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What are Literature Reviews?
Conducting & Reporting Systematic Reviews
Finding Systematic Reviews
Tutorials & Tools for Literature Reviews
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What are Systematic Reviews? (3 minutes, 24 second YouTube Video)

Systematic Literature Reviews: Steps & Resources

These steps for conducting a systematic literature review are listed below .

Also see subpages for more information about:

The different types of literature reviews, including systematic reviews and other evidence synthesis methods
Tools & Tutorials

Literature Review & Systematic Review Steps

Develop a Focused Question
Scope the Literature (Initial Search)
Refine & Expand the Search
Limit the Results
Download Citations
Abstract & Analyze
Create Flow Diagram
Synthesize & Report Results

1. Develop a Focused Question

Consider the PICO Format: Population/Problem, Intervention, Comparison, Outcome

Focus on defining the Population or Problem and Intervention (don't narrow by Comparison or Outcome just yet!)

"What are the effects of the Pilates method for patients with low back pain?"

Tools & Additional Resources:

PICO Question Help
Stillwell, Susan B., DNP, RN, CNE; Fineout-Overholt, Ellen, PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek, PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M., PhD, RN Evidence-Based Practice, Step by Step: Asking the Clinical Question, AJN The American Journal of Nursing : March 2010 - Volume 110 - Issue 3 - p 58-61 doi: 10.1097/01.NAJ.0000368959.11129.79

2. Scope the Literature

A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature.

Eligible studies may be located by searching in:

Background sources (books, point-of-care tools)
Article databases
Trial registries
Grey literature
Cited references
Reference lists

When searching, if possible, translate terms to controlled vocabulary of the database. Use text word searching when necessary.

Use Boolean operators to connect search terms:

Combine separate concepts with AND (resulting in a narrower search)
Connecting synonyms with OR (resulting in an expanded search)

Search: pilates AND ("low back pain" OR backache )

Video Tutorials - Translating PICO Questions into Search Queries

Translate Your PICO Into a Search in PubMed (YouTube, Carrie Price, 5:11)
Translate Your PICO Into a Search in CINAHL (YouTube, Carrie Price, 4:56)

3. Refine & Expand Your Search

Expand your search strategy with synonymous search terms harvested from:

database thesauri
reference lists
relevant studies

Example:

(pilates OR exercise movement techniques) AND ("low back pain" OR backache* OR sciatica OR lumbago OR spondylosis)

As you develop a final, reproducible strategy for each database, save your strategies in a:

a personal database account (e.g., MyNCBI for PubMed)
Log in with your NYU credentials
Open and "Make a Copy" to create your own tracker for your literature search strategies

4. Limit Your Results

Use database filters to limit your results based on your defined inclusion/exclusion criteria. In addition to relying on the databases' categorical filters, you may also need to manually screen results.

Limit to Article type, e.g.,: "randomized controlled trial" OR multicenter study
Limit by publication years, age groups, language, etc.

NOTE: Many databases allow you to filter to "Full Text Only". This filter is not recommended . It excludes articles if their full text is not available in that particular database (CINAHL, PubMed, etc), but if the article is relevant, it is important that you are able to read its title and abstract, regardless of 'full text' status. The full text is likely to be accessible through another source (a different database, or Interlibrary Loan).

Filters in PubMed
CINAHL Advanced Searching Tutorial

5. Download Citations

Selected citations and/or entire sets of search results can be downloaded from the database into a citation management tool. If you are conducting a systematic review that will require reporting according to PRISMA standards, a citation manager can help you keep track of the number of articles that came from each database, as well as the number of duplicate records.

In Zotero, you can create a Collection for the combined results set, and sub-collections for the results from each database you search. You can then use Zotero's 'Duplicate Items" function to find and merge duplicate records.

File structure of a Zotero library, showing a combined pooled set, and sub folders representing results from individual databases.

Citation Managers - General Guide

6. Abstract and Analyze

Migrate citations to data collection/extraction tool
Screen Title/Abstracts for inclusion/exclusion
Screen and appraise full text for relevance, methods,
Resolve disagreements by consensus

Covidence is a web-based tool that enables you to work with a team to screen titles/abstracts and full text for inclusion in your review, as well as extract data from the included studies.

Screenshot of the Covidence interface, showing Title and abstract screening phase.

Covidence Support
Critical Appraisal Tools
Data Extraction Tools

7. Create Flow Diagram

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review. It depicts the number of records identified, included and excluded. It is best used in conjunction with the PRISMA checklist .

Example PRISMA diagram showing number of records identified, duplicates removed, and records excluded.

Example from: Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46. https://doi.org/10.1007/s11892-021-01414-3

PRISMA Flow Diagram Generator (ShinyApp.io, Haddaway et al. )
PRISMA Diagram Templates (Word and PDF)
Make a copy of the file to fill out the template
Image can be downloaded as PDF, PNG, JPG, or SVG
Covidence generates a PRISMA diagram that is automatically updated as records move through the review phases

8. Synthesize & Report Results

There are a number of reporting guideline available to guide the synthesis and reporting of results in systematic literature reviews.

It is common to organize findings in a matrix, also known as a Table of Evidence (ToE).

Example of a review matrix, using Microsoft Excel, showing the results of a systematic literature review.

Reporting Guidelines for Systematic Reviews
Download a sample template of a health sciences review matrix (GoogleSheets)

Steps modified from:

Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach. Medical Education , 46 (10), 943–952.

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Next: What are Literature Reviews? >>
Last Updated: May 10, 2024 11:25 AM
URL: https://guides.nyu.edu/health

How to Conduct a Literature Review (Health Sciences and Beyond)

What is a literature review, traditional (narrative) literature review, integrative literature review, systematic reviews, meta-analysis, scoping review.

Developing a Research Question
Selection Criteria
Database Search
Documenting Your Search
Organize Key Findings
Reference Management

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Related Guides

Systematic Reviews by Roy Brown Last Updated Oct 17, 2023 513 views this year
Write a Literature Review by John Glover Last Updated Oct 16, 2023 2721 views this year

A literature review provides an overview of what's been written about a specific topic. There are many different types of literature reviews. They vary in terms of comprehensiveness, types of study included, and purpose.

The other pages in this guide will cover some basic steps to consider when conducting a traditional health sciences literature review. See below for a quick look at some of the more popular types of literature reviews.

For additional information on a variety of review methods, the following article provides an excellent overview.

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009 Jun;26(2):91-108. doi: 10.1111/j.1471-1842.2009.00848.x. Review. PubMed PMID: 19490148.

Next: Developing a Research Question >>
Last Updated: Mar 15, 2024 12:22 PM
URL: https://guides.library.vcu.edu/health-sciences-lit-review

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Searching the public health & medical literature more effectively: literature review help.

Getting Started
Articles: Searching PubMed This link opens in a new window
More Sources: Databases, Systematic Reviews, Grey Literature
Organize Citations & Search Strategies
Literature Review Help
Need More Help?

Writing Guides, Manuals, etc.

Literature Review Tips Handouts

Write about something you are passionate about!

About Literature Reviews (pdf)
Literature Review Workflow (pdf)
Search Tips/Search Operators
Quick Article Evaluation Worksheet (docx)
Tips for the Literature Review Workflow
Sample Outline for a Literature Review (docx)

Ten simple rules for writing a literature review . Pautasso M. PLoS Comput Biol. 2013;9(7):e1003149. doi:10.1371/journal.pcbi.1003149

Conducting the Literature Search . Chapter 4 of Chasan-Taber L. Writing Dissertation and Grant Proposals: Epidemiology, Preventive Medicine and Biostatistics. New York: Chapman and Hall/CRC, 2014.

A step-by-step guide to writing a research paper, from idea to full manuscript . Excellent and easy to follow blog post by Dr. Raul Pacheco-Vega.

Data Extraction

Data extraction answers the question “what do the studies tell us?”

At a minimum, consider the following when extracting data from the studies you are reviewing ( source ):

Only use the data elements relevant to your question;
Use a table, form, or tool (such as Covidence ) for data extraction;
Test your methods and tool for missing data elements, redundancy, consistency, clarity.

Here is a table of data elements to consider for your data extraction. (From University of York, Centre for Reviews and Dissemination).

Critical Reading

As you read articles, write notes. You may wish to create a table, answering these questions:

What is the hypothesis?
What is the method? Rigorous? Appropriate sample size? Results support conclusions?
What are the key findings?
How does this paper support/contradict other work?
How does it support/contradict your own approach?
How significant is this research? What is its special contribution?
Is this research repeating existing approaches or making a new contribution?
What are its strengths?
What are its weaknesses/limitations?

From: Kearns, H. & Finn, J. (2017) Supervising PhD Students: A Practical Guide and Toolkit . AU: Thinkwell, p. 103.

Submitting to a Journal? First Identify Journals That Publish on Your Topic

Through Scopus

Visit the Scopus database.
Search for recent articles on your research topic.
Above the results, click “Analyze search results."
Click in the "Documents per year by source" box.
On the left you will see the results listed by the number of articles published on your research topic per journal.

Through Web of Science

Visit the Web of Science database.
In the results, click "Analyze Results" on the right hand side.
From the drop-down menu near the top left, choose "Publication Titles."
Change the "Minimum record count (threshold)," if desired.
Scroll down for a table of results by journal title.
JANE (Journal/Author Name Estimator) Use JANE to help you discover and decide where to publish an article you have authored. Jane matches the abstract of your article to the articles in Medline to find the best matching journals (or authors, or articles).
Jot (Journal Targeter) Jot uses Jane and other data to determine journals likely to publish your article (based on title, abstract, references) against the impact metric of those journals. From Yale University.
EndNote Manuscript Matcher Using algorithms and data from the Web of Science and Journal Citation Reports, Manuscript Matcher identifies the most relevant and impactful journals to which one may wish to submit a manuscript. Access Manuscript Matcher via EndNote X9 or EndNote 20.
DOAJ (Directory of Open Access Journals) Journal Lookup Look up a journal title on DOAJ and find information on publication fees, aims and scope, instructions for authors, submission to publication time, copyright, and more.

Writing Help @UCB

Here is a short list of sources of writing help available to UC Berkeley students, staff, and faculty:

Purdue OWL Excellent collection of guides on writing, including citing/attribution, citation styles, grammar and punctuation, academic writing, and much more.
Berkeley Writing: College Writing Programs "Our philosophy includes small class size, careful attention to building your critical reading and thinking skills along with your writing, personalized attention, and a great deal of practice writing and revising." Website has a Writing Resources Database .
Graduate Writing Center, Berkeley Graduate Division Assists graduate students in the development of academic skills necessary to successfully complete their programs and prepare for future positions. Workshops and online consultations are offered on topics such as academic writing, grant writing, dissertation writing , thesis writing , editing, and preparing articles for publication, in addition to writing groups and individual consultations.
Nature Masterclass on Scientific Writing and Publishing For Postdocs, Visiting Scholars, and Visiting Student Researchers with active, approved appointments, and current UC Berkeley graduate students who are new to publishing or wish to refresh their skills. Part 1: Writing a Research Paper; Part 2: Publishing a Research Paper; Part 3: Writing and Publishing a Review Paper. Offered by Visiting Researcher Scholar and Postdoc Affairs (VSPA) program; complete this form to gain access.

Alternative Publishing Formats

Here is some information and tips on getting your research to a broader, or to a specialized, audience

Creating One-Page Reports One-page reports are a great way to provide a snapshot of a project’s activities and impact to stakeholders. Summarizing key facts in a format that is easily and quickly digestible engages the busy reader and can make your project stand out. From EvaluATE .
How to write an Op-ed (Webinar) Strategies on how to write sharp op-eds for broader consumption, one of the most important ways to ensure your analysis and research is shared in the public sphere. From the Institute for Research on Public Policy .
10 tips for commentary writers From UC Berkeley Media Relations’ 2017 Op-Ed writing workshop.
Journal of Science Policy and Governance JSPG publishes policy memos, op-eds, position papers, and similar items created by students.
Writing Persuasive Policy Briefs Presentation slides from a UCB Science Policy Group session.
3 Essential Steps to Share Research With Popular Audiences (Inside Higher Ed) How to broaden the reach and increase the impact of your academic writing. Popular writing isn’t a distraction from core research!

The Politics of Citation

"One of the feminist practices key to my teaching and research is a feminist practice of citation."

From The Digital Feminist Collective , this blog post emphasizes the power of citing.

"Acknowledging and establishing feminist genealogies is part of the work of producing more just forms of knowledge and intellectual practice."

Here's an exercise (docx) to help you in determining how inclusive you are when citing.

Additional Resources for Inclusive Citation Practices :

BIPOC Scientists Citation guide (Rockefeller Univ.).
Conducting Research through an Anti-Racism Lens (Univ. of Minnesota Libraries).
cleanBib (Code to probabilistically assign gender and race proportions of first/last authors pairs in bibliography entries).
Balanced Citer (Python script guesses the race and gender of the first and last authors for papers in your citation list and compares your list to expected distributions based on a model that accounts for paper characteristics).
Read Black women's work;
Integrate Black women into the CORE of your syllabus (in life & in the classroom);
Acknowledge Black women's intellectual production;
Make space for Black women to speak;
Give Black women the space and time to breathe.
CiteASista .
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Last Updated: May 10, 2024 11:43 AM
URL: https://guides.lib.berkeley.edu/publichealth/litsearch

The Sheridan Libraries

Public Health
Sheridan Libraries
Literature Reviews + Annotating
How to Access Full Text
Background Information
Books, E-books, Dissertations
Articles, News, Who Cited This, More
Google Scholar and Google Books
PUBMED and EMBASE
Statistics -- United States
Statistics -- Worldwide
Avoiding Plagiarism
Citing Sources This link opens in a new window
Copyright This link opens in a new window
Evaluating Information This link opens in a new window
RefWorks Guide and Help This link opens in a new window
Epidemic Proportions
Environment and Your Health, AS 280.335, Spring 2024
Honors in Public Health, AS280.495, Fall 23-Spr 2024
Intro to Public Health, AS280.101, Spring 2024
Research Methods in Public Health, AS280.240, Spring 2024
Social+Behavioral Determinants of Health, AS280.355, Spring 2024
Feedback (for class use only)

Literature Reviews

Organizing/Synthesizing
Peer Review
Ulrich's -- One More Way To Find Peer-reviewed Papers

"Literature review," "systematic literature review," "integrative literature review" -- these are terms used in different disciplines for basically the same thing -- a rigorous examination of the scholarly literature about a topic (at different levels of rigor, and with some different emphases).

1. Our library's guide to Writing a Literature Review

2. Other helpful sites

Writing Center at UNC (Chapel Hill) -- A very good guide about lit reviews and how to write them
Literature Review: Synthesizing Multiple Sources (LSU, June 2011 but good; PDF) -- Planning, writing, and tips for revising your paper

3. Welch Library's list of the types of expert reviews

Doing a good job of organizing your information makes writing about it a lot easier.

You can organize your sources using a citation manager, such as refworks , or use a matrix (if you only have a few references):.

Use Google Sheets, Word, Excel, or whatever you prefer to create a table
The column headings should include the citation information, and the main points that you want to track, as shown

Synthesizing your information is not just summarizing it. Here are processes and examples about how to combine your sources into a good piece of writing:

Purdue OWL's Synthesizing Sources
Synthesizing Sources (California State University, Northridge)

Annotated Bibliography

An "annotation" is a note or comment. An "annotated bibliography" is a "list of citations to books, articles, and [other items]. Each citation is followed by a brief...descriptive and evaluative paragraph, [whose purpose is] to inform the reader of the relevance, accuracy, and quality of the sources cited."*

Sage Research Methods (database) --> Empirical Research and Writing (ebook) -- Chapter 3: Doing Pre-research
Purdue's OWL (Online Writing Lab) includes definitions and samples of annotations
Cornell's guide * to writing annotated bibliographies

* Thank you to Olin Library Reference, Research & Learning Services, Cornell University Library, Ithaca, NY, USA https://guides.library.cornell.edu/annotatedbibliography

What does "peer-reviewed" mean?

If an article has been peer-reviewed before being published, it means that the article has been read by other people in the same field of study ("peers").
The author's reviewers have commented on the article, not only noting typos and possible errors, but also giving a judgment about whether or not the article should be published by the journal to which it was submitted.

How do I find "peer-reviewed" materials?

Most of the the research articles in scholarly journals are peer-reviewed.
Many databases allow you to check a box that says "peer-reviewed," or to see which results in your list of results are from peer-reviewed sources. Some of the databases that provide this are Academic Search Ultimate, CINAHL, PsycINFO, and Sociological Abstracts.

What kinds of materials are not peer-reviewed?

open web pages
most newspapers, newsletters, and news items in journals
letters to the editor
press releases
columns and blogs
book reviews
anything in a popular magazine (e.g., Time, Newsweek, Glamour, Men's Health)

If a piece of information wasn't peer-reviewed, does that mean that I can't trust it at all?

No; sometimes you can. For example, the preprints submitted to well-known sites such as arXiv (mainly covering physics) and CiteSeerX (mainly covering computer science) are probably trustworthy, as are the databases and web pages produced by entities such as the National Library of Medicine, the Smithsonian Institution, and the American Cancer Society.

Is this paper peer-reviewed? Ulrichsweb will tell you.

1) On the library home page , choose "Articles and Databases" --> "Databases" --> Ulrichsweb

2) Put in the title of the JOURNAL (not the article), in quotation marks so all the words are next to each other

3) Mouse over the black icon, and you'll see that it means "refereed" (which means peer-reviewed, because it's been looked at by referees or reviewers). This journal is not peer-reviewed, because none of the formats have a black icon next to it:

<< Previous: Evaluating Information
Next: RefWorks Guide and Help >>
Last Updated: May 2, 2024 6:02 PM
URL: https://guides.library.jhu.edu/public-health

University of Houston Libraries

Literature Reviews in the Health Sciences
Review Comparison Chart
Decision Tools
Systematic Review
Meta-Analysis
Scoping Review
Mapping Review
Integrative Review
Rapid Review
Realist Review
Umbrella Review
Review of Complex Interventions
Diagnostic Test Accuracy Review
Narrative Literature Reviews
Standards and Guidelines

Navigate the links below to jump to a specific section of the page:

When is a Scoping Review methodology appropriate?

Outline of stages, methods and guidance, examples of scoping reviews, supplementary resources.

According to Colquhoun et al. (2014) , a scoping review can be defined as: "a form of knowledge synthesis, which incorporate a range of study designs to comprehensively summarize and synthesize evidence with the aim of informing practice, programs, and policy and providing direction to future research priorities" (p.1291).

Characteristics

Answers a broad question
Scoping reviews serve the purpose of identifying the scope and extent of existing research on a topic
Similar to systematic reviews, scoping reviews follow a step-by-step process and aim to be transparent and replicable in its methods

When to Use It: A scoping review might be right for you if you are interested in:

Examining the extent, range, and nature of research activity
Determining the value of undertaking a full systematic review (e.g. Do any studies exist? Have systematic reviews already been conducted?)
Summarizing the disseminating research findings
Identifying gaps in an existing body of literature

The following stages of conducting a review of complex interventions are derived from Peters et al. (2015) and Levac et al. (2010) .

Timeframe: 12+ months, (same amount of time as a systematic review or longer)

*Varies beyond the type of review. Depends on many factors such as but not limited to: resources available, the quantity and quality of the literature, and the expertise or experience of reviewers" ( Grant & Booth, 2009 ).

Question: Answers broader and topic focused questions beyond those relating to the effectiveness of treatments or interventions. A priori review protocol is recommended.

Is your review question a complex intervention? Learn more about Reviews of Complex Interventions .

Sources and searches: Comprehensive search-may be limited by time/scope restraints, still aims to be thorough and repeatable of all literature. May involve multiple structured searches rather than a single structured search. This will produce more results than a systematic review. Must include a modified PRISMA flow diagram.

Selection: Based on inclusion/exclusion criteria, due to the iterative nature of a scoping review some changes may be necessary. May require more time spent screening articles due to the larger volume of results from broader questions.

Appraisal: Critical appraisal (optional), Risk of Bias assessment (optional) is not applicable for scoping reviews.

Synthesis: (Tabular with some narrative) The extraction of data for a scoping review may include a charting table or form but a formal synthesis of findings from individual studies and the generation of a 'summary of findings' (SOF) table is not required. Results may include a logical diagram or table or any descriptive form that aligns with the scope and objectives of the review. May incorporate a numerical summary and qualitative thematic analysis.

Consultation: (optional)

The following resources provide methods and guidance in the field of scoping reviews.

Methods & Guidance

Cochrane Training: Scoping reviews: what they are and how you can do them A series of videos presented by Dr Andrea C. Tricco and Kafayat Oboirien. Learn the about what a scoping review is, see examples, learn the steps involved, and common methods from Dr. Tricco. Oboirien presents her experiences of conducting a scoping review on strengthening clinical governance in low and middle income countries.
Current Best Practices for the Conduct of Scoping Reviews by Heather Colquhoun An overview on best practices when executing a scoping review.
Joanna Briggs Institute (JBI) Manual for Evidence Synthesis. Chapter 11: Scoping Reviews An extensive and detailed outline within the JBI Manual for Evidence Synthesis on how to properly conduct a scoping review.

Reporting Guideline

PRISMA for Scoping Reviews (PRISMA-ScR) Contains a 20-item checklist for proper reporting of a scoping review plus 2 optional items.
Håkonsen, S. J., Pedersen, P. U., Bjerrum, M., Bygholm, A., & Peters, M. (2018). Nursing minimum data sets for documenting nutritional care for adults in primary healthcare: a scoping review . JBI database of systematic reviews and implementation reports , 16 (1), 117–139. doi: 10.11124/JBISRIR-2017-003386
Kao, S. S., Peters, M., Dharmawardana, N., Stew, B., & Ooi, E. H. (2017). Scoping review of pediatric tonsillectomy quality of life assessment instruments . The Laryngoscope , 127 (10), 2399–2406. doi: 10.1002/lary.26522
Tricco, A. C., Zarin, W., Rios, P., Nincic, V., Khan, P. A., Ghassemi, M., Diaz, S., Pham, B., Straus, S. E., & Langlois, E. V. (2018). Engaging policy-makers, health system managers, and policy analysts in the knowledge synthesis process: a scoping review . Implementation science: IS , 13 (1), 31. doi: 10.1186/s13012-018-0717-x

Anderson, S., Allen, P., Peckham, S., & Goodwin, N. (2008). Asking the right questions: scoping studies in the commissioning of research on the organisation and delivery of health services . Health research policy and systems , 6 , 7. doi: 10.1186/1478-4505-6-7

Arksey, H., & O'Malley, L. (2005). Scoping studies: towards a methodological framework . International journal of social research methodology, 8 (1), 19-32. doi: 10.1080/1364557032000119616

Armstrong, R., Hall, B. J., Doyle, J., & Waters, E. (2011). Cochrane Update. 'Scoping the scope' of a cochrane review . Journal of public health (Oxford, England) , 33 (1), 147–150. doi: 10.1093/pubmed/fdr015

Colquhoun, H. (2016). Current best practices for the conducting of scoping reviews . Symposium Presentation - Impactful Biomedical Research: Achieving Quality and Transparency . https://www.equator-network.org/wp-content/uploads/2016/06/Gerstein-Library-scoping-reviews_May-12.pdf

Colquhoun, H. L., Levac, D., O'Brien, K. K., Straus, S., Tricco, A. C., Perrier, L., Kastner, M., & Moher, D. (2014). Scoping reviews: time for clarity in definition, methods, and reporting . Journal of clinical epidemiology , 67 (12), 1291–1294. doi: 10.1016/j.jclinepi.2014.03.013

Davis, K., Drey, N., & Gould, D. (2009). What are scoping studies? A review of the nursing literature . International journal of nursing studies , 46 (10), 1386–1400. doi: 10.1016/j.ijnurstu.2009.02.010

Khalil, H., Peters, M., Godfrey, C. M., McInerney, P., Soares, C. B., & Parker, D. (2016). An evidence-based approach to scoping reviews . Worldviews on evidence-based nursing , 13 (2), 118–123. doi: 10.1111/wvn.12144

Levac, D., Colquhoun, H., & O'Brien, K. K. (2010). Scoping studies: advancing the methodology . Implementation science: IS , 5 , 69. doi: 10.1186/1748-5908-5-69

Lockwood, C., Dos Santos, K. B., & Pap, R. (2019). Practical guidance for knowledge synthesis: scoping review methods . Asian nursing research , 13 (5), 287–294. doi: 10.1016/j.anr.2019.11.002

Morris, M., Boruff, J. T., & Gore, G. C. (2016). Scoping reviews: establishing the role of the librarian . Journal of the Medical Library Association: JMLA , 104 (4), 346–354. doi: 10.3163/1536-5050.104.4.020

Munn, Z., Peters, M., Stern, C., Tufanaru, C., McArthur, A., & Aromataris, E. (2018). Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach . BMC medical research methodology , 18 (1), 143. doi: 10.1186/s12874-018-0611-x

O'Brien, K. K., Colquhoun, H., Levac, D., Baxter, L., Tricco, A. C., Straus, S., Wickerson, L., Nayar, A., Moher, D., & O'Malley, L. (2016). Advancing scoping study methodology: a web-based survey and consultation of perceptions on terminology, definition and methodological steps . BMC health services research , 16 , 305. doi: 10.1186/s12913-016-1579-z

Peters, M. D., Godfrey, C. M., Khalil, H., McInerney, P., Parker, D., & Soares, C. B. (2015). Guidance for conducting systematic scoping reviews . International journal of evidence-based healthcare , 13 (3), 141–146. doi: 10.1097/XEB.0000000000000050

Peters, M. D. J., Godfrey, C., McInerney, P., Munn, Z., Tricco, A. C., & Khalil, H. (2020). Chapter 11: Scoping Reviews . In Aromataris, E. & Munn, Z. (Eds.), JBI Manual for Evidence Synthesis . Joanna Briggs Institute. doi: 10.46658/JBIMES-20-12

Peters, M., Marnie, C., Tricco, A. C., Pollock, D., Munn, Z., Alexander, L., McInerney, P., Godfrey, C. M., & Khalil, H. (2021). Updated methodological guidance for the conduct of scoping reviews . JBI evidence implementation , 19 (1), 3–10. doi: 10.1097/XEB.0000000000000277

Pham, M. T., Rajić, A., Greig, J. D., Sargeant, J. M., Papadopoulos, A., & McEwen, S. A. (2014). A scoping review of scoping reviews: advancing the approach and enhancing the consistency . Research synthesis methods , 5 (4), 371–385. doi: 10.1002/jrsm.1123

Tricco, A. C., Lillie, E., Zarin, W., O'Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., Lewin, S., … Straus, S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation . Annals of internal medicine , 169 (7), 467–473. doi: 10.7326/M18-0850

Tricco, A., Oboirien, K., Lotfi, T., & Sambunjak, D. (2017, August). Scoping reviews: what they are and how you can do them . Cochrane Training. https://training.cochrane.org/resource/scoping-reviews-what-they-are-and-how-you-can-do-them

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Other Names for a Scoping Review

Scoping Study
Systematic Scoping Review
Scoping Report
Scope of the Evidence
Rapid Scoping Review
Structured Literature Review
Scoping Project
Scoping Meta Review

Limitations of a Scoping Review

The following challenges of conducting a scoping review are derived from Grant & Booth (2009) , Peters et al. (2015) , and O'Brien (2016) .

