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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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Table of contents

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.

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.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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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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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

• Strategy: Literature Reviews

What is a literature review?

Typically, a literature review is a written discussion that examines publications about  a particular subject area or topic. 

A Literature Review provides an overview of selected sources on a topic.

Depending on disciplines, publications, or authors a literature review may be:  

a summary of sources an organized presentation of sources a synthesis or interpretation of sources an evaluative analysis of sources

A Literature Review may be part of a process or a product . 

It may be: 

a part of your research process a part of your final research publication an independent publication

Why do a literature review?

The Literature Review will place your research in context . 

It will help you and your readers: 

Locate   patterns, relationships, connections, agreements, disagreements, & gaps in understanding Identify methodological and theoretical foundations Identify landmark and exemplary works Situate your voice in a broader conversation with other writers, thinkers, and scholars

The Literature Review will aid your research process. 

It will help you to: 

establish your knowledge understand what has been said define your questions establish a relevant methodology refine your voice situate your voice in the conversation

What does a literature review look like?

The Literature Review structure and organization . 

an introduction or overview a body or organizational sub-divisions a conclusion or an explanation of significance

The body of a literature review may be organized: 

chronologically: organized by date of publication  methodologically: organized by type of research method used  thematically: organized by concept, trend, or theme  ideologically: organized by belief, ideology, or school of thought

• Find a focus
• Find models
• Review your target publication
• Track citations 
• Read critically
• Manage your citations
• Ask friends, faculty, and librarians

• Next: Managing Sources >>
• Literature Review
• Managing Sources

More sources

• Byrne, D. (2017). Reviewing the literature. Project Planner. 10.4135/9781526408518.
• Literature Review: By UNC Writing Center
• PhD on Track
• CU Graduate Students Thesis & Dissertation
• CU Honors Thesis
• University of Colorado Boulder Libraries
• Research Guides
• Site: Research Strategies
• Last Updated: Aug 10, 2020 11:33 AM
• URL: https://libguides.colorado.edu/strategies/litreview

Penn State University Libraries

Soc 001: introductory sociology.

• Literature Reviews: Strategies for Writing
• Fake News and Evaluating Sources

Literature Reviews

What is a Literature Review? The literature review is a critical look at the existing research that is significant to the work that you are carrying out. This overview identifies prominent research trends in addition to assessing the overall strengths and weaknesses of the existing research.

Purpose of the Literature Review

• To provide background information about a research topic.
• To establish the importance of a topic.
• To demonstrate familiarity with a topic/problem.
• To “carve out a space” for further work and allow you to position yourself in a scholarly conversation.

Characteristics of an effective literature review In addition to fulfilling the purposes outlined above, an effective literature review provides a critical overview of existing research by

• Outlining important research trends.
• Assessing strengths and weaknesses (of individual studies as well the existing research as a whole).
• Identifying potential gaps in knowledge.
• Establishing a need for current and/or future research projects.

Steps of the Literature Review Process

1) Planning: identify the focus, type, scope and discipline of the review you intend to write. 2) Reading and Research: collect and read current research on your topic. Select only those sources that are most relevant to your project. 3) Analyzing: summarize, synthesize, critique, and compare your sources in order to assess the field of research as a whole. 4) Drafting: develop a thesis or claim to make about the existing research and decide how to organize your material. 5) Revising: revise and finalize the structural, stylistic, and grammatical issues of your paper.

This process is not always a linear process; depending on the size and scope of your literature review, you may find yourself returning to some of these steps repeatedly as you continue to focus your project.

These steps adapted from the full workshop offered by the Graduate Writing Center at Penn State. 

Literature Review Format

 Introduction

• Provide an overview of the topic, theme, or issue.
• Identify your specific area of focus.
• Describe your methodology and rationale. How did you decide which sources to include and which to exclude? Why? How is your review organized?
• Briefly discuss the overall trends in the published scholarship in this area.
•  Establish your reason for writing the review.
•  Find the best organizational method for your review.
•  Summarize sources by providing the most relevant information.
•  Respectfully and objectively critique and evaluate the studies.
•  Use direct quotations sparingly and only if appropriate.

 Conclusion

•  Summarize the major findings of the sources that you reviewed, remembering to keep the focus on your topic.
•  Evaluate the current state of scholarship in this area (ex. flaws or gaps in the research, inconsistencies in findings) 
•  Identify any areas for further research.
•  Conclude by making a connection between your topic and some larger area of study such as the discipline. 
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• Next: Fake News and Evaluating Sources >>
• Last Updated: Oct 20, 2023 10:48 AM
• URL: https://guides.libraries.psu.edu/shenangosoc001

Literature Reviews

What this handout is about.

This handout will explain what literature reviews are and offer insights into the form and construction of literature reviews in the humanities, social sciences, and sciences.

Introduction

OK. You’ve got to write a literature review. You dust off a novel and a book of poetry, settle down in your chair, and get ready to issue a “thumbs up” or “thumbs down” as you leaf through the pages. “Literature review” done. Right?

Wrong! The “literature” of a literature review refers to any collection of materials on a topic, not necessarily the great literary texts of the world. “Literature” could be anything from a set of government pamphlets on British colonial methods in Africa to scholarly articles on the treatment of a torn ACL. And a review does not necessarily mean that your reader wants you to give your personal opinion on whether or not you liked these sources.

What is a literature review, then?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper is likely to contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper’s investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Who writes these things, anyway?

Literature reviews are written occasionally in the humanities, but mostly in the sciences and social sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a literature review is written as a paper in itself.

Let’s get to it! What should I do before writing the literature review?

If your assignment is not very specific, seek clarification from your instructor:

• Roughly how many sources should you include?
• What types of sources (books, journal articles, websites)?
• Should you summarize, synthesize, or critique your sources by discussing a common theme or issue?
• Should you evaluate your sources?
• Should you provide subheadings and other background information, such as definitions and/or a history?

Find models

Look for other literature reviews in your area of interest or in the discipline and read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. You can simply put the word “review” in your search engine along with your other topic terms to find articles of this type on the Internet or in an electronic database. The bibliography or reference section of sources you’ve already read are also excellent entry points into your own research.

Narrow your topic

There are hundreds or even thousands of articles and books on most areas of study. The narrower your topic, the easier it will be to limit the number of sources you need to read in order to get a good survey of the material. Your instructor will probably not expect you to read everything that’s out there on the topic, but you’ll make your job easier if you first limit your scope.

Keep in mind that UNC Libraries have research guides and to databases relevant to many fields of study. You can reach out to the subject librarian for a consultation: https://library.unc.edu/support/consultations/ .

And don’t forget to tap into your professor’s (or other professors’) knowledge in the field. Ask your professor questions such as: “If you had to read only one book from the 90’s on topic X, what would it be?” Questions such as this help you to find and determine quickly the most seminal pieces in the field.

Consider whether your sources are current

Some disciplines require that you use information that is as current as possible. In the sciences, for instance, treatments for medical problems are constantly changing according to the latest studies. Information even two years old could be obsolete. However, if you are writing a review in the humanities, history, or social sciences, a survey of the history of the literature may be what is needed, because what is important is how perspectives have changed through the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is currently of interest to scholars in this field and what is not.

Strategies for writing the literature review

Find a focus.

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Convey it to your reader

A literature review may not have a traditional thesis statement (one that makes an argument), but you do need to tell readers what to expect. Try writing a simple statement that lets the reader know what is your main organizing principle. Here are a couple of examples:

The current trend in treatment for congestive heart failure combines surgery and medicine. More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You’ve got a focus, and you’ve stated it clearly and directly. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories

Just like most academic papers, literature reviews also must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. The following provides a brief description of the content of each:

• Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern.
• Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each).
• Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed?

Organizing the body

Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further.

To help you come up with an overall organizational framework for your review, consider the following scenario:

You’ve decided to focus your literature review on materials dealing with sperm whales. This is because you’ve just finished reading Moby Dick, and you wonder if that whale’s portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980’s. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick, so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel.

Now consider some typical ways of organizing the sources into a review:

• Chronological: If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus.
• By publication: Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies.
• By trend: A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.
• Thematic: Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a “chronological” and a “thematic” approach is what is emphasized the most: the development of the harpoon or the harpoon technology.But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as “evil” in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.
• Methodological: A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the “methods” of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed. Once you’ve decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

• Current Situation: Information necessary to understand the topic or focus of the literature review.
• History: The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Methods and/or Standards: The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research: What questions about the field has the review sparked? How will you further your research as a result of the review?

Begin composing

Once you’ve settled on a general pattern of organization, you’re ready to write each section. There are a few guidelines you should follow during the writing stage as well. Here is a sample paragraph from a literature review about sexism and language to illuminate the following discussion:

However, other studies have shown that even gender-neutral antecedents are more likely to produce masculine images than feminine ones (Gastil, 1990). Hamilton (1988) asked students to complete sentences that required them to fill in pronouns that agreed with gender-neutral antecedents such as “writer,” “pedestrian,” and “persons.” The students were asked to describe any image they had when writing the sentence. Hamilton found that people imagined 3.3 men to each woman in the masculine “generic” condition and 1.5 men per woman in the unbiased condition. Thus, while ambient sexism accounted for some of the masculine bias, sexist language amplified the effect. (Source: Erika Falk and Jordan Mills, “Why Sexist Language Affects Persuasion: The Role of Homophily, Intended Audience, and Offense,” Women and Language19:2).

Use evidence

In the example above, the writers refer to several other sources when making their point. A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be selective

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the review’s focus, whether it is thematic, methodological, or chronological.

Use quotes sparingly

Falk and Mills do not use any direct quotes. That is because the survey nature of the literature review does not allow for in-depth discussion or detailed quotes from the text. Some short quotes here and there are okay, though, if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Notice that Falk and Mills do quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. But if you find yourself wanting to put in more quotes, check with your instructor.

Summarize and synthesize

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. The authors here recapitulate important features of Hamilton’s study, but then synthesize it by rephrasing the study’s significance and relating it to their own work.

Keep your own voice

While the literature review presents others’ ideas, your voice (the writer’s) should remain front and center. Notice that Falk and Mills weave references to other sources into their own text, but they still maintain their own voice by starting and ending the paragraph with their own ideas and their own words. The sources support what Falk and Mills are saying.

Use caution when paraphrasing

When paraphrasing a source that is not your own, be sure to represent the author’s information or opinions accurately and in your own words. In the preceding example, Falk and Mills either directly refer in the text to the author of their source, such as Hamilton, or they provide ample notation in the text when the ideas they are mentioning are not their own, for example, Gastil’s. For more information, please see our handout on plagiarism .

Revise, revise, revise

Draft in hand? Now you’re ready to revise. Spending a lot of time revising is a wise idea, because your main objective is to present the material, not the argument. So check over your review again to make sure it follows the assignment and/or your outline. Then, just as you would for most other academic forms of writing, rewrite or rework the language of your review so that you’ve presented your information in the most concise manner possible. Be sure to use terminology familiar to your audience; get rid of unnecessary jargon or slang. Finally, double check that you’ve documented your sources and formatted the review appropriately for your discipline. For tips on the revising and editing process, see our handout on revising drafts .

Works consulted

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

Anson, Chris M., and Robert A. Schwegler. 2010. The Longman Handbook for Writers and Readers , 6th ed. New York: Longman.

Jones, Robert, Patrick Bizzaro, and Cynthia Selfe. 1997. The Harcourt Brace Guide to Writing in the Disciplines . New York: Harcourt Brace.

Lamb, Sandra E. 1998. How to Write It: A Complete Guide to Everything You’ll Ever Write . Berkeley: Ten Speed Press.

Rosen, Leonard J., and Laurence Behrens. 2003. The Allyn & Bacon Handbook , 5th ed. New York: Longman.

Troyka, Lynn Quittman, and Doug Hesse. 2016. Simon and Schuster Handbook for Writers , 11th ed. London: Pearson.

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

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Literature Reviews

Steps in the literature review process.

• What is a literature review?
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support
• You may need to some exploratory searching of the literature to get a sense of scope, to determine whether you need to narrow or broaden your focus
• Identify databases that provide the most relevant sources, and identify relevant terms (controlled vocabularies) to add to your search strategy
• Finalize your research question
• Think about relevant dates, geographies (and languages), methods, and conflicting points of view
• Conduct searches in the published literature via the identified databases
• Check to see if this topic has been covered in other discipline's databases
• Examine the citations of on-point articles for keywords, authors, and previous research (via references) and cited reference searching.
• Save your search results in a citation management tool (such as Zotero, Mendeley or EndNote)
• De-duplicate your search results
• Make sure that you've found the seminal pieces -- they have been cited many times, and their work is considered foundational 
• Check with your professor or a librarian to make sure your search has been comprehensive
• Evaluate the strengths and weaknesses of individual sources and evaluate for bias, methodologies, and thoroughness
• Group your results in to an organizational structure that will support why your research needs to be done, or that provides the answer to your research question  
• Develop your conclusions
• Are there gaps in the literature?
• Where has significant research taken place, and who has done it?
• Is there consensus or debate on this topic?
• Which methodological approaches work best?
• For example: Background, Current Practices, Critics and Proponents, Where/How this study will fit in 
• Organize your citations and focus on your research question and pertinent studies
• Compile your bibliography

Note: The first four steps are the best points at which to contact a librarian. Your librarian can help you determine the best databases to use for your topic, assess scope, and formulate a search strategy.

Videos Tutorials about Literature Reviews

This 4.5 minute video from Academic Education Materials has a Creative Commons License and a British narrator.

Recommended Reading

• Last Updated: Oct 26, 2022 2:49 PM
• URL: https://guides.lib.utexas.edu/literaturereviews

Organizing and Creating Information

• Citation and Attribution

What Is a Literature Review?

Review the literature, write the literature review, further reading, learning objectives, attribution.

This guide is designed to:

• Identify the sections and purpose of a literature review in academic writing
• Review practical strategies and organizational methods for preparing a literature review

A literature review is a summary and synthesis of scholarly research on a specific topic. It should answer questions such as:

• What research has been done on the topic?
• Who are the key researchers and experts in the field?
• What are the common theories and methodologies?
• Are there challenges, controversies, and contradictions?
• Are there gaps in the research that your approach addresses?

The process of reviewing existing research allows you to fine-tune your research question and contextualize your own work. Preparing a literature review is a cyclical process. You may find that the research question you begin with evolves as you learn more about the topic.

Once you have defined your research question , focus on learning what other scholars have written on the topic.

In order to  do a thorough search of the literature  on the topic, define the basic criteria:

• Databases and journals: Look at the  subject guide  related to your topic for recommended databases. Review the  tutorial on finding articles  for tips. 
• Books: Search BruKnow, the Library's catalog. Steps to searching ebooks are covered in the  Finding Ebooks tutorial .
• What time period should it cover? Is currency important?
• Do I know of primary and secondary sources that I can use as a way to find other information?
• What should I be aware of when looking at popular, trade, and scholarly resources ? 

One strategy is to review bibliographies for sources that relate to your interest. For more on this technique, look at the tutorial on finding articles when you have a citation .

Tip: Use a Synthesis Matrix

As you read sources, themes will emerge that will help you to organize the review. You can use a simple Synthesis Matrix to track your notes as you read. From this work, a concept map emerges that provides an overview of the literature and ways in which it connects. Working with Zotero to capture the citations, you build the structure for writing your literature review.

How do I know when I am done?

A key indicator for knowing when you are done is running into the same articles and materials. With no new information being uncovered, you are likely exhausting your current search and should modify search terms or search different catalogs or databases. It is also possible that you have reached a point when you can start writing the literature review.

Tip: Manage Your Citations

These citation management tools also create citations, footnotes, and bibliographies with just a few clicks:

Zotero Tutorial

Endnote Tutorial

Your literature review should be focused on the topic defined in your research question. It should be written in a logical, structured way and maintain an objective perspective and use a formal voice.

Review the Summary Table you created for themes and connecting ideas. Use the following guidelines to prepare an outline of the main points you want to make. 

• Synthesize previous research on the topic.
• Aim to include both summary and synthesis.
• Include literature that supports your research question as well as that which offers a different perspective.
• Avoid relying on one author or publication too heavily.
• Select an organizational structure, such as chronological, methodological, and thematic.

The three elements of a literature review are introduction, body, and conclusion.

Introduction

• Define the topic of the literature review, including any terminology.
• Introduce the central theme and organization of the literature review.
• Summarize the state of research on the topic.
• Frame the literature review with your research question.
• Focus on ways to have the body of literature tell its own story. Do not add your own interpretations at this point.
• Look for patterns and find ways to tie the pieces together.
• Summarize instead of quote.
• Weave the points together rather than list summaries of each source.
• Include the most important sources, not everything you have read.
• Summarize the review of the literature.
• Identify areas of further research on the topic.
• Connect the review with your research.
• DeCarlo, M. (2018). 4.1 What is a literature review? In Scientific Inquiry in Social Work. Open Social Work Education. https://scientificinquiryinsocialwork.pressbooks.com/chapter/4-1-what-is-a-literature-review/
• Literature Reviews (n.d.) https://writingcenter.unc.edu/tips-and-tools/literature-reviews/ Accessed Nov. 10, 2021

This guide was designed to: 

• Identify the sections and purpose of a literature review in academic writing 
• Review practical strategies and organizational methods for preparing a literature review​

Content on this page adapted from: 

Frederiksen, L. and Phelps, S. (2017).   Literature Reviews for Education and Nursing Graduate Students.  Licensed CC BY 4.0

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• Last Updated: Jan 9, 2024 3:05 PM
• URL: https://libguides.brown.edu/organize

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Organizing Your Social Sciences Research Paper

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

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

Importance of a Good Literature Review

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

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

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

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

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

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally among scholars that become part of the body of epistemological traditions within the field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

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

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

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

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

Systematic Review This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyze data from the studies that are included in the review. The goal is to deliberately document, critically evaluate, and summarize scientifically all of the research about a clearly defined research problem . Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?" This type of literature review is primarily applied to examining prior research studies in clinical medicine and allied health fields, but it is increasingly being used in the social sciences.

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

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

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

Structure and Writing Style

I.  Thinking About Your Literature Review

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

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

The critical evaluation of each work should consider :

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

II.  Development of the Literature Review

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

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

III.  Ways to Organize Your Literature Review

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

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

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

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

IV.  Writing Your Literature Review

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

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

V.  Common Mistakes to Avoid

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

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

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

Writing Tip

Break Out of Your Disciplinary Box!

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

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

Another Writing Tip

Don't Just Review for Content!

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

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

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

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

Yet Another Writing Tip

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

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

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

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

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Literature Review: Outline, Strategies, and Examples [2024]

Writing a literature review might be easier than you think. You should understand its basic rules, and that’s it! This article is just about that.

Why is the literature review important? What are its types? We will uncover these and other possible questions.

Whether you are an experienced researcher or a student, this article will come in handy. Keep reading!

What Is a Literature Review?

• Step-by-Step Strategy

Let’s start with the literature review definition.

Literature review outlooks the existing sources on a given topic. Its primary goal is to provide an overall picture of the study object. It clears up the context and showcases the analysis of the paper’s theoretical methodology.

In case you want to see the examples of this type of work, check out our collection of free student essays .

Importance of Literature Review

In most cases, you need to write a literature review as a part of an academic project. Those can be dissertations , theses, or research papers.

Why is it important?

Imagine your final research as a 100% bar. Let’s recall Pareto law: 20% of efforts make 80% of the result. In our case, 20% is preparing a literature review. Writing itself is less important than an in-depth analysis of current literature. Do you want to avoid possible frustration in academic writing? Make a confident start with a literature review.

Sure, it’s impossible to find a topic that hasn’t been discussed or cited. That is why we cannot but use the works of other authors. You don’t have to agree with them. Discuss, criticize, analyze, and debate.

So, the purpose of the literature review is to give the knowledge foundation for the topic and establish its understanding. Abstracting from personal opinions and judgments is a crucial attribute.

Types of Literature Review

You can reach the purpose we have discussed above in several ways, which means there are several types of literature review.

What sets them apart?

In short, it’s their research methods and structure. Let’s break down each type:

• Meta-analysis implies the deductive approach. At first, you gather several related research papers. Then, you carry out its statistical analysis. As a result, you answer a formulated question.
• Meta-synthesis goes along with the inductive approach. It bases qualitative data assessment.
• Theoretical literature review implies gathering theories. Those theories apply to studied ideas or concepts. Links between theories become more explicit and clear. Why is it useful? It confirms that the theoretical framework is valid. On top of that, it assists in new hypothesis-making.
• Argumentative literature review starts with a problem statement. Then, you select and study the topic-related literature to confirm or deny the stated question. There is one sufficient problem in this type, by the way. The author may write the text with a grain of bias.
• Narrative literature review focuses on literature mismatches. It indicates possible gaps and concludes the body of literature. The primary step here is stating a focused research question. Another name for this type — a traditional literature review.
• Integrative literature review drives scientific novelty. It generates new statements around the existing research. The primary tool for that is secondary data . The thing you need is to review and criticize it. When is the best option to write an integrative literature review? It’s when you lack primary data analysis.

Remember: before writing a literature review, specify its type . Another step you should take is to argue your choice. Make sure it fits the research framework. It will save your time as you won’t need to figure out fitting strategies and methods.

Annotated Bibliography vs. Literature Review

Some would ask: isn’t what you are writing about is just an annotated bibliography ? Sure, both annotated bibliography and literature review list the research topic-related sources. But no more than that. Such contextual attributes as goal, structure, and components differ a lot.

For a more visual illustration of its difference, we made a table:

To sum up: an annotated bibliography is more referral. It does not require reading all the sources in the list. On the contrary, you won’t reach the literature review purpose without examining all the sources cited.

Literature Review: Step-by-Step Strategy

Now it’s time for a step-by-step guide. We are getting closer to a perfect literature review!

✔️ Step 1. Select the Topic

Selecting a topic requires looking from two perspectives. They are the following:

• Stand-alone paper . Choose an engaging topic and state a central problem. Then, investigate the trusted literature sources in scholarly databases.
• Part of a dissertation or thesis . In this case, you should dig around the thesis topic, research objectives, and purpose.

Regardless of the situation, you should not just list several literature items. On the contrary, build a decent logical connection and analysis. Only that way, you’ll answer the research question .

✔️ Step 2. Identify the Review Scope

One more essential thing to do is to define the research boundaries: don’t make them too broad or too narrow.

Push back on the chosen topic and define the number and level of comprehensiveness of your paper. Define the historical period as well. After that, select a pool of credible sources for further synthesis and analysis.

✔️ Step 3. Work with Sources

Investigate each chosen source. Note each important insight you come across. Learn how to cite a literature review to avoid plagiarism.

✔️ Step 4. Write a Literature Review Outline

No matter what the writing purpose is: research, informative, promotional, etc. The power of your future text is in the proper planning. If you start with a well-defined structure, there’s a much higher chance that you’ll reach exceptional results.

✔️ Step 5. Review the Literature

Once you’ve outlined your literature review, you’re ready for a writing part. While writing, try to be selective, thinking critically, and don’t forget to stay to the point. In the end, make a compelling literature review conclusion.

On top of the above five steps, explore some other working tips to make your literature review as informative as possible.

Literature Review Outline

We’ve already discussed the importance of a literature review outline. Now, it’s time to understand how to create it.

An outline for literature review has a bit different structure comparing with other types of paper works. It includes:

• Selected topic
• Research question
• Related research question trends and prospects
• Research methods
• Expected research results
• Overview of literature core areas
• Research problem consideration through the prism of this piece of literature
• Methods, controversial points, gaps
• Cumulative list of arguments around the research question
• Links to existing literature and a place of your paper in the existing system of knowledge.

It can be a plus if you clarify the applicability of your literature review in further research.

Once you outline your literature review, you can slightly shorten your writing path. Let’s move on to actual samples of literature review.

Literature Review Examples

How does a well-prepared literature review look like? Check these three StudyCorgi samples to understand. Follow the table:

Take your time and read literature review examples to solidify knowledge and sharpen your skills. You’ll get a more definite picture of the literature review length, methods, and topics.

Do you still have any questions? Don’t hesitate to contact us! Our writing experts are ready to help you with your paper on time.

❓ What Is the Purpose of a Literature Review?

Literature review solves several problems at once. Its purpose is to identify and gather the top insights, gaps, and answers to research questions. Those help to get a general idea of the degree of topic exploration. As a result, it forms a basis for further research. Or vice versa: it reveals a lack of need for additional studies.

