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How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

Search for relevant literature
Evaluate sources
Identify themes, debates, and gaps
Outline the structure
Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

Quick Run-through
Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

Demonstrate your familiarity with the topic and its scholarly context
Develop a theoretical framework and methodology for your research
Position your work in relation to other researchers and theorists
Show how your research addresses a gap or contributes to a debate
Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
Body image, self-perception, self-esteem, mental health
Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

Your university’s library catalogue
Google Scholar
Project Muse (humanities and social sciences)
Medline (life sciences and biomedicine)
EconLit (economics)
Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

What question or problem is the author addressing?
What are the key concepts and how are they defined?
What are the key theories, models, and methods?
Does the research use established frameworks or take an innovative approach?
What are the results and conclusions of the study?
How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

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meaning of appraisal of literature review

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
Themes: what questions or concepts recur across the literature?
Debates, conflicts and contradictions: where do sources disagree?
Pivotal publications: are there any influential theories or studies that changed the direction of the field?
Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

Most research has focused on young women.
There is an increasing interest in the visual aspects of social media.
But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

Look at what results have emerged in qualitative versus quantitative research
Discuss how the topic has been approached by empirical versus theoretical scholarship
Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
Critically evaluate: mention the strengths and weaknesses of your sources
Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

Sampling methods
Simple random sampling
Stratified sampling
Cluster sampling
Likert scales
Reproducibility

Statistics

Null hypothesis
Statistical power
Probability distribution
Effect size
Poisson distribution

Research bias

Optimism bias
Cognitive bias
Implicit bias
Hawthorne effect
Anchoring bias
Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

To familiarize yourself with the current state of knowledge on your topic
To ensure that you’re not just repeating what others have already done
To identify gaps in knowledge and unresolved problems that your research can address
To develop your theoretical framework and methodology
To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other academic texts , with an introduction , a main body, and a conclusion .

An annotated bibliography is a list of source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a paper .

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Conducting a Literature Review

Literature Review
Developing a Topic
Planning Your Literature Review
Developing a Search Strategy
Managing Citations
Critical Appraisal Tools
Writing a Literature Review

Appraise Your Research Articles

The structure of a literature review should include the following :

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

The critical evaluation of each work should consider :

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

Reviewing the Literature

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

Some questions to ask:

How are they organizing their ideas?
What methods have they used to study the problem?
What theories have been used to explain, predict, or understand their research problem?
What sources have they cited to support their conclusions?
How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?
When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Tools for Critical Appraisal

Now, that you have found articles based on your research question you can appraise the quality of those articles. These are resources you can use to appraise different study designs.

Centre for Evidence Based Medicine (Oxford)

University of Glasgow

"AFP uses the Strength-of-Recommendation Taxonomy (SORT), to label key recommendations in clinical review articles."

SORT: Rating the Strength of Evidence American Family Physician and other family medicine journals use the Strength of Recommendation Taxonomy (SORT) system for rating bodies of evidence for key clinical recommendations.

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In This Article Expand or collapse the "in this article" section Literature Reviews

Introduction, what is a literature review.

Literature Reviews for Thesis or Dissertation
Stand-alone and Systemic Reviews
Purposes of a Literature Review
Texts on Conducting a Literature Review
Identifying the Research Topic
The Persuasive Argument
Searching the Literature
Creating a Synthesis
Critiquing the Literature
Building the Case for the Literature Review Document
Presenting the Literature Review

Other Subject Areas

Forthcoming articles expand or collapse the "forthcoming articles" section.

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Girls' Education in the Developing World
Non-Formal & Informal Environmental Education
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Literature Reviews by Lawrence A. Machi , Brenda T. McEvoy LAST REVIEWED: 21 April 2021 LAST MODIFIED: 27 October 2016 DOI: 10.1093/obo/9780199756810-0169

Literature reviews play a foundational role in the development and execution of a research project. They provide access to the academic conversation surrounding the topic of the proposed study. By engaging in this scholarly exercise, the researcher is able to learn and to share knowledge about the topic. The literature review acts as the springboard for new research, in that it lays out a logically argued case, founded on a comprehensive understanding of the current state of knowledge about the topic. The case produced provides the justification for the research question or problem of a proposed study, and the methodological scheme best suited to conduct the research. It can also be a research project in itself, arguing policy or practice implementation, based on a comprehensive analysis of the research in a field. The term literature review can refer to the output or the product of a review. It can also refer to the process of Conducting a Literature Review . Novice researchers, when attempting their first research projects, tend to ask two questions: What is a Literature Review? How do you do one? While this annotated bibliography is neither definitive nor exhaustive in its treatment of the subject, it is designed to provide a beginning researcher, who is pursuing an academic degree, an entry point for answering the two previous questions. The article is divided into two parts. The first four sections of the article provide a general overview of the topic. They address definitions, types, purposes, and processes for doing a literature review. The second part presents the process and procedures for doing a literature review. Arranged in a sequential fashion, the remaining eight sections provide references addressing each step of the literature review process. References included in this article were selected based on their ability to assist the beginning researcher. Additionally, the authors attempted to include texts from various disciplines in social science to present various points of view on the subject.

Novice researchers often have a misguided perception of how to do a literature review and what the document should contain. Literature reviews are not narrative annotated bibliographies nor book reports (see Bruce 1994 ). Their form, function, and outcomes vary, due to how they depend on the research question, the standards and criteria of the academic discipline, and the orthodoxies of the research community charged with the research. The term literature review can refer to the process of doing a review as well as the product resulting from conducting a review. The product resulting from reviewing the literature is the concern of this section. Literature reviews for research studies at the master’s and doctoral levels have various definitions. Machi and McEvoy 2016 presents a general definition of a literature review. Lambert 2012 defines a literature review as a critical analysis of what is known about the study topic, the themes related to it, and the various perspectives expressed regarding the topic. Fink 2010 defines a literature review as a systematic review of existing body of data that identifies, evaluates, and synthesizes for explicit presentation. Jesson, et al. 2011 defines the literature review as a critical description and appraisal of a topic. Hart 1998 sees the literature review as producing two products: the presentation of information, ideas, data, and evidence to express viewpoints on the nature of the topic, as well as how it is to be investigated. When considering literature reviews beyond the novice level, Ridley 2012 defines and differentiates the systematic review from literature reviews associated with primary research conducted in academic degree programs of study, including stand-alone literature reviews. Cooper 1998 states the product of literature review is dependent on the research study’s goal and focus, and defines synthesis reviews as literature reviews that seek to summarize and draw conclusions from past empirical research to determine what issues have yet to be resolved. Theoretical reviews compare and contrast the predictive ability of theories that explain the phenomenon, arguing which theory holds the most validity in describing the nature of that phenomenon. Grant and Booth 2009 identified fourteen types of reviews used in both degree granting and advanced research projects, describing their attributes and methodologies.

Bruce, Christine Susan. 1994. Research students’ early experiences of the dissertation literature review. Studies in Higher Education 19.2: 217–229.

DOI: 10.1080/03075079412331382057

A phenomenological analysis was conducted with forty-one neophyte research scholars. The responses to the questions, “What do you mean when you use the words literature review?” and “What is the meaning of a literature review for your research?” identified six concepts. The results conclude that doing a literature review is a problem area for students.

Cooper, Harris. 1998. Synthesizing research . Vol. 2. 3d ed. Thousand Oaks, CA: SAGE.

The introductory chapter of this text provides a cogent explanation of Cooper’s understanding of literature reviews. Chapter 4 presents a comprehensive discussion of the synthesis review. Chapter 5 discusses meta-analysis and depth.

Fink, Arlene. 2010. Conducting research literature reviews: From the Internet to paper . 3d ed. Los Angeles: SAGE.

The first chapter of this text (pp. 1–16) provides a short but clear discussion of what a literature review is in reference to its application to a broad range of social sciences disciplines and their related professions.

Grant, Maria J., and Andrew Booth. 2009. A typology of reviews: An analysis of 14 review types and associated methodologies. Health Information & Libraries Journal 26.2: 91–108. Print.

DOI: 10.1111/j.1471-1842.2009.00848.x

This article reports a scoping review that was conducted using the “Search, Appraisal, Synthesis, and Analysis” (SALSA) framework. Fourteen literature review types and associated methodology make up the resulting typology. Each type is described by its key characteristics and analyzed for its strengths and weaknesses.

Hart, Chris. 1998. Doing a literature review: Releasing the social science research imagination . London: SAGE.

Chapter 1 of this text explains Hart’s definition of a literature review. Additionally, it describes the roles of the literature review, the skills of a literature reviewer, and the research context for a literature review. Of note is Hart’s discussion of the literature review requirements for master’s degree and doctoral degree work.

Jesson, Jill, Lydia Matheson, and Fiona M. Lacey. 2011. Doing your literature review: Traditional and systematic techniques . Los Angeles: SAGE.

Chapter 1: “Preliminaries” provides definitions of traditional and systematic reviews. It discusses the differences between them. Chapter 5 is dedicated to explaining the traditional review, while Chapter 7 explains the systematic review. Chapter 8 provides a detailed description of meta-analysis.

Lambert, Mike. 2012. A beginner’s guide to doing your education research project . Los Angeles: SAGE.

Chapter 6 (pp. 79–100) presents a thumbnail sketch for doing a literature review.

Machi, Lawrence A., and Brenda T. McEvoy. 2016. The literature review: Six steps to success . 3d ed. Thousand Oaks, CA: Corwin.

The introduction of this text differentiates between a simple and an advanced review and concisely defines a literature review.

Ridley, Diana. 2012. The literature review: A step-by-step guide for students . 2d ed. Sage Study Skills. London: SAGE.

In the introductory chapter, Ridley reviews many definitions of the literature review, literature reviews at the master’s and doctoral level, and placement of literature reviews within the thesis or dissertation document. She also defines and differentiates literature reviews produced for degree-affiliated research from the more advanced systematic review projects.

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Literature Review: Evaluating sources and critical appraisal of literature

Traditional or narrative literature reviews
Scoping Reviews
Systematic literature reviews
Annotated bibliography
Keeping up to date with literature
Finding a thesis
Evaluating sources and critical appraisal of literature
Managing and analysing your literature
Further reading and resources

Evaluating literature

While you are searching for relevant information about your topic you will need to think about the accuracy of the information, whether the information is from a reputable source, whether it is objective and current. The basic criteria for assessing information and questions you might want to think about are listed below.

Accuracy

Is the information reliable?
Is the information error-free?
Is the information based on proven facts?
Can the information be verified against other reliable sources?

Authority

Who is the author?
Does he or she have the qualifications to speak/write on that topic?
Is the author affiliated with a reputable university or organization in this subject field?
Is the source peer reviewed or refereed?

Objectivity

What is the intended purpose of the information?
Is the information fact or opinion?
Is the information biased?

Currency

When was the information published?
Is the information current or out-dated?
Does currency matter in this topic?

Coverage

Does the information covered meet your information needs?
Does it provide basic or in depth coverage

Critical appraisal or critiquing the literature

Reading critically

The Sage Research Methods Online database (SRMO) is a good source of full text electronic Books, chapters, and articles on a range of research methodologies. It includes a wide range of items in relation to literature review processes, and importantly how to read critically.

Goodwyn, A. & Stables, A. W. (2004). Learning to Read Critically: Learning to read critically in language and literacy : SAGE Publications Ltd doi: 10.4135/9781849209410

Quinton, S. & Smallbone, T. (2006). How to read critically . In Sage Study Skills: Postgraduate research in business (pp. 81-96). : SAGE Publications Ltd doi: 10.4135/9781849209564.n6

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Next: Managing and analysing your literature >>
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Best Practice for Literature Searching

Literature Search Best Practice
What is literature searching?
What are literature reviews?
Hierarchies of evidence
1. Managing references
2. Defining your research question
3. Where to search
4. Search strategy
5. Screening results
6. Paper acquisition
7. Critical appraisal
Further resources
Training opportunities and videos
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Deciding what to include in your review through critical appraisal

Once you have narrowed down your pool of results, it's time to begin critically appraising your articles. Using a checklist helps you scrutinise articles in a consistent, structured way.

Questions to consider include:

Are the aims of the study clearly stated?
Is the study design suitable for the aims?
Are the measurements and methods used clearly described?
Are the correct measurement tools used?
Are the statistical methods described?
Was the sample size adequate?
Are the methods overall described in enough detail that you could replicate the study?
Does the discussion overall reflect the results?
Who funded this study?
What are the specific limitations of what can be concluded from the study?

Working through the questions will help you identify the strengths and weakness of each article, and also identify points to draw on when you write about the literature.

DOWNLOAD THE CRITICAL APPRAISAL CHECKLIST

Additional critical appraisal checklists

REFLECT provides a checklist for evaluating randomized control trials in livestock and food safety.

CASP provides checklists for critical appraisal of studies related to health.

JBI provides checklists for critical appraisal of studies related to health.

Documenting critical appraisal decisions

As you closely examine full articles, you will be making judgements about why to include or exclude each study from your review. Documenting your reasoning will help you reassure yourself and demonstrate to others that you have been systematic and unbiased in your appr aisal decisions.

Keeping track of what you have excluded, and why, will be very helpful if you must defend your work—for instance, if your literature review is part of a dissertation or thesis.

Pulling all the literature you will include in your review into a single chart is a good way to begin to synthesise the literature.

DOWNLOAD THE FULL TEXT SCREENING CHART

Best practice!

