data on specific illicit drug use disorders only (e.g., marijuana, cocaine, and heroin use disorders).

[4] The NSDUH defines binge drinking for males as having 5 or more drinks on the same occasion at least 1 day in the past 30 days. Binge drinking for females is defined as having 4 or more drinks on the same occasion at least 1 day in the past 30. Heavy alcohol use is defined as binge drinking on 5 or more days in the past 30 days based on the thresholds described (SAMHSA, 2021).

Theoretical Background

The various treatment approaches for youths experiencing substance use disorders are grounded in numerous theories. These theories inform treatment programming that works to encourage behavioral change and improve youths’ interpersonal relationships (Liddle et al., 2018, Slesnick and Prestopnik, 2009, Akers et al., 1979). Prevalent theories underlying substance use disorder treatment programs for youth include various learning theories (i.e., cognitive–behavioral), family-based theories, and therapeutic justice. Also, several authors use self-determination theory to examine the influence of motivation in treatment engagement among youths (Bowers et al., 2017; Cleverley, Grenville, and Henderson, 2018).

Learning Theories. Classical, operant, and social learning theories have been applied to understand youths' substance use behavior and to inform treatment programming. Within these theories, substance use is viewed as behavior that is learned in the context of social interactions (e.g., observing parents, siblings, or peers) and that persists depending on whether there are rewards or punishments for the behavior (Akers et al., 1979). These theories inform behavior or cognitive–behavioral models that conceptualize adolescent substance use as learned behaviors initiated and maintained in the context of environmental factors (Waldron and Kaminer, 2004) and that can be changed by modifying thought processes or reinforcing new behaviors (Winters et al., 2018). With this, the majority of individual and group-based cognitive–behavioral treatments have involved multicomponent approaches of cognitive strategies, such as identifying distorted thinking patterns, combined with behavioral strategies, such as problem-solving, coping with cravings, and substance refusal skills training, which teach strategies for avoiding high-risk drug use situations (Waldron and Turner, 2008). These treatments help build youths' motivation to change by providing incentives for abstinence (Winters et al., 2018). Often, cognitive–behavioral therapy for substance use will include components such as self-monitoring, avoidance of stimulus cues, altering reinforcement contingencies, and coping-skills training to manage and resist urges to use. The use of modeling, behavior rehearsal, feedback, and homework assignments are characteristic during treatment sessions (Waldron and Kaminer, 2004).

Self-Determination Theory. This is a theory of human motivation based on three basic psychological needs: 1) autonomy, 2) competence, and 3) relatedness (Deci and Ryan, 2012; Ryan and Deci, 2000). It has been applied in many life domains, including substance use treatment engagement (Bowers et al., 2017; Groshkova, 2010). The theory proposes that there are several types of external motivation and that levels of engagement in treatment are determined by how individuals subjectively perceive these external pressures (Cleverley, Grenville, and Henderson, 2018; Deci and Ryan, 1985; Wild and Enzle, 2002). For example, youths often are extrinsically motivated by their parents to enter treatment. This could result in youths’ resentfully complying out of fear of consequences or, by contrast, understanding and accepting that substance use is an instrumental step toward a better future. These differing patient perceptions lead to different treatment experiences (Cleverley, Grenville, and Henderson, 2018; Ryan and Deci, 2000).

Family Systems Theory . General systems theory, which focuses on how the parts of a system interact with one another, helped inform development of family systems theory, which was developed in the late 1960s and early 1970s. Key concepts in family systems theory are feedback, homeostasis, and boundaries (Lander, Howsare, and Byrne, 2013). Homeostasis refers to the idea that it is the tendency of a system to seek stability and equilibrium (Brown and Christensen, 1986), and in family systems theory this means that each family member tends to function in such a way that keeps the whole system in balance, even if it is not healthy for specific individuals (Lander, Howsare, and Byrne, 2013). Feedback refers to the circular way in which parts of the family system communicate with one another. Finally, boundaries regulate interpersonal contact, either in a healthy way (e.g., boundaries define healthy adult and child roles in the family) or an unhealthy way (e.g., maintaining secrets) [Lander, Howsare, and Byrne, 2013].

Multiple models of family therapy have been developed using the family systems theory and focusing on improving family functioning and social relationships (Waldron and Turner, 2008; Liddle et al., 2009; Liddle et al., 2018), including the multisystemic family systems therapy model. Some treatment programs incorporate concepts from the crisis intervention theory , which contends that families are more amenable to counseling and open to change during a crisis (e.g., youth running away, youth using alcohol or drugs) [Slesnick and Prestopnik, 2009]. Therefore, these programs start by bringing the family together to address the immediate issues the youth is experiencing. In general, approaches that involve family are based on the therapeutic premise that the family has the most significant and long-lasting influence on adolescent development (Winters et al., 2018).

Although family is an important part of a young person's social environment and often is essential to resolving a young person's substance use problems, interventions at the family system level alone may not be sufficient depending on the individual's situation (Liddle, 1999). Therefore, many family and individual treatment approaches address the multiple systems that maintain youths' substance use, including individual, familial, and extrafamilial systems (Liddle, 1999). Many substance-use-treatment programs for youth integrate multiple therapeutic strategies within their treatment service framework, incorporating elements from family-based treatment, group and individual cognitive–behavioral therapy, motivational approaches, among others to enhance outcomes (Gray and Squeglia, 2018). Common components among them are teaching skills to resist the triggers associated with a youth's substance use, addressing life functioning issues that may have contributed to both the onset and maintenance of the substance use (including mental health and family issues), and identifying and building on a young person's strengths (Winters et al., 2018).

Therapeutic Jurisprudence. In addition, courts-based treatment programs for youth are often grounded in the theoretical perspective of therapeutic jurisprudence, which integrates knowledge of mental health and behavioral change with the implementation of law (Wilson, Olaghere, and Kimbrell, 2019). Under therapeutic jurisprudence, it is argued that legal rules and procedures can be used to improve the mental and physical well-being of youths (that is, justice-involved juveniles often with drug-involved offenses) within the court system. The emphasis under this model is on the selection of a therapeutic option that promotes health but does not conflict with the normative values of the justice system, such as due process (Rottman and Casey, 1999). Principles of therapeutic justice include close monitoring of a youth's behavior, multidisciplinary involvement, and collaboration with community-based and governmental organizations (Wilson, Olaghere, and Kimbrell, 2019). Drug courts are a primary example of court-based programs that use the principles of therapeutic jurisprudence (BJA, 2003).

Risk Factors for Substance Use Disorder

Risk factors [1] consist of personal traits, characteristics of the environment, and conditions in the family, school, and community that are linked to a youth's likelihood of engaging in delinquency and other problem behaviors such as substance use (Murray and Farrington, 2010). These risk factors can exist at the individual, peer, school, family, and community levels. Research on risk factors that can affect youths' likelihood of success in substance use treatment programs is largely limited; therefore, the research discussed below focuses on risk factors that are linked to a youth's likelihood of developing a substance use disorder. However, this research is limited, as many studies focus on risk factors of substance use initiation rather than on specific disorders (Bacio et al., 2015). Additional information on substance use initiation can be found in the Substance Use Prevention Programs Literature Review .

Individual . These risk factors include any characteristic directly related to or within a youth that affect the likelihood of their engaging in a specific behavior, such as substance use. These risk factors can stem from genetics, early moral development, personality traits, temperament, and negative life events (Development Services Group, 2015; Wong, Slotboom, and Bijleveld, 2010; Dick et al., 2013; Hodgins, Kratzer, and McNeil, 2001). For example, research has found that genetics play a role in the development of a substance use disorder in youth, and some biobehavioral traits attributed to predisposition for substance use disorders are influenced by genetics (Dick et al., 2013). However, studies emphasize that parenting and environmental factors affect risk factors related to genetics (Hines et al., 2015; Sloboda, Glantz, and Tarter, 2012; Prom–Wormley et al., 2017); this is seen especially in studies involving twins (Dick et al., 2013).

Other researchers have examined the effect of personality profiles on youth substance use disorders. One study found that youths with substance use disorders had greater levels of neuroticism, lower agreeableness, and lower conscientiousness than siblings of similar ages without substance use disorders (Anderson et al., 2007; Kotov et al., 2010).

As previously mentioned, various mental health disorders, such as Attention Deficit Hyperactivity Disorder (ADHD), conduct disorders, and mood disorders, are associated with substance use disorders (Lee et al., 2011; Mason et al., 2019; Torrens et al., 2012; Wilens et al., 2011). A 3-year longitudinal study of adolescents in Taiwan found that conduct disorder and ADHD were two of the most significant predictive factors for adolescent substance use disorder (Gau et al., 2007). In addition, a meta-analysis of 37 longitudinal studies with more than 750,000 participants examining the relationship between childhood psychiatric disorders and subsequent substance abuse found that childhood ADHD, oppositional defiant disorder, conduct disorder, and depression increased the risk of developing substance-related disorders (Groenman, Janssen, and Oosterlaan, 2017). However, researchers in several different studies have emphasized that the relationship between mental health disorders and substance use disorders can be multidirectional, which means causation cannot necessarily be established (Wilens et al., 2004; Winters et al., 2014). In other words, it is difficult to determine whether the mental health disorder preceded the substance use disorder, or the other way around.

Peer. Research on peer influences and substance use disorder is limited. However, available research indicates many findings of the impact of peer influences on youth substance use and initiation. Peer risk factors for substance use include having friends who engage in delinquent behavior, having friends who use substances, and gang membership. Research demonstrates that an association with peers who engage in deviant behavior and use substances is one of the strongest risk factors for youth substance use and initiation (Coffman, Melde, and Esbensen, 2015; Ferguson and Meehan, 2011; Handren, Donaldson, and Crano, 2016; Whitesell et al., 2013). For example, a study of youths in Ohio found that association with delinquent peers was the strongest correlate to substance use, even when other relevant factors (such as family and neighborhood) were controlled for (Ferguson and Meehan, 2011). Peer influences also appear to affect frequency of substance use among youth. A study of 16- to 21-year-olds found that the perceived extent of peer substance involvement was statistically significantly correlated with frequency and intensity of cannabis use, and frequency of drinking alcohol (Boys et al., 1999).

As with studies on individual risk factors, research has shown that the causal pathway between peers and substance use is multidirectional (Winters et al., 2014). Youths choose their peers based on shared interests and behaviors, but interests and behaviors are shaped by peers. Evidence shows that youths who use substances seek friendships with other youths who use substances (Light et al., 2013, Osgood et al., 2013; Young and Rees, 2013). However, there is limited research on the development of youth substance use disorders and peer relationships, compared with the available research on the impact of peer relationships on substance use in general.

School. School risk factors can also affect the risk of developing a future substance use disorder. Poor performance in school, such as low grades and low academic motivation, is linked to initiation of substance use and substance use disorders in youth (Bugbee et al., 2019; Patte, Qian, and Leatherdale, 2017; Weinberg, 2001). Other school factors, such as truancy and suspension, also are associated with substance use disorders (Henry, Knight, and Thornberry, 2012; Flaherty, Sutphen, and Ely; 2012). A longitudinal study of 1,241 girls found that many school behaviors in youth were associated with later substance use disorders, such as low seventh and eighth grade standardized math scores, suspension from school, truancy, and not having a high school diploma (Fothergill et al., 2008). However, this is yet another area where the direction of association is unclear. Whether academic failure leads to substance use disorders or substance use disorders lead to academic failure cannot be determined clearly (Cooley–Strickland et al., 2009; Weinberg, 2001).

Family. Family-level risk factors, such as parental behaviors and family structure, can also affect a youth’s likelihood of developing a substance use disorder. Research has shown that neglect and abuse can make a strong impact on substance use and disorder on a youth. A study of more than 34,000 people found that physical abuse, sexual abuse, emotional abuse, physical neglect, and emotional neglect in youth were all associated with various substance use disorders later in life (Danielson, 2016; Afifi et al., 2012). While research has found that substance use disorders in parents also make a strong impact on youth substance use, there is little research on how parents' substance disorders influence disorders in their children (Biederman et al., 2000; Lucenko et al., 2015, Whitten et al., 2019). Some research indicates that family risk factors may differ by gender. For example, a study of 1,421 youths ages 10 to 16 found that family conflict was significantly associated with substance use disorder for girls but not for boys (Skeer et al., 2011).

Community. Community-level risk factors are another area where there is much research on youth substance use and initiation, but not a lot of research focused on the impact on youth substance use disorders. One study, using data from 38,115 youths ages 11 to 17, found that higher self-reported neighborhood disorganization (defined by the study as perceived levels of safety and crime) was associated with higher levels of substance use dependence as defined by the DSM–4, even after controlling for individual- and family-level risk factors. Youths who reported both medium and high levels of neighborhood disorganization had higher odds of both substance use and dependence, compared with youths who reported low levels of neighborhood disorganization (Winstanley et al., 2008).

[1] For more information, see the Model Programs Guide literature review on Risk Factors for Delinquency .

Protective Factors Against Substance Use Disorders

Protective factors [1] are factors in a youth's life that can prevent or mitigate the likelihood of substance use disorder. These factors are aspects of a youth's life that act as a buffer to reduce negative effects of adversity (Vanderbilt–Adriance and Shaw, 2008). Compared with risk factors, there is less research on protective factors regarding substance use. There is even less research focused on protective factors and substance use disorders or protective factors that increase the likelihood of success in substance use treatment programs (Cleveland et al., 2008).

Similar to risk factors, protective factors can occur on the individual, peer, school, family, and community level. As previously stated, protective factors mitigate the effect of adversity and other risk factors. For example, prosocial peers serve as a protective factor against many forms of deviant behavior, and against substance use and initiation (Osgood et al., 2013). The presence of close peers can also mitigate the effect that metal health disorders, such as depression, have on the likelihood of developing a substance use disorder (Mason et al., 2019).

Additionally, early-sustained abstinence following residential substance use treatment has been shown to be predictive of long-term abstinence, suggesting that even a short period of continuing-care posttreatment can significantly improve long-term abstinence rates (Godley et al., 2007).

Though research on community-level factors often focuses on substance use and initiation, it has been found also to make an impact on a youth’s likelihood of developing a substance use disorder. One study found that higher levels of social capital, defined as community engagement and involvement in various volunteering programs, decreased the likelihood of a youth’s using substances or developing a substance dependence as defined by the DSM–4 (Winstanley et al., 2008). Researchers have also found that family factors, such as living in a household with two parents (Gau et al., 2007), and school factors, such as good academic performance (Gau et al., 2007), can protect against developing a substance use disorder.

For youths with certain mental health disorders, there also is some research on the effect of treatments that use medications on later substance use. For example, some research on treatment for ADHD found that the use of medication as part of treatment reduced later substance use problems in adolescence (Hammerness et al., 2017; Wilens et al., 2003), though other researchers have found that this treatment did not influence substance use outcomes (Wise, Cuffe, and Fischer, 2001; Humphreys, Engs, and Lee, 2013).

[1] For more information, see the Model Programs Guide literature review on Protective Factors Against Delinquency .

