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How to Write a Conclusion for Research Papers (with Examples)

The conclusion of a research paper is a crucial section that plays a significant role in the overall impact and effectiveness of your research paper. However, this is also the section that typically receives less attention compared to the introduction and the body of the paper. The conclusion serves to provide a concise summary of the key findings, their significance, their implications, and a sense of closure to the study. Discussing how can the findings be applied in real-world scenarios or inform policy, practice, or decision-making is especially valuable to practitioners and policymakers. The research paper conclusion also provides researchers with clear insights and valuable information for their own work, which they can then build on and contribute to the advancement of knowledge in the field.

The research paper conclusion should explain the significance of your findings within the broader context of your field. It restates how your results contribute to the existing body of knowledge and whether they confirm or challenge existing theories or hypotheses. Also, by identifying unanswered questions or areas requiring further investigation, your awareness of the broader research landscape can be demonstrated.

Remember to tailor the research paper conclusion to the specific needs and interests of your intended audience, which may include researchers, practitioners, policymakers, or a combination of these.

Table of Contents

What is a conclusion in a research paper, summarizing conclusion, editorial conclusion, externalizing conclusion, importance of a good research paper conclusion, how to write a conclusion for your research paper, research paper conclusion examples.

• How to write a research paper conclusion with Paperpal? 

Frequently Asked Questions

A conclusion in a research paper is the final section where you summarize and wrap up your research, presenting the key findings and insights derived from your study. The research paper conclusion is not the place to introduce new information or data that was not discussed in the main body of the paper. When working on how to conclude a research paper, remember to stick to summarizing and interpreting existing content. The research paper conclusion serves the following purposes: 1

• Warn readers of the possible consequences of not attending to the problem.
• Recommend specific course(s) of action.
• Restate key ideas to drive home the ultimate point of your research paper.
• Provide a “take-home” message that you want the readers to remember about your study.

Types of conclusions for research papers

In research papers, the conclusion provides closure to the reader. The type of research paper conclusion you choose depends on the nature of your study, your goals, and your target audience. I provide you with three common types of conclusions:

A summarizing conclusion is the most common type of conclusion in research papers. It involves summarizing the main points, reiterating the research question, and restating the significance of the findings. This common type of research paper conclusion is used across different disciplines.

An editorial conclusion is less common but can be used in research papers that are focused on proposing or advocating for a particular viewpoint or policy. It involves presenting a strong editorial or opinion based on the research findings and offering recommendations or calls to action.

An externalizing conclusion is a type of conclusion that extends the research beyond the scope of the paper by suggesting potential future research directions or discussing the broader implications of the findings. This type of conclusion is often used in more theoretical or exploratory research papers.

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The conclusion in a research paper serves several important purposes:

• Offers Implications and Recommendations : Your research paper conclusion is an excellent place to discuss the broader implications of your research and suggest potential areas for further study. It’s also an opportunity to offer practical recommendations based on your findings.
• Provides Closure : A good research paper conclusion provides a sense of closure to your paper. It should leave the reader with a feeling that they have reached the end of a well-structured and thought-provoking research project.
• Leaves a Lasting Impression : Writing a well-crafted research paper conclusion leaves a lasting impression on your readers. It’s your final opportunity to leave them with a new idea, a call to action, or a memorable quote.

Writing a strong conclusion for your research paper is essential to leave a lasting impression on your readers. Here’s a step-by-step process to help you create and know what to put in the conclusion of a research paper: 2

• Research Statement : Begin your research paper conclusion by restating your research statement. This reminds the reader of the main point you’ve been trying to prove throughout your paper. Keep it concise and clear.
• Key Points : Summarize the main arguments and key points you’ve made in your paper. Avoid introducing new information in the research paper conclusion. Instead, provide a concise overview of what you’ve discussed in the body of your paper.
• Address the Research Questions : If your research paper is based on specific research questions or hypotheses, briefly address whether you’ve answered them or achieved your research goals. Discuss the significance of your findings in this context.
• Significance : Highlight the importance of your research and its relevance in the broader context. Explain why your findings matter and how they contribute to the existing knowledge in your field.
• Implications : Explore the practical or theoretical implications of your research. How might your findings impact future research, policy, or real-world applications? Consider the “so what?” question.
• Future Research : Offer suggestions for future research in your area. What questions or aspects remain unanswered or warrant further investigation? This shows that your work opens the door for future exploration.
• Closing Thought : Conclude your research paper conclusion with a thought-provoking or memorable statement. This can leave a lasting impression on your readers and wrap up your paper effectively. Avoid introducing new information or arguments here.
• Proofread and Revise : Carefully proofread your conclusion for grammar, spelling, and clarity. Ensure that your ideas flow smoothly and that your conclusion is coherent and well-structured.

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Remember that a well-crafted research paper conclusion is a reflection of the strength of your research and your ability to communicate its significance effectively. It should leave a lasting impression on your readers and tie together all the threads of your paper. Now you know how to start the conclusion of a research paper and what elements to include to make it impactful, let’s look at a research paper conclusion sample.

How to write a research paper conclusion with Paperpal?

A research paper conclusion is not just a summary of your study, but a synthesis of the key findings that ties the research together and places it in a broader context. A research paper conclusion should be concise, typically around one paragraph in length. However, some complex topics may require a longer conclusion to ensure the reader is left with a clear understanding of the study’s significance. Paperpal, an AI writing assistant trusted by over 800,000 academics globally, can help you write a well-structured conclusion for your research paper. 

• Sign Up or Log In: Create a new Paperpal account or login with your details.  
• Navigate to Features : Once logged in, head over to the features’ side navigation pane. Click on Templates and you’ll find a suite of generative AI features to help you write better, faster.  
• Generate an outline: Under Templates, select ‘Outlines’. Choose ‘Research article’ as your document type.  
• Select your section: Since you’re focusing on the conclusion, select this section when prompted.  
• Choose your field of study: Identifying your field of study allows Paperpal to provide more targeted suggestions, ensuring the relevance of your conclusion to your specific area of research. 
• Provide a brief description of your study: Enter details about your research topic and findings. This information helps Paperpal generate a tailored outline that aligns with your paper’s content. 
• Generate the conclusion outline: After entering all necessary details, click on ‘generate’. Paperpal will then create a structured outline for your conclusion, to help you start writing and build upon the outline.  
• Write your conclusion: Use the generated outline to build your conclusion. The outline serves as a guide, ensuring you cover all critical aspects of a strong conclusion, from summarizing key findings to highlighting the research’s implications. 
• Refine and enhance: Paperpal’s ‘Make Academic’ feature can be particularly useful in the final stages. Select any paragraph of your conclusion and use this feature to elevate the academic tone, ensuring your writing is aligned to the academic journal standards. 

By following these steps, Paperpal not only simplifies the process of writing a research paper conclusion but also ensures it is impactful, concise, and aligned with academic standards. Sign up with Paperpal today and write your research paper conclusion 2x faster .  

The research paper conclusion is a crucial part of your paper as it provides the final opportunity to leave a strong impression on your readers. In the research paper conclusion, summarize the main points of your research paper by restating your research statement, highlighting the most important findings, addressing the research questions or objectives, explaining the broader context of the study, discussing the significance of your findings, providing recommendations if applicable, and emphasizing the takeaway message. The main purpose of the conclusion is to remind the reader of the main point or argument of your paper and to provide a clear and concise summary of the key findings and their implications. All these elements should feature on your list of what to put in the conclusion of a research paper to create a strong final statement for your work.

A strong conclusion is a critical component of a research paper, as it provides an opportunity to wrap up your arguments, reiterate your main points, and leave a lasting impression on your readers. Here are the key elements of a strong research paper conclusion: 1. Conciseness : A research paper conclusion should be concise and to the point. It should not introduce new information or ideas that were not discussed in the body of the paper. 2. Summarization : The research paper conclusion should be comprehensive enough to give the reader a clear understanding of the research’s main contributions. 3 . Relevance : Ensure that the information included in the research paper conclusion is directly relevant to the research paper’s main topic and objectives; avoid unnecessary details. 4 . Connection to the Introduction : A well-structured research paper conclusion often revisits the key points made in the introduction and shows how the research has addressed the initial questions or objectives. 5. Emphasis : Highlight the significance and implications of your research. Why is your study important? What are the broader implications or applications of your findings? 6 . Call to Action : Include a call to action or a recommendation for future research or action based on your findings.

The length of a research paper conclusion can vary depending on several factors, including the overall length of the paper, the complexity of the research, and the specific journal requirements. While there is no strict rule for the length of a conclusion, but it’s generally advisable to keep it relatively short. A typical research paper conclusion might be around 5-10% of the paper’s total length. For example, if your paper is 10 pages long, the conclusion might be roughly half a page to one page in length.

In general, you do not need to include citations in the research paper conclusion. Citations are typically reserved for the body of the paper to support your arguments and provide evidence for your claims. However, there may be some exceptions to this rule: 1. If you are drawing a direct quote or paraphrasing a specific source in your research paper conclusion, you should include a citation to give proper credit to the original author. 2. If your conclusion refers to or discusses specific research, data, or sources that are crucial to the overall argument, citations can be included to reinforce your conclusion’s validity.

The conclusion of a research paper serves several important purposes: 1. Summarize the Key Points 2. Reinforce the Main Argument 3. Provide Closure 4. Offer Insights or Implications 5. Engage the Reader. 6. Reflect on Limitations

Remember that the primary purpose of the research paper conclusion is to leave a lasting impression on the reader, reinforcing the key points and providing closure to your research. It’s often the last part of the paper that the reader will see, so it should be strong and well-crafted.

• Makar, G., Foltz, C., Lendner, M., & Vaccaro, A. R. (2018). How to write effective discussion and conclusion sections. Clinical spine surgery, 31(8), 345-346.
• Bunton, D. (2005). The structure of PhD conclusion chapters.  Journal of English for academic purposes ,  4 (3), 207-224.

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• 9. The Conclusion
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The conclusion is intended to help the reader understand why your research should matter to them after they have finished reading the paper. A conclusion is not merely a summary of the main topics covered or a re-statement of your research problem, but a synthesis of key points derived from the findings of your study and, if applicable, where you recommend new areas for future research. For most college-level research papers, two or three well-developed paragraphs is sufficient for a conclusion, although in some cases, more paragraphs may be required in describing the key findings and their significance.

Conclusions. The Writing Center. University of North Carolina; Conclusions. The Writing Lab and The OWL. Purdue University.

Importance of a Good Conclusion

A well-written conclusion provides you with important opportunities to demonstrate to the reader your understanding of the research problem. These include:

• Presenting the last word on the issues you raised in your paper . Just as the introduction gives a first impression to your reader, the conclusion offers a chance to leave a lasting impression. Do this, for example, by highlighting key findings in your analysis that advance new understanding about the research problem, that are unusual or unexpected, or that have important implications applied to practice.
• Summarizing your thoughts and conveying the larger significance of your study . The conclusion is an opportunity to succinctly re-emphasize  your answer to the "So What?" question by placing the study within the context of how your research advances past research about the topic.
• Identifying how a gap in the literature has been addressed . The conclusion can be where you describe how a previously identified gap in the literature [first identified in your literature review section] has been addressed by your research and why this contribution is significant.
• Demonstrating the importance of your ideas . Don't be shy. The conclusion offers an opportunity to elaborate on the impact and significance of your findings. This is particularly important if your study approached examining the research problem from an unusual or innovative perspective.
• Introducing possible new or expanded ways of thinking about the research problem . This does not refer to introducing new information [which should be avoided], but to offer new insight and creative approaches for framing or contextualizing the research problem based on the results of your study.

Bunton, David. “The Structure of PhD Conclusion Chapters.” Journal of English for Academic Purposes 4 (July 2005): 207–224; Conclusions. The Writing Center. University of North Carolina; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion. San Francisco Edit, 2003-2008; Conclusions. The Writing Lab and The OWL. Purdue University; Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8.

Structure and Writing Style

I.  General Rules

The general function of your paper's conclusion is to restate the main argument . It reminds the reader of the strengths of your main argument(s) and reiterates the most important evidence supporting those argument(s). Do this by clearly summarizing the context, background, and necessity of pursuing the research problem you investigated in relation to an issue, controversy, or a gap found in the literature. However, make sure that your conclusion is not simply a repetitive summary of the findings. This reduces the impact of the argument(s) you have developed in your paper.

When writing the conclusion to your paper, follow these general rules:

• Present your conclusions in clear, concise language. Re-state the purpose of your study, then describe how your findings differ or support those of other studies and why [i.e., what were the unique, new, or crucial contributions your study made to the overall research about your topic?].
• Do not simply reiterate your findings or the discussion of your results. Provide a synthesis of arguments presented in the paper to show how these converge to address the research problem and the overall objectives of your study.
• Indicate opportunities for future research if you haven't already done so in the discussion section of your paper. Highlighting the need for further research provides the reader with evidence that you have an in-depth awareness of the research problem but that further investigations should take place beyond the scope of your investigation.

Consider the following points to help ensure your conclusion is presented well:

• If the argument or purpose of your paper is complex, you may need to summarize the argument for your reader.
• If, prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the end of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration that returns the topic to the context provided by the introduction or within a new context that emerges from the data [this is opposite of the introduction, which begins with general discussion of the context and ends with a detailed description of the research problem]. 

The conclusion also provides a place for you to persuasively and succinctly restate the research problem, given that the reader has now been presented with all the information about the topic . Depending on the discipline you are writing in, the concluding paragraph may contain your reflections on the evidence presented. However, the nature of being introspective about the research you have conducted will depend on the topic and whether your professor wants you to express your observations in this way. If asked to think introspectively about the topics, do not delve into idle speculation. Being introspective means looking within yourself as an author to try and understand an issue more deeply, not to guess at possible outcomes or make up scenarios not supported by the evidence.

II.  Developing a Compelling Conclusion

Although an effective conclusion needs to be clear and succinct, it does not need to be written passively or lack a compelling narrative. Strategies to help you move beyond merely summarizing the key points of your research paper may include any of the following:

• If your essay deals with a critical, contemporary problem, warn readers of the possible consequences of not attending to the problem proactively.
• Recommend a specific course or courses of action that, if adopted, could address a specific problem in practice or in the development of new knowledge leading to positive change.
• Cite a relevant quotation or expert opinion already noted in your paper in order to lend authority and support to the conclusion(s) you have reached [a good source would be from your literature review].
• Explain the consequences of your research in a way that elicits action or demonstrates urgency in seeking change.
• Restate a key statistic, fact, or visual image to emphasize the most important finding of your paper.
• If your discipline encourages personal reflection, illustrate your concluding point by drawing from your own life experiences.
• Return to an anecdote, an example, or a quotation that you presented in your introduction, but add further insight derived from the findings of your study; use your interpretation of results from your study to recast it in new or important ways.
• Provide a "take-home" message in the form of a succinct, declarative statement that you want the reader to remember about your study.

III. Problems to Avoid

Failure to be concise Your conclusion section should be concise and to the point. Conclusions that are too lengthy often have unnecessary information in them. The conclusion is not the place for details about your methodology or results. Although you should give a summary of what was learned from your research, this summary should be relatively brief, since the emphasis in the conclusion is on the implications, evaluations, insights, and other forms of analysis that you make. Strategies for writing concisely can be found here .

Failure to comment on larger, more significant issues In the introduction, your task was to move from the general [the field of study] to the specific [the research problem]. However, in the conclusion, your task is to move from a specific discussion [your research problem] back to a general discussion framed around the implications and significance of your findings [i.e., how your research contributes new understanding or fills an important gap in the literature]. In short, the conclusion is where you should place your research within a larger context [visualize your paper as an hourglass--start with a broad introduction and review of the literature, move to the specific analysis and discussion, conclude with a broad summary of the study's implications and significance].

Failure to reveal problems and negative results Negative aspects of the research process should never be ignored. These are problems, deficiencies, or challenges encountered during your study. They should be summarized as a way of qualifying your overall conclusions. If you encountered negative or unintended results [i.e., findings that are validated outside the research context in which they were generated], you must report them in the results section and discuss their implications in the discussion section of your paper. In the conclusion, use negative results as an opportunity to explain their possible significance and/or how they may form the basis for future research.

Failure to provide a clear summary of what was learned In order to be able to discuss how your research fits within your field of study [and possibly the world at large], you need to summarize briefly and succinctly how it contributes to new knowledge or a new understanding about the research problem. This element of your conclusion may be only a few sentences long.

Failure to match the objectives of your research Often research objectives in the social and behavioral sciences change while the research is being carried out. This is not a problem unless you forget to go back and refine the original objectives in your introduction. As these changes emerge they must be documented so that they accurately reflect what you were trying to accomplish in your research [not what you thought you might accomplish when you began].

Resist the urge to apologize If you've immersed yourself in studying the research problem, you presumably should know a good deal about it [perhaps even more than your professor!]. Nevertheless, by the time you have finished writing, you may be having some doubts about what you have produced. Repress those doubts! Don't undermine your authority as a researcher by saying something like, "This is just one approach to examining this problem; there may be other, much better approaches that...." The overall tone of your conclusion should convey confidence to the reader about the study's validity and realiability.

Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8; Concluding Paragraphs. College Writing Center at Meramec. St. Louis Community College; Conclusions. The Writing Center. University of North Carolina; Conclusions. The Writing Lab and The OWL. Purdue University; Freedman, Leora  and Jerry Plotnick. Introductions and Conclusions. The Lab Report. University College Writing Centre. University of Toronto; Leibensperger, Summer. Draft Your Conclusion. Academic Center, the University of Houston-Victoria, 2003; Make Your Last Words Count. The Writer’s Handbook. Writing Center. University of Wisconsin Madison; Miquel, Fuster-Marquez and Carmen Gregori-Signes. “Chapter Six: ‘Last but Not Least:’ Writing the Conclusion of Your Paper.” In Writing an Applied Linguistics Thesis or Dissertation: A Guide to Presenting Empirical Research . John Bitchener, editor. (Basingstoke,UK: Palgrave Macmillan, 2010), pp. 93-105; Tips for Writing a Good Conclusion. Writing@CSU. Colorado State University; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion. San Francisco Edit, 2003-2008; Writing Conclusions. Writing Tutorial Services, Center for Innovative Teaching and Learning. Indiana University; Writing: Considering Structure and Organization. Institute for Writing Rhetoric. Dartmouth College.

Writing Tip

Don't Belabor the Obvious!

Avoid phrases like "in conclusion...," "in summary...," or "in closing...." These phrases can be useful, even welcome, in oral presentations. But readers can see by the tell-tale section heading and number of pages remaining that they are reaching the end of your paper. You'll irritate your readers if you belabor the obvious.

Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8.

Another Writing Tip

New Insight, Not New Information!

Don't surprise the reader with new information in your conclusion that was never referenced anywhere else in the paper. This why the conclusion rarely has citations to sources. If you have new information to present, add it to the discussion or other appropriate section of the paper. Note that, although no new information is introduced, the conclusion, along with the discussion section, is where you offer your most "original" contributions in the paper; the conclusion is where you describe the value of your research, demonstrate that you understand the material that you’ve presented, and position your findings within the larger context of scholarship on the topic, including describing how your research contributes new insights to that scholarship.

Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8; Conclusions. The Writing Center. University of North Carolina.

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Home » Research Paper Conclusion – Writing Guide and Examples

Research Paper Conclusion – Writing Guide and Examples

Table of Contents

Research Paper Conclusion

Definition:

A research paper conclusion is the final section of a research paper that summarizes the key findings, significance, and implications of the research. It is the writer’s opportunity to synthesize the information presented in the paper, draw conclusions, and make recommendations for future research or actions.

The conclusion should provide a clear and concise summary of the research paper, reiterating the research question or problem, the main results, and the significance of the findings. It should also discuss the limitations of the study and suggest areas for further research.

Parts of Research Paper Conclusion

The parts of a research paper conclusion typically include:

Restatement of the Thesis

The conclusion should begin by restating the thesis statement from the introduction in a different way. This helps to remind the reader of the main argument or purpose of the research.

Summary of Key Findings

The conclusion should summarize the main findings of the research, highlighting the most important results and conclusions. This section should be brief and to the point.

Implications and Significance

In this section, the researcher should explain the implications and significance of the research findings. This may include discussing the potential impact on the field or industry, highlighting new insights or knowledge gained, or pointing out areas for future research.

Limitations and Recommendations

It is important to acknowledge any limitations or weaknesses of the research and to make recommendations for how these could be addressed in future studies. This shows that the researcher is aware of the potential limitations of their work and is committed to improving the quality of research in their field.

Concluding Statement

The conclusion should end with a strong concluding statement that leaves a lasting impression on the reader. This could be a call to action, a recommendation for further research, or a final thought on the topic.

How to Write Research Paper Conclusion

Here are some steps you can follow to write an effective research paper conclusion:

• Restate the research problem or question: Begin by restating the research problem or question that you aimed to answer in your research. This will remind the reader of the purpose of your study.
• Summarize the main points: Summarize the key findings and results of your research. This can be done by highlighting the most important aspects of your research and the evidence that supports them.
• Discuss the implications: Discuss the implications of your findings for the research area and any potential applications of your research. You should also mention any limitations of your research that may affect the interpretation of your findings.
• Provide a conclusion : Provide a concise conclusion that summarizes the main points of your paper and emphasizes the significance of your research. This should be a strong and clear statement that leaves a lasting impression on the reader.
• Offer suggestions for future research: Lastly, offer suggestions for future research that could build on your findings and contribute to further advancements in the field.

Remember that the conclusion should be brief and to the point, while still effectively summarizing the key findings and implications of your research.

Example of Research Paper Conclusion

Here’s an example of a research paper conclusion:

Conclusion :

In conclusion, our study aimed to investigate the relationship between social media use and mental health among college students. Our findings suggest that there is a significant association between social media use and increased levels of anxiety and depression among college students. This highlights the need for increased awareness and education about the potential negative effects of social media use on mental health, particularly among college students.

Despite the limitations of our study, such as the small sample size and self-reported data, our findings have important implications for future research and practice. Future studies should aim to replicate our findings in larger, more diverse samples, and investigate the potential mechanisms underlying the association between social media use and mental health. In addition, interventions should be developed to promote healthy social media use among college students, such as mindfulness-based approaches and social media detox programs.

Overall, our study contributes to the growing body of research on the impact of social media on mental health, and highlights the importance of addressing this issue in the context of higher education. By raising awareness and promoting healthy social media use among college students, we can help to reduce the negative impact of social media on mental health and improve the well-being of young adults.