Is not easier than a systematic review.
Is not faster than a systematic review; may take longer .
More citations to screen.
Different screening criteria/process than a systematic review.
Often leads to a broader, less defined search.
Requires multiple structured searches instead of one.
Increased emphasis for hand searching the literature.
May require larger teams because of larger volume of literature.
Inconsistency in the conduct of scoping reviews.

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Public Health: Literature reviews

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Popular search strategies

Section Objective

What is a literature review, clearly stated research question, search terms, searching worksheets, boolean and / or.

Systematic reviews
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The content in the Literature Review section defines the literature review purpose and process, explains using the PICO format to ask a clear research question, and demonstrates how to evaluate and modify search results to improve the accuracy of the retrieval.

A literature review seeks to identify, analyze and summarize the published research literature about a specific topic. Literature reviews are assigned as course projects; included as the introductory part of master's and PhD theses; and are conducted before undertaking any new scientific research project.

The purpose of a literature review is to establish what is currently known about a specific topic and to evaluate the strength of the evidence upon which that knowledge is based. A review of a clinical topic may identify implications for clinical practice. Literature reviews also identify areas of a topic that need further research.

A systematic review is a literature review that follows a rigorous process to find all of the research conducted on a topic and then critically appraises the research methods of the highest quality reports. These reviews track and report their search and appraisal methods in addition to providing a summary of the knowledge established by the appraised research.

The UNC Writing Center provides a nice summary of what to consider when writing a literature review for a class assignment. The online book, Doing a literature review in health and social care : a practical guide (2010), is a good resource for more information on this topic.

Obviously, the quality of the search process will determine the quality of all literature reviews. Anyone undertaking a literature review on a new topic would benefit from meeting with a librarian to discuss search strategies. A consultaiton with a librarian is strongly recommended for anyone undertaking a systematic review.

Use the email form on our Ask a Librarian page to arrange a meeting with a librarian.

The first step to a successful literature review search is to state your research question as clearly as possible.

It is important to:

be as specific as possible
include all aspects of your question

Clinical and social science questions often have these aspects (PICO):

People/population/problem (What are the characteristics of the population? What is the condition or disease?)
Intervention (What do you want to do with this patient? i.e. treat, diagnose)
Comparisons [not always included] (What is the alternative to this intervention? i.e. placebo, different drug, surgery)
Outcomes (What are the relevant outcomes? i.e. morbidity, death, complications)

If the PICO model does not fit your question, try to use other ways to help be sure to articulate all parts of your question. Perhaps asking yourself Who, What, Why, How will help.

Example Question: Is acupuncture as effective of a therapy as triptans in the treament of adult migraine?

Note that this question fits the PICO model.

Population: Adults with migraines
Intervention: Acupuncture
Comparison: Triptans/tryptamines
Outcome: Fewer Headache days, Fewer migraines

A literature review search is an iterative process. Your goal is to find all of the articles that are pertinent to your subject. Successful searching requires you to think about the complexity of language. You need to match the words you use in your search to the words used by article authors and database indexers. A thorough PubMed search must identify the author words likely to be in the title and abstract or the indexer's selected MeSH (Medical Subject Heading) Terms.

Start by doing a preliminary search using the words from the key parts of your research question.

Step #1: Initial Search

Enter the key concepts from your research question combined with the Boolean operator AND. PubMed does automatically combine your terms with AND. However, it can be easier to modify your search if you start by including the Boolean operators.

migraine AND acupuncture AND tryptamines

The search retrieves a number of relevant article records, but probably not everything on the topic.

Step #2: Evaluate Results

Use the Display Settings drop down in the upper left hand corner of the results page to change to Abstract display.

Review the results and move articles that are directly related to your topic to the Clipboard .

Go to the Clipboard to examine the language in the articles that are directly related to your topic.

look for words in the titles and abstracts of these pertinent articles that differ from the words you used
look for relevant MeSH terms in the list linked at the bottom of each article

The following two articles were selected from the search results and placed on the Clipboard.

Here are word differences to consider:

Initial search used acupuncture. MeSH Terms use Acupuncture therapy.
Initial search used migraine. Related word from MeSH Terms is Migraine without Aura and Migraine Disorders.
Initial search used tryptamines. Article title uses sumatriptan. Related word from MeSH is Sumatriptan or Tryptamines.

With this knowledge you can reformulate your search to expand your retrieval, adding synonyms for all concepts except for manual and plaque.

#3 Revise Search

Use the Boolean OR operator to group synonyms together and use parentheses around the OR groups so they will be searched properly. See the image below to review the difference between Boolean OR / Boolean AND.

Here is what the new search looks like:

(migraine OR migraine disorders) AND (acupuncture OR acupuncture therapy) AND (tryptamines OR sumatriptan)

Search Worksheet Example: Acupuncture vs. Triptans for Migraine
Search Worksheet
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Public health: literature reviews.

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What is a Systematic Literature Review?

If you are doing a literature review as part of your capstone project, please see this document for guidance on format and structure.

What is a literature review?

There are different types of literature reviews, for an overview on the differences between them please see this page . This page's main focus is systematic literature reviews -- please scroll down to find resources for doing scoping reviews .

At its most basic, a systematic review is a secondary study that summarizes research on a specific topic by means of explicit and rigorous methods. These are based on previously published works in the field and do not include new data or experiments.

Systematic reviews use a formal process to identify , select , appraise , analyze , and summarize the findings.

Try starting out by formulating and defining a clear, specific research question. The PICO Framework (standing for Population/problem, Intervention, Comparison and Outcome) is a guideline for focusing and answering health-related questions, and a well-formed clinical question covers these areas:

Developing a Protocol

What is a literature review protocol? Essentially, it is a document prepared before a review is started that serves as a guide to carrying it out. It describes the rationale, hypothesis, and planned methods of the review. The protocol should contain specific guidelines to identify and screen relevant articles for the review as well as outline the review methods for the entire process.

Why make a protocol for your literature review?

The key elements of a protocol are:

1 . Background/purpose

2 . Objectives/review question

3 . Methods

a . Selection criteria (such as: type of intervention, type of outcome, population of studies, types of studies, types of publications, publication dates, language, and location)

b . Search Strategy

c . Data Collection

d . Displaying data

e . Analysis and synthesis

A good way to develop a protocol is to use PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). PRISMA is a set of reporting standards for sharing your findings with the research community.

Use the PRISMA checklist and the PRISMA flow chart to help make sure your review is as thorough as possible.

See the full PRISMA statement here .

Below are some examples and templates for review protocols.

Protocol template from the World Health Organization

Protocol template from Cochrane

Protocol guidelines from the Campbell Collaboration

Search Strategy & Screening Tools

Free search strategy tools.

citationchaser Takes a starting set of articles and finds all of the articles that these records cite (their references), and all of the articles that cite them.
MeSH on Demand Identifies MeSH terms in submitted text & lists related Pubmed articles.
Pubmed PubReMiner Provides detailed analysis of PubMed Search results.
Yale MeSH Analyzer Extracts indexing information from MEDLINE articles to allow users to visually scan and compare key metadata.

Free screening tools.

Abstrackr Citation screening software created by Brown's Center for Evidence Synthesis in Health.
Abstrackr Tutorial
ASReview ASReview LAB is a free open-source machine learning tool for screening and systematically labeling a large collection of textual data.
ASReview Tutorials
Colandr Free, web-based, open-access tool for conducting evidence synthesis projects.
Colandr Tutorial
Rayyan Rayyan is a web-tool designed to help researchers working on systematic reviews, scoping reviews and other knowledge synthesis projects, by dramatically speeding up the process of screening and selecting studies.
Rayyan Tutorial
Systematic Review Data Repository SRDR+ is a free tool for data extraction, management, and archiving during systematic reviews.
SRDR+ Tutorials
PRISMA Statement
PRISMA-Equity Extension
STROBE statement
Finding What Works in Health Care: Standards for Systematic Reviews
Five Steps to Conducting a Systematic Review
Guide for Developing a Protocol for Conducting Literature Reviews
Summarizing and Synthesizing with a Literature Matrix
What is a Systematic Literature Review and how do I do one?

Scoping Reviews

A scoping review is a type of knowledge synthesis that uses a systematic and iterative approach to identify and synthesize an existing or emerging body of literature on a given topic. While there are several reasons for conducting a scoping review, the main reasons are to map the extent, range, and nature of the literature, as well as to determine possible gaps in the literature on a topic. Scoping reviews are not limited to peer-reviewed literature.

Mak S, Thomas A. Steps for Conducting a Scoping Review. J Grad Med Educ . 2022;14(5):565-567. doi:10.4300/JGME-D-22-00621.1

JBI Manual for Evidence Synthesis, Chapter 11: Scoping Reviews JBI, formerly known as the Joanna Briggs Institute, is an international research organization which develops and delivers evidence-based information, software, education and training.
PCC Question Outline The PCC Question outline helps frame the scoping review question and highlights important concepts for the literature search. From the Bernard Beck Medical Library at Washington U. St. Louis.
PRISMA-ScR This checklist contains 20 essential reporting items and 2 optional items to include when completing a scoping review.
Scoping Reviews: what they are & how you can do them Five videos featuring Dr Andrea C. Tricco presenting the definition of a scoping review, examples of scoping reviews, steps of the scoping review process, and methods used.
Scoping Review Guide SUNY Stony Brook University's Scoping Review Guide covers information you need to know to prepare for and conduct a scoping review.

Peters, M.D.J., Marnie, C., Colquhoun, H. et al. Scoping reviews: reinforcing and advancing the methodology and application. Syst Rev 10 , 263 (2021). https://doi.org/10.1186/s13643-021-01821-3

Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine . 2018;169(7):467-473. doi:10.7326/M18-0850

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Bettany-Saltikov J. How to do a systematic literature review in nursing: a step-by-step guide.Maidenhead: Open University Press; 2012

Bowers D, House A, Owens D. Getting started in health research.Oxford: Wiley-Blackwell; 2011

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Developing a framework for critiquing health research. 2005. https://tinyurl.com/y3nulqms (accessed 22 July 2019)

Cognetti G, Grossi L, Lucon A, Solimini R. Information retrieval for the Cochrane systematic reviews: the case of breast cancer surgery. Ann Ist Super Sanita. 2015; 51:(1)34-39 https://doi.org/10.4415/ANN_15_01_07

Dixon-Woods M, Cavers D, Agarwal S Conducting a critical interpretive synthesis of the literature on access to healthcare by vulnerable groups. BMC Med Res Methodol. 2006; 6:(1) https://doi.org/10.1186/1471-2288-6-35

Guyatt GH, Sackett DL, Sinclair JC Users' guides to the medical literature IX. A method for grading health care recommendations. JAMA. 1995; 274:(22)1800-1804 https://doi.org/10.1001/jama.1995.03530220066035

Hanley T, Cutts LA. What is a systematic review? Counselling Psychology Review. 2013; 28:(4)3-6

Cochrane handbook for systematic reviews of interventions. Version 5.1.0. 2011. https://handbook-5-1.cochrane.org (accessed 23 July 2019)

Jahan N, Naveed S, Zeshan M, Tahir MA. How to conduct a systematic review: a narrative literature review. Cureus. 2016; 8:(11) https://doi.org/10.7759/cureus.864

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Methley AM, Campbell S, Chew-Graham C, McNally R, Cheraghi-Sohi S. PICO, PICOS and SPIDER: a comparison study of specificity and sensitivity in three search tools for qualitative systematic reviews. BMC Health Serv Res. 2014; 14:(1) https://doi.org/10.1186/s12913-014-0579-0

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Mueller J, Jay C, Harper S, Davies A, Vega J, Todd C. Web use for symptom appraisal of physical health conditions: a systematic review. J Med Internet Res. 2017; 19:(6) https://doi.org/10.2196/jmir.6755

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Carrying out systematic literature reviews: an introduction

Alan Davies

Lecturer in Health Data Science, School of Health Sciences, University of Manchester, Manchester

View articles · Email Alan

Systematic reviews provide a synthesis of evidence for a specific topic of interest, summarising the results of multiple studies to aid in clinical decisions and resource allocation. They remain among the best forms of evidence, and reduce the bias inherent in other methods. A solid understanding of the systematic review process can be of benefit to nurses that carry out such reviews, and for those who make decisions based on them. An overview of the main steps involved in carrying out a systematic review is presented, including some of the common tools and frameworks utilised in this area. This should provide a good starting point for those that are considering embarking on such work, and to aid readers of such reviews in their understanding of the main review components, in order to appraise the quality of a review that may be used to inform subsequent clinical decision making.

Since their inception in the late 1970s, systematic reviews have gained influence in the health professions ( Hanley and Cutts, 2013 ). Systematic reviews and meta-analyses are considered to be the most credible and authoritative sources of evidence available ( Cognetti et al, 2015 ) and are regarded as the pinnacle of evidence in the various ‘hierarchies of evidence’. Reviews published in the Cochrane Library ( https://www.cochranelibrary.com) are widely considered to be the ‘gold’ standard. Since Guyatt et al (1995) presented a users' guide to medical literature for the Evidence-Based Medicine Working Group, various hierarchies of evidence have been proposed. Figure 1 illustrates an example.

Systematic reviews can be qualitative or quantitative. One of the criticisms levelled at hierarchies such as these is that qualitative research is often positioned towards or even is at the bottom of the pyramid, thus implying that it is of little evidential value. This may be because of traditional issues concerning the quality of some qualitative work, although it is now widely recognised that both quantitative and qualitative research methodologies have a valuable part to play in answering research questions, which is reflected by the National Institute for Health and Care Excellence (NICE) information concerning methods for developing public health guidance. The NICE (2012) guidance highlights how both qualitative and quantitative study designs can be used to answer different research questions. In a revised version of the hierarchy-of-evidence pyramid, the systematic review is considered as the lens through which the evidence is viewed, rather than being at the top of the pyramid ( Murad et al, 2016 ).

Both quantitative and qualitative research methodologies are sometimes combined in a single review. According to the Cochrane review handbook ( Higgins and Green, 2011 ), regardless of type, reviews should contain certain features, including:

Clearly stated objectives
Predefined eligibility criteria for inclusion or exclusion of studies in the review
A reproducible and clearly stated methodology
Validity assessment of included studies (eg quality, risk, bias etc).

The main stages of carrying out a systematic review are summarised in Box 1 .

Formulating the research question

Before undertaking a systemic review, a research question should first be formulated ( Bashir and Conlon, 2018 ). There are a number of tools/frameworks ( Table 1 ) to support this process, including the PICO/PICOS, PEO and SPIDER criteria ( Bowers et al, 2011 ). These frameworks are designed to help break down the question into relevant subcomponents and map them to concepts, in order to derive a formalised search criterion ( Methley et al, 2014 ). This stage is essential for finding literature relevant to the question ( Jahan et al, 2016 ).

It is advisable to first check that the review you plan to carry out has not already been undertaken. You can optionally register your review with an international register of prospective reviews called PROSPERO, although this is not essential for publication. This is done to help you and others to locate work and see what reviews have already been carried out in the same area. It also prevents needless duplication and instead encourages building on existing work ( Bashir and Conlon, 2018 ).

A study ( Methley et al, 2014 ) that compared PICO, PICOS and SPIDER in relation to sensitivity and specificity recommended that the PICO tool be used for a comprehensive search and the PICOS tool when time/resources are limited.

The use of the SPIDER tool was not recommended due to the risk of missing relevant papers. It was, however, found to increase specificity.

These tools/frameworks can help those carrying out reviews to structure research questions and define key concepts in order to efficiently identify relevant literature and summarise the main objective of the review ( Jahan et al, 2016 ). A possible research question could be: Is paracetamol of benefit to people who have just had an operation? The following examples highlight how using a framework may help to refine the question:

What form of paracetamol? (eg, oral/intravenous/suppository)
Is the dosage important?
What is the patient population? (eg, children, adults, Europeans)
What type of operation? (eg, tonsillectomy, appendectomy)
What does benefit mean? (eg, reduce post-operative pyrexia, analgesia).

An example of a more refined research question could be: Is oral paracetamol effective in reducing pain following cardiac surgery for adult patients? A number of concepts for each element will need to be specified. There will also be a number of synonyms for these concepts ( Table 2 ).

Table 2 shows an example of concepts used to define a search strategy using the PICO statement. It is easy to see even with this dummy example that there are many concepts that require mapping and much thought required to capture ‘good’ search criteria. Consideration should be given to the various terms to describe the heart, such as cardiac, cardiothoracic, myocardial, myocardium, etc, and the different names used for drugs, such as the equivalent name used for paracetamol in other countries and regions, as well as the various brand names. Defining good search criteria is an important skill that requires a lot of practice. A high-quality review gives details of the search criteria that enables the reader to understand how the authors came up with the criteria. A specific, well-defined search criterion also aids in the reproducibility of a review.

Search criteria

Before the search for papers and other documents can begin it is important to explicitly define the eligibility criteria to determine whether a source is relevant to the review ( Hanley and Cutts, 2013 ). There are a number of database sources that are searched for medical/health literature including those shown in Table 3 .

The various databases can be searched using common Boolean operators to combine or exclude search terms (ie AND, OR, NOT) ( Figure 2 ).

Although most literature databases use similar operators, it is necessary to view the individual database guides, because there are key differences between some of them. Table 4 details some of the common operators and wildcards used in the databases for searching. When developing a search criteria, it is a good idea to check concepts against synonyms, as well as abbreviations, acronyms and plural and singular variations ( Cognetti et al, 2015 ). Reading some key papers in the area and paying attention to the key words they use and other terms used in the abstract, and looking through the reference lists/bibliographies of papers, can also help to ensure that you incorporate relevant terms. Medical Subject Headings (MeSH) that are used by the National Library of Medicine (NLM) ( https://www.nlm.nih.gov/mesh/meshhome.html) to provide hierarchical biomedical index terms for NLM databases (Medline and PubMed) should also be explored and included in relevant search strategies.

Searching the ‘grey literature’ is also an important factor in reducing publication bias. It is often the case that only studies with positive results and statistical significance are published. This creates a certain bias inherent in the published literature. This bias can, to some degree, be mitigated by the inclusion of results from the so-called grey literature, including unpublished work, abstracts, conference proceedings and PhD theses ( Higgins and Green, 2011 ; Bettany-Saltikov, 2012 ; Cognetti et al, 2015 ). Biases in a systematic review can lead to overestimating or underestimating the results ( Jahan et al, 2016 ).

An example search strategy from a published review looking at web use for the appraisal of physical health conditions can be seen in Box 2 . High-quality reviews usually detail which databases were searched and the number of items retrieved from each.

A balance between high recall and high precision is often required in order to produce the best results. An oversensitive search, or one prone to including too much noise, can mean missing important studies or producing too many search results ( Cognetti et al, 2015 ). Following a search, the exported citations can be added to citation management software (such as Mendeley or Endnote) and duplicates removed.

Title and abstract screening

Initial screening begins with the title and abstracts of articles being read and included or excluded from the review based on their relevance. This is usually carried out by at least two researchers to reduce bias ( Bashir and Conlon, 2018 ). After screening any discrepancies in agreement should be resolved by discussion, or by an additional researcher casting the deciding vote ( Bashir and Conlon, 2018 ). Statistics for inter-rater reliability exist and can be reported, such as percentage of agreement or Cohen's kappa ( Box 3 ) for two reviewers and Fleiss' kappa for more than two reviewers. Agreement can depend on the background and knowledge of the researchers and the clarity of the inclusion and exclusion criteria. This highlights the importance of providing clear, well-defined criteria for inclusion that are easy for other researchers to follow.

Full-text review

Following title and abstract screening, the remaining articles/sources are screened in the same way, but this time the full texts are read in their entirety and included or excluded based on their relevance. Reasons for exclusion are usually recorded and reported. Extraction of the specific details of the studies can begin once the final set of papers is determined.

Data extraction

At this stage, the full-text papers are read and compared against the inclusion criteria of the review. Data extraction sheets are forms that are created to extract specific data about a study (12 Jahan et al, 2016 ) and ensure that data are extracted in a uniform and structured manner. Extraction sheets can differ between quantitative and qualitative reviews. For quantitative reviews they normally include details of the study's population, design, sample size, intervention, comparisons and outcomes ( Bettany-Saltikov, 2012 ; Mueller et al, 2017 ).

Quality appraisal

The quality of the studies used in the review should also be appraised. Caldwell et al (2005) discussed the need for a health research evaluation framework that could be used to evaluate both qualitative and quantitative work. The framework produced uses features common to both research methodologies, as well as those that differ ( Caldwell et al, 2005 ; Dixon-Woods et al, 2006 ). Figure 3 details the research critique framework. Other quality appraisal methods do exist, such as those presented in Box 4 . Quality appraisal can also be used to weight the evidence from studies. For example, more emphasis can be placed on the results of large randomised controlled trials (RCT) than one with a small sample size. The quality of a review can also be used as a factor for exclusion and can be specified in inclusion/exclusion criteria. Quality appraisal is an important step that needs to be undertaken before conclusions about the body of evidence can be made ( Sambunjak and Franic, 2012 ). It is also important to note that there is a difference between the quality of the research carried out in the studies and the quality of how those studies were reported ( Sambunjak and Franic, 2012 ).

The quality appraisal is different for qualitative and quantitative studies. With quantitative studies this usually focuses on their internal and external validity, such as how well the study has been designed and analysed, and the generalisability of its findings. Qualitative work, on the other hand, is often evaluated in terms of trustworthiness and authenticity, as well as how transferable the findings may be ( Bettany-Saltikov, 2012 ; Bashir and Conlon, 2018 ; Siddaway et al, 2019 ).

Reporting a review (the PRISMA statement)

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) provides a reporting structure for systematic reviews/meta-analysis, and consists of a checklist and diagram ( Figure 4 ). The stages of identifying potential papers/sources, screening by title and abstract, determining eligibility and final inclusion are detailed with the number of articles included/excluded at each stage. PRISMA diagrams are often included in systematic reviews to detail the number of papers included at each of the four main stages (identification, screening, eligibility and inclusion) of the review.