Substance Use Treatment Utilization

Research indicates that treatment initiation, engagement, and completion among youths with substance use disorders is low—significantly lower than among adults (Alinsky et al., 2020; Brorson et al., 2013; Cummings et al., 2011; Merikangas et al., 2010). Because engagement and retention in treatment is one of the strongest predictors of improved outcomes among adolescents (Acevedo et al., 2020), examining utilization is important.

The NSDUH asks respondents who have used alcohol or illicit drugs in their lifetime whether they ever have received substance use treatment, and for those who have received treatment whether this treatment was received in the 12 months before completing the survey. Treatment includes care received at any location, such as a hospital (inpatient), a rehabilitation facility (inpatient or outpatient), a mental health center, an emergency room, a private doctor's office, prison or jail, or a self-help group (e.g., Alcoholics or Narcotics Anonymous). In acknowledgment  of the COVID–19 pandemic, the NSDUH also asked respondents whether they had received professional counseling, medication, or treatment through virtual or telehealth services. The 2020 NSDUH additionally collected information on treatment received at specialty facilities, which was defined as treatment received at a hospital (inpatient only), a drug or alcohol rehabilitation facility (inpatient or outpatient), or a mental health center. Specialty facilities did not include any services received virtually (SAMHSA, 2021).

In 2020, 6.4 percent (1.6 million) of youths ages 12 to 17 demonstrated a need for substance use treatment (regardless of whether they met criteria for substance use disorder). This is defined by the NSDUH as if respondents indicated they felt they needed treatment. Among these youths, 3.5 percent previously received substance use treatment in a specialty facility. Among youths ages 12 to 17 who met the criteria for a substance use disorder, 7.6 percent received any kind of substance use treatment within the past year. The 2020 NSDUH found that 98.4 percent of youths ages 12 to 17 who did not receive treatment at a specialty facility cited that they did not feel they needed treatment (SAMHSA, 2021).

Among the 644,000 youths ages 12 to 17 in 2020 with a co-occurring substance use disorder and a major depressive episode in the past year, 69 percent (438,000 youths) received either substance use treatment at a specialty facility or mental health services in the past year, 66.8 percent (424,000 youths) received only mental health services, and 0.9 percent (6,000 youths) received both substance use treatment at a specialty facility and mental health services (SAMHSA, 2021).

Factors That Influence Participation in Treatment

Several factors influence participation in treatment programs. A small body of literature evaluates these factors, which include motivation, preexisting mental health disorders, diagnoses, family support, and demographic variables such as gender, race, ethnicity, and age (Haughwout et al., 2016; Settipani et al., 2018; Groshkova, 2010; McHugh et al., 2018). Studies examine various aspects of participation, including program initiation, program engagement, and program completion (Bowers, 2021; Haughwout et al., 2016; Becan et al., 2015).

Severity of the problem. Haughwout and colleagues (2016) used NSDUH findings from 2002 through 2013 to examine treatment-seeking behaviors among youth. They found that treatment utilization was higher among those youths who met criteria for a substance use disorder, compared with those youths who used substances but did not meet criteria for substance use disorder. Treatment engagement was greater for youths with illicit drug use disorders, such as marijuana dependence, compared with alcohol use disorder. Overall, findings indicated that, among youths with a substance use disorder, the severity of the problems caused by substance use (e.g., involvement in the criminal justice system) and the perceived need for treatment were associated with higher treatment utilization. Additionally, youths with illicit drug use disorders using more than one substance had an increased treatment utilization rate (Haughwout et al., 2016).

Family influence. Some studies examine family factors such as parental discipline styles, expectations, support, and socioeconomic status (e.g., Berridge et al., 2017; Dakof, Tejeda, and Liddle, 2001; Haughwout et al., 2016; Santisteban et al., 2015; Settipani et al., 2018). For example, a study of 224 youths ages 12 to 17 who were referred to drug treatment found that youths who had parents with higher expectations for their children’s educational attainment were more likely to participate in at least four drug abuse treatment sessions than youths who did not have parents with these high expectations (Dakof, Tejeda, and Liddle, 2001). Also, analysis of NSDUH data from 2002 through 2013 found that talking with parents about the need for treatment increased treatment utilization (Haughwout et al., 2016). A qualitative study of 31 youths and young adults ages 17 to 25 found that those who entered treatment indicated that pressure from parents to enter treatment, and parental support such as making appointments, providing financial support, and ensuring medication adherence were significant motivations for entering treatment (Cleverley, Grenville, and Henderson, 2018). A study of 110 Hispanic substance-misusing adolescents assessed parenting practices in five dimensions: 1) positive parenting, 2) discipline effectiveness, 3) discipline avoidance, 4) rules on having a set time to be home, and 5) extent of involvement. They found that youths who had parents with better discipline strategies and who felt effective and competent in their parenting were more likely to seek residential or outpatient treatment services (Santisteban et al., 2015). This study also found that youths with parents who had spent more years in the United States were more likely to use outpatient services (as compared with no services), and youths with parents who had lower parenting stress were more likely to use residential treatment services (compared with no services).

Finally, some studies have found that family financial and educational situations can influence treatment seeking behaviors. In a study of 189 youths seeking treatment for substance use concerns, 70 percent reported that they expected their finances to have an impact on their treatment (Settipani et al., 2018). Additionally, a longitudinal study of 358 adolescents in outpatient programs found that parental education was significantly associated with attendance at 12-step programs, meaning that adolescents whose parents had higher levels of education were more likely to attend the treatment program than those with parents with lower levels of education (Lui et al., 2017). However, the same study found no socioeconomic differences in treatment initiation or treatment retention. This may be due to everyone in the sample's having health insurance and to the near-full employment status of the adolescents' parents.

Other mental health diagnoses. Externalizing disorders have been identified as risk factors for not participating in or not successfully completing substance use treatment (Santisteban et al., 2015; Wise, Cuffe, and Fischer, 2001), while internalizing disorders have been identified as predictors of participating in treatment (Bowers, 2021). A study of 91 adolescents in a residential substance abuse treatment program examined factors associated with successful treatment, as defined by the treatment team at the time of discharge in terms of attendance, positive interactions in groups, level of denial, quality of projects, interactions with peers and staff, and meeting individualized treatment plan goals (Wise, Cuffe, and Fischer, 2001). They found that participants with Attention Deficit Hyperactivity Disorder (ADHD) or Conduct Disorder were less likely to participate successfully in treatment than those without ADHD or Conduct Disorder. Another study of more than 300 youths and young people ages 14 to 24 who were receiving outpatient services for concurrent disorders found that the strongest predictor of attending five or more sessions was having an internalizing problem (Bowers, 2021). In other words, individuals with higher levels of internalizing problems (such as depression) were more engaged in treatment than those with lower levels of internalizing problems.

Motivation. Motivation is considered a key factor in successfully engaging in substance use treatment (DiClemente, 1999; Groshkova, 2010). The role of motivation is particularly relevant to youth, since many enter treatment because it has been mandated or recommended, as opposed to self-referring (Bowers et al., 2017; Cleverley, Grenville, and Henderson, 2018; Knight et al., 2016). Several studies have examined the influence of motivation on participation in substance use treatment. A study of 547 youths from multiple substance use treatment programs found that participants with higher pretreatment motivation were more likely to have stronger relationships with program counselors, which predicted more successful outcomes after leaving the programs (Joe et al., 2014). Motivation also predicted stronger relationships with peers in the treatment program. A small qualitative study of 31 youths ages 17 to 25 in mental health treatment found that internal factors, such as wanting to better their academic, social, or financial situation, and external factors, such as familial pressure, were identified as motivating these young people to seek treatment (Bowers et al., 2017). Several interventions have been designed to increase youths' motivation to engage in treatment (Becan et al., 2015; Knight et al., 2016).

Gender. There is limited information on gender differences in treatment engagement for substance use disorders. Some research has found that adolescent girls are more likely than adolescent boys to receive treatment for alcohol use disorder, while boys are more likely than girls to receive treatment for marijuana use disorder, or for any type of illicit substance treatment overall (Haughwout et al., 2016; McHugh et al., 2018). Other studies have found no difference in treatment initiation or retention by gender (e.g., Lui et al., 2017). Several studies have found that girls have a higher comorbidity between substance use disorder and mental health disorders and greater histories of trauma than boys (e.g., Fernández-Artamendi, Martínez-Loredo, and López-Núñez, 2021; Yildiz, Ciftci, and Yalcin, 2020), which can affect engagement and success in treatment interventions. Once youths are in a treatment program, some studies have found that girls are more likely than boys to engage, succeed, and complete the program. For example, a study of 91 adolescents in a residential substance abuse treatment program (Wise, Cuffe, and Fischer, 2001, mentioned above) found that girls were more likely than boys to successfully participate in treatment.

Race and ethnicity. Several studies have examined racial and ethnic disparities among substance use treatment utilization. In their analyses of more than 140,000 adolescents from the NSDUH , Cummings and colleagues (2011) found that among youths with substance use disorders Black and Hispanic adolescents were less likely than white adolescents to receive treatment. A literature review of behavioral health services for youths of racial and ethnic minority groups found that, compared with non-Latino white adolescents with a substance use disorder, Black adolescents with a substance use disorder reported receiving less specialty and informal care, while Latinos with a substance use disorder reported receiving fewer informal services (Alegria et al., 2011). Several studies of youth in the juvenile justice system have found similar racial and ethnic disparities (e.g., Farenthold, 2010; Mansion and Chassin, 2016). A systematic literature review of studies examining juvenile justice system processing found that most studies examining referral to mental health or substance misuse treatment from within the juvenile justice system found at least some race effects disadvantaging youths of color (Spinney et al., 2016). For example, a study of about 600 juveniles on probation in New York found that, relative to white juveniles, Black and Hispanic juveniles who were screened and referred for mental health or substance use services were significantly less likely to access them (Wasserman et al., 2009). The study also found that Black juveniles were significantly less likely than others to participate in the initial screening. However, racial and ethnic disparities in referral to and utilization of substance use treatment are not always found (e.g., Mulvey, Schubert, and Chung, 2007; Yan and Dannerbeck, 2011).

Types of Substance Use Treatment Programs and Outcome Evidence

Treatment programs primarily focus on helping youths with existing substance use issues who have been clinically diagnosed with a substance use disorder by the Diagnostic and Statistical Manual for Mental Disorders criteria. However, some treatment programs serve youths without a formal diagnosis who exhibit or report risky substance use behavior or have come into contact with the justice system.

For youths currently experiencing substance use disorders, particularly youths involved in the juvenile justice system, more intensive services may be needed, compared with the programming youths may receive in prevention interventions. Treatment services typically are more comprehensive than prevention programs, owing to their retroactive (rather than proactive) focus. Specifically, treatment programs include components related to prosocial development as a means to address existing antisocial behaviors, negative peer relations, and poor family functioning (Development Services Group, 2015).

It is important to recognize that programs that have been shown to reduce adult substance use may not translate as well for youth. Substance-using youths seldom are dependent on substances in the traditional sense that adults experience addiction. Youths and adults may misuse drugs for different reasons, and there are differences in the psychology of juvenile and adult substance use disorders (Bureau of Justice Assistance, 2003). Adolescence is an important development phase that involves changes in cognitive, emotional, behavioral, and social skills necessary for a productive life that are influenced by important relationships, such as those with family, friends/peers, school, and the community (Development Services Group, 2015; Gray and Squeglia, 2018).

Various types of youth substance use treatment programs, including those featured in the Model Programs Guide, are discussed below. 

Motivational Interviewing

Motivational interviewing (MI) is a counseling method that can be implemented as a standalone program or can be incorporated as an element of a larger program. MI uses collaborative, client-centered, goal-oriented communication to address hesitancy toward behavioral change by encouraging and evoking personal desires for transformation (Stein et al., 2006b, Naar–King, 2011). MI aims to increase an individual's perspective on the importance of change. When provided to youths with substance use issues, the long-term goal is to help them reduce or stop using drugs and alcohol. A youth's subtle desires for change are uncovered through a series of selective interviews guiding the youth to concentrate on their behaviors and explore overarching goals in regard to personal motivations, values, and opinions and reasons to change (Stein et al., 2006b; D’Amico et al., 2013).

Stein and colleagues (2006b) examined the effects of a standalone MI program for substance abuse issues of juveniles in a state facility . The program focused on youth engagement with substance use therapy and targeted youths who reported regular or binge marijuana or alcohol use or who were sentenced to a post-adjudication facility. For this program, motivational interviewing was designed to be modified as appropriate to be meaningful for each youth and their desire to change. This MI program was delivered by research counselors and consisted of four components: 1) establishing rapport, 2) assessing the youth’s motivation for change, 3) motivational enhancement, and 4) establishing goals for change. The study authors compared youths receiving MI with a control group of youths who did not receive MI. They found that the control group experienced statistically significantly more negative engagement with substance use therapy than the MI treatment group, meaning that youths who received MI were more likely than youth in the control group to take treatment seriously (Stein et al., 2006b). However, there was no statistically significant impact on positive treatment engagement, meaning juveniles who received MI were no more likely to actively participate in treatment sessions, compared with youths in the control group. Another study by Stein and colleagues (2006a), which examined the same sample of youths 3 months later, found the effectiveness of MI treatment appeared to be mediated by depressive symptoms. The authors found that, compared with the control group, the MI treatment group had statistically significantly lower self-reported measures of risky driving behavior (such as driving under the influence of alcohol and marijuana), but only for youths with low depressive symptoms. When examining youths with high depressive symptoms, researchers found the control group had statistically significantly lower self-reported measures of risky driving behavior, compared with the MI treatment group. The entire treatment group was statistically significantly less likely to report driving solo under the influence of alcohol, compared with the control group, but there were no statistically significant differences between the groups in driving alone under the influence of marijuana or being a passenger in a car operated by a driver under the influence of alcohol or marijuana (Stein et al., 2006b).

Juvenile Drug Courts/Court-Based Programs

Juvenile drug courts (JDCs)are specialized juvenile court dockets for youths with substance use problems and substance use disorders in need of specialized treatment services, allowing for intensive judicial supervision that is not ordinarily available in traditional juvenile courts (Latimer, Morton–Bourgon, and Chrétien, 2006; Mitchell et al., 2012; Shaffer, 2006; Drake, 2012). JDCs work conjointly with treatment providers, social services, school and vocational programs, law enforcement, probation, and other agencies (Latimer, Morton–Bourgon, and Chrétien, 2006; Mitchell et al., 2012; Shaffer, 2006; Drake, 2012). Core elements of JDCs include drug testing and treatment services, regular judicial contact, and meetings with a case manager and/or a probation officer. Additionally, most JDCs make referrals for educational programs, job training, and mental health services. [1]

Evaluations of programs have found mixed results with regard to the effectiveness of JDCs in both substance use and recidivism outcomes. For example, Juvenile Drug Courts in Utah operate with basic drug court components, including screening and assessment, individualized treatment plans, judicial supervision, community-based treatment, regular court hearings, accountability and compliance monitoring, comprehensive services, and a nonadversarial team approach (Hickert et al., 2011). An evaluation of the four largest JDCs in Utah by Hickert and colleagues (2011) found no statistically significant difference between youths who participated in the JDCs and youths in the probation comparison group for alcohol and other drug recidivism after 30 months. However, they did find that youths in the JDCs had statistically significantly fewer subsequent criminal offenses (i.e., recidivism of any offense), compared with youths in the comparison group. Other evaluations have shown more positive results. The Baltimore County (Md.) Juvenile Drug Court targets 13- to 17-year-olds who admit to drug or alcohol abuse. The program has four phases, each of which focuses on different aspects of treatment and services. The first two phases are highly structured and include frequent treatment sessions, supervision meetings, and drug testing. The last two phases are designed as aftercare phases, which involve decreasing supervision and treatment sessions and focus on relapse prevention. An evaluation by Mackin and colleagues (2010) showed youths in the program had statistically significantly lower average numbers of re-arrests for drug charges and total re-arrests (for any charge), compared with youths in the comparison group, at the 2-year follow-up.