Purpose of Research Paper Conclusion

The purpose of a research paper conclusion is to provide a summary and synthesis of the key findings, significance, and implications of the research presented in the paper. The conclusion serves as the final opportunity for the writer to convey their message and leave a lasting impression on the reader.

The conclusion should restate the research problem or question, summarize the main results of the research, and explain their significance. It should also acknowledge the limitations of the study and suggest areas for future research or action.

Overall, the purpose of the conclusion is to provide a sense of closure to the research paper and to emphasize the importance of the research and its potential impact. It should leave the reader with a clear understanding of the main findings and why they matter. The conclusion serves as the writer’s opportunity to showcase their contribution to the field and to inspire further research and action.

When to Write Research Paper Conclusion

The conclusion of a research paper should be written after the body of the paper has been completed. It should not be written until the writer has thoroughly analyzed and interpreted their findings and has written a complete and cohesive discussion of the research.

Before writing the conclusion, the writer should review their research paper and consider the key points that they want to convey to the reader. They should also review the research question, hypotheses, and methodology to ensure that they have addressed all of the necessary components of the research.

Once the writer has a clear understanding of the main findings and their significance, they can begin writing the conclusion. The conclusion should be written in a clear and concise manner, and should reiterate the main points of the research while also providing insights and recommendations for future research or action.

Characteristics of Research Paper Conclusion

The characteristics of a research paper conclusion include:

• Clear and concise: The conclusion should be written in a clear and concise manner, summarizing the key findings and their significance.
• Comprehensive: The conclusion should address all of the main points of the research paper, including the research question or problem, the methodology, the main results, and their implications.
• Future-oriented : The conclusion should provide insights and recommendations for future research or action, based on the findings of the research.
• Impressive : The conclusion should leave a lasting impression on the reader, emphasizing the importance of the research and its potential impact.
• Objective : The conclusion should be based on the evidence presented in the research paper, and should avoid personal biases or opinions.
• Unique : The conclusion should be unique to the research paper and should not simply repeat information from the introduction or body of the paper.

Advantages of Research Paper Conclusion

The advantages of a research paper conclusion include:

• Summarizing the key findings : The conclusion provides a summary of the main findings of the research, making it easier for the reader to understand the key points of the study.
• Emphasizing the significance of the research: The conclusion emphasizes the importance of the research and its potential impact, making it more likely that readers will take the research seriously and consider its implications.
• Providing recommendations for future research or action : The conclusion suggests practical recommendations for future research or action, based on the findings of the study.
• Providing closure to the research paper : The conclusion provides a sense of closure to the research paper, tying together the different sections of the paper and leaving a lasting impression on the reader.
• Demonstrating the writer’s contribution to the field : The conclusion provides the writer with an opportunity to showcase their contribution to the field and to inspire further research and action.

Limitations of Research Paper Conclusion

While the conclusion of a research paper has many advantages, it also has some limitations that should be considered, including:

• I nability to address all aspects of the research: Due to the limited space available in the conclusion, it may not be possible to address all aspects of the research in detail.
• Subjectivity : While the conclusion should be objective, it may be influenced by the writer’s personal biases or opinions.
• Lack of new information: The conclusion should not introduce new information that has not been discussed in the body of the research paper.
• Lack of generalizability: The conclusions drawn from the research may not be applicable to other contexts or populations, limiting the generalizability of the study.
• Misinterpretation by the reader: The reader may misinterpret the conclusions drawn from the research, leading to a misunderstanding of the findings.

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Conclusions

What this handout is about.

This handout will explain the functions of conclusions, offer strategies for writing effective ones, help you evaluate conclusions you’ve drafted, and suggest approaches to avoid.

About conclusions

Introductions and conclusions can be difficult to write, but they’re worth investing time in. They can have a significant influence on a reader’s experience of your paper.

Just as your introduction acts as a bridge that transports your readers from their own lives into the “place” of your analysis, your conclusion can provide a bridge to help your readers make the transition back to their daily lives. Such a conclusion will help them see why all your analysis and information should matter to them after they put the paper down.

Your conclusion is your chance to have the last word on the subject. The conclusion allows you to have the final say on the issues you have raised in your paper, to synthesize your thoughts, to demonstrate the importance of your ideas, and to propel your reader to a new view of the subject. It is also your opportunity to make a good final impression and to end on a positive note.

Your conclusion can go beyond the confines of the assignment. The conclusion pushes beyond the boundaries of the prompt and allows you to consider broader issues, make new connections, and elaborate on the significance of your findings.

Your conclusion should make your readers glad they read your paper. Your conclusion gives your reader something to take away that will help them see things differently or appreciate your topic in personally relevant ways. It can suggest broader implications that will not only interest your reader, but also enrich your reader’s life in some way. It is your gift to the reader.

Strategies for writing an effective conclusion

One or more of the following strategies may help you write an effective conclusion:

• Play the “So What” Game. If you’re stuck and feel like your conclusion isn’t saying anything new or interesting, ask a friend to read it with you. Whenever you make a statement from your conclusion, ask the friend to say, “So what?” or “Why should anybody care?” Then ponder that question and answer it. Here’s how it might go: You: Basically, I’m just saying that education was important to Douglass. Friend: So what? You: Well, it was important because it was a key to him feeling like a free and equal citizen. Friend: Why should anybody care? You: That’s important because plantation owners tried to keep slaves from being educated so that they could maintain control. When Douglass obtained an education, he undermined that control personally. You can also use this strategy on your own, asking yourself “So What?” as you develop your ideas or your draft.
• Return to the theme or themes in the introduction. This strategy brings the reader full circle. For example, if you begin by describing a scenario, you can end with the same scenario as proof that your essay is helpful in creating a new understanding. You may also refer to the introductory paragraph by using key words or parallel concepts and images that you also used in the introduction.
• Synthesize, don’t summarize. Include a brief summary of the paper’s main points, but don’t simply repeat things that were in your paper. Instead, show your reader how the points you made and the support and examples you used fit together. Pull it all together.
• Include a provocative insight or quotation from the research or reading you did for your paper.
• Propose a course of action, a solution to an issue, or questions for further study. This can redirect your reader’s thought process and help them to apply your info and ideas to their own life or to see the broader implications.
• Point to broader implications. For example, if your paper examines the Greensboro sit-ins or another event in the Civil Rights Movement, you could point out its impact on the Civil Rights Movement as a whole. A paper about the style of writer Virginia Woolf could point to her influence on other writers or on later feminists.

Strategies to avoid

• Beginning with an unnecessary, overused phrase such as “in conclusion,” “in summary,” or “in closing.” Although these phrases can work in speeches, they come across as wooden and trite in writing.
• Stating the thesis for the very first time in the conclusion.
• Introducing a new idea or subtopic in your conclusion.
• Ending with a rephrased thesis statement without any substantive changes.
• Making sentimental, emotional appeals that are out of character with the rest of an analytical paper.
• Including evidence (quotations, statistics, etc.) that should be in the body of the paper.

Four kinds of ineffective conclusions

• The “That’s My Story and I’m Sticking to It” Conclusion. This conclusion just restates the thesis and is usually painfully short. It does not push the ideas forward. People write this kind of conclusion when they can’t think of anything else to say. Example: In conclusion, Frederick Douglass was, as we have seen, a pioneer in American education, proving that education was a major force for social change with regard to slavery.
• The “Sherlock Holmes” Conclusion. Sometimes writers will state the thesis for the very first time in the conclusion. You might be tempted to use this strategy if you don’t want to give everything away too early in your paper. You may think it would be more dramatic to keep the reader in the dark until the end and then “wow” them with your main idea, as in a Sherlock Holmes mystery. The reader, however, does not expect a mystery, but an analytical discussion of your topic in an academic style, with the main argument (thesis) stated up front. Example: (After a paper that lists numerous incidents from the book but never says what these incidents reveal about Douglass and his views on education): So, as the evidence above demonstrates, Douglass saw education as a way to undermine the slaveholders’ power and also an important step toward freedom.
• The “America the Beautiful”/”I Am Woman”/”We Shall Overcome” Conclusion. This kind of conclusion usually draws on emotion to make its appeal, but while this emotion and even sentimentality may be very heartfelt, it is usually out of character with the rest of an analytical paper. A more sophisticated commentary, rather than emotional praise, would be a more fitting tribute to the topic. Example: Because of the efforts of fine Americans like Frederick Douglass, countless others have seen the shining beacon of light that is education. His example was a torch that lit the way for others. Frederick Douglass was truly an American hero.
• The “Grab Bag” Conclusion. This kind of conclusion includes extra information that the writer found or thought of but couldn’t integrate into the main paper. You may find it hard to leave out details that you discovered after hours of research and thought, but adding random facts and bits of evidence at the end of an otherwise-well-organized essay can just create confusion. Example: In addition to being an educational pioneer, Frederick Douglass provides an interesting case study for masculinity in the American South. He also offers historians an interesting glimpse into slave resistance when he confronts Covey, the overseer. His relationships with female relatives reveal the importance of family in the slave community.

Works consulted

We consulted these works while writing this handout. This is not a comprehensive list of resources on the handout’s topic, and we encourage you to do your own research to find additional publications. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. For guidance on formatting citations, please see the UNC Libraries citation tutorial . We revise these tips periodically and welcome feedback.

Douglass, Frederick. 1995. Narrative of the Life of Frederick Douglass, an American Slave, Written by Himself. New York: Dover.

Hamilton College. n.d. “Conclusions.” Writing Center. Accessed June 14, 2019. https://www.hamilton.edu//academics/centers/writing/writing-resources/conclusions .

Holewa, Randa. 2004. “Strategies for Writing a Conclusion.” LEO: Literacy Education Online. Last updated February 19, 2004. https://leo.stcloudstate.edu/acadwrite/conclude.html.

You may reproduce it for non-commercial use if you use the entire handout and attribute the source: The Writing Center, University of North Carolina at Chapel Hill

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• Writing Tips

How to Write a Conclusion for a Research Paper

3-minute read

• 29th August 2023

If you’re writing a research paper, the conclusion is your opportunity to summarize your findings and leave a lasting impression on your readers. In this post, we’ll take you through how to write an effective conclusion for a research paper and how you can:

·   Reword your thesis statement

·   Highlight the significance of your research

·   Discuss limitations

·   Connect to the introduction

·   End with a thought-provoking statement

Rewording Your Thesis Statement

Begin your conclusion by restating your thesis statement in a way that is slightly different from the wording used in the introduction. Avoid presenting new information or evidence in your conclusion. Just summarize the main points and arguments of your essay and keep this part as concise as possible. Remember that you’ve already covered the in-depth analyses and investigations in the main body paragraphs of your essay, so it’s not necessary to restate these details in the conclusion.

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Highlighting the Significance of Your Research

The conclusion is a good place to emphasize the implications of your research . Avoid ambiguous or vague language such as “I think” or “maybe,” which could weaken your position. Clearly explain why your research is significant and how it contributes to the broader field of study.

Here’s an example from a (fictional) study on the impact of social media on mental health:

Discussing Limitations

Although it’s important to emphasize the significance of your study, you can also use the conclusion to briefly address any limitations you discovered while conducting your research, such as time constraints or a shortage of resources. Doing this demonstrates a balanced and honest approach to your research.

Connecting to the Introduction

In your conclusion, you can circle back to your introduction , perhaps by referring to a quote or anecdote you discussed earlier. If you end your paper on a similar note to how you began it, you will create a sense of cohesion for the reader and remind them of the meaning and significance of your research.

Ending With a Thought-Provoking Statement

Consider ending your paper with a thought-provoking and memorable statement that relates to the impact of your research questions or hypothesis. This statement can be a call to action, a philosophical question, or a prediction for the future (positive or negative). Here’s an example that uses the same topic as above (social media and mental health):

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• How to Write Discussions and Conclusions

The discussion section contains the results and outcomes of a study. An effective discussion informs readers what can be learned from your experiment and provides context for the results.

What makes an effective discussion?

When you’re ready to write your discussion, you’ve already introduced the purpose of your study and provided an in-depth description of the methodology. The discussion informs readers about the larger implications of your study based on the results. Highlighting these implications while not overstating the findings can be challenging, especially when you’re submitting to a journal that selects articles based on novelty or potential impact. Regardless of what journal you are submitting to, the discussion section always serves the same purpose: concluding what your study results actually mean.

A successful discussion section puts your findings in context. It should include:

• the results of your research,
• a discussion of related research, and
• a comparison between your results and initial hypothesis.

Tip: Not all journals share the same naming conventions.

You can apply the advice in this article to the conclusion, results or discussion sections of your manuscript.

Our Early Career Researcher community tells us that the conclusion is often considered the most difficult aspect of a manuscript to write. To help, this guide provides questions to ask yourself, a basic structure to model your discussion off of and examples from published manuscripts. 

Questions to ask yourself:

• Was my hypothesis correct?
• If my hypothesis is partially correct or entirely different, what can be learned from the results? 
• How do the conclusions reshape or add onto the existing knowledge in the field? What does previous research say about the topic? 
• Why are the results important or relevant to your audience? Do they add further evidence to a scientific consensus or disprove prior studies? 
• How can future research build on these observations? What are the key experiments that must be done? 
• What is the “take-home” message you want your reader to leave with?

How to structure a discussion

Trying to fit a complete discussion into a single paragraph can add unnecessary stress to the writing process. If possible, you’ll want to give yourself two or three paragraphs to give the reader a comprehensive understanding of your study as a whole. Here’s one way to structure an effective discussion:

Writing Tips

While the above sections can help you brainstorm and structure your discussion, there are many common mistakes that writers revert to when having difficulties with their paper. Writing a discussion can be a delicate balance between summarizing your results, providing proper context for your research and avoiding introducing new information. Remember that your paper should be both confident and honest about the results! 

• Read the journal’s guidelines on the discussion and conclusion sections. If possible, learn about the guidelines before writing the discussion to ensure you’re writing to meet their expectations. 
• Begin with a clear statement of the principal findings. This will reinforce the main take-away for the reader and set up the rest of the discussion. 
• Explain why the outcomes of your study are important to the reader. Discuss the implications of your findings realistically based on previous literature, highlighting both the strengths and limitations of the research. 
• State whether the results prove or disprove your hypothesis. If your hypothesis was disproved, what might be the reasons? 
• Introduce new or expanded ways to think about the research question. Indicate what next steps can be taken to further pursue any unresolved questions. 
• If dealing with a contemporary or ongoing problem, such as climate change, discuss possible consequences if the problem is avoided. 
• Be concise. Adding unnecessary detail can distract from the main findings. 

Don’t

• Rewrite your abstract. Statements with “we investigated” or “we studied” generally do not belong in the discussion. 
• Include new arguments or evidence not previously discussed. Necessary information and evidence should be introduced in the main body of the paper. 
• Apologize. Even if your research contains significant limitations, don’t undermine your authority by including statements that doubt your methodology or execution. 
• Shy away from speaking on limitations or negative results. Including limitations and negative results will give readers a complete understanding of the presented research. Potential limitations include sources of potential bias, threats to internal or external validity, barriers to implementing an intervention and other issues inherent to the study design. 
• Overstate the importance of your findings. Making grand statements about how a study will fully resolve large questions can lead readers to doubt the success of the research. 

Snippets of Effective Discussions:

Consumer-based actions to reduce plastic pollution in rivers: A multi-criteria decision analysis approach

Identifying reliable indicators of fitness in polar bears

• How to Write a Great Title
• How to Write an Abstract
• How to Write Your Methods
• How to Report Statistics
• How to Edit Your Work

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There’s a lot to consider when deciding where to submit your work. Learn how to choose a journal that will help your study reach its audience, while reflecting your values as a researcher…

How to write a strong conclusion for your research paper

Last updated

17 February 2024

Reviewed by

Writing a research paper is a chance to share your knowledge and hypothesis. It's an opportunity to demonstrate your many hours of research and prove your ability to write convincingly.

Ideally, by the end of your research paper, you'll have brought your readers on a journey to reach the conclusions you've pre-determined. However, if you don't stick the landing with a good conclusion, you'll risk losing your reader’s trust.

Writing a strong conclusion for your research paper involves a few important steps, including restating the thesis and summing up everything properly.

Find out what to include and what to avoid, so you can effectively demonstrate your understanding of the topic and prove your expertise.

• Why is a good conclusion important?

A good conclusion can cement your paper in the reader’s mind. Making a strong impression in your introduction can draw your readers in, but it's the conclusion that will inspire them.

• What to include in a research paper conclusion

There are a few specifics you should include in your research paper conclusion. Offer your readers some sense of urgency or consequence by pointing out why they should care about the topic you have covered. Discuss any common problems associated with your topic and provide suggestions as to how these problems can be solved or addressed.

The conclusion should include a restatement of your initial thesis. Thesis statements are strengthened after you’ve presented supporting evidence (as you will have done in the paper), so make a point to reintroduce it at the end.

Finally, recap the main points of your research paper, highlighting the key takeaways you want readers to remember. If you've made multiple points throughout the paper, refer to the ones with the strongest supporting evidence.

• Steps for writing a research paper conclusion

Many writers find the conclusion the most challenging part of any research project . By following these three steps, you'll be prepared to write a conclusion that is effective and concise.

• Step 1: Restate the problem

Always begin by restating the research problem in the conclusion of a research paper. This serves to remind the reader of your hypothesis and refresh them on the main point of the paper. 

When restating the problem, take care to avoid using exactly the same words you employed earlier in the paper.

• Step 2: Sum up the paper

After you've restated the problem, sum up the paper by revealing your overall findings. The method for this differs slightly, depending on whether you're crafting an argumentative paper or an empirical paper.

Argumentative paper: Restate your thesis and arguments

Argumentative papers involve introducing a thesis statement early on. In crafting the conclusion for an argumentative paper, always restate the thesis, outlining the way you've developed it throughout the entire paper.

It might be appropriate to mention any counterarguments in the conclusion, so you can demonstrate how your thesis is correct or how the data best supports your main points.

Empirical paper: Summarize research findings

Empirical papers break down a series of research questions. In your conclusion, discuss the findings your research revealed, including any information that surprised you.

Be clear about the conclusions you reached, and explain whether or not you expected to arrive at these particular ones.

• Step 3: Discuss the implications of your research

Argumentative papers and empirical papers also differ in this part of a research paper conclusion. Here are some tips on crafting conclusions for argumentative and empirical papers.

Argumentative paper: Powerful closing statement

In an argumentative paper, you'll have spent a great deal of time expressing the opinions you formed after doing a significant amount of research. Make a strong closing statement in your argumentative paper's conclusion to share the significance of your work.

You can outline the next steps through a bold call to action, or restate how powerful your ideas turned out to be.

Empirical paper: Directions for future research

Empirical papers are broader in scope. They usually cover a variety of aspects and can include several points of view.

To write a good conclusion for an empirical paper, suggest the type of research that could be done in the future, including methods for further investigation or outlining ways other researchers might proceed.

If you feel your research had any limitations, even if they were outside your control, you could mention these in your conclusion.

After you finish outlining your conclusion, ask someone to read it and offer feedback. In any research project you're especially close to, it can be hard to identify problem areas. Having a close friend or someone whose opinion you value read the research paper and provide honest feedback can be invaluable. Take note of any suggested edits and consider incorporating them into your paper if they make sense.

• Things to avoid in a research paper conclusion

Keep these aspects to avoid in mind as you're writing your conclusion and refer to them after you've created an outline.

Dry summary

Writing a memorable, succinct conclusion is arguably more important than a strong introduction. Take care to avoid just rephrasing your main points, and don't fall into the trap of repeating dry facts or citations.

You can provide a new perspective for your readers to think about or contextualize your research. Either way, make the conclusion vibrant and interesting, rather than a rote recitation of your research paper’s highlights.

Clichéd or generic phrasing

Your research paper conclusion should feel fresh and inspiring. Avoid generic phrases like "to sum up" or "in conclusion." These phrases tend to be overused, especially in an academic context and might turn your readers off.

The conclusion also isn't the time to introduce colloquial phrases or informal language. Retain a professional, confident tone consistent throughout your paper’s conclusion so it feels exciting and bold.

New data or evidence

While you should present strong data throughout your paper, the conclusion isn't the place to introduce new evidence. This is because readers are engaged in actively learning as they read through the body of your paper.

By the time they reach the conclusion, they will have formed an opinion one way or the other (hopefully in your favor!). Introducing new evidence in the conclusion will only serve to surprise or frustrate your reader.

Ignoring contradictory evidence

If your research reveals contradictory evidence, don't ignore it in the conclusion. This will damage your credibility as an expert and might even serve to highlight the contradictions.

Be as transparent as possible and admit to any shortcomings in your research, but don't dwell on them for too long.

Ambiguous or unclear resolutions

The point of a research paper conclusion is to provide closure and bring all your ideas together. You should wrap up any arguments you introduced in the paper and tie up any loose ends, while demonstrating why your research and data are strong.

Use direct language in your conclusion and avoid ambiguity. Even if some of the data and sources you cite are inconclusive or contradictory, note this in your conclusion to come across as confident and trustworthy.

• Examples of research paper conclusions

Your research paper should provide a compelling close to the paper as a whole, highlighting your research and hard work. While the conclusion should represent your unique style, these examples offer a starting point:

Ultimately, the data we examined all point to the same conclusion: Encouraging a good work-life balance improves employee productivity and benefits the company overall. The research suggests that when employees feel their personal lives are valued and respected by their employers, they are more likely to be productive when at work. In addition, company turnover tends to be reduced when employees have a balance between their personal and professional lives. While additional research is required to establish ways companies can support employees in creating a stronger work-life balance, it's clear the need is there.

Social media is a primary method of communication among young people. As we've seen in the data presented, most young people in high school use a variety of social media applications at least every hour, including Instagram and Facebook. While social media is an avenue for connection with peers, research increasingly suggests that social media use correlates with body image issues. Young girls with lower self-esteem tend to use social media more often than those who don't log onto social media apps every day. As new applications continue to gain popularity, and as more high school students are given smartphones, more research will be required to measure the effects of prolonged social media use.

What are the different kinds of research paper conclusions?

There are no formal types of research paper conclusions. Ultimately, the conclusion depends on the outline of your paper and the type of research you’re presenting. While some experts note that research papers can end with a new perspective or commentary, most papers should conclude with a combination of both. The most important aspect of a good research paper conclusion is that it accurately represents the body of the paper.

Can I present new arguments in my research paper conclusion?

Research paper conclusions are not the place to introduce new data or arguments. The body of your paper is where you should share research and insights, where the reader is actively absorbing the content. By the time a reader reaches the conclusion of the research paper, they should have formed their opinion. Introducing new arguments in the conclusion can take a reader by surprise, and not in a positive way. It might also serve to frustrate readers.

How long should a research paper conclusion be?