❓ How Do You Structure a Literature Review?

Like any other academic paper, a literature review consists of three parts: introduction, main body, and the conclusion. Each of them needs full disclosure and logical interconnection

The introduction contains the topic overview, its problematics, research methods, and other general attributes of academic papers.

The body reveals how each of the selected literature sources answers the formulated questions from the introduction.

The conclusion summarizes the key findings from the body, connects the research to existing studies, and outlines the need for further investigation.

To ensure the success of your analysis, you should equally uphold all of these parts.

❓ What Must a Literature Review Include?

A basic literature review includes the introduction with the research topic definition, its arguments, and problems. Then, it has a synthesis of the picked pieces of literature. It may describe the possible gaps and contradictions in existing research. The practical relevance and contribution to new studies are also welcome.

❓ What Are the 5 C’s of Writing a Literature Review?

Don’t forget about these five C’s to make things easier in writing a literature review:

Cite . Make a list of references for research you’ve used and apply proper citation rules. Use Google Scholar for this.

Compare . Make a comparison of such literature attributes as theories, insights, trends, arguments, etc. It’s better to use tables or diagrams to make your content visual.

Contrast . Use listings to categorize particular approaches, themes, and so on.

Critique . Critical thinking is a must in any scientific research. Don’t take individual formulations as truth. Explore controversial points of view.

Connect . Find a place of your research between existing studies. Propose new possible areas to dig further.

❓ How Long Should a Literature Review Be?

In most cases, professors or educational establishment guidelines determine the length of a literature review. Study them and stick to their requirements, so you don’t get it wrong.

If there are no specific rules, make sure it is no more than 30% of the whole research paper.

If your literature review is not a part of the thesis and goes as a stand-alone paper — be concise but explore the research area in-depth.

• Literature Reviews – The University of North Carolina at Chapel Hill
• What is a literature review? – The Royal Literary Fund
• Literature Review: Purpose of a Literature Review – University of South Carolina
• The Literature Review: A Few Tips On Conducting It – University of Toronto
• Steps for Conducting a Lit Review – Florida A&M University Libraries
• Types of Literature Review – Business Research Methodology
• How to Conduct a Literature Review: Types of Literature Reviews – University Libraries
• Annotated bibliography VS. Literature Review – UNT Dallas Learning Commons
• Literature Review: Conducting & Writing – University of West Florida
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3 Literature Review

Charitianne Williams

By the end of this chapter, you will be able to do the following:

• Understand the purpose and function of a literature review.
• Structure a literature review according to basic genre expectations.
• Synthesize ideas from multiple sources using a synthesis matrix.
• Choose between narrative or parenthetical citation and direct quoting, or paraphrase with intent and purpose.

I. Introduction

The purpose of a literature review is just that—it reviews. This means that literature reviews examine a text after it was produced, with all the benefits that hindsight allows a reader. In popular culture, we commonly review movies, restaurants, vacation spots, products, etc. In those reviews, you look back at the single thing you are reviewing and your experience with it. You focus on the strengths and weaknesses of your experience and judge the experience as positive or negative while recommending or not recommending the place or product and explaining why.

An academic literature review does something different, although some of the skills and strategies you use remain the same. The job of a literature review is to examine a collection of research or scholarship (not a single thing or text) on a given topic and show how that scholarship fits together. Literature reviews summarize, describe, evaluate, and synthesize the work of other authors and researchers while looking for common trends/patterns, themes, inconsistencies, and gaps in this previous research. The main strategy writers of a literature review use is synthesis.

SYNTHESIS: the combination of ideas and elements to form a complete system or theory.

A good metaphor for synthesis is cooking! Imagine the ingredients for a loaf of bread laid out on a kitchen cabinet. Each ingredient—eggs, milk, flour, sugar, salt, yeast—have their own purpose and can be combined in different ways to form food other than bread. Knowing all of those individual attributes that make an egg an egg, or the difference between yeast and flour, is what makes you a chef. When you combine all these ingredients according to the recipe, you get something different than all the ingredients on their own: and most of us would rather eat a slice of bread than a spoonful of flour. The product of synthesis is like bread. Synthesis takes a list of ingredients and makes them into something more than the ingredients alone.

Usually, the writers of a literature review will start with a question that they want to answer through informed and research-based evidence gathered while reading others’ work on related topics. The “thesis” or controlling idea of a literature review may be that same question ( “This review seeks to answer…” ) or it may be a statement describing the reviewed research. The thesis reflects the purpose of the literature review as a genre and is different from the thesis you will write for the research paper that argues a claim or asserts a new idea.

Example 3.1: Look at this thesis statement taken from the introduction of a literature review in environmental psychology on the relationship between “nature sounds” and restorative environments:

From this example, we can learn many things about literature reviews:

• They are explicit and focused on their topic. The opening states an observable truth about the current research ( emphasizes nature ), is followed by a general condition ( positive psychological experiences) within that research, and then finally focuses on describing how a particular outcome is achieved (listening to nature sounds is restorative).
• They seek to pre vent or eliminate misunderstanding. Note the use of specialized key terms, exacting transitional phrases, and meaningful verbs in the thesis such as “ restorative environments,” “in particular,” and “ generate .”
• They seek to forward understanding. In other words, literature reviews examine and link together evidence described and validated in the research of others so a reader can learn how a field is developing. ( Research seems to agree that nature sounds can relieve stress and fatigue–this review will examine that conclusion so readers can understand/ build on how and why.)

Moving from the beginning to the very end of the literature review, we can also learn many things about literature reviews from the sources used. Think of each text listed in the References section of a literature review as contributing pieces to a gigantic puzzle.

Example 3.2: Look at the first three articles listed in the References for the article excerpted above:

Abbott, L. C., Taff, D., Newman, P., Benfield, J. A., and Mowen, A. J. (2016). The influence of natural sounds on attention restoration. J. Park Recreation Adm. 34, 5–15. doi: 10.18666/JPRA-2016-V34-I3-6893

Aletta, F., and Kang, J. (2019). Promoting healthy and supportive acoustic environments: going beyond the quietness. Int. J. Environ. Res. Public Health 16:4988. doi: 10.3390/ijerph16244988

Aletta, F., Oberman, T., and Kang, J. (2018). Associations between positive health-related effects and soundscapes perceptual constructs: a systematic review. Int. J. Environ. Res. Public Health 15:2392. doi: 10.3390/ijerph15112392

None of these sources are exactly the same. One focuses on sound and attention, the next two on sound and health, and none of them are quite the same as sound and restoration —but they are all pieces of the puzzle that give a full understanding of how sound and restorative environments relate.

As the author of the literature review, it is your job to join the pieces together, giving your reader a complete picture of what researchers know about your topic.

Literature reviews are an indispensable tool for researchers. Instead of having to read dozens of articles on a topic, a researcher could instead read a literature review that synthesizes what is known and puts each piece of scholarship into conversation with the others. This could be not only quicker, but also more valuable.

Have you heard the saying that the whole is more than the sum of its parts? The knowledge constructed by a well-written literature review often outweighs the knowledge constructed by simply reading each article in the References section on its own because the author of a literature review processes and analyzes the information for the reader.

Literature reviews occur in two general forms—as a background section in a scholarly work or as a stand-alone genre in and of itself. In both situations, the basic purpose and structure of the literature review is similar: it is the length and the scope that varies. For example, consider the previous chapter, the Proposal. In most proposals, you will want to convince your audience that you are informed on the background of your topic—a literature review is how you would do that. Since a proposal is commonly a short text, you do not have the space to summarize every piece of research. You must select an important set and synthesize that information into a small section signaling your expertise.

On the other hand, consider a professional journal intended to keep its readers up to date on new technologies and findings in a specific field or career. New ideas and discoveries are emerging every day, and it can be difficult to stay on top of all of these new findings, understand how they fit together, and also keep track of your own career responsibilities! A magazine might hire an author to read all the new research on a specific topic and synthesize it into a single article, a state-of-the-art review, so that practitioners in a field can read a single 25-page article instead of 100 25-page articles.

More Resources 3.1: Literature Reviews

II. Rhetorical Considerations: Voice

Using the scholarship of other writers and researchers is one of the things that differentiates academic writing from other types of writing. Using others’ scholarship in a meaningful way that creates new knowledge without mischaracterizing the original findings takes effort, attention, and usually several rounds of revision and rewriting. One of the issues is voice , which refers to the attitude and tone of a text—think of it as what the text “sounds like” in your head as you read it. Voice is an important element of cohesion , or what some people think of as “flow.” Creating a consistent voice in the mind of your reader helps them fit all the information in a text together in the way the author intends. Check out this advice from APAstyle.org about academic style and voice.

Think back to your annotated bibliography and how you created your summaries. You probably used key terms from the original authors’ texts, but because you had to take whole articles and restate the meaning in a short paragraph, there wasn’t room to just repeat the words of the original author. So you had to write the summaries in your voice . If you used those key terms correctly and in ways similar to original authors, those key terms probably did not interfere with cohesiveness and voice. However, in the literature review, you have many more voices to synthesize than you did to summarize in the annotated bibliography. Maintaining a consistent and cohesive voice will be challenging. An important way to maintain voice is through paraphrasing, discussed later in this chapter.

More Resources 3.2: Transitions

Another important way to maintain cohesion is through the use of metadiscourse (see Chapter 2) and transitional phrases. See this link for the use and meaning of transitional phrases, sometimes called signposts .

III. The Literature Review Across the Disciplines

Example 3.3: Academic and Professional Examples

Structure of Literature Reviews

While the details vary across disciplines, all literature reviews tend to have similar basic structure. The introduction of a literature review informs the reader on the topic by defining key terms, citing key researchers or research periods in the field, and introducing the main focus of the review in a descriptive thesis statement. The introduction also explains the organization of the review. In a literature review, you organize your discussion of the research by topic or theme— not article or author. This is in direct contrast to the annotated bibliography, which is often the first step in the writing process for a literature review.

In the annotated bibliography, you organize your entries in alphabetical order by authors’ last names. Each annotation is directly connected to a single text. A literature review is connected to a collection of texts, and therefore must be organized in a way that reflects this.

Example 3.4: Let’s examine the full paragraph that the thesis statement we analyzed earlier came from:

A systematic review by Aletta et al. (2018) has identified links between positive urban soundscapes (which may also include nature sounds) and health and well-being, including stress recovery. Given the emphasis on nature w ithin restorative environments (see Hartig et al., 2014 ), the present narrative literature review focuses on evidence for positive psychological experiences of nature sounds and soundscapes specifically, and in particular how listening to these can generate perceptions and outcomes of restoration from stress and fatigue. This review has five key objectives, summarized in Figure 1 [in the article] . First, it explores literature regarding the impact of nature sounds on perceptions and experiences of wider natural environments. Second, it examines evidence regarding cognitive and affective appraisals of nature sounds and their contributions to overall perceptions of restorative environments. Third, literature regarding restorative outcomes in response to nature sounds is assessed. Fourth, the relevance of key restoration theories to this top ic is examined and areas where these theories are limited are identified. Fifth, a possible new theoretical area of interest—semantic associations with nature—is discussed and exemplified by recent acoustics research (Ratcliffe, 2021, emphasis added).

Notice how the thesis statement (in bold ) is followed by an explicit description of the five key objectives—which correspond to the titles (usually called headings ) of the five major sections of the body of the literature review. The introduction basically outlines the body of the literature review to make it easier for a researcher to find the specific information they are looking for. What follows each of these headings is an analysis and synthesis of the topic described in the heading—which is what we mean when we say a literature review is organized by topic.

Example 3.5: See how the body sections of a literature review synthesize research and evidence in relation to a focused topic. Read this example taken from a literature review in another discipline, nursing.

The introduction states that the review’s purpose is to understand the issues facing nurses in situations such as the COVID-19 pandemic. The researchers found several themes in the research that all contributed to nurses’ experiences. This paragraph describes one of those themes which the authors label “Professional collegiality”:

3.2.2. Professional collegiality

Professional camaraderie amongst nursing colleagues working during a pandemic was high (Ives et al., 2009, Kim, 2018, Liu a nd Liehr , 2009). Nurses acknowledged the importance of caring for their co-workers and in sharing the load. Some nurses associated the experience with working on a battlefield, whereby they worked together as a team protecting one another (Chung et al., 20 05, Kang et al., 2018, Liu and Liehr , 2009). Appreciation of their nursing colleagues was demonstrated through sharing their experiences, willingness to work together and encouraging a team spirit (Shih et al., 2007, Chung et al., 2005, Chiang et al., 2007 ). (Ratcliffe, 2021, p.4)

In this single paragraph, there are seven different research articles cited, and some of them are cited twice. There is no way to write a coherent paragraph summarizing seven different research articles at once—instead, the authors of this paragraph reviewed what the researchers said about collegiality, found where their findings pointed in the same direction, and put those connections into their own words. This is the importance of the review’s body section: it is here where you really dig into the content, meaning, and implications of the scholarship you are discussing.

The end of a literature review looks different from the one- or two-paragraph conclusion we are used to in other texts. The end is often made up of multiple sections, each with a slightly different purpose, although all are probably recognizable to you. A “Discussion” section is almost always present, where the author summarizes the most important findings of each section. In most cases, the “Discussion” section does not contain new information, but ties the different body sections together in ways that provide a deeper analysis.

The end of a literature review may also contain an “Implications for Future Research” or “Resolution” after the Discussion—sometimes this final section is even called “Conclusion.” What this last section looks like is often dependent upon the type of review you are writing, and whether the review is standing alone as a complete text or part of a larger project.

In any situation, across all disciplines, it is important to understand how your literature review is meant to inform the reader and what kind of review is appropriate for the context, in order to decide how you should structure the beginning and end of your review.

Types of Literature Reviews

There are different types of literature reviews, although in undergraduate study the Traditional or Narrative Review is most common. Narrative reviews are somewhat exploratory in their content—in a narrative review you are synthesizing the results of specific texts selected for their connection to your topic. Narrative reviews almost always end with a section describing areas for future research if they are a stand-alone text, or a section describing why the author’s research is so needed if part of a larger research article. The chart below outlines the key differences between three major literature review types. Notice that each type has a slightly different purpose. You might think about which type best fits your project as you read.

Table 3.1: Types of Literature Reviews

More Resources 3.3: Literature Review Structures

IV. Research Strategies: Developing a Methodology

Systematic and scoping reviews should always contain a Research Methodology that explains to your reader exactly how you found the research you are reviewing. Often Narrative Reviews will also contain a research methodology, although it will be slightly different since they are not comprehensive reviews, meaning, they do not attempt to find all the research on a topic—by design, they cover only a specific portion. Even if you are not required to write up your methodology, you need clear research strategies to find the appropriate scholarship for your literature review.

Example 3.6: Check out this excerpt from the methods sections from a psychology literature review. Note how the authors clearly describe what types of sources they’ll be using as well as their steps throughout the research process.

Drawing on individual case studies, archival reports, correlational studies, and laboratory and field experiments, this monograph scrutinizes a sequence of events during which confessions may be obtained from criminal suspects and used as evidence. First, we examine the pre-interrogation interview, a process by which police …( Kassin and Gudjonsson , 2004, p.33)

Example 3.7: Here is another example from the field of education. In it the authors describe two separate searches they performed to gather the literature—the first search used key terms they decided upon before reading any scholarship, and the second search used the terms that they found were common to that first set of texts (see more about key terms here and in the Annotated Bibliography chapter).

We conducted two rounds of literature searches, utilizing the following databases: World CAT (general search), EB SCO Academic Search Complete, EBSCO Education Source, and Linguistics and Language Behavior Abstracts (ProQuest). In the first round, we searched using every possible combination of the following terms: ‘race,’ ‘language teaching,’ ‘ethnicity,’ ‘language p edagogy,’ ‘Whiteness,’ ‘racialized,’ ‘antiracism,’ and ‘ nativeness .’ For the second round of our literature search, we searched using terms that we saw emerging from the literature such as ‘racial identities of language learners,’ ‘racial identities of lan guage teachers,’ ‘language varieties and language teaching,’ ‘race and language teacher education,’ ‘race and educational policy,’ ‘race and language programs,’ and ‘race and language curriculum’ and also repeated our earlier searches in order to keep the literature updated. (Von Esch et al., 2020, p. 392)

No matter the type of research (see a description of qualitative vs. quantitative research ), the specific genres (see descriptions of academic research genres ), or the time frame (see a discussion on the importance of publication date ) you use for your review, it is important to think through the options, make a decision, and incorporate all your research knowledge—use of key terms, use of subject filters, use of specialized databases, etc.—into a coherent and meaningful process that results in the best scholarship for your inquiry and review.

Here’s a video to help you get started on using databases for research:

Library Referral: Connecting the Conversation with Scholarly Sources and Beyond​

(by Annie R. Armstrong)

Research involves drawing from numerous voices from a range of source types. The sources you choose to include in your conversation are context-specific and might vary depending on your topic or the parameters of your assignment. Review your assignment description and talk to your instructor about guidelines. While most research papers emphasize scholarly sources, expertise isn’t always equated with scholarliness and you might want to branch out. For example, a research paper focusing on exploitation of Native American land and communities by the mining industry should make some attempt to include sources generated by the communities under discussion, especially if their point of view is not represented in the peer-reviewed, scholarly sources you’ve found. Think about who the stakeholders are as related to various aspects of your topic and how you can tap into their voices through available resources. You may want to consult a librarian about this.

The chart below summarizes the breadth of source types available through library websites versus the open web:

Table 3.2: Scholarly Sources and Beyond

V. Reading Strategies: Intertextuality and Graphic Organizers

Typically we think of reading as something we do to learn the content of a text—and this is absolutely true! But true understanding means knowing the relationships between and impact of separate but related topics, which might mean understanding how different texts—generally focused on one topic—overlap or differ.

Intertextuality refers to the connections that exist between texts. Intertextuality as a reading strategy means looking for the connections between the text you are reading and others you have already read; anticipating connections with other texts that you have not yet read, but plan to; as well as connections to whole disciplines, fields, and social phenomena. Reading for intertextuality means looking for opportunities to connect texts with each other, and keeping track of those connections in a productive way.

This means note-taking is essential to intertextual reading. Once you have thought carefully about why you are reading a text, what types of information to look for, and what you will do with that information, you can better decide how to keep track of that information. In regards to literature reviews, one type of graphic organizer dominates: the Synthesis Matrix.

The synthesis matrix is a way to keep track of the themes, concepts, and patterns that are emerging from your reading—NOT all the individual content of each article. This is important, yes, and you will need the citations, but literature reviews move one step further into the topic than simply identifying the pieces. You will need to synthesize.

If you have an annotated bibliography of sources already, it is the perfect way to start your synthesis matrix. An annotated bibliography is often the first step in preparing for a literature review, and is quite similar to an ingredient list, if we are using the metaphor from the introduction. (For a detailed description of how to write an annotated bibliography, see Chapter 1 ).

In your annotations, you will have selected the most important information that text supplies in relation to your topic. For an example, let’s take the Conference on College Composition and Communication’s statement “ Students’ Right to Their Own Language ,” which contains two annotated bibliographies. The second uses more recent sources and looks most like the annotated bibliographies you will write as a student, so let’s start there.

Example 3.8: Here are three annotations from that bibliography. As you read, take notice of the different highlighted colors. Phrases italicized and highlighted green identify ideas related to linguistic identity , phrases bolded and highlighted in blue identify concepts related to grammar analysis , and phrases underlined and highlighted orange identify groups and ideas related to educational objectives :

Fought, Carmen. Chicano English in Context. New York: Palgrave Macmillan, 2003.

Based primarily on data collected from adolescent and young adult native speakers in Los Angeles , this book is a comprehensive sociolinguistic study of language and language change in Latino/a communities. It provides the basics of Chicano English (CE) structure (phonology, syntax, and semantics) and its connection to the social and cultural identity of its speakers, along with detailed analyses of particular sociolinguistic variables. Emphasis is given to the historical, social, and linguistic contexts of CE. In addition, the differences between native and non-native CE speakers are covered. A final chapter discusses the future of research on CE.

Lippi-Green, Rosina. English with an Accent: Language, Ideology, and Discrimination in the United States . London and New York: Routledge, 1997.

The author examines linguistic facts about the structure and function of language , explores commonly held myths about language, and develops a model of “the language subordination process.” Then, using a case-study approach, she applies the model to specific institutional practices (e.g., in education, news media, business) to show how false assumptions about language lead to language subordination. The author analyzes specific groups and individuals (speakers of African American English, Southern U.S. English, and the foreign-language accent of Latinos and Asian Americans) and discusses why and how some embrace linguistic assimilation while others resist it.

Nero, Shondel J. Englishes in Contact: Anglophone Caribbean Students in an Urban College. Cresskill, NJ: Hampton Press, 2001.

This qualitative study of four anglophone Caribbean students at a New York City college offers an in-depth examination of the students’ written and spoken language and the challenges faced by both students and teachers as such students acquire academic literacy. Case studies of the four participants include excerpts from tape-recorded interviews, which reflect their linguistic self-perception, and sociolinguistic and educational experiences in their home countries and in New York City. Samples of their college writing over four semesters are represented and analyzed on morphosyntactic and discourse levels to determine the patterns that emerge when Creole English speakers attempt to write Standard Written English. Related issues such as language and identity , language attitudes, and educational responses to ethnolinguistic diversity are also discussed.

Once you have identified a concept like “language and identity” for your literature review, you can start getting “intertextual”! Review your other annotated sources and your new sources for their discussion of language and identity, as well as parallel concepts—what else do researchers address when they discuss language and identity? What do they discuss instead? Go back to the methods you used to come up with key terms for your literature search—the same strategies now apply to your reading. Also look for “umbrella” concepts, patterns in methodologies—anything that emerges while you read intertextually, focusing on the text in front of you while also remembering all the others you read before. Look for the themes in your annotated bibliography and keep track of the page numbers where these themes appear—plan to go back to those pages several times as you write your literature review.

This is a different type of reading than you did for the annotated bibliography, and might mean you go back and reread your sources several times in this new way—don’t think of this as just repeating labor you have already performed. This is new work, designed to uncover new things in the research. Re-reading articles multiple times is something all serious writers do, and something you should do, too. It isn’t redundant, it is recur sive .

Table 3.3: Synthesis Matrix for Individuals’ Choices in Linguistic Identity

Put your sources into conversations around your themes, as shown in the table above. Notice that the top row names the themes covered in that column, put into original wording similar, but not identical, to the wording in the annotated bibliographies. Not every source will address every topic—not every article is the same. The last row starts to describe what is happening in each column across the whole collection of texts. In this way, your synthesis matrix takes the ingredient list provided by the annotated bibliography and makes it into a recipe for your final product—the literature review.

More Resources 3.4: Synthesis Matrix

VI. Writing Strategies: Citation, Quotation, and Paraphrase

Citation is when you use the work of other authors in your writing and mark that portion of your writing so your reader understands what idea is being “borrowed.” Citation also tells your reader where they could find that original idea in the original text, and how your text fits together with the web of other texts related to your topic: in other words, citations help create intertextuality. A citation placed in your sentences should refer directly to the full bibliographic information in your Works Cited or References page.

As you read in Chapter 1, there are different styles of citation including AMA, APA, CMS, and MLA. You can refer back to that chapter for a more detailed explanation of each. In this section, we’ll cover the basics that are common to citation practices. Most academic styles use the original author’s last name as the central part of the in-text citation, since References pages usually list cited works alphabetically by last name, but some use footnotes or endnotes instead, listing works in the order they were cited. It is important to know which academic style you are using for your literature review so that you can make the right choice.

In-text citation takes one of two forms: parenthetical or narrative. In a narrative citation the author of the original work is mentioned in the sentence.

Example 3.9: Here’s an example taken from the introduction of the same literature review discussed in the Research Strategies: Developing a Methodology section of this chapter.