Numerous meta-analyses examining the effectiveness of juvenile drug courts have also found mixed effects. When examining measures of general recidivism, Drake (2012) and Shaffer (2006) found small, statistically significant decreases in the recidivism of JDC participants, compared with nonparticipants. Conversely, Latimer and colleagues (2006) did not find a statistically significant impact of JDCs on recidivism measures. With regard to other outcomes, Mitchell and colleagues (2012) reviewed four studies that examined the effect of JDCs on drug use and found no statistically significant effect. Tanner–Smith and colleagues (2016) reviewed eight studies and also found an overall non–statistically significant effect on drug use, suggesting that JDCs have not been found to have a consistent effect on drug use.

An example of a court-based program is the Juvenile Breaking the Cycle (JBTC) Program in Lane County, Oregon . The program was a post-arrest effort designed to help substance-using youth, using a comprehensive approach. The primary goals of the program were to increase access to treatment, reduce substance use, and reduce delinquency among high-risk, antisocial youths through intensive case-management services. Youths ages 9 to 18 with alcohol or other drug problems and assessed as high risk for involvement in serious and chronic offenses were eligible for JBTC. Components of the model included substance abuse treatment, mental health services, judicial oversight (incorporating drug court for some participants), and case management that consisted of supervision by a probation counselor and service coordination by a service coordinator (along with urinalysis). Lattimore and colleagues (2004) found that participation in the JBTC program had no statistically significant effect on whether youths reported using alcohol or illicit drugs (other than marijuana), at the follow-up period. However, participation in the JBTC program was associated with a statistically significant reduction in marijuana use. Regarding recidivism outcomes, JBTC youths were statistically significantly less likely to be re-arrested, and participation in the JBTC program was associated with a statistically significant decrease in the number of re-arrests after 12 months (Lattimore et al., 2004). 

Family-Inclusive Therapy

As previously discussed, research has shown that family dynamics often contribute to the development of youths' substance use disorders (Van Ryzin et al., 2016). The importance of family involvement and familial relationships in the recovery of substance-using youths is regularly reiterated throughout evaluation research of treatment programs (Christie, Cheetham, and Lubman, 2020). Other studies have shown family-based treatments to have higher retention rates, which may be related to positive treatment outcomes (Rowe and Liddle, 2003; Liddle et al., 2018). Further, intensive family-based treatments have been shown to reduce family and community environmental risk factors (such as familial conflict or association with negative peer groups) that contribute to adolescent substance use problems and disorders (Liddle et al., 2009; Liddle et al., 2018; Horigian, Anderson, and Szapocznik, 2016).

In general, family-based interventions can include a wide range of programs that are designed to decrease youths’ problem and antisocial behaviors, including substance use, by making positive changes in their familial and social environments (Dopp et al., 2017). Specifically, these interventions focus on establishing better communication and reducing conflict between parents and youths, improving parenting skills, and helping youths better engage with their families and in their school environment (Baldwin et al., 2012). Various therapies inform the specific treatment techniques used, including behavioral and cognitive–behavioral therapies. Dopp and colleagues (2017) conducted a meta-analysis of 24 effect sizes from 10 studies and found that family-based treatment had statistically significant positive effects on substance use for treatment group youths, compared with control group youths.

Numerous specific therapeutic models concentrate on including the family in treatment services for youth. Multidimensional Family Therapy (MDFT) is a well-established approach for youth substance use treatment (Liddle et al., 2001; Waldron and Turner, 2008; Rigter et al., 2013; van der Pol et al., 2018) that promotes communication among family members, targeting social competence and parental involvement/relationships. The MDFT approach is individualized, family based, and comprehensive, requiring collaboration across many social systems (Liddle et al., 2009). Using a multidimensional approach, the MDFT intervention emphasizes improving four major domains for youth, which are seen as contributing factors to the rise and decline of behavioral problems in a youth's life: 1) the youth, 2) parents, 3) family, and 4) the community (that is, peers, school, and so forth) [Liddle et al., 2018; Rigter et al., 2013; van der Pol, 2018]. Overall, the goal of the program is to improve individual and family functioning to reduce substance misuse and related problem behaviors (such as committing crimes). There have been numerous evaluations of MDFT. Rigter and colleagues (2013) evaluated the efficacy of MDFT on substance use and dependence among Western European youths ages 13 to 18 from five outpatient treatment sites. Eligible youths were diagnosed with a cannabis-use disorder by the DSM–4 guidelines and had at least one parent willing to participate. However, at the 12-month follow-up, there were no statistically significant differences in the prevalence of diagnosis of cannabis use disorder between youths in the MDFT intervention group and youths in the treatment-as-usual comparison group. Conversely, Liddle and colleagues (2018) evaluated the efficacy of MDFT in a sample of youths in the United States diagnosed with a substance use disorder and at least one comorbid psychiatric disorder. At the 18-month follow-up, youths in the MDFT intervention group reported a statistically significant decrease in substance use problems, compared with youths in the treatment-as-usual group.

Another example of an intervention that incorporates family into programming services is the Multisystemic Therapy | Family Integrated Transitions (MST–FIT) program, which provides integrated and family services to youths in a residential facility who have committed offenses and have co-occurring mental health and chemical dependency disorders (Trupin et al., 2011). Services are provided during a youth's transition from incarceration back into the community. The overall goal of MST–FIT is to provide necessary treatment to youths to reduce recidivism. The program also seeks to connect youths and families to appropriate community supports, increase youths' abstinence from alcohol and drugs, improve youths' mental health, and increase youths' prosocial behavior. Trupin and colleagues (2011) found that the MST–FIT program statistically significantly reduced felony recidivism at 36 months postrelease; however, the program did not have a statistically significant effect on measures of overall recidivism (i.e., felony and misdemeanors combined), misdemeanor recidivism, or violent felony recidivism. In addition, the program evaluation did not examine the impact on youths' substance use.

Multisystemic Therapy | Substance Abuse (MST for substance use) is a version of multisystemic therapy (MST) for youths with substance abuse and dependency issues who are diagnosed using the DSM–4 . Although the emphasis is on youths, MST operates by incorporating the youths' family and friends and addressing all potential spheres of behavioral influence. It aims to enhance a family's capacity to keep track of adolescent behavior and instill clear rewards and punishments for positive and negative/irresponsible behavior. Henggeler and colleagues (2002) found that youths who received MST for substance abuse showed statistically significantly higher rates of abstinence from marijuana, compared with control group youths who did not receive MST, at the 4-year follow-up. However, there were no statistically significant differences between groups on cocaine use. Another study by Henggeler and colleagues (2006) found no statistically significant difference in alcohol use between youths who participated in a drug court program and received MST for substance abuse and youths in the control group who received no services, at the 12-month follow-up. However, youths who received MST in a drug court program showed statistically significant reductions in heavy alcohol use, marijuana use, and multiple-/poly-drug use, compared with control group youths.

Some interventions specifically aim to treat youths' substance abuse after a family crisis. Ecologically Based Family Therapy (EBFT) is a home-based, family preservation model for families in crisis because a youth has run away from home. The model targets 12- to 17-year-olds who are staying in a runaway shelter and dealing with substance use issues. Treatment begins by preparing the youth and the family members, in individual sessions, to come together and talk about the issues that led to the runaway episode. After the individual sessions, the family and youth are brought together to address the issues associated with the dysfunctional interactions between family members and the continuation of problem behaviors. An evaluation by Slesnick and Prestopnik (2009) found that treatment group youths who participated in EBFT reported a statistically significant reduction in the percentage of days they used alcohol or drugs, compared with control group youths who received services as usual, at the 15-month follow-up. 

Residential-Based Treatment

Youths may receive treatment while they are placed in a residential facility. The period of residential placement offers an opportunity to intervene in the cycle of youths' drug or alcohol use. Different types of residential-based substance use treatment programs are available, including therapeutic communities or group counseling (Mitchell, Wilson, and MacKenzie, 2012). Residential treatment is an important option for youths at high risk of overdose or suicide, those who present a public safety risk, or are without family members who can be involved in treatment (Liddle et al., 2018).

Incarceration-Based Therapeutic Communities (TC) for Juveniles employ a comprehensive, residential drug-treatment program model for substance-using youths who have committed offenses. The programs are designed to foster changes in attitudes, perceptions, and behaviors related to youth substance use. The TC for juveniles uses a developmentally appropriate comprehensive approach to a) address substance use and mental health issues and b) promote healthy development. Mitchell, Wilson, and MacKenzie (2012) synthesized four studies looking at the effectiveness of incarceration-based TCs for youths in reducing recidivism and found no statistically significant difference between treatment group and comparison group youths on recidivism postrelease. Drake (2012) analyzed the effect sizes from three studies on the efficacy of incarceration-based TCs for juveniles on recidivism and also found no statistically significant difference between treatment group and comparison group youths on recidivism postrelease. However, the results from both meta-analyses should be interpreted with caution, given the limited number of studies included. Further, neither meta-analysis examined the effectiveness of incarceration-based TCs in reducing substance use.

Brief Interventions

Brief interventions designed to address substance use in youth vary in terms of length and structure and can be delivered in an electronic format, in-person by a service provider (such as a counselor, physician, or nurse), or even self-administered by youth. In general, these are concise, convenient, and cost-effective interventions designed to motivate and provide resources to participants to help them change their alcohol or drug consumption behavior, and to seek more intensive treatment if needed (Tanner–Smith and Lipsey, 2015). However, one limitation to this type of program is that it usually is not targeted specifically toward substance use disorder, and therefore substance use disorder is not typically an outcome of interest. This is an area where more research is required (Smedslund et al., 2017).

Computerized Brief Interventions for Youth Alcohol Use are designed to appeal to younger generations who have grown up in the digital media age (Smedslund et al., 2017). Specifically, these interventions target individuals ages 15 to 25, who are high or risky consumers of alcohol but motivated to change. Risky consumption of alcohol is defined as consuming 1) at least 5 beverages during any one drinking session or more than 14 alcoholic beverages a week for males and 2) 4 beverages during any one drinking session or more than 7 alcoholic beverages a week for females. Computerized brief interventions usually consist of three components: 1) assessment, 2) feedback, and 3) decisionmaking. The assessment component classifies users as low-risk, medium-risk, high-risk, or very high-risk alcohol drinkers and provides the individuals with a recommendation on whether they would benefit from a more formalized treatment program than the computerized brief intervention. The feedback component provides the users with information on their scores after each assessment and responds to their reactions to their assessment. Finally, the decisionmaking component asks users to specify their motivation for behavioral change. Smedslund and colleagues (2017) aggregated the results of 15 studies (those that included both assessment and feedback components, but no decisionmaking component) and found that computerized brief interventions statistically significantly reduced short-term alcohol consumption for youths who participated, compared with youths who received no interventions.

Targeted Brief Alcohol Interventions (BAI) for Alcohol Use for Adolescents and Young Adults seek to reduce alcohol use or alcohol-related problems for youths and young adults using a short-term intervention (one to five sessions). BAIs can be delivered in a variety of settings such as primary care/student health centers, schools/universities, and emergency rooms; for youths, they can also be self-administered by participants. They typically include at least one of the following components: a discussion of alcohol consumption, feedback on risk or levels of alcohol use, comparisons with local or national norms, information on potential harms, or coping strategies and goal-setting plans for dealing with drinking situations. Tanner–Smith and Lipsey (2015) reviewed 24 studies that included adolescent samples (ages 11 to 17) and found that youths who participated in BAIs reported statistically significant reductions in levels of alcohol consumption and levels of alcohol-related problems, compared with control group youths. 

Prevention Programming

Prevention programs are typically designed to deter adolescents from initial substance use. However, some early prevention programs are designed specifically with the goal of making a long-term impact on substance use disorders. These programs have a theoretical framework surrounding the goal of reducing early risk factors that can lead to later problem behaviors such as substance use disorders (Kellman et al., 2008).

Good Behavior Game is one such program. It is a classroom management strategy designed to reduce aggressive and disruptive classroom behavior. By preventing these early risk factors, it seeks to reduce future problem behaviors such as criminal activity and substance use. Good Behavior Game is a group-contingent reinforcement game, in which students work in teams and are rewarded as a team for following classroom rules. This creates an incentive for students to manage their own behavior through group reinforcement and mutual self-interest. Kellman and colleagues (2008) conducted a randomized controlled trial to examine the impact of Good Behavior Game on lifetime alcohol abuse or dependence disorders. The participants were ages 5 to 10 during the program and were surveyed 14 years after the program ended. The study authors found that treatment group participants had lower rates for lifetime alcohol abuse or dependence disorders, compared with the control group, at the 14-year follow-up. This difference was statistically significant.

[1] For more information, see the MPG literature review on Juvenile Drug Courts .

Limitations of Research on Treatment Programs

Although there is research on how well treatment programs can (or cannot) reduce youth substance use and/or improve substance use disorders, it has some limitations. Most substance use treatment programs evaluated within the juvenile justice system typically examine recidivism-based outcomes and often neglect to examine substance use outcomes fully (Trupin et al., 2011; Anspach and Ferguson, 2005; Hickert et al., 2011). In addition, because these programs are so closely linked with the juvenile justice system, they usually rely on one measure of substance use, such as one or more positive drug screen results (Anspach and Ferguson, 2005; Hickert et al., 2011). While instances of positive drug screens may be one way to measure substance use, this measure fails to incorporate self-reported drug or alcohol use, or substance use identified through other screening methods administered by service professionals.

Further, with research of youth substance use disorders and treatment programs, there often are barriers to conducting research with young people. It can be particularly challenging to follow up with youths who struggle to access services because of their inaccessibility, and there are ethical considerations related to consent in youth participants (Christie, Cheetham, and Lubman, 2020).