There's no set length for a research paper conclusion. However, it's a good idea not to run on too long, since conclusions are supposed to be succinct. A good rule of thumb is to keep your conclusion around 5 to 10 percent of the paper's total length. If your paper is 10 pages, try to keep your conclusion under one page.

What should I include in a research paper conclusion?

A good research paper conclusion should always include a sense of urgency, so the reader can see how and why the topic should matter to them. You can also note some recommended actions to help fix the problem and some obstacles they might encounter. A conclusion should also remind the reader of the thesis statement, along with the main points you covered in the paper. At the end of the conclusion, add a powerful closing statement that helps cement the paper in the mind of the reader.

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In a short paper—even a research paper—you don’t need to provide an exhaustive summary as part of your conclusion. But you do need to make some kind of transition between your final body paragraph and your concluding paragraph. This may come in the form of a few sentences of summary. Or it may come in the form of a sentence that brings your readers back to your thesis or main idea and reminds your readers where you began and how far you have traveled.

So, for example, in a paper about the relationship between ADHD and rejection sensitivity, Vanessa Roser begins by introducing readers to the fact that researchers have studied the relationship between the two conditions and then provides her explanation of that relationship. Here’s her thesis: “While socialization may indeed be an important factor in RS, I argue that individuals with ADHD may also possess a neurological predisposition to RS that is exacerbated by the differing executive and emotional regulation characteristic of ADHD.”

In her final paragraph, Roser reminds us of where she started by echoing her thesis: “This literature demonstrates that, as with many other conditions, ADHD and RS share a delicately intertwined pattern of neurological similarities that is rooted in the innate biology of an individual’s mind, a connection that cannot be explained in full by the behavioral mediation hypothesis.”  

Highlight the “so what”  

At the beginning of your paper, you explain to your readers what’s at stake—why they should care about the argument you’re making. In your conclusion, you can bring readers back to those stakes by reminding them why your argument is important in the first place. You can also draft a few sentences that put those stakes into a new or broader context.

In the conclusion to her paper about ADHD and RS, Roser echoes the stakes she established in her introduction—that research into connections between ADHD and RS has led to contradictory results, raising questions about the “behavioral mediation hypothesis.”

She writes, “as with many other conditions, ADHD and RS share a delicately intertwined pattern of neurological similarities that is rooted in the innate biology of an individual’s mind, a connection that cannot be explained in full by the behavioral mediation hypothesis.”  

Leave your readers with the “now what”  

After the “what” and the “so what,” you should leave your reader with some final thoughts. If you have written a strong introduction, your readers will know why you have been arguing what you have been arguing—and why they should care. And if you’ve made a good case for your thesis, then your readers should be in a position to see things in a new way, understand new questions, or be ready for something that they weren’t ready for before they read your paper.

In her conclusion, Roser offers two “now what” statements. First, she explains that it is important to recognize that the flawed behavioral mediation hypothesis “seems to place a degree of fault on the individual. It implies that individuals with ADHD must have elicited such frequent or intense rejection by virtue of their inadequate social skills, erasing the possibility that they may simply possess a natural sensitivity to emotion.” She then highlights the broader implications for treatment of people with ADHD, noting that recognizing the actual connection between rejection sensitivity and ADHD “has profound implications for understanding how individuals with ADHD might best be treated in educational settings, by counselors, family, peers, or even society as a whole.”

To find your own “now what” for your essay’s conclusion, try asking yourself these questions:

• What can my readers now understand, see in a new light, or grapple with that they would not have understood in the same way before reading my paper? Are we a step closer to understanding a larger phenomenon or to understanding why what was at stake is so important?  
• What questions can I now raise that would not have made sense at the beginning of my paper? Questions for further research? Other ways that this topic could be approached?  
• Are there other applications for my research? Could my questions be asked about different data in a different context? Could I use my methods to answer a different question?  
• What action should be taken in light of this argument? What action do I predict will be taken or could lead to a solution?  
• What larger context might my argument be a part of?  

What to avoid in your conclusion  

• a complete restatement of all that you have said in your paper.  
• a substantial counterargument that you do not have space to refute; you should introduce counterarguments before your conclusion.  
• an apology for what you have not said. If you need to explain the scope of your paper, you should do this sooner—but don’t apologize for what you have not discussed in your paper.  
• fake transitions like “in conclusion” that are followed by sentences that aren’t actually conclusions. (“In conclusion, I have now demonstrated that my thesis is correct.”)
• picture_as_pdf Conclusions

How to Write a Conclusion for a Research Paper

Find out which type of conclusion best suits your research, how to write it step-by-step, and common mistakes to avoid.

When writing a research paper, it can be challenging to make your point after providing an extensive amount of information. For this reason, a well-organized conclusion is essential. 

A research paper’s conclusion should be a brief summary of the paper’s substance and objectives; what you present in your research paper can gain impact by having a strong conclusion section.

In this Mind The Graph article, you will learn how to write a conclusion for a research report in a way that inspires action and helps the readers to better understand your research paper. This article will provide you the definition and some broad principles before providing step-by-step guidance.

What is a conclusion for a research paper and why is it important?

A conclusion is where you summarize the main points and, if appropriate, make new research suggestions. It is not merely a summary of the key points discussed or a rehash of your research question.

The reader is expected to comprehend from the article’s conclusion why your study should be significant to them after reading it. A conclusion of one or two well-developed paragraphs is appropriate for the majority of research papers; however, in a few unusual cases, more paragraphs may be required to highlight significant findings and their importance.

Just as the introduction is responsible for giving the reader a first impression on the subject, the conclusion is the chance to make a final impression by summarizing major information of your research paper and, most often, giving a different point of view on significant implications.

Adding a strong conclusion to your research paper is important because it’s a possibility to give the reader the comprehension of your research topic. Given that the reader is now fully informed on the subject, the conclusion also gives you a chance to restate the research problem effectively and concisely.

Examples of conclusions for a research paper

Now that you are aware of what a conclusion is and its significance for a research paper, it is time to provide you with some excellent samples of well-structured conclusions so you may get knowledge about the type of conclusion you can use for your research paper.

Argumentative Research Paper Conclusion

The most convincing arguments from your research paper should be added to the conclusion if you want to compose a strong argumentative conclusion.

Additionally, if your thesis statement expresses your perspective on the subject, you should think about restarting it as well as including any other pertinent information.

Example: As a result of the sixth extinction, which is currently affecting Earth, many species are vanishing every day. There are at least three strategies that people could employ to keep them from going extinct entirely in the ensuing fifty years. More recycling options, innovative plastic production techniques, and species preservation could save lives.

Analytical Research Paper Conclusion

The first thing you should do is reiterate your thesis and list the main elements of your arguments.

There should undoubtedly be a spotlight on a bigger context in the analytical research paper conclusion, which is the key distinction between it and other types of conclusions. It means you can add some meaning to the findings.

Example: Elon Musk has revolutionized the way we drive, pay for things, and even fly. His innovations are solely motivated by the desire to simplify things, but they inevitably alter the course of history. When Musk was a student, he had his first idea for PayPal, which is now among the most widely used methods of online payment. Likewise with Tesla automobiles.

Comparative Research Paper Conclusion

The conclusion of a comparative essay should be deeply analytical. To clearly express your conclusions, you must be very thorough when reviewing the data. Furthermore, the sources must be reliable.

A paraphrased thesis statement and a few sentences describing the significance of your study research are also required, as per normal.

Example: Gas-powered vehicles are ineffective and inefficient compared to electric vehicles. Not only do they emit fewer pollutants, but the drivers also get there more quickly. Additionally, gas cars cost more to maintain. Everything stems from the details of the far more straightforward engines used in electric cars.

How to write a conclusion for a research paper

In this section, you will learn how to write a conclusion for a research paper effectively and properly. These few easy steps will enable you to write the most convincing conclusion to your research paper.

1. Remember about the main topic

The statement must be written clearly and concisely to be effective, just one sentence. Remember that your conclusion should be concise and precise, expressing only the most important elements.

2. Reaffirm your thesis

Restate the research paper’s thesis after that. This can be done by going back to the original thesis that you presented in the research’s introduction. The thesis statement in your conclusion must be expressed differently from how it was in the introduction. This section can also be written effectively in a single sentence.

3. Sum important points in a summary

It’s time to make a list of the important arguments in your research paper. This phase can be made simpler by reading over your research and emphasizing only the main ideas and evidence.

Remember that the conclusion should not contain any new information. Focus only on the concepts you cover in your paper’s main body as a result. And also, keep in mind that this brief summary reminds your readers of the importance of the topic you are researching.

4. Emphasize the importance

At this stage, you can genuinely express a few words about how significant your arguments are. A succinct but impactful sentence can successfully achieve its aim. You could also attempt to examine this circumstance from a wider perspective.

Give an example of how your discoveries have affected a certain field. It would be beneficial if you made an effort to answer the question, “So what?” if there was any ambiguity.

5. Finish up your argument

As you wrap up your conclusion, consider posing a question or a call to action that will encourage readers to consider your point of view even further. This sentence can also answer any queries that were not addressed in the paper’s body paragraphs.

In addition, if there is an unresolved question in the main body, this is a fantastic area to comment on.

Common mistakes you should avoid

After learning the fundamentals of producing a strong research paper conclusion, it’s time to learn the common mistakes to avoid.

• Weak conclusion: If your ending is weak, readers will feel dissatisfied and disappointed. Writing ambiguous closing lines for essays also lowers the quality of the paper and the capacity of your arguments to support your main topic.
• Abrupt conclusion: Your research has to be an expression of your writing as a whole, not just a section. Therefore, make sure your thoughts are fully stated.
• Adding new information: Only your research should only be summarized in the conclusion. As the conclusion cannot contain extra information, make sure to offer all of your conclusions and supporting evidence in the body paragraphs.
• Absence of focus: A conclusion needs to be concise and well-focused. Avoid concluding the research with inane or superfluous details.
• Absurd length: Research must be of a proper length—neither too long nor too short. If you write more than is necessary, you can miss the point, which is to revisit the paper’s argument straightforwardly. Additionally, if you write too little, your readers will think you’re being negligent. It should be written in at least one or two whole paragraphs.

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How to Write a Conclusion for a Research Paper

Last Updated: May 8, 2024 Approved

This article was co-authored by Christopher Taylor, PhD . Christopher Taylor is an Adjunct Assistant Professor of English at Austin Community College in Texas. He received his PhD in English Literature and Medieval Studies from the University of Texas at Austin in 2014. wikiHow marks an article as reader-approved once it receives enough positive feedback. This article received 42 testimonials and 83% of readers who voted found it helpful, earning it our reader-approved status. This article has been viewed 2,259,454 times.

The conclusion of a research paper needs to summarize the content and purpose of the paper without seeming too wooden or dry. Every basic conclusion must share several key elements, but there are also several tactics you can play around with to craft a more effective conclusion and several you should avoid to prevent yourself from weakening your paper's conclusion. Here are some writing tips to keep in mind when creating a conclusion for your next research paper.

Sample Conclusions

Writing a basic conclusion.

• Do not spend a great amount of time or space restating your topic.
• A good research paper will make the importance of your topic apparent, so you do not need to write an elaborate defense of your topic in the conclusion.
• Usually a single sentence is all you need to restate your topic.
• An example would be if you were writing a paper on the epidemiology of infectious disease, you might say something like "Tuberculosis is a widespread infectious disease that affects millions of people worldwide every year."
• Yet another example from the humanities would be a paper about the Italian Renaissance: "The Italian Renaissance was an explosion of art and ideas centered around artists, writers, and thinkers in Florence."

• A thesis is a narrowed, focused view on the topic at hand.
• This statement should be rephrased from the thesis you included in your introduction. It should not be identical or too similar to the sentence you originally used.
• Try re-wording your thesis statement in a way that complements your summary of the topic of your paper in your first sentence of your conclusion.
• An example of a good thesis statement, going back to the paper on tuberculosis, would be "Tuberculosis is a widespread disease that affects millions of people worldwide every year. Due to the alarming rate of the spread of tuberculosis, particularly in poor countries, medical professionals are implementing new strategies for the diagnosis, treatment, and containment of this disease ."

• A good way to go about this is to re-read the topic sentence of each major paragraph or section in the body of your paper.
• Find a way to briefly restate each point mentioned in each topic sentence in your conclusion. Do not repeat any of the supporting details used within your body paragraphs.
• Under most circumstances, you should avoid writing new information in your conclusion. This is especially true if the information is vital to the argument or research presented in your paper.
• For example, in the TB paper you could summarize the information. "Tuberculosis is a widespread disease that affects millions of people worldwide. Due to the alarming rate of the spread of tuberculosis, particularly in poor countries, medical professionals are implementing new strategies for the diagnosis, treatment, and containment of this disease. In developing countries, such as those in Africa and Southeast Asia, the rate of TB infections is soaring. Crowded conditions, poor sanitation, and lack of access to medical care are all compounding factors in the spread of the disease. Medical experts, such as those from the World Health Organization are now starting campaigns to go into communities in developing countries and provide diagnostic testing and treatments. However, the treatments for TB are very harsh and have many side effects. This leads to patient non-compliance and spread of multi-drug resistant strains of the disease."

• Note that this is not needed for all research papers.
• If you already fully explained what the points in your paper mean or why they are significant, you do not need to go into them in much detail in your conclusion. Simply restating your thesis or the significance of your topic should suffice.
• It is always best practice to address important issues and fully explain your points in the body of your paper. The point of a conclusion to a research paper is to summarize your argument for the reader and, perhaps, to call the reader to action if needed.

• Note that a call for action is not essential to all conclusions. A research paper on literary criticism, for instance, is less likely to need a call for action than a paper on the effect that television has on toddlers and young children.
• A paper that is more likely to call readers to action is one that addresses a public or scientific need. Let's go back to our example of tuberculosis. This is a very serious disease that is spreading quickly and with antibiotic-resistant forms.
• A call to action in this research paper would be a follow-up statement that might be along the lines of "Despite new efforts to diagnose and contain the disease, more research is needed to develop new antibiotics that will treat the most resistant strains of tuberculosis and ease the side effects of current treatments."

• For example, if you are writing a history paper, then you might discuss how the historical topic you discussed matters today. If you are writing about a foreign country, then you might use the conclusion to discuss how the information you shared may help readers understand their own country.

Making Your Conclusion as Effective as Possible

• Since this sort of conclusion is so basic, you must aim to synthesize the information rather than merely summarizing it.
• Instead of merely repeating things you already said, rephrase your thesis and supporting points in a way that ties them all together.
• By doing so, you make your research paper seem like a "complete thought" rather than a collection of random and vaguely related ideas.

• Ask a question in your introduction. In your conclusion, restate the question and provide a direct answer.
• Write an anecdote or story in your introduction but do not share the ending. Instead, write the conclusion to the anecdote in the conclusion of your paper.
• For example, if you wanted to get more creative and put a more humanistic spin on a paper on tuberculosis, you might start your introduction with a story about a person with the disease, and refer to that story in your conclusion. For example, you could say something like this before you re-state your thesis in your conclusion: "Patient X was unable to complete the treatment for tuberculosis due to severe side effects and unfortunately succumbed to the disease."
• Use the same concepts and images introduced in your introduction in your conclusion. The images may or may not appear at other points throughout the research paper.

• Include enough information about your topic to back the statement up but do not get too carried away with excess detail.
• If your research did not provide you with a clear-cut answer to a question posed in your thesis, do not be afraid to indicate as much.
• Restate your initial hypothesis and indicate whether you still believe it or if the research you performed has begun swaying your opinion.
• Indicate that an answer may still exist and that further research could shed more light on the topic at hand.

• This may not be appropriate for all types of research papers. Most research papers, such as one on effective treatment for diseases, will have the information to make the case for a particular argument already in the paper.
• A good example of a paper that might ask a question of the reader in the ending is one about a social issue, such as poverty or government policy.
• Ask a question that will directly get at the heart or purpose of the paper. This question is often the same question, or some version of it, that you may have started with when you began your research.
• Make sure that the question can be answered by the evidence presented in your paper.
• If desired you can briefly summarize the answer after stating the question. You could also leave the question hanging for the reader to answer, though.

• Even without a call to action, you can still make a recommendation to your reader.
• For instance, if you are writing about a topic like third-world poverty, you can various ways for the reader to assist in the problem without necessarily calling for more research.
• Another example would be, in a paper about treatment for drug-resistant tuberculosis, you could suggest donating to the World Health Organization or research foundations that are developing new treatments for the disease.

Avoiding Common Pitfalls

• These sayings usually sound stiff, unnatural, or trite when used in writing.
• Moreover, using a phrase like "in conclusion" to begin your conclusion is a little too straightforward and tends to lead to a weak conclusion. A strong conclusion can stand on its own without being labeled as such.

• Always state the main argument or thesis in the introduction. A research paper is an analytical discussion of an academic topic, not a mystery novel.
• A good, effective research paper will allow your reader to follow your main argument from start to finish.
• This is why it is best practice to start your paper with an introduction that states your main argument and to end the paper with a conclusion that re-states your thesis for re-iteration.

• All significant information should be introduced in the body of the paper.
• Supporting evidence expands the topic of your paper by making it appear more detailed. A conclusion should narrow the topic to a more general point.
• A conclusion should only summarize what you have already stated in the body of your paper.
• You may suggest further research or a call to action, but you should not bring in any new evidence or facts in the conclusion.

• Most often, a shift in tone occurs when a research paper with an academic tone gives an emotional or sentimental conclusion.
• Even if the topic of the paper is of personal significance for you, you should not indicate as much in your paper.
• If you want to give your paper a more humanistic slant, you could start and end your paper with a story or anecdote that would give your topic more personal meaning to the reader.
• This tone should be consistent throughout the paper, however.

• Apologetic statements include phrases like "I may not be an expert" or "This is only my opinion."
• Statements like this can usually be avoided by refraining from writing in the first-person.
• Avoid any statements in the first-person. First-person is generally considered to be informal and does not fit with the formal tone of a research paper.

Community Q&A

You Might Also Like

• ↑ http://owl.english.purdue.edu/owl/resource/724/04/
• ↑ http://www.crlsresearchguide.org/18_Writing_Conclusion.asp
• ↑ http://writing.wisc.edu/Handbook/PlanResearchPaper.html#conclusion
• ↑ http://writingcenter.unc.edu/handouts/conclusions/
• ↑ http://writing2.richmond.edu/writing/wweb/conclude.html

About This Article

To write a conclusion for a research paper, start by restating your thesis statement to remind your readers what your main topic is and bring everything full circle. Then, briefly summarize all of the main points you made throughout your paper, which will help remind your readers of everything they learned. You might also want to include a call to action if you think more research or work needs to be done on your topic by writing something like, "Despite efforts to contain the disease, more research is needed to develop antibiotics." Finally, end your conclusion by explaining the broader context of your topic and why your readers should care about it, which will help them understand why your topic is relevant and important. For tips from our Academic co-author, like how to avoid common pitfalls when writing your conclusion, scroll down! Did this summary help you? Yes No

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Online Guide to Writing and Research

The research process, explore more of umgc.

• Online Guide to Writing

Planning and Writing a Research Paper

Draw Conclusions

As a writer, you are presenting your viewpoint, opinions, evidence, etc. for others to review, so you must take on this task with maturity, courage and thoughtfulness.  Remember, you are adding to the discourse community with every research paper that you write.  This is a privilege and an opportunity to share your point of view with the world at large in an academic setting.

Because research generates further research, the conclusions you draw from your research are important. As a researcher, you depend on the integrity of the research that precedes your own efforts, and researchers depend on each other to draw valid conclusions. 

To test the validity of your conclusions, you will have to review both the content of your paper and the way in which you arrived at the content. You may ask yourself questions, such as the ones presented below, to detect any weak areas in your paper, so you can then make those areas stronger.  Notice that some of the questions relate to your process, others to your sources, and others to how you arrived at your conclusions.

Checklist for Evaluating Your Conclusions

Key takeaways.

• Because research generates further research, the conclusions you draw from your research are important.
• To test the validity of your conclusions, you will have to review both the content of your paper and the way in which you arrived at the content.

Mailing Address: 3501 University Blvd. East, Adelphi, MD 20783 This work is licensed under a  Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License . © 2022 UMGC. All links to external sites were verified at the time of publication. UMGC is not responsible for the validity or integrity of information located at external sites.

Table of Contents: Online Guide to Writing

Chapter 1: College Writing

How Does College Writing Differ from Workplace Writing?

What Is College Writing?

Why So Much Emphasis on Writing?

Chapter 2: The Writing Process

Doing Exploratory Research

Getting from Notes to Your Draft

Introduction

Prewriting - Techniques to Get Started - Mining Your Intuition

Prewriting: Targeting Your Audience

Prewriting: Techniques to Get Started

Prewriting: Understanding Your Assignment

Rewriting: Being Your Own Critic

Rewriting: Creating a Revision Strategy

Rewriting: Getting Feedback

Rewriting: The Final Draft

Techniques to Get Started - Outlining

Techniques to Get Started - Using Systematic Techniques

Thesis Statement and Controlling Idea

Writing: Getting from Notes to Your Draft - Freewriting

Writing: Getting from Notes to Your Draft - Summarizing Your Ideas

Writing: Outlining What You Will Write

Chapter 3: Thinking Strategies

A Word About Style, Voice, and Tone

A Word About Style, Voice, and Tone: Style Through Vocabulary and Diction

Critical Strategies and Writing

Critical Strategies and Writing: Analysis

Critical Strategies and Writing: Evaluation

Critical Strategies and Writing: Persuasion

Critical Strategies and Writing: Synthesis

Developing a Paper Using Strategies

Kinds of Assignments You Will Write

Patterns for Presenting Information

Patterns for Presenting Information: Critiques

Patterns for Presenting Information: Discussing Raw Data

Patterns for Presenting Information: General-to-Specific Pattern

Patterns for Presenting Information: Problem-Cause-Solution Pattern

Patterns for Presenting Information: Specific-to-General Pattern

Patterns for Presenting Information: Summaries and Abstracts

Supporting with Research and Examples

Writing Essay Examinations

Writing Essay Examinations: Make Your Answer Relevant and Complete

Writing Essay Examinations: Organize Thinking Before Writing

Writing Essay Examinations: Read and Understand the Question

Chapter 4: The Research Process

Planning and Writing a Research Paper: Ask a Research Question

Planning and Writing a Research Paper: Cite Sources

Planning and Writing a Research Paper: Collect Evidence

Planning and Writing a Research Paper: Decide Your Point of View, or Role, for Your Research

Planning and Writing a Research Paper: Draw Conclusions

Planning and Writing a Research Paper: Find a Topic and Get an Overview

Planning and Writing a Research Paper: Manage Your Resources

Planning and Writing a Research Paper: Outline

Planning and Writing a Research Paper: Survey the Literature

Planning and Writing a Research Paper: Work Your Sources into Your Research Writing

Research Resources: Where Are Research Resources Found? - Human Resources

Research Resources: What Are Research Resources?