BEST PRACTICE RECOMMENDATION : If you include any direct quotes in your chart (or in any notes) be sure to use quotation marks so that you don’t later mistake the words for your own.

BEST PRACTICE RECOMMENDATION: The more carefully you record each of the steps of your process, the more easily reproducible it will be. This is especially important for research abstracts and articles found in conference proceedings.

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Published: 08 April 2022

How to appraise the literature: basic principles for the busy clinician - part 1: randomised controlled trials

Aslam Alkadhimi 1 ,
Samuel Reeves 2 &
Andrew T. DiBiase 3

British Dental Journal volume 232 , pages 475–481 ( 2022 ) Cite this article

815 Accesses

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Critical appraisal is the process of carefully, judiciously and systematically examining research to adjudicate its trustworthiness and its value and relevance in clinical practice. The first part of this two-part series will discuss the principles of critically appraising randomised controlled trials. The second part will discuss the principles of critically appraising systematic reviews and meta-analyses.

Evidence-based dentistry (EBD) is the integration of the dentist's clinical expertise, the patient's needs and preferences and the most current, clinically relevant evidence. Critical appraisal of the literature is an invaluable and indispensable skill that dentists should possess to help them deliver EBD.

This article seeks to act as a refresher and guide for generalists, specialists and the wider readership, so that they can efficiently and confidently appraise research - specifically, randomised controlled trials - that may be pertinent to their daily clinical practice.

Evidence-based dentistry is discussed.

Efficient techniques for critically appraising randomised controlled trials are described.

Important methodological and statistical considerations are explicated.

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How to appraise the literature: basic principles for the busy clinician - part 2: systematic reviews and meta-analyses

Aslam Alkadhimi, Samuel Reeves & Andrew T. DiBiase

Making sense of the literature: an introduction to critical appraisal for the primary care practitioner

Kishan Patel & Meera Pajpani

Critical appraisal of systematic reviews of intervention in dentistry published between 2019-2020 using the AMSTAR 2 tool

Patrícia Pauletto, Helena Polmann, … Graziela De Luca Canto

Burls A. What is critical appraisal? 2014. Available at http://www.whatisseries.co.uk/whatiscritical-appraisal/ (accessed April 2021).

Hong B, Plugge E. Critical appraisal skills teaching in UK dental schools. Br Dent J 2017; 222: 209-213.

Isham A, Bettiol S, Hoang H, Crocombe L. A Systematic Literature Review of the Information-Seeking Behaviour of Dentists in Developed Countries. J Dent Educ 2016; 80: 569-577.

Critical Appraisal Skills Programme. CASP Checklist. Available at https://casp-uk.net/wp-content/uploads/2018/01/CASP-Randomised-Controlled-Trial-Checklist-2018.pdf (accessed April 2021).

Schulz K F, Altman D G, Moher D, CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Int Med 2010; 152 : 726-732.

Sterne J A C, Savović J, Page M J et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019; DOI: 10.1136/bmj.l4898.

Petrou S, Grey A. Economic evaluation alongside randomised controlled trials: design, conduct, analysis, and reporting. BMJ 2011; DOI: 10.1136/bmj.d1548.

Black W C. The CE plane: a graphic representation of cost-effectiveness. Med Decis Making 1990; 10: 212-214.

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Senior Registrar in Orthodontics, The Royal London Hospital Barts Health NHS Trust and East Kent Hospitals University NHS Foundation Trust, London, UK

Aslam Alkadhimi

Dental Core Trainee, East Kent Hospitals University NHS Foundation Trust, UK

Samuel Reeves

Consultant Orthodontist, East Kent Hospitals University NHS Foundation Trust, UK

Andrew T. DiBiase

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Contributions

Aslam Alkadhimi contributed to conceptualisation, literature search, original draft preparation and drafting and critically revising the manuscript; Samuel Reeves contributed to original draft preparation and editing; and Andrew DiBiase contributed to supervision, draft editing and critically revising the manuscript.

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Correspondence to Aslam Alkadhimi .

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The authors declare no competing interests.

Ethical approval and consent to participate did not apply to this study.

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Alkadhimi, A., Reeves, S. & DiBiase, A. How to appraise the literature: basic principles for the busy clinician - part 1: randomised controlled trials. Br Dent J 232 , 475–481 (2022). https://doi.org/10.1038/s41415-022-4096-y

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Published : 08 April 2022

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DOI : https://doi.org/10.1038/s41415-022-4096-y

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A Guide to Literature Reviews

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How to Write a Literature Review

This video teaches you about writing a Literature Review (3:43).

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A literature review is both a summary and explanation of the current state of knowledge on a focused topic as found in academic books, journal articles and all other sources connected to the subject of study. Its aim is to provide an overview of sources you have explored while researching a particular topic and to demonstrate to your readers how your research fits within the larger field of study.

A literature review must:

be organized around the research question you are developing
cohesively summarize results of what is and is not known
identify gaps in the available literature
formulate questions that you feel needs further research

Adapted with permission and thanks from The Literature Review Research Guide originally created by Dr. Robert V. Labaree , University of Southern California.

Next: Importance of a Good Literature Review >>
Last Updated: Jan 22, 2024 3:26 PM
URL: https://libguides.mcmaster.ca/litreview

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

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

What is the purpose of literature review?
a. Habitat Loss and Species Extinction:
b. Range Shifts and Phenological Changes:
c. Ocean Acidification and Coral Reefs:
d. Adaptive Strategies and Conservation Efforts:
How to write a good literature review
Choose a Topic and Define the Research Question:
Decide on the Scope of Your Review:
Select Databases for Searches:
Conduct Searches and Keep Track:
Review the Literature:
Organize and Write Your Literature Review:
Frequently asked questions

What is a literature review?

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

What is the purpose of literature review?

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

Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge.
Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field.
Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research.
Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered.
Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research.
Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature.

Literature review example

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

Literature Review on Climate Change Impacts on Biodiversity:

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

a. Habitat Loss and Species Extinction:

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

b. Range Shifts and Phenological Changes:

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

c. Ocean Acidification and Coral Reefs:

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

d. Adaptive Strategies and Conservation Efforts:

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

How to write a good literature review

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

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

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

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

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

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

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

Conducting a literature review

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

Choose a Topic and Define the Research Question:

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

Decide on the Scope of Your Review:

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

Select Databases for Searches:

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

Conduct Searches and Keep Track:

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

Review the Literature:

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

Organize and Write Your Literature Review:

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

The literature review sample and detailed advice on writing and conducting a review will help you produce a well-structured report. But remember that a literature review is an ongoing process, and it may be necessary to revisit and update it as your research progresses.

Frequently asked questions

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

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

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

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

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

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

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

References

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

Paperpal is an AI writing assistant that help academics write better, faster with real-time suggestions for in-depth language and grammar correction. Trained on millions of research manuscripts enhanced by professional academic editors, Paperpal delivers human precision at machine speed.

Try it for free or upgrade to  Paperpal Prime , which unlocks unlimited access to premium features like academic translation, paraphrasing, contextual synonyms, consistency checks and more. It’s like always having a professional academic editor by your side! Go beyond limitations and experience the future of academic writing.  Get Paperpal Prime now at just US$19 a month!

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Literature Review Guide

The Literature Review

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

What is a Literature Review? What is its purpose?

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

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

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

What a Literature Review is not

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

From the Online Library

SAGE Research Methods This link opens in a new window SAGE Research Methods is a web-based research methods tool that covers quantitative, qualitative and mixed methods. Researchers can explore methods and concepts to help design research projects, understand a particular method or identify a new method, and write up research. Sage Research Methods focuses on methodology rather than disciplines, and is of potential use to researchers from the social sciences, health sciences and other research areas.
Sage Research Methods Project Planner - Reviewing the Literature View the resources and videos for a step-by-step guide to performing a literature review.

The Literature Review: Step by Step

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

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

Getting Started

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

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

What is Academic Literature?

What is the difference between popular and scholarly literature?

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

Database Search Tips

Boolean Operators
Keywords vs. Subjects
Creating a Search String
Library databases are collections of resources that are searchable, including full-text articles, books, and encyclopedias.
Searching library databases is different than searching Google. Best results are achieved when using Keywords linked with Boolean Operators .
Applying Limiters such as full-text, publication date, resource type, language, geographic location, and subject help to refine search results.
Utilizing Phrases or Fields , in addition to an awareness of Stop Words , can focus your search and retrieve more useful results.
Have questions? Ask a Librarian

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

Using AND

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

Venn diagram of the AND connector

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

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

Venn diagram of the OR connector

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

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

Venn diagram of the NOT connector

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

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

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

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

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

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

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

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

"cell phone"

"distracted driving"

"car accident"

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

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

For example:

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

Resource type
Publication date
Geographic location

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

EBSCO ProQuest

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

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

Journal title
Date of Publication

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

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

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

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

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

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

company in America
company of America
company for America

Creating an Search String

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

Database Search Menu Template Use this search menu template to plan a database search.
Last Updated: Feb 16, 2024 10:01 AM
URL: https://guides.rasmussen.edu/LitReview

Open access
Published: 14 November 2019

How to tackle the conundrum of quality appraisal in systematic reviews of normative literature/information? Analysing the problems of three possible strategies (translation of a German paper)

Marcel Mertz ORCID: orcid.org/0000-0002-4871-4219 1

BMC Medical Ethics volume 20 , Article number: 81 ( 2019 ) Cite this article

5836 Accesses

26 Citations

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In the last years, there has been an increase in publication of systematic reviews of normative (“argument-based”) literature or of normative information (such as ethical issues) in bioethics. The aim of a systematic review is to search, select, analyse and synthesise literature in a transparent and systematic way in order to provide a comprehensive and unbiased overview of the information sought, predominantly as a basis for informed decision-making in health care. Traditionally, one part of the procedure when conducting a systematic review is an appraisal of the quality of the literature that could be included.

However, while there are established methods and standards for appraising e.g. clinical studies or other empirical research, quality appraisal of normative literature (or normative information) in the context of a systematic review is still rather a conundrum – not only is it unclear how it could or should be done, but also the question whether it necessarily must be done is not settled yet. Based on a pragmatic definition of “normative literature” as well as on a typology of different types of systematic reviews of normative literature/information, this paper identifies and critically discusses three possible strategies of conducting quality appraisal.

Conclusions

The paper will argue that none of the three strategies is able to provide a general and satisfying solution to the problems associated with quality appraisal of normative literature/information. Still, the discussion of the three strategies allows outlining minimal conditions that elaborated strategies have to meet in future, and facilitates sketching a theoretically and practically promising strategy.

Peer Review reports

(This paper is a translated and slightly modified version of: Mertz M. Qualitätsbewertung in systematischen Übersichtsarbeiten normativer Literatur. Eine Problemanalyse. Z Evid Fortbild Qual Gesundhwes 2017;127–128:11–20; the original title and abstract were altered for the translated version.)

It is more or less impossible to conceive of modern healthcare without (concomitant) reflections upon its norms and ethics. Despite the increased focus on evidence-based healthcare, however, normative and ethical considerations that aim to and indeed should support decision-making and regulation efforts in healthcare practice often still appear to be “eminence-based”. Thus manuals on the creation of guidelines and health technology assessment (HTA) reports, for example, often lack suggestions on how to integrate normative and ethical considerations or even how to capture them in the first place (e.g. [ 1 , 2 , 3 ]). However, evidence-based decision-making requires as its foundation – besides clinical experience/internal evidence and patient preferences – systematically collated, comprehensive and balanced external information and external evidence (e.g. from clinical trials or healthcare research) to scientifically justify the decisions taken (cf. [ 4 ]). Systematic reviews (referred to as “SR” in the following) constitute such a foundation.

For information searched for on specific topics, the SR method aims to identify published studies ( search ), select relevant studies of sufficient quality ( selection ), evaluate these ( analysis ) and summarize or synthesise the individual findings ( synthesis ) (cf. [ 5 ] for a similar method of procedure) in a transparent and reproducible way. This method endeavours to guarantee the completeness of the information collected and minimize the risk of bias. Furthermore, this method includes quality weightings of each individual publication in its overall results.

Medical ethics or bioethics [ 6 , 7 ], the academic field that engages in such normative and ethical considerations, is rooted in the humanities – that is, in theological and philosophical tradition among others – and hence is less familiar with the SR method (cf. [ 8 ]). However, due to its interdisciplinary nature, the profile of medical ethics is constantly changing. Formerly, the field’s roots in the ethos of medical practitioners, theology, philosophy and law meant that a philosophical approach to research and clinical judgement played an important role in medical practice. In recent times, however, the profile of medical ethics has changed following the increased integration of empirical insights and research methods taken from the social sciences (see [ 9 , 10 , 11 , 12 , 13 ] and many more).

Alongside the spread of evidence-based medicine (EBM), it is probably these developments that have led to the gradual embracing of SR methods to respond to ethical issues in clinical [ 14 , 15 , 16 ] or research [ 17 , 18 , 19 ] contexts. While SRs are by no means as widely spread in medical ethics as in EBM, they are no longer merely a niche phenomenon. Evidence shows that the number of SRs is increasing both in medical ethics and in technology assessment, for example as part of research accompanying ELSA (Ethical, Legal, and Social Aspects) or HTA projects. A recently conducted (meta-)SR showed that in the last two decades (1997–2015), more than 180 reviews were published on ethical topics in the medical field [ 20 ]. Of these reviews, almost half (47%, n = 84) analysed normative literature either exclusively or in addition to empirical literature (such as social-scientific studies). Here, normative literature refers to literature that includes normative and ethical considerations, such as ethical arguments, concepts, principles or recommendations [ 20 ].