Several pieces offered a comprehensive review of the historical literature on the formation of Black English as a construct in the context of slavery and Jim Crow, and the historical teaching of Black English within the U .S. context, including Wheeler ( 2016 ) and Alim and Baugh (2007). Wheeler (2016) equated Standard English with ‘White’ English and challenged its hegemony in dialectically diverse classrooms. She named the “racism inherent in [fostering] bidialectalism [th rough teaching]” (p. 380), arguing that we are acknowledging that the only way for African-Americans to be upwardly mobile was to learn how to speak ‘White’ English. Alim (2010) , explained, “By uncritically presenting language varieties as ‘equal’ but diff ering in levels of ‘appropriateness,’ language and Dialect Awareness programs run the risk of silently legitimizing ‘Standard English’” (p. 215)…. Current work addressing AAVE studies has been shifting focus to translingualism and to promoting such pedag ogies as code-meshing (Young, Barrett, Young Rivera and Lovejoy, 2014) and translanguaging (García & Wei, García and Wei, 2014) , embedded in a critical analysis of the racial logics underpinning the denigration of some languages. This work, combined with e xtensive examinations of the connections between race, language, teaching, and identity ( e.g. Flores & Rosa, 2015; Alim et al., 2016 ), has laid a foundation for a raciolinguistics approach to teaching, which we return to later in this article. (Von Esch et al., 2020, p. 399, emphasis added .)

In the first sentence, we see two narrative citations just before the period. These citations state the authors’ names as a part of the sentence, and put the publication date of the articles in parenthesis. It makes sense to use a narrative citation in the topic sentence, since most of the paragraph is a synthesis of Wheeler and Alim’s research. The second sentence starts with Wheeler’s name in the subject position, and the fourth sentence starts with Alim’s name in the subject position—both are narrative citations, a form chosen by the author to emphasize the importance and similarities in the two articles.

In the last two sentences, we see parenthetical citations. The citation information is in parenthesis within the sentences, which focuses the reader on the ideas, not the research itself. Imagine you were reading this article out loud—you would most certainly say the narrative citations “Wheeler” and “Alim”; you might choose not to say “Young, Barrett, Young-Rivera, & Lovejoy, 2014,” though, and no one listening to you would notice the omission. This is the most important difference between narrative and parenthetical citation—narrative draws attention to the researchers, while parenthetical allows a focus on ideas. In academic writing, you often have reason to use both, but it is important to note that using parenthetical citation is less disruptive to your voice—it keeps a reader focused on the ideas you are explaining.

Usually you are citing a type of quotation in your text (although different disciplines have other situations that they cite). Direct quotation and paraphrase are usually what we talk about when we talk about using resources in your writing, although summary is cited as well.

Direct quotation is when you take the original words of one author and place them in your own text. When you quote in your own writing, you mark the copied text—usually with quotation marks “” around the text and a citation afterwards. Quoting is useful when the original author is an important authority on a topic or if you want to define/describe another’s point of view in a way that leaves no room for misinterpretation.

In a literature review, a direct quote will almost always be accompanied by a narrative citation. But direct quoting can cause some issues in your own text, such as a sudden shift in voice and a loss of cohesion; the potential for misunderstanding and misrepresentation, since the quote has been separated from its original context; and wordiness —quotes can take up too much space both in terms of the quote itself, and of the explanation and context you must provide for the introduced idea. For these reasons, literature reviews do not contain much direct quoting.

Paraphrasing is a way to accomplish similar goals to direct quoting without causing the same problems. Paraphrasing is when you use only the original author’s key terms and ideas, but your own words. Paraphrasing still contains a citation afterwards that directs the reader to the full bibliographic information in your Works Cited, but does not require quotation marks since the language is yours. Paraphrase may be longer or shorter than the original author’s text, and uses both narrative and parenthetical citation. Paraphrase also allows you to cite more than one piece of research containing the same idea in a single sentence, such as the last sentence in the example paragraph above. This kind of citation string is important to literature reviews because it clearly identifies patterns and trends in research findings.

Key Takeaways

• Literature reviews are a synthesis of what other researchers have discovered on your topic. Think of reviews as “the big picture.”
• Taking so much information from other sources can get confusing–use section headings to keep your review organized and clear.
• Diverse citation, quotation, and paraphrasing techniques are necessary to help your reader understand where the ideas are coming from, AND to help make the ideas “stick together.”
• Keeping all the new knowledge you are learning from your sources organized is hard! Take notes using citations and use a graphic organizer to keep yourself on track.

Fernandez, Lord, H., Halcomb, E., Moxham, L., Middleton, R., Alananzeh, I., & Ellwood, L. (2020). Implications for COVID-19: A systematic review of nurses’ experiences of working in acute care hospital settings during a respiratory pandemic. International Journal of Nursing Studies , 111. https://doi.org/10.1016/j.ijnurstu.2020.103637

Kassin, S. M., & Gudjonsson, G. H. (2004). The psychology of confessions. Psychological Science in the Public Interest , 5 (2), 33–67. https://doi.org/10.1111/j.1529-1006.2004.00016.x

National Council of Teachers of English. (2018, June 16). Students’ right to their own language (with bibliography) . Conference on College Composition and Communication. Retrieved July 24, 2022, from https://cccc.ncte.org/cccc/resources/positions/srtolsummary

NEIU Libraries. (2020). “How should I search in a database?”  YouTube . https://www.youtube.com/watch?v=8fgBF0EuH_o

Ratcliffe, E. (2021). Summary Flowchart [Image]. Frontiers in Psychology. https://www.frontiersin.org/articles/10.3389/fpsyg.2021.570563/full#B3

Ratcliffe, E. (2021). Sound and soundscape in restorative natural environments: A narrative literature review. Frontiers in Psychology , 12 . https://doi.org/10.3389/fpsyg.2021.570563

Sasaki. K. (2022). Synthesis and Recipes [Image].

Von Esch, K., Motha, S., & Kubota, R. (2020). Race and language teaching. Language Teaching, 53 (4), 391-421. doi:10.1017/S0261444820000269

Writing for Inquiry and Research Copyright © 2023 by Charitianne Williams is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Political Science Subject Guide: Literature Reviews

• Political Science
• Books & Dissertations
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More Literature Review Writing Tips

• Thesis Whisperer- Bedraggled Daisy Lay advice on writing theses and dissertations. This article demonstrates in more detail one aspect of our discussion

Books on the Literature Review

What is a literature review?

"A literature review is an account of what has been published on a topic by accredited scholars and researchers. [...] In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries."

(from "The Literature Review: A Few Tips on Writing It," http://www.writing.utoronto.ca/advice/specific-types-of-writing/literature-review )

Strategies for conducting your own literature review

1. Use this guide as a starting point. Begin your search with the resources linked from the political science subject guide. These library catalogs and databases will help you identify what's been published on your topic.

2. What came first? Try bibliographic tracing. As you're finding sources, pay attention to what and whom these authors cite. Their footnotes and bibliographies will point you in the direction of additional scholarship on your topic.

3. What comes next? Look for reviews and citation reports. What did scholars think about that book when it was published in 2003? Has anyone cited that article since 1971? Reviews and citation analysis tools can help you determine if you've found the seminal works on your topic--so that you can be confident that you haven't missed anything important, and that you've kept up with the debates in your field. You'll find book reviews in JSTOR and other databases. Google Scholar has some citation metrics; you can use Web of Science ( Social Sciences Citation Index ) for more robust citation reports.

4. Stay current. Get familiar with the top journals in your field, and set up alerts for new articles. If you don't know where to begin, APSA and other scholarly associations often maintain lists of journals, broken out by subfield . In many databases (and in Google Scholar), you can also set up search alerts, which will notify you when additional items have been added that meet your search criteria.

5. Stay organized. A citation management tool--e.g., RefWorks, Endnote, Zotero, Mendeley--will help you store your citations, generate a bibliography, and cite your sources while you write. Some of these tools are also useful for file storage, if you'd like to keep PDFs of the articles you've found. To get started with citation management tools, check out this guide . 

How to find existing literature reviews

1. Consult Annual Reviews.  The Annual Review of Political Science consists of thorough literature review essays in all areas of political science, written by noted scholars. The library also subscribes to Annual Reviews in economics, law and social science, sociology, and many other disciplines.

2. Turn to handbooks, bibliographies, and other reference sources. Resources like Oxford Bibliographies Online and assorted handbooks ( Oxford Handbook of Comparative Politics , Oxford Handbook of American Elections and Political Behavior , etc.) are great ways to get a substantive introduction to a topic, subject area, debate, or issue. Not exactly literature reviews, but they do provide significant reference to and commentary on the relevant literature--like a heavily footnoted encyclopedia for specialists in a discipline. 

3. Search databases and Google Scholar.   Use the recommended databases in the "Articles & Databases" tab of this guide and try a search that includes the phrase "literature review."

4. Search in journals for literature review articles.  Once you've identified the important journals in your field as suggested in the section above, you can target these journals and search for review articles. 

5. Find book reviews.  These reviews can often contain useful contextual information about the concerns and debates of a field. Worldwide Political Science Abstracts is a good source for book reviews, as is JSTOR . To get to book reviews in JSTOR, select the advanced search option, use the title of the book as your search phrase, and narrow by item type: reviews. You can also narrow your search further by discipline.

6. Cast a wide net--don't forget dissertations.  Dissertations and theses often include literature review sections. While these aren't necessarily authoritative, definitive literature reviews (you'll want to check in Annual Reviews for those), they can provide helpful suggestions for sources to consider.

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Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.

Handbook of eHealth Evaluation: An Evidence-based Approach [Internet].

Chapter 9 methods for literature reviews.

Guy Paré and Spyros Kitsiou .

9.1. Introduction

Literature reviews play a critical role in scholarship because science remains, first and foremost, a cumulative endeavour ( vom Brocke et al., 2009 ). As in any academic discipline, rigorous knowledge syntheses are becoming indispensable in keeping up with an exponentially growing eHealth literature, assisting practitioners, academics, and graduate students in finding, evaluating, and synthesizing the contents of many empirical and conceptual papers. Among other methods, literature reviews are essential for: (a) identifying what has been written on a subject or topic; (b) determining the extent to which a specific research area reveals any interpretable trends or patterns; (c) aggregating empirical findings related to a narrow research question to support evidence-based practice; (d) generating new frameworks and theories; and (e) identifying topics or questions requiring more investigation ( Paré, Trudel, Jaana, & Kitsiou, 2015 ).

Literature reviews can take two major forms. The most prevalent one is the “literature review” or “background” section within a journal paper or a chapter in a graduate thesis. This section synthesizes the extant literature and usually identifies the gaps in knowledge that the empirical study addresses ( Sylvester, Tate, & Johnstone, 2013 ). It may also provide a theoretical foundation for the proposed study, substantiate the presence of the research problem, justify the research as one that contributes something new to the cumulated knowledge, or validate the methods and approaches for the proposed study ( Hart, 1998 ; Levy & Ellis, 2006 ).

The second form of literature review, which is the focus of this chapter, constitutes an original and valuable work of research in and of itself ( Paré et al., 2015 ). Rather than providing a base for a researcher’s own work, it creates a solid starting point for all members of the community interested in a particular area or topic ( Mulrow, 1987 ). The so-called “review article” is a journal-length paper which has an overarching purpose to synthesize the literature in a field, without collecting or analyzing any primary data ( Green, Johnson, & Adams, 2006 ).

When appropriately conducted, review articles represent powerful information sources for practitioners looking for state-of-the art evidence to guide their decision-making and work practices ( Paré et al., 2015 ). Further, high-quality reviews become frequently cited pieces of work which researchers seek out as a first clear outline of the literature when undertaking empirical studies ( Cooper, 1988 ; Rowe, 2014 ). Scholars who track and gauge the impact of articles have found that review papers are cited and downloaded more often than any other type of published article ( Cronin, Ryan, & Coughlan, 2008 ; Montori, Wilczynski, Morgan, Haynes, & Hedges, 2003 ; Patsopoulos, Analatos, & Ioannidis, 2005 ). The reason for their popularity may be the fact that reading the review enables one to have an overview, if not a detailed knowledge of the area in question, as well as references to the most useful primary sources ( Cronin et al., 2008 ). Although they are not easy to conduct, the commitment to complete a review article provides a tremendous service to one’s academic community ( Paré et al., 2015 ; Petticrew & Roberts, 2006 ). Most, if not all, peer-reviewed journals in the fields of medical informatics publish review articles of some type.

The main objectives of this chapter are fourfold: (a) to provide an overview of the major steps and activities involved in conducting a stand-alone literature review; (b) to describe and contrast the different types of review articles that can contribute to the eHealth knowledge base; (c) to illustrate each review type with one or two examples from the eHealth literature; and (d) to provide a series of recommendations for prospective authors of review articles in this domain.

9.2. Overview of the Literature Review Process and Steps

As explained in Templier and Paré (2015) , there are six generic steps involved in conducting a review article:

• formulating the research question(s) and objective(s),
• searching the extant literature,
• screening for inclusion,
• assessing the quality of primary studies,
• extracting data, and
• analyzing data.

Although these steps are presented here in sequential order, one must keep in mind that the review process can be iterative and that many activities can be initiated during the planning stage and later refined during subsequent phases ( Finfgeld-Connett & Johnson, 2013 ; Kitchenham & Charters, 2007 ).

Formulating the research question(s) and objective(s): As a first step, members of the review team must appropriately justify the need for the review itself ( Petticrew & Roberts, 2006 ), identify the review’s main objective(s) ( Okoli & Schabram, 2010 ), and define the concepts or variables at the heart of their synthesis ( Cooper & Hedges, 2009 ; Webster & Watson, 2002 ). Importantly, they also need to articulate the research question(s) they propose to investigate ( Kitchenham & Charters, 2007 ). In this regard, we concur with Jesson, Matheson, and Lacey (2011) that clearly articulated research questions are key ingredients that guide the entire review methodology; they underscore the type of information that is needed, inform the search for and selection of relevant literature, and guide or orient the subsequent analysis. Searching the extant literature: The next step consists of searching the literature and making decisions about the suitability of material to be considered in the review ( Cooper, 1988 ). There exist three main coverage strategies. First, exhaustive coverage means an effort is made to be as comprehensive as possible in order to ensure that all relevant studies, published and unpublished, are included in the review and, thus, conclusions are based on this all-inclusive knowledge base. The second type of coverage consists of presenting materials that are representative of most other works in a given field or area. Often authors who adopt this strategy will search for relevant articles in a small number of top-tier journals in a field ( Paré et al., 2015 ). In the third strategy, the review team concentrates on prior works that have been central or pivotal to a particular topic. This may include empirical studies or conceptual papers that initiated a line of investigation, changed how problems or questions were framed, introduced new methods or concepts, or engendered important debate ( Cooper, 1988 ). Screening for inclusion: The following step consists of evaluating the applicability of the material identified in the preceding step ( Levy & Ellis, 2006 ; vom Brocke et al., 2009 ). Once a group of potential studies has been identified, members of the review team must screen them to determine their relevance ( Petticrew & Roberts, 2006 ). A set of predetermined rules provides a basis for including or excluding certain studies. This exercise requires a significant investment on the part of researchers, who must ensure enhanced objectivity and avoid biases or mistakes. As discussed later in this chapter, for certain types of reviews there must be at least two independent reviewers involved in the screening process and a procedure to resolve disagreements must also be in place ( Liberati et al., 2009 ; Shea et al., 2009 ). Assessing the quality of primary studies: In addition to screening material for inclusion, members of the review team may need to assess the scientific quality of the selected studies, that is, appraise the rigour of the research design and methods. Such formal assessment, which is usually conducted independently by at least two coders, helps members of the review team refine which studies to include in the final sample, determine whether or not the differences in quality may affect their conclusions, or guide how they analyze the data and interpret the findings ( Petticrew & Roberts, 2006 ). Ascribing quality scores to each primary study or considering through domain-based evaluations which study components have or have not been designed and executed appropriately makes it possible to reflect on the extent to which the selected study addresses possible biases and maximizes validity ( Shea et al., 2009 ). Extracting data: The following step involves gathering or extracting applicable information from each primary study included in the sample and deciding what is relevant to the problem of interest ( Cooper & Hedges, 2009 ). Indeed, the type of data that should be recorded mainly depends on the initial research questions ( Okoli & Schabram, 2010 ). However, important information may also be gathered about how, when, where and by whom the primary study was conducted, the research design and methods, or qualitative/quantitative results ( Cooper & Hedges, 2009 ). Analyzing and synthesizing data : As a final step, members of the review team must collate, summarize, aggregate, organize, and compare the evidence extracted from the included studies. The extracted data must be presented in a meaningful way that suggests a new contribution to the extant literature ( Jesson et al., 2011 ). Webster and Watson (2002) warn researchers that literature reviews should be much more than lists of papers and should provide a coherent lens to make sense of extant knowledge on a given topic. There exist several methods and techniques for synthesizing quantitative (e.g., frequency analysis, meta-analysis) and qualitative (e.g., grounded theory, narrative analysis, meta-ethnography) evidence ( Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005 ; Thomas & Harden, 2008 ).

9.3. Types of Review Articles and Brief Illustrations

EHealth researchers have at their disposal a number of approaches and methods for making sense out of existing literature, all with the purpose of casting current research findings into historical contexts or explaining contradictions that might exist among a set of primary research studies conducted on a particular topic. Our classification scheme is largely inspired from Paré and colleagues’ (2015) typology. Below we present and illustrate those review types that we feel are central to the growth and development of the eHealth domain.

9.3.1. Narrative Reviews

The narrative review is the “traditional” way of reviewing the extant literature and is skewed towards a qualitative interpretation of prior knowledge ( Sylvester et al., 2013 ). Put simply, a narrative review attempts to summarize or synthesize what has been written on a particular topic but does not seek generalization or cumulative knowledge from what is reviewed ( Davies, 2000 ; Green et al., 2006 ). Instead, the review team often undertakes the task of accumulating and synthesizing the literature to demonstrate the value of a particular point of view ( Baumeister & Leary, 1997 ). As such, reviewers may selectively ignore or limit the attention paid to certain studies in order to make a point. In this rather unsystematic approach, the selection of information from primary articles is subjective, lacks explicit criteria for inclusion and can lead to biased interpretations or inferences ( Green et al., 2006 ). There are several narrative reviews in the particular eHealth domain, as in all fields, which follow such an unstructured approach ( Silva et al., 2015 ; Paul et al., 2015 ).

Despite these criticisms, this type of review can be very useful in gathering together a volume of literature in a specific subject area and synthesizing it. As mentioned above, its primary purpose is to provide the reader with a comprehensive background for understanding current knowledge and highlighting the significance of new research ( Cronin et al., 2008 ). Faculty like to use narrative reviews in the classroom because they are often more up to date than textbooks, provide a single source for students to reference, and expose students to peer-reviewed literature ( Green et al., 2006 ). For researchers, narrative reviews can inspire research ideas by identifying gaps or inconsistencies in a body of knowledge, thus helping researchers to determine research questions or formulate hypotheses. Importantly, narrative reviews can also be used as educational articles to bring practitioners up to date with certain topics of issues ( Green et al., 2006 ).

Recently, there have been several efforts to introduce more rigour in narrative reviews that will elucidate common pitfalls and bring changes into their publication standards. Information systems researchers, among others, have contributed to advancing knowledge on how to structure a “traditional” review. For instance, Levy and Ellis (2006) proposed a generic framework for conducting such reviews. Their model follows the systematic data processing approach comprised of three steps, namely: (a) literature search and screening; (b) data extraction and analysis; and (c) writing the literature review. They provide detailed and very helpful instructions on how to conduct each step of the review process. As another methodological contribution, vom Brocke et al. (2009) offered a series of guidelines for conducting literature reviews, with a particular focus on how to search and extract the relevant body of knowledge. Last, Bandara, Miskon, and Fielt (2011) proposed a structured, predefined and tool-supported method to identify primary studies within a feasible scope, extract relevant content from identified articles, synthesize and analyze the findings, and effectively write and present the results of the literature review. We highly recommend that prospective authors of narrative reviews consult these useful sources before embarking on their work.

Darlow and Wen (2015) provide a good example of a highly structured narrative review in the eHealth field. These authors synthesized published articles that describe the development process of mobile health ( m-health ) interventions for patients’ cancer care self-management. As in most narrative reviews, the scope of the research questions being investigated is broad: (a) how development of these systems are carried out; (b) which methods are used to investigate these systems; and (c) what conclusions can be drawn as a result of the development of these systems. To provide clear answers to these questions, a literature search was conducted on six electronic databases and Google Scholar . The search was performed using several terms and free text words, combining them in an appropriate manner. Four inclusion and three exclusion criteria were utilized during the screening process. Both authors independently reviewed each of the identified articles to determine eligibility and extract study information. A flow diagram shows the number of studies identified, screened, and included or excluded at each stage of study selection. In terms of contributions, this review provides a series of practical recommendations for m-health intervention development.

9.3.2. Descriptive or Mapping Reviews

The primary goal of a descriptive review is to determine the extent to which a body of knowledge in a particular research topic reveals any interpretable pattern or trend with respect to pre-existing propositions, theories, methodologies or findings ( King & He, 2005 ; Paré et al., 2015 ). In contrast with narrative reviews, descriptive reviews follow a systematic and transparent procedure, including searching, screening and classifying studies ( Petersen, Vakkalanka, & Kuzniarz, 2015 ). Indeed, structured search methods are used to form a representative sample of a larger group of published works ( Paré et al., 2015 ). Further, authors of descriptive reviews extract from each study certain characteristics of interest, such as publication year, research methods, data collection techniques, and direction or strength of research outcomes (e.g., positive, negative, or non-significant) in the form of frequency analysis to produce quantitative results ( Sylvester et al., 2013 ). In essence, each study included in a descriptive review is treated as the unit of analysis and the published literature as a whole provides a database from which the authors attempt to identify any interpretable trends or draw overall conclusions about the merits of existing conceptualizations, propositions, methods or findings ( Paré et al., 2015 ). In doing so, a descriptive review may claim that its findings represent the state of the art in a particular domain ( King & He, 2005 ).

In the fields of health sciences and medical informatics, reviews that focus on examining the range, nature and evolution of a topic area are described by Anderson, Allen, Peckham, and Goodwin (2008) as mapping reviews . Like descriptive reviews, the research questions are generic and usually relate to publication patterns and trends. There is no preconceived plan to systematically review all of the literature although this can be done. Instead, researchers often present studies that are representative of most works published in a particular area and they consider a specific time frame to be mapped.

An example of this approach in the eHealth domain is offered by DeShazo, Lavallie, and Wolf (2009). The purpose of this descriptive or mapping review was to characterize publication trends in the medical informatics literature over a 20-year period (1987 to 2006). To achieve this ambitious objective, the authors performed a bibliometric analysis of medical informatics citations indexed in medline using publication trends, journal frequencies, impact factors, Medical Subject Headings (MeSH) term frequencies, and characteristics of citations. Findings revealed that there were over 77,000 medical informatics articles published during the covered period in numerous journals and that the average annual growth rate was 12%. The MeSH term analysis also suggested a strong interdisciplinary trend. Finally, average impact scores increased over time with two notable growth periods. Overall, patterns in research outputs that seem to characterize the historic trends and current components of the field of medical informatics suggest it may be a maturing discipline (DeShazo et al., 2009).

9.3.3. Scoping Reviews

Scoping reviews attempt to provide an initial indication of the potential size and nature of the extant literature on an emergent topic (Arksey & O’Malley, 2005; Daudt, van Mossel, & Scott, 2013 ; Levac, Colquhoun, & O’Brien, 2010). A scoping review may be conducted to examine the extent, range and nature of research activities in a particular area, determine the value of undertaking a full systematic review (discussed next), or identify research gaps in the extant literature ( Paré et al., 2015 ). In line with their main objective, scoping reviews usually conclude with the presentation of a detailed research agenda for future works along with potential implications for both practice and research.

Unlike narrative and descriptive reviews, the whole point of scoping the field is to be as comprehensive as possible, including grey literature (Arksey & O’Malley, 2005). Inclusion and exclusion criteria must be established to help researchers eliminate studies that are not aligned with the research questions. It is also recommended that at least two independent coders review abstracts yielded from the search strategy and then the full articles for study selection ( Daudt et al., 2013 ). The synthesized evidence from content or thematic analysis is relatively easy to present in tabular form (Arksey & O’Malley, 2005; Thomas & Harden, 2008 ).

