the literature review its role within research

Literature Reviews

• First Online: 07 June 2024

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• George P. Moschis 2  

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A literature review is a critical component of a scientific study and holds significant importance, as literature reviews serve several important functions within the research process:

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Moschis, G.P. (2024). Literature Reviews. In: Academic Research in Business and the Social Sciences. Springer, Cham. https://doi.org/10.1007/978-3-031-56548-9_8

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Literature Review - what is a Literature Review, why it is important and how it is done

What are literature reviews, goals of literature reviews, types of literature reviews, about this guide/licence.

• Strategies to Find Sources
• Evaluating Literature Reviews and Sources
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 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. " - Quote from Taylor, D. (n.d) "The literature review: A few tips on conducting it"

Source NC State University Libraries. This video is published under a Creative Commons 3.0 BY-NC-SA US license.

What are the goals of creating a Literature Review?

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 

- Baumeister, R.F. & Leary, M.R. (1997). "Writing narrative literature reviews," Review of General Psychology , 1(3), 311-320.

When do you need to write a Literature Review?

• When writing a prospectus or a thesis/dissertation
• When writing a research paper
• When writing a grant proposal

In all these cases you need to dedicate a chapter in these works to showcase what have been written about your research topic and to point out how your own research will shed a new light into these body of scholarship.

Literature reviews are also written as standalone articles as a way to survey a particular research topic in-depth. This type of literature reviews look at a topic from a historical perspective to see how the understanding of the topic have change through time.

What kinds of literature reviews are written?

• Narrative Review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.
• Book review essays/ Historiographical review essays : This is a type of review that focus on a small set of research books on a particular topic " to locate these books within current scholarship, critical methodologies, and approaches" in the field. - LARR
• Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L.K. (2013). Research in Communication Sciences and Disorders . San Diego, CA: Plural Publishing.
• Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M.C. & Ilardi, S.S. (2003). Handbook of Research Methods in Clinical Psychology . Malden, MA: Blackwell Pub.
• Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). "Qualitative meta-synthesis: A question of dialoguing with texts," Journal of Advanced Nursing , 53(3), 311-318.

Guide adapted from "Literature Review" , a guide developed by Marisol Ramos used under CC BY 4.0 /modified from original.

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• Last Updated: Jul 3, 2024 10:56 AM
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Research Methods

• Getting Started
• Literature Review Research
• Research Design
• Research Design By Discipline
• SAGE Research Methods
• Teaching with SAGE Research Methods

Literature Review

• What is a Literature Review?
• What is NOT a Literature Review?
• Purposes of a Literature Review
• Types of Literature Reviews
• Literature Reviews vs. Systematic Reviews
• Systematic vs. Meta-Analysis

Literature Review  is a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works.

Also, we can define a literature review as the collected body of scholarly works related to a topic:

• Summarizes and analyzes previous research relevant to a topic
• Includes scholarly books and articles published in academic journals
• Can be an specific scholarly paper or a section in a research paper

The objective of a Literature Review is to find previous published scholarly works relevant to an specific topic

• Help gather ideas or information
• Keep up to date in current trends and findings
• Help develop new questions

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Helps focus your own research questions or problems
• Discovers relationships between research studies/ideas.
• Suggests unexplored ideas or populations
• Identifies major themes, concepts, and researchers on a topic.
• Tests assumptions; may help counter preconceived ideas and remove unconscious bias.
• Identifies critical gaps, points of disagreement, or potentially flawed methodology or theoretical approaches.
• Indicates potential directions for future research.

All content in this section is from Literature Review Research from Old Dominion University 

Keep in mind the following, a literature review is NOT:

Not an essay 

Not an annotated bibliography  in which you summarize each article that you have reviewed.  A literature review goes beyond basic summarizing to focus on the critical analysis of the reviewed works and their relationship to your research question.

Not a research paper   where you select resources to support one side of an issue versus another.  A lit review should explain and consider all sides of an argument in order to avoid bias, and areas of agreement and disagreement should be highlighted.

A literature review serves several purposes. For example, it

• provides thorough knowledge of previous studies; introduces seminal works.
• helps focus one’s own research topic.
• identifies a conceptual framework for one’s own research questions or problems; indicates potential directions for future research.
• suggests previously unused or underused methodologies, designs, quantitative and qualitative strategies.
• identifies gaps in previous studies; identifies flawed methodologies and/or theoretical approaches; avoids replication of mistakes.
• helps the researcher avoid repetition of earlier research.
• suggests unexplored populations.
• determines whether past studies agree or disagree; identifies controversy in the literature.
• tests assumptions; may help counter preconceived ideas and remove unconscious bias.

As Kennedy (2007) notes*, 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 original studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally that become part of the lore of 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 several approaches to how they can be done, depending upon the type of analysis underpinning your study. Listed below are definitions of types of literature reviews:

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

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. A well-done integrative review meets the same standards as primary research in regard to clarity, rigor, and replication.

Historical Review      Few things rest in isolation from historical precedent. Historical reviews are focused 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 [content], but how they said it [method of analysis]. This approach provides a framework of understanding at different levels (i.e. those of theory, substantive fields, research approaches and data collection and analysis techniques), enables researchers to draw on 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, and helps highlight many ethical issues which we should be aware of and consider as we go through our 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 analyse data from the studies that are included in the review. 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?"

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

* Kennedy, Mary M. "Defining a Literature."  Educational Researcher  36 (April 2007): 139-147.

All content in this section is from The Literature Review created by Dr. Robert Larabee USC

Robinson, P. and Lowe, J. (2015),  Literature reviews vs systematic reviews.  Australian and New Zealand Journal of Public Health, 39: 103-103. doi: 10.1111/1753-6405.12393

What's in the name? The difference between a Systematic Review and a Literature Review, and why it matters . By Lynn Kysh from University of Southern California

Systematic review or meta-analysis?

A  systematic review  answers a defined research question by collecting and summarizing all empirical evidence that fits pre-specified eligibility criteria.

A  meta-analysis  is the use of statistical methods to summarize the results of these studies.

Systematic reviews, just like other research articles, can be of varying quality. They are a significant piece of work (the Centre for Reviews and Dissemination at York estimates that a team will take 9-24 months), and to be useful to other researchers and practitioners they should have:

• clearly stated objectives with pre-defined eligibility criteria for studies
• explicit, reproducible methodology
• a systematic search that attempts to identify all studies
• assessment of the validity of the findings of the included studies (e.g. risk of bias)
• systematic presentation, and synthesis, of the characteristics and findings of the included studies

Not all systematic reviews contain meta-analysis. 

Meta-analysis is the use of statistical methods to summarize the results of independent studies. By combining information from all relevant studies, meta-analysis can provide more precise estimates of the effects of health care than those derived from the individual studies included within a review.  More information on meta-analyses can be found in  Cochrane Handbook, Chapter 9 .

A meta-analysis goes beyond critique and integration and conducts secondary statistical analysis on the outcomes of similar studies.  It is a systematic review that uses quantitative methods to synthesize and summarize the results.

An advantage of a meta-analysis is the ability to be completely objective in evaluating research findings.  Not all topics, however, have sufficient research evidence to allow a meta-analysis to be conducted.  In that case, an integrative review is an appropriate strategy. 

Some of the content in this section is from Systematic reviews and meta-analyses: step by step guide created by Kate McAllister.

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Literature Reviews

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What is a literature review?

Why conduct a literature review, stages of a literature review, lit reviews: an overview (video), check out these books.

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• 1. Define your research question
• 2. Plan your search
• 3. Search the literature
• 4. Organize your results
• 5. Synthesize your findings
• 6. Write the review
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Definition: A literature review is a systematic examination and synthesis of existing scholarly research on a specific topic or subject.

Purpose: It serves to provide a comprehensive overview of the current state of knowledge within a particular field.

Analysis: Involves critically evaluating and summarizing key findings, methodologies, and debates found in academic literature.

Identifying Gaps: Aims to pinpoint areas where there is a lack of research or unresolved questions, highlighting opportunities for further investigation.

Contextualization: Enables researchers to understand how their work fits into the broader academic conversation and contributes to the existing body of knowledge.

tl;dr  A literature review critically examines and synthesizes existing scholarly research and publications on a specific topic to provide a comprehensive understanding of the current state of knowledge in the field.

What is a literature review NOT?

❌ An annotated bibliography

❌ Original research

❌ A summary

❌ Something to be conducted at the end of your research

❌ An opinion piece

❌ A chronological compilation of studies

The reason for conducting a literature review is to:

Literature Reviews: An Overview for Graduate Students

While this 9-minute video from NCSU is geared toward graduate students, it is useful for anyone conducting a literature review.

Writing the literature review: A practical guide

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Writing literature reviews: A guide for students of the social and behavioral sciences

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So, you have to write a literature review: A guided workbook for engineers

Telling a research story: Writing a literature review

The literature review: Six steps to success

Systematic approaches to a successful literature review

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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.

Research Process :: Step by Step

• Introduction
• Select Topic
• Identify Keywords
• Background Information
• Develop Research Questions
• Refine Topic
• Search Strategy
• Popular Databases
• Evaluate Sources
• Types of Periodicals
• Reading Scholarly Articles
• Primary & Secondary Sources
• Organize / Take Notes
• Writing & Grammar Resources
• Annotated Bibliography
• Literature Review
• Citation Styles
• Paraphrasing
• Privacy / Confidentiality
• Research Process
• Selecting Your Topic
• Identifying Keywords
• Gathering Background Info
• Evaluating Sources

Organize the literature review into sections that present themes or identify trends, including relevant theory. You are not trying to list all the material published, but to synthesize and evaluate it according to the guiding concept of your thesis or research question.  

What is a literature review?