Research Resources: Where Are Research Resources Found?

Research Resources: Where Are Research Resources Found? - Electronic Resources

Research Resources: Where Are Research Resources Found? - Print Resources

Structuring the Research Paper: Formal Research Structure

Structuring the Research Paper: Informal Research Structure

The Nature of Research

The Research Assignment: How Should Research Sources Be Evaluated?

The Research Assignment: When Is Research Needed?

The Research Assignment: Why Perform Research?

Chapter 5: Academic Integrity

Academic Integrity

Giving Credit to Sources

Giving Credit to Sources: Copyright Laws

Giving Credit to Sources: Documentation

Giving Credit to Sources: Style Guides

Integrating Sources

Practicing Academic Integrity

Practicing Academic Integrity: Keeping Accurate Records

Practicing Academic Integrity: Managing Source Material

Practicing Academic Integrity: Managing Source Material - Paraphrasing Your Source

Practicing Academic Integrity: Managing Source Material - Quoting Your Source

Practicing Academic Integrity: Managing Source Material - Summarizing Your Sources

Types of Documentation

Types of Documentation: Bibliographies and Source Lists

Types of Documentation: Citing World Wide Web Sources

Types of Documentation: In-Text or Parenthetical Citations

Types of Documentation: In-Text or Parenthetical Citations - APA Style

Types of Documentation: In-Text or Parenthetical Citations - CSE/CBE Style

Types of Documentation: In-Text or Parenthetical Citations - Chicago Style

Types of Documentation: In-Text or Parenthetical Citations - MLA Style

Types of Documentation: Note Citations

Chapter 6: Using Library Resources

Finding Library Resources

Chapter 7: Assessing Your Writing

How Is Writing Graded?

How Is Writing Graded?: A General Assessment Tool

The Draft Stage

The Draft Stage: The First Draft

The Draft Stage: The Revision Process and the Final Draft

The Draft Stage: Using Feedback

The Research Stage

Using Assessment to Improve Your Writing

Chapter 8: Other Frequently Assigned Papers

Reviews and Reaction Papers: Article and Book Reviews

Reviews and Reaction Papers: Reaction Papers

Writing Arguments

Writing Arguments: Adapting the Argument Structure

Writing Arguments: Purposes of Argument

Writing Arguments: References to Consult for Writing Arguments

Writing Arguments: Steps to Writing an Argument - Anticipate Active Opposition

Writing Arguments: Steps to Writing an Argument - Determine Your Organization

Writing Arguments: Steps to Writing an Argument - Develop Your Argument

Writing Arguments: Steps to Writing an Argument - Introduce Your Argument

Writing Arguments: Steps to Writing an Argument - State Your Thesis or Proposition

Writing Arguments: Steps to Writing an Argument - Write Your Conclusion

Writing Arguments: Types of Argument

Appendix A: Books to Help Improve Your Writing

Dictionaries

General Style Manuals

Researching on the Internet

Special Style Manuals

Writing Handbooks

Appendix B: Collaborative Writing and Peer Reviewing

Collaborative Writing: Assignments to Accompany the Group Project

Collaborative Writing: Informal Progress Report

Collaborative Writing: Issues to Resolve

Collaborative Writing: Methodology

Collaborative Writing: Peer Evaluation

Collaborative Writing: Tasks of Collaborative Writing Group Members

Collaborative Writing: Writing Plan

General Introduction

Peer Reviewing

Appendix C: Developing an Improvement Plan

Working with Your Instructor’s Comments and Grades

Appendix D: Writing Plan and Project Schedule

Devising a Writing Project Plan and Schedule

Reviewing Your Plan with Others

By using our website you agree to our use of cookies. Learn more about how we use cookies by reading our  Privacy Policy .

Organizing Academic Research Papers: 9. The Conclusion

• Purpose of Guide
• Design Flaws to Avoid
• Glossary of Research Terms
• Narrowing a Topic Idea
• Broadening a Topic Idea
• Extending the Timeliness of a Topic Idea
• Academic Writing Style
• Choosing a Title
• Making an Outline
• Paragraph Development
• Executive Summary
• Background Information
• The Research Problem/Question
• Theoretical Framework
• Citation Tracking
• Content Alert Services
• Evaluating Sources
• Primary Sources
• Secondary Sources
• Tertiary Sources
• What Is Scholarly vs. Popular?
• Qualitative Methods
• Quantitative Methods
• Using Non-Textual Elements
• Limitations of the Study
• Common Grammar Mistakes
• Avoiding Plagiarism
• Footnotes or Endnotes?
• Further Readings
• Annotated Bibliography
• Dealing with Nervousness
• Using Visual Aids
• Grading Someone Else's Paper
• How to Manage Group Projects
• Multiple Book Review Essay
• Reviewing Collected Essays
• About Informed Consent
• Writing Field Notes
• Writing a Policy Memo
• Writing a Research Proposal
• Acknowledgements

The conclusion is intended to help the reader understand why your research should matter to them after they have finished reading the paper. A conclusion is not merely a summary of your points or a re-statement of your research problem but a synthesis of key points. For most essays, one well-developed paragraph is sufficient for a conclusion, although in some cases, a two-or-three paragraph conclusion may be required.

Importance of a Good Conclusion

A well-written conclusion provides you with several important opportunities to demonstrate your overall understanding of the research problem to the reader. These include:

• Presenting the last word on the issues you raised in your paper . Just as the introduction gives a first impression to your reader, the conclusion offers a chance to leave a lasting impression. Do this, for example, by highlighting key points in your analysis or findings.
• Summarizing your thoughts and conveying the larger implications of your study . The conclusion is an opportunity to succinctly answer the "so what?" question by placing the study within the context of past research about the topic you've investigated.
• Demonstrating the importance of your ideas . Don't be shy. The conclusion offers you a chance to elaborate on the significance of your findings.
• Introducing possible new or expanded ways of thinking about the research problem . This does not refer to introducing new information [which should be avoided], but to offer new insight and creative approaches for framing/contextualizing the research problem based on the results of your study.

Conclusions . The Writing Center. University of North Carolina; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion . San Francisco Edit, 2003-2008.

Structure and Writing Style

https://writing.wisc.edu/wp-content/uploads/sites/535/2018/07/conclusions_uwmadison_writingcenter_aug2012.pdf I.  General Rules

When writing the conclusion to your paper, follow these general rules:

• State your conclusions in clear, simple language.
• Do not simply reiterate your results or the discussion.
• Indicate opportunities for future research, as long as you haven't already done so in the discussion section of your paper.

The function of your paper's conclusion is to restate the main argument . It reminds the reader of the strengths of your main argument(s) and reiterates the most important evidence supporting those argument(s). Make sure, however, that your conclusion is not simply a repetitive summary of the findings because this reduces the impact of the argument(s) you have developed in your essay.

Consider the following points to help ensure your conclusion is appropriate:

• If the argument or point of your paper is complex, you may need to summarize the argument for your reader.
• If, prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the end of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration that returns the topic to the context provided by the introduction or within a new context that emerges from the data.

The conclusion also provides a place for you to persuasively and succinctly restate your research problem, given that the reader has now been presented with all the information about the topic . Depending on the discipline you are writing in, the concluding paragraph may contain your reflections on the evidence presented, or on the essay's central research problem. However, the nature of being introspective about the research you have done will depend on the topic and whether your professor wants you to express your observations in this way.

NOTE : Don't delve into idle speculation. Being introspective means looking within yourself as an author to try and understand an issue more deeply not to guess at possible outcomes.

II.  Developing a Compelling Conclusion

Strategies to help you move beyond merely summarizing the key points of your research paper may include any of the following.

• If your essay deals with a contemporary problem, warn readers of the possible consequences of not attending to the problem.
• Recommend a specific course or courses of action.
• Cite a relevant quotation or expert opinion to lend authority to the conclusion you have reached [a good place to look is research from your literature review].
• Restate a key statistic, fact, or visual image to drive home the ultimate point of your paper.
• If your discipline encourages personal reflection, illustrate your concluding point with a relevant narrative drawn from your own life experiences.
• Return to an anecdote, an example, or a quotation that you introduced in your introduction, but add further insight that is derived from the findings of your study; use your interpretation of results to reframe it in new ways.
• Provide a "take-home" message in the form of a strong, succient statement that you want the reader to remember about your study.

III. Problems to Avoid Failure to be concise The conclusion section should be concise and to the point. Conclusions that are too long often have unnecessary detail. The conclusion section is not the place for details about your methodology or results. Although you should give a summary of what was learned from your research, this summary should be relatively brief, since the emphasis in the conclusion is on the implications, evaluations, insights, etc. that you make. Failure to comment on larger, more significant issues In the introduction, your task was to move from general [the field of study] to specific [your research problem]. However, in the conclusion, your task is to move from specific [your research problem] back to general [your field, i.e., how your research contributes new understanding or fills an important gap in the literature]. In other words, the conclusion is where you place your research within a larger context. Failure to reveal problems and negative results Negative aspects of the research process should never be ignored. Problems, drawbacks, and challenges encountered during your study should be included as a way of qualifying your overall conclusions. If you encountered negative results [findings that are validated outside the research context in which they were generated], you must report them in the results section of your paper. In the conclusion, use the negative results as an opportunity to explain how they provide information on which future research can be based. Failure to provide a clear summary of what was learned In order to be able to discuss how your research fits back into your field of study [and possibly the world at large], you need to summarize it briefly and directly. Often this element of your conclusion is only a few sentences long. Failure to match the objectives of your research Often research objectives change while the research is being carried out. This is not a problem unless you forget to go back and refine your original objectives in your introduction, as these changes emerge they must be documented so that they accurately reflect what you were trying to accomplish in your research [not what you thought you might accomplish when you began].

Resist the urge to apologize If you've immersed yourself in studying the research problem, you now know a good deal about it, perhaps even more than your professor! Nevertheless, by the time you have finished writing, you may be having some doubts about what you have produced. Repress those doubts!  Don't undermine your authority by saying something like, "This is just one approach to examining this problem; there may be other, much better approaches...."

Concluding Paragraphs. College Writing Center at Meramec. St. Louis Community College; Conclusions . The Writing Center. University of North Carolina; Conclusions . The Writing Lab and The OWL. Purdue University; Freedman, Leora  and Jerry Plotnick. Introductions and Conclusions . The Lab Report. University College Writing Centre. University of Toronto; Leibensperger, Summer. Draft Your Conclusion. Academic Center, the University of Houston-Victoria, 2003; Make Your Last Words Count . The Writer’s Handbook. Writing Center. University of Wisconsin, Madison; Tips for Writing a Good Conclusion . Writing@CSU. Colorado State University; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion . San Francisco Edit, 2003-2008; Writing Conclusions . Writing Tutorial Services, Center for Innovative Teaching and Learning. Indiana University; Writing: Considering Structure and Organization . Institute for Writing Rhetoric. Dartmouth College.

Writing Tip

Don't Belabor the Obvious!

Avoid phrases like "in conclusion...," "in summary...," or "in closing...." These phrases can be useful, even welcome, in oral presentations. But readers can see by the tell-tale section heading and number of pages remaining to read, when an essay is about to end. You'll irritate your readers if you belabor the obvious.

Another Writing Tip

New Insight, Not New Information!

Don't surprise the reader with new information in your Conclusion that was never referenced anywhere else in the paper. If you have new information to present, add it to the Discussion or other appropriate section of the paper.  Note that, although no actual new information is introduced, the conclusion is where you offer your most "original" contributions in the paper; it's where you describe the value of your research, demonstrate your understanding of the material that you’ve presented, and locate your findings within the larger context of scholarship on the topic.

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Writing a Paper: Conclusions

Writing a conclusion.

A conclusion is an important part of the paper; it provides closure for the reader while reminding the reader of the contents and importance of the paper. It accomplishes this by stepping back from the specifics in order to view the bigger picture of the document. In other words, it is reminding the reader of the main argument. For most course papers, it is usually one paragraph that simply and succinctly restates the main ideas and arguments, pulling everything together to help clarify the thesis of the paper. A conclusion does not introduce new ideas; instead, it should clarify the intent and importance of the paper. It can also suggest possible future research on the topic.

An Easy Checklist for Writing a Conclusion

It is important to remind the reader of the thesis of the paper so he is reminded of the argument and solutions you proposed.

Think of the main points as puzzle pieces, and the conclusion is where they all fit together to create a bigger picture. The reader should walk away with the bigger picture in mind.

Make sure that the paper places its findings in the context of real social change.

Make sure the reader has a distinct sense that the paper has come to an end. It is important to not leave the reader hanging. (You don’t want her to have flip-the-page syndrome, where the reader turns the page, expecting the paper to continue. The paper should naturally come to an end.)

No new ideas should be introduced in the conclusion. It is simply a review of the material that is already present in the paper. The only new idea would be the suggesting of a direction for future research.

Conclusion Example

As addressed in my analysis of recent research, the advantages of a later starting time for high school students significantly outweigh the disadvantages. A later starting time would allow teens more time to sleep--something that is important for their physical and mental health--and ultimately improve their academic performance and behavior. The added transportation costs that result from this change can be absorbed through energy savings. The beneficial effects on the students’ academic performance and behavior validate this decision, but its effect on student motivation is still unknown. I would encourage an in-depth look at the reactions of students to such a change. This sort of study would help determine the actual effects of a later start time on the time management and sleep habits of students.

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Research Paper Conclusion – A Comprehensive Guide

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Composing the conclusions for research papers plays a significant intellectual demand in academic writing. The final paragraphs of a paper ought to encompass the essence of the study, avoiding the appearance of redundancy. An effectively constructed conclusion has the capacity to enhance and strengthen the overall integrity of your research paper . This article delves into the importance of research paper conclusions, the methodology for crafting one, and provides a comprehensive guide.

Inhaltsverzeichnis

• 1 Research Paper Conclusion — In a Nutshell
• 2 Definition: Research paper conclusion
• 3 Research paper conclusion – Step 1
• 4 Research paper conclusion – Step 2
• 5 Research paper conclusion – Step 3
• 6 Research paper conclusion examples

Research Paper Conclusion — In a Nutshell

• Keep your thesis , essential ideas, and facts brief in a research paper conclusion.
• Avoid starting with “in conclusion” or “in summary” as they are redundant.
• If you’re overwhelmed, stick to a basic summary format.

Definition: Research paper conclusion

A research paper conclusion wraps up your ideas and leaves a lasting impact on the reader.

Research paper conclusion goals are to:

• Summarize the paper’s research problem .
• Recap your arguments or findings.
• Provide significant takeaways from your paper.

The research paper conclusion depends on whether your work delivers empirical research results or builds an argument from sources .

The steps below illustrate how to write a reasonable research paper conclusion.

Research paper conclusion – Step 1

Summarizing the research question :

Reiterating your research problem is the first order of business for your research paper conclusion. You will have already spent a lot of time discussing this issue in the body, so now you can step back and look at the overall perspective.

You shouldn’t restate a problem precisely as it was introduced. Find a unique technique to loop back to the problem from the body’s details.

✓ Phrases to use

An argumentation paper suggesting new steps to lessen agriculture’s environmental impact might say:

✓ Although the significance of cattle in climate change is well-known, countries like the Netherlands fail to address it with urgency.

An empirical paper on Instagram and body image might state the situation this way:

✓ As social media becomes a more significant part of young people’s daily life, it is vital to comprehend the influence on their evolving sense of self.

✗ Phrases to avoid

Avoid beginning your conclusion with terms such as “In conclusion” or “To conclude,” as these are too obvious and can make your writing appear unsophisticated. Your conclusion’s content and placement should make its role evident without needing extra signposting.

✗ In conclusion,…

✗ To conclude…

✗ In summary,…

Research paper conclusion – Step 2

Summarizing the content:

After refocusing on the problem, outline how the study addressed it and what conclusions it reached.

This may entail restating your thesis and reasoning or summarizing overall findings, depending on the type of your research work.

Argumentative paper

An argumentative paper’s thesis statement is delivered in the paper’s introduction and expresses the paper’s central assertion. Restating the thesis and demonstrating its development throughout the article is essential to every research paper conclusion.

Summarize the body’s primary arguments and how they prove your thesis. If your argument is controversial, you may present counterarguments and explain why your thesis holds up.

Don’t discuss your proof or propose fresh ideas; outline your argument.

Empirical paper

This is the section of an empirical paper where you should summarize your significant findings. Don’t go into detail (you’ve already delivered your detailed results and discussion), but clearly state your research questions.

Describe your key findings, even if they were not what you expected or desired, and explain how they led to your conclusion.

Research paper conclusion – Step 3

The implications:

After summarizing major arguments or facts, the conclusion considers broader ramifications. This includes conveying the practical or theoretical implications from your study as a call to action or future research proposals.

Argumentative papers typically conclude with a powerful thesis statement. In the event of a practical argument, make a call to action :

“What steps do you believe the individuals or organizations involved should take in response to your argument?”

Suppose your issue is more theoretical and inappropriate for a call to action. In that case, the research paper conclusion should convey the argument’s relevance by proposing a new understanding of the topic or setting the basis for future research.

In the research paper conclusion of an empirical article, you can either make recommendations for practice (such as in clinical or policy papers) or make suggestions for further research.

Regardless of the extent of your research, there is always a potential for additional exploration into related topics, and you will frequently uncover new questions and issues during the research process.

Conclude your work on an optimistic note by proposing how you or other researchers could expand on this issue in the future and address any shortcomings of the current paper.

Research paper conclusion examples

The tabs below exhibit argumentative and empirical research paper conclusions.

What should I include in a research paper conclusion?

A research paper conclusion should include these elements:

• Problem restatement
• An overview of your main points
• A brief overview of study implications

Can I present new arguments in a research paper conclusion?

No, the research paper conclusion isn’t the place for new arguments or proof. You may be tempted to keep a strong argument for last, but research papers have a more formal framework.

All your facts and justifications should be in the body of the paper. The research paper conclusion should recap and reflect on previous evidence and arguments, not propose new ones.

How long should a research paper conclusion be?

An excellent research paper conclusion needs at least one paragraph. A lengthy document will likely need multiple paragraphs to conclude adequately.

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities.

INTRODUCTION

Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve.

Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes. [1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research. [2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.” [3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops. [4]  Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture.

I.     Global Cultural Perspective of Embryonic Stem Cells

Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense, [5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research. [6] Consequently, global engagement in ESC research depends on social-cultural acceptability.

a.     US and Rights-Based Cultures

In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism, [7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.” [8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed. [9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field. [10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture. [11]

b.     Ubuntu and Collective Cultures

African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama , which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,” [12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth. [13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value. [14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society.

Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.” [15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail.

Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable. [16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus [17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines. [18]

Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim. [19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research. [20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF.  Their use is conditioned on consent, and available only to married couples. [21] The community's receptiveness to stem cell research depends on including communitarian African ethics.

c.     Asia

Some Asian countries also have a collective model of ethics and decision making. [22] In China, the ethics model promotes a sincere respect for life or human dignity, [23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life. [25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research. [26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions. [27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency. [28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021. [29] However, issues still need to be addressed in implementing effective IRB review and approval procedures.

The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy, [30] research ethics should also adapt to ensure respect for the values of its represented peoples.

Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies. [31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells. [32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval, [33] and in another instance, the oocyte source was unclear and possibly violated ethical standards. [34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust.

d.     Middle East

Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells, [35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research. [36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors. [37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so. [38]

Jordan has a positive research ethics culture. [39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial. [40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation. [41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.” [42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes.

e.     Europe

In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected. [43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44]

For example, in Germany, Lebenzusammenhang , or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.” [45]  Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount. [46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007. [47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization. [48] Spain’s approach differs still, with a comprehensive regulatory framework. [49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility. [50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices. [51]

II.     Religious Perspectives on ESC

Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives.

The Qur'an states:

“And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.” [52]

Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception. [53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible. [54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research. [55]

In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided. [56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden. [57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all. [58] Acceptance varies on applied beliefs and interpretations.

Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero, [59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all. [60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime. [61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit. [62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets. [63]

Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life. [64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception: [65]

“If she is found pregnant, until the fortieth day it is mere fluid,” [66]

Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation. [67] Stem cell research is accepted due to application of these religious laws.

We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory , which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions. [68] We only wish to show that the interaction with morality varies between cultures and countries.

III.     A Flexible Ethical Approach

The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities.

While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe. [69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation.

For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent. [70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context, [71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders.  This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research.

Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values. [72]

An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions. [73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion.

IV.     Concerns

Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values. [74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions.

Other concerns include medical tourism, which may promote health inequities. [75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments. [76]

For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.” [77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices. [78]

The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.” [79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds. [80]

While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research.

For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society.

This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model.

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[5] Concerning the moral philosophies of stem cell research, our paper does not posit a personal moral stance nor delve into the “when” of human life begins. To read further about the philosophical debate, consider the following sources:

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[7] Socially, at its core, the Western approach to ethics is widely principle-based, autonomy being one of the key factors to ensure a fundamental respect for persons within research. For information regarding autonomy in research, see: Department of Health, Education, and Welfare, & National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978). The Belmont Report. Ethical principles and guidelines for the protection of human subjects of research.; For a more in-depth review of autonomy within the US, see: Beauchamp, T. L., & Childress, J. F. (1994). Principles of Biomedical Ethics . Oxford University Press.

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[9] Stem Cell Research Enhancement Act of 2005, H. R. 810, 109 th Cong. (2001). https://www.govtrack.us/congress/bills/109/hr810/text ; Bush, G. W. (2006, July 19). Message to the House of Representatives . National Archives and Records Administration. https://georgewbush-whitehouse.archives.gov/news/releases/2006/07/20060719-5.html

[10] National Archives and Records Administration. (2009, March 9). Executive order 13505 -- removing barriers to responsible scientific research involving human stem cells . National Archives and Records Administration. https://obamawhitehouse.archives.gov/the-press-office/removing-barriers-responsible-scientific-research-involving-human-stem-cells

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[13] Source for further reading: Tangwa G. B. (2007). Moral status of embryonic stem cells: perspective of an African villager. Bioethics , 21(8), 449–457. https://doi.org/10.1111/j.1467-8519.2007.00582.x , see also Mnisi, F. M. (2020). An African analysis based on ethics of Ubuntu - are human embryonic stem cell patents morally justifiable? African Insight , 49 (4).