Data synthesis

The combined results of the screened studies can be analysed qualitatively by grouping them together under themes and subthemes, often referred to as meta-synthesis or meta-ethnography ( Siddaway et al, 2019 ). Sometimes this is not done and a summary of the literature found is presented instead. When the findings are synthesised, they are usually grouped into themes that were derived by noting commonality among the studies included. Inductive (bottom-up) thematic analysis is frequently used for such purposes and works by identifying themes (essentially repeating patterns) in the data, and can include a set of higher-level and related subthemes (Braun and Clarke, 2012). Thomas and Harden (2008) provide examples of the use of thematic synthesis in systematic reviews, and there is an excellent introduction to thematic analysis by Braun and Clarke (2012).

The results of the review should contain details on the search strategy used (including search terms), the databases searched (and the number of items retrieved), summaries of the studies included and an overall synthesis of the results ( Bettany-Saltikov, 2012 ). Finally, conclusions should be made about the results and the limitations of the studies included ( Jahan et al, 2016 ). Another method for synthesising data in a systematic review is a meta-analysis.

Limitations of systematic reviews

Apart from the many advantages and benefits to carrying out systematic reviews highlighted throughout this article, there remain a number of disadvantages. These include the fact that not all stages of the review process are followed rigorously or even at all in some cases. This can lead to poor quality reviews that are difficult or impossible to replicate. There also exist some barriers to the use of evidence produced by reviews, including ( Wallace et al, 2012 ):

Lack of awareness and familiarity with reviews
Lack of access
Lack of direct usefulness/applicability.

Meta-analysis

When the methods used and the analysis are similar or the same, such as in some RCTs, the results can be synthesised using a statistical approach called meta-analysis and presented using summary visualisations such as forest plots (or blobbograms) ( Figure 5 ). This can be done only if the results can be combined in a meaningful way.

Meta-analysis can be carried out using common statistical and data science software, such as the cross-platform ‘R’ ( https://www.r-project.org), or by using standalone software, such as Review Manager (RevMan) produced by the Cochrane community ( https://tinyurl.com/revman-5), which is currently developing a cross-platform version RevMan Web.

Carrying out a systematic review is a time-consuming process, that on average takes between 6 and 18 months and requires skill from those involved. Ideally, several reviewers will work on a review to reduce bias. Experts such as librarians should be consulted and included where possible in review teams to leverage their expertise.

Systematic reviews should present the state of the art (most recent/up-to-date developments) concerning a specific topic and aim to be systematic and reproducible. Reproducibility is aided by transparent reporting of the various stages of a review using reporting frameworks such as PRISMA for standardisation. A high-quality review should present a summary of a specific topic to a high standard upon which other professionals can base subsequent care decisions that increase the quality of evidence-based clinical practice.

Systematic reviews remain one of the most trusted sources of high-quality information from which to make clinical decisions
Understanding the components of a review will help practitioners to better assess their quality
Many formal frameworks exist to help structure and report reviews, the use of which is recommended for reproducibility
Experts such as librarians can be included in the review team to help with the review process and improve its quality

CPD reflective questions

Where should high-quality qualitative research sit regarding the hierarchies of evidence?
What background and expertise should those conducting a systematic review have, and who should ideally be included in the team?
Consider to what extent inter-rater agreement is important in the screening process

Usman Iqbal 2024 Convocation Alumni Speaker

BUSPH Convocation pamphlet placed in red flowers

A Letter to Our Graduates, the Class of 2024

Literature reviews ..

A literature review is systematic examination of existing research on a proposed topic (1). Public health professionals often consult literature reviews to stay up-to-date on research in their field (1–3). Researchers also frequently use literature reviews as a way to identify gaps in the research and provide a background for continuing research on a topic (1,2). This section will provide an overview of the essential elements needed to write a successful literature review.

Collecting Articles

Do not hesitate to reach out to a reference librarian at the BUMC Alumni Medical Library for assistance in collecting your research.

Reviewing the Research

After selecting the articles for your review, read each article and takes notes to keep track of each paper (3). One way to effectively take notes is to create a table listing each article’s research question, methods, results, limitations, etc. Once you have finished reading the articles, critically think about why each one is important to your discussion (1,2,4). Try to group articles based on similar content, such as similar study populations, methods, or results (4). Most literature reviews do not require you to organize your articles in a certain manner; however, you should think about how you would logically tie your articles together so that you are analyzing them, not simply summarizing each article (4).

Organizing your Review

While there is no standard organization for a literature review, literature reviews generally follow this structure (1,3):

Introduction. The introduction should identify a research question and relate it to a public health topic. The significance of the public health problem and topic should be described.
Body. The body of a literature review should be organized so that the review flows logical from one subtopic to another subtopic. Consider breaking this section into the following sections:
Methods. Describe how you obtained your articles. Be sure to include the names of search engines and key words used to generate searches. Detail your inclusion and exclusion criteria (i.e. did not fit your definition of your outcome). Consider creating a flow chart to illustrate your search process.
Results/Discussion. Explain what the literature says about your question. What did the studies find? Is their conflicting evidence? What are the limitations of the current studies? What gaps exist in the literature? What are the outstanding research questions? A table of your studies can be a great tool to summarize of the essential information.
Conclusion. Review your findings and how they relate to your research questions. Use this space to propose needs in the research, if appropriate.

Collecting articles, reviewing your research, and organizing your review are the first steps toward writing a literature review. Reading examples of peer-reviewed literature reviews is an excellent way to brainstorm how to organize your research and tables.

Additional Resources

The following resources also provide a more in-depth discussion on writing literature reviews:

Ten Simple Rules for Writing a Literature Review (requires BU Kerberos Login)
Handout on Writing Literature Reviews from UNC Writing Center
Tips for Writing a Public Health Literature Review from Tulane University
Get the Lit: The Literature Review Video from Texas A&M University Writing Center
University of North Carolina at Chapel Hill. Literature Reviews [Internet]. The Writing Center. [cited 2014 Jul 15]. Available from: http://writingcenter.unc.edu/handouts/literature-reviews/
Tips for writing a public health literature review [Internet]. Tulane University School of Public Health and Tropical Medicine 1. Department of Community Health Sciences; [cited 2014 Jul 15]. Available from: http://tulane.edu/publichealth/mchltp/upload/Writing-Lit-review.pdf
Pautasso M. Ten Simple Rules for Writing a Literature Review. PLoS Comput Biol. 2013 Jul 18;9(7):e1003149.
Get Lit: The Literature Review [Internet]. 2011 [cited 2014 Jul 15]. Available from: http://www.youtube.com/watch?v=Y1hG99HUaOk&feature=youtube_gdata_player

Systematic Review
Open access
Published: 10 May 2024

Network meta-analysis of the intervention effects of different exercise measures on Sarcopenia in cancer patients

Rui Liu 1 na1 ,
XY Gao 1 na1 &
Li Wang 1

BMC Public Health volume 24 , Article number: 1281 ( 2024 ) Cite this article

20 Accesses

2 Altmetric

Metrics details

This study aims to investigate the impact of four exercise modes (aerobic exercise, resistance exercise, aerobic combined with resistance multimodal exercise, and stretching) on the physical performance of cancer patients.

Randomized controlled trials (RCTs) were exclusively collected from PubMed, EMBASE, Web of Science, and The Cochrane Library, with a search deadline of April 30, 2023. Different exercise interventions on the physical performance of cancer patients were studied, and the Cochrane risk of bias assessment tool was employed to evaluate the quality of the included literature. Data analysis was conducted using STATA 15.1 software.

This study included ten randomized controlled trials with a combined sample size of 503 participants. Network meta-analysis results revealed that aerobic combined with resistance multimodal exercise could reduce fat mass in cancer patients (SUCRA: 92.3%). Resistance exercise could improve lean mass in cancer patients (SUCRA: 95.7%). Furthermore, resistance exercise could enhance leg extension functionality in cancer patients with sarcopenia (SUCRA: 83.0%).

This study suggests that resistance exercise may be more beneficial for cancer-related sarcopenia.In clinical practice, exercise interventions should be tailored to the individual patients’ circumstances.

Registration number

This review was registered on INPLASY2023110025; DOI number is https://doi.org/10.37766/inplasy2023.11.0025 .

Peer Review reports

Sarcopenia is a systemic syndrome characterized primarily by the weakening or loss of muscle mass and function [ 1 ]. Its pathogenesis is associated with inflammatory responses, hormone levels, and insulin resistance within the body, subsequently leading to disruptions in protein synthesis and the onset of sarcopenia [ 2 , 3 ]. Based on differing mechanisms of occurrence, sarcopenia is classified into primary (i.e., degenerative) and secondary types, with the former being more prevalent among older people. At the same time, the latter is commonly observed in cases of chronic wasting. Tumor patients constitute a prominent demographic affected by secondary muscle atrophy, with an incidence rate of approximately 38.6%. This condition is closely linked to postoperative complications, chemotherapy toxicity reactions, and overall survival rates [ 4 ]. Statistics reveal that for tumor patients, a 25% reduction in body mass corresponds to a loss of 75% of skeletal muscle myocardium protein. Even more concerning, sarcopenia is responsible for approximately one-fifth of all tumor-related fatalities [ 5 , 6 , 7 ].

So far, the existing drug treatments have not been entirely satisfactory, and the accompanying side effects and high medical costs have restricted the clinical application of such therapies. Therefore, the search for a cost-effective, low-side-effect, non-pharmaceutical alternative has become increasingly important. Several studies suggest that exercise interventions can effectively delay the onset of sarcopenia in cancer patients, improve their quality of life, and extend their survival periods, making them the most efficient measure for treating sarcopenia [ 8 , 9 , 10 , 11 ]. However, due to the diverse nature and distinct characteristics of exercise intervention measures, there is currently no unanimous consensus on which exercise intervention is the most effective.

Network meta-analysis is an advanced, evidence-based technique that enables direct or indirect comparisons of the effects of multiple interventions on a particular disease and ranks their relative efficacy for improvement [ 12 ]. In this study, we aim to evaluate the impact of various exercise interventions on the physical performance of cancer patients with sarcopenia. By comparing these exercise interventions, we aim to provide valuable insights for healthcare professionals and patients.

Materials and methods

Search strategy.

Through a computer search encompassing four electronic databases, namely PubMed, EMBASE, Web of Science, and The Cochrane Library, covering the period from their inception to April 2023, the retrieval strategy was structured by the PICOS framework: (P) Population: cancer patients; (I) Intervention: exercise; (C) Control Group: a control group receiving standard care or stretching exercises exclusively; (O) Outcomes: lean mass, fat mass, and leg extension test (leg extension); (S) Study Type: randomized controlled trials. Taking PubMed as an example, the detailed search strategy is shown in Table 1 .

Inclusion criteria

(1) The experimental group and various exercise training methods as interventions for tumor patients. (2) The control group comprises patients receiving exercise interventions distinct from those in the experimental group or receiving routine care. (3) A clinical randomized controlled trial. (4) Outcomes encompass at least one of the following indicators: lean mass, fat mass, and leg extension test.

Exclusion criteria

(1) Literature lacking complete or accessible data; (2) non-randomized controlled trials, including quasi-randomized controlled trials and animal studies; (3) conference abstracts, case reports, and communications; (4) outcome measures that cannot be converted or aggregated; (5) literature not in the English language.

Study selection

Literature screening and exclusion were carried out using EndNote 20, a literature management software. Initially, two researchers independently conducted literature screening using the inclusion and exclusion criteria. Duplicate titles, non-randomized controlled trial studies, retrospective papers, conference papers, protocols, and correspondence were eliminated. Subsequently, the abstracts of the remaining literature were reviewed to determine their inclusion or exclusion. Any remaining literature was then subjected to a cross-check and comparison by both researchers. If the assessments were identical, the literature was included; in cases of disagreement, the third investigator facilitated discussion and resolution.

Data extraction

Seven predetermined data elements were chosen: (1) author’s name, (2) year of publication, (3) country, (4) study duration, (5) sample size, (6) mean age, and (7) outcome measures for exercise intervention.

Literature quality evaluation

The assessment of literature quality was conducted independently by two researchers, with a subsequent thorough review of the results. In cases of disagreement, a third party was consulted for evaluation. The evaluation of the risk of bias was carried out using the Cochrane 5.1.0 Risk Assessment Tool (ROB), considering seven key domains: (1) random sequence generation; (2) allocation concealment; (3) blinding of participants and experimenters; (4) investigator blinding; (5) completeness of outcome data; (6) selective reporting of results; and (7) other potential sources of bias. Each domain was categorized as having “high risk of bias,” “low risk of bias,” or “unclear.” Trials were then stratified into three levels of risk of bias based on the number of components with high ROB: high risk (5 or more), moderate risk (3 to 4), and low risk (2 or fewer) [ 13 ]. The results were ultimately presented in charts and tables.

Data analysis

Employing various exercise interventions, all outcome measures were treated as continuous variables, and the presentation and analysis included mean, standard deviation (SD) and mean-variance (MD, representing the absolute difference between the treatment and control groups and calculated using the same sample size) or standardized mean difference (SMD, indicating the mean of the groups divided by the standard deviation between subjects, suitable for data analysis in trials of varying sizes), along with 95% confidence interval (CI) [ 14 ]. Given the heterogeneity among studies, we opted for a random effects model for the analysis rather than a fixed effects model [ 15 ].

The Stata software, version 15.1, was employed for the NMA summary and analysis, utilizing the Bayesian Markov Chain Monte Carlo algorithm. To assess consistency, node splitting was applied, with a threshold of a p -value greater than 0.05 indicating the use of the consistency model; otherwise, the inconsistency model was employed [ 16 ]. Stata generated the network graph, where each node represents an independent intervention, and the connecting lines between nodes signify direct comparisons between interventions. The size of each node and the width of the lines are proportional to the number of trials conducted [ 17 ].

The greater the SUCRA value, the higher the likelihood of being the most effective intervention [ 17 ]. When determining the ranking of SUCRA, in addition to comparing the area under the cumulative ranking probability curve for different exercise interventions (surface under the cumulative ranking, SUCRA), it is essential to interpret the clinical significance of these interventions carefully. Furthermore, to address the possibility of publication bias in NMA, we constructed a network funnel plot and visually assessed its symmetry to detect the presence of small-sample effects [ 17 ].

Literature screening process

Following a thorough search across multiple databases, an initial screening identified 1,541 relevant articles. A manual search yielded nine more articles, and with the assistance of Endnote software, 339 duplicate entries were removed. Subsequent examinations of titles and abstracts resulted in excluding 1,106 articles deemed irrelevant. This process left 73 articles for full-text evaluation, eventually culminating in the inclusion of 10 pieces in the meta-analysis (Fig. 1 ).

Flow chart of literature screening

Out of the ten studies included [ 11 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ], 2 of them [ 11 , 22 ] were categorized as low risk, while 8 [ 11 , 20 , 22 , 25 ] were classified as medium risk. All the included studies referred to random allocation, with 4 [ 11 , 18 , 20 , 21 ] explicitly mentioning the use of computerized grouping, while the remaining literature indicated randomization. In three [ 11 , 21 , 22 ] of the studies, a specific concealed allocation scheme was proposed. Due to the nature of the exercise intervention, achieving blinding for both the subjects and assessors was challenging, as patients and their families needed to provide informed consent before participating in the experiments. All the studies described the rate and reasons for loss to follow-up, and the outcome measures were comprehensive. The baseline characteristics of the intervention groups were reasonably balanced, with no signs of selective reporting. For detailed information, please refer to Fig. 2 A and B.

( A ) Risk of bias plot for literature quality assessment; ( B ) Scale plot of risk of bias for literature quality evaluation

Basic characteristics of the included literature

This study incorporated ten randomized controlled trials (RCTs), encompassing 503 patients diagnosed with malignancies, with 310 male and 193 female participants. The selected studies contained four distinct types of exercises models: 5 RCTs introduced resistance exercises in the experimental group [ 11 , 19 , 21 , 25 ], 5 RCTs implemented aerobic combined with resistance multimodal exercise [ 16 , 18 , 22 , 23 , 24 ], and 2 RCTs within the control group utilized stretching exercises [ 11 , 22 ], while the remaining control groups involved routine activities without any additional interventions. All ten of the included studies reported fat mass as an outcome measure [ 11 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ], lean mass as an outcome measure [ 11 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ], and six studies measured leg extension as an outcome indicator [ 11 , 18 , 19 , 20 , 21 , 22 ]. These studies were distributed across regions, with three originating from the Americas, two from Europe, and six from Oceania. Detailed characteristics of the included studies are presented in Table 2 .

Mesh Meta-analysis results

The full figures are detailed in Figs. 3 A and 4 A, and 5 A.

The NMA plot of fat mass; B Fat mass SUCRA Fig

The NMA plot of lean mass; B Lean mass SUCRA Fig

The NMA plot of leg extension; B Leg extension SUCRA Fig

A total of 10 randomized controlled trials (RCTs) was included, and multiple exercise interventions, primarily focusing on routine exercise, formed a complex network structure comprising two interconnected loops. The node-splitting test assessed the consistency between indirect and direct outcomes from all studies. The results of the network meta-analysis indicated that stretching [MD = -4.02, 95% CI = (10.42, 2.38)] and aerobic combined with resistance multi modal exercise [MD = -6.09, 95% CI = (-10.84, -1.34)] exhibited superior performance compared to conventional practice in comparison with the control group. The top-ranking intervention, based on the best-ranking results, was aerobic combined with resistance multimodal exercise, demonstrating the most effective reduction in tumor fat mass (SUCRA: 92.3%, as depicted in Fig. 3 B). Further comparisons between different exercise interventions are presented in Table 3 .

A total of 10 randomized controlled trials (RCTs) were included in the analysis. Multiple exercise interventions, predominantly centered around routine exercises, formed a complex network structure, resulting in two interconnected closed loops. Consistency between indirect and direct outcome indicators from all studies was evaluated. The network meta-analysis revealed that resistance exercise [MD = 14.00, 95% CI = (4.41, 23.60)] outperformed conventional exercise compared to the control group. The highest-ranking results demonstrated that resistance exercise was the most effective in increasing lean mass in tumor patients with sarcopenia (SUCRA: 95.7%, as depicted in Fig. 4 B). Detailed comparisons between the various exercise interventions can be found in Table 4 .

Leg extension

A total of 6 randomized controlled trials (RCTs) were incorporated into the study, and various exercise interventions were primarily based on routine exercises, resulting in a complex network structure with a closed loop. To assess the consistency between indirect and direct indicators from all studies, the node-splitting test was employed. The network meta-analysis indicated that resistance exercise [MD = 68.27, 95% CI = (26.25, 110.30)] and aerobic combined with resistance multimodal exercise [MD = 57.97, 95% CI = (5.23, 121.16)] outperformed the control group. The top-ranking results highlighted that resistance exercise was the most effective in enhancing the Leg extension function in cancer patients with sarcopenia (SUCRA: 83.0%, as displayed in Fig. 5 B). Detailed comparisons between the diverse exercise interventions can be found in Table 5 .

Publication bias trial

A publication bias funnel plot was generated for the intervention effect indicators of various exercise modalities on sarcopenia in cancer patients (Fig. 6 A, B and C), and no notable publication bias was observed upon visual inspection of the funnel plot.

( A ) The funnel plot of fat mass bias; ( B ) The funnel plot of lean mass bias; ( C ) The funnel plot of leg extension bias

A total of 10 randomized controlled trials (RCTs) were included, comprising a combined total of 503 cancer patients. Through the comparative analysis of the effects of various exercise interventions, including aerobic exercise, resistance exercise, aerobic resistance combined with multimodal training, and stretching exercise in cancer patients, our study demonstrates that differences in exercise interventions highlight the variability in their capacity to enhance sarcopenia and function in patients with sarcopenia-related tumours. Cancer patients must select targeted exercise interventions carefully. Resistance exercise exhibits the most favourable impact on improving lean mass and leg extension, while aerobic combined with resistance multimodal exercise is most effective in reducing fat mass in tumor patients with sarcopenia. Upon a comprehensive assessment, we assert that resistance exercise is competitive in ameliorating sarcopenia in cancer patients.

While ‘sarcopenia’ is defined as the loss of muscle mass or function, it is increasingly acknowledged that sarcopenia can also coexist with obesity. Excessive fat can obscure the absence of skeletal muscle mass. Thus, the measurement of fat mass is an essential component in the diagnosis of sarcopenia. Early detection, diagnosis, and exercise intervention are pivotal for prognosis improvement and sarcopenia treatment [ 27 , 28 , 29 ]. For cancer patients, engaging in 150 min of moderate or 75 min of high-intensity exercise per week is deemed safe. It can reduce abnormal lipid accumulation in skeletal muscle, enhance glucose circulation metabolism, and decrease fat mass [ 18 , 30 , 31 , 32 ]. Regular fat mass measurements enable dynamic patient monitoring and adjustment of the regimen to achieve the optimal treatment outcome. The results demonstrate that combined resistance exercise is effective in reducing fat mass, which is statistically significant when compared to the control group. In contrast to resistance exercise, aerobic combined with resistance exercise offers more diversity, not only increasing exercise engagement but also boosting participants’ motivation, thus yielding more pronounced exercise effects.

Within the domain of studies about “sarcopenia,” assessments of lean mass (also known as lean weight or fat-free mass) are customarily incorporated, as they represent one of the paramount indicators of sarcopenia [ 31 ]. The reduction in muscle mass observed in sarcopenia often stems from a combination of muscle atrophy and cell death. At the molecular level, previous research has pointed to the association between sarcopenia and mitochondrial dysfunction, along with alterations in protein synthesis and degradation [ 32 , 33 , 34 ]. The measurement of lean mass allows us to furnish concrete evidence regarding the effectiveness of exercise interventions on skeletal muscle. Exercise interventions have the potential to stimulate the production of crucial regulatory components within skeletal muscle mitochondria, suppress ubiquitin-proteasome system (UPS) activity, enhance the expression of autophagy-related genes, improve mitochondrial oxidative capacity, and increase muscle blood flow [ 35 , 36 , 37 ]. Our findings indicate that resistance exercise yields significant intervention effects on lean mass in patients with tumor-related sarcopenia. This can be attributed to the stimulation of mitochondrial “biogenesis” through resistance exercise, which accelerates muscle cell signalling, increases mitochondrial count, enhances glucose transporter capacity and reduces the production of muscle growth inhibitors. Consequently, this process inhibits the proliferation and differentiation of myoblasts in developing muscles [ 38 , 39 , 40 ].

The relationship between lower limb strength and physical function is more closely intertwined than that of the upper limbs. Resistance exercise has found widespread use in the treatment of tumor-related sarcopenia patients. Impedance exercise, involving the application of external force to facilitate synergistic and antagonistic muscle training, can enhance lower limb muscle strength and endurance among patients with tumor-related sarcopenia, thus leading to improved leg extension function. Our results demonstrate a significant intervention effect of resistance exercise on leg extension function in tumor-related sarcopenia patients. This can be attributed to the requirements of muscle strength during resistance exercise, which consequently impacts the power of muscle motor units and the number and type of muscle fibers and fosters muscle growth and repair. Such improvements in muscle contraction afford patients greater control during leg extension, reducing muscle fatigue and pain [ 38 , 39 , 40 ]. Furthermore, the persistent mechanical strain on osteocytes induced by resistance training can promote their physical deformation, subsequently expediting bone remodeling and tissue regeneration and ultimately enhancing bone density [ 41 ]. Therefore, the study of tumor-related sarcopenia patients underscores that regular resistance exercise training represents a practical approach for restoring and enhancing leg extension function, ultimately improving the overall quality of life.

Advantage and limitations

Therapies aimed at addressing tumor-induced sarcopenia have garnered significant attention. Moderate exercise has demonstrated its potential to enhance overall bodily function and augment muscle mass in tumor patients. This study consolidates data from 10 eligible studies involving 503 patients to corroborate the efficacy of four exercise modes: resistance exercise, aerobic combined resistance multimodal exercise, and stretching exercise. In comparison to the meta-analysis of relevant literature, resistance exercise has shown a more pronounced impact on patients by bolstering both muscle strength and mass. This study provides valuable guidance for future research endeavors.

This study has its limitations. First, it relies on currently available English literature about tumor sarcopenia, which may introduce certain constraints to the study findings. Second, there exists some degree of heterogeneity and bias in the study results. Third, the research is influenced by variations in disease types, cultural backgrounds, and the healthcare systems of cancer patients. Therefore, it is imperative to tailor exercise interventions to individual needs based on the specific circumstances of each patient. Our study has not yet included aerobic capacity testing and leg press testing, and thus cannot assess physical performance, which is what we are working towards in the future.