A literature review is an account of what has been published on a topic by accredited scholars and researchers. Occasionally you will be asked to write one as a separate assignment, but more often it is part of the introduction to an essay, research report, or thesis. 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

A literature review must do these things:

• be organized around and related directly to the thesis or research question you are developing
• synthesize results into a summary of what is and is not known
• identify areas of controversy in the literature
• formulate questions that need further research

Ask yourself questions like these:

• What is the specific thesis, problem, or research question that my literature review helps to define?
• What type of literature review am I conducting? Am I looking at issues of theory? methodology? policy? quantitative research (e.g. on the effectiveness of a new procedure)? qualitative research (e.g., studies of loneliness among migrant workers)?
• What is the scope of my literature review? What types of publications am I using (e.g., journals, books, government documents, popular media)? What discipline am I working in (e.g., nursing psychology, sociology, medicine)?
• How good was my information seeking? Has my search been wide enough to ensure I've found all the relevant material? Has it been narrow enough to exclude irrelevant material? Is the number of sources I've used appropriate for the length of my paper?
• Have I critically analyzed the literature I use? Do I follow through a set of concepts and questions, comparing items to each other in the ways they deal with them? Instead of just listing and summarizing items, do I assess them, discussing strengths and weaknesses?
• Have I cited and discussed studies contrary to my perspective?
• Will the reader find my literature review relevant, appropriate, and useful?

Ask yourself questions like these about each book or article you include:

• Has the author formulated a problem/issue?
• Is it clearly defined? Is its significance (scope, severity, relevance) clearly established?
• Could the problem have been approached more effectively from another perspective?
• What is the author's research orientation (e.g., interpretive, critical science, combination)?
• What is the author's theoretical framework (e.g., psychological, developmental, feminist)?
• What is the relationship between the theoretical and research perspectives?
• Has the author evaluated the literature relevant to the problem/issue? Does the author include literature taking positions she or he does not agree with?
• In a research study, how good are the basic components of the study design (e.g., population, intervention, outcome)? How accurate and valid are the measurements? Is the analysis of the data accurate and relevant to the research question? Are the conclusions validly based upon the data and analysis?
• In material written for a popular readership, does the author use appeals to emotion, one-sided examples, or rhetorically-charged language and tone? Is there an objective basis to the reasoning, or is the author merely "proving" what he or she already believes?
• How does the author structure the argument? Can you "deconstruct" the flow of the argument to see whether or where it breaks down logically (e.g., in establishing cause-effect relationships)?
• In what ways does this book or article contribute to our understanding of the problem under study, and in what ways is it useful for practice? What are the strengths and limitations?
• How does this book or article relate to the specific thesis or question I am developing?

Text written by Dena Taylor, Health Sciences Writing Centre, University of Toronto

http://www.writing.utoronto.ca/advice/specific-types-of-writing/literature-review

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What is a literature review?

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

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

Why is it important?

A literature review is important because it:

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

APA7 Style resources

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1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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What is a Literature Review? How to Write It (with Examples)

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

Table of Contents

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

How to write a good literature review 

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

What is a literature review?

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

What is the purpose of literature review?

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

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

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

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

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

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

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

Literature review example

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

Literature Review on Climate Change Impacts on Biodiversity:

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

a. Habitat Loss and Species Extinction:

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

b. Range Shifts and Phenological Changes:

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

c. Ocean Acidification and Coral Reefs:

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

d. Adaptive Strategies and Conservation Efforts:

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

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

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

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

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

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

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

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

Conducting a literature review

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

Choose a Topic and Define the Research Question:

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

Decide on the Scope of Your Review:

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

Select Databases for Searches:

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

Conduct Searches and Keep Track:

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

Review the Literature:

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

Organize and Write Your Literature Review:

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

Whether you’re exploring a new research field or finding new angles to develop an existing topic, sifting through hundreds of papers can take more time than you have to spare. But what if you could find science-backed insights with verified citations in seconds? That’s the power of Paperpal’s new Research feature!  

How to write a literature review faster with Paperpal?

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

Here’s how to use the Research feature:  

• Ask a question: Get started with a new document on paperpal.com. Click on the “Research” feature and type your question in plain English. Paperpal will scour over 250 million research articles, including conference papers and preprints, to provide you with accurate insights and citations. 
• Review and Save: Paperpal summarizes the information, while citing sources and listing relevant reads. You can quickly scan the results to identify relevant references and save these directly to your built-in citations library for later access. 
• Cite with Confidence: Paperpal makes it easy to incorporate relevant citations and references into your writing, ensuring your arguments are well-supported by credible sources. This translates to a polished, well-researched literature review. 

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

Frequently asked questions

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

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

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

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

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

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

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

References 

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

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Why is it important to do a literature review in research?

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 “A substantive, thorough, sophisticated literature review is a precondition for doing substantive, thorough, sophisticated research”. Boote and Baile 2005

Authors of manuscripts treat writing a literature review as a routine work or a mere formality. But a seasoned one knows the purpose and importance of a well-written literature review.  Since it is one of the basic needs for researches at any level, they have to be done vigilantly. Only then the reader will know that the basics of research have not been neglected.

The aim of any literature review is to summarize and synthesize the arguments and ideas of existing knowledge in a particular field without adding any new contributions.   Being built on existing knowledge they help the researcher to even turn the wheels of the topic of research.  It is possible only with profound knowledge of what is wrong in the existing findings in detail to overpower them.  For other researches, the literature review gives the direction to be headed for its success. 

The common perception of literature review and reality:

As per the common belief, literature reviews are only a summary of the sources related to the research. And many authors of scientific manuscripts believe that they are only surveys of what are the researches are done on the chosen topic.  But on the contrary, it uses published information from pertinent and relevant sources like

• Scholarly books
• Scientific papers
• Latest studies in the field
• Established school of thoughts
• Relevant articles from renowned scientific journals

and many more for a field of study or theory or a particular problem to do the following:

• Summarize into a brief account of all information
• Synthesize the information by restructuring and reorganizing
• Critical evaluation of a concept or a school of thought or ideas
• Familiarize the authors to the extent of knowledge in the particular field
• Encapsulate
• Compare & contrast

By doing the above on the relevant information, it provides the reader of the scientific manuscript with the following for a better understanding of it:

• It establishes the authors’  in-depth understanding and knowledge of their field subject
• It gives the background of the research
• Portrays the scientific manuscript plan of examining the research result
• Illuminates on how the knowledge has changed within the field
• Highlights what has already been done in a particular field
• Information of the generally accepted facts, emerging and current state of the topic of research
• Identifies the research gap that is still unexplored or under-researched fields
• Demonstrates how the research fits within a larger field of study
• Provides an overview of the sources explored during the research of a particular topic

Importance of literature review in research:

The importance of literature review in scientific manuscripts can be condensed into an analytical feature to enable the multifold reach of its significance.  It adds value to the legitimacy of the research in many ways:

• Provides the interpretation of existing literature in light of updated developments in the field to help in establishing the consistency in knowledge and relevancy of existing materials
• It helps in calculating the impact of the latest information in the field by mapping their progress of knowledge.
• It brings out the dialects of contradictions between various thoughts within the field to establish facts
• The research gaps scrutinized initially are further explored to establish the latest facts of theories to add value to the field
• Indicates the current research place in the schema of a particular field
• Provides information for relevancy and coherency to check the research
• Apart from elucidating the continuance of knowledge, it also points out areas that require further investigation and thus aid as a starting point of any future research
• Justifies the research and sets up the research question
• Sets up a theoretical framework comprising the concepts and theories of the research upon which its success can be judged
• Helps to adopt a more appropriate methodology for the research by examining the strengths and weaknesses of existing research in the same field
• Increases the significance of the results by comparing it with the existing literature
• Provides a point of reference by writing the findings in the scientific manuscript
• Helps to get the due credit from the audience for having done the fact-finding and fact-checking mission in the scientific manuscripts
• The more the reference of relevant sources of it could increase more of its trustworthiness with the readers
• Helps to prevent plagiarism by tailoring and uniquely tweaking the scientific manuscript not to repeat other’s original idea
• By preventing plagiarism , it saves the scientific manuscript from rejection and thus also saves a lot of time and money
• Helps to evaluate, condense and synthesize gist in the author’s own words to sharpen the research focus
• Helps to compare and contrast to  show the originality and uniqueness of the research than that of the existing other researches
• Rationalizes the need for conducting the particular research in a specified field
• Helps to collect data accurately for allowing any new methodology of research than the existing ones
• Enables the readers of the manuscript to answer the following questions of its readers for its better chances for publication
• What do the researchers know?
• What do they not know?
• Is the scientific manuscript reliable and trustworthy?
• What are the knowledge gaps of the researcher?

22. It helps the readers to identify the following for further reading of the scientific manuscript:

• What has been already established, discredited and accepted in the particular field of research
• Areas of controversy and conflicts among different schools of thought
• Unsolved problems and issues in the connected field of research
• The emerging trends and approaches
• How the research extends, builds upon and leaves behind from the previous research

A profound literature review with many relevant sources of reference will enhance the chances of the scientific manuscript publication in renowned and reputed scientific journals .

References:

http://www.math.montana.edu/jobo/phdprep/phd6.pdf

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What is a literature review?

Conducting a literature review, organizing a literature review, writing a literature review, helpful book.

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A  literature review  is a compilation of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works.

• Summarizes and analyzes previous research relevant to a topic
• Includes scholarly books and articles published in academic journals
• Can be an specific scholarly paper or a section in a research paper

The objective of a Literature Review is to find previous published scholarly works relevant to an specific topic

• Help gather ideas or information
• Keep up to date in current trends and findings
• Help develop new questions

A literature review is important because it:

• Explains the background of research on a topic
• Demonstrates why a topic is significant to a subject area
• Helps focus your own research questions or problems
• Discovers relationships between research studies/ideas
• Suggests unexplored ideas or populations
• Identifies major themes, concepts, and researchers on a topic
• Tests assumptions; may help counter preconceived ideas and remove unconscious bias
• Identifies critical gaps, points of disagreement, or potentially flawed methodology or theoretical approaches

Source: "What is a Literature Review?", Old Dominion University,  https://guides.lib.odu.edu/c.php?g=966167&p=6980532

1. Choose a topic. Define your research question. 

Your literature review should be guided by a central research question. It represents background and research developments related to a specific research question, interpreted, and analyzed by you in a synthesized way. 