Definition of the problem

Such SRs of normative literature are carried out based upon a distinct methodological repertoire that ranges from literature search and selection strategies to qualitative and occasionally quantitative methods of analysis and synthesis (cf. [ 20 , 21 ]). In contrast to SRs in medicine or generally empirical disciplines (e.g. [ 22 , 23 ]), there are currently no accepted guidelines or manuals on how to carry out SRs of normative literature, but only some published suggestions (e.g. [ 8 , 24 , 25 , 26 , 27 , 28 ]). For this reason, only unsatisfactory answers have been provided to methodological questions on how to conduct SRs of normative literature thus far. One of these questions concerns the so-called quality/critical appraisal of the literature to be included, which constitutes a key element of (“traditional”) SRs. In such appraisals, the credibility of a clinical intervention study, for example, is judged following an evaluation first and foremost of its internal validity , that is, of whether the study design and the actual conducting of the study are able to ensure that the findings are indeed accurate for the patients studied. Footnote 1 In particular, the appraisal critically examines whether a bias or a confounder that would (statistically) distort the result can be excluded [ 29 ].

The results of the quality appraisal have a significant influence upon the weighting of the information collected in regard to the overall synthesis. Only studies that meet methodological minimum or adequacy standards should be included in an SR. Furthermore, higher-quality studies are given a higher weighting, so that in the ideal case the SR’s results are “better” than the results of individual studies. Accordingly, an SR of normative literature needs to state explicitly how the step of quality appraisal is to be dealt with.

Overall, however, the suggestions for SRs of normative literature made to date fail to analyse precisely problems regarding quality appraisal, even though quality appraisal is identified as a challenge (e.g. in [ 26 , 27 ]). Thus it is hardly surprising that only 24% (20 of 84) of the reviews in the abovementioned (meta-)SR on reviews of normative literature take the step of quality appraisal into account [ 21 ]. Five of these 20 reviews even explicitly refrain from conducting a quality appraisal, citing a lack of suitable or applicable methods or criteria for a quality appraisal of normative literature [ 21 ].

The present paper aims to tackle the problem of the criteria and methods required to make a quality appraisal of normative literature – or, more precisely: of normative information – within an SR on ethical topics possible. As a first step, a justification of SRs of normative literature is provided. Also, “normative literature” and “normative information”, respectively, are defined more precisely. Next, possible types of SRs of normative literature/information are presented. Three possible solution strategies, the options they offer and their limitations are discussed by reference to, among other things, sample suggestions for quality appraisals made thus far. Subsequently, the paper systematically identifies where, how and by whom quality appraisals can be carried out before concluding by discussing which solution strategy is most suitable to be pursued further.

SRs of normative literature/information

Justification and aims of srs of normative literature/information.

Not only statistical information, but normative considerations are important if decisions in healthcare are to be as informed as possible. Accordingly, the value of SRs of normative literature/information consists of their ability to provide comprehensive and transparently collated normative information, for example on a) all known ethical challenges (e.g.: lack of clarity regarding the values or principles relevant to the situation in question; dilemmas; conflicts between norms or principles; weighing of needs) involved in acts undertaken in a clinical or practical research context when using a new (bio-)technology or health intervention (e.g. genome editing processes or informing a patient or relative about a dementia diagnosis), b) all positive and negative arguments that are important for a particular medical decision (e.g. for or against medically assisted suicide), or c) concepts of normative significance in research and clinical practice (e.g. concepts of informed consent in biobank research). Some SRs address ethics specialists, while others aim to support decision-making processes and address persons working in clinics or groups developing guidelines, for example.

Regardless of their target audience, SRs aim to guarantee that all (legitimate) concepts, arguments and challenges are “on the table” at the beginning of a decision-making process and are only set aside once they have been weighed up rationally.

Normative literature/information

In light of this background, it is hardly surprising that “normative literature” is often also referred to as “argument-based” or “reason-based” literature (thus e.g. [ 16 , 25 , 28 ]). While such designations intuitively seem to make sense to distinguish this literature from empirical literature (e.g. a social-scientific or clinical study), this differentiation fails to convince in conceptual terms: after all, empirical literature also includes arguments and reasons, as empirical evidence serves to support conclusions or premises that in turn are supposed to support a conclusion [ 30 ].

However, it is not easy to come up with a fully convincing theoretical definition of “normative literature”. While there appears to be a certain intuitive agreement on the scope of the concept – that is, what kinds of publication it does and does not refer to – as the designations “argument-based” and “reason-based” and the results of the meta-SR [ 20 , 21 ] suggest, the intension of the expression – the definition of the characteristic traits of what the concept refers to – is much more difficult to grasp. For this reason, the definition suggested in the following has a pragmatic claim: it aims to include what has been discussed (hitherto) in the debate on SRs of normative literature/information; and it aims to do justice to the non-empirical (or not wholly empirical) literature identified and evaluated in the SRs carried out to date in medical ethics (cf. [ 20 , 21 ]), that is, to make it possible to distinguish between different types of SRs of normative literature/information (see Types of SRs of normative literature/information below). Therefore the definition will not be able to exclude every possible grey area:

Normative literature is literature that (i) aims to evaluate judgements, decisions, acts, (social) practices, technologies, institutions, organizations and general states of the world from a moral or legal point of view and/or to define/set out which decision or course of action is or should be morally or legally necessary, prohibited or permitted; or that (ii) aims to develop, interpret or criticize the evaluative or prescriptive concepts required for this.

To render this more precise, it should be noted that “decisions” can also include regulations (policy), and “judgements” can also include reasons for or against decisions. “Concepts” also includes values, norms, principles and theoretical frameworks; the enumeration at the beginning of the definition (judgements, decisions...) should not be understood as conclusive.

“Empirical literature”, on the other hand, does not serve the purpose of evaluation but rather (only) of description, explanation and prediction. The fact that empirical information may be necessary for an evaluation plays no role in this: the literature’s aim is decisive, not the way in which the findings of the literature (e.g. of a clinical trial) may or have to be utilized. However, some information found in empirical literature can, in principle, be used as normative information, e.g. perspectives on a specific ethical dilemma in praxis that were elicited by an interview study. In this regard, at least some parts of empirical literature can be included in SRs of normative literature/information.

The definition provided above takes into account jurisprudential and legal literature insofar as it can be of ethical relevance. Of course it can also be seen as a type of normative literature in its own right. As this essay is concerned primarily with normative ethical literature and information, however, legal literature will only be touched upon in passing.

Types of SRs of normative literature/information

Different types of SRs of normative literature/information can be distinguished based upon their different purposes and units of analysis, i.e. based upon the normative information that is extracted from the literature. This typology is important as the kind of normative information searched for has significant implications for the question of how normative literature – or the information itself – can be appraised. Taking a typology developed by McDougall ([ 8 ], p. 91), the examples mentioned above and the findings of the (meta-)SR on overviews of normative literature [ 20 , 21 ] as a starting point, one can distinguish between at least six different types, listed in Table 1 below:

According to Strech et al. (e.g. [ 32 , 33 ]), “ethical issues” in SRs of ethical issues are defined in such a way that an ethical issue is present when either one or several principles are not considered in an action situation or a decision-making process (even though they should be considered), or when there is a conflict between two or more principles and they thus need to be weighed against one another. The four-principle approach is taken as a starting point. This approach is well established in medical ethics and formulates four principles of “medium” scope (as keywords: respect for patient autonomy , non-maleficence , beneficence , and justice ). More generally, “ethical issues” cover what was described above under “ethical challenges”, such as a lack of clarity concerning relevant values or principles, the existence of dilemmas or situations in which needs need to be weighed up in general (also cf. [ 20 ]).

Some of the SRs listed in Table 1 may also use empirical literature, but here they are only viewed from the perspective of their use for finding normative information. McDougall’s typology also includes further SRs of empirical literature in medical ethics that are not listed here. When considering jurisprudential and legal literature as normative literature, SRs of legal norms (e.g. national or international laws and regulations), SRs of case law (e.g. of state or federal courts) or SRs of legal commentaries (e.g. on legal norms or on case law) are conceivable. However, this paper will not go into these possible types in greater detail due to its focus upon SRs of normative ethical literature/information and due to the lack of actual examples of such SRs.

As (ethical) arguments can be of significance in one way or another in most kinds of normative literature, they will be given particular emphasis in the following section and used as an example.

Solution strategies for the quality appraisal of normative literature/information

As already mentioned above, at present there are no standards for the quality appraisal of normative literature or information within SRs. For this reason, the solution attempts that currently exist and those that are conceivable for the problem of quality appraisal are summarized in three strategies: firstly, appraisal using (global) reporting guidelines , secondly appraisal using (procedural) quality assurance guidelines or the decision to forego an independent appraisal , and thirdly the appraisal using content-related quality criteria . Only the latter strategy will focus decidedly on the normative information itself, while the other strategies are focussing more on appraising a piece of literature.

Solution strategy 1: appraisal using (global) reporting criteria

The first solution strategy follows the idea of reporting guidelines (see [ 40 ]) and the criteria derived from them that are usually implemented in the form of checklists. Here, the text from the literature (e.g. journal article) is appraised as a whole (is the article’s reporting of sufficient quality or not?). The McCullough model of an SR of ethical conclusions [ 25 ] serves as an example of this strategy, pursuing the aim of formulating an ethical recommendation for action on the basis of the normative information found. The model suggests various criteria that can be gone through like a checklist and that evaluate the following domains ([ 25 ], p. 69): whether the publication has used a focused question; whether the publication has searched for literature and how clear an account it gives of the literature; the quality of the ethical analysis and arguments; the clear description of the conclusion; and the clear specification of the clinical application of the ethical analysis, argumentation and conclusion. The domains were developed according to the authors’ earlier suggestions for appraising “argument-based ethics” ([ 26 ]; for comparable criteria see [ 41 , 42 ]). Each domain is evaluated using a “scoring system” either as “0″ (criteria are not met), “1″ (criteria are met in their entirety) or “1/2″ (criteria are partially met).

The McCullough model was strongly criticized, especially by Sofaer and Strech [ 27 ]. Criticism targeted its overly subjective and random scoring system in particular, although the authors themselves had already admitted this was a limitation ([ 25 ], p. 72). However, the scoring system is by no means compulsory for this first solution strategy, which is why the following subsections will examine those problems that generally impede appraisals that use reporting criteria:

One-sidedness

A “catalogue” of criteria such as that of McCullough et al. becomes one-sided as soon as it is used to evaluate not only philosophical literature in a narrower sense, but, for example, guidelines or legal literature (cf. [ 27 ]), as these kinds of texts can differ markedly in regard to their methodology and the accounts given. Furthermore, such reporting criteria are often formulated according to the publication standards of “analytical” philosophy, or analogously to the empirical (social) sciences, and thus place the contributions of “continental” philosophy or the other humanities at a disadvantage. Hence a tendency towards distortion becomes part of the evaluation, as “continental” philosophical contributions are less able to meet the criteria due to the different reporting conventions.

Such reporting criteria are designed not least for journal articles, and are not really applicable to all contributions in edited books and certainly not to whole monographs. While the latter are not covered in “traditional” medical SRs, there are good reasons for considering them in SRs of normative literature [ 32 ].

Lack of differentiation in global appraisals

One aim of the first solution strategy is to evaluate a text’s quality of reporting as a whole in order to decide whether to include or exclude it on this basis. This global appraisal is based upon the implicit premise that a text’s (reporting) quality says something about the quality of the (individual pieces of) information as a whole . However, this premise is more plausible when applied to empirical literature (especially clinical trials) than to normative literature: an empirical study’s reporting is key to reviewing and verifying the quality of the data and their analysis. In the best case, the reporting corresponds to the trial actually carried out; therefore, it is (more) justified to define the quality of the trial’s results based on the article’s reporting quality. Where normative literature is concerned, however, this kind of interrelation is present to a much lesser extent, for these texts may contain several pieces of normative information (or arguments) – both those endorsed as well as those criticized [ 27 ]. Furthermore, an article that by and large fulfils the criteria of good reporting (e.g. “uses a focused question” or “clear account given of the conclusion”) may nevertheless be questionable in terms of its content, containing weak arguments or making ethically dubious recommendations, for example. Accordingly, we cannot conclude from “poor compliance with reporting criteria” that the “concrete content of the literature is of poor quality”. More decisively, an article that does not fully meet reporting criteria can nevertheless be significant in terms of its content (e.g. presenting a good argument). Ultimately, not including normative information in the synthesis of an SR of normative literature because the text is not of high (reporting) quality overall would lead to a distorted selection of normative information and achieve precisely the opposite of that which quality appraisal is supposed to ensure. This procedure is conceivable at best in SRs of ethical conclusions .