[14] Jecker, N. S., & Atuire, C. (2021). Bioethics in Africa: A contextually enlightened analysis of three cases. Developing World Bioethics , 22 (2), 112–122. https://doi.org/10.1111/dewb.12324

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[18] Oosthuizen, H. (2013). Legal and Ethical Issues in Stem Cell Research in South Africa. In: Beran, R. (eds) Legal and Forensic Medicine. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-32338-6_80 , see also: Gaobotse G (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

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[21] Kooli, C. Review of assisted reproduction techniques, laws, and regulations in Muslim countries.  Middle East Fertil Soc J   24 , 8 (2020). https://doi.org/10.1186/s43043-019-0011-0 ; Gaobotse, G. (2018) Stem Cell Research in Africa: Legislation and Challenges. J Regen Med 7:1. doi: 10.4172/2325-9620.1000142

[22] Pang M. C. (1999). Protective truthfulness: the Chinese way of safeguarding patients in informed treatment decisions. Journal of medical ethics , 25(3), 247–253. https://doi.org/10.1136/jme.25.3.247

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[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

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Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

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[43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

[44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France.  Biotechnology Law Report ,  32 (6), 349–356. https://doi.org/10.1089/blr.2013.9865

[45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3

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[47] Regulation of Stem Cell Research in Germany . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany

[48] Regulation of Stem Cell Research in Finland . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland

[49] Regulation of Stem Cell Research in Spain . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain

[50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered:

Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110.

Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ...  Revista do Colegio Brasileiro de Cirurgioes ,  41 (5), 374–377. https://doi.org/10.1590/0100-69912014005013

Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India . Routledge.

For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe . Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe   

[51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights.  Cultura (Iasi, Romania) ,  14 (2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent?  Research Ethics ,  13 (1), 23-41.  https://doi.org/10.1177/1747016116650235

[52] The Qur'an  (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23

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[54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics , 31: 399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386

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Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

Article Details

This work is licensed under a Creative Commons Attribution 4.0 International License .

• Open access
• Published: 09 May 2024

Older adults at greater risk for Alzheimer’s disease show stronger associations between sleep apnea severity in REM sleep and verbal memory

• Kitty K. Lui 1 , 2 ,
• Abhishek Dave 2 , 3 ,
• Kate E. Sprecher 4 , 5 , 6 , 7 ,
• Miranda G. Chappel-Farley 8 , 9 ,
• Brady A. Riedner 10 ,
• Margo B. Heston 6 , 7 ,
• Chase E. Taylor 11 ,
• Cynthia M. Carlsson 12 , 13 , 6 , 7 ,
• Ozioma C. Okonkwo 12 , 13 , 6 , 7 ,
• Sanjay Asthana 12 , 13 , 6 , 7 ,
• Sterling C. Johnson 12 , 13 , 6 , 7 ,
• Barbara B. Bendlin 12 , 13 , 6 , 7 ,
• Bryce A. Mander 2 , 3 , 9 &
• Ruth M. Benca 10 , 14 , 2 , 5 , 9  

Alzheimer's Research & Therapy volume  16 , Article number:  102 ( 2024 ) Cite this article

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Obstructive sleep apnea (OSA) increases risk for cognitive decline and Alzheimer’s disease (AD). While the underlying mechanisms remain unclear, hypoxemia during OSA has been implicated in cognitive impairment. OSA during rapid eye movement (REM) sleep is usually more severe than in non-rapid eye movement (NREM) sleep, but the relative effect of oxyhemoglobin desaturation during REM versus NREM sleep on memory is not completely characterized. Here, we examined the impact of OSA, as well as the moderating effects of AD risk factors, on verbal memory in a sample of middle-aged and older adults with heightened AD risk.

Eighty-one adults (mean age:61.7 ± 6.0 years, 62% females, 32% a polipoprotein E ε4 allele ( APOE4) carriers, and 70% with parental history of AD) underwent clinical polysomnography including assessment of OSA. OSA features were derived in total, NREM, and REM sleep. REM-NREM ratios of OSA features were also calculated. Verbal memory was assessed with the Rey Auditory Verbal Learning Test (RAVLT). Multiple regression models evaluated the relationships between OSA features and RAVLT scores while adjusting for sex, age, time between assessments, education years, body mass index (BMI), and APOE4 status or parental history of AD. The significant main effects of OSA features on RAVLT performance and the moderating effects of AD risk factors (i.e., sex, age, APOE4 status, and parental history of AD) were examined.

Apnea–hypopnea index (AHI), respiratory disturbance index (RDI), and oxyhemoglobin desaturation index (ODI) during REM sleep were negatively associated with RAVLT total learning and long-delay recall. Further, greater REM-NREM ratios of AHI, RDI, and ODI (i.e., more events in REM than NREM) were related to worse total learning and recall. We found specifically that the negative association between REM ODI and total learning was driven by adults 60 + years old. In addition, the negative relationships between REM-NREM ODI ratio and total learning, and REM-NREM RDI ratio and long-delay recall were driven by APOE4 carriers.

Greater OSA severity, particularly during REM sleep, negatively affects verbal memory, especially for people with greater AD risk. These findings underscore the potential importance of proactive screening and treatment of REM OSA even if overall AHI appears low.

Obstructive sleep apnea (OSA) is characterized by recurrent pharyngeal airway collapses that cause complete (apneas) or partial (hypopneas) cessations of airflow that lead to sleep fragmentation and intermittent hypoxemia [ 1 ]. Meta-analyses have shown that sleep-disordered breathing (SDB), including OSA, increases incidence of Alzheimer’s disease (AD), and people with AD were five times more likely to have OSA [ 2 , 3 ]. Proposed mechanisms suggest that OSA accelerates expression of AD pathologies, medial temporal lobe (MTL) degeneration, and memory impairment through OSA-related hypoxemia [ 4 , 5 , 6 , 7 , 8 ]. Though, some have reported that the cognitive consequences of OSA are diminished in older age [ 9 ]. Verbal memory deficits, specifically learning and recall of word list, is considered as the most sensitive marker of early cognitive changes associated with AD [ 10 , 11 , 12 ], and OSA-related hypoxemia could exacerbate AD risk through its impact on the hippocampus, a brain region critical for the formation and processing of episodic memories and is especially vulnerable to injury from oxygen deprivation [ 13 , 14 ]. While OSA severity has been linked to poor verbal memory performance, especially word lists learning tests [ 8 , 15 ], the exact OSA features driving these relationships, as well as whether respiratory events occurring during non-rapid eye movement (NREM) or rapid eye movement (REM) sleep are more damaging, have remained unclear.

During REM sleep, there is higher neurometabolic demand in regions impacted in early AD compared to NREM sleep [ 16 , 17 , 18 ]. In addition, during REM sleep, there is an increased susceptibility of upper airway collapse due to inhibition of the genioglossus muscle (the major upper airway dilator muscle that helps stabilize breathing) [ 19 ]. There are also lower hypoxic and hypercapnic respiratory drives during REM sleep which results in longer durations of apneas and hypopneas, and more instances of oxyhemoglobin desaturation than in NREM sleep [ 20 ]. These specific features of REM sleep and OSA events during REM sleep allude to the possibility that OSA during REM sleep may impart greater cognitive consequences, however, this has yet to be fully examined.

Furthermore, AD risk factors, such as older age, female sex, and apolipoprotein E ε4 ( APOE4 ) genotype have been implicated in OSA as well. OSA and AD are both more prevalent in the aging population [ 21 ]. Roughly 40–80% of people with AD carry at least one APOE4 allele and older adults with APOE4 may have increased risk for SDB, although this has not been consistently reported [ 22 , 23 ]. Moreover, the effects of APOE4 on the associations between OSA and memory have remained unclear [ 24 , 25 ], though it appears that OSA’s effects on memory networks may be stronger in β-amyloid positive older adults [ 26 ]. There are also sex differences in both AD and OSA risk. Women are nearly twice as likely to be diagnosed with AD and have a more severe disease progression that is characterized by faster memory decline and more pathological tau accumulation [ 27 , 28 , 29 , 30 ]. While men are at increased risk for OSA, OSA prevalence substantially rises in post-menopausal women, yet women typically remain underdiagnosed [ 31 , 32 ]. There is some evidence that suggests women with OSA may develop stronger OSA-related memory impairments than men with OSA, though, results have been inconsistent [ 33 , 34 , 35 ]. OSA is also expressed differentially by sex, with apneas and hypopneas more likely to occur in REM sleep in women than men [ 36 , 37 ]. Thus, there is a possibility of interplay between OSA and AD risk factors of age, sex, and APOE4 , that may synergistically cause stronger memory impairments. However, these interactions have yet to be fully examined.

Here, in the current study, we sought to examine OSA expression separately during REM and NREM sleep as it related to verbal memory, and whether AD risk factors moderated these relationships. We combined clinical polysomnography (PSG) with verbal memory measured by the Rey Auditory Verbal Learning Test (RAVLT) in a cohort of middle- and older- aged adults enriched for parental history and genetic risk for AD. We aimed to extend the current literature by testing the following hypotheses: 1) greater OSA severity, particularly during REM sleep, is associated with impaired verbal learning and delayed recall and 2) that in significant associations, the relationships are stronger among older adults, women, and/or individuals with increased genetic and parental risk for AD.

Clinical methods

One hundred fifteen cognitively unimpaired middle- and older-aged adults from the Wisconsin Alzheimer’s Disease Research Center (ADRC) Clinical Core, a prospective cohort study enriched for probable parental history of AD relative to the general population [ 38 ], were enrolled in a sub-study, the Predicting Alzheimer’s from Metabolic Markers and Sleep (PAMMS). From their ADRC visit, participants underwent cognitive assessments of declarative and semantic memory, attention, executive function, language, and visuospatial processing using the National Alzheimer’s Coordinating Center Uniform Data Set (UDS) neuropsychological battery version 3 and additional assessments [ 39 ]. Clinical diagnosis of cognitively unimpaired status was determined using the 2011 National Institute on Aging-Alzheimer’s Association (NIA-AA) workgroup diagnostic criteria and confirmed by multidisciplinary consensus conference (Table S 1 ) [ 40 , 41 ].

Of the 115 participants in PAMMS, 89 underwent a subcomponent of the study with polysomnography (PSG) with high-density EEG (hdEEG). This portion of the study excluded for individuals with a past history or current neurological, psychiatric, medical conditions, or treatments that impacted their cognition, or hindered their ability to complete any aspects of the study protocol, taking medications known to influence sleep or sleep electroencephalography (EEG), including antipsychotic medications, non-selective serotonin reuptake inhibitors (SSRIs) antidepressants, neuroleptics, chronic anxiolytics, sedative hypnotics, and stimulants, and was currently undergoing treatment for SDB (e.g. continuous positive airway pressure). Participants completed PSG with hdEEG approximately within 1 year of cognitive assessment. RAVLT scores were taken from their cognitive assessment at the ADRC. In addition, participant’s APOE 4 genotyped by DNA extraction from whole blood samples using competitive allele-specific PCR based KASP genotyping for rs429358, as previously reported [ 42 ]. The final sample size consisted of 81 participants with valid PSG data and RAVLT scores (e.g., oxyhemoglobin saturation levels not recorded the whole night would be considered invalid data).

Polysomnography

To assess sleep and OSA severity, participants underwent clinical PSG with 256-channel hdEEG. A thorough description of PSG with hdEEG recording and sleep scoring has been previously described [ 43 ]. From PSG, sleep architecture measures of total sleep time (TST), time in bed (TIB), sleep onset latency, wake after sleep onset (WASO), and percent of TST spent in N1, N2, N3, and REM were derived. Additionally, clinical measures reflecting sleep disorder characteristics were calculated, including apnea–hypopnea index (AHI; number of apneas and hypopneas per hour), respiratory disturbance index (RDI; number of apneas, hypopneas, and respiratory-related arousals per hour), oxyhemoglobin desaturation index (ODI; number of oxyhemoglobin desaturations ≥ 4% per hour). The AHI is a traditional measure for OSA diagnosis, with the American Academy of Sleep Medicine (AASM) clinical criterion of an AHI ≥ 5 for at least mild OSA [ 44 , 45 ]. The RDI captures additional information regarding respiratory events that do not meet criteria for a hypopnea, yet still lead to an arousal, and thus disrupt continuous sleep [ 44 , 45 ]. The AASM criteria for OSA diagnosis is RDI ≥ 5, if daytime sleepiness is present, and RDI ≥ 15 if not. The ODI is a clinically informative measure on the frequency of drops in oxyhemoglobin saturation levels, a marker of intermittent hypoxemia, which has been associated with poor cardiovascular outcomes, including elevated stroke risk, and increased risk of mortality [ 46 , 47 , 48 ].

Furthermore, nadir blood oxyhemoglobin saturation level, mean blood oxyhemoglobin saturation, duration of time spent with < 90% blood oxyhemoglobin saturation, and periodic leg movements during sleep index (PLMSI; number of PLMs per hour) were analyzed. These measures besides PLMSI, also reflects the degree of hypoxemia that occurs during sleep, and are additionally diagnostically important for OSA [ 45 , 47 ]. This study included participants with and without OSA and used the clinical measures of OSA as continuous variables for statistical analyses.

In addition, AHI, RDI, ODI, and duration of time spent with < 90% oxyhemoglobin saturation in REM and NREM sleep were also derived. To measure whether an individual had more REM or NREM OSA features throughout the night, ratios of AHI, RDI, and ODI between REM and NREM sleep were also calculated [ 49 , 50 , 51 , 52 ]. The NREM/REM ratios provide context of whether there is predominance of OSA events in a specific sleep stage across the sleep period. There are well characterized physiological differences in REM versus NREM sleep; specifically, OSA in REM sleep leads to more severe OSA events and has been linked to poor cardiovascular outcomes [ 7 , 16 , 17 , 18 , 19 , 20 , 53 , 54 , 55 , 56 ]. While some studies reported no significant differences between those with OSA events predominantly in NREM sleep versus REM sleep in clinical features such as BMI, daytime sleepiness, and depression [ 50 , 51 ], there have been established physiological and polysomnographic differences in those that express OSA events more in REM sleep and in those that express OSA events more in NREM sleep [ 51 , 52 ]. For instance, in predominant NREM OSA, ventilatory control is worse with higher loop gain, whereas in predominant REM OSA, the upper airway is more collapsible. Furthermore, people with more predominant NREM OSA had longer sleep onset latency, less sleep efficiency, and lower mean oxyhemoglobin saturation. There has yet to be an examination of the ratio of REM OSA events to NREM OSA event as it relates to memory.

Rey Auditory Verbal Learning Test (RAVLT)

The RAVLT is a standard neuropsychological assessment for verbal memory that it MTL-dependent, a sensitive marker of memory impairment in preclinical AD, and commonly used in AD research and clinical practice for diagnosis [ 57 , 58 , 59 , 60 ]. Further, OSA severity has been linked to poor verbal memory performance [ 8 ].

The test includes one learning phase, two recall phases, and one recognition phase. During the learning phase, a list of 15 words is read to the participant five times, and the participant repeat the words they remember after each trial. An interference list of 15 words is then read aloud once, and the short-delay recall ability is assessed after the interference list. Long-delay recall is then assessed after 20 min. A total learning score is derived by summing the number of remembered words in trials 1 through 5 (range: 0–75). Short-delay recall was measured as total number of words recalled after the interference list (range: 0–15), and long-delay recall was measured as total number of words after the 20-min delay (range: 0–15).

Statistical analyses

The purpose of this study was to comprehensively examine the distinct features of OSA (e.g., number of OSA-related events per hour or time spent during sleep with blood oxyhemoglobin levels in hypoxemia) across the whole night and broken down by distinct sleep stages (NREM versus REM), since there are physiological differences in these brain states [ 16 , 17 , 18 , 19 , 20 ]. Thus, the OSA characteristics that were analyzed were AHI, RDI, and ODI, and sleep duration spent with < 90% blood oxyhemoglobin saturation for total sleep, REM sleep, and NREM sleep. Total sleep nadir blood oxyhemoglobin saturation, total sleep mean blood oxyhemoglobin saturation, and WASO were also analyzed. RAVLT measures included total learning, short-delay recall, and long-delay recall. Normality of variables were analyzed with a Shapiro–Wilk test. All AHI, RDI, and ODI measures were log-transformed with a constant added to meet normality assumptions.

Independent sample t-tests were conducted to analyze group differences by sex, APOE4 status, and parental history of AD. Student’s t-tests were used if assumptions of normality and variance were met. Mann Whitney U-tests were used if assumptions of normality were violated. Kendall rank correlation was conducted on the associations between age and OSA characteristics. Paired samples t-tests were used to analyze REM versus NREM AHI, RDI, ODI, and duration spent with < 90% blood oxyhemoglobin saturation. Student’s t-test was used if assumptions of normality and Wilcoxon signed-rank test was used if assumptions of normality were violated.

Multiple linear regression models were used to analyze the relationships between OSA characteristics (predictors) and RAVLT (outcomes), controlling for sex, age, time between PSG and RAVLT, APOE4 status, body mass index (BMI), and years of education. One participant’s BMI was not measured and another's APOE4 status was not obtained, and thus were not included in statistical analyses that included those measures. Across all 15 models, the Benjamin-Hochberg method for False Discovery Rate (FDR) correction was used to correct multiple comparisons [ 61 ]. Regressions were repeated, substituting APOE4 status for parental history of AD.

To further understand the relative impact of OSA during REM sleep against NREM sleep on verbal memory performance, post hoc analyses included using the Steiger’s Z test to directly compare the correlation strengths of the associations between REM and NREM sleep apnea features and RAVLT scores [ 62 ]. Also, REM-NREM AHI, RDI, and ODI ratios were calculated, and the ratios were log-transformed with a constant added to meet normality assumptions. Multiple linear regression models were then used to analyze the associations between the OSA feature by sleep stage ratios and RAVLT scores while controlling for the same covariates. Regressions were repeated substituting APOE4 status for parental history of AD as a covariate.

For significant sleepstage findings, we wanted to account for the possible effects of sleep duration in that sleep stage on the significant associations between OSA features and RAVLT measures. Thus, we conducted follow-up analyses that included percent of time spent in that sleep stage in the models. Also, to disentangle whether total number of OSA events in that sleep stage or sleep duration in that sleep stage (i.e., the values that go into calculating AHI/RDI/ODI) was driving the detected effects, we conducted linear regression models with those separate measures as predictors. Total number of apnea/hypopneas, respiratory disturbances, and oxyhemoglobin desaturations during REM sleep were all log-transformed to meet assumptions of normality.

For significant associations between OSA characteristics and verbal memory, we investigated the moderating effects of sex, age, APOE4 status, and parental history of AD ( APOE4 status and parental history of AD in separate regression models) on those relationships. To further probe significant interactions with either APOE4 status or parental history of AD, we grouped participants into three groups consisting of 1) people with no APOE4 or parental history of AD, 2) people with either APOE 4 or parental history of AD, and 3) people with both APOE4 and parental history of AD. Analysis of covariance (ANCOVA) was used to analyze interactions between AD risk group and OSA features as it predicted verbal memory while controlling for the same covariates mentioned above. Slopes of the relationship between OSA features and verbal memory between the 3 groups were compared and Tukey’s method was used to correct for multiple comparison [ 63 ]. For significant interactions with age, Johnson-Neyman intervals and simple slope analyses were used to determine how much of the sample was driving the significant moderating effect [ 64 , 65 , 66 ]. All statistical analysis was conducted on JASP (Version 0.17.3) and RStudio (Version 2021.09.2).

Sample characteristics

Participant demographics and RAVLT scores of the 81 participants are shown in Table  1 . Sleep architecture and OSA characteristics are shown in Table  2 . In this sample, the average age was 61.7 ± 6.0 years (age range: 44–88 years), 60% participants were female, 32.5% of them were APOE4 carriers, 69.1% had parental history of AD, and 26.3% were both APOE4 carriers and had parental history of AD. The average time between PSG and RAVLT assessments was 0.31 ± 0.50 years. Nearly half of the cohort (44.44%) had OSA (AHI ≥ 5/h) and 16.05% had moderate or severe OSA (AHI ≥ 15/h). OSA severity was significantly higher in REM sleep than in NREM sleep (AHI: (t(80) = 7.91, p <  0.001), RDI: (t(81) = 5.11, p <  0.001), ODI: (t(81) = 9.64, p <  0.001). Remarkably, the duration spent with blood oxyhemoglobin levels < 90% did not differ significantly between REM and NREM sleep stages (1.83 ± 4.57 versus 2.55 ± 7.21, z = 0.06, p =  0.96), despite the fact that participants spent significantly more of the sleep period in NREM than in REM sleep stages (NREM:279.49 ± 57.71 min versus REM:59.80 ± 28.69 min, t(80) = 36.17, p <  0.001). This resulted in the proportion of time spent with blood oxyhemoglobin levels < 90% being significantly higher during REM than in NREM sleep stages (REM: 0.04 ± 0.11 versus NREM:0.01 ± 0.03, z = 3.68, p <  0.001).

Sex, age, APOE4 status, parental history of AD effects on OSA

Overall, male participants had more severe OSA than females (see Table S 2 ). However, females did have a significantly higher REM-NREM ODI ratio (t(79) = 2.45, p =  0.02). There were no significant associations observed between age and any OSA characteristics (all p >  0.10; see Table S 3 ). APOE4 carriers had significantly lower overall AHI, RDI, and ODI; REM AHI, as well as lower NREM AHI and ODI when compared to APOE4 non-carriers (all p <  0.05; see Table S 4 ), indicating that in this cohort, APOE4 carriers did not have greater OSA severity compared to non-carriers. There was also no significant difference in OSA characteristics among participants with and without a parental history of AD (all p >  0.30; see Table S 5 ). These findings indicate that those with higher AD risk did not show evidence of greater OSA severity in this cognitively intact cohort.

Sex, age, APOE4 status, parental history of AD effects on verbal memory

As previously reported, females had higher RAVLT scores than males (all p <  0.05; see Table S 6 ) [ 67 ]. Age and verbal memory were not significantly correlated (all p >  0.10; see Table S 7 ) and RAVLT scores did not significantly differ between APOE4 carriers and non-carriers (all p >  0.20; see Table S 8 ). Interestingly, participants with parental history of AD performed better across the RAVLT compared to those without parental history of AD (all p <  0.002; see Table S 9 ).