• Make sure your research question is not too broad or too narrow.
• Write down terms that are related to your question for they will be useful for searches later. 

2. Decide on the scope of your review. 

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.
• Consider these things when planning your time for research. 

3. Select the databases you will use to conduct your searches. 

• By Research Guide 

4. Conduct your searches and find the literature. 

• Review the abstracts carefully - this will save you time!
• Many databases will have a search history tab for you to return to for later.
• Use bibliographies and references of research studies to locate others.
• Use citation management software such as Zotero to keep track of your research citations. 

5. Review the literature. 

Some questions to help you analyze the research: 

• What was the research question you are reviewing? What are the authors trying to discover? 
• Was the research funded by a source that could influence the findings? 
• What were the research methodologies? Analyze the literature review, samples and variables used, results, and conclusions. Does the research seem complete? Could it have been conducted more soundly? What further questions does it raise? 
• If there are conflicted studies, why do you think that is? 
• How are the authors viewed in the field? Are they experts or novices? Has the study been cited? 

Source: "Literature Review", University of West Florida,  https://libguides.uwf.edu/c.php?g=215113&p=5139469

A literature review is not a summary of the sources but a synthesis of the sources. It is made up of the topics the sources are discussing. Each section of the review is focused on a topic, and the relevant sources are discussed within the context of that topic. 

1. Select the most relevant material from the sources

• Could be material that answers the question directly
• Extract as a direct quote or paraphrase 

2. Arrange that material so you can focus on it apart from the source text itself

• You are now working with fewer words/passages
• Material is all in one place

3. Group similar points, themes, or topics together and label them 

• The labels describe the points, themes, or topics that are the backbone of your paper’s structure

4. Order those points, themes, or topics as you will discuss them in the paper, and turn the labels into actual assertions

• A sentence that makes a point that is directly related to your research question or thesis 

This is now the outline for your literature review. 

Source: "Organizing a Review of the Literature – The Basics", George Mason University Writing Center,  https://writingcenter.gmu.edu/writing-resources/research-based-writing/organizing-literature-reviews-the-basics

• Literature Review Matrix Here is a template on how people tend to organize their thoughts. The matrix template is a good way to write out the key parts of each article and take notes. Downloads as an XLSX file.

The most common way that literature reviews are organized is by theme or author. Find a general pattern of structure for the review. When organizing the review, consider the following: 

• the methodology 
• the quality of the findings or conclusions
• major strengths and weaknesses
• any other important information

Writing Tips: 

• Be selective - Select only the most important points in each source to highlight in the review. It should directly relate to the review's focus.
• Use quotes sparingly.
• Keep your own voice - Your voice (the writer's) should remain front and center. .   
• Aim for one key figure/table per section to illustrate complex content, summarize a large body of relevant data, or describe the order of a process
• Legend below image/figure and above table and always refer to them in text 

Source: "Composing your Literature Review", Florida A&M University,  https://library.famu.edu/c.php?g=577356&p=3982811

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Conducting a Literature Review

What is a literature review.

• Types of Literature Reviews
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The literature of a literature review is not made up of novels and short stories and poetry—but is the collection of writing and research that has been produced on a particular topic.

The purpose of the literature review is to give you an overview of a particular topic. Your job is to discover the research that has been done, the major perspectives, and the significant thinkers and writers (experts) who have published on the topic you’re interested in. In other words, it’s a survey of what has been written and argued about your topic.

By the time you complete your literature review you should have written an essay that demonstrates that you:

• Understand the history of what’s been written and researched on your topic.
• Know the significance of the current academic thinking on your topic, including what the controversies are.
• Have a perspective about what work remains to be done on your topic.

Thus, a literature review synthesizes your research into an explanation of what is known and what is not known on your topic. If the topic is one from which you want to embark on a major research project, doing a literature review will save you time and help you figure out where you might focus your attention so you don’t duplicate research that has already been done.

Just to be clear: a literature review differs from a research paper in that a  literature review  is a summary and synthesis of the major arguments and thinking of experts on the topic you’re investigating, whereas a  research paper  supports a position or an opinion you have developed yourself as a result of your own analysis of a topic.

Another advantage of doing a literature review is that it summarizes the intellectual discussion that has been going on over the decades—or centuries—on a specific topic and allows you to join in that conversation (what academics call academic discourse) from a knowledgeable position.

The following presentation will provide you with the basic steps to follow as you work to complete a literature review.

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Ten Simple Rules for Writing a Literature Review

Marco pautasso.

1 Centre for Functional and Evolutionary Ecology (CEFE), CNRS, Montpellier, France

2 Centre for Biodiversity Synthesis and Analysis (CESAB), FRB, Aix-en-Provence, France

Literature reviews are in great demand in most scientific fields. Their need stems from the ever-increasing output of scientific publications [1] . For example, compared to 1991, in 2008 three, eight, and forty times more papers were indexed in Web of Science on malaria, obesity, and biodiversity, respectively [2] . Given such mountains of papers, scientists cannot be expected to examine in detail every single new paper relevant to their interests [3] . Thus, it is both advantageous and necessary to rely on regular summaries of the recent literature. Although recognition for scientists mainly comes from primary research, timely literature reviews can lead to new synthetic insights and are often widely read [4] . For such summaries to be useful, however, they need to be compiled in a professional way [5] .

When starting from scratch, reviewing the literature can require a titanic amount of work. That is why researchers who have spent their career working on a certain research issue are in a perfect position to review that literature. Some graduate schools are now offering courses in reviewing the literature, given that most research students start their project by producing an overview of what has already been done on their research issue [6] . However, it is likely that most scientists have not thought in detail about how to approach and carry out a literature review.

Reviewing the literature requires the ability to juggle multiple tasks, from finding and evaluating relevant material to synthesising information from various sources, from critical thinking to paraphrasing, evaluating, and citation skills [7] . In this contribution, I share ten simple rules I learned working on about 25 literature reviews as a PhD and postdoctoral student. Ideas and insights also come from discussions with coauthors and colleagues, as well as feedback from reviewers and editors.

Rule 1: Define a Topic and Audience

How to choose which topic to review? There are so many issues in contemporary science that you could spend a lifetime of attending conferences and reading the literature just pondering what to review. On the one hand, if you take several years to choose, several other people may have had the same idea in the meantime. On the other hand, only a well-considered topic is likely to lead to a brilliant literature review [8] . The topic must at least be:

• interesting to you (ideally, you should have come across a series of recent papers related to your line of work that call for a critical summary),
• an important aspect of the field (so that many readers will be interested in the review and there will be enough material to write it), and
• a well-defined issue (otherwise you could potentially include thousands of publications, which would make the review unhelpful).

Ideas for potential reviews may come from papers providing lists of key research questions to be answered [9] , but also from serendipitous moments during desultory reading and discussions. In addition to choosing your topic, you should also select a target audience. In many cases, the topic (e.g., web services in computational biology) will automatically define an audience (e.g., computational biologists), but that same topic may also be of interest to neighbouring fields (e.g., computer science, biology, etc.).

Rule 2: Search and Re-search the Literature

After having chosen your topic and audience, start by checking the literature and downloading relevant papers. Five pieces of advice here:

• keep track of the search items you use (so that your search can be replicated [10] ),
• keep a list of papers whose pdfs you cannot access immediately (so as to retrieve them later with alternative strategies),
• use a paper management system (e.g., Mendeley, Papers, Qiqqa, Sente),
• define early in the process some criteria for exclusion of irrelevant papers (these criteria can then be described in the review to help define its scope), and
• do not just look for research papers in the area you wish to review, but also seek previous reviews.

The chances are high that someone will already have published a literature review ( Figure 1 ), if not exactly on the issue you are planning to tackle, at least on a related topic. If there are already a few or several reviews of the literature on your issue, my advice is not to give up, but to carry on with your own literature review,

The bottom-right situation (many literature reviews but few research papers) is not just a theoretical situation; it applies, for example, to the study of the impacts of climate change on plant diseases, where there appear to be more literature reviews than research studies [33] .

• discussing in your review the approaches, limitations, and conclusions of past reviews,
• trying to find a new angle that has not been covered adequately in the previous reviews, and
• incorporating new material that has inevitably accumulated since their appearance.

When searching the literature for pertinent papers and reviews, the usual rules apply:

• be thorough,
• use different keywords and database sources (e.g., DBLP, Google Scholar, ISI Proceedings, JSTOR Search, Medline, Scopus, Web of Science), and
• look at who has cited past relevant papers and book chapters.

Rule 3: Take Notes While Reading

If you read the papers first, and only afterwards start writing the review, you will need a very good memory to remember who wrote what, and what your impressions and associations were while reading each single paper. My advice is, while reading, to start writing down interesting pieces of information, insights about how to organize the review, and thoughts on what to write. This way, by the time you have read the literature you selected, you will already have a rough draft of the review.

Of course, this draft will still need much rewriting, restructuring, and rethinking to obtain a text with a coherent argument [11] , but you will have avoided the danger posed by staring at a blank document. Be careful when taking notes to use quotation marks if you are provisionally copying verbatim from the literature. It is advisable then to reformulate such quotes with your own words in the final draft. It is important to be careful in noting the references already at this stage, so as to avoid misattributions. Using referencing software from the very beginning of your endeavour will save you time.