Possible mixing of reporting criteria and content-related quality criteria

McCullough et al. also include a criterion about the quality of the ethical analysis and the arguments in their catalogue, possibly in order to mitigate the problem discussed above. However, this criterion differs markedly from the other reporting criteria, and hence it is doubtful whether such a criterion is consistent with the other criteria – after all, reporting criteria only evaluate whether something has been mentioned sufficiently frequently, not the quality of what is reported. Furthermore, given that the reporting is appraised as a whole, this criterion is not sufficiently differentiated in terms of content to be able to make reliable statements on the quality of concrete content. However, if the criterion were differentiated further and operationalized more precisely, for example to examine a text’s individual arguments, it would no longer correspond to a reporting criterion, but would instead merge with the content-related quality criteria of solution strategy 3 examined in greater depth below. Finally, the question of whether this criterion would be able to balance out possible flaws in adhering to the reporting criteria would require further clarification.

Conclusion solution strategy 1

The first solution strategy can at best be applied to SRs of ethical conclusions that focus mainly on a text’s “all things considered” conclusion (as in the McCullough model) – provided the normative text to be evaluated discusses only one single line of argument and thus arrives at a definite conclusion. The abovementioned problem of one-sidedness could be mitigated by developing a comprehensive catalogue of criteria that takes account of different kinds of normative literature and different styles in a differentiated manner. However, as soon as the aim is to review the quality of individual pieces of information (among other things), for example in SRs of ethical arguments or SRs of ethical issues , reporting criteria and the global appraisal that goes hand in hand with them are no longer differentiated enough. Even if the quality of analysis and argumentation is (also) considered – which is already tantamount to a content-focused appraisal procedure, however – a blanket appraisal such as that of McCullough et al. fails to clarify how the hitherto unresolved question of how to evaluate the content of normative literature is to be dealt with. For example, the question of how a valid deductive argument with false premises should be evaluated ([ 27 ], p. 319) needs to be resolved. Footnote 2 This is aggravated by the fact that in inductive (e.g. probability conclusion) and abductive forms of argument (e.g. “conclusion to the best explanation”), which also occur in medical ethics, validity is an irrelevant criterion: there are no (formal) logical rules of conclusion (however, e.g. statistical considerations may play a role), which is why we need to speak not of validity, but of strength or explanatory power . Furthermore, we simply do not always know whether an argument’s (empirical) premises are true or not. This can itself form the subject of current scientific debate. Not least, the appropriateness of normative and evaluative premises is an excellent topic of rational debate. It is true that solution strategy 3, discussed below, will also face these issues; however, a criterion along the lines of “quality of argumentation in this article; good – not good?” to be “checked off” from a reporting-criteria-style checklist will not be able to provide any answers to these questions, and therefore the appraisal will contain comparatively high levels of subjectivity. While the latter can be somewhat mitigated by, for example, a method characterized by a consensus-driven approach in which different researchers carry out their evaluation independently of one another and then compare their results, it cannot be avoided entirely. Finally, SRs using normative information from (also) empirical literature is not well-considered in this strategy, as it is focussing solely on (a piece of) normative literature as a whole.

Solution strategy 2: appraisal using (procedural) quality assurance criteria

McDougall, who drew upon McCullough’s model for her own SR of ethical conclusions [ 26 , 31 ], finally rejected this model because of the abovementioned problems with this quality appraisal method and instead fell back upon using criteria associated with the characteristics of a primarily procedural quality assurance of a text: if an article was published in a journal that uses peer review, or was published as a book chapter in a volume printed by a “prominent academic publisher”, it is assumed that its quality is sufficient ([ 26 ], p. 95). Accordingly, the peer review process and the academic publishers’ reputation, which is assumed to be based (among other things) on their quality assurance, thus served as a criterion. McDougall explicitly chose not to evaluate the literature further.

The Strech-et-al. model of SRs of ethical issues [ 14 , 32 , 33 ] also falls back upon such quality assurance criteria. These SRs aim to cover as comprehensive a range of ethical issues concerning a medical condition and its treatment as possible. They do not aim to make any recommendations for dealing with these issues. Here, quality assurance criteria are dealt with as part of the criteria for inclusion or exclusion and not as a separate step in the selection process. Publication in a peer-reviewed journal or a serious academic book publication likewise serves as a quality assurance criterion; in addition, “national-level reports” are seen to assure quality ([ 32 ], p. 401; similarly [ 14 ], p. 202–203; [ 33 ], p. 7).

The selection of procedural quality assurance criteria and the foregoing of any quality appraisal beyond this are justified with the descriptive aim of generating as comprehensive a spectrum of the ethical issues in question as possible; the literature’s quality is not relevant to achieving this aim ([ 33 ], p. 7). The authors of the Sofaer-Strech model for SRs of ethical arguments [ 27 , 28 ] argue in a similar vein. This model likewise has a descriptive aim, namely a comprehensive representation of all reasons (arguments) concerning an ethical issue. Because of this aim, it is not necessary to evaluate the quality of the literature ([ 27 ], p. 320). However, the authors do acknowledge that this procedure is owed to a certain pragmatism and the difficulty of developing quality assurance criteria for normative literature ([ 27 ], p. 324f).

Usually, peer review and similar processes cannot be used as quality assurance criteria for SRs of ethical recommendations . However, the reputation, (e.g. political) legitimation or the (disclosed) methods of the respective organization (e.g. expert association) take on a comparable function when generating recommendations.

Nevertheless, this solution strategy is not without its problems:

The limitations of the peer review process and other quality controls

Quality assurance through peer review has its limits, some of which are considerable [ 43 , 44 ]. For this reason, it is a rather weak criterion for the quality of normative literature. Furthermore, it hardly makes sense that only articles to have gone through peer review and high-ranking book publications should be included if it is claimed that quality appraisal plays no role in the respective aim of the SRs of normative literature – after all, normative information such as arguments or significant issues can also be found in “grey” literature or less high-ranking book publications (e.g. self-published books). Accordingly, a more convincing approach is to use this criterion as one of several criteria for inclusion or exclusion that determine which texts are selected from the hypothetical total amount of relevant literature. The justification for this is pragmatic (reducing the amount of literature to be viewed while remaining transparent concerning the search procedure), or is simply restricted to increased “epistemic trust” arising from the fact that the literature included has gone through at least a certain form of quality assurance. However, even then no direct conclusions can be drawn concerning the quality of individual pieces of normative information.

Aim-dependency

The argument that an independent quality appraisal can be eschewed depending on the SR’s aim and that referring to the publication medium’s quality assurance is sufficient is only convincing in the case of SRs of normative literature with a highly descriptive orientation. Of course, in the first instance all SRs of normative literature are necessarily descriptive in regard to their findings, that is, their summary of normative information. Only the kind of synthesis decides whether normative conclusions are drawn from the descriptive compilation of normative information. However, not all SRs of normative literature pursue an exclusively descriptive aim. For this reason, choosing not to carry out an independent quality appraisal can be justified only in the case of individual SRs of normative literature on the basis of their questions or more generally for particular kinds of SRs of normative literature, not for SRs of normative literature in general. This restricts the scope of this solution strategy markedly – unless one argues that SRs of normative literature are only allowed to pursue exclusively descriptive aims.

Problematic content quality

Apart from the possible charge that purely descriptive aims fail to fulfil the mandate of medical ethics as a normative endeavour – such as assessing what particular normative information means for ethical decision-making or for formulating recommendations and so on – the importance of the quality of the information compiled for an SR of normative literature is downplayed unjustly. This is particularly the case when the evaluation of the information is left up to the users of SRs of normative literature, who may not be familiar with medical ethics. For example, arguments can be one-sided, somewhat implausible or even draw fallacious conclusions, but the users of SRs of normative literature may not recognize this in some circumstances. The same also applies to ethical issues. An ethical issue in the literature could be insufficiently theoretically or empirically grounded or simply be irrelevant (also see solution strategy 3).

Conclusion solution strategy 2

Procedural quality assurance criteria may be admissible as a minimum standard from a pragmatic point of view. In the case of SRs of ethical issues, SRs of ethical concepts and SRs of ethical norms in particular, referring to these criteria can be seen as sufficient, as here it is easy to justify that their sole aim is to describe the topics, norms and so on occurring and discussed in scientific literature. Much the same goes for SRs of ethical recommendations . It is also an advantage of this strategy that it can encompass empirical literature as a source of normative information, as a criteria such as “being peer-reviewed” is quite independent of the type of literature. However, quality assurance criteria are not a convincing solution to the problem of quality appraisal in general, as can be seen particularly clearly in the case of SRs of ethical conclusions and SRs of ethical arguments , which do not pursue purely descriptive goals but aim to support ethically appropriate decision-making. In any case, leaving an independent evaluation of quality out without giving reasons for doing so is not legitimate, and will remain so until there are recognized methodological standards that render a quality appraisal unnecessary (and that authors can explicitly refer to). The fact that the type of SR of normative literature/information in question does not depend on the quality of the text or the normative information it contains is a legitimate reason to forego an appraisal. As argued above, however, it is not always easy to prove that this is the case.

Solution strategy 3: appraisal using content-related quality criteria

The third solution strategy was already mentioned in the discussion of the first strategy: criteria that refer directly to the quality of the content of the normative information in question (e.g. arguments or issues) are employed in the appraisal. Here, existing criteria and methods from the field of informal and formal logic, rhetoric, critical thinking and philosophy in general (e.g. [ 45 , 46 , 47 ] and many more) can be drawn upon. For example, the evaluative criteria for deductive arguments (validity and soundness), inductive arguments (strength) and abductive arguments (explanatory power) as well as the respective operationalizations for subtypes of inductive arguments in particular (e.g. inductive generalization, statistical syllogism or analogy conclusion) can be used (cf. [ 46 ]). Likewise, criteria for certain types of definition can be formulated using definition theory. Especially the ample literature on informal fallacies, together with knowledge of typical sources of cognitive bias (e.g. heuristics) can be used to pose critical questions, including those concerning the production of normative information. Various well-known rebuttal and criticism strategies (such as counterexamples, reductio ad absurdum, horned dilemma etc.) could also be transformed into suitable questions or be operationalized in criteria. Thus the focus could shift to the semantics, truth and plausibility as well as the justification of premises. Footnote 3

Thus far, however, there are no concrete models of a quality appraisal method for SRs of normative literature/information that this solution strategy could outline. For this reason, the possibilities and challenges of this strategy will be explored cursorily here:

Position of the appraisal within the methodological process

In “traditional” SRs, quality appraisal usually forms part of the selection step (selecting the texts). In solution strategy 3, it scarcely seems to make sense to include the evaluation of quality in the selection stage. Individual pieces of normative information need to be first identified in order to be evaluated, which is part of the analysis step; but for this step, texts already need to have been selected. The appraisal would then determine whether normative information is actually extracted, that is, whether it becomes part of the analysis of an SR or not. However, appraisal would not (or no longer) decide whether a given text is included or not.

Likewise, undertaking the evaluation only in the final synthesis step is also conceivable (suggested in [ 27 ], p. 324–325): the synthesis of normative information, such as ethical arguments, would only include those items of information for which a certain level of quality could be vouchsafed. Furthermore, the respective appraisal of quality can be noted transparently for each information (e.g. argument) or its summary.

Implementing existing criteria in appraising normative information

There is not really a need for completely new criteria or methods to evaluate normative information. However, applying these criteria and methods in a time-efficient and objective manner appears to be difficult, even though an SR of ethical arguments with a normative aim, for example, really would require such an elaborate appraisal. For example, making statements about an argument’s quality would usually necessitate a reconstruction, analysis and criticism of its structure and content. This requires the researchers carrying out the SR both to possess sufficient knowledge of the abovementioned criteria and, in most cases, be familiar with the content of the argument’s subject. Seminars on informal logic regularly illustrate how time-consuming it can be to reconstruct arguments adequately and evaluate them fairly. One of the reasons for this is the fact that in practice, the question of whether an argument is “good” or not inevitably is a discursive matter: some will agree and list reasons in favour, others will disagree and will likewise offer support for their opinion (thereto, cf. [ 27 ]). Footnote 4 Evaluating an argument without presenting another argument on why it is “good” or “bad” will probably tend to be overly subjective. What is missing are practicable, albeit not overly simplified criteria and methods for evaluating especially arguments, but also issues and concepts within the context of SRs of normative literature or normative information.

Ethical relevance as an attribute of quality

Where the evaluation of the individual items of normative information is concerned, another question of relevance arises, namely that of the information’s ethical relevance. This needs to be distinguished from the relevance criteria that apply to the selection of literature. The question of the ethical relevance of normative information may become noticeable in the analysis and especially the synthesis stages. In the analysis, because of often more or less implicit evaluations a decision will have to be made on whether information is extracted or not; in the synthesis, the decision concerns whether and how the information is to form part of the summary. That is, instead of extracting all arguments from the literature selected, for example, those regarded as irrelevant to the ethical problem at hand will not be extracted – whether because they are simply not applicable thematically (e.g. an argument concerning abortion in an SR on post-trial access), are judged to be secondary on the basis of the values, norms and criteria they use (e.g. a deontological argument when utilitarian criteria are assumed), their empirical premises (if present) are regarded as insufficiently supported or overly speculative, or the actions they demand cannot be (“realistically”) put into practice. Similarly, an ethical issue could also be irrelevant, for example because it hardly ever occurs empirically. Footnote 5 Accordingly, when the aim is to outline ethically relevant arguments or issues, the relevance of the individual items of normative information seems to become a characteristic of quality: irrelevant arguments or aspects would distort the results of an SR. Only SRs fully committed to descriptivity will be able to avoid the question of relevance as part of their quality appraisal. Besides the theoretical identification of ethical relevance with quality, the main problem is the question of which methods (e.g. application of ethical theories?) can be used to define this relevance to limit subjectivity or at least intransparency.