The findings of this study underscore the superiority of resistance exercise over other exercise modalities in enhancing muscle mass and function. Consequently, the inclusion of resistance exercise in the rehabilitation regimen for cancer patients is of paramount importance. Tailoring the intervention to the individual circumstances of the patients and implementing it promptly is crucial for achieving optimal outcomes. Additionally, further investigation into the specific application methods and results of exercise in the rehabilitation of cancer patients is warranted to offer more scientifically informed guidance for clinical practice.

Data availability

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

Abbreviations

Randomized controlled trials

Risk Assessment Tool

Standard deviation

Confidence interval

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Acknowledgements

We would like to acknowledge the reviewers for their helpful comments on this paper.

This work was supported by the Nursing project of Beijing Hope Marathon Fund of China Cancer Foundation (Item number: LC2022C03).

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Loneliness in Emerging Adulthood: A Scoping Review

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Emma M. Kirwan ORCID: orcid.org/0000-0001-8536-023X 1 , 2 ,
Annette Burns 3 ,
Páraic S. O’Súilleabháin 1 , 2 ,
Sarah Summerville 1 ,
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Loneliness is prevalent during emerging adulthood (approximately 18–25 years) and is an important issue given it has been linked to poorer physical and mental health outcomes. This preregistered scoping review aimed to provide an overview of the literature on loneliness in emerging adulthood, including the (a) conceptualization and measurement of loneliness, (b) loneliness theories used, (c) risk factors and outcomes examined, (d) sex-gender differences observed, and (e) characteristics of emerging adult samples previously researched. Following the Joanna Briggs Institute (JBI) guidelines, seven electronic databases were searched for articles focused on loneliness published from 2016 to 2021, where the mean age of participants was ≥ 18 and ≤ 25 years. Of the 4068 papers screened, 201 articles were included in the final review. Findings suggest the need for a clearer consensus in the literature regarding the conceptualization of loneliness for emerging adults and more qualitative work exploring emerging adults’ subjective experiences of loneliness. Results highlight an over-reliance on cross-sectional studies. Over two thirds of articles described their sample as university students and the median percentage of females was 63.30%. Therefore, fewer cross-sectional studies using convenience samples and more population-based, longitudinal research is needed to understand the factors predicting loneliness over time, and the downstream impact of loneliness for emerging adults.

Estimating the prevalence of social and emotional loneliness across the adult lifespan

“where are all the lonely people” a population-based study of high-risk groups across the life span.

“It’s a feeling of complete disconnection”: experiences of existential loneliness from youth to older adulthood

Avoid common mistakes on your manuscript.

Introduction

Loneliness is commonly defined as the unpleasant feeling that accompanies the experience of perceiving the quantity or quality of one’s social relationships as inadequate (Perlman & Peplau, 1981 ). While loneliness is common across the lifespan, it is particularly prevalent in young, or emerging adults (Barreto et al., 2021 ; Hawkley et al., 2022 ). Prevalence estimates from the United Kingdom suggest up to 31% of emerging adults experience loneliness at least some of the time, and 5–7% feel lonely often (Matthews et al., 2019 ). In the United States, about 24% of emerging adults report feeling lonely “a lot of the day” (Witters, 2023 ), and almost one in three (32.6%) emerging adults in India report high levels of loneliness (Banerjee & Kohli, 2022 ). Emerging adult loneliness has been independently associated with indictors of poorer physical and mental health, including hypertension, anxiety and depressive symptoms, alcohol problems, and long-term mental illness (Christiansen et al., 2021 ). Therefore, loneliness is an important issue in emerging adulthood and good quality research is a key step in offsetting this potential harm. However, the literature is lacking a review that summarizes important aspects of the research in emerging adulthood, including how loneliness is conceptualized and measured, which loneliness theories are used, which risk factors and outcomes of loneliness have been examined, if there are sex-gender differences in loneliness, and the characteristics of emerging adults previously included in research in this area. This information is needed to provide a basis for rigorous loneliness research for this group. Therefore, this scoping review addresses this gap.

Loneliness in Emerging Adulthood

The transition from adolescence to full-fledged adulthood in developed countries is longer and more challenging to define than in previous points in history. This is primarily due to engaging in traditional markers of adulthood such as marriage and parenthood at later ages, and the widespread uptake of education beyond secondary school (Arnett, 2024 ). Arnett’s theory of emerging adulthood ( 2000 , 2024 ) describes a distinct life-stage, from late teens through mid-to-late twenties. When age ranges are needed to describe emerging adulthood, ages 18–25 years are considered a conservative estimate, as few 18–25-year-olds have entered stable adulthood (Arnett, 2024 ). However, the specific age of the beginning and end of this life stage is variable, and critics have noted that the concept of emerging adulthood is heavily influenced by cultural, socioeconomic, and educational factors (Shanahan & Longest, 2009 ). Culture plays an important role in variation in the length and content of emerging adulthood, and the markers of established adulthood (Arnett, 2024 ). For instance, in keeping with the Chinese tradition of collectivism, a key marker of adulthood for Chinese emerging adults is the ability to financially support their parents, whereas this is not typically endorsed in the United States (Nelson & Luster, 2015 ).

Despite these critiques, there is general agreement that the prolonged entry into adulthood has resulted in significant developmental challenges (Côté, 2014 ). Typical features of emerging adulthood include identity exploration and greater self-focus, which may lead to instability in emerging adults’ social networks (Arnett & Mitra, 2020 ). Major social transitions occurring during young, or emerging, adulthood include moving out of the parental home, or beginning university or employment (Arnett, 2024 ). An age-normative perspective suggests that the timing of ongoing physical and psychological changes, unique societal expectations, and key social transitions places emerging adults at increased risk of loneliness (Qualter et al., 2015 ). Given the vulnerability to loneliness in this age group, robust research is needed to understand loneliness in emerging adulthood.

Recognizing that emerging adults are at particular risk for loneliness emphasizes the need to consider factors associated with loneliness in this group. However, the research priorities in relation to examining risk factors and outcomes of loneliness in emerging adulthood are unclear. One existing scoping review explored the literature on loneliness in youth (aged 15–24 years; Adib & Sabharwal, 2023 ); however, the review was limited in scope with a specific focus on social support and relationship factors like parenting bonds, both of which were inversely associated with loneliness. The extent to which other factors that may be associated with loneliness, for example mental health issues and technology use (Matthews et al., 2019 ), are focused on in the literature with emerging adults have not been reviewed. Additionally, gender differences in loneliness are important for understanding who is most vulnerable to loneliness. While one comprehensive meta-analysis suggested that young adult males were lonelier than females (Maes et al., 2019 ), this study considered a much wider age range (21–40 years) as young adulthood. Therefore, summarizing sex-gender differences in emerging adulthood merits consideration. Finally, persistent sampling bias issues mean that loneliness research generalized to emerging adults may be based on convenience samples of university undergraduates which may not represent diverse groups (Nielsen et al., 2017 ). It is unclear to what extent specific groups who disproportionately experience loneliness, such as migrants and people with poor health (Barreto et al., 2023 ), are focused on in the literature. Understanding who we study when we study emerging adults is of importance; therefore, a summary of the characteristics of emerging adults included in loneliness research is needed to support robust research in this area.

A key aspect of understanding loneliness in emerging adulthood is a clear conceptualization and distinction from related concepts. Loneliness is a subjective and emotional experience that is related to, but distinct from social isolation, which is the objective count of social contacts (Wigfield et al., 2022 ). Across all ages, loneliness is only weakly associated with measures of social contact (Luhmann & Hawkley, 2016 ). In other words, it is not the mere absence of social contact that impacts lonely individuals, but rather the perceived discrepancy between one’s desired and actual social relationships (Perlman & Peplau, 1981 ). Loneliness is also distinct from solitude in that loneliness is an unwanted experience, whereas solitude, or being alone, is a conscious choice that is often described as positive (Weinstein et al., 2023 ). The fact that loneliness and related concepts have been conflated or confused underscores the importance of a clear conceptual understanding of loneliness (Wigfield et al., 2022 ). Defining and measuring constructs of interest are a foundational part of rigorous research (Flake & Fried, 2020 ), yet no review has summarized how loneliness has been conceptualized and measured in research with emerging adults.

While loneliness has often been considered unidimensional, there has long been a conceptualization of loneliness as multidimensional. For example, Weiss’ ( 1973 ) interactionist approach proposed that relationship-specific types of loneliness arise as the result of deficits in two types of social needs; the need for close attachment figures (emotional loneliness) and the need for a meaningful social network (social loneliness). Social and emotional loneliness are distinct, but correlated, states that arise from different events in a person’s life; emotional loneliness might occur as the result of a romantic relationship breakup, whereas social loneliness can occur after moving to a new town. Recent research demonstrated distinct developmental trajectories for social and emotional loneliness across emerging adulthood (von Soest et al., 2020 ) and midlife (Manoli et al., 2022 ). Emotional loneliness levels moderately increase across emerging adulthood, whereas social loneliness substantially decreases throughout emerging adulthood (von Soest et al., 2020 ), suggesting that multidimensional conceptualizations of loneliness warrant consideration.

The complex nature of loneliness means that several other theories have conceptualized loneliness. Prominent approaches include the cognitive discrepancy model (Peplau & Perlman, 1982 ), the evolutionary theory (Cacioppo et al., 2006 ), the psychodynamic theory (Reichmann, 1959 ), and the existential approach (Moustakas, 1961 ). Although theoretical approaches to loneliness may overlap in their definitions, they can differ in proposed causes of loneliness. For example, the cognitive discrepancy model considers the influence of personality, cultural, and situational factors and proposes that loneliness is caused by a person appraising a deficiency in their social relationships (Peplau & Perlman, 1982 ). The evolutionary theory of loneliness suggests that loneliness arises as a signal of social pain to motivate reconnection and is transient for most individuals (Cacioppo et al., 2006 ; Spithoven et al., 2019 ). Other theories, such as the socio-cognitive model, focus on the mechanisms through which loneliness persists and impacts health (Cacioppo & Hawkley, 2009 ). However, no review has summarized how loneliness has been conceptualized and what theories of loneliness have been used in the emerging adult literature.

Current Study

Although there has been an acceleration of research on loneliness in emerging adulthood and recognition that loneliness is an important issue for young people’s health, there is no existing scoping review summarizing key aspects of this literature. The goal of this preregistered scoping review was to provide a descriptive overview of the existing literature on loneliness in emerging adulthood to inform future research. This review was guided by the following research question: What is known from the available literature about loneliness in emerging adults? The research sub-questions included how has loneliness been conceptualized and measured in research in emerging adults (Research Question 1)?, what loneliness theories have been used in research on loneliness in emerging adulthood (Research Question 2)?, what risk factors and outcomes for loneliness have been previously examined in emerging adulthood (Research Question 3)?, what is the evidence on sex-gender differences in loneliness in emerging adults (Research Question 4)?, and what are the characteristics of emerging adults included in previous loneliness research (Research Question 5)?.

Given the focus on loneliness in emerging adulthood, a topic with increasing and disparate literature, a scoping review, rather than a systematic review, was considered most appropriate (Munn et al., 2018 ). This scoping review was informed by the Joanna Briggs Institute (JBI) framework for scoping reviews (Peters et al., 2015 ) and Arksey and O’Malley’s ( 2005 ) seminal work. The reporting of results was guided by Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR; Tricco et al., 2018 ). This review was preregistered on Open Science Framework ( https://osf.io/c7ke9 ). To complete a feasible review, some amendments to the protocol were necessary and are outlined below (labelled as Amendment to Protocol 1–4).

Identifying Relevant Studies

Following preliminary searches of two databases (PsycInfo and Medline) to become familiar with key terms, the following electronic databases were searched in June 2021; Scopus, PubMed, PsycArticles, PsycInfo, Medline, ScienceDirect, and Applied Social Sciences Index and Abstracts (ASSIA). The search was updated in April 2022 to source articles published until the end of 2021. The search terms describe the concepts loneliness and young, or emerging, adults (see Table 1 ). The search was tailored to the specific requirements of each electronic database (see Supplementary Material 1 for example of a database search).

Initially, the search included peer-reviewed journal articles published between the years 2000–2021. Given that Arnett’s ( 2000 ) seminal work on emerging adulthood was published in the year 2000, it was expected to yield more research on the target population after this year. Using this year limit, 313 articles were eligible for inclusion in the review. However, following discussion among the authors, a consensus was reached that given the large volume of relevant literature, a year limit of 2016–2021 was sufficient for a feasible narrative summary of the recent literature on loneliness in emerging adulthood (Amendment to Protocol 1). The increase in research interest on loneliness in emerging adulthood in 2016 is shown in Fig. 1 .

The number of articles eligible for inclusion by year of publication. Note Solid vertical line indicates the cut off from 2016 to 2021 following Amendment to Protocol 1

Grey literature in the form of difficult-to-locate studies or reports by organizations interested in youth mental health (e.g., Jigsaw, SpunOut. i.e., National Youth Council of Ireland) were searched for by posting general requests (in October 2021) for relevant information on Twitter and mentioning relevant youth and research network organizations (“@organization”) in such tweets to encourage reposting (Adams et al., 2016 ). Additionally, a large loneliness research network placed a request for literature in their newsletter distributed to experts in the field (in December 2021). No additional eligible articles that had not already been identified were located.

The study protocol outlined the aim for an additional search for reports by relevant organizations interested in youth mental health by identifying organization websites using a search engine like Google. After a preliminary search for this type of grey literature, consensus was reached that following grey literature search strategies outlined by others (i.e., Adams et al., 2016 ) was a satisfactory search for grey literature (Amendment to Protocol 2). Grey literature was a complementary part of the search strategy and considering the large volume of identified peer-reviewed articles, peer-reviewed literature was prioritized in this review. This decision was also influenced by the consideration that when using search engines like Google, even if the search engine search was replicable, other researchers may not retrieve the same results on replication, as Google indexes websites based on several predictors: geographical location, previous search history, popularity, and so on (Bates, 2011 ).

Study Selection

Research where loneliness was a key focus of the work was included. This was determined by the inclusion of loneliness in an aim, objective, research question, or hypothesis. Quantitative studies that reported on loneliness under a broader term were included; for example, studies measuring or reporting on the construct of loneliness but describing it in the aims or objectives under broader terms like “psychological well-being”, “mental health”, or similar. Following preliminary screening, additional inclusion criteria outlined that where it was difficult to determine if loneliness was a key focus of quantitative research, articles must have reported analysis beyond the prevalence of loneliness to be included. With regards to qualitative research, if it was unclear if loneliness was a key focus of the work, articles must have discussed loneliness as a key concept in the introduction to be included (Amendment to Protocol 3).

To identify the types of available evidence in the area (Munn et al., 2018 ), qualitative, quantitative, mixed-methods, systematic reviews, and meta-synthesis articles were included.

Articles where the age of participants was ≥ 18 and ≤ 25 years were included. Articles that included a wider age range but reported a mean age ≥ 18 and ≤ 25 years were included. Following preliminary screening, further clarification was added to the inclusion criteria detailing where studies were longitudinal in design, included studies must report loneliness for age ≥ 18 and ≤ 25 years at least one time point (Amendment to Protocol 4).

Included research articles were not limited by population groups, specific life-events, specific samples, setting, or geographical location.

Included articles were not limited by measure of loneliness.

Included articles were published in English (the researchers’ only language).

Narrative reviews and loneliness scale development articles were excluded, as well as editorials, commentaries, opinion pieces, dissertations, and book chapters (labelled as “wrong article type or study design” in Fig. 2 ). Figure 2 summarizes the study selection process. In total, 8,863 articles were retrieved from the electronic database search. EndNote X9 software was used to manage references and facilitate duplicate record removal. Following duplicate record removal, 4,068 articles were screened by title and abstract on Rayyan ( https://rayyan.ai/ , Ouzzani et al., 2016 ). Fifty percent of titles and abstracts were blindly screened by a second reviewer (SS), inter-rater agreement was 98.00%. After title and abstract screening, 754 articles were included for full text screening. During full-text screening, EK contacted authors via ResearchGate to request their full-text articles and 13 of these requests were unsuccessful. Second reviewers (SS, MMG, AG) screened 50% of full-text articles. Inter-rater agreement for full-text articles was 94.19%. All disagreements were resolved through discussion; a further reviewer (AMC) was consulted on six (0.79%) decisions during full text screening.

PRISMA flow chart of the study selection

Data Charting

Data charting was conducted for all included articles by one reviewer (EK) by entering information into Microsoft Excel tables. The data charting form was pre-piloted on a random selection of articles and was refined to ensure all relevant information was extracted. A proportion of data charting (10%) was checked by a second reviewer (MMcG) for accuracy. The data charting form included (a) bibliographic information, (b) key study and subject matter information, (c) the conceptualization and measurement of loneliness, (d) the loneliness theories included, (e) the examined predictors and outcomes for loneliness, (f) sex-gender differences, and (g) characteristics of emerging adult samples included. The detailed list of information for which data were charted can be found in Supplementary Material 2.

Summarizing, and Reporting the Findings

Given that the aim of this review was to provide a descriptive summary of the available literature on loneliness in emerging adulthood, the quality of included studies was not assessed. All findings were included in the narrative review. Checks were completed to ensure the findings of the included systematic review were not duplicated in the results. Tables and narrative summaries were generated for each research sub-question to present a descriptive overview of the research on loneliness in emerging adulthood (Peters et al., 2015 ).

Study Context and Characteristics

After eligibility screening, 201 articles were included in the final scoping review. The publication year of included articles ranged from 2016 to 2021 (see Fig. 1 ). A small number of articles identified in the original search that were published online in 2020 or 2021 but were assigned to a journal issue in 2022 (e.g., Arslan et al., 2022 ; Hopmeyer et al., 2022 ) were retained. Research on loneliness in emerging adulthood represents a growing area of research, with almost half (47.26%) of the included articles published in 2020 and 2021.

The sample sizes within original research articles ranged from 4 to 71,988. Studies using quantitative analysis had sample sizes ranging from 35 to 71,988. Qualitative and mixed-method studies conducting qualitative analysis had sample sizes ranging from 4 to 686. The sole included systematic review and meta-analysis (Buecker et al., 2021 ) included data from 124,855 participants.

Included original articles were conducted in 44 countries across five continents. Thirteen (6.47%) articles included samples from more than one country. Almost half (49.25%) of the articles included samples from Western countries where English is the primary language. The breakdown of how many articles included samples from each country are as follows: USA ( k = 66, 32.84%), China ( k = 21, 10.45%), UK ( k = 18, 8.96%), Turkey ( k = 12, 5.97%), Poland ( k = 11, 5.47%), Australia ( k = 9, 4.48%), Germany ( k = 5, 2.49%), Denmark ( k = 4, 1.99%). The Netherlands, South Korea, Canada, Hungary, South Africa, and Spain were each included in three (1.49%) articles. Singapore, Greece, Republic of Ireland, Israel, and Bangladesh were each included in two (1.00%) articles. Finland, Italy, Northern Ireland, Norway, Slovakia, Austria, Hong Kong, Indonesia, Japan, Sweden, Thailand, Malaysia, and Nigeria were each included in one (0.50%) article. Included original research articles had a general community or university setting (including online surveys) ( k = 186, 92.54%), or were conducted in a clinical or laboratory setting (e.g., an outpatient clinic) ( k = 13, 6.47%).

Study Design

Included articles were quantitative ( k = 190, 94.53%), mixed method ( k = 8, 3.98%), qualitative ( k = 1, 0.50%), systematic review and meta-analyses ( k = 1, 0.50%), and qualitative protocol ( k = 1, 0.50%) studies. The following study designs were included; cross-sectional ( k = 151, 75.12%), longitudinal ( k = 44, 21.89%), and experimental ( k = 4, 1.99%).

Covid-19 Related Studies

Thirty (14.93%) articles explored loneliness in relation to the Covid-19 pandemic. Most studies ( k = 23) explored the prevalence of loneliness or the association of loneliness with factors such as life satisfaction, mental health, quality of life during pandemic restrictions, or in the broader context of Covid-19 pandemic. For example, one study compared the reported prevalence of mental health issues and loneliness in emerging adults in the UK and China during the pandemic (Liu et al., 2021 ), reporting higher loneliness levels in the UK. Some studies ( k = 3) examined specific Covid-19 related factors, such as “Covid-19 worry” (Mayorga et al., 2021 ) and “Coronavirus anxiety” (Arslan et al., 2022 ), in relation to loneliness. Merolla et al. ( 2021 ) used experience sampling and nightly diary surveys to examine how pandemic related anxiety and depressive symptoms manifested in daily perceptions of loneliness; Covid-19 related anxiety was independently associated with greater loneliness. Other studies ( k = 2) focused on emerging adults’ relocations during the pandemic (Conrad et al., 2021 ; Fanari & Segrin, 2021 ). For example, a longitudinal examination of the extent to which the stressor of forced re-entry from studying abroad during the Covid-19 pandemic was predictive of loneliness in U.S. emerging adults (Fanari & Segrin, 2021 ). Lastly, one study conducted during the Covid-19 pandemic evaluated two interventions for depression and loneliness (Cruwys et al., 2021 ).

Research Question 1: Conceptualization and Measurement of Loneliness

Over half ( k = 112; 55.72%) of the articles included an explicit definition of loneliness, while another five (2.49%) articles did not formally define loneliness beyond describing it as “perceived social isolation”. Although there was some variation in the way loneliness was defined, for example, describing loneliness as thwarted belongingness (Chu et al., 2016 ), or as the response to the absence of a relationship (Andangsari & Dhowi, 2016 ), loneliness was mostly defined as an emotionally unpleasant subjective experience that occurs when a person perceives their social relationships to be inadequate (Perlman & Peplau, 1981 ). While most ( k = 187, 93.03%) articles did not explicitly articulate multiple dimensions of loneliness, 14 (6.97%) articles considered a multidimensional conceptualization of loneliness referring to: social and emotional loneliness ( k = 6, 2.98%); social, romantic, and family loneliness ( k = 6, 2.98%); isolation, relational connectedness, and collective connectedness ( k = 1, 0.50%); romantic loneliness ( k = 1, 0.50%).

In total, this scoping review identified 16 measures of loneliness in included articles. The University of California Los Angeles (UCLA; Russell et al., 1980 ) Loneliness scale was the most employed measure with 161 (80.10%) included articles using a version of this scale. Twelve (5.97%) studies employed a single-item direct measure of loneliness, such as “How lonely did you feel in the past week?”. See Supplementary Material 3 for a full summary of measures of loneliness in included articles.

Most qualitative or mixed-method studies employed semi-structured interviews to explore loneliness ( k = 4). Others used open ended survey responses ( k = 2), free association task ( k = 1), or group discussions and reflective journal responses ( k = 1).

Research Question 2: Loneliness Theories

Of the 201 included articles, 29 (14.43%) articles explicitly referenced a loneliness theory in their introduction. While it is possible that some articles implicitly used loneliness theory, articles were considered to have explicitly stated use of loneliness theory if a loneliness theory was referenced in the introduction or aims of the article. Some articles referred to more than one loneliness theory. Seven loneliness theories (see Table 2 for summary) were clearly articulated in loneliness research on emerging adults.

Research Question 3: Risk Factors and Outcomes

A wide range of risk factors and outcomes were examined in association with loneliness in quantitative or mixed-method studies (see Supplementary Material 4 for detail). Most articles examining factors associated with loneliness were cross-sectional in design; longitudinal studies mostly examined loneliness risk factors ( k = 25, 12.44%), outcomes were examined in 13 (6.47%) longitudinal studies. Of the longitudinal research examining predictors of loneliness, family and social relationship factors, such as perceived social support, were the most studied risk factors ( k = 7). Whereas mental health outcomes, like depression, were the most examined loneliness outcomes in longitudinal studies ( k = 6).

Only two longitudinal studies examined within- and between-person variances in loneliness development and the risk and outcome factors associated with changes; one explored the interindividual differences in loneliness development and mental health outcomes in emerging adulthood (Hutten et al., 2021 ). Another examined longitudinal within- and between-person associations of substance use, social influences, and loneliness among emerging adults who use drugs (Bonar et al., 2022 ).