Rule 4: Choose the Type of Review You Wish to Write

After having taken notes while reading the literature, you will have a rough idea of the amount of material available for the review. This is probably a good time to decide whether to go for a mini- or a full review. Some journals are now favouring the publication of rather short reviews focusing on the last few years, with a limit on the number of words and citations. A mini-review is not necessarily a minor review: it may well attract more attention from busy readers, although it will inevitably simplify some issues and leave out some relevant material due to space limitations. A full review will have the advantage of more freedom to cover in detail the complexities of a particular scientific development, but may then be left in the pile of the very important papers “to be read” by readers with little time to spare for major monographs.

There is probably a continuum between mini- and full reviews. The same point applies to the dichotomy of descriptive vs. integrative reviews. While descriptive reviews focus on the methodology, findings, and interpretation of each reviewed study, integrative reviews attempt to find common ideas and concepts from the reviewed material [12] . A similar distinction exists between narrative and systematic reviews: while narrative reviews are qualitative, systematic reviews attempt to test a hypothesis based on the published evidence, which is gathered using a predefined protocol to reduce bias [13] , [14] . When systematic reviews analyse quantitative results in a quantitative way, they become meta-analyses. The choice between different review types will have to be made on a case-by-case basis, depending not just on the nature of the material found and the preferences of the target journal(s), but also on the time available to write the review and the number of coauthors [15] .

Rule 5: Keep the Review Focused, but Make It of Broad Interest

Whether your plan is to write a mini- or a full review, it is good advice to keep it focused 16 , 17 . Including material just for the sake of it can easily lead to reviews that are trying to do too many things at once. The need to keep a review focused can be problematic for interdisciplinary reviews, where the aim is to bridge the gap between fields [18] . If you are writing a review on, for example, how epidemiological approaches are used in modelling the spread of ideas, you may be inclined to include material from both parent fields, epidemiology and the study of cultural diffusion. This may be necessary to some extent, but in this case a focused review would only deal in detail with those studies at the interface between epidemiology and the spread of ideas.

While focus is an important feature of a successful review, this requirement has to be balanced with the need to make the review relevant to a broad audience. This square may be circled by discussing the wider implications of the reviewed topic for other disciplines.

Rule 6: Be Critical and Consistent

Reviewing the literature is not stamp collecting. A good review does not just summarize the literature, but discusses it critically, identifies methodological problems, and points out research gaps [19] . After having read a review of the literature, a reader should have a rough idea of:

• the major achievements in the reviewed field,
• the main areas of debate, and
• the outstanding research questions.

It is challenging to achieve a successful review on all these fronts. A solution can be to involve a set of complementary coauthors: some people are excellent at mapping what has been achieved, some others are very good at identifying dark clouds on the horizon, and some have instead a knack at predicting where solutions are going to come from. If your journal club has exactly this sort of team, then you should definitely write a review of the literature! In addition to critical thinking, a literature review needs consistency, for example in the choice of passive vs. active voice and present vs. past tense.

Rule 7: Find a Logical Structure

Like a well-baked cake, a good review has a number of telling features: it is worth the reader's time, timely, systematic, well written, focused, and critical. It also needs a good structure. With reviews, the usual subdivision of research papers into introduction, methods, results, and discussion does not work or is rarely used. However, a general introduction of the context and, toward the end, a recapitulation of the main points covered and take-home messages make sense also in the case of reviews. For systematic reviews, there is a trend towards including information about how the literature was searched (database, keywords, time limits) [20] .

How can you organize the flow of the main body of the review so that the reader will be drawn into and guided through it? It is generally helpful to draw a conceptual scheme of the review, e.g., with mind-mapping techniques. Such diagrams can help recognize a logical way to order and link the various sections of a review [21] . This is the case not just at the writing stage, but also for readers if the diagram is included in the review as a figure. A careful selection of diagrams and figures relevant to the reviewed topic can be very helpful to structure the text too [22] .

Rule 8: Make Use of Feedback

Reviews of the literature are normally peer-reviewed in the same way as research papers, and rightly so [23] . As a rule, incorporating feedback from reviewers greatly helps improve a review draft. Having read the review with a fresh mind, reviewers may spot inaccuracies, inconsistencies, and ambiguities that had not been noticed by the writers due to rereading the typescript too many times. It is however advisable to reread the draft one more time before submission, as a last-minute correction of typos, leaps, and muddled sentences may enable the reviewers to focus on providing advice on the content rather than the form.

Feedback is vital to writing a good review, and should be sought from a variety of colleagues, so as to obtain a diversity of views on the draft. This may lead in some cases to conflicting views on the merits of the paper, and on how to improve it, but such a situation is better than the absence of feedback. A diversity of feedback perspectives on a literature review can help identify where the consensus view stands in the landscape of the current scientific understanding of an issue [24] .

Rule 9: Include Your Own Relevant Research, but Be Objective

In many cases, reviewers of the literature will have published studies relevant to the review they are writing. This could create a conflict of interest: how can reviewers report objectively on their own work [25] ? Some scientists may be overly enthusiastic about what they have published, and thus risk giving too much importance to their own findings in the review. However, bias could also occur in the other direction: some scientists may be unduly dismissive of their own achievements, so that they will tend to downplay their contribution (if any) to a field when reviewing it.

In general, a review of the literature should neither be a public relations brochure nor an exercise in competitive self-denial. If a reviewer is up to the job of producing a well-organized and methodical review, which flows well and provides a service to the readership, then it should be possible to be objective in reviewing one's own relevant findings. In reviews written by multiple authors, this may be achieved by assigning the review of the results of a coauthor to different coauthors.

Rule 10: Be Up-to-Date, but Do Not Forget Older Studies

Given the progressive acceleration in the publication of scientific papers, today's reviews of the literature need awareness not just of the overall direction and achievements of a field of inquiry, but also of the latest studies, so as not to become out-of-date before they have been published. Ideally, a literature review should not identify as a major research gap an issue that has just been addressed in a series of papers in press (the same applies, of course, to older, overlooked studies (“sleeping beauties” [26] )). This implies that literature reviewers would do well to keep an eye on electronic lists of papers in press, given that it can take months before these appear in scientific databases. Some reviews declare that they have scanned the literature up to a certain point in time, but given that peer review can be a rather lengthy process, a full search for newly appeared literature at the revision stage may be worthwhile. Assessing the contribution of papers that have just appeared is particularly challenging, because there is little perspective with which to gauge their significance and impact on further research and society.

Inevitably, new papers on the reviewed topic (including independently written literature reviews) will appear from all quarters after the review has been published, so that there may soon be the need for an updated review. But this is the nature of science [27] – [32] . I wish everybody good luck with writing a review of the literature.

Acknowledgments

Many thanks to M. Barbosa, K. Dehnen-Schmutz, T. Döring, D. Fontaneto, M. Garbelotto, O. Holdenrieder, M. Jeger, D. Lonsdale, A. MacLeod, P. Mills, M. Moslonka-Lefebvre, G. Stancanelli, P. Weisberg, and X. Xu for insights and discussions, and to P. Bourne, T. Matoni, and D. Smith for helpful comments on a previous draft.

Funding Statement

This work was funded by the French Foundation for Research on Biodiversity (FRB) through its Centre for Synthesis and Analysis of Biodiversity data (CESAB), as part of the NETSEED research project. The funders had no role in the preparation of the manuscript.

Matada Research

Understanding the importance of a literature review in research

• March 29, 2023

Gerald Naepi

When conducting research, a literature review plays a crucial role as it provides an overview of the existing literature related to a specific topic. Its main objective is to identify the gaps in the current knowledge and provide direction for future research. This article delves into the purpose and structure of a literature review, along with the various types of literature reviews typically employed in research. By familiarising themselves with the different types of literature reviews and their unique features, researchers can determine which review type would best suit their research question and help them achieve their desired results.

Purpose of a literature review in research

The primary goal of a literature review in research is to offer a comprehensive overview of the relevant research within a given area. A well-executed literature review should provide readers with a clear understanding of the theoretical and empirical contributions made in the field, while also highlighting areas that require further exploration or investigation. Additionally, literature reviews help researchers identify gaps in existing knowledge that can lead to new hypotheses or questions for future study.

When conducting a literature review, researchers should pay close attention to key themes and topics covered by previous studies, including the approaches used to answer specific questions or address particular issues. This ensures that any conclusions drawn by the researcher are supported by established evidence and build on prior work in the field. Moreover, when synthesising information from multiple studies, researchers should aim to identify conflicting opinions or discrepancies in the literature and draw implications for further study. Through this process, a comprehensive literature review can provide invaluable insights into the current state of research and inform future studies.

Literature review format

The format of a literature review in research typically consists of the following elements:

Introduction: The introduction is an important part of a literature review, as it gives the reader a sense of what to expect. It should start with a clear statement of the research question or objective, so that the reader understands what the review is trying to achieve. It’s also important to explain why the topic is important, so that the reader understands the relevance of the review. Finally, the introduction should give the reader an overview of the structure and organisation of the review, so that they can easily navigate through the rest of the content.

Search Strategy: The search strategy should be comprehensive, focused, and systematic. It involves selecting appropriate databases, developing effective search terms, and utilizing other sources to collect information. To begin, the researcher needs to determine the most relevant databases to search. Depending on the topic, discipline, and research question, different databases may be more suitable. Some commonly used databases are PubMed, Scopus, Web of Science, and Google Scholar. Once the databases are selected, the researcher can develop a set of search terms that accurately reflect the topic and research question. These search terms can be a combination of keywords and subject headings. Other sources of information may include reference lists, grey literature, conference proceedings, and experts in the field. These sources can provide additional insights and help to ensure a comprehensive search.

The search strategy should be documented in detail to enable replication and transparency. This documentation should include the databases searched, search terms used, search dates, and any filters or limits applied. By having a clear and systematic search strategy, the researcher can ensure that they have identified all relevant literature and that the research findings are reliable and valid.