Conclusion solution strategy 3

The third solution strategy is probably best able to accommodate the specific traits of normative literature and especially information, and the methodological particularities of corresponding SRs – foremost in the case of SRs of ethical arguments or SRs with a (strong) normative aim. Also, this strategy allows for appraising normative information extracted from empirical literature as well. The question of the availability of criteria and methods that are both adapted to the purposes of SRs and practicable remains unanswered – at least for now. (See Table 2 for an overview of the suitability and challenges of the solution strategies.)

The “6Qs” of a method for appraising the quality of normative literature

Regardless of the concrete way in which the problems of the three solution strategies are tackled, their discussion has clearly shown not only that is it unclear exactly how , using which criteria or method, a quality appraisal is to be carried out, but that not even the question of what exactly is to be appraised and where within the methodological procedure of an SR of normative literature this appraisal should take place has been clarified.

On the basis of the strategies discussed, the findings of the meta-SR [ 20 , 21 ] and further theoretical considerations, however, it is possible to define some minimum conditions for the design of a quality appraisal method for normative literature. That is, regardless of its respective concrete design, a method needs to make statements on certain aspects if it is to adequately appraise the quality of normative literature. These minimum conditions can be expressed as six questions or “6Qs”, respectively: what (the element or information in a text that is evaluated), which (which text; genre of the respective text), where (in the procedure of carrying out the SR), how (using which criteria or methods), whereby (the process of applying the criteria or methods) and who (which disciplinary or methodological background do the researchers need to have). Table 3 provides an overview with four sample answers to these questions, without making any claim to comprehensiveness.

The responses in the categories can be combined in different ways to outline a concrete solution strategy (e.g. “individual piece of normative information (conclusion)” plus “normative ethical text” plus “separate appraisal following inclusion” plus “reporting criteria” plus “individual researcher with review” plus “no specific background”). However, some answers in one category may suggest or exclude answers in another category. For example, if the entire text is to be evaluated, then this appraisal will not be possible in the analysis or synthesis steps. Anyone wanting to use quality assurance criteria will necessarily (also) evaluate the entire text. And those committing themselves to content-related quality criteria will probably need researchers to have a suitable disciplinary/methodological background. This illustrates that the “6Qs” and the sample ways of answering them in Table 3 can serve as a heuristics for developing newer or more refined quality appraisal methods. However, they can also be used analytically to systematically classify existing methods.

It is probably undisputed that SRs alone are unable to “do medical ethics”. Philosophical or interdisciplinary detailed analyses of the respective ethical challenges, key normative concepts and relevant norms remain necessary. This is affirmed from the perspective of SRs of normative literature themselves: after all, this type of literature forms their subject.

However, SRs of normative literature/information make it possible to search, select, analyse and summarize this literature in as transparent and undistorted a way as possible. As a form of “evidence-based” ethics, they should be understood as part of evidence-based healthcare. Therefore, such SRs are of particular relevance to anyone producing systematically developed decision guidance such as guidelines or HTA reports. Not least, systematic accounts of all ethical arguments made thus far concerning a particular topic, for example, may be of significance for research in medical ethics itself. In this way, arguments less strongly debated in the literature can be given an equal weighting, countering one-sided lines of argument [ 27 ]. Accordingly, making methodological contributions to improving the quality of SRs of normative literature/information, especially where the key aspect of quality appraisal is concerned, is all the more important.

But which quality appraisal method seems most promising? It seems obvious that it would be one that is able to provide clear answers to the “6Qs” and that in principle follows solution strategy 3, although it can certainly draw upon complementary criteria from the other two solution strategies. In doing so, however, it needs to do justice to the aims of an SR (descriptive/normative) and the SR type ( SR of ethical arguments, SR of ethical issues etc.). This can include the justified decision to forego an (independent) appraisal of quality. The method would furthermore have to be adaptive, that is, it would need to adapt its appraisal to the different kinds of normative literature (ethical/legal) and to the normative information searched for (argument, issues, concepts...). Finally, content-related quality criteria, for example the evaluation of arguments, should not be applied during the selection, as in “traditional” SRs, but only during the synthesis .

Despite its greater complexity, an approach that combines criteria and methods will be more effective than the “one size fits all” approaches suggested and discussed thus far (e.g. [ 24 , 28 ]).

Availability of data and materials

Not applicable.

Generalizability and transferability to practice, which are subsumed under external validity, have not been considered to any great extent in quality appraisals thus far (cf. [ 29 ]).

The validity of a deductive argument is a purely formal trait that exists independently of the premises’ truth or even meaningfulness. An argument is valid if the premises employed necessarily lead to the conclusion given; the content of premises and conclusion is irrelevant. Therefore, a valid argument is not always sound. This is only the case if validity is present and true premises have been used.

Content-related quality criteria could thus be defined both by their content in a narrower sense (e.g. “Is an argument’s premise true or at least plausibly acceptable?”) and in formal (logical) terms (e.g. “Is a deductive argument valid?”). Both can be key to the quality of the content of a normative information item and are thus subsumed under “content-related quality criteria”, especially in distinction to the reporting and quality assurance criteria discussed above.

It is not possible to answer the meta-ethical question of whether it is even philosophically possible in principle to define objective criteria for the quality of normative information that go beyond e.g. the logical validity of deductive arguments, especially as a large number of mainly epistemological presuppositions are decisive for this – for example, whether cognitivism is assumed (including the assumption that normative propositions such as norms can be true in the same way as empirical propositions) or non-cognitivism (including the assumption that normative propositions cannot be true and only express that speaker’s feelings, for example). As the present author assumes that discourse is inevitable in the (interdisciplinary) practice of a scholarly or scientific method (such as an SR), ultimately the aim of a method for appraising the quality of normative literature can only be to develop critically reviewed and grounded criteria and methods that are able to create intersubjective consensus and that those carrying out such SRs are able to put into practice. Anyone rejecting as a matter of principle the possibility of criteria that are pragmatic and able to achieve intersubjective consensus will probably have little interest in carrying out SRs of normative literature. However, the present essay is not written for those espousing such positions, as it assumes that criteria that are pragmatic and able to achieve intersubjective consensus are fundamentally possible.

Whether an issue occurs empirically or not, or whether an empirical premise in an ethical argument is true or well founded, requires pertinent empirical literature. The extent to which the empirical occurrence of ethical issues or the (sufficient/insufficient) support of empirical premises can or should be used to determine ethical relevance is a meta-ethical question that cannot be dealt with within the scope of this paper.

Abbreviations

Evidence-based Medicine

Ethical, Legal, and Social Aspects

Health Technology Assessment

Systematic Review(s)

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Acknowledgements

I thank Anna Genske, Daniel Strech and especially Hannes Kahrass for their valuable comments for the original German version of the paper. I additionally thank Textwork Translations for translating the German version.

This research was not specifically funded and was conducted as part of the authors’ permanent position as head of a working group at Hannover Medical School.

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Mertz, M. How to tackle the conundrum of quality appraisal in systematic reviews of normative literature/information? Analysing the problems of three possible strategies (translation of a German paper). BMC Med Ethics 20 , 81 (2019). https://doi.org/10.1186/s12910-019-0423-5

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( a nd) D iscussion

Title and Abstract: The title presents a starting point in determining whether or not the article has potential to be included in an EBP review. Ideally, the title should be informative. It should also help the reader to understand what type of study is being reported. But don’t rely solely on a title! They can be misleading. Be careful that it is not just an informative article or opinion piece.

In qualitative articles, the title will normally include the central phenomenon and group under investigation. In quantitative articles, the title communicates the key variables and the population (PIO components). Again, these are the usual title components, but not always.

Quantitative article title:

Qualitative article title:

The abstract will be at the start of the paper. It contains a brief description of the study. Abstract components include a brief introduction, aims/goals, methods/methodology, and the results and conclusions. Some abstracts also include the research question, hypothesis, and implications to practice.

This is located after the title it is usually set apart by the use of a box, shading, or italics. The abstract is a great starting point in quickly filtering articles that may be of use. It’s a nice thumbnail sketch. But, caution! Don’t forgo reading the article! The abstract should serve as a screening device only.

Introduction: The introduction is the start of the article after the abstract. It normally does not contain a heading. The introduction contains the author’s literature review. When critically appraising an article, if the abstract appears relevant, then move onto reading the introduction. The introduction contains the background as well as a problem statement that tells the reader why the study was eventually conducted. It is presented within the context of a current literature review, and it should contain the knowledge gap between what is known and what the study seeks to find (AKA: what is not known yet). It usually (but not always) contains a statement of expected results or hypothesis as well. The literature review section of an article is a summary or analysis of all the published research for prior findings in research and other information that the author read before doing his/her own research. This section is part of the introduction (or in a section called Background). This is the “Review of Literature” (ROL) that the research/author conducted before beginning his/her own study. The articles and information in the Introduction will be cited. It is important to review those citations (found in the References section of an article) to make sure they are up to date and provides a state-of-the-art synthesis of current evidence on the research problem. The ROL also needs to provide a strong rationale for the new study that the researcher wants to conduct. The Introduction section of an article is very similar to your Introduction section of the EBP Poster that you are working on.

The introduction will also usually include a description of the central concepts or variables (sometimes these are in the Methods section instead); the study purpose, research questions, or hypotheses; a review of literature; theoretical/conceptual framework, and the study significance/need for the study.

Quantitative introduction:

Qualitative introduction:

Does the review seem thorough and up-to-date? Did it include major studies on the topic? Did it include recent research?
Did the review rely mainly on research reports, using primary sources?
Did the review critically appraise and compare key studies? Did it identify important gaps in the literature?
Was the review well organized? Is the development of ideas clear?
Did the review use appropriate language, suggesting the tentativeness of prior findings? Is the review objective?
If the review was in the introduction for a new study, did the review support the need for the study?
If the review was designed to summarize evidence for clinical practice, did it draw appropriate conclusions about practice implications?

Methods: This section describes how a study is conducted. In quantitative studies, the methods section contains the research design, sampling plan, methods for measuring variables and collecting data, the study procedures, participant protection, and analytic methods and procedures. In qualitative studies, the methods section discusses many of the same issues as quantitative researchers do but with different emphases. More information is provided about the research setting in a more organically focused fashion, in the context of the study.

Quantitative Methods:

Qualitative Methods:

Results : The results section contains the findings of the study. This section is very objective without any researcher interpretation. These are the raw findings from data. The statistical tests will be names, the value of the statistics will be listed, statistical significance will be listed, and the level of significance is listed. The level of significance, which we will come back to later in the modules, is an index of how probably it is that the findings were not just simply due to chance and is listed as the p value. In qualitative studies, the results are a bit different. They are organized according to major themes (thematic results) and most often include raw data as quotes from the study participants.

Figures and tables are usually presented – some inferential and some descriptive. Also look to see whether the results report statistical versus clinical significance. You might have to look up unfamiliarly terminology regarding statistical tests.

Quantitative results:

Qualitative results:

Discussion : This section should be tied back to the introduction. The study findings should be discussed and meaning given to the raw data results. The weaknesses/limitations and bias should be reported. Any limitations and bias should be discussed in this section as well. If there is clinical significance, this will usually be discussed.

Critical Aspects of Appraisal

In module 12, we will dive deep into specific appraisal criteria, and we will delve into critical appraisal components a little at a time up to that point. However, we need to have an understanding of why we need to be able to critically appraise published research.

Critical appraising evidence is an essential step in EBP in response to a clinical question (Polit & Beck, 2021). The process of systematically evaluating research for its reliability, importance, and significance is critical appraisal (Hall & Roussel, 2014). The process is necessary in considering whether the research was conducted appropriately, because not all research is awesome.

Critical appraisal is the process of carefully and systematically assessing the outcome of scientific research (evidence) to judge its trustworthiness, value, and relevance in a particular context. Critical appraisal looks at the way a study is conducted and examines factors such as internal validity, generalizability, and relevance.

Critical appraisal allows us to:

reduce information overload by eliminating irrelevant or weak studies
identify the most relevant papers
distinguish evidence from opinion, assumptions, misreporting, and belief
assess the validity of the study
assess the usefulness and clinical applicability of the study
recognize any potential for bias.

The beginning guidelines for critical appraisal include asking:

How relevant is the research problem to the actual practice of nursing?
Was the study quantitative or qualitative? How did you make that determination?
What was the underlying purpose (or purposes) of the study? (Therapy/Intervention, Diagnosis/Assessment, Prognosis, Etiology/Harm, Description, or Meaning?)
What might be some clinical implications of this research? To what type of people and settings is the research most relevant? If the things were accurate, how might you use the results of this study?

An inference is a conclusion drawn. It is a challenge to design studies to support inferences that are reliable (accurate and consistent data; concerns the truthfulness in the data obtained and the degree to which any measuring tool controls random error, and if it can be reproduced under the same conditions) and valid (soundness of the evidence; validity is about what an instrument measures and how well it does so, and whether the results really do represent what they were supposed to measure) in quantitative studies, and that are trustworthy in qualitative studies. Thus, every article, even if peer-reviewed, needs to be critically appraised.

Some further aspects of critical appraisal include the following.