Associations between sleep apnea and verbal memory and total learning

Total AHI (b = -4.47, p =  0.09), RDI (b = -3.70, p =  0.17, and ODI (b = -5.17, p =  0.09) were not significantly associated with total learning. Similar results were observed when substituting APOE4 status with parental history of AD in the models. When testing OSA metrics by sleep stage, we found that REM AHI (b = -4.84, p =  0.01, FDR-corrected p =  0.07), REM RDI (b = -5.65, p =  0.01, FDR-corrected p =  0.06), and REM ODI (b = -7.91, p =  0.001, FDR-corrected p =  0.02) were all significantly associated with total learning, with REM ODI as the only significant predictor following FDR correction (Fig.  1 A-C). In the models with parental history of AD as the covariate instead of APOE4 status, REM RDI and REM ODI were significant predictors of total learning after FDR correction (all FDR-corrected p <  0.05). However, these same features in NREM sleep were not significantly associated with total learning performance after adjusting for covariates (NREM AHI: (b = -1.32, p =  0.63), NREM RDI: (b = -1.47, p =  0.56), NREM ODI: (b = -2.41, p =  0.40)). In addition, WASO, TST nadir and average oxyhemoglobin desaturation, and duration spent with < 90% blood oxyhemoglobin saturation in TST, NREM, and REM were not significantly associated with total learning (all p >  0.40; See Table S 10 for full statistical details). Similar insignificant results were found with models that included parental history of AD instead of APOE4 status (all ps > 0.30; See Table S 11 for full statistical details).

Scatter plots showing the relationships of ( A ) AHI, (B ) RDI, and ( C ) ODI during REM sleep to RAVLT total learning scores while controlling for age, sex, time between assessments, years of education, BMI, and APOE4 status

Steiger’s Z test revealed that correlations between total learning and AHI (z = 1.66, p =  0.10), RDI (z = 1.29, p =  0.20), and ODI (z = 1.51, p =  0.13) did not differ significantly between REM and NREM sleep. Although there were no significant differences in correlation strengths between REM and NREM OSA features in their associations with RAVLT total learning, the regression models indicated that REM OSA features, especially REM ODI, were significant predictors of verbal learning deficits, whereas NREM OSA features were not. Further, multiple regression models revealed that the ratios of REM-NREM AHI (b = -6.07, p =  0.01), RDI (b = -6.65, p =  0.01), and ODI (b = -7.42, p =  0.01) were significantly associated with total learning (Fig.  2 A-C; see Table S 12 ). Consistent results were found in models with parental history of AD instead of APOE4 status as the covariate (all p <  0.02; see Table S 13 ). These findings indicated that greater OSA severity during REM sleep in comparison to NREM sleep was associated with diminished total learning performance.

Scatter plots showing the relationships of REM-NREM ( A ) AHI, ( B ) RDI, and ( C ) ODI ratios to RAVLT total learning scores while controlling for age, sex, time between assessments, years of education, BMI, and APOE4 status

Associations between sleep apnea and short-delay recall

Overall AHI (b = -0.84, p =  0.27), RDI (b = -0.44, p =  0.56), and ODI (b = -0.80, p =  0.37) were not significantly related to short-delay recall. REM AHI (b = -1.38, p =  0.01, FDR-corrected p =  0.21) and REM ODI (b = -1.54, p =  0.03, FDR-corrected p =  0.23) were associated with short-delay recall but were no longer significant after FDR correction (See Table S 14 for full statistical details of all predictors). In models with parental history of AD instead of APOE4 status, REM AHI was associated with short-delay recall ( p =  0.04; FDR-corrected p =  0.48), but not after FDR correction (See Table S 15 for full statistical details of all predictors). Steiger’s Z test revealed a significant difference in the correlation strengths between short-delay recall and AHI during REM sleep versus during NREM sleep (z = 2.81, p =  0.005), demonstrating that REM AHI was more strongly associated with short-delay recall than NREM AHI. Moreover, multiple regression models indicated that REM-NREM AHI (b = -2.38, p <  0.001), RDI (b = -1.77, p =  0.02), and ODI (b = -2.02, p =  0.03) ratios were negatively associated with short-delay recall, both in models featuring APOE4 status (See Table S 16 ) and parental history of AD as covariates (all p <  0.03; See Table S 17 ). Thus, individuals with more severe sleep apnea had worse short-delay recall, particularly if OSA was more prevalent during REM sleep as opposed to during NREM sleep.

Associations between sleep apnea and long-delay recall

Total AHI, RDI, and ODI were not significantly associated with long-delay recall (all p >  0.07). However, REM AHI (b = -1.96, p =  0.001, FDR-corrected p =  0.01), REM RDI (b = -1.83, p =  0.01, FDR-corrected p =  0.04), and REM ODI (b = -2.46, p =  0.001, FDR-corrected p =  0.02) were all significantly associated with worse long-delay recall (Fig.  3 A-C). In models with parental history of AD instead of APOE4 status as the covariate, REM AHI, REM RDI, and REM ODI remained significant predictors (all FDR corrected p <  0.05). Demonstrating specificity, these same OSA parameters during NREM sleep were not significantly predictive of long-delay recall (NREM AHI (b = 0.07, p =  0.93), NREM RDI (b = -0.70, p =  0.93), NREM ODI (b = -0.08, p =  0.93). Nadir and average oxyhemoglobin desaturation during total sleep, duration spent with < 90% blood oxyhemoglobin saturation across total sleep and in NREM and REM sleep stages, and WASO were also not significant predictors (all p >  0.12; See Table S 18 for full statistical results). Similar insignificant results were found with models with NREM OSA severity predicting long-delay recall that included parental history of AD instead of APOE4 status (See Table S 19 for full statistical results).

Scatter plots showing the relationships of ( A ) AHI, ( B ) RDI, and ( C ) ODI during REM sleep to RAVLT long-delay scores while controlling for age, sex, time between assessments, years of education, BMI, and APOE4 status 

Steiger’s Z tests revealed significant differences in the correlation strengths between long-delay recall and REM AHI (z = 2.90, p =  0.004) and REM ODI (z = 2.14, p =  0.03) versus NREM features, but not in RDI (z = 1.85, p =  0.07), indicating that the frequency of events and extent of oxyhemoglobin desaturations in REM sleep were more strongly associated with long-delay recall than in NREM sleep. Further, multiple regression models showed that the ratios of REM-NREM AHI (b = -2.95, p <  0.001), RDI (b = -2.62, p =  0.001), and ODI (b = -2.94, p <  0.001) were significantly negatively associated with long-delay recall (Fig.  4 A-C; See Table S 20 ). Results from models with parental history of AD in place of APOE4 status were similar (all p <  0.003; See Table S 21 ). These results complement our initial findings by demonstrating that that worse verbal memory learning and recall performance were specifically associated with greater OSA severity during REM sleep and not during NREM sleep.

Scatter plots showing the relationships of REM-NREM ( A ) AHI, ( B ) RDI, and ( C ) ODI ratios to RAVLT long-delay scores while controlling for age, sex, time between assessments, years of education, BMI, and APOE4 status

Given the significant associations between REM OSA features and verbal memory, we wanted to account for the possible influence of percentage of REM sleep in these models. We found that even when controlling for percentage of REM sleep, REM AHI, RDI, and ODI, in addition to NREM-REM AHI, NREM-REM RDI, and NREM-REM ODI ratios were still associated with RAVLT measures (all p >  0.05; See Tables S 22 and S 23 for full statistical details). Furthermore, we probed whether total number of OSA events during REM sleep or total duration of REM sleep (i.e., the two values that go into calculating OSA indices) may be driving the significant associations between REM OSA features and verbal memory. We found that REM sleep duration was not significantly associated with RAVLT performance (all p >  0.25; see Tables S 24 and S 25 ). In contrast, total amount of apneas and hypopneas in REM sleep was associated with RAVLT total learning, short-delay, and long-delay significantly or on a trend level (all p <  0.09; See Tables S 26 and S 27 for full statistical details). Total number of respiratory-related arousals in addition to apneas/hypopneas (the total number of events in RDI) in REM sleep were also related to RAVLT total learning and long-delay recall (ps < 0.05; See Tables S 28 and S 29 for full statistical details). Lastly, total number of oxyhemoglobin desaturations during REM sleep was associated with total learning and long-delay recall (all p <  0.05; see Tables S 30 and S 31 for full statistical details). All models controlled for the same covariates with either APOE 4 status or parental history of AD. These findings suggest that the impact of OSA during REM sleep on verbal memory is more strongly associated with the OSA-related events themselves rather than their effects on REM sleep duration, per se. As a control analysis, we also analyzed whether periodic limb movement of sleep index (PMLSI) was associated with RAVLT performance. We found that there was no significant association between PLSMI and verbal memory (all p <  0.06).

The moderating effects of AD risk factors on verbal memory

Next, we examined the moderating influence of sex, age, and genetic and familial risk of AD on the significant relationships between OSA variables (i.e., OSA indices in REM sleep and REM-NREM ratios) and verbal memory. We found that APOE4 carriers demonstrated a significant association between REM-NREM ODI ratio and total learning (b = -18.17, p <  0.01) as opposed to non-carriers (b = -4.12, p =  0.17; Fig.  5 A). Full statistical details with all interactions between OSA features and AD risk factors predicting RAVLT total learning (with APOE4 status as a covariate in the models) are presented in Table S 32 . In models with parental history of AD as the covariate, age significantly moderated the association between REM ODI and total learning (b = -0.47, p <  0.05). There were significant effects at the mean age and at 1SD above the mean age (all p <  0.01; Fig.  5 B), with 80% of the sample in the significant moderating range (Figure S 1 ). Full statistical details with all interactions between OSA features and AD risk factors predicting RAVLT total learning (with parental history of AD as a covariate in the models) are presented in Table S 33 . Taken together, these findings indicate that the negative impact of oxyhemoglobin desaturations during REM sleep (relative to NREM sleep) on RAVLT total learning was more pronounced in those that were APOE4 carriers and in those aged 60 or older. Further, REM-NREM RDI ratio was significantly associated with long-delay recall in APOE4 carriers (b = -5.42, p <  0.01) but not in those without APOE4 (b = -1.67, p =  0.06; Fig.  5 C). Full statistical details with all interactions between OSA features and AD risk factors predicting long-delay recall (with APOE4 status as a covariate in the models) are presented in Table S 34 . There were no significant interactions between OSA factors and AD risk factors on long-delay recall when parental history of AD was a covariate in the models (See Table S 35 ). This suggests that the association between higher REM-NREM RDI and long-delay recall was specific to individuals with genetic risk for AD.

A The association between REM-NREM ODI ratio and RAVLT total learning scores was significantly moderated by APOE4 status. Only the APOE4 carriers showed that more oxyhemoglobin saturations during REM sleep as opposed to NREM sleep was related to worse learning performance. B The association between REM ODI and RAVLT total learning scores was moderated by age. A significant moderating effect was present at the mean age and 1 SD above the mean age (in 80% of the sample). C The association between REM-NREM RDI ratio and RAVLT long-delay recall score was moderated by APOE4 status. A significant moderating effect was observed for only APOE4 carriers in that, more respiratory events during REM sleep than in NREM sleep was associated with fewer words remembered after a 20-min delay

Lastly, we binned participants into the 3 groups based on presence or absence of APOE4 status and parental history of AD: 1) people with no AD risk factors, 2) people with either APOE4 status or parental history of AD, and 3) people with both AD risk factors. We then used ANCOVA models to examine interactions between OSA characteristics and AD risk factor groups as it related to verbal memory. In individuals with both AD risk factors, we found that higher REM RDI (b = -14.08, 95%CI:[-21.53, -6.63]), REM-NREM RDI ratio (b = -23.20, 95%CI:[-35.34, -11.06]) and REM-NREM ODI (b = -23.49, 95%CI:[-35.46, -11.51]) were significantly associated with worse total learning (See Figure S 2 and Tables S 36 -S 38 for contrast testing). Similarly, in individuals that were both APOE4 positive and had parental history of AD, higher REM-NREM RDI ratio was significantly associated with lower long-delay recall (b = -8.27, 95%CI:[-12.13, -4.42]; See Figure S 3 and Table S 39 for contrast testing results). Overall, these findings suggest that more OSA-related events in REM sleep (relative to NREM sleep) strongly impaired word list learning and recall, especially for those that had both parental and genetic risk for AD.

In this study, we assessed the relationships between OSA features and verbal memory performance of a word list, and tested the moderating effects of biological sex, age, APOE4 status, and parental history of AD on these relationships. We found that greater OSA severity during REM sleep was associated with worse word list learning and delay memory recall in a cohort of cognitively unimpaired middle- and older- aged adults enriched for AD risk. Additionally, more oxyhemoglobin desaturations during REM sleep versus NREM sleep were associated with worse learning performance, specifically in those that were older than 60 years old and APOE4 carriers. Further, more respiratory events and arousals during REM sleep, as opposed to during NREM sleep, had a greater negative impact on recall performance for those who were APOE4 carriers. The negative effects of OSA during REM sleep, specifically respiratory disturbances and oxyhemoglobin desaturations, on verbal memory seemed to be most prominent in those that had a parent with AD and was an APOE4 carrier. Since AD risk factors (e.g., female sex, older age, or genetic or familial risk) were not associated with more severe OSA in this current study, these findings were not simply driven by increased OSA severity in individuals with AD risk factors. Though it is possible this could be related to lower survival from conversion to mild cognitive impairment (MCI) or AD in older adults with AD risk and more severe OSA [ 9 , 21 , 68 , 69 ]. That being said, our results support the hypothesis that the memory consequences of OSA are particularly important for cognitively intact older adults with AD risk factors (older age, APOE4 positivity, and parental history of AD), particularly when OSA events occur during REM sleep.

OSA predominantly expressed in REM sleep is a common condition and REM-sleep related physiological changes lead to increased susceptibility to airway collapse, with longer durations of apneas and hypopneas and more severe oxyhemoglobin desaturations [ 19 , 20 , 53 , 70 ]. This is consistent with our findings that demonstrated higher AHI, RDI, and ODI scores during REM sleep relative to NREM sleep and extends the current literature by demonstrating that OSA events in REM sleep were more strongly linked with verbal memory performance than OSA events in NREM sleep. However, future investigations comparing samples enriched for more severe REM or NREM OSA are needed to determine whether it is specifically REM OSA severity that negatively impacts verbal memory performance.

REM OSA may impact verbal memory learning and recall via active disruption of memory processing or through long-term damage to brain structures and brain network function relevant for memory processing during REM sleep. While considerable attention has been given to the role of NREM sleep features in memory processing [ 71 ], there is evidence that REM sleep also supports memory. Neuroplastic processes needed for both memory consolidation and forgetting has been observed during REM sleep, in addition, hippocampal replay also occurs during this sleep stage [ 72 , 73 ]. Further, behaviorally, REM sleep has been linked to both emotional and spatial navigational memory [ 74 ]. Metabolic demand is also greater during REM sleep as opposed to wake and NREM sleep, including in memory-relevant regions, such as the MTL [ 17 , 18 ]. Therefore, OSA events in REM sleep could potentially cause memory deficits through both 1) transient disruptions in cerebral glucose metabolism in memory networks actively supporting memory processing during REM sleep and 2) long term degeneration of memory networks resultant from the presence of repeated hypoxia during high metabolic demand.

Varga and colleagues demonstrated the acute cognitive consequences of REM OSA in which they found that when withdrawing positive airway pressure (PAP) treatment specifically during REM sleep, spatial memory performance was reduced when compared to continued PAP treatment during REM sleep [ 16 ]. Although, the impact of withdrawing treatment during NREM sleep was not assessed, these findings indicated that REM OSA could cause transient MTL dysfunction by actively disrupting memory formation and consolidation even prior to neurodegenerative processes.

The effects of intermittent hypoxemia during OSA is a likely contributor to the hippocampal atrophy reported in people with OSA and explains memory impairments observed in OSA [ 5 , 6 , 7 , 8 , 9 , 13 , 14 ]. A possible mechanism of OSA’s impact on the hippocampus is through the presence of AD pathologies, with evidence supporting that hypoxemia exacerbates expression of both β-amyloid and tau that will in turn cause neurodegeneration and cognitive deficits [ 75 , 76 , 77 ]. Another potential mechanism is that hypoxia and sleep fragmentation specifically in REM sleep could accelerate neurodegeneration and cognitive decline via a vascular pathway [ 54 , 55 , 56 , 78 , 79 ]. REM sleep is characterized by increased sympathetic activation, decreased vagal tone, and cardiovascular instability, and REM OSA has been linked to poor cardiovascular health [ 20 , 54 , 55 , 56 ]. While REM sleep has shown to have high cerebral blood flow in memory-relevant brain areas, REM OSA severity has also been associated with reduced regional cerebral blood flow in those regions [ 78 , 79 ]. In addition, older adults with cardiovascular risk factors were more likely to have memory deficits [ 80 ]. Thus, it is possible that the compounded effects of REM OSA and vascular dysfunction greatly increases oxidative stress, neuroinflammation, blood brain barrier breakdown, and/or endothelial dysfunction causing neurodegenerative-associated memory deficits in older adults [ 20 , 77 ].

We found that AD risk factors including older age and both parental and genetic risk for AD all exacerbated the effect of OSA severity during REM sleep on word list learning and recall. While it has been reported that the associations between OSA and cognition are weaker in older age, our findings suggested in contrast, that the relationship between oxygen desaturations in REM sleep and verbal memory were actually strongest in older individuals [ 9 ]. As our cohort consisted of individuals with undiagnosed OSA and we are unaware of the true age of OSA onset, it is quite possible that some of the older participants may have had untreated OSA longer than the younger participants. We thus cannot discount that our findings may be more related to the consequences of the duration of untreated OSA than age of OSA onset, per se.

While it is remains unclear whether APOE4 status increases risk for SDB, our findings suggest that APOE4 carriers may be more vulnerable to the impact of OSA, especially during REM sleep, on memory function. Other studies have reported similar findings in that, in APOE4 carriers, OSA severity was associated with worse memory and executive function and had increased odds of cognitive decline [ 25 , 81 , 82 , 83 ]. Furthermore, disrupted sleep and APOE4 status may synergistically exacerbate expression of hallmark AD pathologies of β-amyloid and tau [ 84 , 85 ].

The combined effects of parental history of AD and APOE4 positivity has shown to have strong negative effects on learning and memory [ 86 , 87 ]. In addition, older age, family history of AD, and APOE4 status have been linked to a smaller hippocampus and greater accumulation of pathological β-amyloid and tau [ 88 , 89 ]. Moreover, in a subset of this cohort, we found that increasing age was related to elevated cerebral spinal fluid (CSF) markers of tau phosphorylation and neuroinflammation, which were then associated with impaired sleep-dependent memory [ 43 ]. This points to the possibility that accumulation of AD pathologies might be intensified by REM-related OSA leading to poor memory function, with the effects strongest or even just specific to those that are older and with parental and/or genetic risk for AD. Alternatively, REM OSA may contribute to cognitive impairment through cerebrovascular disease, and may be a factor to the common comorbidity of AD and vascular cognitive impairment [ 90 ]. Prospective studies will be necessary to investigate whether REM OSA accelerates expression of AD pathologies or promotes cognitive impairment through cerebrovascular dysfunction, or both, as well as why individuals with AD risk factors and OSA may be more cognitively impaired.

We did not find sex-specific effects in the associations between OSA and memory. In this specific cohort, males presented with more severe NREM and REM OSA, and had worse verbal memory performance than females. The lack of a sex effect could be due to a cognitively healthy sample that included females with a less severe OSA presentation. While females have increased risk for AD and present with greater levels of pathological tau in regions associated with AD compared to males, it is possible that the negative effects of OSA on verbal memory performance may be more exaggerated only once women are tau and/or β-amyloid positive, due to the female verbal memory advantage [ 28 , 29 , 67 , 91 , 92 ]. This verbal memory advantage tends to be diminished when women progress from MCI to AD who present with steeper memory decline than men [ 30 ]. In support of this possibility, the average age of this cohort was < 65 years old and in a subsample of 58 participants from this cohort, they were almost entirely β-amyloid and tau negative (based on CSF assessment) [ 43 ]. Future studies are needed that combine multimodal neuroimaging, sleep apnea testing, and other cognitive measures, to examine this in more detail. Regardless, it is important to state that despite the cohort being largely β-amyloid and tau negative, AD risk still remained a significant moderator of OSA-memory relationships, indicating that these effects cannot be entirely explained by and may even precede β-amyloid positivity, despite recent findings [ 26 ].

Some limitations of this study should be addressed. This was a cross-sectional study that found correlational relationships between OSA characteristics during REM sleep and verbal memory. Longitudinal studies will be necessary to examine how treatment of REM-related OSA would affect memory decline and progression to MCI or AD. Given the study sample size and number of analyses computed, it is possible that the study was underpowered to detect some significant associations. However, the focus of the current study was to contrast the relative strengths of associations between OSA features and memory when events occurred during NREM or REM sleep. While we think these effects are likely robust, it will be important to replicate these findings in a larger study. Further, the memory testing and sleep measurements did not typically occur on the same day. While we controlled for time between measurements, this study does not directly address memory processing that occurs over a night of sleep, but rather informs upon sleep abnormalities and memory associations at the trait level of individual differences. Another limitation is that this study had exclusions of multiple medications that are commonly taken by older adults, which could potentially bias the sample and reduce the generalizability of the results. It is also important to note that this cohort was mostly White (88%) and that these findings may not be generalizable, since racial/ethnic disparities and differences exist for both OSA and AD risk factors and the relationships between these risk factors are not well studied in underrepresented populations [ 93 , 94 ].

Our findings further support the possibility that OSA could be a modifiable risk factor for AD through its impact on one of the more sensitive markers of AD, impairment in word list learning and recall. A future direction is to extend our analyses to examine OSA’s relationship with other cognitive measures that are impaired in AD, including verbal memory of stories, nonverbal memory, and executive function. This will further elucidate OSA as a contributor to AD and provide further support that treatment may reduce risk for cognitive decline [ 9 ]. There is some evidence that continuous positive airway pressure (CPAP) adherence decreases the odds of AD dementia and slowed cognitive decline [ 95 , 96 , 97 ]. Importantly, a systematic review reported that PAP treatment adherence only covers mostly the first half of the night, which could potentially leave much of REM sleep OSA untreated, since REM sleep dominates the latter half of the night [ 98 ]. It will be critical for future investigations to examine whether more aggressive OSA treatment that covers the entire sleep period would mitigate cognitive impairment and AD risk in individuals with OSA. With growth of the aging population, there is a need for interventions targeting prevention of MCI and AD, and early diagnosis and effective treatment of OSA may be one approach that could reduce risk for neurodegenerative diseases and cognitive dysfunction associated with AD.