Research Question 4: Sex-Gender Differences in Loneliness

In total, 48 (23.88%) studies explored sex-gender differences in loneliness; 40 reported no statistically significant ( p > 0.05) difference between male and female loneliness scores, whereas there were eight reports of a significant ( p < 0.05) sex-gender difference. Of those that reported significant sex-gender differences, six studies reported higher female loneliness scores and two studies reported higher male loneliness scores. Most studies ( k = 4) reporting significant sex-gender differences measured loneliness using the 20-item UCLA Loneliness Scale (Russell et al., 1980 ), others ( k = 2) used the Social and Emotional Loneliness Scale for Adults (SELSA; DiTommaso & Spinner, 1993 ), one used the Loneliness in Context Questionnaire for College Students (Asher & Weeks, 2014 ), and one used a direct single-item measure. See Table 3 for a complete summary of results.

Research Question 5: Characteristics of Emerging Adult Samples Included in Loneliness Research

The minimum mean age of included studies was 18.00 years, the maximum mean age was 24.78 years. The gender split of included studies ranged from 0% female to 100% female. The median percentage of females in included samples was 63.30%. Over two thirds ( k = 137, 68.16%) of articles described their sample as either all or mostly (> 80% of sample) university students. The remaining articles included: general community samples ( k = 24, 11.94%), specific samples (e.g., inflammatory bowel disease patients, see Supplementary Material 5 for full details of articles including specific emerging adult samples) ( k = 20, 9.95%), population representative samples ( k = 11, 5.47%), high school students ( k = 6, 2.94%). Some articles ( k = 3, 1.49%) did not report information on their sample or sample information was not applicable.

Despite an increase of research interest in loneliness in younger age groups and recognition that loneliness is an important issue for emerging adults’ health (Christiansen et al., 2021 ), there was no existing scoping review summarizing the key aspects of this literature. Reviews can reduce research waste by identifying priority research questions and key gaps in the literature, mapping existing methodological approaches, and clarifying terms and concepts used in the literature (Khalil et al., 2022 ). Therefore, a scoping review was most appropriate to provide an overview of the literature and identify priorities for future research on loneliness in emerging adulthood.

Three key issues are apparent from this review. First, there was a lack of clear conceptualization of loneliness and prioritization of unidimensional conceptualizations of loneliness in emerging adults, which may be related to the measure of loneliness used. Second, despite the volume of research identified, there was a lack of qualitative research exploring the subjective experience of loneliness. This suggests that the relevance of existing conceptualizations of loneliness for emerging adults who have experienced it remains unclear. Third, while a range of risk factors and outcomes for loneliness have been examined in the literature, research tends to be cross-sectional in design and based on convenience samples of university students. Some additional considerations are noted. Relatively few articles explicitly articulated the use of loneliness theory in their research. Relatively few articles reported on sex-gender differences in loneliness; those that did reported mixed results. Finally, loneliness in emerging adulthood is a growing area of research, with some of this growth due to a focus on loneliness in the context of the Covid-19 pandemic.

Definitions of loneliness in included articles tended to align with Perlman and Peplau’s ( 1981 ) widely used definition. Definitions acknowledged both the affective (i.e., the negative emotional experience) and cognitive (i.e., the discrepancy between one’s actual and desired social relations) components of loneliness. A few articles did not explain what is meant by loneliness beyond describing it as perceived social isolation, which does not account for the more complex affective and cognitive aspects of loneliness. While there may be general agreement that loneliness is a subjective emotional experience, the finding that just over half of all articles included a formal definition of loneliness leaves open the possibility that the conceptualization is implicit, poorly understood, or even that loneliness is akin to separate constructs like chosen solitude or objective social isolation. The distinction between concepts like social isolation and loneliness is critical given that across age groups, loneliness is only weakly associated with objective measures of contact with friends and family (Luhmann & Hawkley, 2016 ). A lack of clear definition of loneliness and conflation with other distinct, but related, terms contribute to conceptual confusion which can have practical implications; for example, policy responses designed for lonely people often aim to increase their social connections, therefore reducing social isolation rather than focusing on reducing experiences of subjective loneliness (Wigfield et al., 2022 ).

Other loneliness distinctions potentially relevant for understanding loneliness in emerging adulthood include a multi-dimensional conceptualization of social and emotional loneliness (von Soest et al., 2020 ). These facets are proposed to differentially develop depending on the type of social relationship a person perceives to be inadequate (Weiss, 1973 ). In addition, existential loneliness was described in recent qualitative work as occurring particularly during young adulthood for some individuals (McKenna-Plumley et al., 2023 ). A lack of transparent reporting on the conceptualization of loneliness has important implications for its measurement (Flake & Fried, 2020 ). The finding that few included articles considered different aspects of loneliness, and most did not explicitly discuss whether loneliness was unidimensional or multidimensional, suggests that a unidimensional conceptualization of loneliness is implicit. This is reflected in the frequent use of the UCLA Loneliness Scale (Russell et al., 1980 ), originally designed as a unidimensional measure. Although the UCLA includes items considered to align with social (11 items) and emotional (7 items) loneliness (Maes et al., 2022 ), there is no agreed multi-factorial structure of this measure, and using UCLA subscales may not be the best way of measuring multidimensional loneliness; given studies that report the same number of factors differ in terms of the items that are allocated to which factors and the interpretation of the factors (Maes et al., 2022 ). Additionally, although single-item loneliness measures have shown adequate reliability (Mund et al., 2022 ) and may be useful as brief screening measures in large-scale surveys (Reinwarth et al., 2023 ), few articles reported the use of direct single-item loneliness measures; perhaps because of concerns of potential socially desirable responding. Loneliness measurement is central to the validity of studies examining the risk factors and consequences of the experience in emerging adults (Flake & Fried, 2020 ). Therefore, future research should clearly report the conceptualization and measurement of loneliness.

One approach to achieving consensus on conceptualizations of loneliness in emerging adulthood is through more inductive and exploratory qualitative methods. The only qualitative study eligible for inclusion here focused on young adults living in London’s most deprived areas who described loneliness as being linked to feeling excluded, social media, sadness, and low self-worth (Fardghassemi & Joffe, 2021 ). While this study gives an insight into loneliness in this demographic, the experiences of loneliness for emerging adults more broadly are lacking in the literature. Further, there is a lack of qualitative research exploring the complexities of the life stage more generally (Schwab & Syed, 2015 ). Loneliness is an inherently subjective experience. Qualitative methods allow individuals to describe their experience in their own words and are ideally suited for examining how relevant existing conceptualizations of loneliness are for emerging adults. Exploring the meaning of loneliness for those who have experienced it should be a key research priority; a gap which has been addressed among early adolescents (Verity et al., 2021 ). Although the major features of emerging adulthood may vary between cultures, it is a distinct developmental period of the lifespan (Arnett, 2024 ). To assume emerging adults share the same social roles, developmental tasks, and societal expectations as adolescents underestimates the increased independence, self-focus, and instability (Arnett et al., 2014 ) that may be central to loneliness during this stage. Therefore, qualitative research focused on understanding loneliness within the complexities of the life-stage of emerging adulthood is needed.

Of the articles that explicitly considered loneliness theory, most considered approaches that typically focus on individual level characteristics that may increase a person’s risk for loneliness. For example, the evolutionary theory of loneliness (Cacioppo et al., 2006 ), suggests that younger age groups, due to ongoing development of brain regions associated with cognitive control, may be more sensitive to their social environment and more prone to loneliness beyond the typical features of emerging adulthood (Wong et al., 2018 ). However, societal, and cultural factors are also likely to contribute to loneliness by influencing a person’s social norms (van Staden & Coetzee, 2010 ). The cognitive discrepancy theory emphasizes the role of individual attributes, as well as wider cultural norms in how a person perceives their social relationships (Peplau & Perlman, 1982 ). Theories of loneliness are not mutually exclusive; developing a causal understanding of loneliness in emerging adulthood likely requires the integration of theory. For example, McHugh Power et al. ( 2018 ) synthesized model of loneliness considers both interindividual factors, such as the role of culture in shaping social norms about emerging adults’ social lives, and intraindividual factors, such as changes in the brain regions responsible for social processes, in the development of loneliness. Further, loneliness can be explored within broader theoretical frameworks not specific to loneliness. Developmental approaches can inform research on specific life events and developmental tasks during a particular life stage that may increase a person’s risk of loneliness. For example, employing Erikson’s ( 1968 ) psychosocial theory in research exploring the link between identity formation and loneliness in adolescents and emerging adults (Lindekilde et al., 2018 ).

An age-normative life span perspective suggests that different factors drive loneliness at different ages (Luhmann & Hawkley, 2016 ). For example, peer relations may be more strongly associated with loneliness during adolescence and emerging adulthood, where friendships are their primary social connections, as opposed to older age groups (Qualter et al., 2015 ). This aligns with the finding that family and social relationship factors, such as perceived social support from peers, were the most examined risk factors for loneliness in emerging adulthood in longitudinal studies. Perhaps unsurprisingly, aspects of mental health were the most examined outcomes of loneliness. It is also plausible that poorer mental health predicts or has a reciprocal relationship with loneliness during emerging adulthood; emerging adults with depressive symptoms may withdraw from their social relationships or perceive more social rejection (Achterbergh et al., 2020 ). Despite examining a range of loneliness risk factors and outcomes, included studies were mostly cross-sectional and conducted in Western countries with convenience samples comprising university students. Therefore, the third key issue with this literature highlights the persistent sampling bias and lack of representation and diversity in the field (Nielsen et al., 2017 ).

Sex-gender differences are also important for understanding who is vulnerable to loneliness. Most studies reported no significant difference. A small number reported a significant difference, mostly reporting higher loneliness among females. Gender differences in loneliness have been hypothesized to emerge in adolescence, where females may be more at risk of adolescent-onset internalizing problems (Martel, 2013 ). However, a meta-analysis reported a significant, but small, effect of gender on loneliness in young adulthood, finding greater loneliness in males (Maes et al., 2019 ). The variation of findings in studies examining sex-gender differences have long been attributed to differences in how loneliness is assessed (Borys & Perlman, 1985 ). Given that few a-priori hypotheses on gender differences in loneliness have been proposed (Maes et al., 2019 ), future research should report analysis examining sex-gender differences to determine whether sex-gender represents a vulnerability factor for loneliness.

Finally, the findings suggest that loneliness in emerging adulthood is a fast-growing area of research; almost half of all included articles were published in the years 2020 and 2021. Some of this growth was due to the Covid-19 pandemic making the issue of loneliness in younger age groups even more salient than before (Holt-Lunstad, 2021 ). Although not all who are socially isolated are lonely (Luhmann & Hawkley, 2016 ), this increased focus on loneliness is unsurprising considering that response measures aimed at mitigating the spread of Covid-19, like social distancing orders, and remote work and education, resulted in less social contact and greater social isolation. One systematic review comparing loneliness before and during the Covid-19 pandemic found an increase in loneliness in younger participant groups (Ernst et al., 2022 ). However, this increase was from studies including only university student samples; how the pandemic has impacted loneliness during emerging adulthood more generally remains unclear. The theory of emerging adulthood describes a range of developmental transitions to achieve adulthood, such as moving out of the parental home (Arnett, 2024 ). For some emerging adults, Covid-19 measures may have halted or even reversed steps towards adulthood, resulting in increased loneliness. For example, emerging adults forced to relocate from college campuses to live with parents and guardians experienced greater loneliness than those who did not relocate (Conrad et al., 2021 ). Life events that impact the achievement of normative social transitions and result in some emerging adults feeling out of sync may be important to consider in the development of loneliness during emerging adulthood.

Strengths and Limitations

The strengths of this review included preregistration of the protocol on Open Science Framework and rigorous methodology following well-established scoping review guidelines (Peters et al., 2015 ). One potential limitation is the inclusion criteria that articles needed to report a mean age of 18–25 years. This age range is sometimes extended to age 29; however, 18–25 years is appropriate when conservative age ranges are required to describe emerging adulthood (Arnett, 2024 ). Although a large volume of articles was included, the year limit and lack of grey literature means that there is a possibility that relevant research was not included in this review. While articles were not excluded based on geographical location, included articles were limited to those published in or translated to the English language only, potentially influencing this review’s results.

Future Research

Based on these findings, future studies should provide a clear conceptualization of loneliness, including articulation of loneliness as a uni- or multi-dimensional construct. Studies should specify the theoretical approach (if any) that is informing the research. To generate a clearer understanding of sex-gender differences, these should be reported.

Regarding broad research priorities for loneliness, given the skew towards cross-sectional convenience samples of Western, educated emerging adults, longitudinal research that is population-based or focuses on under-studied cohorts should be prioritized. The current literature does not adequately explore the emergence of specific forms of loneliness, the predictors of loneliness development, and the long-term outcomes of emerging adult loneliness. Developmental trends, the stability of loneliness, and the factors associated with interindividual differences in loneliness during emerging adulthood appear to have also been neglected. Previous research underscores the importance of identifying the characteristics of emerging adults more likely to develop loneliness and the factors that, when changed, correspond to changes in loneliness (Mund et al., 2020 ). Therefore, longitudinal research should seek to identify emerging adults most at risk of developing sustained or intensely felt loneliness in response to common life events, like finishing school. Also, identifying emerging adults who are at risk of loneliness due to developmental transitions being halted or reversed is a consideration for future longitudinal research. Given potential cultural differences in the markers of adulthood and developmental tasks of emerging adulthood (Nelson & Luster, 2015 ), research should consider cultural norms in the relationship between social transitions and loneliness during this life stage.

The high prevalence of loneliness during emerging adulthood indicates that loneliness is an issue of importance requiring good quality research. However, no review has provided an overview of key aspects of the literature on loneliness in emerging adulthood. This scoping review provided a descriptive summary of 201 articles on loneliness in emerging adulthood and serves as an initial step highlighting issues with the current research and identifying priorities for future research. Specifically, findings suggest the need for a clearer consensus in the literature regarding the conceptualization of loneliness during emerging adulthood. Second, this review highlights the need for more qualitative work exploring young people’s subjective experiences of loneliness, which is key for understanding the complexities of loneliness during emerging adulthood. Finally, the results indicate that this literature needs fewer cross-sectional studies using convenience samples and more population-based, longitudinal research to understand the factors predicting loneliness over time, and the downstream impact of loneliness for emerging adults.

Data Availability

All data collected for this study were obtained from published peer-review literature. Data extracted to inform this review are available on reasonable request from the corresponding author.

Articles included in the scoping review are marked with (•)

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The authors gratefully acknowledge the editor of Adolescent Research Review and anonymous reviewers for their helpful feedback.

Open Access funding provided by the IReL Consortium. The first author is in receipt of an Irish Research Council Government of Ireland Postgraduate Scholarship (GOIPG/2021/345). The sponsor had no role in the study design, analysis, interpretation of the data, or writing of the article.

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Emma M. Kirwan, Páraic S. O’Súilleabháin, Sarah Summerville, Máire McGeehan, Jennifer McMahon & Ann-Marie Creaven

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Emma M. Kirwan, Páraic S. O’Súilleabháin, Máire McGeehan, Jennifer McMahon & Ann-Marie Creaven

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Annette Burns

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EMK conceived of the study, participated in study design, coordination, and interpretation of the data, and drafted the manuscript; AB conceived of the study, participated in study design and coordination, and drafted the manuscript; PSO’S conceived of the study, participated in study design and coordination, and drafted the manuscript; SS performed data screening and drafted the manuscript; MMG performed data screening and charting, and drafted the manuscript; JMM contributed to study conceptualization, methodology, and drafted the manuscript; AG performed data screening and drafted the manuscript; AMC conceived of the study, participated in study design, coordination, and interpretation of the data, and drafted the manuscript. All authors read and approved the final manuscript.

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Kirwan, E.M., Burns, A., O’Súilleabháin, P.S. et al. Loneliness in Emerging Adulthood: A Scoping Review. Adolescent Res Rev (2024). https://doi.org/10.1007/s40894-024-00240-4

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Published: 01 May 2024

The effectiveness of virtual reality training on knowledge, skills and attitudes of health care professionals and students in assessing and treating mental health disorders: a systematic review

Cathrine W. Steen 1 , 2 ,
Kerstin Söderström 1 , 2 ,
Bjørn Stensrud 3 ,
Inger Beate Nylund 2 &
Johan Siqveland 4 , 5

BMC Medical Education volume 24 , Article number: 480 ( 2024 ) Cite this article

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Virtual reality (VR) training can enhance health professionals’ learning. However, there are ambiguous findings on the effectiveness of VR as an educational tool in mental health. We therefore reviewed the existing literature on the effectiveness of VR training on health professionals’ knowledge, skills, and attitudes in assessing and treating patients with mental health disorders.

We searched MEDLINE, PsycINFO (via Ovid), the Cochrane Library, ERIC, CINAHL (on EBSCOhost), Web of Science Core Collection, and the Scopus database for studies published from January 1985 to July 2023. We included all studies evaluating the effect of VR training interventions on attitudes, knowledge, and skills pertinent to the assessment and treatment of mental health disorders and published in English or Scandinavian languages. The quality of the evidence in randomized controlled trials was assessed with the Cochrane Risk of Bias Tool 2.0. For non-randomized studies, we assessed the quality of the studies with the ROBINS-I tool.

Of 4170 unique records identified, eight studies were eligible. The four randomized controlled trials were assessed as having some concern or a high risk of overall bias. The four non-randomized studies were assessed as having a moderate to serious overall risk of bias. Of the eight included studies, four used a virtual standardized patient design to simulate training situations, two studies used interactive patient scenario training designs, while two studies used a virtual patient game design. The results suggest that VR training interventions can promote knowledge and skills acquisition.

Conclusions

The findings indicate that VR interventions can effectively train health care personnel to acquire knowledge and skills in the assessment and treatment of mental health disorders. However, study heterogeneity, prevalence of small sample sizes, and many studies with a high or serious risk of bias suggest an uncertain evidence base. Future research on the effectiveness of VR training should include assessment of immersive VR training designs and a focus on more robust studies with larger sample sizes.

Trial registration

This review was pre-registered in the Open Science Framework register with the ID-number Z8EDK.

Peer Review reports

A robustly trained health care workforce is pivotal to forging a resilient health care system [ 1 ], and there is an urgent need to develop innovative methods and emerging technologies for health care workforce education [ 2 ]. Virtual reality technology designs for clinical training have emerged as a promising avenue for increasing the competence of health care professionals, reflecting their potential to provide effective training [ 3 ].

Virtual reality (VR) is a dynamic and diverse field, and can be described as a computer-generated environment that simulates sensory experiences, where user interactions play a role in shaping the course of events within that environment [ 4 ]. When optimally designed, VR gives users the feeling that they are physically within this simulated space, unlocking its potential as a dynamic and immersive learning tool [ 5 ]. The cornerstone of the allure of VR is its capacity for creating artificial settings via sensory deceptions, encapsulated by the term ‘immersion’. Immersion conveys the sensation of being deeply engrossed or enveloped in an alternate world, akin to absorption in a video game. Some VR systems will be more immersive than others, based on the technology used to influence the senses. However, the degree of immersion does not necessarily determine the user’s level of engagement with the application [ 6 ].

A common approach to categorizing VR systems is based on the design of the technology used, allowing them to be classified into: 1) non-immersive desktop systems, where users experience virtual environments through a computer screen, 2) immersive CAVE systems with large projected images and motion trackers to adjust the image to the user, and 3) fully immersive head-mounted display systems that involve users wearing a headset that fully covers their eyes and ears, thus entirely immersing them in the virtual environment [ 7 ]. Advances in VR technology have enabled a wide range of VR experiences. The possibility for health care professionals to repeatedly practice clinical skills with virtual patients in a risk-free environment offers an invaluable learning platform for health care education.

The impact of VR training on health care professionals’ learning has predominantly been researched in terms of the enhancement of technical surgical abilities. This includes refining procedural planning, familiarizing oneself with medical instruments, and practicing psychomotor skills such as dexterity, accuracy, and speed [ 8 , 9 ]. In contrast, the exploration of VR training in fostering non-technical or ‘soft’ skills, such as communication and teamwork, appears to be less prevalent [ 10 ]. A recent systematic review evaluates the outcomes of VR training in non-technical skills across various medical specialties [ 11 ], focusing on vital cognitive abilities (e.g., situation awareness, decision-making) and interprofessional social competencies (e.g., teamwork, conflict resolution, leadership). These skills are pivotal in promoting collaboration among colleagues and ensuring a safe health care environment. At the same time, they are not sufficiently comprehensive for encounters with patients with mental health disorders.

For health care professionals providing care to patients with mental health disorders, acquiring specific skills, knowledge, and empathic attitudes is of utmost importance. Many individuals experiencing mental health challenges may find it difficult to communicate their thoughts and feelings, and it is therefore essential for health care providers to cultivate an environment where patients feel safe and encouraged to share feelings and thoughts. Beyond fostering trust, health care professionals must also possess in-depth knowledge about the nature and treatment of various mental health disorders. Moreover, they must actively practice and internalize the skills necessary to translate their knowledge into clinical practice. While the conventional approach to training mental health clinical skills has been through simulation or role-playing with peers under expert supervision and practicing with real patients, the emergence of VR applications presents a compelling alternative. This technology promises a potentially transformative way to train mental health professionals. Our review identifies specific outcomes in knowledge, skills, and attitudes, covering areas from theoretical understanding to practical application and patient interaction. By focusing on these measurable concepts, which are in line with current healthcare education guidelines [ 12 ], we aim to contribute to the knowledge base and provide a detailed analysis of the complexities in mental health care training. This approach is designed to highlight the VR training’s practical relevance alongside its contribution to academic discourse.

A recent systematic review evaluated the effects of virtual patient (VP) interventions on knowledge, skills, and attitudes in undergraduate psychiatry education [ 13 ]. This review’s scope is limited to assessing VP interventions and does not cover other types of VR training interventions. Furthermore, it adopts a classification of VP different from our review, rendering their findings and conclusions not directly comparable to ours.

To the best of our knowledge, no systematic review has assessed and summarized the effectiveness of VR training interventions for health professionals in the assessment and treatment of mental health disorders. This systematic review addresses the gap by exploring the effectiveness of virtual reality in the training of knowledge, skills, and attitudes health professionals need to master in the assessment and treatment of mental health disorders.

This systematic review follows the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis [ 14 ]. The protocol of the systematic review was registered in the Open Science Framework register with the registration ID Z8EDK.

We included randomized controlled trials, cohort studies, and pretest–posttest studies, which met the following criteria: a) a population of health care professionals or health care professional students, b) assessed the effectiveness of a VR application in assessing and treating mental health disorders, and c) reported changes in knowledge, skills, or attitudes. We excluded studies evaluating VR interventions not designed for training in assessing and treating mental health disorders (e.g., training of surgical skills), studies evaluating VR training from the first-person perspective, studies that used VR interventions for non-educational purposes and studies where VR interventions trained patients with mental health problems (e.g., social skills training). We also excluded studies not published in English or Scandinavian languages.

Search strategy

The literature search reporting was guided by relevant items in PRISMA-S [ 15 ]. In collaboration with a senior academic librarian (IBN), we developed the search strategy for the systematic review. Inspired by the ‘pearl harvesting’ information retrieval approach [ 16 ], we anticipated a broad spectrum of terms related to our interdisciplinary query. Recognizing that various terminologies could encapsulate our central ideas, we harvested an array of terms for each of the four elements ‘health care professionals and health care students’, ‘VR’, ‘training’, and ‘mental health’. The pearl harvesting framework [ 16 ] consists of four steps which we followed with some minor adaptions. Step 1: We searched for and sampled a set of relevant research articles, a book chapter, and literature reviews. Step 2: The librarian scrutinized titles, abstracts, and author keywords, as well as subject headings used in databases, and collected relevant terms. Step 3: The librarian refined the lists of terms. Step 4: The review group, in collaboration with a VR consultant from KildeGruppen AS (a Norwegian media company), validated the refined lists of terms to ensure they included all relevant VR search terms. This process for the element VR resulted in the inclusion of search terms such as ‘3D simulated environment’, ‘second life simulation’, ‘virtual patient’, and ‘virtual world’. We were given a peer review of the search strategy by an academic librarian at Inland Norway University of Applied Sciences.

In June and July 2021, we performed comprehensive searches for publications dating from January 1985 to the present. This period for the inclusion of studies was chosen since VR systems designed for training in health care first emerged in the early 1990s. The searches were carried out in seven databases: MEDLINE and PsycInfo (on Ovid), ERIC and CINAHL (on EBSCOhost), the Cochrane Library, Web of Science Core Collection, and Scopus. Detailed search strategies from each database are available for public access at DataverseNO [ 17 ]. On July 2, 2021, a search in CINAHL yielded 993 hits. However, when attempting to transfer these records to EndNote using the ‘Folder View’—a feature designed for organizing and managing selected records before export—only 982 records were successfully transferred. This discrepancy indicates that 11 records could not be transferred through Folder View, for reasons not specified. The process was repeated twice, consistently yielding the same discrepancy. The missing 11 records pose a risk of failing to capture relevant studies in the initial search. In July 2023, to make sure that we included the latest publications, we updated our initial searches, focusing on entries since January 1, 2021. This ensured that we did not miss any new references recently added to these databases. Due to a lack of access to the Cochrane Library in July 2023, we used EBMR (Evidence Based Medicine Reviews) on the Ovid platform instead, including the databases Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Cochrane Clinical Answers. All references were exported to Endnote and duplicates were removed. The number of records from each database can be observed in the PRISMA diagram [ 14 ], Fig. 1 .