Ever ask someone’s opinion about the “best” brand of shoes or “best” local coffee? Their answer is based on their own experience, thus biased to their opinion. Bias is a distortion or an influence that results in an error in inference.

When reading articles, we need to be very aware of the potential for bias. Some examples of factors creating bias include:

Lack of participants’ candor
Faulty methods of data collection
Researcher’s preconceptions
Participants’ awareness of being in a special study
Faulty study design
Survey question design

Survey questions are very commonly biased. With regard to bias in surveys, it is always wise to utilize participant anonymity as this would make it more likely to obtain truthful answers especially when questions are controversially-based.

Surveys are used frequently in research, so let’s dive into how surveys can thwart research results. Depending on how they are asked, questions can lead the respondent intentionally down a path to a certain answer or are phrased in a manner that can be confusing to them, leading to unclear responses. The following are some examples:

Leading questions : These are easy to spot, as it is clear there is a “correct” answer that the question is leading you toward. This will always result in false information as there was never an option for an honest response.

Example: “What problems did you have with the product?”

You can see that this question was set up in a way to assume there was something wrong in the first place.

Alternative: “On a scale of 1-10, how satisfied were you with the product?”

Introduction
Clinical Question
Methodology (at least, the start of it)
Minimum of 8 articles on your Synthesis of Literature Table
Rough notes under the Results Section

Here is an example of a poster’s Methodology section:

References & Attribution

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Haedtke, C., Smith, M., VanBuren, J., Kein, D., Turvey, C. (2017). The relationships among pain, depression, and physical activity in patients with heart failure. Journal of Cardiovascular Nursing, 32 (5), E21-E25.

Hall, H. & Roussel, L. (2014). Evidence-based practice: An integrative approach to research, administration, and practice. Jones & Bartlett.

Polit, D. & Beck, C. (2021). Lippincott CoursePoint Enhanced for Polit’s Essentials of Nursing Research (10th ed.). Wolters Kluwer Health.

Evidence-Based Practice & Research Methodologies Copyright © by Tracy Fawns is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Critical appraisal of the literature. Why do we care?

Avaliação crítica da literatura. por que nos importamos, juliana carvalho ferreira.

1 . Methods in Epidemiologic, Clinical, and Operations Research-MECOR-program, American Thoracic Society/Asociación Latinoamericana del Tórax, Montevideo, Uruguay.

2 . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.

Cecilia Maria Patino

3 . Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

PRACTICAL SCENARIO

Investigators conducted a noninferiority, double-blind clinical trial involving 4,215 patients with mild asthma, randomly assigned to receive twice-daily placebo plus budesonide-formoterol used as needed vs. maintenance therapy with twice-daily budesonide plus terbutaline as needed. They found that budesonide-formoterol used as needed was noninferior to twice-daily budesonide concerning the rate of severe asthma exacerbations but was inferior in controlling symptoms. 1

HOW TO CRITICALLY APPRAISE THE MEDICAL LITERATURE

As clinicians, when we read a paper reporting the benefit of a given intervention, we make a judgment regarding whether we should use those results to inform how we care for our patients. In our example, after reading the paper, we ask ourselves: should a clinician working in a public hospital in Brazil start prescribing budesonide-formoterol as needed rather than maintenance budesonide for her patients with mild asthma? What criteria should guide her decision to adopt a new intervention? One may think that if a study is published in a high-impact, peer-reviewed journal, it is of high quality and should therefore be used to guide clinical decision making. However, if the population included in the study or the context is different from her population, that may not be the case. Therefore, examining the external validity of a study is critical to informing local practice.

Other commonly used criteria are related to evaluating the quality of the evidence by evaluating the type of study design used. The pyramid of evidence puts meta-analyses at the top (as providing the highest quality of evidence), followed by systematic reviews and randomized controlled trials; then come observational studies (cohort, case-control, and cross-sectional studies); whereas case reports and case series are categorized as offering the lowest quality of evidence. Although those criteria may be helpful, making a detailed appraisal of a paper, taking into account aspects other than the study design, is a skill that researchers and clinicians can learn and apply when reading the literature.

Critical appraisal is the systematic evaluation of clinical research papers that helps us establish if the results are valid and if they could be used to inform medical decision in a given local population and context. There are several published guidelines for critically appraising the scientific literature, most of which are structured as checklists and address specific study designs. 2 Although different appraisal tools may vary, the general structure is shown in Table 1 .

The items in Table 1 are a guide to appraising the content of a research article. There are also guidelines for appraising the quality of reporting of health research which focus on the reporting accuracy and completeness of research studies. 3 These two types of appraisal (content and reporting) are complementary and should both be used, because it is possible that a research paper has high reporting quality but is not relevant to the context in question.

KEY MESSAGE

Critical appraisal of the literature is an essential skill for researchers and clinicians, and there are easy-to-use guidelines. Clinicians have the responsibility to help patients make health-related decisions, which should be based on high-quality, valid research that is applicable in their context.

Urban Infrastructure Research pp 35–40 Cite as

An Appraisal on Literature Review

Alok Tiwari 2
First Online: 25 February 2016

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Part of the book series: SpringerBriefs in Geography ((BRIEFSGEOGRAPHY))

Literature referred and utilized by the research investigators are valued in this chapter. As the urban infrastructure domain covers range of academic and professional disciplines, it warrants a comprehensive consultation of literature from local to global levels and also from unpublished sources to pervasive sources to lay a sound understanding of the challenges and the multifarious characteristics of urban infrastructure issues.

Literature review
Theoretical context
Articulating general idea
Formulation of hypotheses

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Published: 17 November 2023

Reversing frailty in older adults: a scoping review

Aurélie Tonjock Kolle 1 ,
Krystina B. Lewis 1 , 2 , 3 ,
Michelle Lalonde 1 , 4 &
Chantal Backman 1 , 2 , 5

BMC Geriatrics volume 23 , Article number: 751 ( 2023 ) Cite this article

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Individuals 65 years or older are presumably more susceptible to becoming frail, which increases their risk of multiple adverse health outcomes. Reversing frailty has received recent attention; however, little is understood about what it means and how to achieve it. Thus, the purpose of this scoping review is to synthesize the evidence regarding the impact of frail-related interventions on older adults living with frailty, identify what interventions resulted in frailty reversal and clarify the concept of reverse frailty.

We followed Arksey and O’Malley’s five-stage scoping review approach and conducted searches in CINAHL, EMBASE, PubMed, and Web of Science. We hand-searched the reference list of included studies and conducted a grey literature search. Two independent reviewers completed the title, abstract screenings, and full-text review using the eligibility criteria, and independently extracted approximately 10% of the studies. We critically appraised studies using Joanna Briggs critical appraisal checklist/tool, and we used a descriptive and narrative method to synthesize and analyze data.

Of 7499 articles, thirty met the criteria and three studies were identified in the references of included studies. Seventeen studies (56.7%) framed frailty as a reversible condition, with 11 studies (36.7%) selecting it as their primary outcome. Reversing frailty varied from either frail to pre-frail, frail to non-frail, and severe to mild frailty. We identified different types of single and multi-component interventions each targeting various domains of frailty. The physical domain was most frequently targeted (n = 32, 97%). Interventions also varied in their frequencies of delivery, intensities, and durations, and targeted participants from different settings, most commonly from community dwellings (n = 23; 69.7%).

Some studies indicated that it is possible to reverse frailty. However, this depended on how the researchers assessed or measured frailty. The current understanding of reverse frailty is a shift from a frail or severely frail state to at least a pre-frail or mildly frail state. To gain further insight into reversing frailty, we recommend a concept analysis. Furthermore, we recommend more primary studies considering the participant’s lived experiences to guide intervention delivery.

Peer Review reports

Within the next few decades, the population of people aged 65 and over will continue to rise more than all other age groups, with roughly one in six people over 65 by 2050, compared to one in eleven in 2019 [ 1 ]. Individuals over 65 years are presumably at greater risk of becoming frail [ 2 , 3 , 4 ]. Theoretically, frailty is considered a clinically recognized state of vulnerability that results from an age-related decline in reserve and function, compromising an individual’s ability to cope with the daily challenges of life [ 5 , 6 ]. The Frailty Phenotype (FP), which is the most dominant conceptual model in literature [ 3 , 7 , 8 , 9 , 10 ], considers an individual frail by the presence of at least three of five phenotypes: weakness, low levels of physical activity, unintentional weight loss, slow walking speed, and exhaustion. Physical, cognitive, psychological, and social impairments often characterize the different domains of frailty [ 11 ]. The physical domain is devoted to FP-related conditions [ 12 ], the cognitive domain is the co-existence of physical deficits and mild cognitive impairments [ 13 ], the psychological domain focuses on an individual’s coping mechanisms based on their own experiences [ 14 ], and the social domain looks at a person’s limited participation in social activities and limitations in social support [ 15 ]. Frail older adults are prone to adverse outcomes such as frequent falls, hospitalizations, disabilities, loneliness, cognitive decline, depression, poor quality of life, and even death [ 16 , 17 , 18 ]. In response, researchers have proposed various interventions to prevent or slow frailty progression by either targeting a single domain (e.g., physical, social, cognitive, etc.) using single component interventions or targeting two or more domains using multi-component interventions.

For example, Hergott and colleagues investigated the effects of a single-component intervention, functional exercise, on acromegaly-induced frailty [ 19 ]. Abizanda and colleagues examined the effects of a multi-component intervention, composed of nutrition and physical activity, on frail older people’s physical function and quality of life [ 20 ]. Some studies indicate that certain single or multi-component interventions can either reduce frailty, slow its progression, and possibly reverse it [ 3 , 21 , 22 ]. The current understanding of reverse frailty lacks clarity, and the characteristics of interventions related to frailty reversal have not yet been examined in a systematic manner.

Authors have determined the reversal of frailty using various measures. For instance, Kim and colleagues’ study evaluating an intervention composed of exercise and nutritional supplementation in frail elderly community-dwellers demonstrated reversals in FP components [ 23 ]. Components included fatigue, low physical activity, and slow walking, an improvement from the presence of 5 components of frailty (according to the FP) to 2, considered a pre-frail state [ 23 ]. Conversely, De Souto and colleagues demonstrated frailty reversal based on changes in frailty index (FI) scores, a measure of accumulation of deficits [ 24 ]. A FI score of 0.22 or greater indicates frailty, score less than or equal to 0.10 indicates a non-frail state [ 25 , 26 , 27 , 28 , 29 ]. Hergott et al. (2020) used frailty severity to indicate frailty reversal. Participants in their study reversed frailty from a severe state to a mild state [ 19 ]. These studies demonstrate the variability in how reversing frailty is measured and understood. For a more comprehensive understanding of reverse frailty and the characteristics of interventions associated with it, a comprehensive review of the literature on this topic is needed. Therefore, through a scoping review, the aim of this study is to provide an overview and synthesis of interventions that have been implemented for frail older adults, to determine whether some interventions have had an impact on reversing frailty.

This methodology is ideal because it encompasses a broad scope and can comprehensively analyze and synthesize data on a subject [ 30 ]. Findings from this review will synthesize the evidence regarding the impact of frail-related interventions on older adults living with frailty, identify what interventions resulted in frailty reversal and clarify the concept of reverse frailty.

Guiding conceptual framework

The deficit accumulation model framework, unlike the FP, considers frailty as more than a physical deficit but rather an accumulation of health-related deficits across multiple domains [ 31 ]. For this reason, the deficit accumulation model framework serves as our guiding conceptual framework. Through this framework, we recognize frailty as a complex phenomenon, strengthening the case for interventions addressing other health and personal concerns, such as illness, environmental disturbance, social dysfunction, cognitive decline, and psychosocial distress. This framework provides a helpful lens through which we can examine the number of domains addressed in the reported interventions and their relationship to one another.

We followed Arksey and O’Malley’s [ 30 ] five-stage approach, elaborated by Levac et al., [ 32 ] and Joanna Briggs Institute (JBI) for scoping review [ 33 ]. They propose six stages: (1) identifying the research question, (2) locating relevant studies, (3) selecting the study, (4) charting data, (5) summarizing results, and (6) consulting with stakeholders. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes Extension for Scoping Reviews (PRISMA-ScR) checklist [ 34 ] to guide study reporting. Refer to Additional file 1 .

Stage one: identifying the research question

According to Levac and colleagues, fundamental research questions should be broad enough to enable comprehensive analysis and appropriate mapping of relevant literature [ 32 ]. Following this, our three research questions are as follows:

What is the available literature on the impact of interventions for frail older adults?

Did any of these interventions result in frailty reversal?

What does it mean to reverse frailty?

Stage two: identifying relevant studies

Using the research questions as a guide, we engaged in an iterative process that involved searching the literature, identifying search terms, developing, and refining search strategies, to identify appropriate studies. We also sought the assistance of an experienced librarian who gave guidance on the use of various electronic databases, provided validation on the appropriateness of the methodology for this study, and conducted a peer-review of the search strategies. An overview of each step is provided below.

Eligibility criteria

JBI’s PCC mnemonic guided eligibility criteria, where P (population): frail older people over 65yrs of age, C (concept): frailty outcome, and C (context): all contexts. We included French and English studies of frail older adults over 65 years because most studies focused on frailty target this age group [ 35 , 36 , 37 , 38 ]. All types of interventions for frail older adults were included, except for interventions intended to prevent frailty. We did not apply any limitations to study dates, and settings. All study designs (quantitative, qualitative, and mixed methods) were considered for inclusion. We excluded conference abstracts, theses, dissertations, and knowledge syntheses, but did refer to their reference list for potential studies. Lastly, we performed a grey literature scan to identify relevant primary studies to ensure a comprehensive literature search.