Inclusion and Exclusion Criteria: Inclusion criteria refer to the characteristics that a study must have to be included in the review, while exclusion criteria refer to the characteristics that disqualify a study from being included. The inclusion and exclusion criteria may vary depending on the research question, but generally, they should be clearly defined and stated in the methods section of the review. Common criteria include study design, population, intervention or exposure, and outcome measures. For example, a systematic review on the effectiveness of a particular drug for a specific condition may include only randomized controlled trials (RCTs) with a minimum sample size of 50 participants, and exclude non-randomized studies or studies with a high risk of bias.

Defining clear inclusion and exclusion criteria is crucial in ensuring that the studies included in the review are relevant, appropriate, and of high quality. It also helps to minimize bias and enhance the validity of the review’s findings. Additionally, transparent reporting of inclusion and exclusion criteria allows readers to assess the rigor of the review process and the generalizability of the findings to their own context.

Methodology: The methodology section typically involves outlining the procedures and techniques employed to collect relevant data and information, including any data extraction forms that were used. Additionally, this section may also include information about the process of data extraction, such as how the data was collected, coded, and analysed. Furthermore, it is essential to include a description of the quality assessment process used to ensure that the extracted data was reliable and valid. This may involve explaining the criteria used to evaluate the quality of the studies, as well as any potential biases or limitations that were taken into consideration. By providing a thorough description of the methodology, readers will be able to assess the rigor of the research and better understand the context and implications of the findings.

Results: The results section summarises the main outcomes and findings of the review process, including the key themes, concepts, and trends identified in the literature. The results section provides a clear and concise description of the analysed data and should be presented in a logical and organized manner to make it easy for readers to understand. The results section of a literature review provides an overview of the evidence and information obtained from the analysed sources and explains how the findings support or challenge the research question or hypothesis. It is essential to ensure that the results are presented accurately, and any limitations or weaknesses of the study are acknowledged to provide a transparent and objective review of the literature.

Discussion: The discussion section of a literature review in research is an important component that provides a critical analysis of the literature reviewed in the study. This section allows the researcher to present their findings and interpretations of the literature, as well as to draw conclusions about the research question or problem being investigated. In the discussion section, the researcher will typically summarise the key findings of the literature review and then discuss these findings in relation to the research question or problem. The discussion section may also identify gaps in the literature and suggest areas for further research, as well as discuss the implications of the findings for theory, practice, or policy. Ultimately, the discussion section of a literature review should provide a comprehensive and insightful analysis of the literature reviewed, which contributes to the overall understanding of the research question or problem at hand.

Conclusion: The conclusion section in a literature review summarises the key findings and implications of the reviewed studies. It is the final part of the literature review that brings together all the main points and themes discussed in the previous sections. In this section, the researcher should provide a critical evaluation of the reviewed literature, highlighting the strengths and limitations of the studies, and how they relate to the research question or problem. The conclusion section should also address any gaps or inconsistencies in the existing literature and suggest future research directions. Furthermore, it should provide a clear and concise summary of the main findings and their significance for the field of study.

References: The reference section provides a comprehensive list of all the sources that have been cited in the literature review, including books, journal articles, reports, and other relevant materials. The purpose of the reference section is to give credit to the authors whose work has been used to support the arguments and ideas presented in the paper. Additionally, the reference section allows readers to locate and retrieve the sources that have been cited, which can help them further explore the topic or verify the accuracy of the information presented. The reference section is typically organized in alphabetical order by the last name of the first author of each source, and it includes all of the necessary bibliographic information such as the title of the work, the name of the journal or book, the date of publication, and the page numbers

Download our literature review template

Types of literature review in research

Literature reviews in research can be conducted for a variety of reasons, including to gain a comprehensive understanding of a topic, to identify research gaps, or to support the development of research proposals.

Here are the different types of literature reviews in research:

• Narrative Literature Review: A narrative literature review is an overview of the literature on a specific topic or research question that does not follow a structured or systematic approach. It is a qualitative review that summarizes and synthesizes the findings from different studies.
• Systematic Literature Review: A systematic literature review is a rigorous and structured approach to reviewing literature that involves a comprehensive search strategy, inclusion/exclusion criteria, and critical appraisal of the quality of evidence. It involves a meta-analysis and quantitative synthesis of data from multiple studies.
• Meta-analysis: A meta-analysis is a quantitative review of the literature that involves statistical analysis of the data from multiple studies. It combines the results of different studies to produce an overall estimate of the effect size of a particular intervention or treatment.
• Scoping Review: A scoping review is a type of literature review that aims to map the existing literature on a topic, identify research gaps, and provide an overview of the evidence. It is useful when the research question is broad or unclear.
• Rapid Review: A rapid review is a type of systematic review that uses streamlined methods to quickly and efficiently review the literature. It is useful when there is a time constraint or when there is a need to update a previous review.
• Umbrella Review: An umbrella review is a type of systematic review that synthesizes the findings of multiple systematic reviews on a particular topic. It provides a higher level of evidence by combining the findings from multiple studies.
• Critical Review: A critical review involves the evaluation and analysis of the strengths and weaknesses of the literature on a particular topic. It assesses the quality, credibility, and relevance of the literature and identifies research gaps.

Literature review example:

A literature review can play a crucial role in connecting with qualitative talanoa research. Talanoa is a research approach that emphasises collaboration, dialogue, and relationships within Pacific communities. Conducting a thorough literature review can help researchers to identify existing knowledge and gaps in ta specific field. This can inform the design of Talanoa research that centers on community engagement and dialogue. By reviewing literature that focuses on Pacific cultures, histories, and knowledge systems, researchers can develop a deeper understanding of the context and values of the community they are working with. This can help to build trust and establish meaningful relationships between researchers and community members.

An example of a literature review is our social research on Pacific peoples’ concerns about COVID-19, titled “The $7 cabbage dilemma: Pacific peoples’ experiences and New Zealand’s COVID-19 response.pdf” The objective of our study was to investigate how the COVID-19 pandemic impacted the wellbeing of Pacific peoples in New Zealand. To accomplish this, we conducted a comprehensive literature review of existing research on Pacific peoples’ urban climate change, health, economy, and housing in New Zealand. Through our talanoa-based research, we discovered that many Pacific peoples were worried about the cost of living, access to healthcare, support for parents, and affordable healthy food options, which were all connected to the broader themes of urban climate change, health, economy, and housing that we had identified in our literature review.

In conclusion, a literature review is an essential component of research as it helps to identify gaps in existing knowledge, provide direction for future research and support or challenge research questions or hypotheses. The purpose of a literature review is to offer a comprehensive overview of the relevant research within a given area, identify key themes and topics, and synthesize information from multiple studies. Researchers need to pay attention to the different types of literature reviews and their unique features when conducting literature reviews to determine which review type would best suit their research question and help them achieve their desired results. A well-structured literature review should include an introduction, search strategy, inclusion and exclusion criteria, methodology and results sections. A well-executed literature review ensures that the research findings are reliable and valid and provides invaluable insights into the current state of research to inform future studies.

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By: Gerald Naepi

[email protected].

Welcome to the new OASIS website! We have academic skills, library skills, math and statistics support, and writing resources all together in one new home.

• Walden University
• Faculty Portal

Library Guide to Capstone Literature Reviews: Library Guide to Capstone Literature Reviews

The role of the literature review.

Your literature review gives readers an understanding of the scholarly research on your topic.

In your literature review you will:

• demonstrate that you are a well-informed scholar with expertise and knowledge in the field by giving an overview of the current state of the literature
• find a gap in the literature, or address a business or professional issue, depending on your doctoral study program; the literature review will illustrate how your research contributes to the scholarly conversation
• provide a synthesis of the issues, trends, and concepts surrounding your research

Be aware that the literature review is an iterative process. As you read and write initial drafts, you will find new threads and complementary themes, at which point you will return to search, find out about these new themes, and incorporate them into your review.

The purpose of this guide is to help you through the literature review process. Take some time to look over the resources in order to become familiar with them. The tabs on the left side of this page have additional information.

Short video: Research for the Literature Review

Short Video: Research for the Literature Review

(4 min 10 sec) Recorded August 2019 Transcript 

Literature review as a dinner party

To think about the role of the literature review, consider this analogy:  pretend that you throw a dinner party for the other researchers working in your topic area. First, you’d need to develop a guest list.

• The guests of honor would be early researchers or theorists; their work likely inspired subsequent studies, ideas, or controversies that the current researchers pursue.
• Then, think about the important current researchers to invite. Which guests might agree with each other?  Which others might provide useful counterpoints?
• You likely won’t be able to include everyone on the guest list, so you may need to choose carefully so that you don’t leave important figures out. 
• Alternatively, if there aren’t many researchers working in your topic area, then your guest list will need to include people working in other, related areas, who can still contribute to the conversation.

After the party, you describe the evening to a friend. You’ll summarize the evening’s conversation. Perhaps one guest made a comment that sparked a conversation, and then you describe who responded and how the topic evolved. There are other conversations to share, too. This is how you synthesize the themes and developments that you find in your research. Thinking about your literature research this way will help you to present your dinner party (and your literature review) in a lively and engaging way.

Short video: Empirical research

Video: How to locate and identify empirical research for your literature review

(6 min 16 sec) Recorded May 2020 Transcript 

Here are some useful resources from the Writing Center, the Office of Research and Doctoral Services, and other departments within the Office of Academic Support. Take some time to look at what is available to help you with your capstone/dissertation.

• Familiarize yourself with Walden support
• Doctoral Capstone Resources website
• Capstone writing resources
• Office of Student Research Administration
• Office of Research and Doctoral Services
• Visit the Writing Center

You can watch recorded webinars on the literature review in our Library Webinar Archives .

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Click through the PLOS taxonomy to find articles in your field.