Other limitations exist when attempting to examine the specific components that make a program effective, particularly with regard to different types of illicit or licit substance use. If different family, courts-based, or residential-based programs incorporate similar elements, it is difficult to discern which specific program components successfully affect substance use (Trupin et al., 2011; Henggeler et al., 2006). For example, motivational interviewing can be implemented as a standalone program (Stein et al., 2006a; Stein et al., 2006b) or it may be included as a specific component in a juvenile drug court or as part of a specific program, such as Multidimensional Family Therapy. MDFT and juvenile drug court programs both incorporate some kind of family-based treatment (Waldron and Turner, 2008; Liddle et al., 2018; Liddle et al., 2009; Hickert et al., 2011; Anspach and Ferguson, 2005). Additionally, there is limited research into which types of programs are the most effective for different types of substances (McGovern and Carroll, 2013).

Further, there is little research on pharmacotherapy for youth licit and illicit substance use (Squeglia et al., 2019; Winters et al., 2018). Although research on adults with substance use disorders has shown positive results with treatments such as Methadone Maintenance Therapy and Buprenorphine Maintenance Therapy , especially when addressing opioid use disorders/dependence (Mattick et al., 2009; Mattick et al., 2014), this research has not be conducted much with youth, in part because a) federal regulations restrict methadone access for adolescents, b) training and U.S. Food and Drug Administration approval are required for prescribing buprenorphine, and c) there is stigma regarding medications for opioid use disorder (Chatterjee et al., 2019). However, there is some evidence that reception of medication-assisted treatments influences treatment duration among youths. Researchers examining a sample of more than 4,500 youths ages 13 to 22 found that youths who received opioid use disorder medication (e.g., buprenorphine, naltrexone) within 3 months of diagnosis with an opioid use disorder stayed in treatment longer than those who did not receive the medication (150 days of treatment, compared with 67 days of treatment) [Hadland et al., 2018]. Research indicates that the effect of pharmacotherapy for youth is unclear.

Additionally, most youths who participate in substance use treatment programs are not able to sustain long-term substance use reduction or cessation; some interventions do not see results related to continued substance use lasting more than 1 year posttreatment, including some of the programs discussed in the previous section (Tanner–Smith and Lipsey, 2015; Gray and Squeglia, 2018; Dennis et al., 2004). This has encouraged the development of aftercare or continuing care programs (Godley et al., 2007; Godley et al., 2014), usually after residential treatment or drug court participation. As stated previously, research shows that early-sustained abstinence is predictive of long-term abstinence (Godley et al., 2007). However, many substance use treatment programs for youth still lack this component, with youths returning to the community without the continued support needed to promote continued abstinence (Godley et al., 2007). Further research is needed regarding the effectiveness of aftercare or continuing care for youth following both outpatient and residential treatment, and on the best approaches for implementation (Kaminer, Burleson, and Burke, 2008; Godley et al., 2014; Gonzales et al., 2014).

Conclusions

Though rates of substance use disorder among youth have declined and leveled off since the first decade of the 2000s, it remains a prevalent issue, and research demonstrates a clear need for treatment programs directed toward adolescents (Chatterjee et al., 2019; SAMSHA, 2021).

There are a wide range of substance use treatment programs for adolescents, depending on their needs and situation. Family-inclusive therapies, for example, are common substance-use-disorder treatment programs, because family dynamics often make a strong impact on the development of substance use disorders (Van Ryzin et al., 2016). Residential-based treatment programs are also important in the field, as they are beneficial for youths with a substance use disorder who may not have family able to become involved with their treatment (Liddle et al., 2018).

Though 2.8 percent of youths ages 12 to 17 experienced alcohol use disorder in the past year, and 4.9 percent of 12- to 17-year-olds met criteria for at least one illicit drug use disorder, there is still limited research regarding specific risk factors, protective factors, and treatment options for youths diagnosed with a substance use disorder, according to DSM–4 criteria (Bacio et al., 2015; Cleveland et al., 2008; SAMSHA, 2021). Further research could overcome current limitations, such as examining substance use–related outcomes outside of the juvenile justice system, conducting studies on pharmacotherapy for youths' licit and illicit substance use, and exploring risk and protective factors specifically surrounding substance use disorders in youths.

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About this Literature Review

Suggested Reference: Development Services Group, Inc. January  2023. "Substance Use Treatment Programs."  Literature review. Washington, DC: Office of Juvenile Justice and Delinquency Prevention.  https://ojjdp.ojp.gov/model-programs-guide/literature-reviews/Substance-Use-Treatment-Programs

Prepared by Development Services Group, Inc., under Contract Number: 47QRAA20D002V. 

Last Update: January 2023

• Open access
• Published: 29 May 2024

Evaluation of knowledge, attitude, practices and effectiveness of menstrual hygiene interventions in rural schools from Lilongwe, Malawi

• Russel Chidya 1 , 2 ,
• Olivia Kachuma 3 ,
• Tchaka Thole 3 ,
• Louis Banda 3 ,
• Mark Loewenberger 3 &
• Jennifer Nicholson 3  

BMC Public Health volume  24 , Article number:  1435 ( 2024 ) Cite this article

Metrics details

Menstrual hygiene management (MHM) is associated with the menstrual process in women and adolescent girls who face cultural and financial challenges in rural areas of many developing countries. As part of the pilot study, we assessed the sustainability and effectiveness of the approaches and lessons learned from the MHM project intervention in rural areas of Lilongwe, Malawi.

Rural primary schools ( n  = 4) were purposively selected where an MHM intervention was implemented in Lilongwe, Malawi. The study employed a mixed-method research design. Assessments and data collection were performed through surveys of learners, literature reviews, key informant interviews (KIIs) ( n  = 90), and 20 focus group discussions (FGDs). The study participants included boys and adolescent girls ( n  = 100, 11–19 years; grades 5–8), teachers, mother groups, and community leaders from the selected schools.

All the schools had water sanitation and hygiene facilities and latrines (45% improved, 54% ventilated improved pit latrines – VIPs) that promoted menstrual hygiene for adolescent girls. However, two of the schools studied (50%, n  = 4) did not have separate washrooms for changing sanitary materials. There was a slight increase in latrine coverage in Kabuthu zone communities (90% at baseline versus 93.4% at midterm). However, the coverage dropped to 85.7% at the final evaluation, which was attributed to too much rain received in the area that damaged most of the latrines. There was a significant reduction ( p  < 0.05) in the number of girls failing to attend classes due to menstruation (70% at baseline versus 14% at final evaluation). Furthermore, the project resulted in the majority of girls (94.4%) having access to school. There was a strong uptake and adoption of sanitary products (reusable pads and menstrual cups) among adolescent girls of all age groups. The study has demonstrated that the inclusion of key stakeholders such as health workers, parents, mother groups and community leaders promoted the uptake and sustainability of reusable pads and menstrual cups and MHM interventions and programs.

The MHM project implementation improved adolescent girls’ education in the area. The inclusion of boys and other key stakeholders in the health education talks addressed issues of stigma and discrimination. The study, therefore, calls for comprehensive training on MHM and hygiene education to remove discrimination and harmful cultural practices.

Peer Review reports

Introduction

Background information.

Women and girls, especially from developing countries, are faced with problems in managing their menstruation as a result of cultural taboos, lack of knowledge, inadequate access to safe and secure water, sanitation, hygiene (WASH) services, and lack of affordable menstrual products [ 1 , 2 ]. According to WHO/UNICEF, menstrual hygiene management (MHM) is simply defined as the management of hygiene associated with the menstrual process. Furthermore, adequate MHM is ‘ access to clean absorbents including sufficient washing, drying, storage and wrapping of reusable absorbents; adequate frequency of absorbent change; washing the body with soap and water; adequate disposal facilities; privacy for managing menstruation; and basic understanding of menstruation and how to manage it with dignity and without fear or embarrassment’ [ 1 , 3 ]. The concept of MHM has been expanded to menstrual health and hygiene (MHH) to encompass the sociocultural and economic elements that influence the menstrual management of women and girls [ 3 , 4 ].

The provision of adequate MHH among girls and women is reported to contribute to the attainment of Sustainable Development Goals (SDGs) for good health (SDG 3), education (SDG 4), gender equality (SDG 5), and clean water and sanitation (SDG 6) [ 3 ]. However, many girls and women in low- and middle-income countries (LMICs) do not have adequate MHH services [ 3 , 4 ]. Access to WASH services for MHM and MHH must be considered a basic right of girls and women to lessen gender discrepancies in education, health and sociopolitical and economic participation [ 4 , 5 ]. Previous studies in Sub-Saharan Africa and elsewhere have shown that WASH interventions through the provision of sanitary materials, water, soap and privacy keep girls in school and have a mixed impact on school absenteeism and performance [ 6 , 7 , 8 ]. In Malawi, various institutional/legal frameworks and strategies on gender equality, the empowerment of women and girls and human dignity are employed by several key stakeholders and organizations. For example, the Canadian Physicians for Aid & Relief (CPAR) Malawi implemented an MHM project intervention in Lilongwe rural schools aligned with Global Affairs Canada’s Feminist International Assistance Policy (FIAP). Furthermore, the MHM project implementation is in line with the National Gender Policy (2015), which aims to increase advocacy for girls’ and boys’ conducive learning environment, and Malawi 2063, which stresses the need to reinforce the gender equality and empowerment of women and girls to shape their decisions at the household, community and national levels.

Malawi has approximately 50.7% of its population living below the poverty line and approximately 25% living in poverty, especially in rural areas [ 3 ]. Poverty is exacerbated by low educational outcomes, including failure to complete primary schooling, especially among girls and women in rural areas. As girls start menses, they begin to miss school activities to the point where they drop out of school entirely, jeopardizing their ability to contribute more effectively to their own and their families’ social and economic well-being. A study conducted under the Malawi Red Cross showed that girls in their menses had a significantly higher level of knowledge compared to boys, and knowledge in girls was associated with better MHM practices and with reduced absenteeism [ 9 ]. A study conducted in seven schools in and around Lilongwe, Malawi by WaterAid in 2021 concluded 3 recurring issues impacting MHM for adolescent girls: (a) cultural around menstruation – menstruation being seen as strictly secret, and parents do not talk to children about it; (b) ignorance about menstrual issues being prevalent among schoolgirls and in their communities; and (c) inadequate WASH facilities and infrastructure in visited schools. Several projects and interventions on MHM and MHH have been implemented in rural Malawi to address such issues and challenges [ 8 , 9 , 10 ].

Context of the study

Several studies on linkages between menstruation and school absenteeism have been widely conducted in Africa and elsewhere [ 8 , 11 , 12 , 13 ]. An earlier study by Grant et al. [ 14 ] on menstruation and absenteeism in rural Malawi noted several factors contributing to menstruation-related absenteeism. This included lack of school toilet privacy, lack of education by family and teachers on puberty and MHM, and physical menstrual discomfort. In the same study, long distances between home and school also prevented girls from going back and forth, hence contributing to absenteeism [ 14 ]. Such barriers and challenges significantly disrupt girls’ education and development, which later leads to ripple effects. There are no recent disaggregated data on school drop-out rates in Malawi [ 9 ]. However, UNICEF Malawi gathered significant anecdotal evidence that girls stay home while menstruating [ 10 ].

Menstrual cup promotion has been promoted among university girls at Mzuzu University in Malawi [ 10 ]. Although the project was successful, a small sample size (10 women) was used. Furthermore, the project did not target girls below university age, and there was no follow-up program. Many MHM projects in Malawi have focused simply on providing menstrual products and some WASH activities [ 8 , 9 , 10 ]. This addresses immediate short-term needs but does not incorporate the approach needed to promote sustainable change. The CPAR MHM project implemented an innovative MHM project in rural Lilongwe through a participatory approach by testing and promoting the use of menstrual cups and reusable pads alongside MHM behavior change interventions. The current study on MHM and MHH, therefore, provides a significant opportunity for knowledge sharing among WASH practitioners, education, and health promoters in the country. This study, therefore, assessed the sustainability and effectiveness of the approaches and lessons learned from the CPAR MHM/MHH project intervention for scaling up and replicability in other rural areas in Malawi and elsewhere. It aimed to evaluate knowledge, attitudes, and practices among learners, teachers and community members and the effectiveness and sustainability of menstrual hygiene interventions in rural schools from Traditional Authority (TA) Kabudula in Lilongwe, Malawi. The study aimed to achieve the following specific objectives: (a) to evaluate availability and access to water and sanitation facilities, menstrual products, and menstruation management among adolescent girls; (b) to assess the knowledge, attitude, and practices regarding MHM among learners (girls and boys), teachers and community members in the study area; (c) to assess the project intervention on feasibility, acceptability, and changes in menstruation-related knowledge, practices, perceptions, and self-reported school absenteeism from baseline to end line among girls; and (d) to determine the sustainability, replicability and scalability of the MHM interventions in rural schools from Malawi and elsewhere.

Theoretical framework of the study

This study is grounded on a general hypothesis that the inability of girls up to the age of 18 to effectively manage their menstrual health is a significant cause of absenteeism and school dropout and that the use of menstrual cups and/or reusable sanitary pads improves girls’ menstrual health management and reduces absenteeism and dropout rates. The implementation of the MHM project was centered on gender-based analysis (GBA). The GBA underpins an understanding that health variances between boys (or men) and girls (or women) can be related to the various roles and responsibilities that culture assigns to them. This study employed the “ Theory of Change ” ( ToC ) approach to evaluate the knowledge, attitudes, and practices among learners, teachers and community members and the effectiveness of menstrual hygiene interventions in rural schools from the study area. Furthermore, the study used the “ Theory of Planned Behavior ” (TPB) [ 15 ]. The ToC is a theory that gives a detailed description and illustration of how and why the desired change is expected to happen in a particular situation [ 16 ]. It explains how activities are understood to contribute to a series of results that produce the final intended impacts. The TPB depicts that human action is influenced by three major factors: a favorable or unfavorable evaluation of the behavior, perceived social pressure to perform or not perform the behavior, and perceived capability to perform the behavior [ 15 ].

Methodology

Study setting and mhm interventions.

This study was conducted in Lilongwe District located in the central region (Fig.  1 ). It is the capital city of Malawi, which stands at an altitude of 1,050 m. Specifically, the study was conducted in TA Kabudula under the Kabuthu education zone where rural primary schools ( n  = 4), namely, Kabuthu, Milala, Kamphelatsoka, and Chifeni, were selected. The schools under study were purposively selected based on the implementation of the MHM project by CPAR. The rural locations were initially identified by CPAR’s Rapid Gender Analysis (RGS) (September 2021) and more in-depth GBA (December 2021). The two analyses showed traditional and cultural beliefs being more ingrained, less available menstrual products and unaffordable, and having fewer opportunities to acquire information to dispel misconceptions and ignorance regarding MHM. The CPAR MHM/MHH project interventions implemented in the area included training and provision of menstrual cups and sanitary pads to adolescent girls from the four schools. Furthermore, the project involved MHM education, awareness campaigns and capacity building among adolescent boys, teachers, mother groups, girls’ councilors, traditional leaders, school and health management committees; parents and community members.

Source Authors

Map of Lilongwe showing the study area.