Search terms

An a priori concept analysis [ 39 ] of frailty and frailty interventions revealed relevant search terms regarding the population of interest which included ‘frail elderly, frail, aged hospital patient, institutionalized elderly, very elderly, geriatrics, senior, and aged’. These keywords were presented to and approved by an academic librarian (VL). To capture a comprehensive list of studies that may be relevant, we looked at all types of interventions on frail older adults aimed at either reducing, improving, managing, enhancing, treating, or reversing frailty. Medical Subject Headings (MeSH) and boolean operators of these terms were used in different databases to identify relevant studies.

Search strategy

Two academic librarians (VL & VC) guided the development of the search strategy and selected databases. We conducted the searches between August 6th and August 9th, 2021, using MEDLINE (OVID interface), Embase (OVID interface), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science. We first implemented the search in MEDLINE (Fig. 1 ), which we later adapted for the other three databases. We manually searched for relevant studies from the reference lists of included/eligible articles and reviewed conference abstracts and secondary analyzes to identify primary studies. A third academic librarian (LS) peer-reviewed the search strategy using the Peer Review of Electronic Search Strategies (PRESS) guidelines [ 40 ] on August 19th, 2021, without modification. On August 23rd, 2021, we imported the results in RIS format into Covidence, a web-based system for systematic reviews provided by Cochrane [ 41 , 42 ], which also removed duplicates. We did not import the articles identified via hand-searching the reference list into Covidence for screening. However, two reviewers independently assessed the articles’ eligibility according to our eligibility criteria.

Ovid MEDLINE search strategy

Stage three: study selection

There were two reviewers (AK, OB) involved in this stage, which involved a first and second screening level. The first level included an independent screening of the titles and abstracts, and we decided by selecting ‘yes’, ‘no’, or ‘maybe’. To qualify for full-text screening, a study must receive two ‘yes’ or two ‘maybe’ votes. Two ‘no’ votes moved the study to exclude, and one ‘no’ vote along with one ‘yes’ or ‘maybe’ vote moved it to conflicts, pending resolution. After consultation with the second reviewer, the first author (AK) and second reviewer (OB) resolved the conflicts together. Following this first-level screen, the second level involved a full-text review of all studies included at the title-abstract level. Using the same principles as the first level screening, the first author (AK) and another reviewer (MA) completed this stage [ 41 , 42 ]. In cases where full-text articles could not be located or had to be purchased, the corresponding authors were contacted once by email to request copies. We excluded the articles if we did not receive a response after two weeks. We also searched Google Scholar for conference abstracts to see if the full text of the papers had been published and accessible. For most searches, this process was ineffective, leading to the exclusion of all conference abstracts. Articles excluded with reasons can be found in Additional file 2 .

Stage Four: charting the data

To extract essential information from the articles, we developed a standard Microsoft Excel form a priori. We used the Template for Intervention Description and Replication (TIDieR) checklist [ 43 ] to guide the extraction of the interventions. The form was pilot tested with five articles and revised following recommendations from the research team. After establishing the information to be extracted, we imported the data into Google Forms to facilitate the extracting process for the reviewers. To ensure consistency and reliability in data extraction, two reviewers (AK and MA) independently extracted data from at least 10% of the included studies and compared the results, as recommended by Levac and colleagues [ 32 ]. Once we established consistency, the first author (AK) extracted data from the remaining studies.

Data extracted

Data extraction items include a bibliography (authors, the journal-title and year of publication), setting, study population (frail, number and age of participants), aims of the study, the conceptual framework of frailty used, domains of frailty considered, details on interventions that reduce, enhance, treat or reverse frailty, the framework used to develop interventions, assessment tools or instruments to assess frailty outcome before and/or after the intervention, outcomes (frailty completely, partially, or not reversed). Data extraction items can be found in Additional file 3 .

Quality appraisal (QA)

We critically appraised included studies strengths and limitations of the studies (e.g., randomized controlled trials, quasi-experimental studies, case reports, case series, and cohort studies) using the corresponding JBI checklist for quality appraisal. Checklists, ranged from eight to 13 items [ 35 ]. Answers to the questions in each scale ranged from ‘yes’, ‘no’, and ‘unclear’. Three reviewers (YA, MA, and AK) independently appraised the included studies. After completing the assessment, the first author (AK) sorted the answers to determine any discrepancies. When two reviewers reported the same answer, agreement was achieved. When answers differed, the first author extensively reviewed the study and discussed the differences with the other two to reach a consensus. After completion, we converted all the answers into descriptive variables, with yes representing ‘1’ and no and unclear meaning ‘0’. Following recommendations from some studies [ 44 , 45 ], we used these variables to generate a total score, which we further used to classify a study into “low”, “moderate”, and “high” risk of bias. The quality appraisal interpretation scale can be found in Additional file 4 .

Stage five: summarizing and reporting the results

Data analysis.

To summarize and elaborate on the first research question, we used a narrative synthesis. Initially, we developed a preliminary synthesis by grouping studies that focused on similar concepts such as but not limited to types of interventions, domains of frailty targeted, outcome of interventions, into a tabular format. Next, using excel, we created bar graphs where we explored relationships between and within studies. Through the use of conceptual mapping, we linked multiple pieces of evidence from individual studies to highlight key concepts and ideas [ 46 , 47 ].

Our approach to answering the second research question, comparing study demographics and participant characteristics, was descriptive in nature. Using Excel, we calculated the counts and frequencies of variables in each category and compared their percentages across studies [ 48 ].

Study selection

We identified 7499 potential records, of which thirty met eligibility criteria. In addition, our hand search of references of included studies revealed three eligible studies, reaching a total of thirty-three. We illustrate the screening and selection process for the included studies using the PRISMA 2020 flow diagram for systematic reviews (Fig. 2 ).

PRISMA flow diagram of the search process for studies

Study characteristics

Sample sizes ranged from one to 250,428 participants across the studies. The most common study designs were randomized controlled trials (RCTs) (n = 23) [ 22 , 23 , 24 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 ], quasi-experimental (n = 4) [ 69 , 70 , 71 , 72 ], cohort Studies (n = 3) [ 20 , 73 , 74 ], case series (n = 2) [ 75 , 76 ] and a case report (n = 1) [ 19 ]. Geographically, the studies took place in fifteen different countries, namely Japan (n = 6) [ 23 , 49 , 53 , 58 , 72 , 74 ], Spain (n = 6) [ 20 , 59 , 60 , 62 , 70 , 75 ], United States of America (n = 4) [ 19 , 63 , 64 , 68 ], China (n = 3) [ 51 , 52 , 69 ], Sweden (n = 2) [ 50 , 55 ], South Korea (n = 2) [ 71 , 76 ], Singapore (n = 2) [ 22 , 54 ], Australia (n = 1) [ 66 ], Netherlands (n = 1) [ 65 ], Canada (n = 1) [ 73 ], France (n = 1) [ 24 ], Brazil (n = 1) [ 67 ], Thailand (n = 1) [ 56 ], Turkey (n = 1) [ 57 ], Denmark (n = 1) [ 61 ]. Publication dates ranged from June 23rd, 1994, to January 2nd, 2021, with most articles (n = 24) published after 2015.

Critical appraisal results

The quality assessment scores of the studies ranged from seven to twelve, and study bias was low to moderate for all included studies (Appendix 4). Given that scoping reviews do not mandate the inclusion of studies based on critical appraisal results [ 77 ], we did not exclude studies based on their quality assessment cores.

Participant characteristics

Twelve studies (36.4%) included participants over 65 years of age, 11 studies (33.3%) over 70 years of age, and 10 studies (30.3%) over 75 years of age. Most authors referred to participants as male or female without definition making it difficult to distinguish between gender and sex. Consequently, we present the results as reported in the studies. All but one study reported the sex/gender of participants [ 57 ], with one study having only male participants [ 19 ] and two studies having only female participants as per their eligibility criteria [ 23 , 61 ]. In many studies, the presence of comorbidities beyond frailty was not a requirement for participation (n = 27). Some studies, however, required comorbid conditions for inclusion, such as acromegaly (n = 1) [ 19 ], cardiovascular disease (n = 1) [ 72 ], chronic obstructive pulmonary disease/lung disease (n = 1) [ 60 ], fatigue (n = 1) [ 69 ], and risk of mobility disability and sedentary lifestyle (n = 1) [ 64 ]. Table 1 presents a summary of participant characteristics.

Most and least common domains targeted

Twenty-six studies involved intervention and control groups. Additionally, each study’s intervention targeted at least one domain of frailty. For example, some interventions targeted one single domain (n = 23) [ 19 , 20 , 23 , 49 , 50 , 52 , 53 , 55 , 56 , 57 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 67 , 68 , 70 , 72 , 73 , 74 ], two domains (n = 6) [ 4 , 22 , 54 , 56 , 57 , 78 ], three domains (n = 2) [ 58 , 66 ], and four domains of frailty (n = 2) [ 51 , 71 ]. Counts per domain are presented in Fig. 3 . The most targeted domains were the physical and the cognitive domains. The social domain was the least targeted.

Breakdown of the domains identified in studies

Single and multi-component interventions

Thirteen studies (39.4%) focused on single-component interventions; twelve were physical activity interventions [ 52 , 53 , 56 , 60 , 62 , 63 , 64 , 67 , 70 , 73 , 76 ], and one was a social intervention [ 74 ]. These activities were either individually tailored or performed in a group. Over 50% of the studies focused on multicomponent interventions [ 19 , 20 , 22 , 23 , 24 , 49 , 50 , 51 , 54 , 55 , 58 , 59 , 65 , 66 , 68 , 69 , 71 , 72 , 75 ]. The number of components varied across interventions; from two components to the interventions (n = 10) [ 20 , 23 , 49 , 50 , 55 , 59 , 65 , 68 , 69 , 75 ], three components to the interventions (n = 8) [ 19 , 22 , 24 , 54 , 58 , 66 , 71 , 72 ], or four components to the interventions (n = 2) [ 51 , 71 ]. Characteristics of the interventions are.

included in Table 2 .

Most and least common frailty definitions used

Frailty was defined in all but three studies (n = 30) [ 49 , 61 , 68 ]. Two different definitions of frailty were used dominantly: Fried’s phenotype (n = 20) [ 20 , 22 , 23 , 51 , 52 , 53 , 54 , 56 , 57 , 59 , 62 , 64 , 66 , 67 , 69 , 70 , 71 , 72 , 75 , 76 ], and the Frailty Index (n = 4) [ 24 , 60 , 71 , 73 ]. Notwithstanding, other definitions of frailty involved the use of the clinical frailty scale [ 19 ] and checklist such as the kihon checklist [ 74 ].

Studies without frailty reversal outcome

In the 33 studies included, the results of 22 did not indicate reversal of frailty. Among these, 36.36% (n = 8) focused solely on physical interventions [ 53 , 57 , 60 , 61 , 62 , 63 , 64 , 76 ], while 63.63% (n = 14) combined physical activity with nutritional, cognitive, social, pharmaceutical, or behavioral interventions [ 20 , 24 , 49 , 50 , 51 , 54 , 55 , 58 , 65 , 66 , 68 , 69 , 71 , 75 ]. Although physical activity remains a significant factor in these studies, the types of physical activity (aerobic, strengthening, gait, resistance, etc.) varied. Research suggests that resistance exercise performed at high intensity over a minimum of 12 weeks has the most beneficial effect on physical frailty [ 68 , 79 ]. When done regularly over the course of six months, it has the potential to improve both the physical and physiological aspects of frailty [ 80 ]. In this context, we noted that resistance exercise was more prevalent than other forms of physical activity. Although similar physical activities were often implemented, their characteristics often differed. For example, there was variation in frequency from daily to three times per week, variation in intensity from moderate to high, and variation in duration from 6 weeks to 6 months.

In addition to physical activity, other types of interventions were also used, including cognitive interventions such as memory and reasoning training, pharmaceutical interventions such as medication reconciliation, social interventions such as improving social lifestyles, and behavioral interventions such as goal setting, action plans, and goal execution. Similarly, the characteristics of these interventions were heterogeneous across studies, with some provided as group therapies, and others designed as per the needs of participants.

Studies indicating frailty reversal outcome

Eleven studies reported frailty reversal as an outcome [ 19 , 22 , 52 , 56 , 59 , 67 , 70 , 72 , 73 , 74 , 81 ]. The physical domain was targeted in over 80% of the studies (n = 9) [ 19 , 23 , 52 , 56 , 59 , 67 , 70 , 72 , 73 ], while the social [ 74 ] and cognitive domains [ 22 ] were each targeted in one study. In single-component interventions such as physical activities (n = 5) [ 52 , 56 , 67 , 70 , 73 ], resistance exercises appeared to be the most common, done on its own or in combination with other physical exercises. Meanwhile, the social intervention enhanced the patient’s social capital, a social network that facilitates access to benefits and helps individuals solve problems through association [ 74 ].

The multi-component intervention consisted of physical activity combined with either nutritional counselling/advice or supplements. Some (n = 5) of the interventions included physical activity, nutrition, plus pharmaceutical intervention in one study [ 72 ], physical activity, nutritional plus cognitive intervention in another study [ 22 ], and physical activity combined with occupational and speech therapy [ 19 ], with intervention characteristics varying across studies.