One of the most highly cited scoping reviews in the eHealth domain was published by Archer, Fevrier-Thomas, Lokker, McKibbon, and Straus (2011) . These authors reviewed the existing literature on personal health record ( phr ) systems including design, functionality, implementation, applications, outcomes, and benefits. Seven databases were searched from 1985 to March 2010. Several search terms relating to phr s were used during this process. Two authors independently screened titles and abstracts to determine inclusion status. A second screen of full-text articles, again by two independent members of the research team, ensured that the studies described phr s. All in all, 130 articles met the criteria and their data were extracted manually into a database. The authors concluded that although there is a large amount of survey, observational, cohort/panel, and anecdotal evidence of phr benefits and satisfaction for patients, more research is needed to evaluate the results of phr implementations. Their in-depth analysis of the literature signalled that there is little solid evidence from randomized controlled trials or other studies through the use of phr s. Hence, they suggested that more research is needed that addresses the current lack of understanding of optimal functionality and usability of these systems, and how they can play a beneficial role in supporting patient self-management ( Archer et al., 2011 ).

9.3.4. Forms of Aggregative Reviews

Healthcare providers, practitioners, and policy-makers are nowadays overwhelmed with large volumes of information, including research-based evidence from numerous clinical trials and evaluation studies, assessing the effectiveness of health information technologies and interventions ( Ammenwerth & de Keizer, 2004 ; Deshazo et al., 2009 ). It is unrealistic to expect that all these disparate actors will have the time, skills, and necessary resources to identify the available evidence in the area of their expertise and consider it when making decisions. Systematic reviews that involve the rigorous application of scientific strategies aimed at limiting subjectivity and bias (i.e., systematic and random errors) can respond to this challenge.

Systematic reviews attempt to aggregate, appraise, and synthesize in a single source all empirical evidence that meet a set of previously specified eligibility criteria in order to answer a clearly formulated and often narrow research question on a particular topic of interest to support evidence-based practice ( Liberati et al., 2009 ). They adhere closely to explicit scientific principles ( Liberati et al., 2009 ) and rigorous methodological guidelines (Higgins & Green, 2008) aimed at reducing random and systematic errors that can lead to deviations from the truth in results or inferences. The use of explicit methods allows systematic reviews to aggregate a large body of research evidence, assess whether effects or relationships are in the same direction and of the same general magnitude, explain possible inconsistencies between study results, and determine the strength of the overall evidence for every outcome of interest based on the quality of included studies and the general consistency among them ( Cook, Mulrow, & Haynes, 1997 ). The main procedures of a systematic review involve:

• Formulating a review question and developing a search strategy based on explicit inclusion criteria for the identification of eligible studies (usually described in the context of a detailed review protocol).
• Searching for eligible studies using multiple databases and information sources, including grey literature sources, without any language restrictions.
• Selecting studies, extracting data, and assessing risk of bias in a duplicate manner using two independent reviewers to avoid random or systematic errors in the process.
• Analyzing data using quantitative or qualitative methods.
• Presenting results in summary of findings tables.
• Interpreting results and drawing conclusions.

Many systematic reviews, but not all, use statistical methods to combine the results of independent studies into a single quantitative estimate or summary effect size. Known as meta-analyses , these reviews use specific data extraction and statistical techniques (e.g., network, frequentist, or Bayesian meta-analyses) to calculate from each study by outcome of interest an effect size along with a confidence interval that reflects the degree of uncertainty behind the point estimate of effect ( Borenstein, Hedges, Higgins, & Rothstein, 2009 ; Deeks, Higgins, & Altman, 2008 ). Subsequently, they use fixed or random-effects analysis models to combine the results of the included studies, assess statistical heterogeneity, and calculate a weighted average of the effect estimates from the different studies, taking into account their sample sizes. The summary effect size is a value that reflects the average magnitude of the intervention effect for a particular outcome of interest or, more generally, the strength of a relationship between two variables across all studies included in the systematic review. By statistically combining data from multiple studies, meta-analyses can create more precise and reliable estimates of intervention effects than those derived from individual studies alone, when these are examined independently as discrete sources of information.

The review by Gurol-Urganci, de Jongh, Vodopivec-Jamsek, Atun, and Car (2013) on the effects of mobile phone messaging reminders for attendance at healthcare appointments is an illustrative example of a high-quality systematic review with meta-analysis. Missed appointments are a major cause of inefficiency in healthcare delivery with substantial monetary costs to health systems. These authors sought to assess whether mobile phone-based appointment reminders delivered through Short Message Service ( sms ) or Multimedia Messaging Service ( mms ) are effective in improving rates of patient attendance and reducing overall costs. To this end, they conducted a comprehensive search on multiple databases using highly sensitive search strategies without language or publication-type restrictions to identify all rct s that are eligible for inclusion. In order to minimize the risk of omitting eligible studies not captured by the original search, they supplemented all electronic searches with manual screening of trial registers and references contained in the included studies. Study selection, data extraction, and risk of bias assessments were performed inde­­pen­dently by two coders using standardized methods to ensure consistency and to eliminate potential errors. Findings from eight rct s involving 6,615 participants were pooled into meta-analyses to calculate the magnitude of effects that mobile text message reminders have on the rate of attendance at healthcare appointments compared to no reminders and phone call reminders.

Meta-analyses are regarded as powerful tools for deriving meaningful conclusions. However, there are situations in which it is neither reasonable nor appropriate to pool studies together using meta-analytic methods simply because there is extensive clinical heterogeneity between the included studies or variation in measurement tools, comparisons, or outcomes of interest. In these cases, systematic reviews can use qualitative synthesis methods such as vote counting, content analysis, classification schemes and tabulations, as an alternative approach to narratively synthesize the results of the independent studies included in the review. This form of review is known as qualitative systematic review.

A rigorous example of one such review in the eHealth domain is presented by Mickan, Atherton, Roberts, Heneghan, and Tilson (2014) on the use of handheld computers by healthcare professionals and their impact on access to information and clinical decision-making. In line with the methodological guide­lines for systematic reviews, these authors: (a) developed and registered with prospero ( www.crd.york.ac.uk/ prospero / ) an a priori review protocol; (b) conducted comprehensive searches for eligible studies using multiple databases and other supplementary strategies (e.g., forward searches); and (c) subsequently carried out study selection, data extraction, and risk of bias assessments in a duplicate manner to eliminate potential errors in the review process. Heterogeneity between the included studies in terms of reported outcomes and measures precluded the use of meta-analytic methods. To this end, the authors resorted to using narrative analysis and synthesis to describe the effectiveness of handheld computers on accessing information for clinical knowledge, adherence to safety and clinical quality guidelines, and diagnostic decision-making.

In recent years, the number of systematic reviews in the field of health informatics has increased considerably. Systematic reviews with discordant findings can cause great confusion and make it difficult for decision-makers to interpret the review-level evidence ( Moher, 2013 ). Therefore, there is a growing need for appraisal and synthesis of prior systematic reviews to ensure that decision-making is constantly informed by the best available accumulated evidence. Umbrella reviews , also known as overviews of systematic reviews, are tertiary types of evidence synthesis that aim to accomplish this; that is, they aim to compare and contrast findings from multiple systematic reviews and meta-analyses ( Becker & Oxman, 2008 ). Umbrella reviews generally adhere to the same principles and rigorous methodological guidelines used in systematic reviews. However, the unit of analysis in umbrella reviews is the systematic review rather than the primary study ( Becker & Oxman, 2008 ). Unlike systematic reviews that have a narrow focus of inquiry, umbrella reviews focus on broader research topics for which there are several potential interventions ( Smith, Devane, Begley, & Clarke, 2011 ). A recent umbrella review on the effects of home telemonitoring interventions for patients with heart failure critically appraised, compared, and synthesized evidence from 15 systematic reviews to investigate which types of home telemonitoring technologies and forms of interventions are more effective in reducing mortality and hospital admissions ( Kitsiou, Paré, & Jaana, 2015 ).

9.3.5. Realist Reviews

Realist reviews are theory-driven interpretative reviews developed to inform, enhance, or supplement conventional systematic reviews by making sense of heterogeneous evidence about complex interventions applied in diverse contexts in a way that informs policy decision-making ( Greenhalgh, Wong, Westhorp, & Pawson, 2011 ). They originated from criticisms of positivist systematic reviews which centre on their “simplistic” underlying assumptions ( Oates, 2011 ). As explained above, systematic reviews seek to identify causation. Such logic is appropriate for fields like medicine and education where findings of randomized controlled trials can be aggregated to see whether a new treatment or intervention does improve outcomes. However, many argue that it is not possible to establish such direct causal links between interventions and outcomes in fields such as social policy, management, and information systems where for any intervention there is unlikely to be a regular or consistent outcome ( Oates, 2011 ; Pawson, 2006 ; Rousseau, Manning, & Denyer, 2008 ).

To circumvent these limitations, Pawson, Greenhalgh, Harvey, and Walshe (2005) have proposed a new approach for synthesizing knowledge that seeks to unpack the mechanism of how “complex interventions” work in particular contexts. The basic research question — what works? — which is usually associated with systematic reviews changes to: what is it about this intervention that works, for whom, in what circumstances, in what respects and why? Realist reviews have no particular preference for either quantitative or qualitative evidence. As a theory-building approach, a realist review usually starts by articulating likely underlying mechanisms and then scrutinizes available evidence to find out whether and where these mechanisms are applicable ( Shepperd et al., 2009 ). Primary studies found in the extant literature are viewed as case studies which can test and modify the initial theories ( Rousseau et al., 2008 ).

The main objective pursued in the realist review conducted by Otte-Trojel, de Bont, Rundall, and van de Klundert (2014) was to examine how patient portals contribute to health service delivery and patient outcomes. The specific goals were to investigate how outcomes are produced and, most importantly, how variations in outcomes can be explained. The research team started with an exploratory review of background documents and research studies to identify ways in which patient portals may contribute to health service delivery and patient outcomes. The authors identified six main ways which represent “educated guesses” to be tested against the data in the evaluation studies. These studies were identified through a formal and systematic search in four databases between 2003 and 2013. Two members of the research team selected the articles using a pre-established list of inclusion and exclusion criteria and following a two-step procedure. The authors then extracted data from the selected articles and created several tables, one for each outcome category. They organized information to bring forward those mechanisms where patient portals contribute to outcomes and the variation in outcomes across different contexts.

9.3.6. Critical Reviews

Lastly, critical reviews aim to provide a critical evaluation and interpretive analysis of existing literature on a particular topic of interest to reveal strengths, weaknesses, contradictions, controversies, inconsistencies, and/or other important issues with respect to theories, hypotheses, research methods or results ( Baumeister & Leary, 1997 ; Kirkevold, 1997 ). Unlike other review types, critical reviews attempt to take a reflective account of the research that has been done in a particular area of interest, and assess its credibility by using appraisal instruments or critical interpretive methods. In this way, critical reviews attempt to constructively inform other scholars about the weaknesses of prior research and strengthen knowledge development by giving focus and direction to studies for further improvement ( Kirkevold, 1997 ).

Kitsiou, Paré, and Jaana (2013) provide an example of a critical review that assessed the methodological quality of prior systematic reviews of home telemonitoring studies for chronic patients. The authors conducted a comprehensive search on multiple databases to identify eligible reviews and subsequently used a validated instrument to conduct an in-depth quality appraisal. Results indicate that the majority of systematic reviews in this particular area suffer from important methodological flaws and biases that impair their internal validity and limit their usefulness for clinical and decision-making purposes. To this end, they provide a number of recommendations to strengthen knowledge development towards improving the design and execution of future reviews on home telemonitoring.

9.4. Summary

Table 9.1 outlines the main types of literature reviews that were described in the previous sub-sections and summarizes the main characteristics that distinguish one review type from another. It also includes key references to methodological guidelines and useful sources that can be used by eHealth scholars and researchers for planning and developing reviews.

Typology of Literature Reviews (adapted from Paré et al., 2015).

As shown in Table 9.1 , each review type addresses different kinds of research questions or objectives, which subsequently define and dictate the methods and approaches that need to be used to achieve the overarching goal(s) of the review. For example, in the case of narrative reviews, there is greater flexibility in searching and synthesizing articles ( Green et al., 2006 ). Researchers are often relatively free to use a diversity of approaches to search, identify, and select relevant scientific articles, describe their operational characteristics, present how the individual studies fit together, and formulate conclusions. On the other hand, systematic reviews are characterized by their high level of systematicity, rigour, and use of explicit methods, based on an “a priori” review plan that aims to minimize bias in the analysis and synthesis process (Higgins & Green, 2008). Some reviews are exploratory in nature (e.g., scoping/mapping reviews), whereas others may be conducted to discover patterns (e.g., descriptive reviews) or involve a synthesis approach that may include the critical analysis of prior research ( Paré et al., 2015 ). Hence, in order to select the most appropriate type of review, it is critical to know before embarking on a review project, why the research synthesis is conducted and what type of methods are best aligned with the pursued goals.

9.5. Concluding Remarks

In light of the increased use of evidence-based practice and research generating stronger evidence ( Grady et al., 2011 ; Lyden et al., 2013 ), review articles have become essential tools for summarizing, synthesizing, integrating or critically appraising prior knowledge in the eHealth field. As mentioned earlier, when rigorously conducted review articles represent powerful information sources for eHealth scholars and practitioners looking for state-of-the-art evidence. The typology of literature reviews we used herein will allow eHealth researchers, graduate students and practitioners to gain a better understanding of the similarities and differences between review types.

We must stress that this classification scheme does not privilege any specific type of review as being of higher quality than another ( Paré et al., 2015 ). As explained above, each type of review has its own strengths and limitations. Having said that, we realize that the methodological rigour of any review — be it qualitative, quantitative or mixed — is a critical aspect that should be considered seriously by prospective authors. In the present context, the notion of rigour refers to the reliability and validity of the review process described in section 9.2. For one thing, reliability is related to the reproducibility of the review process and steps, which is facilitated by a comprehensive documentation of the literature search process, extraction, coding and analysis performed in the review. Whether the search is comprehensive or not, whether it involves a methodical approach for data extraction and synthesis or not, it is important that the review documents in an explicit and transparent manner the steps and approach that were used in the process of its development. Next, validity characterizes the degree to which the review process was conducted appropriately. It goes beyond documentation and reflects decisions related to the selection of the sources, the search terms used, the period of time covered, the articles selected in the search, and the application of backward and forward searches ( vom Brocke et al., 2009 ). In short, the rigour of any review article is reflected by the explicitness of its methods (i.e., transparency) and the soundness of the approach used. We refer those interested in the concepts of rigour and quality to the work of Templier and Paré (2015) which offers a detailed set of methodological guidelines for conducting and evaluating various types of review articles.

To conclude, our main objective in this chapter was to demystify the various types of literature reviews that are central to the continuous development of the eHealth field. It is our hope that our descriptive account will serve as a valuable source for those conducting, evaluating or using reviews in this important and growing domain.

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• Cite this Page Paré G, Kitsiou S. Chapter 9 Methods for Literature Reviews. In: Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.
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Murad, M. H., Montori, V. M., Ioannidis, J. P. A., Jaeschke, R., Devereaux, P. J., Prasad, K., Neumann, I., Carrasco-Labra, A., Agoritsas, T., Hatala, R., Meade, M. O., Wyer, P., Cook, D. J., & Guyatt, G. (2014). How to read a systematic review and meta-analysis and apply the results to patient care: Users’ guides to the medical literature .  JAMA : the Journal of the American Medical Association ,  312 (2), 171–179. https://doi.org/10.1001/jama.2014.5559

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Novel Strategies in Diagnosing Heart Failure with Preserved Ejection Fraction: A Comprehensive Literature Review

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• Costantino Mancusi   ORCID: orcid.org/0000-0001-6690-1408 1 ,
• Christian Basile 1 ,
• Carmen Spaccarotella 1 ,
• Giuseppe Gargiulo 1 ,
• Ilaria Fucile 1 ,
• Stefania Paolillo 1 ,
• Paola Gargiulo 1 ,
• Ciro Santoro 1 ,
• Lina Manzi 1 ,
• Federica Marzano 1 ,
• Pasquale Ambrosino 2 ,
• Nicola De Luca 1 &
• Giovanni Esposito 1  

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Heart failure (HF) with preserved ejection fraction (HFpEF) is a prevalent global condition affecting approximately 50% of the HF population. With the aging of the worldwide population, its incidence and prevalence are expected to rise even further. Unfortunately, until recently, no effective medications were available to reduce the high mortality and hospitalization rates associated with HFpEF, making it a significant unmet need in cardiovascular medicine. Although HFpEF is commonly defined as HF with normal ejection fraction and elevated left ventricular filling pressure, performing invasive hemodynamic assessments on every individual suspected of having HFpEF is neither feasible nor practical. Consequently, several clinical criteria and diagnostic tools have been proposed to aid in diagnosing HFpEF. Overall, these criteria and tools are designed to assist healthcare professionals in identifying and evaluating patients who may have HFpEF based on a combination of signs, symptoms, biomarkers, and non-invasive imaging findings. By employing these non-invasive diagnostic approaches, clinicians can make informed decisions regarding the best pharmacological and rehabilitation strategies for individuals with suspected HFpEF. This literature review aims to provide an overview of all currently available methods for diagnosing and monitoring this disabling condition.

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1 Introduction

Heart failure (HF) with preserved ejection fraction (HFpEF; defined as EF > 50%) represents half of the HF population, with rising incidence and prevalence as the world’s population ages [ 1 ]. Until recently [ 2 ], there was no medication available to reduce these patients' high mortality and hospitalization rates, making HFpEF one of the most significant unmet needs in cardiovascular (CV) medicine. Measuring left ventricular EF, typically through echocardiography, is fundamental to phenotype HF and selecting appropriate treatments. However, there are shortcomings in the clinical use of EF, which are elaborated on further. Yet, EF remains the main factor in defining HF and is the principal criterion for enrolling patients in clinical HF trials.

HF with reduced ejection fraction (HFrEF), identified when EF is below 40%, is well-understood, and there are effective treatments for patients with HFrEF. On the other hand, the term HFpEF has traditionally referred to patients showing HF symptoms with a “not reduced” EF. This has been variously defined over the years in different guidelines as being more than 40%, 45%, and now 50%. However, EF alone is not enough to define HFpEF. This clearly emerges from the different definitions and characteristics of patients enrolled for trial in HFpEF over the years. With HF being mostly a clinical diagnosis, novel strategies are needed to better identify patients with HFpEF. This paper aims to review the latest literature on the vast arsenal of diagnostic tools available to detect HFpEF.

2 Epidemiology

HFpEF was initially defined as HF occurring in individuals with a left ventricular (LV) EF exceeding 40% [ 3 ]. Cardiological organizations and societies later formalized various EF-based HF phenotypes, including HF with mid-range or mildly reduced EF (HFmrEF), which encompasses EF values between 40 and 50% [ 4 ]. HFpEF is currently defined as HF with an EF greater than 50%, in the absence of prior reduced EF to distinguish it from HF with improved ejection fraction (HFimpEF), a novel HF phenotype that is emerging as HF therapies progressively ameliorate reverse remodeling and systolic function in patients with HFrEF and HFmrEF [ 5 , 6 ] (Table 1 ).

Previous studies have demonstrated that HF medications are mostly ineffective in lowering cardiovascular mortality in HF patients with EF of 50% and hospitalization for HF over the EF cut-off of 55%. More recently sodium glucose co-transporter 2 inhibitors (SGLT2i) have demonstrated efficacy in treatment of HFpEF reducing morbidity and mortality [ 7 ]. Moreover, recent meta-analysis including patients with HFpEF supports the beneficial effect of neurohormonal inhibitors, ACE inhibitors, angiotensin receptor inhibitors, and angiotensin receptor/neprilysin inhibitor (ARNi) on a composite outcome of death and HF hospitalizations [ 8 , 9 ].

With hypertension being the most represented comorbidity in randomized clinical trials in HFpEF, the treatment of hypertension remains the only therapeutic intervention that has a class 1 recommendation in the recent ACC/AHA guidelines [ 6 ]. Etiology and therapy response in HFrEF and HFmrEF are similar, as established by meta-analyses and molecular research [ 10 , 11 ]. Hence, the concept of HFpEF will remain volatile and keen to change as new information about its phenotyping becomes available.

Invasive hemodynamic assessment, the gold standard for the diagnosis of HF, is neither feasible nor reasonable for all individuals with suspected HFpEF. Therefore, clinical scores and diagnostic tools for HFpEF have been developed [ 12 , 13 ]. Combining clinical and diagnostic parameters, the H2FPEF [ 12 ] and HFA-PEFF [ 13 ] scores discriminate between HFpEF and non-cardiac dyspnea. Interestingly, the application of these scoring systems has shown limited concordance in diagnosis in those with elevated H2FPEF and HFA-PEFF scores, even though both scores correctly identified patients at high risk of HF hospitalization [ 14 ], with only 23% of patients being misclassified when compared to right heart catheterization [ 15 ].

3 Physical Examination

Precise acquisition of anamnestic information and physical examination constitute the foundational stages in assessing patients with HF, with a higher capacity to evaluate the congestive status than inadequate perfusion [ 16 ]. Addressing congestion is a focal point for adjusting medication regimens, as increased congestion is associated with reduced quality of life and a less favorable prognosis [ 17 ].

HFpEF is a heterogeneous syndrome; therefore, the clinical presentation may vary depending on the clinical context. A general physical examination may show signs of systemic or cardiac conditions that either cause or aggravate HF, like anemia, hyperthyroidism, alcoholism, hemochromatosis, high-rate atrial fibrillation, and mitral regurgitation.

Physical manifestations of HF, like heightened jugular venous pressure, pulmonary rales, and peripheral edema, might not be evident in a compensated HF state and are present across the whole spectrum of EF in HF [ 18 , 19 ].

The determination of jugular venous pressure offers a means to evaluate volume status (about left-sided filling pressures) due to the observation that right-sided filling pressures frequently mirror left-sided filling pressures in HFpEF [ 20 ].

Among the predominant manifestations observed in patients with HFpEF, only orthopnea and rales have been identified as robust and autonomous predictors of CV mortality or hospitalization for HF [ 21 ].

As HFpEF advances from a compensated to a more unstable phase, dyspnea, and reduced exercise capacity become evident at lower levels of activity, and conspicuous signs of venous congestion may become observable, potentially resulting in hospital admittance [ 22 ]. Regarding the diagnosis of HF, dyspnea exhibits higher sensitivity and lower specificity, and orthopnea displays higher specificity but lower sensitivity. In comparison, exercise tolerance and fatigue may exceed the extent of evident cardiac anomalies, showing lower sensitivity and specificity [ 23 ].

4 Multimodality Imaging and Natriuretic Peptide

Multimodality imaging is a hybrid approach based on combining multiple imaging techniques to overcome the limitations of individual conventional imaging modalities. Multimodality cardiac imaging has demonstrated an emerging role in the etiological phenotyping, follow-up, and therapeutic management of HFpEF [ 24 , 25 ].

Cardiac magnetic resonance imaging (CMR) is a non-invasive imaging technique for the morphological and functional characterization of the myocardium [ 26 ]. Moreover, emerging evidence has demonstrated CMR's pivotal role in assessing the pathophysiologic mechanisms underlying HFpEF, including myocyte hypertrophy, interstitial fibrosis, coronary microvascular and macrovascular diseases, and metabolic abnormalities [ 27 ].

The metabolic alterations in patients with HFpEF can also be evaluated by positron emission tomography (PET), a helpful imaging method to assess substrate changes in heart metabolism using isotope-labeled substrate compounds. Emerging PET tracers enable non-invasive assessment of coronary flow reserve in HFpEF subjects with documented or suspected CAD [ 28 ].

Iodine-123 metaiodobenzylguanidine (123I-MIBG) scintigraphy is a safe and helpful imaging technique to evaluate cardiac innervation [ 29 ]. Although this technique has been widely studied in HFrEF, current knowledge regarding cardiac sympathetic innervation in HFpEF is limited. However, a recent study conducted on 148 HFpEF patients with non-ischemic etiology showed that 123I-MIBG SPECT imaging can detect cardiac sympathetic nerve dysfunction more accurately than conventional planar imaging, thus providing useful prognostic information in patients with HFpEF [ 30 ].

Together with clinical examination and multimodality imaging, measurement of plasmatic levels of natriuretic peptides (NPs), especially B-type natriuretic peptide (BNP) and the N-terminal fragment of proBNP (NT-proBNP), are valuable biomarkers for HF diagnosis, prognosis, and therapeutic management [ 31 ]. However, the role of NPs in HFpEF is controversial, and their levels should be carefully evaluated on a case-by-case basis and corroborated by other imaging parameters [ 32 ]. Limited data are available regarding NPs in patients with HFpEF [ 33 ], and recent studies suggested that elevated circulating levels of NPs are strong predictors of adverse and fatal CV events in these patients [ 34 , 35 ].