PRISMA flow chart of the records and study selection process

Study selection and data collection

Two reviewers (JS, CWS) independently assessed the titles and abstracts of studies retrieved from the literature search based on the eligibility criteria. We employed the Rayyan website for the screening process [ 18 ]. The same reviewers (JS, CWS) assessed the full-text articles selected after the initial screening. Articles meeting the eligibility criteria were incorporated into the review. Any disagreements were resolved through discussion.

Data extracted from the studies by the first author (CWS) and cross-checked by another reviewer (JS) included: authors of the study, publication year, country, study design, participant details (education, setting), interventions (VR system, class label), comparison types, outcomes, and main findings. This data is summarized in Table 1 and Additional file 1 . In the process of reviewing the VR interventions utilized within the included studies, we sought expertise from advisers associated with VRINN, a Norwegian immersive learning cluster, and SIMInnlandet, a center dedicated to simulation in mental health care at Innlandet Hospital Trust. This collaboration ensured a thorough examination and accurate categorization of the VR technologies applied. Furthermore, the classification of the learning designs employed in the VP interventions was conducted under the guidance of an experienced VP scholar at Paracelcus Medical University in Salzburg.

Data analysis

We initially intended to perform a meta-analysis with knowledge, skills, and attitudes as primary outcomes, planning separate analyses for each. However, due to significant heterogeneity observed among the included studies, it was not feasible to carry out a meta-analysis. Consequently, we opted for a narrative synthesis based on these pre-determined outcomes of knowledge, skills, and attitudes. This approach allowed for an analysis of the relationships both within and between the studies. The effect sizes were calculated using a web-based effect size calculator [ 27 ]. We have interpreted effect sizes based on commonly used descriptions for Cohen’s d: small = 0.2, moderate = 0.5, and large = 0.8, and for Cramer’s V: small = 0.10, medium = 0.30, and large = 0.50.

Risk of bias assessment

JS and CWS independently evaluated the risk of bias for all studies using two distinct assessment tools. We used the Cochrane risk of bias tool RoB 2 [ 28 ] to assess the risk of bias in the RCTs. With the RoB 2 tool, the bias was assessed as high, some concerns or low for five domains: randomization process, deviations from the intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result [ 28 ].

We used the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool [ 29 ] to assess the risk of bias in the cohort and single-group studies. By using ROBINS-I for the non-randomized trials, the risk of bias was assessed using the categories low, moderate, serious, critical or no information for seven domains: confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and selection of the reported result [ 29 ].

We included eight studies in the review (Fig. 1 ). An overview of the included studies is presented in detail in Table 1 .

Four studies were RCTs [ 19 , 20 , 21 , 22 ], two were single group pretest–posttest studies [ 23 , 26 ], one was a controlled before and after study [ 25 ], and one was a cohort study [ 24 ]. The studies included health professionals from diverse educational backgrounds, including some from mental health and medical services, as well as students in medicine, social work, and nursing. All studies, published from 2009 to 2021, utilized non-immersive VR desktop system interventions featuring various forms of VP designs. Based on an updated classification of VP interventions by Kononowicz et al. [ 30 ] developed from a model proposed by Talbot et al. [ 31 ], we have described the characteristics of the interventions in Table 1 . Four of the studies utilized a virtual standardized patient (VSP) intervention [ 20 , 21 , 22 , 23 ], a conversational agent that simulates clinical presentations for training purposes. Two studies employed an interactive patient scenario (IPS) design [ 25 , 26 ], an approach that primarily uses text-based multimedia, enhanced with images and case histories through text or voice narratives, to simulate clinical scenarios. Lastly, two studies used a virtual patient game (VP game) intervention [ 19 , 24 ]. These interventions feature training scenarios using 3D avatars, specifically designed to improve clinical reasoning and team training skills. It should be noted that the interventions classified as VSPs in this review, being a few years old, do not encompass artificial intelligence (AI) as we interpret it today. However, since the interventions include some kind of algorithm that provides answers to questions, we consider them as conversational agents, and therefore as VSPs. As the eight included studies varied significantly in terms of design, interventions, and outcome measures, we could not incorporate them into a meta-analysis.

The overall risk of bias for the four RCTs was high [ 19 , 20 , 22 ] or of some concern [ 21 ] (Fig. 2 ). They were all assessed as low or of some concern in the domains of randomization. Three studies were assessed with a high risk of bias in one [ 19 , 20 ] or two domains [ 22 ]; one study had a high risk of bias in the domain of selection of the reported result [ 19 ], one in the domain of measurement of outcome [ 20 ], and one in the domains of deviation from the intended interventions and missing outcome data [ 22 ]. One study was not assessed as having a high risk of bias in any domain [ 21 ].

Risk of bias summary: review authors assessments of each risk of bias item in the included RCT studies

For the four non-randomized studies, the overall risk of bias was judged to be moderate [ 26 ] or serious [ 23 , 24 , 25 ] (Fig. 3 ). One study had a serious risk of bias in two domains: confounding and measurement of outcomes [ 23 ]. Two studies had a serious risk of bias in one domain, namely confounding [ 24 , 25 ], while one study was judged not to have a serious risk of bias in any domain [ 26 ].

Risk of bias summary: review authors assessments of each risk of bias item in the included non-randomized studies

Three studies investigated the impact of virtual reality training on mental health knowledge [ 24 , 25 , 26 ]. One study with 32 resident psychiatrists in a single group pretest–posttest design assessed the effect of a VR training intervention on knowledge of posttraumatic stress disorder (PTSD) symptomatology, clinical management, and communication skills [ 26 ]. The intervention consisted of an IPS. The assessment of the outcome was conducted using a knowledge test with 11 multiple-choice questions and was administered before and after the intervention. This study reported a significant improvement on the knowledge test after the VR training intervention.

The second study examined the effect of a VR training intervention on knowledge of dementia [ 25 ], employing a controlled before and after design. Seventy-nine medical students in clinical training were divided into two groups, following a traditional learning program. The experimental group received an IPS intervention. The outcome was evaluated with a knowledge test administered before and after the intervention with significantly higher posttest scores in the experimental group than in the control group, with a moderate effects size observed between the groups.

A third study evaluated the effect of a VR training intervention on 299 undergraduate nursing students’ diagnostic recognition of depression and schizophrenia (classified as knowledge) [ 24 ]. In a prospective cohort design, the VR intervention was the only difference in the mental health related educational content provided to the two cohorts, and consisted of a VP game design, developed to simulate training situations with virtual patient case scenarios, including depression and schizophrenia. The outcome was assessed by determining the accuracy of diagnoses made after reviewing case vignettes of depression and schizophrenia. The study found no statistically significant effect of VR training on diagnostic accuracy between the simulation and the non-simulation cohort.

Summary: All three studies assessing the effect of a VR intervention on knowledge were non-randomized studies with different study designs using different outcome measures. Two studies used an IPS design, while one study used a VP game design. Two of the studies found a significant effect of VR training on knowledge. Of these, one study had a moderate overall risk of bias [ 26 ], while the other was assessed as having a serious overall risk of bias [ 25 ]. The third study, which did not find any effect of the virtual reality intervention on knowledge, was assessed to have a serious risk of bias [ 24 ].

Three RCTs assessed the effectiveness of VR training on skills [ 20 , 21 , 22 ]. One of them evaluated the effect of VR training on clinical skills in alcohol screening and intervention [ 20 ]. In this study, 102 health care professionals were randomly allocated to either a group receiving no training or a group receiving a VSP intervention. To evaluate the outcome, three standardized patients rated each participant using a checklist based on clinical criteria. The VSP intervention group demonstrated significantly improved posttest skills in alcohol screening and brief intervention compared to the control group, with moderate and small effect sizes, respectively.

Another RCT, including 67 medical college students, evaluated the effect of VR training on clinical skills by comparing the frequency of questions asked about suicide in a VSP intervention group and a video module group [ 21 ]. The assessment of the outcome was a psychiatric interview with a standardized patient. The primary outcome was the frequency with which the students asked the standardized patient five questions about suicide risk. Minimal to small effect sizes were noted in favor of the VSP intervention, though they did not achieve statistical significance for any outcomes.

One posttest only RCT evaluated the effect of three training programs on skills in detecting and diagnosing major depressive disorder and posttraumatic stress disorder (PTSD) [ 22 ]. The study included 30 family physicians, and featured interventions that consisted of two different VSPs designed to simulate training situations, and one text-based program. A diagnostic form filled in by the participants after the intervention was used to assess the outcome. The results revealed a significant effect on diagnostic accuracy for major depressive disorder for both groups receiving VR training, compared to the text-based program, with large effect sizes observed. For PTSD, the intervention using a fixed avatar significantly improved diagnostic accuracy with a large effect size, whereas the intervention with a choice avatar demonstrated a moderate to large effect size compared to the text-based program.

Summary: Three RCTs assessed the effectiveness of VR training on clinical skills [ 20 , 21 , 22 ], all of which used a VSP design. To evaluate the effect of training, two of the studies utilized standardized patients with checklists. The third study measured the effect on skills using a diagnostic form completed by the participants. Two of the studies found a significant effect on skills [ 20 , 22 ], both were assessed to have a high risk of bias. The third study, which did not find any effect of VR training on skills, had some concern for risk of bias [ 21 ].

Knowledge and skills

One RCT study with 227 health care professionals assessed knowledge and skills as a combined outcome compared to a waitlist control group, using a self-report survey before and after the VR training [ 19 ]. The training intervention was a VP game designed to practice knowledge and skills related to mental health and substance abuse disorders. To assess effect of the training, participants completed a self-report scale measuring perceived knowledge and skills. Changes between presimulation and postsimulation scores were reported only for the within treatment group ( n = 117), where the composite postsimulation score was significantly higher than the presimulation score, with a large effect size observed. The study was judged to have a high risk of bias in the domain of selection of the reported result.

One single group pretest–posttest study with 100 social work and nursing students assessed the effect of VSP training on attitudes towards individuals with substance abuse disorders [ 23 ]. To assess the effect of the training, participants completed an online pretest and posttest survey including questions from a substance abuse attitudes survey. This study found no significant effect of VR training on attitudes and was assessed as having a serious risk of bias.

Perceived competence

The same single group pretest–posttest study also assessed the effect of a VSP training intervention on perceived competence in screening, brief intervention, and referral to treatment in encounters with patients with substance abuse disorders [ 23 ]. A commonly accepted definition of competence is that it comprises integrated components of knowledge, skills, and attitudes that enable the successful execution of a professional task [ 32 ]. To assess the effect of the training, participants completed an online pretest and posttest survey including questions on perceived competence. The study findings demonstrated a significant increase in perceived competence following the VSP intervention. The risk of bias in this study was judged as serious.

This systematic review aimed to investigate the effectiveness of VR training on knowledge, skills, and attitudes that health professionals need to master in the assessment and treatment of mental health disorders. A narrative synthesis of eight included studies identified VR training interventions that varied in design and educational content. Although mixed results emerged, most studies reported improvements in knowledge and skills after VR training.

We found that all interventions utilized some type of VP design, predominantly VSP interventions. Although our review includes a limited number of studies, it is noteworthy that the distribution of interventions contrasts with a literature review on the use of ‘virtual patient’ in health care education from 2015 [ 30 ], which identified IPS as the most frequent intervention. This variation may stem from our review’s focus on the mental health field, suggesting a different intervention need and distribution than that observed in general medical education. A fundamental aspect of mental health education involves training skills needed for interpersonal communication, clinical interviews, and symptom assessment, which makes VSPs particularly appropriate. While VP games may be suitable for clinical reasoning in medical fields, offering the opportunity to perform technical medical procedures in a virtual environment, these designs may present some limitations for skills training in mental health education. Notably, avatars in a VP game do not comprehend natural language and are incapable of engaging in conversations. Therefore, the continued advancement of conversational agents like VSPs is particularly compelling and considered by scholars to hold the greatest potential for clinical skills training in mental health education [ 3 ]. VSPs, equipped with AI dialogue capabilities, are particularly valuable for repetitive practice in key skills such as interviewing and counseling [ 31 ], which are crucial in the assessment and treatment of mental health disorders. VSPs could also be a valuable tool for the implementation of training methods in mental health education, such as deliberate practice, a method that has gained attention in psychotherapy training in recent years [ 33 ] for its effectiveness in refining specific performance areas through consistent repetition [ 34 ]. Within this evolving landscape, AI system-based large language models (LLMs) like ChatGPT stand out as a promising innovation. Developed from extensive datasets that include billions of words from a variety of sources, these models possess the ability to generate and understand text in a manner akin to human interaction [ 35 ]. The integration of LLMs into educational contexts shows promise, yet careful consideration and thorough evaluation of their limitations are essential [ 36 ]. One concern regarding LLMs is the possibility of generating inaccurate information, which represents a challenge in healthcare education where precision is crucial [ 37 ]. Furthermore, the use of generative AI raises ethical questions, notably because of potential biases in the training datasets, including content from books and the internet that may not have been verified, thereby risking the perpetuation of these biases [ 38 ]. Developing strategies to mitigate these challenges is imperative, ensuring LLMs are utilized safely in healthcare education.

All interventions in our review were based on non-immersive desktop VR systems, which is somewhat surprising considering the growing body of literature highlighting the impact of immersive VR technology in education, as exemplified by reviews such as that of Radianti et al. [ 39 ]. Furthermore, given the recent accessibility of affordable, high-quality head-mounted displays, this observation is noteworthy. Research has indicated that immersive learning based on head-mounted displays generally yields better learning outcomes than non-immersive approaches [ 40 ], making it an interesting research area in mental health care training and education. Studies using immersive interventions were excluded in the present review because of methodological concerns, paralleling findings described in a systematic review on immersive VR in education [ 41 ], suggesting the potential early stage of research within this field. Moreover, the integration of immersive VR technology into mental health care education may encounter challenges associated with complex ethical and regulatory frameworks, including data privacy concerns exemplified by the Oculus VR headset-Facebook integration, which could restrict the implementation of this technology in healthcare setting. Prioritizing specific training methodologies for enhancing skills may also affect the utilization of immersive VR in mental health education. For example, integrating interactive VSPs into a fully immersive VR environment remains a costly endeavor, potentially limiting the widespread adoption of immersive VR in mental health care. Meanwhile, the use of 360-degree videos in immersive VR environments for training purposes [ 42 ] can be realized with a significantly lower budget. Immersive VR offers promising opportunities for innovative training, but realizing its full potential in mental health care education requires broader research validation and the resolution of existing obstacles.

This review bears some resemblance to the systematic review by Jensen et al. on virtual patients in undergraduate psychiatry education [ 13 ] from 2024, which found that virtual patients improved learning outcomes compared to traditional methods. However, these authors’ expansion of the commonly used definition of virtual patient makes their results difficult to compare with the findings in the present review. A recognized challenge in understanding VR application in health care training arises from the literature on VR training for health care personnel, where ‘virtual patient’ is a term broadly used to describe a diverse range of VR interventions, which vary significantly in technology and educational design [ 3 , 30 ]. For instance, reviews might group different interventions using various VR systems and designs under a single label (virtual patient), or primary studies may use misleading or inadequately defined classifications for the virtual patient interventions evaluated. Clarifying the similarities and differences among these interventions is vital to inform development and enhance communication and understanding in educational contexts [ 43 ].

Strengths and limitations

To the best of our knowledge, this is the first systematic review to evaluate the effectiveness of VR training on knowledge, skills, and attitudes in health care professionals and students in assessing and treating mental health disorders. This review therefore provides valuable insights into the use of VR technology in training and education for mental health care. Another strength of this review is the comprehensive search strategy developed by a senior academic librarian at Inland Norway University of Applied Sciences (HINN) and the authors in collaboration with an adviser from KildeGruppen AS (a Norwegian media company). The search strategy was peer-reviewed by an academic librarian at HINN. Advisers from VRINN (an immersive learning cluster in Norway) and SIMInnlandet (a center for simulation in mental health care at Innlandet Hospital Trust) provided assistance in reviewing the VR systems of the studies, while the classification of the learning designs was conducted under the guidance of a VP scholar. This systematic review relies on an established and recognized classification of VR interventions for training health care personnel and may enhance understanding of the effectiveness of VR interventions designed for the training of mental health care personnel.

This review has some limitations. As we aimed to measure the effect of the VR intervention alone and not the effect of a blended training design, the selection of included studies was limited. Studies not covered in this review might have offered different insights. Given the understanding that blended learning designs, where technology is combined with other forms of learning, have significant positive effects on learning outcomes [ 44 ], we were unable to evaluate interventions that may be more effective in clinical settings. Further, by limiting the outcomes to knowledge, skills, and attitudes, we might have missed insights into other outcomes that are pivotal to competence acquisition.

Limitations in many of the included studies necessitate cautious interpretation of the review’s findings. Small sample sizes and weak designs in several studies, coupled with the use of non-validated outcome measures in some studies, diminish the robustness of the findings. Furthermore, the risk of bias assessment in this review indicates a predominantly high or serious risk of bias across most of the studies, regardless of their design. In addition, the heterogeneity of the studies in terms of study design, interventions, and outcome measures prevented us from conducting a meta-analysis.

Further research

Future research on the effectiveness of VR training for specific learning outcomes in assessing and treating mental health disorders should encompass more rigorous experimental studies with larger sample sizes. These studies should include verifiable descriptions of the VR interventions and employ validated tools to measure outcomes. Moreover, considering that much professional learning involves interactive and reflective practice, research on VR training would probably be enhanced by developing more in-depth study designs that evaluate not only the immediate learning outcomes of VR training but also the broader learning processes associated with it. Future research should also concentrate on utilizing immersive VR training applications, while additionally exploring the integration of large language models to augment interactive learning in mental health care. Finally, this review underscores the necessity in health education research involving VR to communicate research findings using agreed terms and classifications, with the aim of providing a clearer and more comprehensive understanding of the research.

This systematic review investigated the effect of VR training interventions on knowledge, skills, and attitudes in the assessment and treatment of mental health disorders. The results suggest that VR training interventions can promote knowledge and skills acquisition. Further studies are needed to evaluate VR training interventions as a learning tool for mental health care providers. This review emphasizes the necessity to improve future study designs. Additionally, intervention studies of immersive VR applications are lacking in current research and should be a future area of focus.

Availability of data and materials

Detailed search strategies from each database is available in the DataverseNO repository, https://doi.org/10.18710/TI1E0O .

Abbreviations

Virtual Reality

Cave Automatic Virtual Environment

Randomized Controlled Trial

Non-Randomized study

Virtual Standardized Patient

Interactive Patient Scenario

Virtual Patient

Post Traumatic Stress Disorder

Standardized Patient

Artificial intelligence

Inland Norway University of Applied Sciences

Doctor of Philosophy

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Acknowledgements

The authors thank Mole Meyer, adviser at SIMInnlandet, Innlandet Hospital Trust, and Keith Mellingen, manager at VRINN, for their assistance with the categorization and classification of VR interventions, and Associate Professor Inga Hege at the Paracelcus Medical University in Salzburg for valuable contributions to the final classification of the interventions. The authors would also like to thank Håvard Røste from the media company KildeGruppen AS, for assistance with the search strategy; Academic Librarian Elin Opheim at the Inland Norway University of Applied Sciences for valuable peer review of the search strategy; and the Library at the Inland Norway University of Applied Sciences for their support. Additionally, we acknowledge the assistance provided by OpenAI’s ChatGPT for support with translations and language refinement.

Open access funding provided by Inland Norway University Of Applied Sciences The study forms a part of a collaborative PhD project funded by South-Eastern Norway Regional Health Authority through Innlandet Hospital Trust and the Inland University of Applied Sciences.

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CWS, KS, BS, and JS collaboratively designed the study. CWS and JS collected and analysed the data and were primarily responsible for writing the manuscript text. All authors contributed to the development of the search strategy. IBN conducted the literature searches and authored the chapter on the search strategy in the manuscript. All authors reviewed, gave feedback, and granted their final approval of the manuscript.

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Additional file 1: table 2..

Effects of VR training in the included studies: Randomized controlled trials (RCTs) and non-randomized studies (NRSs).

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Steen, C.W., Söderström, K., Stensrud, B. et al. The effectiveness of virtual reality training on knowledge, skills and attitudes of health care professionals and students in assessing and treating mental health disorders: a systematic review. BMC Med Educ 24 , 480 (2024). https://doi.org/10.1186/s12909-024-05423-0

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ORIGINAL RESEARCH article

Urban amenity and urban economic resilience: evidence from china.

$\r\nRan Du$

1 School of Economics, Huazhong University of Science and Technology, Wuhan, Hubei, China
2 International Business School, Shaanxi Normal University, Xi'an, Shaanxi, China

Under the influence of multiple uncertain factors at home and abroad, urban amenities, as the underlying support for urban renewal activities, are of great significance in enhancing urban economic resilience. The panel data of Chinese cities from 2011 to 2019 is used in this study. Urban amenity is measured from artificial amenities and climate amenities, respectively. By using a two-way fixed effects model, we empirically test the impact of urban amenities on urban economic resilience. The key findings of this study are as follows. (1) Urban amenities can significantly enhance urban economic resilience. (2) Heterogeneity analysis shows that there are regional differences in the role of urban amenities in promoting urban economic resilience, with cities in the eastern region, strong environmental regulations, and high urbanization rates benefiting more. (3) We further find that urban amenities mainly enhance economic resilience by promoting population agglomeration, attracting labor migration, improving the quality of human capital, and stimulating urban innovation. Our conclusions recommend to rationally allocate and optimize urban amenity resources, strengthen urban planning and construction management, and create a more livable urban environment, thereby enhancing urban economic resilience.

1 Introduction

Amid the complex backdrop of markedly increased internal and external environmental risks and the continued instability of the global economic situation, the Chinese economy is facing unprecedented challenges ( 1 , 2 ). Enhancing economic resilience and ensuring stable economic operations have become critical issues that urgently need to be addressed in the process of achieving sustainable economic development ( 3 ). Urban economic resilience refers to the adaptability and resilience of the economic system of a city in the face of external shocks and changes ( 4 ), and is a concentrated expression of whether a country or region could effectively cope with the uncertainty shocks or resist and resolve economic risks. Improving the economic resilience of cities is conducive to the stability of the urban economic system and the high-quality development of the urban economy and society, which is an important focus of urban construction and development, and an inevitable choice for building a new urban development pattern. However, previous studies on the factors affecting urban economic resilience mainly focus on land, labor and capital ( 5 – 7 ). This model of improving urban economic resilience from the perspective of industrial production ignores the “human” factor and the essential needs of human beings, leading to problems such as urban environmental pollution, traffic congestion, too little public space, and shortage of leisure and entertainment facilities. These consequences could constrain the improvement of urban economic resilience. Particularly, China has experienced a rapid urbanization process, with hundreds of thousands of people moving from the countryside to the cities, which has led to a rapid expansion in the size of cities, and cities are facing great challenges in resource allocation and environmental pollution control ( 8 ). Researching urban amenities and economic resilience helps understand how Chinese cities perform in this dynamic change and contributes to the formulation of sustainable urban development strategies.

The Chinese government pointed out that the level of urban planning, construction and governance should be improved, and urban renewal actions should be carried out to build livable cities. In the context of China's new-type urbanization with “people” as the core and people's increasing expectations for a high-quality living environment, urban amenities and livability have become key elements to attract talents, promote innovation and cultivate emerging industries ( 9 ), and are directly related to the quality of life of urban residents and the efficiency of resource utilization in cities ( 10 ). Therefore, the construction of urban amenities not only concerns the quality of life and welfare of individuals but has also become a new driving force for enhancing the overall competitiveness of cities. It could have a positive impact on the long-term economic resilience of cities. Within the overall framework of urban growth theory, research on urban amenity can effectively address the deficiencies of traditional growth theories in explaining urban economic resilience, aiding city policymakers in the rational planning of urban comfort facilities. This approach could enhance local attractiveness and, consequently, improve long-term economic resilience. However, to date, there is scarce literature that delves into the impact of urban amenity on urban economic resilience from both theoretical and empirical perspectives. Therefore, in the context of increasing economic uncertainty, could enhance urban amenity lead to improved economic resilience in cities? What pathways and mechanisms facilitate this impact? Exploring these questions can expedite urban renewal activities, promote the construction of comfortable and livable urban environments, and provide policy direction and practical guidance for exploring ways to strengthen urban economic resilience.