Definition/clarity about the concept of reverse frailty

Authors of 17 studies referred to frailty as a reversible condition. However, the concept of reversing frailty was not defined or explained in six studies [ 22 , 54 , 57 , 58 , 63 , 64 ]. When defined, definitions varied. Some authors defined it as a shift from a frail to pre-frail state (n = 1) [ 56 ], frail to non-frail (n = 2) [ 24 , 59 ], frail to pre- and non-frail (7) [ 23 , 52 , 67 , 70 , 72 , 73 , 74 ], and severe frailty to mild frailty (n = 1) [ 19 ]. What was common across all definitions is that the direction of reversal was from a more severe state of frailty to a less severe state of frailty or pre-frail state. What is different is the degree of frailty, given that some definitions indicated a participant should be frail while others indicated participants being severely frail. This suggests the use of different definitions, criteria, methods, and measures to determine whether frailty reversal occurred. For example, seven of the studies that showed reversal used the definition of Fried et al., [ 23 , 52 , 56 , 59 , 67 , 70 , 72 ], one study used the frailty index [ 73 ], and another study used the clinical frailty scale [ 19 ]. Finally, one study used the Kihon checklist, consisting of 25 yes or no questions on daily-life-related activities, motor functions, nutritional status, oral functions, homebound, cognitive functions, and depressed mood [ 74 ].

Our study aimed to summarize and synthesize evidence on the impact of interventions on frail older adults, to identify those that resulted in frailty reversal and those that did not. In cases where frailty reversal was indicated, we explored the meaning of the concept of reversing frailty. Among the 33 studies included, frailty was revealed to be a complex syndrome encompassing multiple domains, indicating the need for interventions targeting different aspects. Even though some interventions were more prevalent, we observed similarities between types of interventions across studies that showed frailty reversal and those that did not. We noted that the physical domain received the most attention across all studies, whereas the social domain received the least attention in studies with frailty reversal outcomes. Considering that frailty has been defined, addressed, or assessed in multiple ways throughout the studies, further exploration will contribute to clarifying the concept of reversing frailty. These findings lead us to the following points.

Frailty reversal may depend on targeted domains

To the best of our knowledge, the present study is the first to systematically map interventions that indicate frailty reversal as an outcome and relates these interventions to the targeted frailty domains. Using the deficit accumulation model framework as our conceptual framework, we anticipated interventions would target multiple domains of frailty to achieve frailty reversal. However, this was not the case. We identified that the physical domain of frailty is the most frequently targeted as compared to the cognitive, social, and psychological domains. This is supported by the findings of other reviews where authors perceived frailty as primarily a physical impairment, measured by the Fried criteria [ 82 , 83 , 84 , 85 , 86 , 87 ]. This finding suggests that reversing frailty may probably depend on the domain that is targeted by the intervention, or the conceptual framework used to identify and measure its outcome.

Definition of reverse frailty remains unclear

There is no standard definition of reverse frailty, yet the concept appears in several research studies. We used a descriptive approach such as percentages to examine the differences and similarities between the various definitions. A fundamental similarity is that the individual must be deemed frail at baseline. However, the process of determining an individual’s frailty score or status differed among the studies because of the different assessment instruments used. Another similarity was that to reverse frailty, frailty scores or status must not progress to a more severe state but rather improve to a pre-frail or milder state of frailty. Further research is required to clarify this concept, preferably through concept analysis.

Absence of a universal method to reverse frailty

This review included a heterogeneous group of studies with a diverse range of participant characteristics, intervention types, and duration of intervention. Single-component and multi-component interventions have shown efficacy in reversing frailty, with more studies of single-component interventions (i.e., physical activity or social interventions) than the latter.

Use of single-component interventions to reverse frailty

Our study identified physical activity as the most used intervention across studies that reversed frailty. This fits with previous findings that physical activity is essential in interventions for frail older adults [ 85 , 86 , 87 , 88 ]. The activities were performed together (combination exercises) or separately (resistance only). In one study, frailty was reversed as early as six weeks [ 70 ]. The authors attributed this to the combination of resistance, strength training and aerobic exercises. Therefore, when combined with other types of exercise, resistance exercise could promote the rapid improvement of physical frailty.

According to a recent scoping review, social frailty has not received adequate attention [ 15 ]. Based on the findings of our review, we agree with this notion, given we identified only one study [ 74 ] that explored frailty reversal through singular intervention. Using an established checklist of items, the study monitored the effects of enhanced social capital (including interaction with neighbours, trust in the community, social participation in activities) on frailty reversal over two years. The results showed that 31.8% of the participants’ frailty statuses reversed to pre-frail or non-frail Another study [ 58 ] showed that increasing participants’ social capital improved their adherence to activities and encouraged them to continue interventions even after the study had ended. Thus, interventions that consider this approach may have better outcomes when it comes to frailty reversal.

Use of multi-component interventions to reverse frailty

The studies(n = 11) that showed frailty reversal as an outcome employed a combination of two or more intervention components tailored to participant needs or conducted in small groups. Physical activity, particularly resistance exercise, is recommended in conjunction with nutritional interventions as a preventative measure of muscle atrophy in older adults [ 58 ], which may explain why this combination was the most common among the multi-component interventions. We also noted other physical activities such as strength, balance gait and aerobic exercise performed in combination with resistance exercise at varying frequencies and durations. Nutritional interventions included dietary supplements and nutritional education (advice and counselling) on healthy food choices, with the latter being the most reportedly used. We related the advantage of this approach as reported in other studies where Interventions that aimed to empower participants by way of soliciting and incorporating their input (e.g., choosing meals) were more likely to result in participants feeling in control and autonomous over their dietary choices [ 89 , 90 ]. This may explain how nutritional education may provide older adults with more food variety and improved food intake compared with dietary supplements [ 58 ]. In addition to nutritional education and physical activity, Ushijima et al. [ 72 ] also provided medication guidance, to mitigate the effects of polypharmacy, which have been shown to negate the effects of physical and nutritional interventions [ 91 , 92 ].

Recommendations

The results and discussion points above guide our research, practice, and policy recommendations.

In this scoping review, the reporting of the interventions was suboptimal. For example, not all studies reported whether interventions were modified, personalization of interventions were planned, fidelity and adherence were measured, or how intervention fidelity was maintained or improved. Therefore, we recommend that authors use the template for intervention description and replication (TIDIER) checklist [ 43 ] or the Standards for Reporting Implementation Studies (StaRI) [ 93 ] whenever possible to improve intervention reporting. These checklists facilitate clinician use of interventions and researchers’ synthesis and replication. Additionally, we recommend that authors of future studies provide details on the definition and components of frailty. Clinically, this may help identify groups of individuals in need of care and facilitate understanding among researchers.

Despite having no study design restrictions, we did not identify any qualitative or mixed method studies about frailty reversal interventions. None of the included studies reported engaging participants in decision-making or incorporating participant experiences into intervention delivery. A recent scoping review [ 94 ] echoes this concern, as older adults worry that they are not involved in health and well-being decisions. It is known that engaging older adults in decision-making improves health outcomes [ 95 ]. Therefore, we recommend qualitative and mixed methods studies aiming to integrate the older adults’ perspective regarding intervention development, evaluation, or implementation.

Acknowledging that frailty is complex in nature, RCTs with a large sample size could be beneficial to investigate the social, psychological, and cognitive aspects of frailty, which have received little attention to date.

Among the studies that did not report frailty reversal as an outcome, behavioural enhancement was one of the interventions implemented. The use of behavioral enhancement has been associated with the development of self-management skills and the maintenance of long-term changes [ 69 ]. It is therefore our recommendation that more studies consider a behavioural enhancement approach to facilitate adherence to interventions and maintain the benefits of interventions over the long-term. Lastly, given that frailty assessments and measurements are inconsistent, there is a need for more work to standardize them.

Further to considering the perspectives of older adults with frailty, we recommend tailoring interventions to fit the needs and capabilities of individuals rather than generalizing it across an entire population. For example, Latham and colleagues [ 96 ] conducted a resistance training program with Vitamin D supplements over ten weeks for participants with certain functional limitations, such as dependence on others for activities of daily living, prolonged bed rest, or impaired mobility. Contrary to other studies reporting positive effects of resistance exercise, such as improved functional outcomes and decreased frailty scores during this period [ 53 , 58 , 67 , 68 ], Latham and colleagues reported increased fatigue and musculoskeletal injury risks, which may be related to the participants’ functional limitations. We, therefore, recommend tailoring interventions to match participants’ needs and abilities rather than having set durations, frequencies, or intensities of interventions. Another reason is that some older adults may have functional limitations affecting their ability to adhere to prescribed interventions, including the potential adverse effects of polypharmacy on intervention effectiveness [ 92 ].

Research results influence guidelines and expectations for delivering care, services, and programs [ 97 ]. Frailty is becoming a potential public and global health concern, as indicated by the inclusion of studies from North America, Europe, Asia, Australia, etc. This reinforces the need to prevent or reverse this geriatric syndrome. Future studies should investigate frailty in all continents to increase our understanding on the global challenges of expectations, implementation, or care delivery for frail older adults. Such information can facilitate the transfer of healthcare professionals between continents by bridging the knowledge gap concerning frailty, its interventions, and potential strategies for reversing the condition.

Strengths and limitations

Our study has strengths and limitations. We established a reproducible, systematic approach, from the literature search to screening and data extraction. Furthermore, the search strategy was guided and peer-reviewed by academic librarians with extensive knowledge of scoping and systematic reviews. We quality appraised included articles permitting us to have a better sense of the quality of the evidence on this topic. Although not formally published or registered, an a priori protocol approved by the research team guided this study. In comparison to the protocol, a few changes have been made to this study, such as not obtaining expert consultation and revising the research questions.

In terms of limitations, included studies were heterogeneous in their study objectives, frailty definition, frailty domain targeted, and intervention characteristics. Some studies used self-administered questionnaires as outcome measures to assess frailty, potentially increasing the risk of bias and making replication difficult because there is no guarantee of having the same responses among different participants. In addition, two studies did not report the characteristics of the intervention [ 19 , 73 ], and one indicated that participants were frail but did not specify how frailty was determined [ 68 ]. Lastly, we acknowledge that using only a few databases may have limited the number of studies we were able to find.

Conclusions

We used a narrative and descriptive approach to synthesize the included studies. Despite the lack of a standard definition of frailty, we observed similar interventions across studies that reported an outcome of frailty reversal and those that did not. When frailty reversal was indicated, we explored the meaning of the concept. We noted that the physical domain received the most attention across all studies. In contrast, the social domain received the least attention in studies with frailty reversal outcomes.

This study confirms that frailty is a complex and worrying geriatric syndrome. As the world’s population ages, frailty is becoming a serious issue for public and global health. Thus, it is crucial for frailty to be considered a holistic phenomenon with a multi-factor approach rather than merely a physical condition. This requires more research addressing multiple domains to target its prevention and reversal. Our findings indicate that reversing frailty requires that a person first be considered frail, regardless of how frailty is assessed. Although we discovered different ways of assessing frailty among the studies, a key highlight is the fact that the ability to reverse frailty may depend on how frailty is defined and measured. Hence, a consensus on what reverse frailty means is necessary. A promising but challenging area for future research could be qualitative analysis that explores frail older adults’ lived experiences and perspectives. This will guide the development and implementation of possible interventions to reverse this critical geriatric syndrome.

Data availability

Data supporting the findings of this study are available in the article [and its supplementary information files].

Abbreviations

Body Mass Index

Center for Epidemiologic Studies Depression Scale

Medical Literature Analysis and Retrieval System Online

Chronic obstructive pulmonary disease

Cardiopulmonary resuscitation

Frailty Index

Frailty Phenotype

Geriatric Depression Scale

High intensity

Instrumental Activities of Daily Living

Joanna Briggs Institute

Kihon checklist

Multi-component Exercise Program

Medical Subject Headings

Post-intervention follow-up

Peer Review of Electronic Search Strategies

Preferred Reporting Items for Systematic Reviews and Meta-Analyzes

Resident Assessment Instrument-Home Care

Randomized control trials

Resting metabolic rate

Resistance training

Short Physical Performance Battery

Template for Intervention Description and Replication

Standards for Reporting Implementation Studies

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Acknowledgements

We would like to thank the University of Ottawa Health Science Librarians: Valentina Ly (VL), Victoria Cole (VC), and Lindsey Sikora (LS), for their guidance in ensuring searching for relevant studies. Special thanks also go to Ojongetakah Enokenwa Baa and Mbi Ayuk Solange, who acted as secondary screeners for selecting relevant studies.

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Kolle, A.T., Lewis, K.B., Lalonde, M. et al. Reversing frailty in older adults: a scoping review. BMC Geriatr 23 , 751 (2023). https://doi.org/10.1186/s12877-023-04309-y

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Literature Reviews by Lawrence A. Machi , Brenda T. McEvoy LAST REVIEWED: 21 April 2021 LAST MODIFIED: 27 October 2016 DOI: 10.1093/obo/9780199756810-0169

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How to tackle the conundrum of quality appraisal in systematic reviews of normative literature/information? Analysing the problems of three possible strategies (translation of a German paper)

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Solution strategy 1: appraisal using (global) reporting criteria