In conclusion, these findings suggest that more severe OSA during REM sleep and more REM OSA events as opposed to NREM OSA events were linked to worse verbal memory performance. This relationship was particularly true for older adults and individuals with a genetic risk for and parental history of AD. This suggests that the negative memory consequences of OSA, specifically when OSA events occur during REM sleep, are particularly impactful in individuals with multiple AD risk factors. The findings emphasize the importance of a thorough OSA screening with sleep recording capable of assessing sleep stage specific expression of OSA, as certain individuals may have high REM AHI, while presenting with a low overall AHI. This is particularly important given that most ambulatory, non-PSG methods for assessing OSA do not include the capacity to assess REM versus NREM sleep specific OSA expression. Without sleep stage characterization of OSA, individuals that are more susceptible to memory decline, especially those with AD risk factors, may miss the opportunity to be referred for comprehensive neurological/neuropsychological evaluation and aggressive OSA treatment that may delay cognitive decline and/or AD onset.

Availability of data and materials

The data are available upon reasonable request and can be obtained by completing a Wisconsin Alzheimer’s Disease Research Center resource request: https://www.adrc.wisc.edu/apply-resources .

Abbreviations

Alzheimer’s disease

Alzheimer’s Disease Research Center

Apnea–hypopnea Index

Analysis of covariance

Apolipoprotein E ε4

Body mass index

Continuous Positive Airway Pressure

Cerebral spinal fluid

False Discovery Rate

High-density electroencephalography

Mild cognitive impairment

Medial temporal lobe

Non-rapid eye movement

Oxyhemoglobin Desaturation Index

Obstructive Sleep Apnea

Positive airway pressure

Periodic leg movements during sleep index

Rey Auditory Verbal Learning Test

Respiratory Disturbance Index

Rapid eye movement

Sleep Disordered Breathing

Total sleep time

Time in bed

Wake after sleep onset

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Acknowledgements

We would like to thank the research participants and staff of the Wisconsin ADRC and Wisconsin Sleep for their contributions to the study.

This research was supported by grants R56 AG052698, R01 AG027161, R01 AG021155, ADRC P50 AG033514, R01 AG037639, K01 AG068353, and National Research Service Award F31 AG048732 from the National Institute on Aging, and by the Clinical and Translational Science Award (CTSA) program, through the NIH National Center for Advancing Translational Sciences (NCATS), grant UL1TR000427.

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Kitty K. Lui

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Kitty K. Lui, Abhishek Dave, Bryce A. Mander & Ruth M. Benca

Department of Cognitive Sciences, University of California, Irvine, CA, USA

Abhishek Dave & Bryce A. Mander

Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA

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Contributions

K.K.L analyzed the data and wrote the manuscript. A.D. and M.G.C. aided in analyzing the data and writing the manuscript. K.E.S. conducted the experiments, overseeing sleep data collection as part of her dissertation, and aided in data analysis and writing the manuscript. B.A.R. aided in sleep study data collection, provided data analytic tools, and aided in manuscript preparation. M.H. aided in collection and analysis of demographic, and neuropsychological data. C.T. aided in data collection. C.M.C., O.C.O., S.A., and S.C.J. aided data collection, neuropsychological screening, and manuscript preparation. B.B.B. aided study design, provided the subject pool, and aided in data analysis and manuscript preparation. R.M.B. designed the study, oversaw clinical sleep screening procedures, aided in data collection and analysis, and aided writing the manuscript. Lastly, B.A.M. aided in data analysis and writing the manuscript.

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Dr. Mander has served as a consultant for Eisai Co., Ltd. Dr. Benca has served as a consultant for Eisai, Genomind, Idorsia, Jazz, Merck, and Sunovion. Dr. Riedner has several patents related to sleep technology jointly held by the Wisconsin Alumni Research Foundation and Philips Healthcare, and in addition to grant support, has given several lectures sponsored by Philips Healthcare.

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Lui, K.K., Dave, A., Sprecher, K.E. et al. Older adults at greater risk for Alzheimer’s disease show stronger associations between sleep apnea severity in REM sleep and verbal memory. Alz Res Therapy 16 , 102 (2024). https://doi.org/10.1186/s13195-024-01446-3

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Public and Research Interest in Telemedicine From 2017 to 2022: Infodemiology Study of Google Trends Data and Bibliometric Analysis of Scientific Literature

Authors of this article:

Original Paper

• Andrea Maugeri 1 , PhD   ; 
• Martina Barchitta 1 , PhD   ; 
• Guido Basile 2 , MD   ; 
• Antonella Agodi 1 , PhD  

1 Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, Catania, Italy

2 Department of General Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy

Corresponding Author:

Antonella Agodi, PhD

Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”

University of Catania

Via Santa Sofia 87

Catania, 95123

Phone: 39 0953792183

Email: [email protected]

Background: Telemedicine offers a multitude of potential advantages, such as enhanced health care accessibility, cost reduction, and improved patient outcomes. The significance of telemedicine has been underscored by the COVID-19 pandemic, as it plays a crucial role in maintaining uninterrupted care while minimizing the risk of viral exposure. However, the adoption and implementation of telemedicine have been relatively sluggish in certain areas. Assessing the level of interest in telemedicine can provide valuable insights into areas that require enhancement.

Objective: The aim of this study is to provide a comprehensive analysis of the level of public and research interest in telemedicine from 2017 to 2022 and also consider any potential impact of the COVID-19 pandemic.

Methods: Google Trends data were retrieved using the search topics “telemedicine” or “e-health” to assess public interest, geographic distribution, and trends through a joinpoint regression analysis. Bibliographic data from Scopus were used to chart publications referencing the terms “telemedicine” or “eHealth” (in the title, abstract, and keywords) in terms of scientific production, key countries, and prominent keywords, as well as collaboration and co-occurrence networks.

Results: Worldwide, telemedicine generated higher mean public interest (relative search volume=26.3%) compared to eHealth (relative search volume=17.6%). Interest in telemedicine remained stable until January 2020, experienced a sudden surge (monthly percent change=95.7%) peaking in April 2020, followed by a decline (monthly percent change=–22.7%) until August 2020, and then returned to stability. A similar trend was noted in the public interest regarding eHealth. Chile, Australia, Canada, and the United States had the greatest public interest in telemedicine. In these countries, moderate to strong correlations were evident between Google Trends and COVID-19 data (ie, new cases, new deaths, and hospitalized patients). Examining 19,539 original medical articles in the Scopus database unveiled a substantial rise in telemedicine-related publications, showing a total increase of 201.5% from 2017 to 2022 and an average annual growth rate of 24.7%. The most significant surge occurred between 2019 and 2020. Notably, the majority of the publications originated from a single country, with 20.8% involving international coauthorships. As the most productive country, the United States led a cluster that included Canada and Australia as well. European, Asian, and Latin American countries made up the remaining 3 clusters. The co-occurrence network categorized prevalent keywords into 2 clusters, the first cluster primarily focused on applying eHealth, mobile health (mHealth), or digital health to noncommunicable or chronic diseases; the second cluster was centered around the application of telemedicine and telehealth within the context of the COVID-19 pandemic.

Conclusions: Our analysis of search and bibliographic data over time and across regions allows us to gauge the interest in this topic, offer evidence regarding potential applications, and pinpoint areas for additional research and awareness-raising initiatives.

Introduction

The concept of telemedicine—defined as the use of technology to provide health care services remotely—has been around since the early 20th century, but it has gained significant attention globally only in recent years [ 1 ]. The development of technology such as videoconferencing, remote monitoring devices, and mobile health apps has made it possible to deliver health care services remotely, paving the way for the widespread adoption of telemedicine [ 2 - 4 ]. It is worth noting that the term telemedicine also covers health data analysis and the application of big data and artificial intelligence methods for epidemiological research and diagnosis support [ 3 , 5 - 7 ].

The use of technology allows patients to access care from anywhere, at any time and reduces the need for in-person visits, which can be particularly beneficial for individuals with mobility issues, those living in rural or remote areas, and individuals with chronic diseases [ 8 , 9 ]. The potential benefits of telemedicine are numerous, including increased access to health care services, reduced health care costs, and improved patient outcomes [ 8 - 11 ]. Telemedicine can also help to address workforce shortages in health care, particularly in rural and remote areas, by enabling health care providers to deliver care to patients in those regions without the need for travel [ 10 , 12 ].

The COVID-19 pandemic has underscored the significance of telemedicine in maintaining uninterrupted health care delivery while mitigating the risk of virus transmission [ 13 - 18 ]. As an illustration, in light of the imperative to reduce COVID-19 exposure among patients and health care providers, many elective surgical procedures were rescheduled, prompting surgeons to adopt telemedicine as an alternative for preoperative, follow-up, and urgent surgical care consultations [ 15 , 19 ]. The pandemic has therefore forced health care providers to adapt quickly to the new reality of delivering care remotely, leading to a significant increase in the adoption and use of telemedicine globally [ 3 , 20 ]. As demand grew exponentially during the pandemic period, even the telehealth market is expected to grow to US $218.5 billion by 2025 [ 3 ]. Nevertheless, even after the COVID-19 pandemic recedes, it is highly improbable that this mode of health care delivery will be disregarded.

Despite the potential benefits of telemedicine, its adoption and implementation have been slow in some regions. Barriers to adoption include regulatory challenges, technological limitations, and resistance from health care providers and patients. People living in poorer regions, women, the elderly, and those living in rural or remote areas are far less likely to be online than those in wealthier regions [ 1 , 11 ]. Of those connected, nearly 90% use mobile devices to access the internet, which might not be appropriate for delivering digital health services [ 3 ]. A digital divide also exists in terms of digital literacy or low skills, which is a concern for the poorest, elderly, and others with limited access to technology [ 3 ]. For these reasons, understanding the level of interest in telemedicine among the public and research community can help identify areas for improvement. Google Trends is a valuable tool for investigating the level of interest of the general public in a specific topic. As such, it has been used in previous research to analyze the public’s interest in various health and health care–related subjects [ 21 - 32 ]. The same applies to a topic such as telemedicine, for which there is little evidence. From a research standpoint, we have recently observed a significant increase in the number of publications related to telemedicine, indicating a growing interest in this field among researchers. An interest that needs to be mapped in terms of scientists and groups of researchers, countries that are contributing most to the research, and areas of applications.

Overall, this study aims to provide a comprehensive analysis of the level of public and research interest in telemedicine, also consider any potential impact of the COVID-19 pandemic. We therefore limit our analysis to the period between 2017 and 2022, a period of 6 years preceding and following the pandemic. We use 2 different approaches to analyze the level of interest in telemedicine. The first approach is an analysis of Google Trends data, which allows us to analyze the level of interest in telemedicine among the general public. The second approach is a bibliometric data analysis, which involves examining publications related to telemedicine over the past 6 years. Our analysis of search and bibliographic data over time and across regions helps us understand the level of interest in this topic, identify areas for further research and awareness-raising efforts, and inform policy decisions regarding telemedicine adoption and implementation.

Data Collection

Google trends data.

Google Trends provides open access to time-series data related to Google searches for specific terms and topics [ 33 ]. According to the framework proposed by Mavragani and Ochoa [ 34 ], we retrieved Google Trends data separately by using the search topics “telemedicine” or “e-health,” encompassing all search categories. We queried Google Trends on March 9, 2023, and Google Trends data were obtained at the global level, as well as by country, for the period between January 1, 2017, and December 31, 2022. It is worth mentioning that search topics are a group of terms that share the same concept across languages, covering an array of variations, typos, and related searches [ 34 , 35 ]. This precludes the need to enter a set of individual keywords, while maintaining the consistency of search queries across all regions and timeframes [ 34 , 35 ]. Furthermore, using specific search topics without any search category restrictions proves beneficial for capturing the general interest of diverse populations [ 34 , 35 ]. We also obtained data for the “top related topics” that are most frequently searched with the topics under investigation (ie, telemedicine” or “e-health”).

In general, Google Trends data are provided as a normalized measure (ie, relative search volume [RSV]), obtained by dividing the search volume for a given term or topic by the total number of searches. This normalization process resulted in a percentage scale, with 100% corresponding to the peak in search volume in any given time frame and location. The value 0% does not necessarily indicate no searches, but rather a very low search volume for a given term or topic [ 34 ].

Bibliometric Data

Before describing the collection of bibliometric data, it is necessary to distinguish bibliometric analysis from reviews and systematic reviews of scientific literature. The first primarily uses a mechanistic method to track the global research trends in a certain field based on the outputs of scientific literature databases. Reviews and systematic reviews are instead characterized by methodical and replicable methodologies to find, select, and synthesize all available evidence on a particular topic or clinical question.

In our study, we searched the Scopus database for all articles mentioning the terms “telemedicine” or “eHealth” in the title, abstract, and keywords. We have chosen Scopus because it is recognized as the largest scientific literature database of peer-reviewed articles covering a wide range of subjects [ 36 ]. The literature search was conducted on 9th March 2023 and was limited to original articles published in English and in the subject area of medicine from 2017 to 2022. The query string used for the search was: TITLE-ABS-KEY (“telemedicine” OR “eHealth” ) AND PUBYEAR > 2016 AND PUBYEAR < 2023 AND ( LIMIT-TO ( DOCTYPE , “ar” ) ) AND ( LIMIT-TO ( LANGUAGE , “English” ) ) AND ( LIMIT-TO ( SUBJAREA , “MEDI” ) ). The Scopus search result was exported in the format of a CSV file with all data elements, including information on citation, bibliography, abstract, and keywords.

Data Analysis

Google trends data analysis.

We first conducted a univariate analysis and compared the public interest on the topics of telemedicine and eHealth at the global level. Next, a joinpoint regression analysis was carried out to identify possible time points at which public interest trends changed. This analysis was conducted on log-transformed RSV, with 5000 permutations and assuming uncorrelated errors. The grid search method was chosen to determine where to locate joinpoints on the timescale [ 37 ]. Results were reported as the monthly percent change (MPC), calculated as the average percentage change per month between different joinpoints. Joinpoint regression analysis was performed using the Joinpoint Regression Program (version 4.3.1.0; Statistical Research and Applications Branch, National Cancer Institute) provided by the Surveillance, Epidemiology, and End Results Program (National Cancer Institute) on the website. We next mapped the public interest in telemedicine and eHealth by country, selecting the top 5 countries with the greatest interest. In these countries, Google Trends data were correlated with the number of new confirmed COVID-19 cases, deaths, hospitalizations, and patients in the intensive care unit per million residents. These data were obtained from the Our World in Data website [ 38 ]. Results were reported as the Spearman rank correlation coefficient (ρ). All statistical analyses were 2-tailed and performed with a significance level of 0.05.

Descriptive Analysis of Bibliometric Data

Descriptive analysis of bibliometric data was performed using Bibliometrix (K-Synth), an open-source R-tool for automating the stages of data analysis and data visualization [ 39 ]. After loading and converting bibliometric data in R (R Core Team), the main descriptive results were summarized as the number of documents, authors, sources, keywords, timespan, and average number of citations. Accordingly, tables and visualizations were obtained for the annual scientific production, top articles per number of citations, most productive authors, most productive countries, total citations per country, most relevant journals, and most relevant keywords.

Network Analysis of Bibliometric Data

Next, the VOSviewer software (version 1.6.16; Centre for Science and Technology Studies, Leiden University) was used to construct networks projecting authors’ and countries’ collaborations, as well as trending research topics through the analysis of keywords. This mapping method is generally used to estimate the association strength between different bibliometric items (ie, the nodes of the network), which may for example be publications, authors, or keywords [ 40 ]. The relation between 2 items is represented by a link (ie, the edges of the network), which may be a bibliographic coupling link between publications, a coauthorship link between authors, or a co-occurrence link between keywords. Each link has a strength, indicated by a positive number with higher values associated with stronger links [ 40 ]. The association strength may for example be indicated as the number of cited references 2 publications have in common for the bibliographic coupling link; as the number of publications 2 authors have coauthored for the coauthorship links; or as the number of publications in which 2 keywords occur together for the co-occurrence link [ 40 ]. Accordingly, each item receives different attributes, such as the weight and score attributes. Weight is a nonnegative numerical attribute indicating the importance of the item in the network. From a graphical perspective, items with higher weights are shown more prominently than those with lower weights [ 40 ]. Score attributes instead indicate additional numerical properties of the item, which can be only visualized in the overlay visualization of a map. There are also 2 standard weight attributes that can be used for descriptive purposes and computed for each item or the entire network, the links attribute and the total link strength attribute [ 40 ]. By creating the network map, items can be grouped into clusters, which correspond to linked items, labeled with colors and numbers.

We first performed network analyses of coauthorship at the author and country level, using the fractional method to reduce the influence of documents with many authors. With this approach, the strength of a coauthorship between 2 authors is determined considering the number of documents coauthored normalized for the total number of authors of each coauthored document. At the author level, we included authors who have published at least 20 articles on the topic, with no restrictions on the number of citations. At the country level, we included the first 50 countries with the greatest number of articles, with no restrictions on the number of citations. To identify research areas of greatest interest and their connections, we also applied a co-occurrence analysis of author keywords occurring more than 50 times.

Public Interest Over Time

Globally, the mean public interest in telemedicine and eHealth—expressed as RSV—was 26.3% (SD 18.1%) and 17.6% (SD 8.8%), respectively. The greater interest in telemedicine rather than in eHealth is evident from Figure 1 , which shows RSVs from January 2017 to December 2022. According to the above figure, public interest in both topics was stable before the COVID-19 pandemic and then increased rapidly for telemedicine and more gradually for eHealth. Based on the joinpoint regression analysis (Figure S1 in Multimedia Appendix 1 ), public interest in telemedicine was stable until January 2020 (MPC=0.36%), which corresponded to the first joinpoint (37th month of the time series; 95% CI 36-38). Then, public interest suddenly increased (MPC=95.7%) to the highest peak reached in April 2020, which was the second joinpoint detected in the 40th month of the time series (95% CI 39-41). From that point on, public interest decreased (MPC=–22.7%) until August 2020 (ie, the third joinpoint on the 44th month; 95% CI 42-48) and then returned to being stable (MPC=–0.14%). Similarly, public interest in eHealth was stable until January 2020 (MPC=0.34%), which again was the first joinpoint of the time series (37th month; 95% CI 32-43). From that point on, public interest gradually increased (MPC=5.5%) to the highest peak reached in January 2022, which corresponded to the second joinpoint detected in the 61st month of the time series (95% CI 46-63). Then, public interest rapidly decreased (MPC=–20.1%) until May 2022 (ie, the third joinpoint on the 65th month; 95% CI 58-67) and then returned to being almost stable (MPC=1.8%).

Geographic Distribution of Public Interest and Correlations With COVID-19 Data

The map in Figure 2 shows the geographic distribution of public interest in telemedicine from 2017 to 2022. The top 5 countries were Chile, Australia, Canada, the United States, and Puerto Rico (Figure S2 in Multimedia Appendix 1 ). Public interest in eHealth was less widespread (Figure S3 in Multimedia Appendix 1 ), therefore we have not considered this topic for further analyses. For those countries included in the top 5, we evaluated correlations between the RSV for telemedicine and COVID-19 data per million residents. Public interest in Chile was strongly correlated with the number of new cases (ρ=0.718; P <.001), and weakly with the number of new deaths (ρ=0.321; P =.006). In Australia, public interest moderately correlated with the number of new cases (ρ=0.537; P <.001), new deaths (ρ=0.505; P <.001), hospitalized cases (ρ=0.559; P <.001), and patients in the intensive care unit (ρ=0.483; P <.001). Public interest in Canada was weakly correlated with the number of new cases (ρ=0.265; P =.001) and deaths (ρ=0.333; P <.001). In the United States, public interest was weakly correlated with the number of new deaths (ρ=0.295; P <.001). No correlations were evident for the public interest in Puerto Rico.

Common Topics Related to Telemedicine

Despite the considerable impact of the pandemic on the public interest in telemedicine, there were few COVID-19-related topics among those that were commonly searched with telemedicine (Figure S4 in Multimedia Appendix 1 ). In particular, Google users interested in telemedicine mainly searched for general topics including health, physician, health care, medicine, and therapy. Moreover, there were some common topics related to specific telemedicine providers (eg, “Telehealth Ontario,” “Medicare,” “Santa Catarina,” “Cigna,” and “CVS Pharmacy”).

Description of Bibliometric Data

We identified 19,539 original medical articles published in English and indexed in the Scopus database from 2017 to 2022. These articles were published by 2824 different sources (eg, journals and books), with a document average age of 2.8 years. Notably, the first 2 sources (JMIR and Telemedicine and eHealth) published a number of articles that were nearly 40% of the sum of the first 10 sources (Table S1 in Multimedia Appendix 1 ). The overall average number of citations per document was 11.2, while the average number of citations per document and per year was 2.6. The top 10 articles per citation are reported in Table S2 in Multimedia Appendix 1 , their total citations ranged from 506 to 999, while their total citations per year ranged from 121 to 221. A total of 553,913 references were found in the bibliometric analysis of all the articles. The top 10 cited references are reported in Table S3 in Multimedia Appendix 1 , with total citations ranging from 70 to 161.

Research Interest Over Time

Our analysis of the bibliometric data also revealed a significant increase in the number of publications related to telemedicine over the past 6 years ( Figure 3 A). The number of publications per year increased from 1615 in 2017 to 4870 in 2022, showing an overall increase of 201.5% and an annual average growth rate of 24.7%. The greatest increase has been reported between 2019 and 2020, with an annual growth rate of 89.0%. Regarding citations, the average total citations per year decreased from 2017 to 2022 ( Figure 3 B), probably as a consequence of different document ages. By contrast, the average article citations per year were stable from 2017 to 2019, followed by a peak in 2020, and then decreased until 2022 ( Figure 3 C).

Most Productive Authors and Coauthorship Network

Among the included articles, 93,394 authors were appearing 136,956 times overall. In particular, there were 690 single-authored documents written by 642 independent authors. Accordingly, the number of documents per author was 0.2, while the number of coauthors per document was 7.0. Table S4 in Multimedia Appendix 1 shows the list of the 10 most productive authors in terms of total and fractionalized articles. Their contribution to the field ranged from 48 to 80 articles (7.2 to 10.0 fractionalized articles). In Figure 4 it is shown that 71 of the authors who published at least 20 documents (n=80) were well connected. There were 488 links between these authors—which were grouped into 7 clusters—with a total link strength of 988.