Study design, methods, and data collection tools

In July and August 2023, we implemented a mixed-methods research design where both quantitative and qualitative data were collected. Quantitative assessment was performed through school and household surveys. Quantitative data were collected through surveys of learners in the 4 selected schools, while qualitative data were collected using direct observations, key informant interviews (KIIs) or in-depth interviews (IDIs) and focus group discussions (FGDs). A literature review of project documents (baseline, midterm, and end-line progress reports) was made. Furthermore, community-level knowledge-sharing workshop reports and other related MHM/MHH project documents were reviewed and analyzed. The girl’s MHM questionnaire, boys’ FGD guide, household MHM questionnaire, and mother group’s FGD guide were prepared and implemented.

Participants, sample size and inclusion criteria

The study participants included adolescent boys and girls (11–19 years; grades 5–8), Teachers/Head Teachers, Mother Group members, Girls Councilors, Parent-Teacher Association (PTA), Chiefs/GVH, School Management Committees (SMCs), and Community Health Committees. We purposively selected and surveyed a total of 100 adolescents girls at the menarche stage to understand their level of knowledge, adoption, uptake and impact of the MHM interventions. Next, a total of 90 households where the adolescents came from were engaged in interviews to sort their understanding and support of the MHM to their adolescent girls. The study targeted households (HH) with adolescent girls only because of their experience in managing girls during menstruation. Due to the scarcity of such types of households, the study targeted the nearest HHs with such girls. In addition, 8 FGDs, 4 KIIs and 1 survey with boys on myths and misconceptions were conducted in each of the four schools. A total of 20 FGDs were conducted in all the schools, with groups of 5–10 people purposively selected for their first-hand information. Discussions were centered on selected topics specifically on WASH and menstruation while allowing for interesting, new, or unplanned follow-up questions to be asked. Concurrently, direct observation was used to confirm or triangulate the information given through the questionnaire survey and photographic pictures.

The sample size and distribution of participants are summarized and presented in Table  1 . The study used convenience and purposive sampling to identify study participants, namely, teachers, mother group members, PTAs, chiefs, health center management groups, youth groups, and parents. Participants who had stayed in the area for at least 6 months and/or were involved in the MHM/MHH interventions were engaged. To validate the quantitative data, KIIs targeting key districts and community-level informants connected to adolescent girls were employed. Furthermore, the study participants were selected using the inclusion and exclusion criteria summarized in Table  2 . Android tablets programmed in mWater were used for data collection to minimize errors since the program was developed with built-in data validation, skip rules, and constraints in the questionnaire.

Data management and statistical analysis

The qualitative data were analyzed manually through content analysis to contextualize quantitative findings. First, the qualitative data were entered into Microsoft Excel and Word for transcription, translation and cleaning. Preliminary reading of all reports was performed to identify initial key issues. All three approaches to qualitative content analysis as outlined in [ 17 ] were employed. The study assessed the MHM/MHH project intervention uptake and impact by computing prevalence differences at 95% confidence intervals using fixed-effects logistic regression. To ensure the validity and reliability of the results, the authenticity of statements and information received were verified with experts and stakeholders in the area. Furthermore, all the data collection tools were piloted and pretested for their efficiency and correctness before the actual data collection.

Ethical consideration

Ethical approval.

To conduct this study, ethical approval was obtained from the Mzuzu University Research Ethics Committee (MZUNIREC) (Ref. No. MZUNIREC/DOR/23/95). During the implementation of the MHM/MHH interventions in the area, permission and partnerships were made with all relevant government offices, including Ministries of Health, Education, and Community Health Centers outreach clinics. Confidentiality was followed, and instead of names, identification codes were used for analysis purposes. A written informed consent form was signed or thumb printed before any form of data collection. For adolescent boys and girls under 18, written informed assent was obtained from their parents, guardians, or teachers. The adolescent boys and girls aged 18 and above provided consent to take part in the interventions and study.

Access to water and sanitation facilities in schools and at home

The study findings showed that all schools had latrines (45% improved, and 54% ventilated improved pit latrines – VIPs, n  = 4). Despite having separate latrines for boys and girls, all the schools lacked handwashing facilities. As an alternative, schools drew water using basins and buckets and provided it to the students by placing them in front of classrooms for easy access. Although water was available for the students, no soap was provided for cleaning and handwashing. During midterm evaluation, it was noted that the Milala school had no water source following the theft of a pump and vandalized boreholes. At this school, students reportedly carried some water in small bottles to cater to all basic sanitation needs. Only the Milala and Kampheratsoka schools had separate washrooms for changing sanitary materials for adolescent girls. Coupled with the unavailability of water and soap in the washrooms and latrines, the study noted that adolescent girls had challenges cleaning themselves at school. However, this circumstance did not pose a significant impact ( p  < 0.05) on school attendance among the girls, as depicted by improved school attendance during the reporting period.

In communities surrounding the schools

The results showed that there was a significant variation ( p  > 0.05) in access to latrines in the communities surrounding the schools (Fig.  2 ). There was a slight increase in latrine coverage in the Kabuthu zone (90% at baseline (BL) versus 93.4% at midterm evaluation (MTE), n  = 4). However, the coverage dropped to 85.7% at the final evaluation (FE). During the final evaluation, the majority of people used traditional latrines (84.4%) (Fig.  3 ). Conversely, there was a moderate increase (11 to 36.4%) in the presence of hand-washing facilities in homes around the schools (Fig.  3 ). The increase was attributed to the engagement meetings where parents were urged to ensure girls had access to sanitation facilities at home. Improved access to water resulted in adolescent girls being able to clean up and maintain hygiene during menstruation.

Access to latrines in the communities surrounding the schools in the study area

Type of latrine ( a ) and hand-washing facilities ( b ) used in surrounding communities

Absenteeism from primary school

Girls missing out on classes because of menstruation.

The study showed a significant reduction ( p  < 0.05) in the number of girls failing to attend classes due to menstruation from 70% at baseline to 21% at midterm and 14% at the final evaluation. All the girls interviewed (100%, n  = 90) felt comfortable using sanitary products, hence resulting in girls having more classroom learning time, similar to their male counterparts. Furthermore, the FGDs conducted with both teachers and parents revealed that there had been an improvement in the performance of girls during the project compared to the pre-project period. Despite helping reduce absenteeism, the improved availability of menstrual services in the area were noted to bring enormous positive impact and reduction in stigma and discrimination against girls.

Number of days girls missed classes due to menstruation

The number of girls who missed classes and stayed away from school due to monthly periods of less than 3 days, 3 to 5 days and more than 5 days decreased significantly. The girls who missed classes for less than 3 days because of monthly periods reduced from 18 to 8%, while for 3 to 5 days, there was a significant reduction from 63 to 6% ( p  < 0.05). For girls missing classes for more than 5 days, the number reduced to 0% because of the availability of sanitary pads and menstrual cups that helped them manage their menses well. The reduction in the number of days girls stay away from school has had a positive change in school academic performance comparable to that of boys, owing to the availability of MHM services and products.

Improved access to schooling as a result of MHM support

Percentage of girls accessing improved education.

The majority of girls who participated in the program (94.4%, n  = 100) reported improved access to school as a result of overall MHM support provided during the project implementation (Fig.  4 ). Many adolescent girls sampled (83.2%, n  = 100) reported having used reusable sanitary materials compared to baseline findings where only 10% had access and used the same. Similarly, a considerable number of adolescent girls (70%) reportedly used menstrual cups. Thus, the increase in the percentage of girls accessing improved education was attributed to the availability and usage of sanitary pads and menstrual cups, hence resulting in reduced absenteeism. On average, each adolescent girl was reported to have a minimum of 5 reusable sanitary pads and 1 menstrual cup. In addition, the increase in the number of girls accessing improved education was attributed to awareness of menstrual hygiene among boys who stopped bullying girls when in menses. The awareness focused on myths and misconceptions related to MHM as well as the negative impacts of bullying that result in girls staying away from school or completely dropping out.

Percentage of girls accessing improved education after the project intervention

Number of learners comfortable attending school during menstruation

With the MHM project’s interventions, the majority of girl learners (97%, n  = 100) became more comfortable attending school during menstruation compared to the pre-project period (Fig.  5 ). This is an improvement from 26% at baseline to 79.2% during the mid-term evaluation. The girls felt comfortable because they had sanitary pads and menstrual cups that prevented them from messing up during menstruation, hence reducing absenteeism and dropping out. The results from the interviews with girl counselor teachers confirmed that the schools had reusable sanitary pads ready for girls who reached puberty and started menstruation. There was a strong adoption of sanitary products among all age groups, with 99% and 94% coverage for girls aged 10 to 14 and 15 to 18 years, respectively.

Percentage of girl learners comfortable attending school during menstruation

Use of reusable pads and menstrual cups

There was an increase in the number of girls ( n  = 100) using reusable pads (83.2%) compared to menstrual cups (70%). This is because the latter was introduced by the project lately, while the former was fairly being used by some of the students before the project. Furthermore, reusable sanitary pads were fairly cheaper and locally made compared to menstrual cups (Table  3 ). Analysis by schools showed that Milala (100%) was the best to use menstrual cups compared to Chifeni (32%). This was mainly because the large cup sizes purportedly caused pain to young adolescent girls at Chifeni. Chifeni School had younger adolescent girls who participated in the interventions compared to Milala School. The majority of girls (82%) preferred reusable sanitary pads over menstrual cups (Fig.  6 ). Very few girls (18%) reported using menstrual cups exclusively for several reasons, such as pain and difficulty to wear. Furthermore, it was revealed that some girls indicated that the cups were large. Through the provision of sewing machines and pad fabrication training, skills and knowledge were gained by women and adolescent girls to produce pads packaged as part of the MHM kit for girls who had just started their menses. Such an initiative was highlighted by both teachers and community members as a success and the project’s sustainability strategy.

Girls’ preference between reusable sanitary pads and menstrual cups

The majority of girls (60%, n  = 145) trained in the fabrication of reusable sanitary pads were actively involved in continuous production, surpassing the project target of 20%. Interestingly, the girls in the age group of 10–14 years scored the highest (99%) in fabricating reusable sanitary pads. Furthermore, the key informant interviews with mother group members, teachers and local leadership showed that mother group members were highly involved in the fabrication of reusable sanitary pads and training other learners, hence representing a great sign of sustainability. During health education talks and parent engagement meetings, men and boys were deliberately included to improve their knowledge and perceptions toward MHM. A total of 458 men and boys (10–14 years, n  = 187; 15–18 years, n  = 241 and 19 above, n  = 30) were reached during the MHM health talks and a quiz on myths and misconceptions. A total of 144 boys out of 180 managed to score 75% above, representing 80%, a percentage slightly higher than the midterm score of 45.2%.

Improved knowledge and attitudes toward the application of MHM solutions

Parents and community members.

The percentage of parents that encourage girls to attend primary school even during periods of menstruation was evaluated and disaggregated. This was done to assess their level of knowledge and support given to adolescent girls during the monthly periods. In the final evaluation of the project, the results showed that the majority of the parents (64%) encouraged their daughters to attend school even during monthly periods. This was significantly higher than the midterm (46%) and baseline evaluations (8%). After implementation of the MHM interventions, the majority of the parents and community members (62.3%, n  = 90) were comfortable with the menstrual products used by their daughters.

Boys and men

After MHM interventions and awareness campaigns, many boys gained knowledge about menstruation, especially myths and misconceptions. For example, approximately 80% of the boys trained on MHM were able to score above 75% in the post training quizzes compared to 45% during midterm and 0% during baseline. This is an indication of the absorption of knowledge on MHM. In addition, there were no fathers who felt that discussing issues of menstruation with their children was taboo and against cultural beliefs, with 2.40% at baseline, 1.3% at midterm to 0% at final evaluation. Furthermore, there was a significant difference ( p  < 0.05) in the reaction and attitudes of male parents responding to questions about the menstrual issues of their daughters between the baseline and the final evaluation assessments.

Availability of wash facilities in schools and surrounding communities

The four schools involved in our study had latrines separate for girls and boys (45% improved, 54% ventilated improved pit latrines – VIPs). However, these schools lacked handwashing facilities and soap for cleaning and handwashing. This is a problem considering that adolescent girls undergoing menstruation require handwashing facilities and soap for sanitary purposes. Correspondingly, two schools namely Chifeni and Kabuthu did not have separate washrooms for changing sanitary materials, hence depriving them of their privacy and dignity during menstruation. Similar results on the lack of washrooms for changing sanitary materials and poor access to clean water, sanitation and hygiene facilities have been reported in Malawi and elsewhere [ 8 , 18 ]. The lack of latrines both at school and at home has been reported widely in the literature to pose negative impacts on menstrual health for adolescent girls [ 2 , 13 , 19 ]. Furthermore, the absence of proper latrines both in schools and homes has globally been reported to deprive adolescent girls of privacy, safety and dignity to change used menstrual materials within the household in Zambia and Kenya [ 11 , 20 ]. The decrease in the latrine coverage from 90 to 85.7% at the final evaluation in Kabuthu zone (Chifeni school communities) was attributed to too much rain received in the area, which damaged most of the latrines constructed using unburnt bricks and mud. Although the schools are found within the same geographical area, Milala School communities did not receive too much rain naturally, hence managed to maintain their latrine coverage both at the project midterm and final evaluation (90.9%).

Absenteeism from school

The reduction in the number of girls failing to attend classes due to menstruation was attributed to the availability of reusable sanitary pads and menstrual cups provided during the MHM project implementation. During the study girls confessed that the pads and the cups gave them freedom and dignity to attend school even during monthly periods. The positive association between retention of girls and the implementation of MHM education talks, parent engagement meetings, and provision of sanitary pads and menstrual cups showed that the MHM interventions were successful. Generally, the tendency of girls to miss classes was attributed to menstrual-related health problems. The lack of medication for managing menstrual-related health problems (such as abdominal cramps, headaches, and backache) for adolescent girls was attributed to a lack of funding and poverty levels.

MHM products and training provided in project schools

The current study noted the need to procure age-specific menstrual cups to match the young adolescent age ranges that were prevalent at Chifeni School. The differences in adoption of MHM products among schools were attributed to opposing preferences and attitudes toward menstrual cups, hence a need for more awareness of the utilization of menstrual cups. Varied adoption and use of menstrual cups and reusable pads by adolescent girls have been reported in many countries, including rural Nepal [ 21 ], rural western Kenya [ 18 ], and in rural schools of Zambia [ 11 ]. In this study, at the time of the assessment, the project had made available a total of 3084 reusable pads and 580 cups. A total of 1534 reusable pads were locally produced by mother group members and students, while 1550 pads were procured and distributed to students. Conversely, a total of 580 menstrual cups were distributed to 366 adolescent girls, 23 mother group members, 35 female teachers, and 156 women from the community. Through the provision of reusable sanitary pads and menstrual cups in the four schools, the endline survey results showed a positive adoption and usage of the distributed reusable sanitary pads and menstrual cups. Generally, there was increased participation in reusable pad fabrication by students and mother group members in project schools and the community. The enormous leap in availability and usage of reusable sanitary pads after project implementation was attributed to the provision of reusable sanitary pads and training on the fabrication of pads conducted on 145 adolescent girls (representing 39% of adolescent girls in the Kabuthu education zone) and 30 mother group members from the four primary schools studied. Similar findings on MHM among women and girls in Malawi noted that the use of disposable pads was favored by most girls who participated in the study [ 8 ]. Conversely, studies conducted elsewhere showed that rural and poor women and girls resort to using old clothes for menstruation rather than menstrual cups and reusable sanitary pads due to their poor economic status, availability on the local market, cultural acceptability and personal preferences, among others [ 11 , 22 , 23 , 24 , 25 , 26 ]. The use of unsuitable and unhygienic menstrual products is reported to increase rates of pelvic pain, lower genital tract infections, and inflammatory conditions, further exacerbating absenteeism [ 10 ].