According to current European Society of Cardiology (ESC) guidelines, increased levels of NPs (BNP > 35 pg/mL and/or NT-proBNP > 125 pg/mL) represent a diagnostic criterion for HF [ 5 ]. Nevertheless, several studies have reported that NP levels are often normal or even reduced in many patients with HFpEF (20–30%) [ 36 , 37 ].

There is an ongoing debate regarding the best specificity/sensibility threshold for NPs in diagnosing HFpEF. A very informative diagnostic meta-analysis [ 38 ] showed that NPs have reasonable diagnostic performance for detecting HFpEF, with lower sensitivity than specificity and adequate ability to rule out HFpEF, albeit with a shallow positive predictive value.

In a sub-analysis conducted within the I-PRESERVE trial, encompassing a cohort of 2162 patients, Jhund et al. explored the correlation between alterations in NT-proBNP levels over a 6-month follow-up period and subsequent clinical outcomes, including CV death or hospitalization due to HF, as well as all-cause mortality, HF-related death, or HF-related hospitalization. A significant association was found between changes in NT-proBNP levels and the risk of these clinical outcomes, with a notable emphasis on HF-related events. Specifically, an increase of 1000 ng/L in NT-proBNP over 6 months was linked to a two-fold rise in the risk of experiencing cardiovascular death or HF-related hospitalization [ 39 ]. The prognostic significance of NT-proBNP was further assessed through a recent analysis conducted within the EMPEROR-Preserved trial, which involved the enrollment and randomization of 5988 patients with EF greater than 40% and New York Heart Association (NYHA) class II-IV symptoms to either receive empagliflozin or a placebo [ 40 ]. Among these participants, patients with higher NT-proBNP concentrations tended to be older and exhibited more severe manifestations of HF, characterized by lower EF and more pronounced clinical symptoms, as reflected in health status measurements using the Kansas City Cardiomyopathy Questionnaire (KCCQ) scores.

Furthermore, as baseline NT-proBNP levels increased across quartiles, there was a corresponding rise in the risk of CV death. In the placebo group, this risk exceeded four-fold compared to the lowest to the highest quartile, with a substantial increase in HF-related hospitalizations, totaling five-fold more hospitalizations than in the highest quartile. Additionally, an increase in NT-proBNP levels from baseline to the 12-week assessment was correlated with an increased risk of CV death, both in the placebo (HR 1.88) and in the empagliflozin (HR 1.57) groups. Importantly, treatment with empagliflozin demonstrated the ability to improve clinical outcomes across NT-proBNP quartiles without displaying an interaction with baseline NT-proBNP levels, contributing to a mild reduction in NT-proBNP levels [ 40 ].

This lack of consensus regarding NPs' diagnostic and prognostic thresholds in HFpEF has affected the results of large clinical trials, leading to heterogeneous enrollment criteria and the under-use of NPs [ 41 ].

In this context, a recent study by Verbrugge and colleagues showed that, although adverse events were correlated to NP levels, patients with HFpEF and normal NPs showed higher mortality or HF hospitalizations compared with patients without HF, thus underlying the importance of the diagnosis of HFpEF to prevent adverse outcomes [ 42 ].

These findings suggest that differential levels of NPs could reflect distinct stages of HFpEF, which might be linked to different morphological and functional abnormalities of the heart and variable prognosis. Therefore, more studies are needed to better investigate the prognostic potential of NP levels in patients with HFpEF.

5 Echocardiography

Reduced EF is the benchmark to identify patients with HFrEF. At the same time, recognizing the HFpEF pattern implies a stepwise diagnostic approach based on a combined assessment of clinical characteristics and cardiac imaging [ 13 ]. Echocardiography provides critical information in case HF symptoms are present, as these symptoms are clinical manifestations of increased LV filling pressure generated to maintain adequate diastolic filling within the LV with impaired relaxation and increased LV mass [ 5 , 43 , 44 ]. The evaluation of LV geometry, by measuring LV wall thickness and diameters, can stratify morbidity and mortality by tracking structural changes of the LV from remodeling to concentric hypertrophy [ 45 ]. Pathological LV thickening can occur not only as a compensative hypertrophic response caused by chronically increased afterload, as observed in the case of arterial hypertension but also as a result of storage disorders (e.g., Fabry disease) or infiltrative disease (amyloidosis) [ 46 ]. However, even though LV hypertrophy is considered one of the main characteristics of HFpEF, a recent trial demonstrates that almost one-third of the HFpEF population may not express this feature [ 47 ]. This observation highlights that structural changes represent a late phase of adaptation that follows functional alteration (delayed relaxation) and mechanical remodeling (myocardial deformation, atrial dysfunction). These changes occur as a cascade of events resulting in elevated LV filling pressure and, eventually, HF [ 48 ]. Multiparametric assessment of LV filling pressure is necessary to identify better individuals needing intensive medical treatment. Diastolic function is assessed by measuring the trans-mitral pulsed wave velocity of the early filling (E wave), its deceleration time, and the ratio between E wave and A wave (E/A ratio). Considering the U-shape relationship between the E/A ratio and LV filling pressure, additional parameters are demanded to define the degree of diastolic dysfunction [ 49 ]. However, the E/A ratio might be applicable in an emergency setting for rapidly identifying acute HF [ 50 ]. Peak early diastolic annular e’ velocity by tissue Doppler imaging (TDI) represents LV relaxation velocity and is reduced when the LV is less compliant and filling pressure increases. The ratio between trans-mitral E wave velocity and e′ velocity (E/e′ ratio) is considered a robust index of LV filling pressure [ 51 ].

Peak systolic pulmonary artery pressure (sPAP) represents a non-invasive esteem of the Pulmonary capillary wedge pressure (PCWP), which helps identify increased LV filling pressure when causes of precapillary pulmonary hypertension can be excluded. Reddy et al. proposed the H2FPEF score that combines echocardiographic derived sPAP and E/e′ ratio with clinical characteristics to discriminate HFpEF from non-cardiac causes of dyspnea [ 12 ]. The left atrium (LA) is considered a valid litmus test for chronic increased LV filling pressure, as it contributes to preserving LV filling at the expense of volumetric changes. LA volume, either measured by 2D or 3D echocardiography, should, therefore, be routinely measured in patients with suspected HFpEF, and it is also helpful in the emergency department setting [ 52 ]. The recommendation of LV diastolic function proposed an algorithm that incorporates all echocardiographic parameters to estimate LV filling pressure [ 53 ]. However, analysis of the accuracy of the 2016 recommended algorithm for diastolic function assessment showed that up to 30% of the exams could be inconclusive [ 54 ]. In contrast, strain deformation analysis at rest and diastolic stress echo [ 55 ] could help to prevent invasive assessment through heart catheterization. Strain analysis allows quantitative assessment of myocardial deformation throughout the cardiac cycle.

LV longitudinal strain analysis strongly predicts systolic dysfunction, representing an early marker of subendocardial impaired contraction [ 56 ]. It has been reported that despite preserved ejection fraction, abnormalities of longitudinal strain may occur early in patients with HFpEF, thus helping to differentiate this condition from asymptomatic hypertensive heart disease [ 57 , 58 ] with significant differences in prognostic risk stratification [ 59 ]. Additionally, strain polar maps assessed by LV strain analysis may provide visual hints to suggest possible HFpEF etiology [ 60 ] (Fig. 1 ).

Bullseye depicts longitudinal strain analysis of the LV in a polar regional map in which red represents normal contraction that lightens as the contraction is impaired. A Patients show reduced GLS (− 16.7%) with marked reduction of longitudinal contraction of the basal segment, suggesting infiltrative pathology (“apical sparing”). B Similar reduction of GLS as in the former case (− 16.6%) but with a balanced reduction of longitudinal function in all the LV segments

Also, strain analysis allows for studying the LA mechanism during the cardiac cycle, supplying information about reservoir, conduit, and pump function [ 61 ]. LA reservoir function represents the LA filling before the mitral valve’s opening, thus expressing the compliance of the LA wall, and is inversely related to the degree of fibrosis [ 62 ]. It is considered an early marker of LV diastolic dysfunction, having an incremental value to detect elevated LV filling pressure independently from LA geometric measurement [ 63 ] due to a significant correlation to pulmonary wedge pressure measured invasively [ 64 ], being usually reduced in patients with HFpEF [ 65 ]. A recent consensus paper recommends including LA reservoir strain (cut-off value < 18%) in patients with suspected HFpEF, especially in those where LV filling pressure results are undetermined [ 24 ]. Recently, a novel method to create a noninvasive P/V loop and its centroid has been tested using standard echocardiography, providing useful pathophysiologic and prognostic information in patients with HF [ 66 ].

6 Endothelial Dysfunction Assessment

In the context of HFpEF, systemic cardiovascular changes, including endothelial dysfunction, play a pivotal role in its pathophysiology and progression [ 67 ]. To better understand the vascular aspects of HFpEF, non-invasive vascular diagnostic tools have emerged as valuable resources for clinicians and researchers. Flow-mediated dilation (FMD) measures the ability of the brachial artery to dilate in response to increased blood flow, reflecting the endothelial-dependent vasodilatory response. Recent studies, such as the FMD-J study [ 68 ], have highlighted the relevance of FMD, especially in HFpEF hypertensive patients, in detecting increased LV diastolic stiffness.

Arterial stiffness, as assessed by pulse wave velocity, has also gained prominence as another non-invasive parameter of interest in HFpEF. Arterial stiffness reflects the rigidity of the arterial walls, which can affect cardiac afterload and ventricular-arterial coupling. As described in the IDENTIFY-HF study [ 69 ], arterial stiffness increases as vascular comorbidities accumulate, regardless of age, renal function, hemoglobin levels, obesity, smoking status, or hypercholesterolemia. Notably, HFpEF demonstrates the highest levels of arterial stiffness, while HFrEF displays nearly normal levels. This assessment provides valuable insights into the interaction between the heart and the arterial system, shedding light on the complex mechanisms underlying HFpEF.

7 Lung Ultrasound

Lung ultrasonography (LUS) is a straightforward and expeditious technique for evaluating pulmonary congestion among patients diagnosed with HF [ 70 ]. It is widely accessible, particularly within acute care environments [ 71 ].

However, in outpatient primary care settings, its feasibility is limited due to the constrained proficiency of general practitioners and the uneven dissemination of ultrasound equipment. LUS involves the measurement of vertical hyperechoic reverberation artifacts originating from the pleural line, extending uninterrupted to the screen's base, and exhibiting synchronous motion with lung sliding [ 72 ]. These phenomena are categorized as “B-lines,” they are identified through scanning along the intercostal spaces, preferably utilizing a curvilinear transducer. Different epidemiological studies have demonstrated its diagnostic utility in assessing extravascular lung congestion and correctly identifying patients with HF [ 73 , 74 ]. B-lines and pleural effusion are the diagnostic hallmarks of increased extra-vascular lung congestion. Compared to chest X-rays, lung ultrasound demonstrated higher sensitivity, specificity, and accuracy for identifying lung congestion in HF regardless of EF [ 75 ].

Cogliati et al. show that pulmonary congestion at hospital admission and after discharge is more severe in patients with HFrEF compared to those with HFpEF [ 76 ]. In another study, including patients admitted to the cardiology ward, LUS was a fundamental diagnostic tool for detecting subclinical congestions in patients with HFpEF with the number of B-lines as an added predictive value compared to standard echocardiographic parameters [ 77 ]. The diagnostic ability of increased B-lines during exercise to identify HFpEF was tested in ambulatory patients, demonstrating a significant diagnostic incremental value over the established H2FPEF score and LA reservoir strain [ 78 ]. Systemic venous hypertension occurs due to disrupted coupling between the right ventricle and pulmonary artery, potentially impeding fluid clearance processes [ 79 ]. Thus, using LUS to measure pulmonary congestion at rest or with exercise in patients with HFpEF is both timely and attractive. Of course, B-lines can also be associated with other medical conditions, including pulmonary fibrosis and other interstitial lung diseases. In this regard, it is crucial to integrate ultrasound imaging modalities for the correct diagnosis [ 80 ]. Different LUS protocols have been validated, ranging from four to 28 chest zones. Naturally, a greater scanning area leads to higher LUS accuracy but also increases time requirements, suggesting using simplified protocols [ 81 ].

8 Role of Cardiopulmonary Stress Test

Exercise limitation and dyspnea on efforts are common findings in patients with suspected or defined HFpEF. Currently, the cardiopulmonary exercise test (CPET) is the gold standard technique for assessing functional capacity and exercise tolerance while also facilitating the characterization of exercise limitation. This allows for the differentiation of cardiogenic, pulmonary, and vascular etiologies, thus directing the diagnosis and determining the priority of therapeutic targets for healthcare decisions [ 82 ]. Several fundamental criteria must be met to ensure precise testing assessing exercise limitations during maximal efforts. These include maintaining stable clinical conditions, opting for a ramp CPET protocol specifically designed to last between 8 and 12 min, attaining a respiratory exchange ratio equal to or greater than 1.05 to account for the progressive changes in gas exchange parameters (such as peak oxygen uptake [VO 2 ] and work rate [WR]), and accurately identifying ventilatory thresholds and exercise slopes (VO 2 /WR and ventilation/CO 2 production [VE/VCO 2 ] slope) [ 83 ].

Although there is no precise algorithm for the ramp protocol to choose in HF patients, both in HFrEF and in HFpEF, gender, age, CV risk factors, degree of routine exercise, symptom status, and comorbidities should be considered. While used to determine patients’ prognosis and to guide pharmacological treatment and timing for cardiac transplantation in HFrEF, CPET also plays its primary role in differentiating HFpEF from non-cardiac causes of exertional dyspnea. In this context, the HFA-PEFF score algorithm includes CPET in the initial work-up (pre-test assessment) of suspected HFpEF, with the only scope to rule out non-cardiac causes of exercise limitation [ 13 ]. The primary concern is that in HFpEF, the decrease in peak VO 2 is sensitive but non-specific, meaning that in most patients, it is not possible to reliably distinguish HFpEF from non-cardiac forms of dyspnea unless it is at the bottom of the peak VO 2 scale [ 84 ]. Although a peak VO 2 below 14 ml/kg/min strongly suggests the possibility of HFpEF, and a peak VO 2 above 20 ml/kg/min makes HFpEF highly unlikely, the range between these two values still requires additional diagnostic tests such as stress echocardiography or right heart catheterization for a more conclusive evaluation [ 85 ]. However, when all CPET parameters are combined, a distinct HF pattern with cardiac reserve limitation emerges a decreased O 2 pulse, a downward VO 2 /WR relationship shift, and chronotropic incompetence [ 86 ]. Beyond VO 2 , a substantial increase in the VE/VCO 2 slope should lead to further testing for the assessment of a ventilation-perfusion mismatch in a picture of pulmonary vascular involvement, leading to a differential diagnosis between HFpEF with coexisting pre-capillary pulmonary hypertension or chronic thromboembolic pulmonary hypertension [ 87 ].

Moreover, it is also essential to pay attention to the presence of interstitial pulmonary diseases, which could be initially revealed by gas exchange anomalies, such as a lower O 2 saturation (95% at rest or > 5% reduction during the test), an increased dead volume (VD)/tidal volume (VT), consistent reduction in both Forced Expiratory Volume in the first second (FEV1) and forced vital capacity (FVC) with a preserved ratio during spirometry, and a decrease in diffusing capacity for carbon monoxide (DLCO) [ 88 ].

The value of a combined CPET and ecochardiography stress test protocol has also been evaluated to further rule-in patients with HFpEF, especially in the earliest stage of the disease when other diagnostic methodologies may have low specificity or not be indicated due to invasiveness [ 89 ].

HFpEF patients may confound diagnosis, frequently having a modest restrictive impairment on spirometry in addition to a decline in DLCO [ 90 ]. In these cases, chest tomography or right ventricular catheterization may be required to identify or rule out HFpEF [ 5 ]. However, despite its great usefulness, CPET remains only widely available in large tertiary/university centers.

9 Invasive Diagnostic Tools

The diagnosis of HFpEF remains challenging. Indeed, clinical presentation, echocardiographic features, and NP levels may increase the likelihood of diagnosing HFpEF, even though they have a low negative predictive value. This is due to their poor sensitivity and many HFpEF patients having normal resting filling pressures [ 91 , 92 ]. Stress echocardiography or invasive hemodynamic test is indicated in dubious cases or when confirmation is needed [ 13 ]. Therefore, cardiac catheterization plays a crucial role in the differential diagnosis of many patients. Right heart catheterization (RHC) remains the gold standard test to establish the diagnosis of HFpEF [ 93 , 94 ]. It is generally performed using a thermodilution catheter (Swan-Ganz catheter) inserted in the femoral, antecubital, or internal jugular vein through a 7 Fr sheath. The zero-reference level for the pressure transducer is placed at the mid-thoracic line with the patient in the supine position. After 15 min of catheter insertion, resting hemodynamic parameters can be assessed. Measurements should be recorded at the passive end-expiration phase. Right atrial pressure (RAP), pulmonary arterial pressure (PAP), and pulmonary capillary wedge pressure (PCWP) measurements should be averaged over three cardiac cycles in patients with sinus rhythm (more cycles in those with atrial fibrillation). Cardiac output (CO) should be determined by thermodilution or the direct Fick method [ 95 ]. An invasively measured PCWP ≥ 15 mmHg or LV end-diastolic pressure (LVEDP) ≥ 16 mmHg is generally considered diagnostic of HFpEF (5) while concurrently ruling out Pulmonary Hypertension group 1 (characterized by mPAP > 20 mmHg, PCWP ≤ 15 mmHg, and pulmonary vascular resistance > 2 Wood units) [ 96 ].

Left heart catheterization (LHC) is relevant to concomitantly measure LV pressures (LVEDP and LVESP) and elastance using pressure-volume loops. In HFpEF, there is a greater LVEDP (at rest and even greater during exercise), and generally, the PV loop shows an upward and leftward shift [ 97 ]. However, LHC is also helpful in assessing or excluding concomitant coronary artery disease (CAD) or other conditions that can simulate HFpEF (i.e., constrictive pericarditis).

In particular, invasive coronary angiography enables the detection of obstructive epicardial CAD but also assesses coronary microvascular dysfunction (MVD) by evaluating abnormalities of coronary flow reserve (CFR) and index of microvascular resistance (IMR). Indeed, the mechanisms underlying HFpEF are complex, and MVD has been hypothesized to be a potentially relevant driver in its pathophysiology. However, these patients also show a high prevalence of epicardial CAD due to the burden of comorbidities associated with atherosclerosis and HFpEF; therefore, since epicardial CAD affects myocardial perfusion, it is challenging to clarify the relationship between them and HFpEF and MVD in cohorts with highly prevalent epicardial CAD. Invasive studies show that patients with HFpEF have a high prevalence of MVD, ranging between 70 and 85% depending on the diagnostic thresholds used, which vary between studies: CFR ≤ 2 to ≤ 2.5, IMR ≥ 23 to ≥ 25 [ 98 ].

Many HFpEF patients have regular non-invasive and invasive tests at rest [ 93 ]. Indeed, in most patients with HFpEF, due to increased chamber stiffness, volume changes lead to more significant increases in LVEDP during exercise. Furthermore, the exercise-induced increase of CO is reduced due to poor contractile reserve and chronotropic incompetence [ 99 , 100 ]. In such cases, exercise tests are recommended, and exercise RHC has been claimed as the gold-standard diagnostic test for HFpEF [ 82 ]. However, exercise RHC is expensive, time-consuming, has limited availability, and requires operator expertise with difficulties of interpretation due to wide swings in intrathoracic pressures.

Moreover, the procedural approach has not been widely standardized, including patients’ body position, exercise protocol, and hemodynamic measurements and interpretation. These non-negligible limitations could impact the reproducibility and generalizability of the results. Protocols differ slightly between sites but generally include increased supine or standing workload, RAP, PAP, and PCWP; measurement of CO using either direct Fick or thermodilution. It is still debated whether pressures should be measured at the end of expiration or using the average of the respiratory cycle [ 101 , 102 ]. Patients with peak exercise PCWP ≥ 25 mmHg are classified as having HFpEF. Notably, patients with normal or high PCWP at rest and a pathological increase in PCWP during exercise have poor outcomes with increased mortality [ 103 , 104 , 105 ]. Some data show that healthy individuals could exceed these “normal” LV filling pressure parameters during exercise [ 106 ], and with advancing age, there is an increase in PCWP during exercise [ 107 ]. The PCWP/CO slope has been developed and validated to overcome these limitations as a novel method to evaluate LV performance during the exercise RHC [ 102 , 108 ]. This continuous variable showed better diagnostic sensitivity and specificity compared with the peak PCWP criteria for diagnosis of HFpEF and in risk prediction, as it considers the whole workload spectrum [ 105 ]. An exercise PCWP/CO slope > 2 mmHg/L/min has been associated with poor functional capacity and adverse clinical outcomes in HFpEF patients. The Fick method has only validated this diagnostic value [ 109 ].

The diagnostic information can be further implemented by analyzing biventricular interaction and changes in RAP versus PCWP, providing the pressure-induced unfavorable RV to LV interaction mechanisms intended to reduce the LV/RV pressure gradient. A change in the septum becoming less convex toward the right ventricle is documented even at earlier stages of HFpEF [ 110 , 111 ]. In advanced cases, a strong signal of abnormalities in RV to pulmonary circulation coupling can be provided by accurately assessing the pressure-flow relationship during exercise through plotting mPAP versus CO. An mPAP/CO relationship > 3 mmHg/L/min represents a pulmonary hypertensive response, indicating abnormalities in pulmonary vascular reserve, generally associated with a high VE/VCO 2 slope [ 112 ]. Yet, RV to pulmonary circulation uncoupling is responsible for a delayed VO 2 on kinetics during early exercise [ 113 ].

Alternative methods simulating exercise have been proposed due to the limitations of exercise RHC mentioned above and for patients unable to exercise, i.e., saline loading (fluid challenge test), stress echocardiography, and passive leg raises (PLR). Yet, dobutamine infusion during RHC may be more practical than exercise stress but needs additional validation studies to define its utility. Saline load is more straightforward to perform and reaching a PCWP > 18 mmHg immediately after rapid infusion (7 ml/kg) is considered diagnostic of diastolic LV dysfunction, even if its sensitivity is inferior to the exercise test [ 114 , 115 ]. PLR determines an increase of venous return and thus can simulate exercise and an increase in the PCWP. Van de Bovenkamp et al. demonstrated that PCWP ≥ 19 mmHg (24% of cases) has a specificity of 100% for the diagnosis of occult-HFpEF, irrespective of diuretic use. A PCWP (PLR) < 11 mmHg has a 100% sensitivity and negative predictive value for diagnosing occult-HFpEF. According to this data, PLR might be helpful in those patients with normal PCWP at rest to unmask occult-HFpEF or rule it out to restrict the need for exercise RHC in those with intermediate values after PLR (PCWP 11–18 mmHg) [ 116 ]. However, these tests are less physiological as they reproduce exercise less well with increased heart rate, contractility, and loading conditions [ 115 ]. Regarding stress echo the correlation between E/e′ and invasive PCWP or LV End Diastolic Pressure (LVEDP) is poor [ 117 ]. More recently, the role of invasive diagnostics has been clarified by the HFA-PEFF and H2PEFF scores [ 91 , 92 ] (Fig. 2 ).

Diagnostic scores for heart failure with preserved ejection fraction

Among the invasive diagnostic tools for evaluating patients with HFpEF, endo-myocardial biopsy has been helpful in correctly characterizing myocardial structure and identifying patients with unknown amyloidosis [ 118 , 119 ]. Endomyocardial biopsy demonstrated that cardiomyocyte inflammation contributes to the development of diastolic dysfunction triggered by the accumulation of collagen and myocardial fibrosis [ 120 ]. As shown by Hahn et al. in a cohort of 108 patients with HFpEF, endomyocardial biopsy was helpful in the correct identification of myocardial fibrosis and myocyte hypertrophy, CD68+ monocyte infiltration, and even more importantly, the presence of cardiac amyloidosis, which was often unsuspected [ 121 ]. Post-mortem studies have also been performed, contributing to the understanding of the close link between coronary microvascular impairment and myocardial fibrosis [ 122 ].