The remaining part of this paper is organized as follows: Section 2 presents the literature review; Section 3 provides theoretical analysis and research hypotheses; Section 4 outlines the setting of the econometric model and variable explanations; Section 5 presents empirical analysis results; Section 6 concludes the paper and provides research insights.

2 Literature review and theoretical analysis

2.1 literature review.

With the development of information technology in the post-industrial era, cities have become not only carriers for economic benefits but also organic entities that meet the growing needs of residents. In this context, the theory of urban amenity has emerged. Foreign research on urban amenities mainly focuses on the connotation of urban amenities, the evaluation of urban amenities and its realistic value. Amenities are categorized into natural amenities, artificial amenities, and social atmosphere amenities based on the connotation of amenities. The study that urban amenities as pleasant living conditions that could promote population growth and economic growth ( 11 ). Some scholars believe that urban amenity also include various amenities that make residents feel physically and mentally pleased and attract them to live and settle in the city ( 12 ). Rogerson ( 13 ) argued that urban amenities not only enhance the happiness and satisfaction of city residents but also attract investors and innovative talents, serving as a novel external marketing strategy ( 13 ). In the evaluation of amenities, foreign studies mainly measure urban amenities through the following three methods. First, economists generally use housing prices and wage levels to reflect urban amenity, and use hedonic price models to quantify it ( 14 ). Second, a questionnaire is used to investigate the perception of comfort at the individual level ( 15 ). Third, conduct a comprehensive evaluation based on the connotation construction index of amenity items ( 16 , 17 ). In addition, previous research has found that urban amenities can not only provide social value such as culture and art, but also promote urban economic development, thereby generating economic value ( 18 ). Currently, the research on urban amenities in China is mainly based on China's rapid urbanization process and the orientation of urban sustainable development policies, which provides an important research background. Research on urban amenities in China focuses mainly on two aspects: first of all, combined with the reality of China's development, the criteria for the construction of China's amenity system and the dynamic evolution process are proposed ( 19 ); secondly, empirically testing the economic effects of urban amenities on urban development, such as influencing land prices, increasing the degree of industrial agglomeration, and attracting labor inflow ( 20 – 22 ).

As the risks of uncertainty increasingly mount, the study of economic resilience has attracted widespread interest from scholars around the world. Davies explains economic resilience from three dimensions: first, the ability of an economy to withstand external risks and challenges, second, the ability of an economy to recover from negative shocks through self-regulation after the impact, third, the ability to innovate new growth pathways, enhancing the capacity for long-term growth ( 23 , 24 ). Currently, there are various methods for measuring economic resilience, ranging from the sensitivity index method to comprehensive indicator evaluation methods ( 25 – 27 ). Urban economic resilience is thought to be determined by the dynamics of four interacting subsystems: the structural and business subsystem, the labor market subsystem, the financial subsystem, and the governance subsystem ( 4 ). Firstly, in terms of industrial structure and business system, existing scholars mainly study the impact of diversified or specialized industrial structure and technological innovation on economic resilience ( 5 , 28 , 29 ). Secondly, in labor market and financial subsystem, some scholars study the impact of human capital ( 30 ) and digital finance ( 23 , 31 ) on economic resilience. Finally, there are also scholars discussing the influence factors of economic resilience from the perspective of governance such as policy support and political systems ( 32 , 33 ).

Existing theoretical and empirical research on urban amenities and urban economic resilience provides a solid foundation for this paper. However, there are still two shortcomings. Firstly, while current studies have examined the impact of various factors on urban economic resilience, there has been less focus on the influence of urban amenities on urban economic resilience. Therefore, the relationship and impact mechanisms between urban amenities and urban economic resilience require further in-depth research. Secondly, the current methods for measuring different urban amenities levels need improvement. Existing studies often measure urban amenities from the perspective of guaranteeing indicators such as transportation, medical care, and the environment, with less consideration for social factors such as education and culture within the city. In the meanwhile, there is also less focus on the impact of climate amenities on urban economic resilience. Therefore, this paper takes 255 prefecture-level cities nationwide as the research objects, constructs artificial amenities and climate amenities, and studies the impact and internal mechanisms of urban amenities on urban economic resilience.

The marginal contributions of this paper may be reflected in three aspects. Firstly, existing research primarily focuses on the impact of industrial structure ( 6 ), technological innovation ( 5 , 28 ), regional integration ( 7 ), infrastructures ( 34 ), digital finance ( 23 , 31 ), and on economic resilience. Unlike previous studies that mainly focused on economic perspectives in studying economic resilience, this paper starts from the basic needs of “people,” using urban amenities as an entry point to explain how to enhance economic resilience. It supplements relevant studies on factors influencing urban economic resilience.

Secondly, previous studies have often selected indicators focusing on the natural environment and infrastructure to measure urban amenities ( 35 , 36 ), with less emphasis on indicators related to healthcare and transportation. We chose a broader range of suitable indicators to assess the state of urban medical services and transportation infrastructure, thereby more comprehensively measuring urban amenities. Additionally, previous studies mainly used temperature and humidity indexes to study climate amenities ( 36 , 37 ). In our study, based on the national standard for Climatic Suitability Evaluating on Human Settlement formulated by the Chinese government, we measure urban climate amenities more comprehensively, considering factors such as city temperature, humidity, wind speed, and sunlight duration. Thus, our construction of indicators more fully reflects both the artificial and climate amenities of cities, enhancing the accuracy of the indicators.

Thirdly, in terms of research content, we will identify external factors that differentiate the impact of urban amenities construction on urban economic resilience. This paper conducts a heterogeneity analysis from the perspectives of local environmental governance and regional development situations, expanding the directions in which urban amenities exert positive effects and the application scenarios of amenity theory, providing a new development approach for urban development models, offering more targeted support to comprehensively enhance urban economic resilience. Furthermore, from the perspective of urban population aggregation effects and innovation effects, we explore the potential impact mechanisms of amenities construction on urban economic resilience. Through comprehensive analysis of various channels, it helps identify the underlying logical impact.

2.2 Theoretical analysis and research hypotheses

Cities with more amenities can attract highly mobile resources such as capital, technology, and manpower, as well as foreign consumers and investors. This improves the city's competitiveness in acquiring these resources, thereby improving the urban quality and overall competitiveness as a comprehensive consumer product ( 38 ). This is beneficial for strengthening urban economic resilience. In addition, cities that are rich in amenities such as cultural institutions, educational facilities, and leisure spaces generally exhibit higher levels of economic diversification and complexity ( 39 ). The diversity of the economic system can help cities reduce their dependence on a single industry, enhance the city's ability to withstand stress, and enable cities to better cope with the risks of economic uncertainty. In an era of rapid urbanization, urban amenity has received attention for its key role in shaping urban development patterns and enhancing economic resilience.

2.2.1 Urban amenity and population agglomeration effects

Firstly, according to the amenity migration theory, amenities in terms of natural environment, service environment, social culture, etc. are the main reasons for attracting population agglomeration and labor mobility. People tend to choose to move to cities with superior natural environments such as warm winters, cool summers, abundant sunshine, abundant green space and vegetation, and less pollution ( 40 , 41 ). They also tend to move to cities with comfortable service environments such as diverse dining facilities, shopping malls, and efficient transportation infrastructure. At the same time, cities with more amenities develop faster and are more able to attract labor to move in, because cities with high amenity levels not only provide higher economic income but also provide a better quality of life ( 18 ). The process of population agglomeration in high-amenity cities will enhance urban economic resilience. On the one hand, the scale effect caused by population agglomeration can reduce transaction costs and create demand, support stable urban economic growth, and thereby enhance economic resilience. Population agglomeration can bring abundant labor resources to cities, provide enterprises with a variety of labor forces with professional skills, and reduce enterprises' labor search costs ( 29 ). It can also improve the allocation level of factor resources and improve economic efficiency, thereby enhancing urban economic resilience ( 30 ). Population agglomeration can also provide enterprises with a higher degree of talent adaptability, which can effectively avoid sharp changes in enterprise labor demand after economic shocks, quickly realize adaptive production structure adjustments, and thereby achieve sustainable economic resilience. In addition, as the population agglomerates in cities, it will expand the city's internal market demand, prompting industrial entities to produce more products. It will also prompt the government to increase infrastructure construction and improve the level of public services such as education and medical care, thereby reducing the impact of sudden changes in the external environment ( 17 , 30 ). On the other hand, population agglomeration can also produce external effects. Population agglomeration will lead to the expansion and sharing of the labor market, which is conducive to increasing the degree of industrial agglomeration, promoting the refinement of the city's industrial division of labor, and forming an industrial structure system with complementary functions ( 42 ). The diversified industrial agglomeration has the function of an automatic stabilizer, which can effectively enhance urban economic toughness ( 43 ). Thus, urban amenities can increase population aggregation, thereby enhancing urban economic resilience.

Secondly, cities that offer a high quality of life, rich cultural experiences, a good social environment and diverse opportunities tend to attract more highly skilled people ( 44 ). Florida refers to the human capital that generates new technologies, knowledge and art as the “creative class,” which plays a decisive role in the innovative development of cities ( 45 ). Compared with low-skilled labor, high-skill “creative classes” are more sensitive to the living environment and working environment. A more comfortable environment can improve the work satisfaction and comfort of high-skilled talents, improve the efficiency of labor work, and reduce the loss of human capital ( 46 ). Multi-level and multi-skill labor can provide high-quality human capital for the professional industrial chain of the enterprise, and human capital is the key element of regional economic resilience construction ( 47 ). High-quality human capital can accelerate the flow and diffusion of innovative elements, release consumer domestic demand, and stimulate income effects, etc., promote the sustainable development of cities and enterprises ( 48 ). It gives cities the ability to adapt and resist external impact and enhance the urban long-term economic resilience ( 49 ). Therefore, cities with higher comfort standards such as culture and public services can attract the inflow of high-tech talents, and increase the local human capital stock, thereby promoting the high-quality development of cities and enhancing urban economic resilience ( 50 ).

2.2.2 Urban amenity and innovation effects

As mentioned above, urban amenity is a key influencing factor of talent migration. Cities with higher levels of amenities are more able to attract innovative talents, and the comfort migration of talents can enhance urban economic resilience by stimulating innovation ( 51 ). Firstly, high-amenity cities can provide more space and facilities for relieving stress for innovative talents facing high work pressure, helping to create an inclusive and diverse social atmosphere, and providing greater social support for high-risk innovation ( 52 ). Secondly, a pleasant and comfortable environment, along with an innovative atmosphere, contributes to lowering the “talent entry barrier” ( 38 ). It encourages employees to showcase their abilities, enhances the enthusiasm for technological innovation among talents, attracts innovative companies and venture capital institutions, prompts cities to increase policy support for innovation resources, reduces innovation costs for relevant enterprises, and improves overall innovation efficiency. Finally, the concentration of innovative talents with diverse knowledge backgrounds in highly comfortable cities may lead to higher levels of technological spillover. Not only does this enhance the diversity and depth of technology, but it also encourages open and diverse innovative thinking, thereby expanding the boundaries of urban innovation ( 53 ). In addition, well-established infrastructures such as communication facilities can also facilitate technical exchange and information sharing among different cities, creating a diversified pool of technologies and a spillover effect of knowledge. The basis of promoting the efficient integration of traditional factors, drives the emergence of innovative schemes and products, providing businesses with more technological choices and higher-quality technological innovation ( 54 ). Furthermore, the technological innovation of cities also contributes to enhancing the city's economic resilience. On the one hand, innovation can improve the efficiency of resource allocation and the output efficiency of production factors. It can eliminate old production models and expand the scope of use of production factors, thereby deepening specialization, exerting the core driving force of market entities, and thus enhancing economic resilience ( 5 , 55 , 56 ). On the other hand, innovation can drive industrial structural transformation and upgrading, promote the transformation of industries toward rationalization, diversification, and sophistication, improve the overall division of labor and cooperation level of the urban economy, and enable cities to have a strong economic foundation to cope with adverse shocks ( 57 ). Therefore, urban amenities affect the spatial mobility of innovative talents, enhancing the level of urban innovation, and thus forming a city development model of “city amenity attracts talents, talents stimulate innovation, and innovation enhances resilience.”

Based on this, this paper proposes the following hypotheses:

Hypothesis 1: The improvement of urban amenities can enhance the city's economic resilience.

Hypothesis 2: Urban amenities can enhance economic resilience by promoting population agglomeration, attracting labor migration, and increasing the quality of human capital.

Hypothesis 3: Urban amenities can enhance the city's economic resilience by enhancing urban innovation.

In conclusion, the research framework is shown in Figure 1 . It includes impact effects and impact mechanisms.

Figure 1 . Influence diagram of the mechanisms by which urban amenity affects urban economic resilience.

3 Methods and data

3.1 empirical model.

We control individual fixed effects and time-fixed effects. Individual fixed effects are used to control unobservable individual characteristic factors that do not change over time at the individual level but affect urban economic resilience. Time-fixed effects are time-characteristic factors that do not change with individuals but affect urban economic resilience. Fixed effects models can reduce endogeneity problems caused by omitted variables ( 58 ). We use Equation 1 to verify the impact of urban amenities on urban economic resilience.

Where i and t represent the city and time, respectively, j represents the j -th control variable; Resilience represents the economic resilience of the city, Amenity represents the level of artificial amenities of the city, X represents control variables, μ i represents city fixed effects, δ t represents time fixed effects, and ε it is the error term.

3.2 Variables

3.2.1 dependent variable.

There are two main methods for measuring urban economic resilience. One is the indicator system method, which uses a series of indicators to measure economic resilience ( 59 , 60 ). However, the indicator method has certain flaws. There is still no recognized reasonable indicator, and it is easy to confuse the causal relationship. The indicators used by researchers may be the reason why cities have economic resilience. Another method is to measure economic sensitivity indicators such as employment and GDP. Considering that the single indicator method has the characteristics of representativeness and continuity, we use this method to measure economic resilience ( 61 ). At the same time, considering that GDP is the core indicator of urban economic development, the sustained growth of urban GDP is the basis for solving a series of problems such as employment and welfare, and can directly reflect the ability of the urban economy to withstand shocks. Therefore, this article draws on Martin's economic sensitivity index and calculates urban economic resilience based on the ratio of the growth rate of urban regional GDP to the growth rate of China's national regional GDP ( 62 ). The city's economic resilience is evaluated by comparing the sensitivity index value with 1. If the sensitivity index is >1, then the city is more resilient and resistant to shocks than the national average, so the city is more resilient.

3.2.2 Independent variable

At present, urban amenity is mainly measured by constructing an index system. Referring to the research of Diamond ( 46 ) and Zhang and Fang ( 20 ), our selects five major categories of indicators: culture, education, medical care, transportation, and environment, and uses the analytic hierarchy process to construct a comprehensive index that reflects urban artificial amenity (Amenity). We first constructed a hierarchical evaluation index system based on the principles of systematicness and availability of indicators. To avoid randomness in indicator selection, we fully draw on previous research and suggestions from experts in related fields. Secondly, use the upper-level indicators as the benchmark, compare each indicator at the same level, construct a judgment matrix, conduct consistency testing, and determine the weight of each indicator. Finally, according to the weighting method, the weight value of all indicators at this level to the previous level is calculated, and the comprehensive weight is obtained layer by layer. Previous literature also used the entropy weight method to calculate index weights, but the entropy weight method will lead to the loss of data information ( 63 ). Therefore, we use the analytic hierarchy process to determine specific weights. The five major categories of indicator data are all from the “China Urban Statistical Yearbook.” Table 1 reports the types and specific descriptions of the five major categories of indicators. We constructed the urban amenity variable based on these indicator systems.

Table 1 . Selection of indicators for principal component analysis of urban artificial amenities.

In the robustness test, we constructed a climate amenity index (Climate) based on the climate amenity evaluation standard for human settlements proposed by the China Meteorological Administration (GB/T 27963-2011) and replaced artificial amenity with climatic amenity as a proxy variable for urban amenity. The steps to construct climate amenities are as follows. The temperature and humidity index I and wind efficiency index K are calculated according to the following formulas (2) and (3), respectively. Based on the availability of data, the wind efficiency index is used in areas where the average wind speed during the evaluation period is >3m/s, otherwise, the temperature and humidity index is used. Finally, to ensure a consistent trend, according to the classification table of human settlement environment amenity levels in Table 2 . Reassign “levels 1 and 5, levels 2 and 4, and level 3” to 1, 2, and 3, that is, the higher the value, the more comfortable the urban climate will be.

Table 2 . Habitat amenities classification table.

We use Equation 2 to calculate the temperature and humidity index. Among them, I represents the temperature and humidity index, T represents the average temperature during the evaluation period, and RH represents the average relative air humidity during the evaluation period.

We use Equation 3 to calculate the wind efficiency index. Among them, K represents the wind efficiency index, T represents the average temperature during the evaluation period, V represents the average wind speed during the evaluation period, and S represents average sunshine hours during the evaluation period. We construct an urban climate amenity index from this standard design.

3.2.3 Control variables

When conducting empirical analysis, we refer to the research of Xu and Deng ( 56 ), Feng et al. ( 7 ), and Zhang et al. ( 64 ), and select economic scale, financial development level, fixed asset scale, industrial structure, fiscal expenditure and urban freight carrying capacity as control variables. 1. Economic scale (GDP). Cities with larger economies have stronger economic bases and resources in multiple dimensions, making them better able to adapt and respond to adverse economic conditions. This article uses the logarithm of GDP to measure the economic size of a city. 2. Financial development level (Finance). Cities with high financing potential are often able to attract more resources and investments, which can help cities build more resilient economies. We measure it by the ratio of deposit balances of financial institutions to GDP at the end of the year. 3. Scale of fixed assets (Investment). The scale of fixed assets is measured by the ratio of the city's total fixed assets to GDP. 4. Industrial structure (Structure). A diversified industrial structure can not only disperse the risks of economic shocks in a short period but also promote regional innovation and new technology innovation, allowing cities to adapt to resource reorganization and structural transformation and adjustment after the crisis. 5. Financial expenditure (Expenditure). Fiscal spending can improve economic resilience by stimulating demand, building infrastructure, and providing social protection. The city's financial expenditure is measured as the logarithm of the city's general fiscal budget expenditure. 6. Urban freight carrying capacity (Freight). The city's transportation infrastructure helps the city resist the impact of economic risks. The city's freight carrying capacity is measured by the logarithm of highway freight volume.

3.2.4 Mechanism variables

We select the following variables as mechanism variables. 1. Population aggregation (Population). We measure the degree of population agglomeration using the logarithm of urban population density. 2. Labor supply and human capital. Labor supply (Labor) is measured by the ratio of the number of urban employees to the total population at the end of the year. Human capital stock (Humancap) is measured by the number of students in school. 3. Urban innovation. This article uses the following two indicators to evaluate urban innovation: the number of urban patent applications (Patent) and the level of R&D investment (R&D). The level of urban R&D investment is measured by the ratio of urban science education expenditure to GDP.

Considering the completeness of the data and the impact of public events, our study selects 255 cities in China from 2011 to 2019 as research samples. All macro-level data of cities are sourced from the “China Urban Statistical Yearbook.” The climate amenities indicators selected in this study include variables such as average temperature, average relative humidity, average wind speed, and average hours of sunshine for each city. The original meteorological data are obtained from the China Surface Climate Data Daily Value dataset (V3.0). We refer to the design method of Deschênes and Greenstone ( 65 ). We use the inverse distance weighted interpolation method (IDW) to interpolate daily meteorological data into grid data, and then obtain annual meteorological data for each district and county. To eliminate the influence of extreme values, all continuous variable data are trimmed by 1% above and below.

3.4 Probability density plot and descriptive statistics

Figures 2 , 3 respectively present the three-dimensional probability distribution diagrams of urban resilience and amenity of Chinese cities over the years. From Figure 2 , it can be observed that the dispersion and right-skewness of the amenity probability distribution in Chinese cities are increasing year by year, the right tail is lengthening year by year, and the range is gradually expanding. The reason is that although the resilience values in the high quantile increase year by year, the values in the middle and low quantiles do not increase significantly, resulting in the gradual widening of the spatial gap in amenity among Chinese cities. From Figure 3 , we can understand that the overall distribution of urban resilience in China fluctuates violently over the years, and the concentration ratio shows an “S”-shaped trend of first declining, then rising, and then falling again. Overall, there has been no significant improvement. Compared with other years, China's urban resilience was generally low in 2011, while in 2017 China's urban resilience was generally high. This may be due to the impact of the global financial crisis in 2008. China's resilience had not yet fully recovered in 2011. After 2015, China's implementation of supply-side structural reforms revitalized urban resilience. Secondly, we can also find that the spatial differences in urban resilience in 2019 are large, which may be due to the severe differences in urban resilience in China due to the Sino-US trade dispute in 2018. The above characteristics show that China's urban resilience still has room for optimization and improvement.

Figure 2 . Probability density plot of amenity.

Figure 3 . Probability density plot of resilience.

Descriptive statistics of variables are presented in Table 3 . The mean value of resilience is 1.198, that is, the majority of urban economies demonstrate resilience. In addition, the average value of urban amenity is 2.295, the minimum value is 0.769, and the maximum value is 7.152, indicating that there is a significant difference in amenity levels in various cities.

Table 3 . Descriptive statistics.

4 Empirical results analysis

4.1 baseline regression results.

The baseline regression results are shown in Table 4 . Column (1) only includes core explanatory variables, and the results show that the improvement of urban amenities can significantly increase the economic resilience of a region. When control variables, city fixed effects, and year fixed effects are added in sequence from column (2) to column (5), the goodness of fit of the model is significantly improved. At the same time, the test results all show that the impact of urban amenities on urban economic resilience is significantly positive. As can be seen from column (5) in Table 4 , after controlling for other factors, every 1-unit increase in urban amenities will increase urban economic resilience by 0.091 units. This result shows that the improvement of urban amenities can significantly enhance urban economic resilience. Economic resilience. Hypothesis 1 was verified.

Table 4 . Baseline regression results.

4.2 Robustness test

4.2.1 replacing the dependent variable.

In the robustness test, we use two alternative indicators to measure the economic resilience of cities. The first method follows the research of Tan et al. ( 66 ), using China's annual actual GDP growth rate as the counterfactual basis for urban development, then calculating the difference between each city's annual actual GDP growth rate and this counterfactual basis, and using this difference to reflect the city's economic resilience level. This difference is used to construct a sensitivity index reflecting the level of economic resilience of cities. We put the sensitivity index into the benchmark model for regression, and the regression results are shown in column (1) of Table 5 . The second method draws on the relevant research by Chen ( 67 ), using the regional employment sensitivity index to measure China's economic resilience and perform regression using the ratio between the change rate of urban employment and the change rate of national employment as the proxy explained variable. Regression is conducted with the ratio of the change rate of urban employment to the change rate of national employment as the proxy for the explained variable. The regression results are shown in column (2) of Table 5 . The results all show that urban amenities can improve the economic resilience of the city, validating the baseline regression results.

Table 5 . Robustness test.

4.2.2 Replacing the independent variable

This study replaces urban artificial amenity with the climate amenity index. The empirical results are shown in column (3) of Table 5 . The results show that climate amenities can significantly improve a city's economic resilience. The possible reason is that improved climate amenities are more conducive to attracting population agglomeration and business investment. Cities with a pleasant climate are usually rich in natural resources and ecosystem services, which not only provide urban residents with natural places for leisure and entertainment but also help improve their health and quality of life. High-quality ecosystem services can also attract more tourists and businesses, promoting the vigorous development of tourism and cultural industries. In addition, the improvement of investment attractiveness will help promote the city's infrastructure construction and industrial diversity development, thereby improving the city's overall economic level and enhancing the city's economic resilience.

4.2.3 Excluding capital cities samples

As the administrative center of a province, provincial cities usually receive more government support and often have stronger resource attraction. These cities have large populations, high levels of economic development, complete infrastructure, and resource advantages in the construction of urban amenities. The interaction of these factors helps to improve the ability of provincial capital cities to cope with challenges and uncertainties, so the economic resilience of provincial capital cities may be stronger. Therefore, compared with non-provincial capital cities, provincial capital cities have a certain “siphon effect” in terms of resource acquisition and policy support, which may have an impact on the empirical results. To improve the credibility of the research conclusions, the empirical analysis was re-conducted after deleting provincial capital city data from all samples. Column (4) of Table 5 reports the results of regression on all non-provincial capital city samples after excluding provincial capital cities. A one-unit increase in urban amenities is associated with a 0.119-unit increase in economic resilience for non-capital cities. After provincial capital cities are eliminated, non-provincial capital cities without excess resources can also improve urban economic resilience through the construction of amenities. The results show that the impact of urban amenities in non-provincial capital cities on the city's economic resilience is still significantly positive, and the baseline regression is robust.