To ensure the sustainability of the MHM interventions in the study area, there is a need to make the menstrual products available on the local market. Furthermore, the project implementers and key stakeholders in the area should consider subsidizing menstrual products so that adolescent girls and women can afford to purchase them. Some scholars and previous researchers have advocated for all-inclusive sanitation and hygiene education in schools [ 8 , 27 , 28 ], and this is the same recommendation in the study area and elsewhere in the country and beyond. Thus, there is a need for comprehensive training on MHM and hygiene education so that all groups (boys, girls, women and men) fully understand and remove discrimination and harmful cultural practices.

Knowledge and MHM solutions for community leaders and health workers

The current study showed limited knowledge and understanding of MHM and menstruation by all study participants before MHM education implementation. Similar studies on limited knowledge of MHM by boys and men have been reported in Zambia [ 11 ] and in India [ 29 ]. However, after MHM project implementation in Kabuthu education zone in Lilongwe, the study demonstrated that MHM education talks and parent engagement meetings played a major role in the improved retention of girls throughout the project lifetime in the Kabuthu education zone. The comfortability of parents and community members with the menstrual products used by their daughters was attributed to increased awareness campaigns and engagement meetings, where information on proper MHM was shared. Such efforts and campaigns changed the attitude of parents toward the use of improved menstrual materials as well as offering MHM support to girls. Furthermore, community leaders and members hailed the MHM project for challenging harmful cultural norms that projected MHM talks to be feminine and taboo. There were 8 community engagement meetings conducted in all the schools (2 per school) where both men ( n  = 240) and women ( n  = 461) participated. The leaflets (400) and posters (32) distributed in the four schools played a crucial role in raising MHM awareness among adolescent girls and community members. Although the project engaged a few healthcare workers (35%, n  = 20) in facilitating MHM health talks and menstrual cup orientation, the impact was statistically significant ( p  < 0.05). Regarding the perception and knowledge of men and boys in MHM, deliberate efforts made to engage men and boys in addressing menstrual-related challenges such as stigma and bullying adolescent girls at school showed positive results. From the study findings, it is indeed vital that crucial stakeholders such as community members and health workers, parents and community leaders, among others, are included in MHM interventions and programs for sustainability. Such multistakeholder engagement and inclusion also ensure that MHM interventions are monitored and supported even when the project is finished [ 8 ].

Lessons learned and upscaling of the MHM elsewhere

The study has shown that during the implementation of the MHM project, several risks and challenges were encountered. These included cultural resistance to innovation adoption, especially menstrual cups; inflation (adjustment of all the planned activities); COVID-19 lockdowns and restrictions, limited access to MHM products (cups, reusable pad components); cholera outbreaks; and uncertainty of sustainability of the MHM products. To mitigate cultural resistance, the gatekeepers and all key communities and stakeholders were engaged through meetings and the adoption of engagement information, training, and constant impact monitoring of the project in communities surrounding the 4 schools. Several activities were implemented during the same field trip to reduce travel costs and other logistics. During the cholera outbreak, community members surrounding the schools and all members of the school community (learners and teachers) were sensitized to take precautionary measures on how to prevent cholera and to rush to the nearest health facilities in case of cholera cases. On the sustainability of the innovation, the mother group members were sensitized to continue producing the reusable pads and selling the extra ones to the community members so that they would be able to continue buying materials for sewing.

Other lessons learned during the implementation of the MHM in the study area showed that the inclusion and involvement of female teachers and other key stakeholders (mother groups and health officers) during MHM training increased ownership of the project interventions. On the one hand, the presence of female teachers as stakeholders made it easier to manage the delivery of MHM services, including health education. Furthermore, the inclusion of female teachers in the MHM solutions brought girls closer to their teachers and eventually opened up issues of menstruation. On the other hand, the inclusion of boys in the health education talks addressed issues of stigma and discrimination. This allowed for a holistic approach to MHM and helped the boys to better understand issues of MHM, hence support adolescent girls well.

The gender analysis revealed gender gaps in the Kabuthu education zone that exacerbated school absenteeism and dropout among girls. Menstruation was singled out as the main driver of school absenteeism and dropout among adolescent girls. Contributing to challenges of menstruation were cultural and traditional norms related to menstruation, lack of proper and adequate menstrual knowledge and products among girls and communities, lack of adequate female teachers to act as mentors and role models, and stigma and ignorance perpetuating bullying toward adolescent girls. Gratefully, the MHM project addressed these challenges to ensure equitable access to educational learning outcomes for both boys and girls and reduced school absenteeism and dropout related to menstruation among adolescent girls in the Kabuthu education zone. Such lessons learned can be implemented anywhere in Malawi and beyond. To ensure the sustainability and proper promotion of MHM products and hygiene education in the country, the Malawi Government is developing standard protocols, guidelines, and implementation strategies. The ongoing revised National Sanitation and Hygiene Policy (2024) and National Sanitation and Hygiene Strategy (2018–2024) aim to promote user-friendly sanitation and hygiene facilities; establishment of gender equality and social inclusion (GESI) in menstrual health and hygiene management in all sectors; and waste management and MHM in all schools and facilities. The established policy and strategies on sanitation and hygiene in Malawi will ensure that MHM is regulated and provide guidance for decision-making and that menstrual products and services are moderated and accepted for promotion.

Conclusion and recommendations

This study has confirmed that access to sanitary products in schools and at home is crucial for menstrual hygiene and reducing absenteeism for adolescent girls in Malawi. Some schools did not have separate washrooms for changing sanitary materials for adolescent girls. Furthermore, the use of unburnt bricks and nondurable materials was found to compromise the durability of latrines. The results suggest that there is a need for the construction of girl-friendly and durable WASH facilities and washrooms. Following MHM interventions and implementation, the study has shown a significant reduction in girls who missed classes. The awareness and involvement of boys, men and other community leaders and healthcare workers removed the myths and misconceptions related to menstrual hygiene and the impacts of bullying that result in girls staying away from school or completely dropping out. The study, therefore, calls for comprehensive training on MHM and hygiene education so that all groups (boys, girls, women and men) can remove discrimination and harmful cultural practices. Additionally, the study has shown that key stakeholders such as community members and healthcare workers, parents, mother groups and community leaders must be included to promote the uptake and sustainability of reusable pads and menstrual cups and MHM interventions and programs in general. Further areas of research would include longer-term evaluation of the impact and sustainability of the MHM project to support the observations of this study. Key areas would include assessment of continued access and use of menstrual health products, community involvement and impact on girls’ level of education.

Data availability

Useful data are presented in Tables and charts in the report. Additional datasets and files for the study are available from the corresponding author upon request.

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Acknowledgements

We thank teachers, mother groups, head teachers, girls, boys, and their parents for their participation in this study. We are grateful to field and office staff, community leaders and healthcare workers for their support during project implementation and study. Furthermore, we thank the Canadian Physician for Aid and Relief (CPAR), Fund for Innovation and Transformation (FIT), Global Affairs Canada (GAC), and ICN for providing funding for an independent study and assessment of the project implementation.

This study is part of the project “Freedom to Learn for Girls in Rural Malawi – Addressing the Menstruation Barrier” implemented in Lilongwe District, Malawi. The authors are grateful to Canadian Physician for Aid and Relief (CPAR), Fund for Innovation and Transformation (FIT), Global Affairs Canada (GAC), and ICN for the financial support of the study. Funders had no direct role in the study design, data collection, analysis or preparation of the manuscript.

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RC and OK conceptualized and drafted the paper; OK, TT, and LB supported data collection; RC and OK processed and analyzed the data. OK, TT, LB, JN and ML provided technical advice on reusable pads and menstrual cups and manuscript writing. All authors reviewed the manuscript.

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Ethical approval to conduct the study was provided by the Mzuzu University Research Ethics Committee (MZUNIREC) (Ref No. MZUNIREC/DOR/23/95). Further engagement and permission were sought from government authorities. Confidentiality was considered, and a written informed consent form was signed or thumb printed during data collection. For boys and adolescent girls under 18, written informed assent was obtained from their parents, guardians, or teachers.

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Chidya, R., Kachuma, O., Thole, T. et al. Evaluation of knowledge, attitude, practices and effectiveness of menstrual hygiene interventions in rural schools from Lilongwe, Malawi. BMC Public Health 24 , 1435 (2024). https://doi.org/10.1186/s12889-024-18940-w

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Cost-effectiveness of differentiated care models that incorporate economic strengthening for HIV antiretroviral therapy adherence: a systematic review

• Annie Liang 1 ,
• Marta Wilson-Barthes   ORCID: orcid.org/0000-0002-9845-7142 2 &
• Omar Galárraga   ORCID: orcid.org/0000-0002-9985-9266 3  

Cost Effectiveness and Resource Allocation volume  22 , Article number:  46 ( 2024 ) Cite this article

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There is some evidence that differentiated service delivery (DSD) models, which use a client-centered approach to simplify and increase access to care, improve clinical outcomes among people living with HIV (PLHIV) in high HIV prevalence countries. Integrating economic strengthening tools (e.g., microcredit, cash transfers, food assistance) within DSD models can help address the poverty-related barriers to HIV antiretroviral therapy (ART). Yet there is minimal evidence of the cost-effectiveness of these types of multilevel care delivery models, which potentially prohibits their wider implementation.

Using a qualitative systematic review, this article synthesizes the literature surrounding the cost-effectiveness of differentiated service delivery models that employ economic strengthening initiatives to improve HIV treatment adherence in low- and middle-income countries. We searched three academic databases for randomized controlled trials and observational studies published from January 2000 through March 2024 in Sub-Saharan Africa. The quality of each study was scored using a validated appraisal system.

Eighty-nine full texts were reviewed and 3 met all eligibility criteria. Two of the three included articles were specific to adolescents living with HIV. Economic strengthening opportunities varied by care model, and included developmental savings accounts, microenterprise workshops, and cash and non-cash conditional incentives. The main drivers of programmatic and per-patient costs were ART medications, CD4 cell count testing, and economic strengthening activities.

All economic evaluations in this review found that including economic strengthening as part of comprehensive differentiated service delivery was cost-effective at a willingness to pay threshold of at least 2 times the national per capita gross domestic product. Two of the three studies in this review focused on adolescents, suggesting that these types of care models may be especially cost-effective for youth entering adulthood. All studies were from the provider perspective, indicating that additional evidence is needed to inform the potential cost-savings of DSD and economic strengthening interventions to patients and society. Randomized trials testing the effectiveness of DSD models that integrate economic strengthening should place greater emphasis on costing these types of programs to inform the potential for bringing these types of multilevel interventions to scale.

Introduction

Responding to the World Health Organization’s Treat All Policy, low- and middle-income countries (LMICs) are increasingly using differentiated service delivery (DSD) models as a way to rapidly scale up access to life-saving antiretroviral therapy for people living with HIV (PLHIV) [ 1 ]. According to the International AIDS Society, “differentiated service delivery (DSD), previously referred to as differentiated care, is a client-centred approach that simplifies and adapts HIV services across the cascade to reflect the preferences, expectations and needs of people living with and affected by HIV, while reducing unnecessary burdens on the health system” [ 2 ]. DSD models aim to make care “patient-centered” while reducing logistical and administrative burden(s) on traditional, resource-constrained care facilities [ 1 ]. These models have shown to be effective for increasing treatment adherence, but most do not address the persistent poverty-related barriers to HIV care engagement (e.g., long and costly distances to facilities, food insecurity, HIV stigma). A recent systematic review from 20 LMICs found that economic strengthening interventions such as conditional cash transfers, microcredit, and transportation assistance can improve medication adherence and care-seeking behaviors among persons living with HIV, with more moderate impacts on clinical outcomes [ 3 ]. Two other systematic reviews found that, on their own, differentiated HIV service delivery approaches in Sub-Saharan Africa (SSA) generally cost the same as or less than standard HIV care in terms of the cost per patient per year from a patient perspective [ 1 , 4 ]. For providers and health systems, the available economic evidence suggests that DSD models in SSA are not cost saving compared to more traditional facility-based care models [ 4 ]. A 2017 modeling study found that differentiated service delivery models aiming to increase access to ART in SSA could yield up to a 17.5% reduction in health system costs and health workforce requirements over 5 years [ 5 ]. It remains to be seen whether differentiated service delivery models that additionally aim to address poverty-related barriers to care (e.g., food insecurity, long and costing distances to facilities, restricted access to income-generating opportunities) are cost-effective for patients, providers, or society as a whole [ 6 , 7 ].

The purpose of this systematic review is to (i) summarize the current evidence surrounding the cost and cost-effectiveness of differentiated HIV service delivery models that include economic strengthening compared to differentiated service delivery without economic strengthening and to standard HIV care, and (ii) offer a conceptual framework that can help future researchers understand the key components influencing the incremental cost-effectiveness of these holistic models for patients and providers.

Eligibility criteria

Our review focused on studies of the cost-effectiveness of differentiated HIV care models that incorporated at least one economic strengthening component. Articles were excluded if they were not a randomized controlled trial or observational study, did not include both an economic strengthening and a differentiated care component for promoting ART adherence, or did not report a standard metric for assessing cost-effectiveness of an ART adherence intervention. Economic strengthening included any activity that aimed to generate individual- or household-level income or wealth, such as microfinance groups, social protection programs, savings accounts, or training in financial literacy or entrepreneurship. Articles that were not peer reviewed, published in English, or conducted in SSA were also excluded. There were no restrictions on the study population in terms of age, gender, or SSA region. During the abstract round of screening if the study fit all other criteria (differentiated service delivery in Sub-Saharan Africa with economic strengthening) but did not mention whether a cost-analysis was performed, the study was included for full text screening to account for ancillary costeffectiveness analyses.

Information sources & search strategy

We conducted a literature search of articles in PubMed (National Center for Biotechnology Information, Bethesda, Maryland) and EconLit (American Economic Association, Nashville, Tennessee), supplemented by an Internet search of Google Scholar. Prior reviews indicate that DSD interventions have been implemented since the 2000s. Thus, we searched articles published from January 1, 2000 through March 31, 2024 using the terms “HIV or AIDS”, “ antiretroviral therapy”, “economic strengthening”, “differentiated service delivery”, “Sub-Saharan Africa” “cost analysis”, “cost-effectiveness” and “cost-savings”. Literature searched in PubMed used MeSH (Medical Subject Headings) controlled vocabulary to select key search terms. The full search strategy implemented for each database is provided in Additional File 1 .