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Open Access

Peer-reviewed

Research Article

Childhood trauma, PTSD/CPTSD and chronic pain: A systematic review

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Centre Hospitalier Agen-Nérac, Agen, France, UR 4139 Laboratoire de Psychologie, Université de Bordeaux, Bordeaux, France

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing – review & editing

Affiliation UR 4139 Laboratoire de Psychologie, Université de Bordeaux, Bordeaux, France

Roles Methodology, Validation, Writing – review & editing

Roles Conceptualization, Methodology, Supervision, Validation, Writing – review & editing

• Maria Karimov-Zwienenberg, 
• Wilfried Symphor, 
• William Peraud, 
• Greg Décamps

• Published: August 30, 2024
• https://doi.org/10.1371/journal.pone.0309332
• Peer Review
• Reader Comments

Despite the growing body of literature on posttraumatic stress disorder (PTSD) and chronic pain comorbidity, studies taking into account the role of childhood exposure to traumatic and adverse events remains minimal. Additionally, it has been well established that survivors of childhood trauma may develop more complex reactions that extend beyond those observed in PTSD, typically categorized as complex trauma or CPTSD. Given the recent introduction of CPTSD within diagnostic nomenclature, the aim of the present study is to describe associations between childhood trauma in relation to PTSD/CPTSD and pain outcomes in adults with chronic pain.

Following PRSIMA guidelines, a systematic review was performed using the databases Pubmed, PsychInfo, Psychology and Behavioral Sciences Collection, and Web of Science. Articles in English or French that reported on childhood trauma, PTSD/CPTSD and pain outcomes in individuals with chronic pain were included. Titles and abstracts were screened by two authors independently and full texts were consequently evaluated and assessed on methodological quality using JBI checklist tools. Study design and sample characteristics, childhood trauma, PTSD/CPTSD, pain outcomes as well as author’s recommendations for scientific research and clinical practice were extracted for analyses.

Of the initial 295 search records, 13 studies were included in this review. Only four studies explicitly assessed links between trauma factors and pain symptoms in individuals with chronic pain. Findings highlight the long-term and complex impact of cumulative childhood maltreatment (e.g., abuse and neglect) on both PTSD/CPTSD and chronic pain outcomes in adulthood.

This review contributes to current conceptual models of PTSD and chronic pain comorbidity, while adding to the role of childhood trauma and CPTSD. The need for clinical and translational pain research is emphasized to further support specialized PTSD/CPTSD treatment as well as trauma-informed pain management in routine care.

Citation: Karimov-Zwienenberg M, Symphor W, Peraud W, Décamps G (2024) Childhood trauma, PTSD/CPTSD and chronic pain: A systematic review. PLoS ONE 19(8): e0309332. https://doi.org/10.1371/journal.pone.0309332

Editor: Inga Schalinski, Universitat der Bundeswehr München: Universitat der Bundeswehr Munchen, GERMANY

Received: March 21, 2024; Accepted: August 9, 2024; Published: August 30, 2024

Copyright: © 2024 Karimov-Zwienenberg et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Over the past two decades, the comorbidity between chronic pain (i.e., persistent pain >3 months) and post-traumatic stress disorder (PTSD) has been well established [ 1 – 3 ]. PTSD is a psychiatric diagnosis based on the presence of a set of specific symptoms (e.g., flashbacks, hypervigilance, avoidance) that might occur after experiencing or witnessing a life-threatening event such as a disaster or assault. A recent meta-analysis including 21 studies reported higher PTSD prevalence up to 57% in individuals with chronic pain compared to 2–9% in the general population [ 4 ]. In the context of pain management, this alarming comorbidity represents many challenges as it has been associated with higher levels of pain severity [ 5 ], pain disability [ 6 ], and opioid use [ 7 ]. Furthermore, individuals with chronic pain and comorbid PTSD typically report increased levels of PTSD severity, emotional distress and psychiatric comorbidity than controls [ 8 – 10 ].

Several conceptual frameworks have been proposed, such as shared vulnerability and mutual maintenance models suggesting the interplay of neurobiological, emotional and cognitive factors involved in comorbidity [ 2 , 11 , 12 ]. Despite different hypotheses of causality and interaction, the particular nature of the relationship between chronic pain and PTSD remains uncertain. Depending on the studied population or condition, pain could both contribute to and maintain PTSD. Similarly, PTSD has been considered an important risk factor in the development of chronic pain when compared to controls [ 13 ].

Studies agree however that a history of adverse childhood events may be associated with both PTSD and chronic pain in adulthood [ 14 – 16 ]. Childhood adversity typically includes experiences of abuse, neglect as well as exposure to household dysfunction, parental psychopathology and early parental loss [ 17 ]. There is cumulative systematic and meta-analytical evidence demonstrating increased risk of chronic pain and pain-related disability in individuals reporting single or cumulative exposure to adverse childhood events, in particular maltreatment (e.g., childhood abuse, neglect) [ 15 , 18 , 19 ]. Although psychological distress has been identified as a key aspect to this phenomenon, few studies examined the role of PTSD in this context, indicating a gap in clinical and translational pain research, particularly in regard to trauma-informed pain management [ 20 ] as well as psychological treatment for comorbid trauma and chronic pain [ 21 ].

Additionally, it has been well established that survivors of childhood adversity may develop more complex and multifaceted reactions that extend beyond those observed in PTSD. These reactions have been commonly categorized as complex trauma or complex PTSD (CPTSD) [ 22 , 23 ]. CPTSD describes the widespread and long-lasting consequences following exposure to ongoing and often inescapable interpersonal traumatic stress that occurs within the context of a significant relationship (e.g., childhood abuse, intimate personal violence) [ 22 , 24 ]. Disparate adaptations to interpersonal trauma were initially conceptualized as an associated feature of PTSD by Disorders of Extreme Stress Not Otherwise Specified (DESNOS) [ 25 ]. However, due to the lack of sufficient evidence to support its inclusion as a unique diagnostic entity, DESNOS was eventually dropped from the fifth version of the Diagnostic and Statistical Manual (DSM) [ 26 ]. More recently, the World Health Organization published the 11 th version of the International Classification of Diseases (ICD-11) [ 27 ] introducing CPTSD for the first time into diagnostic nomenclature. Alongside the crucial presence of PTSD symptoms, the current model shares many similarities with DESNOS, including affect dysregulation, negative self-concept and interpersonal difficulties which are typically referred to as disturbances in self-organization (i.e., DSO symptoms) [ 28 , 29 ]. Additionally, consistent with recent data [ 30 , 31 ] and earlier conceptual research [ 29 , 32 ], current ICD-11 guidelines expanded trauma exposure definition for PTSD and CPTSD by taking into account different types of interpersonal trauma, including childhood neglect and emotional abuse, in addition to DSM criterion A events. In the context of chronic pain, there is some preliminary evidence suggesting worsened pain outcomes in survivors of childhood abuse with CPTSD as opposed to PTSD symptoms alone [ 33 ]. As PTSD and CPTSD are currently considered related disorders, it seems of timely interest to address how these relate to pain chronicity in order to promote effective treatment options and pain management for individuals with comorbid PTSD/CPTSD and chronic pain.

Despite the growing body of research on the trauma-chronic pain relationship, evidence in relation to PTSD/CPTSD following childhood exposure to traumatic or adverse events remains scarce. The aim of this study is to conduct a systematic review exploring existing data on the described links, while taking into account authors’ recommendations for future research and clinical practice. For the purpose of this review, in line with previous conceptual research and current ICD-11 PTSD/CPTSD guidelines, the term childhood trauma is used to address the exposure of traumatic or adverse events before the age of 18 years.

Specifically, this review seeks to describe in individuals with chronic pain:

• Childhood trauma
• Posttraumatic stress symptomatology, including PTSD and CPTSD symptoms.
• Relationship between childhood trauma and posttraumatic stress symptomatology, including PTSD and CPTSD.
• Relationship between trauma factors and chronic pain symptoms
• Scientific research
• Clinical practice

Search strategy

Before conducting this systematic review, a search in the Prospero database showed that, to our knowledge, no literature review is currently in progress on this subject ( https://www.crd.york.ac.uk/PROSPERO/ accessed on July 2023).

To conduct the present systematic review, we followed the guidelines described by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [ 34 ]. A search was performed from 1st of August 2023 using the following databases: Pubmed (Medline); PsychInfo (EBSCO host ), Psychology & Behavioral Sciences Collection (EBSCO host ), and Web of Science (Web of Knowledge). Search strategy terms are presented in Table 1 .

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0309332.t001

Inclusion and exclusion criteria

As per guidance, PICOTS framework [ 35 ] was used to structure the review process by defining selection criteria as follows: [ 1 ] Population, [ 2 ] Intervention, [ 3 ] Comparison, [ 4 ] Outcome, [ 5 ] Time and [ 6 ] Setting. Predefined inclusion and exclusion criteria are presented in Table 2 .

https://doi.org/10.1371/journal.pone.0309332.t002

Study selection and data extraction

Studies were selected independently by two authors (MKZ and WS) by screening titles and abstracts in systematic review. The selected studies were then subject to full text screening by applying the selection criteria. Reasons were documented during the process. In case of disagreement, discrepancies were adjudicated by a third author (WP) until a consensus was reached among the three authors. Once study eligibility was confirmed, data was extracted between September 2023 and December 2023 by one author (MKZ) which was then verified by a second author (WS). The following items were identified for data collection: authors, year, country, study design, study sample, chronic pain condition, chronic pain symptomatology, childhood trauma exposure, PTSD/CPTSD, interaction data between trauma factors and chronic pain symptomatology, and finally, author’s recommendations for scientific research and clinical practice.

Critical appraisal of study quality

The methodological quality of each included study was independently assessed by two researchers (MKZ and WS) using the corresponding design-specific critical appraisal checklist tools provided by the Joanna Briggs Institute (JBI) [ 36 ]. The following JBI critical appraisal checklist tools were used for this review: case control studies, analytical cross-sectional studies, quasi-experimental, as well as cohort studies. Each component was rated as “Yes”, “No”, “Unclear, or “Not Applicable”. If needed, discrepancies were discussed between reviewers or by consulting a third author (WP) until consensus was reached. Based on previous systematic reviews [ 37 , 38 ], studies with a JBI score higher than 70% were considered as high quality, those with scores between 50% and 70% as moderate quality, and those with a score less than 50% as low quality.