10 Perspectives

Despite its limitations in predicting cardiac functional reserve and symptoms, the diagnosis of HF continues to rely on EF, partly due to historical reasons. Preserved EF holds no diagnostic value for HFpEF except for excluding HFrEF. Future non-invasive real-time measurements of chamber volumes, stroke volumes, CO, and filling pressures, coupled with innovative systolic and diastolic function indices, will significantly diminish the significance of EF in identifying HF (Fig. 3 , Table 2 ).

Diagnostic tools for heart failure with preserved ejection fraction

Moreover, HFpEF patients may encounter hemodynamic limitations in raising stroke volume adequately during exercise, yet specific cut-off points for diagnosing reduced CO reserve have not been established. Unfortunately, reliable data on LV diastolic properties, stroke volume, and CO are obtainable only invasively, ideally via conductance catheterization. While pressure-volume loops and stroke volumes can now be acquired noninvasively through 2D/3D echocardiography and CMR, these measurements require validation within larger HFpEF cohorts. Hence, integrating diverse diagnostic tools is of utmost significance for a precise diagnostic approach to HFpEF.

The relationship between HFpEF and atrial fibrillation is closely intertwined. Overlapping symptoms, indicators, echocardiographic findings, and natriuretic peptide levels exist between the two conditions, and a notable portion of patients in HFpEF registries and trials exhibit atrial fibrillation. Diagnostic thresholds for natriuretic peptides and left atrial volume in sinus rhythm versus atrial fibrillation are primarily derived from existing literature and consensus, necessitating further prospective research for validation.

Controversies persist regarding optimal non-invasive indicators of elevated LV filling pressures and PCWP. The E/e′ index has gained prominence in clinical practice, although its universal support still needs to be completed across all clinical investigations. The diagnostic utility of alternative indices such as retrograde pulmonary venous flow, estimated LV stiffness (diastolic pressure-volume quotient), and left atrial strain rate during atrial contraction in patients with sinus rhythm, as well as the L wave of mitral inflow and left atrial strain warrants additional investigation.

Modern imaging techniques yield a vast amount of digital data related to global and regional LV morphology and function throughout the cardiac cycle, alongside arterial and endothelial function and myocardial perfusion. This data can be amalgamated with comprehensive demographic information, encompassing traditional risk factors, novel biomarkers, and proteomic, metabolomic, and genomic data.

11 Clinical Implications

When all previously reported data are combined, different phenotypes of HFpEF emerge [ 123 ]. Left ventricular hypertrophy with concentric remodeling, arterial hypertension, renal disease, and advanced age are typical of the “Older” phenotype. Elevated right ventricular systolic pressure, obesity, and type II diabetes mellitus are characteristic of the “Metabolic” phenotype. Conversely, low values of NP and younger age are typical of the “Younger” phenotype. It should be noted that these phenotypes are frequently over-lapping and, therefore, a careful multiparametric evaluation should be performed to carefully evaluate the best treatment strategies for these patients, considering that treatment of HFpEF should not be consequently based only on EF but also on signs, symptoms, and comorbidities, with hypertension being the most relevant comorbidity.

Based on the aforementioned HFpEF phenotypes, treatment of comorbidities becomes imperative to reduce cardiovascular events beyond the lone prescription of SGLT2i. Hypertension needs to be treated giving preferences to ACE inhibitors, angiotensin receptor blockers, mineralocorticoid receptor agonist and beta-blockers, drugs that have been neutral for their primary outcome in trials on HFpEF but have shown a small beneficial advantage in HF hospitalization or meta-analysis. A strict control of risk factor like obesity may also prove beneficial, especially considering the high prevalence of obesity in the general population and especially in the hypertensive population, this is even more true in the light of the recent results of the use of GLP-1 receptor agonist in the STEP-HFpEF [ 124 ] and SELECT [ 125 ] trials. Based on the aforementioned bulk of evidences, a tailored treatment beyond SGLT2i should be offered to all patients with HFpEF based on their profiles and respective comorbidities [ 126 ].

12 Conclusions

HFpEF represents a multifaceted clinical syndrome characterized by many contributing elements, etiologies, and pathophysiological presentations. Subsequent research endeavors should focus on assessing and enhancing the suggested diagnostic algorithm while categorizing HFpEF individuals into discrete subgroups. Ideally, a comprehensive investigation would encompass an extensive and diverse patient cohort encountering breathlessness alongside appropriately matched control groups, subjected to the entire spectrum of procedures examined in this manuscript.

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Mancusi, C., Basile, C., Spaccarotella, C. et al. Novel Strategies in Diagnosing Heart Failure with Preserved Ejection Fraction: A Comprehensive Literature Review. High Blood Press Cardiovasc Prev (2024). https://doi.org/10.1007/s40292-024-00629-1

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Centering Indigenous knowledge in suicide prevention: a critical scoping review

• Erynne Sjoblom 1 ,
• Winta Ghidei 1 ,
• Marya Leslie 2 ,
• Ashton James 2 ,
• Reagan Bartel 2 ,
• Sandra Campbell 3 &
• Stephanie Montesanti 1 , 4  

BMC Public Health volume  22 , Article number:  2377 ( 2022 ) Cite this article

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Indigenous peoples of Canada, United States, Australia, and New Zealand experience disproportionately high rates of suicide as a result of the collective and shared trauma experienced with colonization and ongoing marginalization. Dominant, Western approaches to suicide prevention—typically involving individual-level efforts for behavioural change via mental health professional intervention—by themselves have largely failed at addressing suicide in Indigenous populations, possibly due to cultural misalignment with Indigenous paradigms. Consequently, many Indigenous communities, organizations and governments have been undertaking more cultural and community-based approaches to suicide prevention. To provide a foundation for future research and inform prevention efforts in this context, this critical scoping review summarizes how Indigenous approaches have been integrated in suicide prevention initiatives targeting Indigenous populations.

A systematic search guided by a community-based participatory research (CBPR) approach was conducted in twelve electronic bibliographic databases for academic literature and six databases for grey literature to identify relevant articles. the reference lists of articles that were selected via the search strategy were hand-searched in order to include any further articles that may have been missed. Articles were screened and assessed for eligibility. From eligible articles, data including authors, year of publication, type of publication, objectives of the study, country, target population, type of suicide prevention strategy, description of suicide prevention strategy, and main outcomes of the study were extracted. A thematic analysis approach guided by Métis knowledge and practices was also applied to synthesize and summarize the findings.

Fifty-six academic articles and 16 articles from the grey literature were examined. Four overarching and intersecting thematic areas emerged out of analysis of the academic and grey literature: (1) engaging culture and strengthening connectedness; (2) integrating Indigenous knowledge; (3) Indigenous self-determination; and (4) employing decolonial approaches.

Conclusions

Findings demonstrate how centering Indigenous knowledge and approaches within suicide prevention positively contribute to suicide-related outcomes. Initiatives built upon comprehensive community engagement processes and which incorporate Indigenous culture, knowledge, and decolonizing methods have been shown to have substantial impact on suicide-related outcomes at the individual- and community-level. Indigenous approaches to suicide prevention are diverse, drawing on local culture, knowledge, need and priorities.

Peer Review reports

Suicide is a pressing health concern that continues to disproportionately impact Indigenous populations around the globe. Indigenous peoples of Canada, United States, Australia, and New Zealand experience rates of suicide approximately two to three times higher than the general population of their respective countries [ 1 , 2 , 3 , 4 , 5 ]. At the individual-level, the primary risk factors for suicide are mental health disorders, traumatic/stressful life events, and substance abuse [ 6 , 7 , 8 ]. All of these risk factors occur at disproportionately high rates in Indigenous populations as a result of the collective and shared trauma experienced with colonization and contemporary experiences of oppression and social exclusion including dispossession and disconnection from the land, loss of language and culture, grief and loss, and racism [ 9 , 10 , 11 , 12 , 13 , 14 ].

The rate of suicide among First Nations, Métis, and Inuit peoples in Canada is at least two times that of Canada’s general population [ 1 ]. In the United States, the rate of suicide among the American Indian/Alaskan Native population is approximately 3.5 times higher than those among racial/ethnic groups with the lowest rates and about 1.7 times higher than the overall US rate [ 2 , 3 ]. In Australia, suicide rates for Indigenous people ranged from 1.4 to 2.4 times that of non-Indigenous Australians in 2020 [ 4 ]. In New Zealand, suicide among Māori from 2010 to 2012 was 1.8 times greater than among non-Māori, with particularly high rates among Māori men [ 5 ].

Nevertheless, national-level data can obscure considerable variability in suicide rates and patterns between communities and wider regions [ 1 , 4 , 15 , 16 , 17 ]. While there is evidence demonstrating the connection to broader protective factors like employment status, educational attainment, and social support networks at the individual-level [ 6 ] this paper focuses on the community-level risk and protective factors for Indigenous populations. Research has identified a number of community-level factors that have been demonstrated to create resiliency to suicide in Indigenous populations, and can explain much of the observed variability in suicide rates across different communities. These protective factors include advances towards self-determination, efforts to secure Indigenous title to traditional lands, and activities that promote and protect Indigenous culture and language [ 15 , 16 , 18 ]. Research has also demonstrated that integrating Indigenous knowledge into mental wellness promotion, prevention and intervention initiatives has been associated with positive outcomes, including in suicide rates [ 19 , 20 , 21 ]. Calls continue to grow for upholding Indigenous peoples’ right to self-determination in defining effective and culturally-grounded means to address health and wellness needs in their respective communities [ 22 , 23 ]. Moreover, a growing body of research contends that standard suicide prevention programs—primarily rooted in Western individual-level efforts for behavioural change via mental health professional intervention—are culturally misaligned with Indigenous paradigms of health, mental wellbeing, and relationality [ 24 , 25 ]. For these reasons, many Indigenous communities, organizations and governments have been moving away from initiatives designed for the general population and moving towards more cultural and community-based approaches for mental health promotion [ 26 ].

Despite these advancements in knowledge and understanding of the unique factors impacting Indigenous peoples’ risk and resilience for suicide, suicide prevention initiatives continue to fall short of meeting the needs of Indigenous peoples who are at a higher risk of adverse mental health outcomes and experience limited access to appropriate care and resources. Overall, there is a notable gap in comprehensive community-based, culturally safe suicide prevention resources for Indigenous communities. In recent years, many suicide prevention programs targeting Indigenous populations and incorporating Indigenous approaches have been developed; however, a thorough review of these initiatives has yet to be conducted. While a number of reviews of Indigenous suicide prevention initiatives have been conducted, they have focused on specific Indigenous groups (e.g., Indigenous youth, Inuit, or American Indian/ Alaska Native populations), particular programs employed in Indigenous populations (e.g. Adolescent Suicide Prevention Project), or focused on specific types of evidence (e.g. case files or evaluated programs only). To the authors’ knowledge, no reviews to-date have broadly examined suicide prevention efforts employed in Indigenous populations nor explicitly the contribution of Indigenous knowledge. A comprehensive exploration of how Indigenous approaches have been incorporated into suicide prevention efforts to-date could be instrumental in informing and supporting further development of Indigenous-driven suicide prevention. Consequently, this review explores how Indigenous knowledge and approaches have been incorporated in suicide prevention for Indigenous populations.

A critical scoping review was conducted to conceptualize, map and identify gaps in the literature and to assess if Indigenous knowledge was the guiding principle in developing these programs and interventions. Scoping reviews aim to map ‘the key concepts underpinning a research area and the main sources and types of evidence available [ 27 , 28 ]. As such they differ from systematic reviews in focusing on broader topics and a range of study designs with little emphasis on quality; nor are they designed to perform detailed assessments or synthesis of findings [ 29 ]. Our critical scoping review aligned with the processes and objectives of a scoping review as recommended by Arksey and O’Malley [ 29 ] and Levac, Colquhoun, and O’Brien [ 30 ]. Additionally, we applied a two-step process to better align with ethical standards of research involving Indigenous peoples, and to enable Indigenous knowledge to inform the evidence appraisal and interpretation: 1) Indigenous and non-Indigenous co-authors synthesized the evidence; and 2) input was sought from a reference group of Indigenous community leaders with expertise in Indigenous knowledge systems.

Community engagement

This review utilized a community-based participatory research (CBPR) approach. The need for a critical scoping review arose out of an existing project to develop a Métis suicide knowledge awareness training program through extensive community engagement sessions led by the Métis Nation of Alberta (MNA). At the start, the MNA approached the academically-situated members of the research team (SM, WG) to work together to pursue research funding and work in partnership to develop a community-driven, culturally-grounded suicide prevention program. It was determined that this scoping review would provide a thorough knowledge base for how Indigenous approaches have been integrated into suicide prevention targeting Indigenous populations and inform the development of a Métis suicide knowledge awareness intervention. Consequently, the methods, emergent themes and subthemes, analysis of outcomes, and final manuscript were all co-developed between the MNA team members and University-situated research team members.

Information sources and search strategy

A scoping review of both academic and grey literature was employed to examine relevant evidence on how Indigenous knowledge has been incorporated in suicide prevention initiatives. We felt it key to include an online grey literature search in recognition that many Indigenous communities may have implemented suicide prevention efforts that might not always be formalized in the academic literature. We first developed a list of search terms in consultation with a research librarian and used combinations of the following search terms and their synonyms: (suicid* or "self harm"); (communit* or family or families or caregiver* or gatekeeper*); (awareness or prevent* or know* or educat* or train or trained or training); (indigenous people/ or alaska native/ or american indian/ or canadian aboriginal/ or first nation/ or indigenous australian). Search strategies were designed to be suitable to the specific features of each database (Additional file  1 : Appendix A). The following databases were searched: Prospero, Wiley Cochrane Library, Ovid Embase, Ovid Medline, Ovid Global Health, Ovid PsycInfo, EBSCO CINAHL, EBSCO Socindex, ProQuest Dissertations and Theses Global, and SCOPUS. All of the databases were searched from inception to November 2021. The search strategy included both text words and controlled vocabulary (eg: MeSH, EMTREE, etc.) for the concepts “Indigenous people” and “suicide prevention” and “community/caregiver awareness.” In addition, the reference lists of articles that were selected via the search strategy were hand-searched in order to include any further articles that may have been missed.

We also systematically searched for grey literature (Indigenous texts, songs, videos, artform, reports, etc.) in the following online databases and resource hubs: University of Alberta-Native Studies Databases, National Collaborating Center for Indigenous Health, International Journal for Indigenous Health, Health Canada’s National Aboriginal Youth Suicide Prevention Strategy (NAYSPS), Center for Suicide Prevention, and the Thunderbird Partnership Foundation. Additionally, we ran a customized Google Scholar search on the terms “Suicide Prevention” AND (Indigenous OR Aborigin OR First Nation OR Inuit OR Métis OR Native) and examined the first 20 pages of the returned results.

Selection process

The articles resulting from the search were screened for relevance and subjected to a critical appraisal process by two reviewers (WG, ML). Only English language publications were considered. Relevance was established by the research team first by reviewing the title and abstracts of the identified literature against the review objectives. Specifically, articles were included if (1) the papers discussed programs and/or initiatives that aimed to prevent suicide in Indigenous populations and (2) the target population were Indigenous populations of Canada, United States, Australia and New Zealand. Canada, the United States, Australia, and New Zealand are commonly seen as natural comparators in terms of Indigenous well-being. These jurisdictions consistently rank highly on the United Nations Development Programme’s Human Development Index (HDI), yet all have minority Indigenous populations with much poorer health and social conditions than their non-Indigenous population [ 31 ], including a disproportionate burden of suicide. Moreover, Indigenous peoples in these countries share similar experiences as subjects of British colonialism, including comparable colonial histories, laws, policies, and political structures. Such similarities include processes of treaty making (except Australia), policies aimed at assimilation, paternal protectionism, dislocation from the land to make way for settlers, and loss of culture [ 32 , 33 ]. These countries have also undertaken comparable efforts towards reconciliation with Indigenous peoples in recent years [ 34 ]. Where relevance could not be determined from the article title or abstract alone, a review of the full text was conducted. There was no limitation based on study design and source type (academic and grey literature were included). Any literature that did not fit into the above criteria, or that addressed other mental health prevention programs (other than suicide) was excluded. Grey literature articles were screened first on the basis of relevancy of their title to the research objectives of this scoping review, with further review of the full document led to the exclusion of any additional irrelevant grey literature articles.

Article and data management

The following information was extracted from academic literature into a standard extraction form: authors, year of publication, type of publication, objectives of the study, country, target population, type of suicide prevention strategy, description of suicide prevention strategy, and main outcomes of the study. We also took detailed notes on whether suicide knowledge was defined from the perspective of the local Indigenous communities and the level of involvement of local Indigenous communities, including in project development and paper co-authorship. Findings from grey literature were summarized by the research team with consideration of the following questions: What does suicide and suicide prevention mean from an Indigenous perspective? How has Indigenous knowledge been incorporated in suicide prevention?

Thematic analysis

We adopted a thematic analysis approach guided by Métis knowledge and practices to synthesizing and summarizing the findings. Our research team is composed of Indigenous (Métis) and non-Indigenous members. First, two researchers (WG and ML) worked together to read all the articles, annotate them, and identify broad thematic categories. Next, additional researchers (SM, AJ, and RB) discussed each theme and subtheme until they reached consensus in a team meeting. After this team meeting, WG and ML compared and contrasted the various findings to identify recurrent and unique themes. Findings from both academic and grey sources were merged and appropriate themes were applied. All team members reviewed themes, discussed disagreements between them and reached a consensus. Each term, phrase and/or meaning used to contract the categories and themes were confirmed with Métis knowledge holders. The academic literature and grey literature articles were then thematically analyzed by WG and ML simultaneously who used NVivo™ to apply codes to the articles on a consensus basis. This also involved examination of articles to document similarities for the purpose of identifying common themes across suicide prevention, while also detailing their distinctions and differences.

The review process resulted in the collection of 1,352 academic papers and grey literature documents, with 391 articles ultimately considered after duplicates were removed. Of these, 961 were excluded as, despite appearing in the search, upon interrogation of the article title and abstract, it was determined that the content of the article fell outside of the scope of the review objectives. 197 articles necessitated full text review as inclusion could not be determined from the title and abstract alone. Of these, 149 further papers were excluded because they did not align with our review objectives nor did not meet inclusion criteria. 8 articles were identified via a hand-search of the reference lists of relevant reviews. Sixteen articles from the grey literature were ultimately included as well. Thus, our final search process resulted in 72 articles—56 of which were academic papers and 16 grey literature documents—that were included for extraction (Fig.  1 ). The characteristics of the articles along with the overarching themes identified through thematic analysis are summarized in the following section.

Flow chart describing included and excluded articles

Article characteristics

This section presents an overview of the suicide prevention strategies targeting Indigenous populations examined in this review, namely describing the Indigenous communities involved, target demographics, and the types of strategies employed. Articles from the academic literature were primarily peer-reviewed outcomes of primary research activities involving the above types of suicide prevention strategies along with several different types of academic reviews. Articles obtained from the grey literature were diverse and included for suicide prevention guides, strategies, toolkits, outcomes of community engagement, and more typically authored by Indigenous communities and organizations.

Indigenous population and sample

Thirteen articles focused on Indigenous Australians; thirty-two on Indigenous peoples living in the United States (US) (specifically fourteen with Alaska Natives, four Alaska Natives and/or American Indians; eleven American Indians/Native Americans, and three Native Hawaiians); nine on Indigenous peoples in Canada; one on Indigenous peoples in North America; and one on Indigenous peoples in Canada, the US, Australia and New Zealand. No articles involved the Māori of New Zealand. The sample populations reported by studies included Indigenous youth, general community members, or specific subpopulations (such as Indigenous prisoners, students, or males). Notably, no papers incorporated considerations for lesbian, gay, bisexual, transgender, queer, and two-spirited (LGBTQ2 +) or gender diverse Indigenous persons.

Types of articles

The main prevention strategies employed in articles examined in this scoping review comprised: culture as treatment; community prevention activities; gatekeeper training; and education/awareness initiatives. These articles presented peer-reviewed outcomes of primary research activities involving the above types of suicide prevention strategies (39 articles). Methods employed in the primary research articles included pre/post studies (8); randomized (4) and non-randomized (4) control trials; retrospective study design (1); qualitative methods including focus groups, workshops, interviews, and more (15); and mixed-methods approaches (7). The remaining articles were papers describing intervention development and implementation (11 articles) and different types of academic reviews (6 articles). See Additional file 2 : Appendix B for a table detailing key information extracted from academic literature. Articles obtained from the grey literature concerned: guides, strategies, toolkits for suicide prevention in Indigenous populations, outcomes of community engagement on suicide prevention; curriculum documents; brochures, magazine or news articles describing suicide prevention projects; and literature reviews (see Additional file 3 : Appendix C).

Culture as treatment specifically involved engaging Indigenous culture to mitigate suicide risk or “treating” suicidality among individuals, usually on a one-on-one basis. Community prevention initiatives typically involved empowerment programs, multi-level approaches, broader resiliency strategies targeting Indigenous groups and communities at high risk of suicide, or community-based participatory research to inform program development. Gatekeeper training strategies featured prominently. Gatekeeper training involved teaching specific groups of people in the community how to identify and support individuals at high risk of suicide. Education/awareness initiatives involved activities that explicitly aimed to improve suicide knowledge, attitudes, and/or awareness to develop knowledge/skills that are known to be protective against suicide via, for example, school-based programs for youth, multi-media education sessions to interested community members, or culturally-tailored life skills training for youth. 25 articles involved community prevention, 13 concerned educational/awareness initiatives, 7 featured gatekeeper trainings, 3 involved culture as treatment, 1 featured both community prevention and gatekeeper training components, and 1 involved community prevention, gatekeeper, and education/awareness approaches. The remaining 6 were scoping or systematic reviews of Indigenous suicide prevention projects/programs. Community prevention and education/awareness initiatives involved primary prevention that address upstream root causes and aim to prevent suicide ideation or attempts from even happening by reducing risk and promoting protective factors. Gatekeeper training and culture as treatment involved secondary prevention which endeavour to provide support to persons at immediate risk for suicide/self-harm. No articles involved tertiary prevention efforts which might involve postvention to reduce the risk of further suicides or clusters. Levels of suicide prevention and corresponding articles are detailed in Fig.  2 .

Articles by level of suicide prevention [ 35 ]

The findings are presented through four overarching and intertwining thematic areas that emerged out of analysis of the academic and grey literature. These thematic areas focus on (1) engaging culture and strengthening connectedness; (2) integrating Indigenous knowledge; (3) Indigenous self-determination; and (4) employing decolonial approaches. We also highlight components of strategies that exemplify each theme. Table 1 summarizes themes, subthemes and corresponding articles.

Engaging culture and strengthening connectedness

Engaging culture and strengthening connectedness to prevent suicide emerged as an important theme across the articles examined in this critical scoping review. All articles highlighted connection to culture as a crucial component to meaningful and effective suicide prevention in Indigenous populations. Within this theme, we focused on analyzing the ways in which culture and efforts to strengthen connectedness are integrated into suicide prevention content and the resulting impacts.

Generally, engaging culture took on several different forms. First, some initiatives were built around the notion of “culture as intervention” or “culture as treatment,” where engaging Indigenous culture was seen as an important means for mitigating suicide risk or “treating” suicidality among individuals. Culture as intervention or treatment could be the main strategy, or a component of a broader strategy, and took on several forms including resilience retreats/culture camps, cultural teachings/values, ceremony, sharing circles, storytelling, creative arts, narrative approaches to psychotherapy, art therapy, other locally-relevant healing/coping strategies and more [ 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ].

In these initiatives, individual-level effects on suicide risk via cultural connections included increases in the number of protective behaviours which authors argue were fostered by culture-specific beliefs and experiences that make life enjoyable, worthwhile, and meaningful [ 38 ]. Individual-level impacts among participants included reductions in distress, bolstering of protective factors, and reduction in suicide/self-harm behaviours [ 38 , 40 , 44 ]. Activities that involved local Indigenous culture as suicide prevention were observed to have a measurable impact on suicide-related outcomes such as increased positive mood, feelings of belongingness, and perceived coping of participants, even in programs where the specific topic of suicide was not breached [ 36 , 37 ].