Selection process

Initial search results were reviewed by one reviewer (AL). Abstracts and main texts of articles that met all eligibility criteria were double reviewed (AL and MWB), with a third reviewer consulted when necessary (OG).

Data collection process

A data extraction tool was developed to capture the following indicators: study context (e.g., country and region of study), design, population, DSD component(s), economic strengthening activity, costing perspective, main drivers of intervention and per-patient costs, cost-effectiveness metric (e.g., incremental cost-effectiveness ratio), willingness-to-pay threshold (WTP), and a binary indicator of whether the intervention showed to be cost-effective (yes/no). Due to significant heterogeneity across studies in terms of effectiveness and cost-effectiveness outcomes, a meta-analysis was not performed. Search findings were reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [ 8 ].

Quality assessment

Full texts that were standard health economic evaluations were assessed using the validated Quality of Health Economic Studies (QHES) appraisal system developed by Chiou [ 9 , 10 ]. The quality of each full text article was assessed based on the sixteen weighted criteria listed in Additional File 2 . Weighted scores for each criterion were summed to generate an overall quality score ranging from 0 (extremely poor quality) to 100 (excellent quality). Four quality categories (0–25, 25.1–50, 50.1–75, and 75.1–100) were used with scores > 75 indicating high quality studies [ 10 ]. Systematic reviews, micro-costing studies, and qualitative analyses were not scored given our focus on randomized controlled trials (RCTs) and observational studies.

Conceptual framework

Drawing on the papers included in the review, we adapted an existing conceptual framework to synthesize the key components that could be understood to drive the incremental cost-effectiveness of HIV differentiated service delivery models for SSA health systems.

Identified articles

Figure  1 documents the flow of articles through the review and reasons for exclusion. Most of the 89 articles were peer-reviewed journal articles (93.2%), followed by preprints (2.2%), and scientific reports (2.2%). Of the 57 articles that included a DSD intervention, the most common differentiated service delivery model was community-based ART support and adherence counseling. Of the 40 articles that included an economic strengthening (ES) component, conditional economic (cash and non-cash) incentives and microfinance engagement were the most common ES activities. The most common reasons for exclusion were no economic strengthening component and no cost-effectiveness analysis. Eleven of the 89 reviewed articles were traditional cost-effectiveness analyses and thus were appraised for quality using the Chiou grading system; those that were not appraised using the grading system included costing, budget impact, or other types of non-cost-effectiveness evaluations. The 11 articles had an average quality score of 80.73 (out of 100), and all satisfied at least 11 of the 16 grading criteria (Additional File 2 ). Of the 89 full text articles that were assessed, three papers met all eligibility criteria and were included in this narrative review.

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

Background and summary of included articles

All 3 studies scored above a 75 (out of 100) on the QHES appraisal system, indicating high quality studies [ 10 ]. Tozan et al. and Ekwunife et al. scored an 85 on the QHES, satisfying the same criteria. Stevens et al. scored 100 on the QHES, satisfying all criteria. Only Stevens et al. displayed a clear economic model, study methods and analysis, and components of numerator and denominator and justified choice of economic model, main assumptions, and limitations of the study. Although all three included studies were of high quality according to the QHES, each provided minimal rationale for their use of a given economic model which may hinder replicability.

Details of the three included studies are summarized in Table  1 . In brief, Tozan et al. [ 11 ] estimated the incremental costs of providing additional counseling sessions for HIV and ART adherence as well as an incentivized savings account and workshops on asset building to adolescents living with HIV in Uganda. Incremental intervention costs were compared to the cost of providing routine HIV care and social support alone. Ekwunife et al. [ 12 ] estimated the cost-effectiveness of a differentiated care model for young adults living with HIV in Nigeria that included motivational interview sessions and economic incentives based on viral load over 12 months. Stevens et al. [ 13 ] modelled the cost-effectiveness of scaling-up a combination care package in Swaziland, which included SMS reminders for ART adherence, counseling and health commodities for ART adherence (e.g., pillboxes and informational materials), and non-cash financial incentives for adults who newly tested positive for HIV. All included studies utilized a facility-based DSD model. For each study, the additional cost for a given intervention compared to the status quo was $970 [95% CI: $508 − 10,275] per additional patient virally suppressed [ 11 ], $1,419 per additional patient with undetected viral load [ 12 ], and $3,560 per additional quality-adjusted life year (QALY) gained [ 13 ].

Cost-effectiveness of differentiated care with economic strengthening

Table  2 presents the cost-effectiveness outcomes from each included study. All analyses used a provider perspective.

The threshold at which a given intervention was deemed cost-effective varied across studies. Tozan et al. did not report a pre-specified willingness to pay threshold [ 11 ]. Ekwunife et al. specified a willingness to pay threshold of $1,137 per additional QALY gained by the intervention [ 12 ]. Stevens et al. reported a threshold of $9,840 per additional QALY gained (3x Swaziland’s GDP per capita); the Link4Health combination package yielded an incremental cost effectiveness ratio (ICER) of $3,560 per additional QALY gained from the health sector perspective, which the authors deemed cost-effective at a willingness to pay threshold of 3 x Swaziland’s per capita GDP in 2018 [ 13 ]. The cost-effectiveness analysis by Ekwunife et al. [ 12 ] found that combing conditional economic incentives and motivational interviewing was not cost-effective compared to standard care at the authors’ pre-defined willingness to pay threshold of 0.51 times Nigeria’s per capita GDP; the intervention was cost-effective at 1 x Nigeria’s per capita GDP in 2021 ($2,027.80). Tozan et al. [ 11 ] did not report the cost-effectiveness of the combined adherence mentoring and incentivized financial savings account intervention in relation to a pre-defined cost-effectiveness threshold; however the intervention cost less than 2 x Uganda’s per capita GDP ($847.30 in 2021). The respective interventions analyzed by Ekwunife et al. [ 12 ] and Tozan et al. [ 11 ] were cost-effective (compared to standard care) assuming the World Health Organization’s willingness to pay thresholds of 2 to 3 times the national per capita GDP in the trial year. Across the three studies, the main drivers of programmatic and per-patient costs were ART treatment costs, CD4 cell count testing, and economic strengthening activities including the costs to provide non-financial incentives. In the Uganda cluster-randomized trial [ 12 ], the largest cost drivers for the intervention came from viral load tests, CD4 count testing, and patient transportation. Financial incentives and point of care CD4 testing were the main drivers of the observed cost differences in the analysis of the Link4Health cluster-RCT [ 13 ]. For Tozan et al. [ 11 ], intervention activities including health education sessions, microenterprise workshops, and savings accounts contributed the largest difference in costs between intervention and standard care. All interventions were more expensive than standard care in terms of total cost per patient.

Synthesizing framework

Based on the three papers in this review, we adapted an existing conceptual model originally developed by Kahn and colleagues [ 14 ] to illustrate – from a health system perspective – the key components that can be hypothesized to influence the cost-effectiveness of differentiated service delivery models that incorporate economic strengthening. (Fig.  2 ) Increasing patient access to antiretroviral therapy immediately following diagnosis and sustaining access over time (e.g., by offering community- or home-based care visits; accelerating ART initiation following point of care CD4 cell count testing) can be expected to add costs to the health system via an increased demand for higher drug quantities, follow-up tests, and personnel time. Similarly, providing economic strengthening opportunities that address known poverty-related barriers to ART adherence will almost always increase the incremental costs of these care delivery approaches if the initiatives are not self-sustaining. For example, providing economic incentives conditional on achieving a viral load below an assay’s lower detection limit will incur additional costs to health ministries who wish to offer this incentive scheme as part of a government social protection program. However, economic strengthening interventions have the potential to be cost-neutral to health systems if they can generate economic growth on their own, as in the case of saving and lending microfinance groups [ 15 , 16 ] or no fee savings accounts [ 11 ]. Averting new HIV infections and decreasing HIV-related morbidity by achieving an undetectable viral load via ART leads to substantial reductions in both disability-adjusted life years and treatment costs. However, as individuals live longer due to ART, they may develop other chronic diseases that incur additional costs to themselves and the health system [ 17 ]. Thus, differentiated service delivery models that integrate economic strengthening and treatment for co-occurring conditions have the potential to further reduce disease burden without substantially increasing treatment costs.

Conceptual Framework. The conceptual framework was adapted from an existing conceptual model developed by Kahn et al. [ 11 ] The framework illustrates the key components that can be hypothesized to influence the cost-effectiveness of differentiated HIV care approaches that incorporate economic strengthening activities, from a health system perspective

All elements of this synthesizing conceptual framework are drawn from the authors’ analyses of the supporting literature. Further research on the cost-effectiveness impact of these mechanisms is required to support their validity.

This systematic narrative review found one of three studies testing a differentiated service delivery model that includes economic strengthening to be cost-effective for providers at the authors’ pre-determined WTP threshold. All three included articles were cost-effective at the WHO willingness to pay threshold of at least 2 times a given country’s per capita GDP. Sensitivity analyses [ 11 , 12 ] and modeling projections [ 13 ] in these papers suggest that the cost-effectiveness of these types of multilevel interventions would increase as these care models are brought to scale. Ekwunife et al. [ 12 ] found that if CD4 + count tests were performed triannually rather than four times a year, the intervention would become cost-effective. Thus, only minimal adjustments to the differentiated service delivery and ES components could increase the interventions’ cost-effectiveness.

Two of three studies in this review were among adolescents living with HIV. This suggests that cultivating routine medication taking behaviors and establishing positive economic skills (e.g., having a savings account, managing microcredit) may be especially important for lower income adolescents living with HIV who can carry these practices into adulthood. Additionally, two recent feasibility studies did not meet inclusion criteria (i.e., being an RCT or observational study) but were initially screened in this review. Findings from these studies further support the potential of integrating DSD with economic strengthening for improving HIV treatment outcomes along the care continuum (testing, linkage to care, and ART adherence) [ 18 , 19 ].

The World Health Organization’s Treat-All guidance recommends CD4 testing before initiating antiretroviral therapy (ART) and recommends routine viral load monitoring (over CD4 cell count monitoring) for patients on ART [ 20 , 21 ]. Viral load monitoring remains the gold standard for monitoring ART adherence and viral suppression among persons living with diagnosed HIV, even in settings where health systems face financial and resource constraints [ 22 , 23 , 24 ]. Thus, given that the focus of our review is on cost-effectiveness of models for ART adherence among persons with diagnosed HIV, our findings can inform scale-up of DSD models that support the most widely used HIV treatment outcomes.

Recent protocol studies reveal that there remains space in the literature to continue to examine DSD with economic strengthening interventions as an effective and cost-effective method of enhancing ART adherence [ 25 ]. For future research and policymaking, these findings suggest there may be potential for implementing scaled-up DSD with economic strengthening interventions enhancing ART adherence among adolescents and young adults specifically.

Limitations of this systematic review stemmed from the large variability in population, context, and target outcomes across studies, which limited our ability to calculate an overall combined economic effect of these interventions. Additionally, all of the cost-effectiveness analyses in this review calculated cost according to the provider perspective, which limits our ability to quantify the potential economic impact of these combination differentiated care models on patients or society. We aimed to mitigate any potential reviewer bias in the inclusion/exclusion of a quality assessment by using a standardized data extraction tool.

Despite calls for novel cost-effectiveness data of holistic differentiated care models in low- and middle-income countries [ 1 , 6 , 26 , 27 , 28 ], the evidence base surrounding the scale-up potential of DSD interventions and economic strengthening remains sparse. To our knowledge, this is the first review to synthesize the available evidence of poverty-addressing DSD models from a health economics perspective. This evidence is critical for policymakers and health care advocates working to address the economic determinants of HIV treatment adherence with limited resources.

This brief systematic review demonstrated that including economic strengthening tools as part of differentiated service delivery models is effective and largely cost-effective at common thresholds compared to traditional HIV care. Modelling projections suggest that scaling these types of multilevel intervention may improve their cost-effectiveness in the short and medium term. Future research should consider the cost-effectiveness and cost-savings of these comprehensive HIV care models from a patient and societal perspective.

Data availability

Data sharing is not applicable to this article as no new datasets were generated or analyzed during the current study.

Abbreviations

Adolescents Living with HIV

Antiretroviral Therapy

Differentiated Service Delivery

Economic Strengthening

Gross Domestic Product

Incremental Cost-Effectiveness Ratio

Income-Generating Activity

Low- or Middle-Income Country

Motivational Interviewing

People Living with HIV

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Quality-Adjusted Life Year

Randomized Controlled Trial

• Sub-Saharan Africa

Willingness-to-Pay

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Acknowledgements

We thank the authors of the original source papers, whose work we drew on considerably.

Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award number R01MH118075, and by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health through the Providence/Boston Center for Aids Research (CFAR) (award number P30AI042853). One hundred percent of this research was financed with Federal money. The design of the study and collection, analysis and interpretation of data and writing of the manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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AL and OG conceived and designed the work. AL led the analysis and interpretation of the data, and drafted the work. MWB contributed to the analysis and interpretation of data. MWB and OG substantively revised the work. All authors approved the submitted version of the manuscript, and agree to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

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Liang, A., Wilson-Barthes, M. & Galárraga, O. Cost-effectiveness of differentiated care models that incorporate economic strengthening for HIV antiretroviral therapy adherence: a systematic review. Cost Eff Resour Alloc 22 , 46 (2024). https://doi.org/10.1186/s12962-024-00557-w

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• Necip Guven 1 ,
• Can Ozcan 2 ,
• Abdulrahim Dundar 3 ,
• Tulin Turkozu 1 ,
• Sezai Ozkan 1 ,
• Cihan Adanas 1 &
• Mehmet Ata Gokalp 1  

BMC Musculoskeletal Disorders volume  25 , Article number:  395 ( 2024 ) Cite this article

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Introduction

Anterior cruciate ligament (ACL) ruptures are common injuries that typically affect young, physically active individuals and may require surgical reconstruction. Studies have shown that the long time success of ACL reconstruction depends on the surgical technique and the postoperative rehabilitation strategy. However, there is still no consensus on the content of rehabilitation programs. Hence, additional research is required to elucidate the significance of early weight-bearing in the rehabilitation process following ACL reconstruction. The aim of this article is to examine the impact of weight-bearing on the clinical results of ACL reconstruction.

Materials and methods

We retrospectively reviewed patient records who had undergone arthroscopic reconstruction using a semitendinosus-gracilis tendon graft for anterior cruciate ligament rupture between January 2018 and December 2020. The study included the data of 110 patients. The patients were split into two groups: Group 1 underwent early weight-bearing, while Group 2 followed a non-weight-bearing regimen for three weeks. We assessed the patients using the anterior drawer test, Lachman test, range of motion, Lysholm knee scale, Cincinnati scale, Tegner scale, International Knee Documentation Committee (IKDC) form and clinical records. Analytical tests were conducted to compare the results.