4.2.4 Different samples and variable selection

We further select different samples and variables for robustness testing. Firstly, to further reduce the impact of extreme values on model estimation, the samples are winsorized at the 5% level, and the results are shown in column (5) of Table 5 . Robustness results show that the core conclusions of this article still hold. Secondly, industrial agglomeration usually leads to the concentration of resources such as technology, talents, and raw materials, thereby forming a diversified industrial chain and economies of scale, which in turn helps the city respond to market changes and shocks and improve the city's economic resilience. In addition, FDI can introduce new technology and management experience and attract large amounts of capital investment, which is also important for the stable growth of the urban economy. Therefore, we add the proxy variables of industrial agglomeration and FDI to the control variables. This article selects the industry Herfindahl index to measure the degree of industrial agglomeration and uses the proportion of the total output value of foreign-invested enterprises in GDP to measure FDI. The results in column (6) of Table 5 show that after controlling for industrial agglomeration and FDI, the results are still significant.

4.2.5 Endogeneity discussion

To reduce the problem of biased estimation results caused by reverse causality and omitted variables between urban amenities and economic resilience, this paper uses the instrumental variable method for empirical analysis. Drawing on the research of Xu and Deng ( 56 ), urban terrain slope was selected as the instrumental variable. First of all, terrain slope will have a significant impact on the construction form and investment costs of urban infrastructure such as roads, bridges, and parks. It also affects China's population distribution and labor concentration. The layout of infrastructure and population distribution are closely related to urban amenities. Therefore, there is a correlation between urban amenity and urban terrain slope, which meets the assumption of correlation between endogenous variables and instrumental variables. Secondly, the terrain slope is a naturally formed geographical information variable in the city. It has relatively natural exogenous characteristics and does not directly affect the current economic development level and resilience level of the city. It satisfies the homogeneity assumption of instrumental variables.

However, terrain slope is cross-sectional data in the data dimension and does not change with time, which will result in the inability to control the individual effects of cities in empirical regression. Secondly, the impact of the urban slope index on urban amenities may also change over time, and appropriate instrumental variables need to take into account this difference in time dimension. In addition, consider that urban wind speed may affect urban amenities and urban wind speed is determined by large-scale weather systems. Therefore, it is an exogenous factor in local economic activity. To this end, we multiplied the urban terrain slope (Slope) and the urban wind speed (Wind) and took the logarithm to construct an instrumental variable with a time effect.

Columns (1) and (2) of Table 6 are the instrumental variable regression results after adding only core explanatory variables, and columns (3) and (4) are the instrumental variable regression results after adding control variables. As can be seen from Table 6 , the F values in the first stage are all >10, indicating that the instrumental variables and endogenous variables are related, eliminating the problem of weak instrumental variables. It can be seen from the regression results of the second stage that the coefficient of urban amenity is still significantly positive. This result is consistent with the baseline regression results and verifies the improvement effect of urban amenities on urban economic resilience.

Table 6 . Instrumental variable analysis.

4.3 Heterogeneity tests

4.3.1 regional heterogeneity.

Due to geographical differences, preferential policies, and other reasons, China's urban amenity construction and economic development levels have obvious regional differences. Therefore, there may also be differences in the role of urban amenities in promoting urban economic resilience. We divide the sample into eastern central and western cities for group regression. As shown in columns (1) and (2) of Table 7 , for eastern cities, the improvement of urban amenities can significantly enhance urban economic resilience. The possible reason is that eastern cities usually have high population density, large market size, better infrastructure, and richer development resources. Secondly, eastern cities also have advantages in terms of openness and policy support, which results in the level of technology accumulation and the number of high-quality talents in eastern cities being far superior to that in central and western regions. Therefore, the more eastern cities can create a comfortable living environment through a series of policy measures, thereby enhancing urban economic resilience. The central and western regions are faced with problems such as weak economic foundations, lagging infrastructure construction, and serious population loss, which make them face relatively greater difficulties in improving economic resilience through urban amenity construction.

Table 7 . Heterogeneity test.

4.3.2 Environmental regulation

Environmental regulation, as a means of government environmental governance, can effectively reduce environmental pollution problems, improve environmental quality, and enhance urban amenities. In addition, environmental regulatory policies can promote the growth of economic resilience by improving the level of urban technological innovation and promoting urban green transformation. Therefore, areas with strong environmental regulations may enhance the role of urban amenities in promoting urban economic resilience. Referring to the research design method of Chen and Chen ( 68 ), we selected the frequency of words related to environmental regulation in the “Government Work Report” of the prefecture-level city that year to measure the intensity of the city's environmental regulation. We grouped each city according to the median frequency of annual environmental regulation words and obtained the group with high environmental regulation intensity and the group with low environmental regulation intensity. Finally, the group regression analysis results are shown in columns (3) to (4) of Table 7 .

4.3.3 Degree of urbanization

There are significant differences in urbanization rates among different cities, which leads to diversity in the development patterns and speeds of various cities. We divide cities into cities with high urbanization rates and cities with low urbanization rates according to the median urbanization rate of each city. The results are shown in columns (5) and (6) of Table 7 . The results show that when a city's urbanization rate is high, improvements in urban amenities will significantly enhance urban economic resilience. The possible reason is that the urbanization process is usually accompanied by the construction of infrastructure and the optimization of public services, including public transportation, public facilities, education, medical, and community services. High-quality infrastructure and public services can significantly improve the quality of life and satisfaction of urban residents, thereby enhancing the amenities of the city, promoting the development of the urban economy, and improving economic resilience. When the urbanization rate of a city is low, the concentration of production factors is usually relatively low, which may affect the improvement of economic benefits. At the same time, these cities have deficiencies in infrastructure construction and public service provision. Its ability to withstand various risks may also be weaker, affecting the city's economic resilience. Therefore, the urbanization process plays an important supporting role in improving urban amenity and economic resilience.

4.4 Mechanism analysis

According to the aforementioned theoretical analysis, urban amenities may have a significant impact on regional factor supply and resource allocation efficiency. High urban amenity means that the city has good living conditions, employment opportunities, educational resources, medical services, etc. These will increase people's expectations for the quality of life and happiness after migration, thereby increasing their utility expectations of migration. At the same time, areas with high urban amenities can attract high-quality talents in different fields or at different levels, further improving the quality of labor supply and improving the city's human capital level. Therefore, cities with high urban amenities can attract more population inflows and increase the quantity and quality of labor supply. In addition, cities with high urban amenities can also promote technological innovation and increase the supply of intellectual capital. Innovation is an important driving force for economic growth and a key factor in improving production efficiency and competitiveness. Therefore, high urban amenity means that the city has a good innovation atmosphere, scientific research institutions, talent training systems, knowledge exchange channels, etc. These will enhance the effects of population agglomeration and innovation, thereby enhancing urban economic resilience.

To test the channel through which urban amenity affects urban economic resilience, we take urban amenity as the core explanatory variable and replace the explained variables of the model (1) with the degree of population agglomeration, the number of labor forces, human capital, and urban innovation. This model is used to examine the impact of urban amenity on mechanism variables. Columns (1) to (5) of Table 8 respectively verify that the degree of population agglomeration, the number of labor force, human capital, innovation patents, and innovation investment are the paths through which urban amenity affects urban economic resilience. In conclusion, cities with high levels of amenities have a higher quality of life, more labor and high-quality talent inflows, and a stronger innovation atmosphere, which have a positive effect on urban economic resilience. The above analysis has verified to a certain extent the impact mechanism of urban amenities on urban economic resilience.

Table 8 . Mechanism analysis.

5 Discussion

We analyze the relationship between urban amenities and urban economic resilience. Our empirical evidence suggests that urban amenities significantly contribute to enhancing urban economic resilience. This aligns with prior research emphasizing the various benefits of amenities in urban sustainable development ( 16 , 21 , 69 ). Urban amenities, encompassing factors such as green spaces, cultural attractions, and public infrastructure, not only enhance the quality of life for residents but also attract investments, stimulate economic activity, and promote sustainable development. The presence of green spaces, for instance, not only enhances environmental sustainability but also fosters community wellbeing and social cohesion, thereby contributing to enhancing urban economic resilience ( 70 ). Similarly, investments in cultural institutions and recreational facilities not only enrich the urban experience but also promote economic development through tourism, cultural events, and creative industries ( 71 ). In particular, we found that the population agglomeration effect and innovation effect are the influencing mechanisms through which urban amenity improves urban economic resilience. Population agglomeration and innovation effects play a very important role in enhancing the economic resilience of urban areas ( 64 , 67 ). Concentration and innovation of population facilitate economies of scale, resource sharing, and enhanced labor market efficiency, all of which contribute to the resilience of local economies. In conclusion, investing in the development and maintenance of urban amenities emerges as a strategic approach to improving economic resilience.

The regional disparities in the impact of urban amenities on economic resilience are noteworthy. Previous studies find that unreasonable investments in amenities in poor regions could exacerbate socioeconomic inequalities, thereby leading to the exclusion of underprivileged residents from benefiting from urban amenities and displacing long-standing communities ( 72 ). This highlights the importance of tailoring urban development strategies to regional contexts. Similar to previous studies, we find that in more economically developed areas such as the East, the construction of infrastructure and other amenities is more conducive to promoting urban economic development ( 73 , 74 ). Economically developed regions tend to have more diversified economies, meaning they are not solely reliant on one industry. Building amenities can contribute to this diversification by attracting different types of businesses and residents. For instance, a city with a vibrant arts scene may appeal to creative professionals, while excellent recreational opportunities may attract outdoor enthusiasts or retirees. This diversity can help protect the city against economic shocks. In addition, we also found that the stronger the urban environmental regulation, the more conducive it is to enhancing economic resilience through the construction of amenities. Environmental regulations targeting climate change mitigation and adaptation measures can enhance urban resilience to cope with extreme weather events and other economic-related challenges. Investments in green infrastructure, such as flood protection systems and sustainable urban planning, can minimize economic disruptions caused by environmental disasters ( 75 ). Therefore, policymakers should consider local conditions, socio-economic dynamics, and environmental factors when planning and allocating resources for urban amenities.

Previous research shows urban growth and economic development have not coincided with urban resilience policies, plans, and practices ( 76 ). Urbanization, especially in developing nations, is often characterized by rapid expansion and resource-intensive development aimed at bolstering economic growth. However, this growth frequently occurs without adequate consideration for the resilience of urban systems to withstand various shocks, ranging from environmental disasters to economic downturns. Consequently, cities may become more susceptible to disruptions, thereby impeding sustained economic progress. Our research underscores the significance of integrating resilience-focused approaches into urban development strategies, particularly through the adoption of suitable amenities. By investing in infrastructural solutions that prioritize both economic growth and economic resilience, cities can better withstand and recover from adverse events while fostering long-term prosperity. In conclusion, our study underscores the importance of aligning urban development efforts with economic resilience principles to promote sustainable economic growth in developing countries. By the construction of rational and moderate amenities, cities can enhance their capacity to withstand and recover from challenges, ultimately fostering more resilient and prosperous urban environments.

6 Conclusion

At this stage, economic uncertainty is becoming normalized. Increased economic uncertainty may increase market risks and trigger economic turmoil, which will have a profound impact on urban economic development. Therefore, how to deal with economic uncertainty and improve the economic resilience of cities has become an important current research topic. This is related to the efficiency of economic operation and the strategic goal of high-quality development of the Chinese economy. At the same time, urban amenity is an important indicator to measure people's happiness. The construction of urban amenities is an important task that conforms to the laws of urban development and the requirements of the times and reflects the comprehensive strength of the city. This is not only an effective way to deal with economic uncertainty, but also an important measure to achieve high-quality urban development. After measuring the city's artificial amenities and climate amenities, we conducted an empirical analysis based on China's urban panel data from 2011 to 2019, tested the impact of urban amenities on urban economic resilience, and came to the following empirical conclusions. Firstly, whether urban amenity is measured in terms of artificial amenities or climate comfort, cities with more amenity show stronger economic resilience when facing external shocks. Secondly, the impact of urban amenity on urban economic resilience shows regional differences. Compared with central and western cities, eastern cities can significantly enhance the city's economic resilience by improving their amenity. At the same time, the greater the intensity of environmental regulation and the higher the degree of urbanization in a city, the stronger the role of urban amenities in promoting economic resilience. Finally, we find that urban amenity affects economic resilience mainly through mechanisms such as population agglomeration, labor migration, improving the quality of human capital, and stimulating innovation vitality.

In light of the above conclusions, we propose the following policy recommendations: First, we suggest strengthening the incentives for local governments to build livable cities and, based on urban development goals and residents' needs, conduct reasonable allocation and optimization of amenity resources. The government should enhance residents' awareness of participation in urban governance, establish surveys on urban residents' satisfaction with livability, and incorporate urban livability satisfaction into the assessment and evaluation of government performance. Additionally, the government should delve deeply into and make good use of urban cultural resources, creating distinctive cultural blocks and cultural industry parks, among others. In the meanwhile, it should improve the allocation of urban land resources, dedicating more land to the construction of parks, green spaces, sports, and fitness facilities, and other public spaces. Lastly, according to the climate characteristics of different cities, the government should actively create green development space, optimize the urban heat island effect, strengthen environmental governance and ecological restoration, in particular, strictly implement the discharge standards of air pollutants and urban sewage and environmental protection policies, improves the quality of air and water resources, and improves the urban climate environment.

Second, considering the differences in natural conditions and the level of economic and social development between different regions, the government should promote the construction of urban amenities in a manner tailored to local conditions. In the eastern regions and cities with higher urbanization rates, it's crucial to fully leverage the advantages of factor agglomeration and location. The focus should be on improving urban environmental quality and public service levels. By intensifying environmental governance, advancing green and low-carbon development, optimizing urban spatial structure, and enhancing urban management efficiency, the goal should be to create ecologically livable, modern, resilient cities. In addition, the government should pay attention to the regional balance of the allocation of amenity resources, improve the financial transfer payment system, and increase the tilt of amenity resources in the central and western regions and cities with low urbanization rates. Governments at all levels should improve the resource scheduling mechanism for amenity construction and increase special support for these areas such as funds. In the meanwhile, the government should promote the central and western regions and cities with low urbanization rates to invest appropriately in infrastructure construction according to the needs of the population, strengthen the development of the value of natural resources, and foster tourism, leisure, and health care industries. The government should narrow the differences in education, medical, and other resources between regions, and strengthen exchanges between cities in school management, curriculum education, and student training. In particular, it should solve the problem of remote medical care and difficult access to medical care, guide the rational flow of the population, and thus enhance the economic resilience of regional cities.

Third, the government should improve the overall environmental quality of the city, attract population and capital inflows, and stimulate the quality of urban innovation. First and foremost, the government should prioritize human-centric improvements in urban public services and infrastructure, enhance urban green spaces, air quality, and other environmental aspects, foster a shared local culture, and judiciously promote unique cultural products in crafts and cuisine to fully accommodate the diverse needs of various demographics and activities. Concurrently, it should establish a tiered housing system to enhance living comfort, expedite the development of affordable housing, and bolster community governance capabilities, all aimed at forging a conducive environment for work, living, leisure, and travel, thereby attracting populations and labor migration. Moreover, the government should ease household registration constraints, diminish labor mobility barriers, and fortify the urban social welfare system, crafting an open, inclusive, and diverse social milieu. Lastly, the government ought to underscore the significance and timing of constructing various amenities, forge an inclusive environment for innovative talents, and high-caliber research platforms, actively recruit and nurture top-tier talent, bolster the growth of diverse innovative bodies, and facilitate the translation and deployment of scientific and technological advancements to fortify urban economic resilience.

The shortcomings and future development ideas of this paper are as follows: First of all, we mainly use objective index data at the city level. Future studies could further consider the use of subjective evaluation index data of urban residents on the amenity level or individual characteristics data at the micro level, and use Hedonic or other models to estimate the implied price of urban comfort attributes and improve the comfort index construction system. Secondly, the measure of economic resilience in this paper has limitations in the selection of variables and the evaluation of effects and lacks the dynamic evaluation of the time dimension. In the future, multiple macroeconomic indicators and time-varying impulse response functions could be selected and used to measure urban economic resilience, to provide ideas for measuring macroeconomic resilience from a dynamic perspective.

Data availability statement

The original contributions presented in the study are included in the article/ supplementary material, further inquiries can be directed to the corresponding author.

Author contributions

RD: Conceptualization, Formal analysis, Funding acquisition, Software, Writing – original draft, Writing – review & editing. KL: Writing – original draft, Writing – review & editing. DZ: Formal analysis, Software, Writing – review & editing. QF: Conceptualization, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by “the Fundamental Research Funds for the Central Universities” (Grant No. YCJJ20230686).

Conflict of interest

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

Publisher's note

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Keywords: urban amenity, economic resilience, livable city, population agglomeration, sustainable development

Citation: Du R, Liu K, Zhao D and Fang Q (2024) Urban amenity and urban economic resilience: evidence from China. Front. Public Health 12:1392908. doi: 10.3389/fpubh.2024.1392908

Received: 28 February 2024; Accepted: 15 April 2024; Published: 09 May 2024.

Reviewed by:

Copyright © 2024 Du, Liu, Zhao and Fang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ke Liu, liuke7936@snnu.edu.cn

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

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A literature review seeks to identify, analyze and summarize the published research literature about a specific topic. Literature reviews are assigned as course projects; included as the introductory part of master's and PhD theses; and are conducted before undertaking any new scientific research project. The purpose of a literature review is ...
Conducting integrative reviews: a guide for novice nursing researchers
Step 1: Write the review question. The review question acts as a foundation for an integrative study (Riva et al. 2012).Yet, a review question may be difficult to articulate for the novice nursing researcher as it needs to consider multiple factors specifically, the population or sample, the interventions or area under investigation, the research design and outcomes and any benefit to the ...
Public Health: Literature Reviews
JBI, formerly known as the Joanna Briggs Institute, is an international research organization which develops and delivers evidence-based information, software, education and training. The PCC Question outline helps frame the scoping review question and highlights important concepts for the literature search.
Undertaking a scoping review: A practical guide for nursing and
For example, Scott et al. explored guidelines which were easily accessible for handling storage of human breast milk through the search engines Google, Bing, and Yahoo, as well as Public Health sites. It may be valuable to include grey literature in a scoping review for a variety of reasons.
Carrying out systematic literature reviews: an introduction
Before undertaking a systemic review, a research question should first be formulated (Bashir and Conlon, 2018). There are a number of tools/frameworks (Table 1) to support this process, including the PICO/PICOS, PEO and SPIDER criteria (Bowers et al, 2011). These frameworks are designed to help break down the question into relevant subcomponents and map them to concepts, in order to derive a ...
Literature Reviews
Collecting Articles. A literature review is systematic examination of existing research on a proposed topic (1). Public health professionals often consult literature reviews to stay up-to-date on research in their field (1-3). Researchers also frequently use literature reviews as a way to identify gaps in the research and provide a background ...
Literature Review
Literature Review: A literature review gives an overview of the field of inquiry: what has already been said on the topic, who the key writers are, what the prevailing theories and hypotheses are, what questions are being asked, and what methodologies and methods are appropriate and useful.. A critical literature review shows how prevailing ideas fit into your own thesis, and how your thesis ...
Communication in healthcare: a narrative review of the literature and
care determines the smooth running of the health-care system (7). However, countries or healthcare systems without this obligatory gatekeeper function may be at higher risk for suboptimal communication between levels of care. The aim of the present paper is to review the existing literature on quality, efﬁcacy and impact of
Network meta-analysis of the intervention effects of different exercise
Purpose This study aims to investigate the impact of four exercise modes (aerobic exercise, resistance exercise, aerobic combined with resistance multimodal exercise, and stretching) on the physical performance of cancer patients. Methods Randomized controlled trials (RCTs) were exclusively collected from PubMed, EMBASE, Web of Science, and The Cochrane Library, with a search deadline of April ...
Loneliness in Emerging Adulthood: A Scoping Review
Loneliness is prevalent during emerging adulthood (approximately 18-25 years) and is an important issue given it has been linked to poorer physical and mental health outcomes. This preregistered scoping review aimed to provide an overview of the literature on loneliness in emerging adulthood, including the (a) conceptualization and measurement of loneliness, (b) loneliness theories used, (c ...
Data visualisation in scoping reviews and evidence maps on health
The other review was an example of evidence mapping from the environmental health field . All four of the data visualisations included in the paper were available in an interactive format hosted either by the review management software or on Tableau. ... Ogura S, Super L, Hong A. Scoping review and bibliometric analysis of the term "planetary ...
The effectiveness of virtual reality training on knowledge, skills and
Virtual reality (VR) training can enhance health professionals' learning. However, there are ambiguous findings on the effectiveness of VR as an educational tool in mental health. We therefore reviewed the existing literature on the effectiveness of VR training on health professionals' knowledge, skills, and attitudes in assessing and treating patients with mental health disorders.
Urban amenity and urban economic resilience: evidence from China
2 Literature review and theoretical analysis ... 3.3 Sample. Considering the completeness of the data and the impact of public events, our study selects 255 cities in China from 2011 to 2019 as research samples. ... and health care industries. The government should narrow the differences in education, medical, and other resources between ...
A Primer for Increasing Competency in Forensic Psychiatry Research
Empirical research is foundational to the discipline of forensic psychiatry. Candilis and Parker provide a cogent systematic review of the empirical literature on restoration of competence to stand trial using National Institutes of Health quality metrics. Components of the study methodology are highlighted, as they represent current best practices for conducting a systematic review.
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Health (Nursing, Medicine, Allied Health)

What are Systematic Reviews? (3 minutes, 24 second YouTube Video)

Systematic Literature Reviews: Steps & Resources

Literature Review & Systematic Review Steps

1. Develop a Focused Question

Tools & Additional Resources:

2. Scope the Literature

3. Refine & Expand Your Search

Example:

4. Limit Your Results

5. Download Citations

6. Abstract and Analyze

7. Create Flow Diagram

8. Synthesize & Report Results

Steps modified from:

Further reading & examples

How to Conduct a Literature Review (Health Sciences and Beyond)

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Related Guides

Secondary menu

Search form

Writing Guides, Manuals, etc.

Literature Review Tips Handouts

Data Extraction

Critical Reading

Submitting to a Journal? First Identify Journals That Publish on Your Topic

Writing Help @UCB

Alternative Publishing Formats

The Politics of Citation

The Sheridan Libraries

Literature Reviews

"Literature review," "systematic literature review," "integrative literature review" -- these are terms used in different disciplines for basically the same thing -- a rigorous examination of the scholarly literature about a topic (at different levels of rigor, and with some different emphases).

Doing a good job of organizing your information makes writing about it a lot easier.

Synthesizing your information is not just summarizing it. Here are processes and examples about how to combine your sources into a good piece of writing:

Annotated Bibliography

What does "peer-reviewed" mean?

How do I find "peer-reviewed" materials?

What kinds of materials are *not* peer-reviewed?

If a piece of information wasn't peer-reviewed, does that mean that I can't trust it at all?

Is this paper peer-reviewed? Ulrichsweb will tell you.

University of Houston Libraries

When is a Scoping Review methodology appropriate?

Other Names for a Scoping Review

Limitations of a Scoping Review

Medical Librarian

Public Health: Literature reviews

Section Objective

Search & Find

Places & Spaces

Support & Guides

Starting Monday 5/13/24, CCNY Libraries will return to regular hours. Access is limited to CCNY ID holders only. Library services are available online, including research help and InterLibrary Loan .

What is a Systematic Literature Review?

Developing a Protocol

Search Strategy & Screening Tools

Scoping Reviews

Search menu

Carrying out systematic literature reviews: an introduction

Formulating the research question

Search criteria

Title and abstract screening

Full-text review

Data extraction

Quality appraisal

Reporting a review (the PRISMA statement)

Data synthesis

Limitations of systematic reviews

Meta-analysis

CPD reflective questions

Usman Iqbal 2024 Convocation Alumni Speaker

A Letter to Our Graduates, the Class of 2024

Collecting Articles

Reviewing the Research

Organizing your Review

Additional Resources

Network meta-analysis of the intervention effects of different exercise measures on Sarcopenia in cancer patients

Registration number

Materials and methods

Inclusion criteria

Exclusion criteria

Study selection

What kinds of materials are not peer-reviewed?