Study design and participants characteristics

The initial search returned 297 records, of which 36 were retained for full-text analysis. Finally, 13 articles [ 39 – 50 ] were included in this systematic review without disagreement (i.e., inter-judge agreement = 100%). Fig 1 presents a flow-diagram of the research article selection process.

https://doi.org/10.1371/journal.pone.0309332.g001

The 13 studies included in this review were published between 2005 and 2023 and conducted in Europe (Italy, n = 1; Belgium, n = 1; Spain, n = 2; Germany, n = 1), Turkey n = 1; Israel ( n = 3), and the US ( n = 4). Four were case-control studies, 7 cross-sectional studies, 1 quasi-experimental study and 1 cohort study. There was some variety in sample sizes across the studies, ranging from 70 to 295 participants, recruited both from clinical ( n = 9) and community settings ( n = 4). All study populations compromised exclusively ( n = 7) or predominantly female participants (>64%). Finally, Fibromyalgia (FM) was found to be the most studied pain condition ( n = 9), followed by unspecified chronic pain ( n = 3), and Interstitial cystitis/bladder pain syndrome (IC/BPS) ( n = 1). In terms of missing data, it was found that the majority of the included studies did not address all outcomes of interest to this review. Unreported information on outcomes was identified as “Not Reported” (N/R). Study findings are listed in Tables 3 and 4 .

https://doi.org/10.1371/journal.pone.0309332.t003

https://doi.org/10.1371/journal.pone.0309332.t004

Quality of the included studies

The results of the quality assessment are summarized in Table 5 . Quality appraisal using the JBI checklist tools indicated overall moderate to high quality studies. Nine studies scored above 70% [ 39 , 40 , 42 – 44 , 46 – 49 ], three studies scored between 50% and 70% [ 41 , 45 , 51 ], and the remaining one study [ 50 ] scored 13%. The main limitations of the single low-quality study were lack of objective and valid methods of assessment regarding chronic pain outcomes.

https://doi.org/10.1371/journal.pone.0309332.t005

Study objective 1: Descriptive data of trauma factors in individuals with chronic pain

A. childhood trauma..

All but one study [ 47 ] included in this review reported childhood trauma in terms of maltreatment, demonstrating higher prevalence [ 39 , 41 , 42 ] and severity [ 45 , 48 ] for emotional abuse and neglect compared to other forms of childhood maltreatment in individuals reporting chronic pain. In addition, a cohort study [ 48 ] demonstrated significative interrelations between all types of abuse and neglect, except for sexual abuse and neglect in a clinical sample of FM patients. Ciccone et al. [ 40 ] found no differences in childhood physical or sexual abuse between women reporting FM and healthy controls.

When compared with other medical conditions, studies found higher childhood maltreatment rates and severity in individuals with chronic pain, in particular with regards to neglect [ 39 , 41 , 45 ], sexual abuse [ 39 , 41 ], and emotional abuse [ 41 , 45 ].

Only two studies assessed childhood trauma exposure based on PTSD qualifying stressors following DSM criteria [ 42 , 47 ]. For example, Gardoki-Souto et al. [ 42 ] found that most prevalent traumatic events were reported during childhood compared to adulthood. Physical, sexual, and emotional abuse were identified as most commonly reported traumatic events during childhood. McKernan et al. [ 47 ] demonstrated differences in gender, with higher rates of childhood neglect observed in women, while men seemed to report more general disaster/trauma [ 47 ].

Finally, Hart-Johnson & Green [ 43 ] identified confounding effects of race and sex showing higher physical abuse under the age of 14 in male participants with chronic pain as opposed to women reporting chronic pain, with highest rates of abuse reported in black male participants and lowest in white female participants. Sexual penetration during childhood was found to be most prevalent among black female participants when compared with male or white female participants.

b. Posttraumatic stress symptomatology: PTSD/CPTSD.

In this review, the majority of the included studies described PTSD prevalence exclusively for predominantly female FM study samples with rates ranging from 10.7% to 37% [ 39 – 41 , 44 , 45 , 48 , 51 ]. One study [ 42 ] reported PTSD prevalence up to 71% following exposure to cumulative trauma as categorized by age. Results showed that most prevalent traumatic events occurred during childhood but continued into adulthood in the form of both different and recurrent types of events favoring a process of continuous re-traumatization. The lifelong impact of childhood trauma was further emphasized by high levels of current perceived distress in relation to past experiences of early life adversity.

When compared to controls, multiple studies showed higher PTSD prevalence and severity in individuals with chronic pain versus other medical conditions, including rheumatoid arthritis (RA) [ 45 ], functional disorders and achalasia [ 41 ], as well as healthy individuals [ 40 ]. Only one study [ 40 ] investigated PTSD symptom clusters, and found significatively higher rates for Intrusion and Arousal clusters, but not Avoidance when comparing a community sample of women with FM to healthy controls. Groups did not differ in childhood exposure to physical and/or sexual abuse.

Two studies included CPTSD measures in addition to PTSD [ 49 , 50 ] providing evidence for CPTSD and chronic pain comorbidity following childhood sexual abuse. For example, Peles et al. [ 49 ] demonstrated CPTSD prevalence rates between 19.1% and 60% in female survivors of childhood sexual abuse receiving methadone maintenance treatment versus those without a history of opioid addiction. Chronic pain comorbidity rates differed between CPTSD versus non CPTSD patients (100% vs 50%) without a history of addiction. Tsur [ 50 ] investigated PTSD/CPTSD in association with trauma-related pain symptoms and found higher levels of CPTSD symptoms (i.e., PTSD + DSO) linked to higher rates of pain flashbacks (23.1%), which is considered a posttraumatic stress response centralizing around pain, compared to women reporting non-pain flashbacks (36.3%) and no flashback symptoms (40.6%). In both studies, chronic pain was a self-reported outcome based on the presence of persistent pain lasting for more than six months. None of the included studies in this review reported on CPTSD in clinically diagnosed chronic pain patients or those receiving care for pain management.

Study objective 2: Interaction data between trauma factors and pain symptoms in individuals with chronic pain

A. childhood trauma, ptsd/cptsd in individuals with chronic pain..

Except for two studies [ 49 , 50 ], all included studies assessed childhood trauma in relation to PTSD as opposed to CPTSD. Several studies found that more severe childhood trauma, in particular maltreatment, was associated with PTSD in individuals with chronic pain [ 42 , 48 ] when compared to those without PTSD and healthy controls [ 46 ]. For example, in a community sample, higher rates of childhood trauma exposure, including sexual abuse, were found in participants with IC/BPS and comorbid PTSD as opposed to those without PTSD, represented by medium to large effect sizes. No differences were found regarding adult trauma exposure, including physical and sexual abuse, between these groups [ 47 ]. As for evidence on CPTSD outcomes, Tsur [ 50 ] associated higher childhood sexual abuse severity with increased experiences of pain flashbacks as well as CPTSD symptoms compared to controls (i.e., non-pain flashbacks, no flashbacks).

b. Trauma factors and pain symptoms in individuals with chronic pain.

Four studies included in this review explicitly investigated the association between childhood trauma, PTSD/CPTSD, and pain symptoms in individuals with chronic pain [ 41 , 47 , 49 , 50 ]. For example, Coppens et al. [ 41 ] assessed childhood maltreatment in relation to perceived pain experiences and found an indirect effect of childhood abuse and neglect on both quantitative and qualitative pain reports through PTSD severity, representing medium effect sizes. No relationship between childhood maltreatment severity and pain reports was revealed, nor a moderator effect of PTSD, suggesting a mediation effect. Other studies included in this review found direct effects of childhood trauma, in particular neglect and emotional abuse, on pain outcomes, including pain-related health impact and disability [ 39 , 42 ].

McKernan et al. [ 47 ] investigated the role of criterion A trauma on the relationship between chronic pain phenotypes and PTSD. In a convenience sample of participants with IC/BPS and comorbid PTSD, higher rates of current pain and clinically relevant central sensitization (CS) were observed in individuals as opposed to those without PTSD, represented by medium to large effect sizes. When comparing IC/BPS subgroups based on CS levels, all patients with PTSD corresponded to criteria of the widespread IC/BPS phenotype, associated with higher rates of polysymptomatic complaints, psychosocial distress and pain levels. While IC/BPS participants with CS reported higher rates of childhood trauma as well as lifetime physical and sexual abuse, PTSD was shown to be uniquely related over and above trauma exposure to widespread pain phenotype of IC/BPS.

Another study, using quasi-experimental design assessed analgesic responses in FM patients with and without PTSD based on stress-induced changes in pain and intolerance thresholds during a Social Stress Test task [ 46 ]. Results revealed lower basal pressure pain and intolerance thresholds during recovery when compared to healthy controls, indicating hyper sensitivity at basal function in FM patients, regardless the presence of PTSD. In response to acute stress, however, FM patients showed differences in hypo reactivity during the task, such as a lack of hyperalgesic response in FM with PTSD during and after exposure as opposed to a delay of a hyperalgesic response in FM patients without PTSD. Higher childhood trauma severity was found in FM patients with PTSD than those without PTSD. Groups did not vary in pain intensity or chronicity levels of FM symptoms.