The complication rates did not show a significant difference between the groups. Group 1 had higher frequencies of positive anterior drawer and Lachman tests. The Lysholm and Cincinnati knee scores of patients in Group 1 were notably lower than those of patients in Group 2. Additionally, the Tegner activity scores and IKDC scores of patients in Group 1 were also meaningfully lower than those of patients in Group 2. In Group 1 patients, there was no notable relationship observed between body mass index (BMI) and the results of the anterior drawer test (ADT) or Lachman test. However, patients with a BMI of 25 or higher in Group 1 showed a decrease in postoperative IKDC scores. In Group 2 patients, no significant relationship was identified between BMI and either the ADT or the Lachman test outcome.

Based on current literature and current rehabilitation guidelines following ACL reconstruction, the decision to initiate early weight-bearing is based on a limited number of studies with low levels of evidence. In our study, we found that patients who followed a non-weight-bearing regimen for 3 weeks after surgery had better mid-term results than those who were allowed to bear weight early. It appears that further prospective studies on this topic are needed to update rehabilitation guidelines in the next.

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An anterior cruciate ligament (ACL) tear is a widespread injury that typically affects young, physically active individuals and requires reconstruction [ 1 ]. In the United States alone, it is estimated that more than 200,000 new ACL injuries occur every year [ 2 ]. The long-term effectiveness of anterior cruciate ligament reconstruction depends on the chosen method of reconstruction and the postoperative rehabilitation process. Several factors can influence the success of the surgery and rehabilitation, including the patient’s age, physical activity level, body mass index, extent of cartilage damage, range of motion limitations in the knee joint, muscle atrophy, presence of effusion, pain, time elapsed between injury and surgery, smoking habits, and whether the patient underwent preoperative rehabilitation. These factors can contribute to a more successful postoperative rehabilitation process for patients [ 3 ].

A technically flawless reconstruction may have negative outcomes due to inadequate and inappropriate rehabilitation [ 4 ]. Considering that % 35 of athletes do not return to their preinjury sports level within two years after anterior cruciate ligament reconstruction and that %35 of patients develop symptomatic tibiofemoral osteoarthritis in the 10 years after surgery, effective anterior cruciate ligament reconstruction and postoperative rehabilitation are of the utmost importance [ 3 , 5 ]. However, there is no agreement on the best strategy or assessment method for rehabilitation programs [ 6 ]. This can be confusing for both patients and physiotherapists [ 7 ]. A study reviewing six high-quality publications outlining rehabilitation guidelines after anterior cruciate ligament reconstruction found different results regarding the impact of early full weight-bearing on clinical outcomes. This highlighted the need for clearer definitions of accelerated rehabilitation and early load bearing [ 8 ]. Unfortunately, the rate of failed ACL reconstruction requiring reoperation has been reported to be between % 10 and %15 [ 9 ]. Aggressive rehabilitation protocols performed before biological integration and complete ligamentization can cause bone tunnel widening due to exposure of the graft-bone interface to early stresses [ 10 ]. Based on our clinical observations and literature review, we found that there is no consensus on weight bearing after anterior cruciate ligament reconstruction. Therefore, the aim of our study was to address this confusion by investigating the medium-term effects of early weight-bearing compared to non-weight-bearing on the clinical outcomes of rehabilitation following anterior cruciate ligament reconstruction surgery.

We analysed the records of 353 patients who underwent reconstruction with semitendinosus-gracilis tendon grafts for ACL rupture between January 2018 and December 2020. Patients who used braces in the postoperative period, patients with concomitant injuries and patients who did not attend the follow-up appointment were excluded from the study. Patients with isolated anterior cruciate ligament injury were included in the study. The number of patients included in the study was 110 and all operations were performed by 3 surgeons.

The patients were categorized into two groups: Group 1 consisted of 54 patients who were allowed early weight-bearing on the 1st day of the postoperative follow-up period, while Group 2 consisted of 56 patients who were not allowed to non-weight-bearing for 3 weeks. Neither group received preoperative rehabilitation. The results and scores of the anterior drawer test, Lachman test, range of motion, Lysholm knee scale, Cincinnati scale, Tegner scale and International Knee Documentation Committee (IKDC) form were obtained from the patients’ clinical records and control examinations performed by 2 experienced surgeons (Fig.  1 ). The quadriceps muscle strength of the patients was measured with a hand dynamometer by the same surgeons. In addition, perioperative tibial slope was measured.

Surgical technique, medication, and rehabilitation

All patients underwent arthroscopic ACL reconstruction using a tourniquet. Preoperative antibiotic prophylaxis and postoperative low molecular weight heparin prophylaxis were administered. The knee joint was evaluated by opening standard arthroscopy portals. Gracilis and semitendinosus tendons were removed using a tendon stripper. The femoral tunnel was opened in the appropriate position according to the anatomical side and in the appropriate thickness for the graft. The tibial tunnel was opened at a 55-degree angle to the tibial plateau.

The prepared grafts were fixed using a single bundle fixed-loop device in the femur and absorbable screws and staples in the tibia. Drains were used in all patients and removed on postoperative day 1.

Patients in group 1 were given as much weight as they could tolerate the pain with crutches on postoperative day 1. In the following days, the amount of weight bearing was increased and full weight bearing without support was achieved on postoperative day 5. Patients in group 2 were mobilised with crutches on postoperative day 1 and non weight bearing was performed until postoperative day 20. On the 21st postoperative day, the amount of weight bearing was increased and full weight bearing was achieved on the 25th postoperative day. The same rehabilitation programs were applied for both groups except for the weight-bearing protocol. Swelling management was done with Ice, compression and elevation. In both groups, we started open chain exercises from postoperative day 1, full extension and flexion up to 90 degrees were allowed for the first 3 weeks and full flexion was allowed after the 3rd week. After the 3rd postoperative day, they were allowed to lift 1 kg weight and increase weight by 1 kg every 3 days and we also applied a home exercise program for rehabilitation.

Statistical analysis

All data were analysed using SPSS version 26 after coding. The Kolmogorov‒Smirnov test and histogram graphs were utilized to assess whether normal distribution conditions were met. For variables that exhibited normal distribution, the mean and standard deviation values were taken into consideration. For nonnormally distributed parameters, the median and minimum-maximum values were provided. Percentage and ratio values were calculated for nominal and categorical variables. The relationship between the variable of early load or not and the analysis of complications was performed using the chi-square test. Similarly, the Mann‒WhitneyU test was employed to compare the scores with the variable of giving or not giving early load. Two way ANOVA was used in the comparisons of “group 1-group 2” and “BMI groups”. Following this analysis, “Bonferroni post-hoc test” was used to determine the groups making the difference for each score. A statistical significance level of %5was accepted.

Participant flow chart

The study included 110 adult patients who underwent anterior cruciate ligament reconstruction. The number of patients in group 1 was 54 and 56 in group 2. Of these patients, 109 (% 99.1) were male. The median age of the patients in Group 1 was 31.5 years, while in Group 2, it was 28.8 years. Due to some technical problems, the operation time was prolonged in a few cases, the mean operation time was 75 min (range: 65–110 min). Table  1 presents the demographic data.

Tibial slopes of patients in group 1 7.60 ± 0.80, tibial slopes of patients in group 2 7.80 ± 0.79 and there was no statistically significant difference ( p  = 0.782).

There was no notable difference in complication rates between Group 1 and Group 2 ( p  = 0.345). These complications included haemarthrosis, rerupture, infection and deep vein thrombosis. In group 1, 4 patients had rerupture, 2 patients had infection and 1 patient had dvt, whereas in group 2, 3 patients had haemarthrosis, 3 patients had rerupture and 1 patient had infection. Comparisons were made between the postoperative results of the anterior drawer tests (ADT) and Lachman tests of patients in Group 1 and Group 2. It was observed that Group 1 patients had positive anterior drawer tests more frequently than Group 2 patients, which was statistically significant ( p  = 0.024). Similarly, Group 1 patients had positive Lachman tests more frequently than Group 2 patients, which was also statistically significant ( p  = 0.013). When analysing the Lysholm knee scores of patients in both groups, there was no significant difference in the preoperative Lysholm score ( p  = 0.811). However, the postoperative Lysholm knee scores of Group 1 patients were significantly lower than those of Group 2 patients. The score was 46.67 in Group 1 and 64.02 in Group 2 ( p  = 0.004). The Cincinnati knee scores of patients in both groups were not significantly different preoperatively, but postoperatively, Group 1 patients had significantly lower scores ( p  = 0.003). By comparing the postoperative Tegner activity score between the two groups, it was found that Group 1 patients had a significantly lower Tegner score than Group 2 patients ( p  < 0.001). Similarly, when comparing the postoperative IKDC score, Group 1 patients had significantly lower scores than Group 2 patients ( p  = 0.005). There was no significant difference in range of motion between the two groups. When we looked at the quadriceps muscle strength of the patients, it was 127,78  N  ± 11,962 in group 1 and 127,14  N  ± 13,172, in group 2 and it was not statistically significant ( p  = 0.792).

In Group 1, the ADT and Lachman test results were analysed using chi-square analysis based on BMI categories: <25 and ≥ 25. There was no significant correlation observed between the ADT and BMI ( p  = 0.285), as well as between the Lachman test and BMI ( p  = 0.458). Similar findings were observed in Group 2, where no difference was found between the BMI and ADT ( p  = 1) or between the BMI and Lachman test ( p  = 0.573).

When the results of the two-factor comparison were analysed, the interaction effect of early weight bearing and BMI on the Lysholm score was not significant ( p  = 0.134). While the interaction was not significant in Cincinati and Tegner scores ( p  = 0.093/ p  = 272), the interaction was significant only in IKDC score ( p  = 0.048).

Anterior cruciate ligament (ACL) reconstruction is a frequently performed procedure to help patients return to their active lifestyle. Proper rehabilitation of the reconstructed knee is crucial for patients to return totheir previous level of physical activity. Many randomized studies have been conducted to assess the effectiveness of early weight-bearing versus non-weight-bearing after ACL reconstruction [ 11 ]. Early studies on early weight-bearing after ACL reconstruction reported that it reduced anterior knee pain and improved Lysholm scores. However, it is important to note that these studies involved patients who were evaluated at an average of 7 months after undergoing reconstruction with a patellar tendon graft, which may explain the difference in our study results [ 12 ]. A systematic review on rehabilitation after ACL reconstruction in 2016 concluded that early weight-bearing reduced anterior knee pain and did not increase the risk of tunnel widening [ 3 ]. According to the rehabilitation guidelines of the Multicentre Orthopaedic Outcomes Network (MOON) group, postoperative early weight-bearing is recommended [ 4 ]. However, it is worth noting that this recommendation is based on a single study conducted in 1998. In our study, we found that early weight-bearing increased knee laxity and decreased knee scores. Based on these findings, it appears that further studies are needed to inform updates to rehabilitation guidelines.

Even studies conducted on living subjects to develop rehabilitation programs that do not strain or restrict the healing of the ACL graft have not yielded conclusive results regarding the impact of loading on ACL healing [ 13 ]. Publications that highlight the positive outcomes of early motion and weight-bearing also acknowledge the uncertainty surrounding the safe threshold of loading. The debate about which rehabilitation approaches are too aggressive and what level of loading is sufficient persists [ 14 ]. This uncertainty may expose patients to anunnecessary risk of reinjury. Our study’s findings, which show superior scores among patients who did not undergo non-weight-bearing, can contribute to resolving this debate. Clinicians can achieve satisfactory clinical outcomes by refraining from applying weight-bearing to patients for 3 weeks and closely monitoring them during the postoperative rehabilitation process, without concern about the patient experiencing a recurrence of ACL insufficiency. In a publication comparing the clinical and radiological outcomes of patients following a non-weight-bearing regimen for 1 week compared with 2 weeks during the postoperative rehabilitation period, no significant differences were found in Tegner activity level, Lysholm score, anterior laxity, or muscle strength values. However, the same study reported that early weight bearing could potentially increase the risk of femoral tunnel enlargement [ 15 ]. In light of these factors, it would be prudent to avoid implementing aggressive rehabilitation protocols that carry the risk of potential reinjury until the literature provides clearer guidance on this matter. Another study demonstrated that aggressive rehabilitation led to increased femoral tunnel enlargement and decreased IKDC scores, emphasizing the importance of a balanced approach to rehabilitation [ 16 ]. This study emphasised the importance of early mobilisation and rehabilitation to restore normal range of motion after surgery and also observed the positive effects of non-weight bearing on outcomes. In the literature, there are inconsistent and conflicting findings about whether the patient’s BMI is a risk factor for the development of anterior cruciate ligament insufficiency after reconstruction [ 17 ]. In our study, we found that one of the scores decreased but the other scores did not change.

In the current literature, it has been observed that according to rehabilitation guidelines after ACL reconstruction, the decision to begin early weight-bearing is based on low level evidence in a limited number of studies. Our study shows that patients who were not allowed to bear weight for 3 weeks after ACL reconstruction had better results in the mid-term compared to those who started early weight-bearing. Additionally, we found that early weight-bearing in overweight patients led to a greater decrease in knee scores. Therefore, it is important to exercise caution when considering early weight-bearing in the overweight patient group. Future updates to rehabilitation guidelines should include evidence from prospective and more comprehensive studies on early weight bearing.

Restrictions

The retrospective nature of our study is our first limitation. Another limitation of our study may be the lack of preoperative whole knee scores, quadriceps strength data and knee alignment for all patient groups. Another factor is that radiographic imaging methods were not used in our study. More powerful studies can be done by investigating the correlation between clinical scores and radiographic findings. A larger number of patients in the groups would have increased the power of the study. Another limitation is that not all operations were performed by a single surgeon. This may create the possibility that surgeons may affect the results by using a different technique.

Data availability

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

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Department of Orthopaedics and Traumatology, Yuzuncu Yil University, Van, Turkey

Sehmuz Kaya, Yunus Can Unal, Necip Guven, Tulin Turkozu, Sezai Ozkan, Cihan Adanas & Mehmet Ata Gokalp

Department of Orthopaedics and Traumatology, Orhaneli State Hospital, Bursa, Turkey

Department of Orthopaedics and Traumatology, Hitit University, Corum, Turkey

Abdulrahim Dundar

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SK, YCU and MAG designed and directed the article. NG, TT and CO wrote the manuscript. AD, CA and SO revised the manuscript. All authors have read and verifed the underlying data and approved the final version of the manuscript.

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Correspondence to Sehmuz Kaya .

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This retrospective observational study was confirmed by the ethics committee at the local institution. Informed consent forms for surgery were obtained from all subjects before surgery.

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Kaya, S., Unal, Y.C., Guven, N. et al. The impact of early weight-bearing on results following anterior cruciate ligament reconstruction. BMC Musculoskelet Disord 25 , 395 (2024). https://doi.org/10.1186/s12891-024-07525-8

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Received : 05 November 2023

Accepted : 15 May 2024

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DOI : https://doi.org/10.1186/s12891-024-07525-8

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• Anterior cruciate ligament
• Arthroscopic reconstruction
• Rehabilitation
• Early weight bearing
• Body mass index

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