Most Contributing Countries and International Collaboration Network

The majority of publications came from a single country, while 20.8% featured international coauthorships. Table 1 shows the top 10 corresponding author’s countries per document, also considering differences between single-country and multiple-country publications. One thing to note was that the United States alone published almost the same number of articles as the other 9 (6610 vs 6653), representing 33.8% of all articles analyzed. Countries with the highest proportion of multiple-country publications were Germany (31.5%), the United Kingdom (27.9%), and the Netherlands (26.8%); those with the lowest proportion were the United States (11.4%), India (20.3%), and Italy (22.5%). Similar results were evident in terms of citations, with average citations per document ranging from 8.9 for Spain to 15.2 for India (Table S5 in Multimedia Appendix 1 ).

The coauthorship network based on the top 50 most contributing countries is illustrated in Figure 5 . Overall, there were 1051 links with a total link strength of 14,751. Accordingly, countries were divided into 4 clusters. Cluster 1 consisted exclusively of European countries (n=21) with the United Kingdom, Germany, and Italy being the most interconnected; cluster 2 consisted of Asian countries (n=18) led by India and China; cluster 3 consisted of 6 countries, with the United States, Canada, and Australia being the most interconnected; and cluster 4 consisted of 5 countries of Latin America (ie, Brazil, Argentina, Chile, Colombia, and Mexico).

Most Relevant Keywords and Co-Occurrence Network

Overall, 22,798 author’s keywords were found among the included studies. Based on the analysis of the most common keywords, COVID-19-related terms appear in the top 10 (Table S6 in Multimedia Appendix 1 ). In particular, this ranking put “COVID-19” and “pandemic,” respectively, in the 2nd and 8th place. In addition to common terms related to telemedicine (eg, telehealth, eHealth, and mobile health [mHealth]), the analysis also revealed mental health as an area of relevant interest.

The co-occurrence network based on the top 50 most common keywords is illustrated in Figure 6 . Overall, there were 1030 links with a total link strength of 21,275. Accordingly, keywords were divided into 2 clusters. Cluster 1 seemed mostly related to the application of eHealth, mHealth, or digital health to noncommunicable or chronic diseases (eg, diabetes, hypertension, depression, and anxiety) and cluster 2 was instead related to the application of telemedicine and telehealth in the context of the COVID-19 pandemic.

Principal Results and Comparison With Prior Work

Our research highlights the increasing interest in telemedicine among the general public and researchers, particularly in response to the COVID-19 pandemic. Even prior to the outbreak, telemedicine had already demonstrated significant potential across various health care sectors. It offered a practical solution for delivering remote consultations, conducting preoperative evaluations, and facilitating postoperative follow-ups, particularly for patients residing in remote or underserved areas [ 9 , 19 ]. Although telemedicine comes with numerous advantages, it also presents certain drawbacks. For example, it may prove unsuitable for emergency situations requiring immediate hands-on medical attention, necessitating traditional, in-person emergency care [ 41 ]. Additionally, specific diagnostic procedures, like imaging or laboratory tests, may demand specialized equipment unavailable in a patient’s home, potentially impacting diagnostic accuracy [ 42 ]. Furthermore, not all individuals have access to the requisite technology for telemedicine consultations, such as a reliable internet connection, a suitable device, or the technical skills for virtual appointments [ 43 ]. This discrepancy in access can result in health care disparities. Finally, telemedicine involves transmitting sensitive health information over digital networks, posing challenges in ensuring the privacy and security of patient data and carrying a risk of data breaches or unauthorized access [ 43 ].

Despite these advantages and disadvantages, the pandemic served as a catalyst for the widespread adoption and acceptance of telemedicine [ 14 , 15 , 18 ]. Notably, telemedicine has garnered increased attention, especially in the aftermath of the COVID-19 pandemic, where its significance became evident due to the implementation of social distancing measures. However, limited studies have explored the population-level interest in telemedicine, as measured by tools such as Google Trends. Some of these studies are summarized in Table S7 in Multimedia Appendix 1 [ 44 - 51 ]. To the best of our knowledge, our study provides the most recent and comprehensive analysis in this field, shedding light on the level of interest among both the general public and researchers. An example of the use of infodemiological methods to explore global interest in telemedicine during the COVID-19 pandemic can be seen in the study conducted by Leochico et al [ 51 ] in 2020. Their study revealed a significant surge in online searches for telemedicine and related terms after the outbreak of the pandemic [ 51 ]. Extending the analysis period until the end of 2022, our study showed that while the level of public interest in telemedicine experienced a significant increase from January to April 2020, it later declined until August 2020 and eventually stabilized. Nevertheless, public interest has remained slightly higher compared to the pre-pandemic period. This finding is consistent with the results of a Google Trends analysis conducted by Wong et al [ 47 ] on the 50 countries most affected by the COVID-19 pandemic until July 2020. According to our findings, Chile, Australia, Canada, and the United States demonstrated the highest levels of public interest in telemedicine. In these countries, we observed moderate to strong correlations between Google Trends and COVID-19 data, including new cases and deaths, as well as hospitalizations. This finding is consistent with the results reported by Arshad Ali et al [ 45 ], who found a significant global correlation between the increase in COVID-19 cases and deaths and the interest in telemedicine.

With regard to research interest, there are examples of bibliometric analyses that existed even before the COVID-19 pandemic. For instance, Armfield et al [ 52 ] analyzed nearly 18,000 publication records, published between 2009 and 2013, to investigate the themes in telemedicine and telehealth literature. They found that the majority of studies focused on the clinical effectiveness of telemedicine. Other research questions include the adoption and implementation of telemedicine and eHealth technologies in health care systems [ 52 ]. Edirippulige et al [ 53 ] conducted a bibliometric analysis of telemedicine-related literature published until 2018 in highly ranked clinical journals and revealed that the acceptance of telemedicine research by these journals indicated a maturing of the telemedicine field. However, the pandemic has led to a surge of research interest in telemedicine and related fields. Our bibliometric analysis, in fact, revealed a considerable increase in the number of publications, particularly from 2020 onwards. Most of these publications came from a single country, with only 1 in 5 featuring international collaborations. Despite the importance of fostering collaborations among various stakeholders, including academics, health administrators, practitioners, policymakers, and communities, which involve reciprocal knowledge translation, such partnerships are often lacking [ 54 ]. The United States led the way as the most productive country, with Canada and Australia following in a cluster. Meanwhile, European, Asian, and Latin American countries comprised the other 3 clusters. Previous studies already demonstrated the predominant role of the United States, with Lan et al [ 55 ] providing a general overview, and Kumar et al [ 56 ] analyzing the trends in orthopedics and trauma-related telemedicine during the COVID-19 pandemic. Another aspect of our analysis focused on whether the different terms, such as telemedicine, telehealth, eHealth, mHealth, and so forth, can be used interchangeably or if each of them refers to a specific area of research. Fatehi and Wootton [ 57 ] conducted a bibliometric analysis in 2012 to examine the trends in the use of terms such as telemedicine, telehealth, and eHealth. They discovered that these terms were frequently used interchangeably, with a growing prevalence of the term “eHealth” in more recent years. On the contrary, our analysis revealed a specific focus on the use of eHealth, mHealth, or digital health for noncommunicable and chronic diseases, while telemedicine and telehealth were predominantly used in the context of the COVID-19 pandemic. The analysis by Lan et al [ 55 ], limited to the application of telemedicine to COVID-19, showed similar results. In particular, telemedicine was mainly used to provide mental health services, health care services delivery, and to control cross-infection. In contrast, the term “mobile apps” was closely associated with chronic illness entities such as diabetes, heart failure, and asthma, as well as health service entities such as patient education and self-care [ 55 ].

Limitations

While Google Trends provides a valuable tool for analyzing public interest, there are several limitations to this approach. First, Google Trends only provides information on internet searches and does not account for offline discussions, media coverage, or other forms of engagement with the topic. This means that our results may not be representative of the entire population or capture the full extent of public interest. Second, the data provided by Google Trends are aggregated and anonymous, making it difficult to determine the specific demographics, motivations, or intentions behind the searches. This can limit the ability to draw meaningful conclusions or make accurate predictions about public behavior or attitudes toward telemedicine. Third, Google Trends data may be subject to various biases, such as the effect of media coverage or search engine optimization strategies. Additionally, the results may be influenced by factors such as seasonality, news events, or changes in search algorithms, making it challenging to compare trends over time or across different regions. Some of these limitations also apply to bibliometric analysis. First, bibliometric data may not reflect the complete picture of research interest as not all research is published and indexed in databases. Some research may be unpublished or published in non-indexed sources. Second, bibliometric analysis may not capture changes in research interest in real time. It can take some time for research to be published, indexed, and reflected in bibliometric data, meaning that the data may not reflect the most current state of research interest. Third, bibliometric analysis may not capture the full range of research interest as it is limited to the keywords used in publications. For instance, to offer a more comprehensive overview, one might consider examining interest in other trending subjects, like generative artificial intelligence and large language models. Finally, bibliometric analysis does not provide insights into the reasons behind the trends observed. It is limited to providing quantitative data on the number and frequency of publications and citations, and cannot provide qualitative insights into the motivations or drivers behind the research interest. For all these reasons, while the analysis of Google Trends and bibliometric data can provide a useful starting point for understanding public and research interest in telemedicine, it is essential to supplement this analysis with other sources of data and to interpret the results with caution.

Conclusions

Our study offers a comprehensive picture of the evolving landscape of telemedicine and its growing importance in health care delivery. By analyzing search and bibliographic data across regions and over time, our study provides valuable insights into the level of interest in telemedicine. This information serves to pinpoint potential application fields, identify gaps in this research, and emphasize areas that warrant additional attention and efforts in raising awareness.

Data Availability

The data sets analyzed during this study are available from the corresponding author on reasonable request.

Authors' Contributions

AM, MB, and AA conceived and designed the study. AM and MB contributed to data collection. AM and MB contributed to the data analysis. AM, MB, GB, and AA contributed to the interpretation of results. AM, MB, GB, and AA contributed to writing the paper.

Conflicts of Interest

None declared.

Additional outputs from the examination of Google Trends and bibliometric data.

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Abbreviations

Edited by A Mavragani; submitted 19.06.23; peer-reviewed by D Dinh, G Gallo, D Gunasekeran; comments to author 30.11.23; revised version received 01.12.23; accepted 03.01.24; published 16.05.24.

©Andrea Maugeri, Martina Barchitta, Guido Basile, Antonella Agodi. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 16.05.2024.

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

New Research Says Social Media Could Have a Positive Influence on Our Fitness

Your social media feed could be getting you moving according to a new study

Whatever side of that debate you fall on, science has weighed in with new evidence showing that social media might not be as bad as we once thought, while shedding light on what really gets us moving, and why.

Turns out showing off six pack abs and perfectly curated content may not be the thing truly motivating us. Who knew?

The research , published in the International Journal of Information Management, aimed to provide insights into the effectiveness of various types of social media content for promoting physical activity. It examined factors such as how users use social media, how they perceive t fitness content, and their intentions regarding exercise after viewing the content.

The Methods

The research is composed of two parts that investigate the factors that influence social media engagement and its influence on participants engaging in movement in the UK. The first study, based on existing online content and the trust in information published on social media, analysed exercise participation as a result of fitness content on social media.

The second part, based on the findings of the first study, investigated what type of specific information published on social media can generate a greater impact on the promotion of physical activity and the motivate individuals to improve their current levels of fitness.

The study examined factors such as user engagement levels, perceptions of the content, and intentions regarding physical activity.

The Results

• The study revealed that social media users engaged more with fitness content when it featured individuals who deviated from conventional perceptions of thinness and muscularity.
• Highlighting the intrinsic benefits (how training makes us feel ) of sports and fitness practices resonated particularly positively with the participants.
• Aligning individuals with the same gender as the user appeared vital for engagement.
• Although nuanced, these insights provide valuable guidance for tailoring content to maximise its impact on users and enhance their motivation to get fitter. It can also give you an insight into what type of social media content is likely to give your motivation the biggest boost.

The Conclusion

The study concluded that users engaging with social media content focused on physical activity had the potential of increased intentions to improve their physical fitness. The study emphasised the importance of featuring individuals with varied and realistic body types, while highlighting the intrinsic benefits of physical activity related to personal wellbeing. It also showed that aligning individuals with content from those of the same gender was found to be essential for engagement.

What This Means for Us

The research found that more intrinsically focused content (e.g. how training feels rather than how it makes us look) is more likely to get us moving. This sentiment is echoed in numerous studies examining the value of intrinsic motivators vs extrinsic for exercise adherence.

The findings offer valuable insights for tailoring our content to maximise its impact on our engagement and also encourage the likelihood of us participating in exercise. We can do this by following:

• Credible sources
• Sources that have a focus on the health benefits of exercise rather than just the aesthetics
• A diverse range of different body types from different demographics

Kate is a fitness writer for Men’s Health UK where she contributes regular workouts, training tips and nutrition guides. She has a post graduate diploma in Sports Performance Nutrition and before joining Men’s Health she was a nutritionist, fitness writer and personal trainer with over 5k hours coaching on the gym floor. Kate has a keen interest in volunteering for animal shelters and when she isn’t lifting weights in her garden, she can be found walking her rescue dog.

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Why businesses need explainable AI—and how to deliver it

Businesses increasingly rely on artificial intelligence (AI) systems to make decisions that can significantly affect individual rights, human safety, and critical business operations. But how do these models derive their conclusions? What data do they use? And can we trust the results?

Addressing these questions is the essence of “explainability,” and getting it right is becoming essential. While many companies have begun adopting basic tools to understand how and why AI models render their insights, unlocking the full value of AI requires a comprehensive strategy. Our research finds that companies seeing the biggest bottom-line returns from AI —those that attribute at least 20 percent of EBIT to their use of AI—are more likely than others to follow best practices that enable explainability. 1 “ The state of AI in 2021 ,” McKinsey, December 8, 2021. Further, organizations that establish digital trust among consumers through practices such as making AI explainable are more likely to see their annual revenue and EBIT grow at rates of 10 percent or more. 2 Jim Boehm, Liz Grennan, Alex Singla, and Kate Smaje, “ Why digital trust truly matters ,” McKinsey, September 12, 2022.

Even as explainability gains importance, it is becoming significantly harder. Modeling techniques that today power many AI applications, such as deep learning and neural networks, are inherently more difficult for humans to understand. For all the predictive insights AI can deliver, advanced machine learning engines often remain a black box. The solution isn’t simply finding better ways to convey how a system works; rather, it’s about creating tools and processes that can help even the deep expert understand the outcome and then explain it to others.

To shed light on these systems and meet the needs of customers, employees, and regulators, organizations need to master the fundamentals of explainability. Gaining that mastery requires establishing a governance framework, putting in place the right practices, and investing in the right set of tools.

What makes explainability challenging

Explainability is the capacity to express why an AI system reached a particular decision, recommendation, or prediction. Developing this capability requires understanding how the AI model operates and the types of data used to train it. That sounds simple enough, but the more sophisticated an AI system becomes, the harder it is to pinpoint exactly how it derived a particular insight. AI engines get “smarter” over time by continually ingesting data, gauging the predictive power of different algorithmic combinations, and updating the resulting model. They do all this at blazing speeds, sometimes delivering outputs within fractions of a second.

Disentangling a first-order insight and explaining how the AI went from A to B might be relatively easy. But as AI engines interpolate and reinterpolate data, the insight audit trail becomes harder to follow.

Complicating matters, different consumers of the AI system’s data have different explainability needs. A bank that uses an AI engine to support credit decisions will need to provide consumers who are denied a loan with a reason for that outcome. Loan officers and AI practitioners might need even more granular information to help them understand the risk factors and weightings used in rendering the decision to ensure the model is tuned optimally. And the risk function or diversity office may need to confirm that the data used in the AI engine are not biased against certain applicants. Regulators and other stakeholders also will have specific needs and interests.

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Five ways explainable ai can benefit organizations.

Mastering explainability helps technology, business, and risk professionals in at least five ways (exhibit):

• Increasing productivity. Techniques that enable explainability can more quickly reveal errors or areas for improvement, making it easier for machine learning operations (MLOps) teams tasked with supervising AI systems to monitor and maintain AI systems efficiently. As an example, understanding the specific features that lead to the model output helps technical teams confirm whether patterns identified by the model are broadly applicable and relevant to future predictions or instead reflect one-off or anomalous historical data.
• Building trust and adoption. Explainability is also crucial to building trust. Customers, regulators, and the public at large all need to feel confident that the AI models rendering consequential decisions are doing so in an accurate and fair way. Likewise, even the most cutting-edge AI systems will gather dust if intended users don’t understand the basis for the recommendations being supplied. Sales teams, for instance, are more apt to trust their gut over an AI application whose suggested next-best actions seem to come from a black box. Knowing why an AI application made its recommendation increases sales professionals’ confidence in following it.
• Surfacing new, value-generating interventions. Unpacking how a model works can also help companies surface business interventions that would otherwise remain hidden. In some cases, the deeper understanding into the why of a prediction can lead to even more value than the prediction or recommendation itself. For example, a prediction of customer churn in a certain segment can be helpful by itself, but an explanation of why the churn is likely can reveal the most effective ways for the business to intervene. For one auto insurer, using explainability tools such as SHAP values revealed how greater risk was associated with certain interactions between vehicle and driver attributes. The company used these insights to adjust its risk models, after which its performance improved significantly.
• Ensuring AI provides business value. When the technical team can explain how an AI system functions, the business team can confirm that the intended business objective is being met and spot situations where something was lost in translation. This ensures that an AI application is set up to deliver its expected value.
• Mitigating regulatory and other risks. Explainability helps organizations mitigate risks. AI systems that run afoul of ethical norms, even if inadvertently, can ignite intense public, media, and regulatory scrutiny. Legal and risk teams can use the explanation provided by the technical team, along with the intended business use case, to confirm the system complies with applicable laws and regulations and is aligned with internal company policies and values. In some sectors, explainability is a requirement. For example, a recent bulletin issued by the California Department of Insurance requires insurers to explain adverse actions taken based on complex algorithms. 3 California Insurance Commission, “Allegations of racial bias and unfair discrimination in marketing, rating, underwriting, and claims practices by the insurance industry,” Bulletin 2022-5, June 30, 2022. As use of AI grows, organizations can expect more rules concerning explainability. New regulations, such as the draft EU AI regulation , may contain specific explainability compliance steps. Even when not specifically mandated, companies will need to confirm that any tool used to render actions such as credit determinations comply with applicable antidiscrimination laws, as well as laws prohibiting unfair or deceptive practices.

Why digital trust truly matters

How businesses can make ai explainable.

Organizations that build a framework for explainability and acquire the right enabling tools will be better positioned to capture the full value of deep learning and other AI advances. We suggest organizations start by including explainability as one of the key principles within their responsible AI guidelines. Then organizations can operationalize this principle by establishing an AI governance  committee to set standards and guidance for AI development teams, including guidelines for use-case-specific review processes, and by investing in the right talent, technology, research, and training.

Establish an AI governance committee to guide AI development teams

Establishment of an AI governance committee includes recruiting its members and defining the scope of work. The explainability and risk assessment of AI use cases may be complex, requiring an understanding of the business objective, the intended users, the technology, and any applicable legal requirements. For this reason, organizations will want to convene a cross-functional set of experienced professionals, including business leaders, technical experts, and legal and risk professionals. Bringing in diverse points of view internally and externally can also help the company test whether the explanations developed to support an AI model are intuitive and effective for different audiences.

A key function of the committee will be setting standards for AI explainability. As part of the standards-setting process, effective AI governance committees often establish a risk taxonomy that can be used to classify the sensitivity of different AI use cases. The taxonomy links to guidance that outlines expectations and standards with respect to different use cases. For example, is an explanation necessary to comply with regulatory requirements, or is the goal simply to provide an overview of functionality to aid adoption? The taxonomy also clarifies when escalation to a review board or legal may be required.

Because each AI use case can present a different set of risks and legal requirements related to explainability, organizations should establish a process for model development teams to assess each use case. This process better positions the organization to manage these risks and capture value from AI. Tracking the outcome of these assessments within a central inventory helps ensure the organization can monitor the use of AI systems for compliance with law and adherence to responsible AI principles.

As part of the review process, teams will need to consider whether to go beyond the basic explainability requirements, based on the potential value resulting from, for example, greater trust, adoption, or productivity. In some cases, a trade-off may exist between explainability and accuracy. For example, simplifying an AI model’s mechanics might improve user trust, but in some—not all—cases, a shift might make the model less accurate. When trade-offs exist, teams will need to weigh the competing considerations, including any regulatory requirements, and escalate to leadership as necessary.

Teams may be able to address these trade-offs themselves. Sometimes they can reverse-engineer the factors driving predictive outcomes for advanced AI models by tracking model performance and discerning patterns. They can then try to replicate the complex model using simpler and better-understood statistical methods such as logistic regression. In some cases, the result will be an equally high-performing model with outputs that are inherently explainable.

Invest in the right talent, explainability technology, research, and training

The rapid pace of technological and legal change within the area of explainability makes it urgent for companies to hire the right talent, invest in the right set of tools, engage in active research, and conduct ongoing training.

High-performing organizations develop a talent strategy to support AI governance across the enterprise. These companies seek to retain legal and risk colleagues who can actively and meaningfully engage with both the business and technologists to navigate applicable regulations, meet consumer expectations, and “future-proof” core products (including features and data sets) as the law evolves. Similarly, companies are well served to hire technologists familiar with legal issues or focused on technology ethics.

Investment in explainability technology should aim to acquire appropriate tools for meeting the needs identified by development teams during the review process. For example, more advanced tooling may provide a robust explanation in a context that would otherwise require teams to sacrifice accuracy. Although the up-front cost of bespoke solutions may be higher, it sometimes pays off in the long run because they can take into account the context in which the model is being deployed, including the intended users and any legal or regulatory requirements. Companies considering off-the-shelf and open-source tools should understand any limitations of these options. For example, some explainability tools rely on post-hoc explanations that deduce the relevant factors based only on a review of the system output. If this limited approach yields a less-than-accurate explanation of the causal factors driving the outcome, users’ confidence in the system output might be unwarranted.

Research is an ongoing requirement because legal and regulatory requirements, as well as consumer expectations and industry norms, are changing rapidly. AI governance committees will want to actively monitor and, where possible, conduct their own research in this space to ensure continual learning and knowledge development. The committee should also establish a training program to ensure employees across the organization understand and are able to apply the latest developments in this space.

People use what they understand and trust. This is especially true of AI. The businesses that make it easy to show how their AI insights and recommendations are derived will come out ahead, not only with their organization’s AI users, but also with regulators and consumers—and in terms of their bottom lines.

Liz Grennan is an associate partner in McKinsey’s Stamford office, Andreas Kremer is a partner in the Berlin office, Alex Singla is a senior partner in the Chicago office, and Peter Zipparo is associate general counsel, based in the New York office.

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