Second, engaging cultural connections arose as an important means to create new or adapt existing suicide prevention strategies to increase effectiveness and appropriateness in Indigenous contexts. Initiatives often took the form of gatekeeper trainings or educational/awareness initiatives and were typically created or adapted from the ground up either in partnership with or, less frequently, under the leadership of the respective Indigenous community [ 48 , 49 , 50 , 51 ]. Cultural inclusion in the design of programs or adaptation involved a multitude of factors including: acknowledgement of the impacts of colonization and ongoing marginalization on suicide in Indigenous contexts, integration of Indigenous pedagogies (i.e. team-teaching, land-based learning, experiential/hands-on activities, etc.), emphasis on the holistic aspects of wellbeing, focus on strengths-based approaches, incorporating art, and inclusion of Indigenous languages and cultural values [ 36 , 45 , 46 , 47 , 48 , 51 , 52 , 53 , 54 , 55 ].

Authors underlined the positive impacts of integrating local Indigenous culture at both the individual- and community-level. For instance, individual-level impacts for gatekeeper trainings included improved attitudes toward suicide, increases in participants’ knowledge and confidence in how to identify individuals at-risk of suicide, increases in intended and actual assisting behaviours, and significant improvements in understanding the links between cultural strengths, social and emotional wellbeing and suicide prevention [ 47 , 48 , 51 , 52 ]. Moreover, participants in culturally-grounded suicide education and awareness initiatives were shown to have less suicidal ideation and “negative thinking”, expressed fewer feelings of hopelessness, could come to terms with the ‘cycle of grief,’ demonstrated reduced stigma towards suicide and increased willingness to seek help, and had an increase in psychological service utilization [ 49 , 56 , 57 , 58 ]. Participants in community suicide prevention programs which integrated culture had significant increases in positive mood, feelings of belongingness, perceived coping, reasons for living, and overall resiliency [ 36 , 38 , 41 ].

Strengthening connectedness was consistently identified by articles as an important element for effective suicide prevention in Indigenous populations. We included it along with the theme of engaging culture as it was typically discussed as a key Indigenous cultural value which contrasted conventional Western approaches to suicide prevention. While there is much diversity in Indigenous ways of being and knowing, the ontologies of interconnectedness and relationality are shared across many of the Indigenous populations involved in articles reviewed. Strengthening connectedness comprised emphasis on encouraging intergenerational relationships, particularly between youth and Elders, strengthening connectedness within families and whole communities, and bolstering cultural continuity.

Fostering relationships between youth and Elders was a frequent community-identified means of prevention to support protective factors and promote healing among youth via opportunities to learn cultural teachings, language, and connect with the land and spirit with Elders who are the holders of a community’s traditional knowledge. Three strategies featured approaches that brought together youth and Elders as part of suicide prevention, which were noted to have implications for protective factors against suicide among youth such as strengthening youth reasons for living and combating “discontinuity” [ 38 , 60 , 61 ]. Furthermore, a participatory action research project that sought to explore community-identified risk factors as well as strategies to strengthen protective factors found connection between youth and Elders to be an important community-level strategy to suicide prevention [ 62 ].

This importance of bringing together youth and Elders was also echoed across the grey literature, typically as outcomes of community engagement on suicide prevention. Reports emphasized how Indigenous culture, knowledge, and language—which impart protection against suicide—are transferred from Elders to youth and suicide prevention thus needs to foster these relationships [ 63 , 64 , 65 , 66 ]. This sentiment is embodied in a quote from an Elder from an Australian Indigenous community experiencing high rates of youth suicide and self-harm: “The only way to stop suicide is to fulfill our cultural obligation to teach our young ….strength of character through strength of culture” [ 64 ]. Other suicide prevention initiatives did not necessarily bring together youth and Elders as an intervention component, but still created opportunities for connecting them as part of community engagement processes [ 44 , 59 , 66 , 67 , 68 , 69 , 70 , 79 ].

Notably, academic and grey literature articles also spoke to the importance of strengthening connectedness within families and across community as part of suicide prevention [ 62 , 69 , 71 , 72 , 73 ]. For families, this could include restoring and strengthening connections within and between families through shared activities (especially cultural or spiritual activities); offering life skills programs; and providing access to education and/or training [ 62 , 71 ]. For communities, fostering connections might involve a focus on youth (i.e., drop-in centres, camps, connect to Elders, health promotion and education sessions, parenting programs, restore sporting competitions); restoring and strengthening a sense of community through shared activities (i.e., community events, fun days, competitions, projects); upholding self-determination; men’s and women’s groups; and providing access to employment, education, housing and transport [ 62 , 72 ].

Several articles noted the importance of efforts to bolster cultural continuity as part of suicide prevention. Authors stressed how strengthening “cultural continuity,” or the degree to which a community participates in actions symbolic of their sense of community as a cultural group, has positive implications for mental wellness, resilience, and thus suicide in Indigenous contexts [ 65 , 71 , 74 , 75 ]. Many cite the research of Chandler and Lalonde [ 15 , 16 ] to underline that a community’s effort to preserve the continuity of their collective culture can impact continuity at the individual-level and act as a hedge against suicide by facilitating individuals’ endurance through life’s routine hardships and build a connection to a sense of self and identity.

Despite the expressed importance of including cultural continuity in suicide prevention, no initiatives involved explicit efforts to support continuity of collective culture at the community-level to impact suicide. When culture was integrated into suicide prevention, it was primarily done so to impact the wellbeing, knowledge and/or behaviours of individuals, not the community as a whole. This was also reflected in the outcome measures captured in program evaluations.

A final subtheme around the definition of cultural intervention emerged from the literature reviewed in this scoping study. Many articles made the distinction between cultural intervention and culturally appropriate or culturally safe intervention. In the former, Indigenous culture is both a central focus of the intervention activities and underlies the theory guiding the intervention. In this sense, a cultural intervention is more likely to be transformative; underpinned by Indigenous ontologies, epistemologies, and/or worldviews; incorporate Indigenous notions of suicide; and be rooted in community defined and prioritized health issues [ 38 , 39 , 68 , 69 , 73 ].

Culturally-appropriate, -sensitive, -tailored, or -safe interventions, on the other hand, may incorporate Indigenous cultural activities, teachings, language and more but can still be dominated by and reproduce conventional Western/colonial understandings of mental wellness and perpetuate colonial power dynamics [ 38 , 39 , 55 , 69 , 73 , 76 , 77 , 78 ]. As one author notes, the focus on culture by outsiders in health intervention has “too often been a shallow or surface translation describing more macro-level, formulaic, and ahistorical aspects of [Indigenous] life.” [ 53 ]. Cultural adaptations of conventional suicide prevention strategies may be more susceptible to reliance on the underlying Western/colonial assumptions of the original intervention and typically involve modifying “non-active” treatment components of the intervention for cultural acceptability such as language or style of the intervention, who delivers it, or the treatment setting [ 50 ]. Many adaptations also place importance on finding a balance between meeting community/cultural needs and preserving fidelity/standardization [ 54 , 56 , 71 , 80 ].

Integrating Indigenous knowledge

Integrating Indigenous knowledge into suicide prevention arose as a prominent theme across articles included in this scoping review. In this section, we specifically focus on how Indigenous knowledge impacts the conceptualizing of the issue of suicide and subsequently shapes how programs are designed and implemented. The majority of articles attempted to define the issue of suicide from an Indigenous perspective as a foundational step to developing an appropriately community-driven initiative. This was achieved through two methods: via author-driven definitions or via definitions acquired through community engagement processes. In cases where definitions were proposed by authors, suicide was commonly defined in connection to assumed Indigenous notions of wellness in general. For example, one study’s authors characterized suicide in alignment with Indigenous perspectives which “[focus] more on understanding and addressing what is going on around the individual than addressing what is going on inside” [ 76 ]. Focusing on what is going on around the individual meant consideration of the “complex socio-cultural, political, biological and psychological phenomenon that needs to be understood in the context of colonization, loss of land and culture, transgenerational trauma, grief and loss, and racism and discrimination” [ 46 ].

Some strategies informed by this notion employed multi-level approaches (community-wide events, policy efforts, educational programs for youth, and traditional ceremonies) that involved multiple sectors of the community simultaneously (individuals, families, wider community) [ 38 , 69 , 73 , 76 , 90 ]. Others took aim at intervening on one or more of these broader determinants like, for example, seeking to support knowledge transfer via intergenerational relationships or just generally integrating Indigenous culture into curriculum content [ 60 ]. Other initiatives incorporated locally-relevant content, information about Indigenous culture or colonization and ongoing marginalization and how they contribute to the issue of suicide in Indigenous contexts [ 46 , 49 , 81 ].

On the other hand, articles that sought community-based understandings of suicide via engagement processes tended to emphasize a focus on strengths and resilience in opposition to the typical focus on deficits and problems [ 45 , 53 , 54 , 55 , 60 , 67 , 69 , 73 , 76 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 ]. This is illustrated in a statement from an Elder who co-led the development of a youth resiliency project and co-authored the resulting paper: “Why do we talk about suicide all the time!? Let’s talk about love!” [ 45 ]. Thus, strategies informed from Indigenous notions of suicide intentionally shifted from a focus on deficit—which is more typical of conventional Western suicide prevention—to a focus on life promotion with attention to existing community strengths and assets, while upholding community control and sovereignty and supporting local empowerment [ 44 , 68 , 76 , 90 , 91 , 93 ]. This connects with the subsequent section in which we discuss the theme of Indigenous self-determination in suicide prevention.

Indigenous self-determination

Self-determination in suicide prevention was frequently identified as an essential requirement for success. The majority of articles employed some means to ensure some level of self-determination was achieved via community engagement in the design and/or implementation of suicide prevention. This was commonly achieved by employing community-based participatory research (CBPR) or participatory action research approaches. CBPR was utilized “to address power differentials through shared learning ….[it] is a move toward reconciliation, reciprocity, and production of culturally relevant prevention measures” [ 68 ]. Community engagement was seen by authors as a key requirement for success, as it increases community relevance, appropriateness, and in particular, ownership of suicide prevention [ 38 , 39 , 45 , 57 , 68 , 76 , 82 , 93 , 97 , 99 , 100 ].

The emergent subtheme of ownership referred not to the legal sense of the word (i.e., the right to possess and control the initiative) [ 100 ] but more to the community stepping up to take on responsibility in executing an initiative while being invested in seeing out its success [ 45 , 57 , 65 , 83 , 97 , 99 ]. In this sense, community ownership in a strategy has implications for acceptability, uptake, participation, and dedication to investing necessary resources. Another reason why community ownership was expressed as crucial to suicide prevention success is because it is correlated with longevity and sustainability [ 45 , 57 , 83 ].

Indigenous authorship also emerged as a notable subtheme of Indigenous self-determination in suicide prevention. Many of the articles reviewed here highlighted that they were co-authored by members of the specific target Indigenous communities or members of broader Indigenous communities [ 36 , 39 , 41 , 43 , 44 , 45 , 46 , 47 , 50 , 51 , 53 , 56 , 60 , 67 , 68 , 69 , 80 , 84 , 94 , 97 ]. Indigenous authorship was important to ensure materials represent content as intended by community stakeholders, particularly when it comes to native language expertise [ 60 ].

Employing decolonial approaches

Lastly, employing decolonial approaches in suicide prevention creation and implementation was a prominent theme in the literature. Decoloniality—or the creation of “locally-governed, community-based, and culturally-responsive systems of care” [ 55 ]—has been touched upon in many of the themes already discussed above (i.e., incorporating Indigenous knowledge and culture, upholding self-determination, community-engaged approaches). In this section, we hence focus on other attributes of decolonial approaches highlighted in the literature, namely avoidance of pan-Indigenous approaches, integrating contextual considerations, and more generally, approaches that might diverge from features of conventional Western suicide prevention.

Use of pan-Indigenous approaches was cautioned in the literature and authors advised against application of Indigenous-driven suicide prevention in contexts that they were not designed for [ 56 , 67 , 71 , 90 ]. This is because pan-Indigenous strategies may not be reflective of diverse cultural practices, values, sociohistorical context, and geographic considerations unique to each group. Authors stress that programs need to be adaptable to the local community context. This is especially pertinent in the issue of suicide, which can vary significantly from community to community [ 56 , 68 ].

In line with this, integrating contextual considerations into suicide prevention was also expressed as an important decolonial component. This subtheme was most prominent in recommendations for suicide prevention in Indigenous populations outlined in the grey literature. Contextual considerations included gaining the knowledge of a community’s unique risk and protective factors, incorporating local examples where possible, respect for and adherence to local protocol, involvement of local experts/Elders, developing culture-centered understanding of suicide, assessing community readiness, building and maintaining relationships, contemplating the impact of recent incidents of suicide, considering existing level of trauma and unresolved grief, and incorporating healing components [ 48 , 55 , 68 , 76 , 93 , 98 ].

Other decolonial approaches detailed in the literature specifically took aim at breaking down some of the features common in conventional, Western programs that tend to persist in Indigenous programs (especially cultural adaptions) despite communities finding them unhelpful. This includes allowing for flexibility, especially in contrast to rigid, standardized procedures employed by some interventions like, for example, in Applied Suicide Intervention Skills Training (ASIST). Flexibility could include encouraging use of Indigenous language, carrying out sessions in outdoor settings, allowing for adjusting of required time commitment, creating space for ceremony/spirituality, and more [ 54 , 59 , 68 , 79 , 82 , 92 ].

Articles also discussed avoidance of clinical language or jargon which can create barriers to understanding content. Finally, articles discussed efforts to break down power imbalances between Western and Indigenous approaches by, for example, focusing on local empowerment and capacity by training Indigenous facilitators, involving locally-recognized experts/leaders/healers, and employing Indigenous ways of learning versus a focus on employing clinical experts or utilizing the typical didactic educational models [ 44 , 48 , 54 , 79 , 91 , 98 ]. According to authors, breaking down power imbalances could also involve creating a practice of reflexivity as part of the strategy, where researchers and developers actively reflect on their relationships, position, and privilege and how they are fulfilling their obligations to community [ 45 , 54 , 82 , 91 , 97 ].

This scoping review set out to identify and describe what is known about the types of Indigenous approaches to suicide prevention that are employed with Indigenous populations and their implications for program outcomes. All articles, from both the academic and grey literature, were from Canada, the United States, or Australia. Notably, no suicide prevention initiatives from New Zealand were identified in our search strategy. We hypothesize that this may be because a higher rate of suicide among Māori in comparison to non-Māori is a relatively newer phenomenon and no public-facing reports on prevention strategies have been published yet [ 101 ]. There was also a notable absence of inclusion of considerations for Indigenous sexual minorities and gender diverse persons in suicide prevention. While the suicide rates among these groups is not well-known, two-spirited, queer, gay, lesbian, bisexual, or transgendered Indigenous persons experience suicide-related risk factors at a much higher rate than cis-gendered, heterosexual Indigenous persons [ 102 ]. Indigenous sexual minorities and gender diverse persons’ experiences around suicide, risk and protective factors may also be unique—including compounded effects of discrimination, arguably necessitating special consideration in suicide prevention [ 103 ].

Another noteworthy gap was the absence of articles concerning Indigenous approaches to tertiary suicide prevention, namely suicide and crisis response and postvention. Conventional crisis response and acquiring care via the medical system for a suicide attempt or self-harm may be present problems for Indigenous peoples as these systems may be culturally unsafe and possibly less helpful than they could be. In order to respond to a lack of accessible and culturally safe crisis and suicide response services, many First Nations in Canada are establishing their own mobile crisis response teams (e.g., Manitoba Keewatinowi Okimakanak, n.d.; Southern Chiefs Organization, 2022; Thunderbird Partnership Foundation, 2018 [ 104 , 105 , 106 ]). The activities of these teams commonly have culturally inclusive elements, but still follow mostly Western crisis response models. We are unaware of any Indigenous approaches to suicide postvention; however, given the issues many Indigenous communities face following the suicide of a fellow community member including trauma, grief and loss, and possibilities of suicide clusters [ 107 ], further exploration is warranted.

The grey literature articles included toolkits, guides, information resources, and strategies to support Indigenous communities and/or organizations in developing and implementing suicide prevention programs and increasing suicide knowledge and awareness. Both academic and grey literature articles emphasized the role of culture, community connectedness and Indigenous knowledge in the prevention of suicide. Whereas the grey literature articles provided practical “how to” resources, information and guidance for delivering suicide prevention programs, the academic literature provided knowledge of “what works” by reviewing the outcomes of different suicide prevention strategies and interventions in Indigenous communities, including effective approaches to community engagement, and identifying key components of culturally-appropriate, -sensitive, -tailored, or -safe interventions.

Outcomes of this critical scoping review align with much of the work being done within the context of the broader field of Indigenous mental wellness promotion and Indigenous health research in general, which is increasingly looking to approaches that are decolonizing; founded on community engagement and self-determination; and inclusive of Indigenous culture, language and knowledge [ 26 , 108 , 109 ]. Moreover, in Indigenous mental wellness promotion, there is also an increasing focus on intervening beyond the individual to the family- and community-level, with an emphasis on fostering strength and resiliency [ 110 , 111 ]. Family and community are important resources for developing a sense of belonging, connectedness, meaning, and identity, all of which are well-established protective factors for overall mental wellness and suicide in Indigenous populations [ 112 ]. It is within the family and the community where Indigenous culture, knowledge and language is transmitted, positive cultural identity forms, and where one can seek out support in a crisis [ 112 ]. However, in many Indigenous contexts, family and community environments have been severely damaged with colonization [ 13 , 113 ]. Hence why community engagement outcomes consistently point to a need to move beyond the individual to support family and community strengths [ 53 ]. This need was echoed in articles examined in this review; however, we found that few suicide prevention initiatives employed broader family and community approaches.

Many of the suicide prevention programs identified as “community prevention” still primarily focused on protective and risk factors among individual participants and not on broader familial and community elements. As noted by Cox et al., [ 62 ] family-level intervention activities could involve a wide variety of initiatives—but especially cultural or spiritual activities—to restore and strengthen connections within and between families. Community-level suicide prevention activities might focus on bolstering the fabric of community by creating places and reasons to gather, unite, and build connection. This could be achieved through a variety of community-driven activities, for example via sports, competitions, ceremony, celebrations, gardening, learning programs, traditional land use, medicine picking, community groups, advocacy, and self-determination efforts [ 62 ].

This gap was also observed within program evaluations examined for this review, the majority of which did not incorporate any type of community-level outcome measure. The rare few that did attempt to measure, for example, community connectedness via social network characteristics [ 93 ], changes in community readiness for suicide prevention [ 39 ], or community-level changes in suicide and self-harm behaviours [ 59 ]. No evaluations included family-level outcome measures. Overall, we found that efforts to include family- and community-level initiatives within suicide prevention and evaluation did not adequately meet the need or sufficiently answer the consistent calls for such considerations from Indigenous communities [ 53 , 83 , 85 ]. Future suicide prevention development and implementation must do more to address this need.

In this review, we examined the ways in which Indigenous approaches have been incorporated into suicide prevention targeting Indigenous populations and the resulting impacts. Incorporation of Indigenous culture and knowledge as well as decolonizing efforts into suicide prevention was consistently shown to have positive implications for suicide-related outcomes. The meaningful inclusion of these components into suicide prevention, however, is dependent on the extent to which community self-determination is respected and upheld. From the articles reviewed here, which primarily involved partnerships between Western institutions and Indigenous communities, self-determination was best upheld where community engagement efforts were employed from before the development of a prevention program began all the way through implementation and evaluation to the finish. These engagement processes—especially those utilizing community-based participatory research (CBPR) approaches—also had a particular focus on restructuring the relationships between power, knowledge production, and public health policy and practice [ 24 , 55 ]. Suicide prevention strategies that employed such community-engaged approaches were transformative and privileged Indigenous knowledge, culture, language, and locally-driven strategies that were decolonizing in nature. Decades have come to pass with no alleviation of suicide rates within Indigenous populations in Canada, the United States, Australia, and New Zealand. Dominant Western approaches to suicide prevention by themselves have largely failed at addressing suicide in Indigenous populations [ 114 ]. Consequently, future suicide prevention development and implementation must endeavor to privilege self-determined Indigenous approaches that are developed via comprehensive community engagement processes. While our review examined protective factors for suicide prevention within Indigenous populations in Canada, the United States, Australia, and New Zealand, higher suicide rates among Indigenous peoples compared to non-Indigenous populations have also been reported in Latin American countries including Brazil, Peru, Colombia, and Chile [ 115 ]. However, there is limited research evidence on Indigenous suicide in Latin American countries. A possible explanation for this lack of research could be that suicide among Indigenous peoples in those countries is significantly underreported.

Many of the suicide prevention efforts incorporated an evaluation component to measure impacts on suicide-related outcomes and were able to demonstrate some level of evidence for effectiveness. However, few evaluations were scientifically and methodologically rigorous [ 83 , 116 , 117 ]. In a systematic review of evaluations of suicide prevention targeting Indigenous populations and critique of their methodological quality, authors point out that evaluations were vulnerable to bias; heavily focused on proximal outcomes versus intermediate or distal outcomes; measured proxy outcomes like hopelessness and depression while ignoring suicide and self-harm behaviours entirely; and failed to consider cost [ 117 ]. In addition, it has been noted that there are considerable challenges related to suicide surveillance, including that national health data systems often lack Indigenous identifiers, do not capture data from some regions, and do not routinely engage Indigenous communities in data governance [ 118 ]. While we recognize that evaluation methodologies are heavily grounded in Western ways of knowing and constructs of “value” [ 119 ], evaluation outcomes are often crucial for justifying to funders (most often Western/colonial institutions) for continued resources for programming [ 117 ]. Moreover, evaluation can provide valuable insight into program goals, activities, strengths, areas for improvement, and cost-effectiveness [ 120 , 121 ] and do not have to rely purely on Western epistemologies.

Practices to uphold Indigenous self-determination in suicide prevention (i.e. community engaged, participatory approaches) should extend to the evaluation phase in order to ensure outcomes measured are also meaningful to community and reflect Indigenous worldviews and ways of knowing [ 119 , 121 ]. Evaluation processes that are culturally inclusive and community-driven have a number of crucial benefits. For instance, community-engaged suicide prevention evaluation ensures the needs and knowledge of the community remain central and community ownership, control, access and possession of evaluation outcomes and surveillance data are safeguarded. This includes how outcomes and surveillance data are shared, mitigating potential for harm that Indigenous communities have faced with non-inclusive research and surveillance [ 119 , 122 ]. Unfortunately, most of the suicide prevention initiatives examined for this scoping review did not extend community engagement processes to the evaluation phase and thus failed to develop measures and evaluation tools based in Indigenous knowledge, focused on community-level outcome measures, or inclusive of Indigenous culture. Future work involving suicide prevention evaluation should ensure processes of community engagement are incorporated.

This critical scoping review is limited in two ways. Firstly, scoping studies provide a narrative or descriptive account of research and do not seek to appraise their quality or effectiveness [ 29 ]. Thus, in the context of this paper, which seeks to describe how Indigenous approaches have been integrated into suicide prevention, we do not evaluate individual program content, approaches to establishing programs, their methods, or their impacts. Instead, in employing a critical lens to this review, we sought to examine underlying structures of power and meaning that organize relationships, institutions, and knowledge production in suicide prevention, how Indigenous peoples are challenging these structures, and the resultant impacts on suicide outcomes [ 86 ] Secondly, this study is limited to the review of public-facing, written Indigenous suicide prevention only. Further exploration into informal, oral, and/or non-publicly facing initiatives would be required to create a more comprehensive picture of how Indigenous peoples are intervening on suicide in their communities.

The urgent need to reduce the disproportionately high rates of suicide in Indigenous populations of Australia, New Zealand, Canada and the United States has been widely acknowledged. Conventional Western approaches to suicide prevention by themselves have largely failed at addressing this disproportionate burden. On the other hand, initiatives that are built upon comprehensive community engagement processes and which incorporate Indigenous culture, knowledge, and decolonizing methods have been shown to have substantial impact on suicide-related outcomes in the communities in which they are employed. Indigenous approaches to suicide prevention are diverse, drawing on local culture, knowledge, need and priorities. Nevertheless, substantial barriers persist to implementing such strategies. Existing funding and health service provision systems operate from a Western, biomedical model and may be unable or unwilling to provide the resources required to invest in Indigenous approaches, highlighting the importance of evaluation to establish efficacy. On a practical level, the findings from this critical scoping review may be useful to Indigenous communities and their partners to inform their own endeavours to develop and implement suicide prevention. We hope that the outcomes presented here encourage funders, health promotion experts, and government decision-makers to support community-driven, Indigenous-approaches to suicide prevention.

Availability of data and materials

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

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Acknowledgements

The authors wish to thank the Métis Nation of Alberta (MNA) for their guidance in determining the objectives and questions for the review, interpretation and feedback on the themes, and supporting with identifying a reference group of Indigenous community leaders with expertise in Indigenous knowledge systems.

This work was funded by the Alberta Addiction and Mental Health Strategic Clinical Network (SCN)’s Valuing Mental Health Innovation and Integration Research grant.

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Contributions

Erynne Sjoblom refined and organized the emergent themes and was the lead in writing the manuscript. Winta Ghidei conducted the literature search, paper selection and annotation, and data extraction. Ghidei also assisted in identifying broad thematic categories and refining subthemes. Marya Leslie assisted with paper annotation and in refining thematic categories as well as offering a perspective from her experience in Indigenous community wellness program management. Ashton James led in identifying and refining thematic categories via a consensus-building process and also contributed to the review and editing of the manuscript. Reagan Bartel aided in identifying and refining thematic categories and reviewed final themes. She also provided leadership and support to the MNA team involved in the project. Stephanie Montesanti is the senior researcher and academic lead of the project. She led the funding acquisition for the study, oversaw the whole scoping review process, contributed to identifying and refining themes, and review and editing of the manuscript. Sandra Campbell designed and conducted the search strategy for the academic literature. The author(s) read and approved the final manuscript.

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Supplementary Information

Additional file 1: appendix a..

Academic Literature Search Strategy and Terms by Database.

Additional file 2: Appendix B.

Academic literature data extraction table [ 123 , 124 ].

Additional file 3:

Appendix C. Summary of grey literature articles [ 125 , 126 , 127 , 128 , 129 , 130 ].

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Sjoblom, E., Ghidei, W., Leslie, M. et al. Centering Indigenous knowledge in suicide prevention: a critical scoping review. BMC Public Health 22 , 2377 (2022). https://doi.org/10.1186/s12889-022-14580-0

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• Indigenous populations
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The efficacy and safety of cannabidiol (CBD) in pediatric patients with Dravet Syndrome: a narrative review of clinical trials

• Nicholas Aderinto 1 , 8 ,
• Gbolahan Olatunji 2 ,
• Emmanuel Kokori 2 ,
• Yusuf Ismaila Ajayi 3 ,
• Olumide Akinmoju 4 ,
• Abiola Samuel Ayedun 5 ,
• Oluwapelumi Ikeoluwa Ayoola 6 &
• Noah Oluwaseun Aderinto 7  

European Journal of Medical Research volume  29 , Article number:  182 ( 2024 ) Cite this article

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Dravet Syndrome (DS) is a rare and severe form of childhood epilepsy that is often refractory to conventional antiepileptic drugs. Emerging evidence suggests that Cannabidiol (CBD) offer therapeutic benefits for DS. This review aims to evaluate the efficacy and safety of CBD in pediatric patients with DS based on data from ten clinical trials.

A review was conducted to identify clinical trials assessing the efficacy and safety of CBD in pediatric patients diagnosed with DS. PubMed, MEDLINE, Scopus, Web of Science, and relevant grey literature were systematically searched for relevant articles up to October 2023, and clinical trials within the last 10 years were included. The search strategy incorporated controlled vocabulary terms and keywords related to "Cannabidiol," "Dravet Syndrome," and "pediatric patients."

The analysis revealed promising efficacy outcomes. Notably, CBD demonstrated substantial reductions in seizure frequency, with some patients achieving seizure freedom. The findings emphasised the consistency of CBD's efficacy across different patient subgroups. The safety profile of CBD was generally acceptable, with adverse events often being manageable.

This review consolidates evidence from multiple clinical trials, affirming the potential of CBD as a promising treatment option for pediatric patients with DS. While further research is needed to address existing knowledge gaps, CBD's efficacy and acceptable safety profile make it a valuable addition to the therapeutic tools for DS.

Introduction

Dravet Syndrome (DS), also known as Severe Myoclonic Epilepsy of Infancy (SMEI), is a rare and debilitating form of epilepsy characterised by recurrent febrile and afebrile seizures, ataxia, cognitive impairment, and developmental delays [ 1 , 2 ]. Onset typically occurs in early infancy and imposes a substantial burden on the quality of life for affected individuals [ 3 ]. It is primarily caused by mutations in the SCN1A gene, leading to neuronal hyperexcitability and intractable seizures [ 4 ]. Additionally, patients with DS are at risk of sudden unexplained death, making early and effective seizure control crucial [ 5 ].

The genetic basis of DS is largely attributed to heterozygous mutations in the NaV1.1 alpha subunit of voltage-gated sodium ion channels encoded by the SCN1A gene [ 6 , 7 ]. These mutations result in the loss of function of NaV1.1 channels, which is critical for normal brain function and leads to seizures and epilepsy [ 8 , 9 ]. In some cases, these pathogenic SCN1A variants can be inherited, while in others, de novo mutations occur [ 10 , 11 ]. Other genes like SCN1B, GABRA1, PCDH19, GABRG2, HCN1, and STXBP1 have also been implicated in DS, although not all cases are genetic, and not all genetic mutations result in DS [ 11 ].

DS typically manifests in the first year of life, often with a normal early childhood development followed by the onset of seizures around 4–12 months of age [ 12 ]. Seizures can be medically refractory, leading to recurrent status epilepticus and various comorbidities, including intellectual disability, ataxia, and an increased risk of early mortality [ 13 ]. Therefore, the impact of DS on affected individuals is profound, encompassing not only seizures but also developmental and cognitive challenges [ 14 , 15 , 16 ]. Despite several decades of research, current treatment options for DS remain limited, often necessitating the use of polypharmacy with antiepileptic drugs [ 17 ]. Medications like sodium valproate, topiramate, and stiripentol are commonly used, but some, like carbamazepine, should be avoided [ 18 ]. Recent studies have demonstrated the efficacy of stiripentol in managing seizures associated with DS [ 19 , 20 ]. Notably, stiripentol has shown potential as an additional therapy, offering a new avenue for improving seizure control in individuals with this challenging condition [ 21 ]. Additionally, dietary therapies, such as the ketogenic diet, and non-pharmacologic strategies, like avoiding seizure triggers, are considered [ 22 ]. In addition, emerging evidence suggests that other antiepileptic drugs with sodium channel-blocking properties, such as oxcarbazepine and lamotrigine, also pose a risk of exacerbating seizures in individuals with DS. While these interventions can reduce seizure frequency and disease severity, they do not address the underlying pathogenesis.

Cannabidiol (CBD), a non-psychoactive compound derived from the cannabis plant, has garnered attention as a potential treatment for DS [ 23 , 24 , 25 ]. Clinical trials, along with the FDA's approval of Epidiolex for DS and Lennox–Gastaut Syndrome, highlight CBD's potential as an alternative therapy [ 26 , 27 ]. Existing studies often focus on specific aspects of the potential treatment, such as seizure reduction or safety profiles, rather than providing a holistic view of CBD's efficacy and safety in managing the multifaceted challenges of DS [ 28 , 29 ].

While the predominant emphasis in the literature lies in investigating the impact of CBD on convulsive seizures in pediatric patients with DS. Studies have begun to shed light on the potential efficacy of CBD in mitigating various seizure manifestations beyond convulsions, such as absence seizures and myoclonic seizures [ 30 , 31 ]. Moreover, CBD has demonstrated a well-documented interaction with clobazam. Studies have consistently reported that co-administration of CBD and clobazam can lead to alterations in the pharmacokinetics of both substances [ 32 , 33 ]. This interaction highlights the necessity for close monitoring and potential dosage adjustments when utilising CBD alongside other anti-epileptics in the treatment of DS. This review aims to examine the existing body of evidence regarding the efficacy and safety of CBD in the management of DS, considering the limitations of current treatment options and the potential benefits of CBD-based therapies.

Methodology

Literature search strategy

In this study, an extensive search was conducted in PubMed, MEDLINE, Scopus, Web of Science, and relevant grey literature. The search incorporated a range of search terms, such as "cannabidiol," "CBD," "Dravet Syndrome," "seizures," and related keywords. Studies published from the inception of each database until the present were included in the search. The search was specifically limited to articles published in the English language. See Fig.  1 .

Inclusion and exclusion criteria

For inclusion, the study must be a clinical trial, published within the last 10 years to provide the latest evidence, published in the English language and focused on the use of CBD in the management of DS in individuals aged 18 or less. This review specifically looked at studies that addressed seizure reduction, safety profiles, and broader impacts on DS. Animal studies, meta-analyses, reviews, and observational studies were excluded.

Data extraction

For each selected study, relevant information, such as study design, sample size, patient demographics, CBD dosing regimen, treatment duration, outcomes measured, and reported results, was extracted. Two reviewers carried out the data extraction process independently, and any discrepancies were resolved through discussion and, if necessary, consultation with a third reviewer.

Data synthesis and analysis

A narrative synthesis approach was employed to summarise and analyse the findings of the selected studies. The effectiveness of CBD in reducing seizures, its impact on cognitive and developmental outcomes, and its safety profile were subject to thorough examination. Heterogeneity in study designs, patient populations, and dosing regimens was carefully considered when concluding, and any inconsistencies or discrepancies in the literature were brought to attention.

This study reviewed data from ten distinct clinical trials. See Table  1 . These interventions varied in terms of the type of CBD administered, which could be a pharmaceutical formulation or plant-derived. The doses of CBD ranged from 2 to 20 mg/kg/d, with varying treatment durations spanning from 4 to 72 weeks. Additionally, the frequency of administration varied, with some studies utilising once-daily dosing and others opting for twice-daily schedules. The duration of follow-up showed significant diversity across these studies, extending from 4 to 72 weeks. In total, these ten studies included 1,724 participants. On average, each study featured approximately 172.4 participants. CBD doses ranged from a minimum of 2.5 mg/kg/day to 30 mg/kg/day, with preparations typically being highly purified CBD in a 100 mg/ml oral solution, and the mean modal dose across the studies was approximately 22 mg/kg/day. The primary efficacy outcomes were evaluated based on the percentage reduction in convulsive and total seizures. Furthermore, clinical improvement was assessed through the Subject/Clinician Global Impression of Change (SCGIC) scale, and quality of life was measured using the Childhood Epilepsy Questionnaire. The reduction in seizure frequency for convulsive seizures ranged from 38 to 74%, and for total seizures, it varied from 40 to 84%. SCGIC scale reported improvements in the range of 81–84%. In addition, 24-h ambulatory EEG was utilised to monitor EEG spikes, aligning these outcome measures with those commonly employed to assess the efficacy of other antiepileptic drugs (AEDs).

Efficacy outcomes

The analysis of the ten clinical trials provides a profound understanding of the efficacy of CBD in pediatric patients with DS. Iannone et al. conducted a randomised open-label extension trial [ 34 ]. Their findings show that CBD at 25 mg/kg per day had a remarkable impact. At the 3-month follow-up, 40.2% of patients substantially reduced seizure frequency, with 1.2% experiencing seizure freedom. A particularly interesting aspect is the observed stability in patient retention across the diagnosis spectrum, suggesting the potential for CBD's consistent efficacy. This study also revealed that CBD's efficacy remained independent of the dosage used, which has implications for treatment optimisation.

Devinsky et al. study demonstrated a 48.7% reduction in convulsive seizure frequency and a 45.7% reduction in total seizure frequency [ 23 ]. Notably, the findings indicated that CBD at 20 mg/kg/ per day did not significantly influence concomitant antiepileptic drug (AED) levels, reinforcing its efficacy as an independent therapeutic agent. The open-label extension trial by Scheffer et al. highlighted the sustainability of CBD's efficacy at 22 mg/kg per day [ 18 ]. Patients in this study experienced sustained, clinically meaningful reductions in seizure frequency. After 12 weeks, add-on CBD treatment led to a 50% reduction in median monthly major motor seizures and a 44% reduction in total seizures. Moreover, the study reported that 83% or more of patients or caregivers noted an improvement in their overall condition. The inclusion of patients taking concomitant valproic acid provided valuable insights into CBD's potential as a long-term treatment option for those with DS.

Miller et al. embarked on a double-anonymized, placebo-controlled, randomised clinical trial involving pediatric patients aged 2 to 18 [ 28 ]. The study underscored the improved safety and tolerability profile of a 10-mg/kg/d CBD dosage, significantly advancing in treating children with treatment-resistant DS. In a study conducted by Halford et al. involving patients with an average age of 9.8 years, significant reductions in convulsive and total seizures were reported with CBD of 100 mg/mL in oral solution [ 35 ]. While over 80% of patients or caregivers noted improvements in their overall condition, it underscores the substantial enhancement in the quality of life for DS patients.

Linda et al. reported substantial reductions in major motor and total seizures with 10 mg/kg per day of CBD [ 24 ]. Devinsky et al. reported statistically significant reductions in convulsive and total seizure frequency with 20 mg/kg per day of CBD [ 36 ]. Additionally, the study noted improvements in Subject/Caregiver Global Impression of Change (S/CGIC) scores, demonstrating CBD's positive impact on seizure control and patients' overall well-being. Similarly, Bláthnaid et al. reported a statistically significant improvement in quality of life, a median motor seizure reduction of 70.6%, and a 50% responder rate of 63%, emphasising the transformative potential of CBD at 2 to 16 mg/kg per day in enhancing the lives of young patients with DS [ 22 ].

Devinsky et al. noted that CBD at 20 mg/kg per day led to a more substantial reduction in convulsive seizure frequency compared to a placebo [ 29 ]. However, it is important to recognise that this increased efficacy was associated with higher rates of adverse events, underscoring the importance of balancing therapeutic benefits with potential risks. In Devinsky et al., the study leading to FDA approval, the findings pointed to a statistically significant reduction in the median frequency of convulsive seizures per month with CBD at 20 mg/kg per day, reaffirming the potential of this treatment in effectively reducing seizure frequency in patients with DS [ 23 ].

In terms of efficacy, a noteworthy observation is the absence of substantial distinctions among different dosages, 5 mg/kg/day, 10 mg/kg/day, and 20 mg/kg/day, compared to the placebo [ 23 , 28 , 34 ]. All treatment groups exhibited considerable enhancements in reducing seizure frequency relative to the placebo; however, discernible variations between these dosage tiers were notably limited.

Safety outcomes

Ensuring the safety of CBD in pediatric patients with DD is paramount. Each of the reviewed clinical trials provides valuable insights into the safety profile of CBD in this patient population. The randomised open-label extension trial conducted by Iannone et al. reported that 31.2% of patients dropped out for various reasons. Common adverse events included somnolence (22.6%), diarrhoea (11.9%), transaminase elevation, and loss of appetite [ 34 ]. Notably, only 1.1% of patients met withdrawal criteria. In the case of Devinsky et al., the study identified common adverse events associated with CBD, including pyrexia, somnolence, decreased appetite, sedation, vomiting, ataxia, and abnormal behaviour [ 23 ]. Intriguingly, six patients taking CBD and valproate experienced elevated transaminases, but none met the criteria for drug-induced liver injury, and all patients eventually recovered. The study indicated that lethargy is particularly common in patients taking CBD alongside clobazam. The study emphasised that exposure to CBD and its metabolites increases proportionally with the dose.

The open-label extension trial by Scheffer et al. reported that adverse events occurred in 97% of patients, with the majority being mild (23%) or moderate (50%) [ 18 ]. Commonly reported adverse events included diarrhoea (43%), pyrexia (39%), decreased appetite (31%), and somnolence (28%). Importantly, 9% of patients experienced liver transaminase elevations greater than three times the upper limit of normal, although none of these cases led to severe liver injury. For Miller et al. specific safety data with percentages were not provided [ 28 ]. However, the study emphasised that long-term add-on CBD treatment for DS was generally well tolerated, with an adverse event profile similar to that observed in controlled trials. Similarly, for Halford et al. specific safety data with percentages were unavailable [ 35 ]. Nevertheless, it was reported that long-term treatment with add-on CBD in patients with DS produced sustained seizure reductions with no new safety concerns.

The data provided by Linda et al. did not specify the percentages of adverse events [ 24 ]. Nonetheless, it was noted that CBD had an acceptable safety profile. Safety data from this study emphasised the overall tolerability of CBD in patients with DS. Miller et al. reported that long-term add-on CBD treatment for DS was generally well tolerated [ 36 ]. McCoy et al. reported that adverse events common during titration included somnolence, anorexia, and diarrhoea [ 22 ]. Abnormalities of liver transaminases and platelets were observed with concomitant valproic acid therapy. Nevertheless, this THC-containing cannabinoid preparation was generally considered safe and well-tolerated.

The review of data from ten distinct clinical trials provides valuable insights into the use of CBD in pediatric patients with DS. These studies varied in terms of CBD type, dosage, treatment duration, and frequency of administration, yet they collectively shed light on the potential of CBD for managing DS.

The variability in CBD interventions across these studies presents challenges and opportunities for future research and clinical practice. While this diversity reflects real-world clinical scenarios, it complicates determining optimal treatment regimens. Whether pharmaceutical or plant-derived, the type of CBD administered could impact efficacy and safety. Moreover, the wide range of CBD doses and treatment durations underscores the need for further investigation into the most effective and sustainable treatment protocols. Additionally, the diverse frequency of administration across studies prompts whether once-daily or twice-daily dosing is more advantageous. Further exploration in this area could provide valuable guidance for treatment optimisation.

The collective findings from the ten clinical trials investigating the efficacy of CBD in pediatric patients with DS provide compelling insights into the potential of CBD as a therapeutic intervention. These trials consistently revealed notable reductions in both convulsive and total seizures, with some achieving remarkable results. For instance, Iannone et al. noted a 40.2% reduction in seizure frequency, with 1.2% of patients experiencing seizure freedom, while Devinsky et al. reported a 48.7% reduction in convulsive seizure frequency and a 45.7% reduction in total seizure frequency [ 23 , 34 ].

These outcomes suggest a promising avenue for treatment. However, there is a pressing need for long-term studies to assess the sustained efficacy and safety of CBD in DS patients. While short-term results are encouraging, understanding the effects of extended CBD treatment is crucial. Additionally, future research must identify optimal dosages, as personalised dosing strategies could enhance treatment outcomes and minimise potential risks. Comparative studies that assess CBD's efficacy in comparison to other treatments or in conjunction with standard antiepileptic drugs (AEDs) can provide additional insights into its role in the treatment landscape. Furthermore, investigating how genetic and clinical factors influence individual responses to CBD treatment is vital. Identifying potential predictors of treatment outcomes can facilitate treatment customisation and improve overall efficacy and safety.

Safety considerations are paramount when assessing the use of CBD in pediatric patients with DS. The trials revealed that while CBD holds promise as a therapeutic intervention, it is not without adverse effects. Common adverse events reported across the trials included somnolence, diarrhoea, pyrexia, decreased appetite, vomiting, ataxia, sedation, and abnormal behaviour. Although relatively common, these adverse events were generally mild to moderate in intensity. Notably, a fraction of patients experienced elevated liver transaminases, albeit without severe liver injury, emphasising the importance of vigilant monitoring for potential liver-related adverse events. Importantly, the dropout rates due to adverse events in these trials were generally low, suggesting that most patients could tolerate CBD treatment. The trials also highlighted that while adverse events were observed, most patients did not meet withdrawal criteria, indicating an overall favourable risk–benefit profile.

These trials' results underscore CBD's promising role in managing DS, providing hope for improved seizure management and quality of life. However, the variability in CBD interventions and the occurrence of adverse events necessitate further investigation. Future research should determine the most effective treatment regimens, considering the type, dose, duration, and frequency of CBD administration. Long-term effects and interactions with other antiepileptic medications also require thorough examination. These findings hold practical significance for clinicians managing pediatric DS patients, emphasising the need for individualised treatment plans and close monitoring for adverse events. CBD-based therapies offer a valuable addition to the existing treatment options for DS, potentially improving patient outcomes and quality of life.

Limitations of review

This review, which analysed data from ten distinct clinical trials involving many pediatric patients with DS, offers valuable insights into the efficacy and safety of CBD treatment. However, it is essential to acknowledge several limitations inherent to this review. The review's restriction to English-language studies poses a notable limitation. By focusing exclusively on English-language research, there is a risk of missing out on valuable non-English literature. This could introduce a language bias, potentially excluding relevant findings from studies conducted in other languages. Also, this review concentrated on clinical trials, thereby excluding observational studies. Despite these limitations, this systematic review offers valuable insights into CBD's potential benefits in managing DS. The synthesis of evidence and clinical implications outlined in the review provides a strong foundation for further research and clinical decision-making.

This review offers a comprehensive and in-depth analysis of the existing evidence on the efficacy and safety of CBD in pediatric patients diagnosed with DS. The findings, compiled from ten distinct clinical trials, consistently point to the potential of CBD as a valuable therapeutic option for managing DS. Notably, CBD remarkably reduces seizure frequency and enhances the overall quality of life for affected patients. One of the most intriguing findings is the consistent efficacy of CBD across various studies, irrespective of the dosage administered. This suggests that CBD holds promise as a treatment that can deliver reliable results for a broad spectrum of DS patients. However, it is crucial to underscore the critical balance between its increased efficacy in some cases and the higher occurrence of adverse events. This balance reinforces the need for a cautious and individualised approach to treatment, ensuring that the therapeutic benefits outweigh potential risks.

The results of this review have significant implications for clinical practice, research endeavours, and healthcare policies. Clinicians managing pediatric patients with DS should consider CBD as a valuable adjunct therapy, particularly for cases refractory to other treatments. However, it is imperative to stay updated with evolving research and best practices to optimise CBD treatment regimens. While this review sheds light on the potential of CBD in transforming the management of DS, it also emphasises the need for further research. Well-designed clinical trials are warranted to refine treatment protocols, explore the optimal CBD dosage, and assess the durability of its therapeutic effects. Addressing long-term safety concerns, especially when CBD is used in conjunction with other antiepileptic drugs, is crucial to ensure the well-being of DS patients. Future research should delve deeper into the underlying mechanisms of CBD's antiseizure effects and its potential interactions with other medications. This will enhance our understanding of CBD's role in DS management and open new avenues for therapeutic innovation.

Availability of data and materials

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

Abbreviations

• Antiepileptic drugs

Cannabidiol

• Dravet Syndrome

Electroencephalogram

Food and Drug Administration

Sodium Voltage-Gated Channel Alpha Subunit 1

Severe Myoclonic Epilepsy of Infancy

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Department of Medicine and Surgery, Ladoke Akintola University Teaching Hospital, Ogbomoso, Nigeria

Nicholas Aderinto

Department of Medicine and Surgery, University of Ilorin, Ilorin, Nigeria

Gbolahan Olatunji & Emmanuel Kokori

Department of Medicine and Surgery, Obafemi Awolowo University Teaching Hospital, Ife, Nigeria

Yusuf Ismaila Ajayi

Department of Medicine and Surgery, University of Ibadan, Ibadan, Nigeria

Olumide Akinmoju

Department of Medicine, University of Abuja, Abuja, Nigeria

Abiola Samuel Ayedun

Bowen University, Iwo, Nigeria

Oluwapelumi Ikeoluwa Ayoola

Department of Paediatrics and Child Health, UNIOSUN Teaching Hospital, Osogbo, Nigeria

Noah Oluwaseun Aderinto

Department of Medicine and Surgery, Ladoke Akintola University of Technology, PMB 5000, Ogbomosho, Nigeria

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NA conceptualised the study; all authors were involved in the literature review; YIA and NA extracted the data from the review studies; all authors wrote the final and first drafts. All authors read and approved the final manuscript.

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Correspondence to Nicholas Aderinto .

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Aderinto, N., Olatunji, G., Kokori, E. et al. The efficacy and safety of cannabidiol (CBD) in pediatric patients with Dravet Syndrome: a narrative review of clinical trials. Eur J Med Res 29 , 182 (2024). https://doi.org/10.1186/s40001-024-01788-6

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Received : 08 November 2023

Accepted : 11 March 2024

Published : 18 March 2024

DOI : https://doi.org/10.1186/s40001-024-01788-6

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• Cannabidiol (CBD)
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