Regarding CPTSD, two studies investigated associations with chronic pain comorbidity in female survivors of childhood sexual abuse. For example, a cross-sectional study conducted in a clinical sample, demonstrated positive correlations between chronic pain symptoms (e.g., pain severity, number of painful body regions), sexual abuse-related PTSD and CPTSD severity in adulthood. Age of onset of first experience of sexual abuse was negatively associated with pain duration [ 49 ]. Another study provided evidence for understanding the link between childhood sexual abuse, CPTSD and chronic pain by highlighting the role of somatic pain-related manifestations of PTSD/CPTSD, in particular pain flashbacks. Further, results identified peritraumatic pain during childhood sexual abuse as a risk factor for chronic pain in adulthood [ 50 ]. Overall, both studies including CPTSD measurement highlighted high prevalence of chronic pain in survivors of childhood sexual abuse associated with higher psychiatric comorbidity, namely CPTSD.

Finally, two studies demonstrated transcultural validity for associations between childhood trauma, PTSD and chronic pain symptoms drawing from evidence obtained in clinical settings across Europe, North America, and the Middle-East [ 44 , 45 ]. A study conducted in a community sample elucidated differences in chronic pain experiences in relation to abuse history based on sex differences [ 43 ]. Particularly, molestation was associated with higher affective pain, but only in men with chronic pain when compared with female participants. Similarly, childhood molestation predicted pain-related PTSD only in men, when controlling for race, sex and education. Female survivors of childhood sexual abuse were equally likely to have pain-related PTSD as women without a history of abuse.

Study objective 3: Author’s recommendations for future research and clinical practice

A. scientific research..

In the study of etiology and pathophysiology of chronic pain, comorbid mental disorders and psychological distress should be considered [ 44 ]. Additional research is also needed identifying mediating or moderating factors on the childhood trauma–HPA axis dysregulation relationship in chronic pain, using psychophysiological measures [ 48 , 51 ]. Suggested characteristics of childhood trauma typically include developmental timing and subtypes, while calling for empirical attention to childhood neglect [ 45 ], as well as subsequent experiences of violence or abuse, and ongoing interpersonal relations later in life [ 48 ]. Concurrently, more attention should be addressed to pain-specific posttraumatic stress symptoms (e.g., pain flashbacks, avoidance of trauma-related pain sensations), as well as somatic manifestations of CPTSD in relation to chronic pain [ 50 ]. Future research should assess trauma focused-interventions in FM in order to further clarify trauma-based etiology of FM in comparison to other functional somatic syndromes, medically unexplained symptoms, somatic symptoms, and related psychopathology [ 42 ]. Some findings included in this review also warrant further investigation on whether some psychological states of detachment (e.g., dissociation) might explain hypo reactivity in FM patients as a coping strategy. When addressing trauma in the context of chronic pain, differences in patients based on the presence of PTSD should be considered in future research by using a differential profile approach [ 46 ]. Finally, in the study of abuse and trauma in relation to chronic pain, more research should include men [ 43 ].

b. Clinical practice.

The majority of the included studies recommend systematic screening for trauma factors such as childhood trauma and PTSD/CPTSD [ 41 , 42 ], regardless of race, age or gender [ 43 ]. Specific training might be needed to reduce identified barriers (e.g., lack of time, discomfort with subject, or lack of familiarity with the role of abuse) to appropriate and effective screening methods [ 43 ]. Screening procedures should also include detection for potential comorbid mental disorders in relation to abuse, such as somatoform dissociation disorder and alexithymia, using appropriate tools [ 44 , 51 ]. Trauma-focused therapies may include Eye Movement Desensitization and Reprocessing (EMDR) [ 42 ], as well as intervention techniques based on Eccleston’s model of tripartite system of threat protection in order to support FM patients with and without PTSD to engage in more adaptive stress responses [ 46 ]. As PTSD appears to be associated with the “widespread” pain phenotype, multimodal treatment should be considered for these patients [ 47 ]. Trauma-informed care is recommended in a more general way, emphasizing patient-care provider trust and rapport, reducing anxiety and increasing patient control and safety during appointments and medical examination procedures [ 47 ]. Finally, clinicians treating survivors of abuse should specifically inquire about chronic pain complaints, in order to facilitate tailored adequate approaches in comprehensive treatment [ 49 ].

Despite the growing evidence on the trauma-pain relationship, literature examining the association between childhood trauma and PTSD in relation to pain outcomes remains limited. This review further adds on existing systematic data by including evidence on CPTSD in individuals with chronic pain. In total, 13 studies were included in this systematic review. Study highlights have been summarized into the following sections in order to guide future research as well as recommended evidence-based clinical practice and policy in routine pain management.

Childhood trauma: Neglect and emotional abuse in individuals with chronic pain

Different aspects of childhood trauma have been previously identified as risk factors for chronic pain conditions, such as nature of trauma [ 15 , 52 ], and cumulative experiences of maltreatment to [ 19 , 53 , 54 ]. In addition to existing systematic and metanalytical data, studies included in this review particularly emphasize the long-term consequences of emotional abuse and neglect as opposed to physical and sexual abuse. Consistent with DSM A-criterion type of traumatic events, other reviews typically focused on the impact of abuse specific childhood trauma (e.g., physical abuse, sexual abuse) [ 10 , 52 , 55 , 56 ]. There is some research, however, indicating an independent relationship between PTSD symptoms and chronic pain outcomes following the presence of criterion A trauma history [ 57 ]. Moreover, present findings provide evidence for the expanded definition of trauma exposure by current PTSD/CPTSD ICD-11 guidelines, in particular with respect to the inclusion of childhood neglect and emotional abuse, in addition to DSM A criterion events. Despite suggested relevance to chronic pain etiology and PTSD/CPTSD comorbidity, research clarifying the differential impact of neglect and emotional abuse alongside events of childhood physical and sexual abuse remains minimal and warrants further investigation whether and to what extent these forms of trauma are associated with unique healthcare needs in chronic pain management.

The long-term impact of childhood trauma: Evidence for differential patterns in PTSD/CPTSD and pain modulation processes

In total, only four studies included in this review explicitly investigated relationships between childhood trauma, PTSD/CPTSD and pain outcomes in individuals with chronic pain. The present findings are in accordance with other research demonstrating the negative impact of PTSD on pain outcomes when linked to childhood maltreatment compared to lower levels of pain typically experienced by individuals who have been diagnosed with PTSD alone [ 54 , 58 ]. The long-term impact of cumulative childhood trauma was further recognized by an indirect dose-response relationship associated with increased risk of re-traumatization, higher levels of PTSD and perceived distress when compared to adulthood trauma. Similar to results of a recent systematic review [ 1 ], certain chronic pain phenotypes (e.g., “widespread pain”) were identified as risk factors for described links.

This review also included evidence on biomarkers involved in pain modulation processes (e.g., cortisol secretion, pressure pain thresholds). In addition to existing systematic data [ 59 ], study findings support inhibitory capacity of adaptive allodynic responses in chronic pain patients with a history of childhood trauma by adding information to the role of PTSD. In this connection, differential neurophysiological patterns in chronic pain patients with PTSD compared to those without PTSD were associated with two main psychological/behavioral responses, namely hyperarousal and dissociation [ 46 , 48 ]. This hypothesis is in line with previous studies, suggesting a unique paradoxical pain profile in individuals with chronic pain and PTSD, characterized by both pain-related hypo- and hyperresponsivity when compared to controls [ 8 , 60 ]. Other research has emphasized the role of childhood versus adulthood trauma exposure in advancing current understanding of differential PTSD-related conditions (e.g., dissociation, depression) and physical health symptoms, including pain [ 61 ].

It is important to note, however, that results associating childhood trauma, PTSD, and pain are typically obtained in the absence of any CPTSD assessment. Only one study included in this review examined differential role of CPTSD symptoms in relation to childhood trauma, while identifying pain-related somatic manifestations (e.g., pain flashbacks) both as maintaining and worsening factors of chronic pain outcomes. These results are consistent with some preliminary research demonstrating associations between CPTSD symptoms (i.e., DSO symptoms) and higher rates of somatization [ 62 ] as well as abusive pain personification in individuals with childhood trauma compared to those with PTSD [ 33 ]. Despite important implications for empirical and clinical efforts as argued by a recent review [ 63 ], our understanding of trauma-related bodily experiences remains an underdeveloped realm of translational pain research. In particular, findings in this review corroborate the current lack of validated and standardized assessment for pain-related trauma factors (e.g., peri and posttraumatic pain) which was identified as a major barrier to more robust methodological evidence. The need for future research adopting a differential analytical approach (e.g., cluster analysis), has also been issued to verify theorized relationships in order to extend current conceptual models of comorbidity and pain phenotypes by considering the unique features of CPTSD alongside PTSD symptoms.

Trauma–pain comorbidity: Intersectional disparities

Although transcultural validity of trauma factors in chronic pain outcomes was consistently reported in this review [ 44 , 45 ], the majority of the included study samples represented predominantly Caucasian and female individuals suffering from FM. Only one study provided some insight into intersectional disparities regarding childhood abuse in adults with chronic pain [ 43 ]. Findings corroborate the lack of available evidence identified by a recent review [ 64 ], emphasizing the critical need for more inclusive research to ensure that underrepresented groups receive equitable benefit from chronic pain research in terms of health and social policy. The same applies to trauma factors that remain oftentimes under-recognized, under-treated, or inadequately treated among marginalized groups [ 65 ]. More research is needed to explore the interplay of social factors (e.g., socioeconomic status, gender, race) and health disparities, while building on evidence for a more precise understanding of trauma-pain comorbidity and management within social context.

Trauma focused treatment versus trauma-informed care

Considering the widespread prevalence of childhood trauma and both its long-term and complex impact on posttraumatic symptoms and pain related outcomes later in life, recommendations for clinical practice included in this review address the need for systematic screening of trauma factors in individuals seeking care for chronic pain. Consequently, psychotherapeutic strategies should target PTSD/CPTSD to relief illness burden, helping individuals with chronic pain to engage in more adaptive stress responses and promote general functioning [ 41 , 42 , 46 ]. Despite extensive literature on psychological treatment for PTSD, there is currently no “gold standard” for CPTSD screening or intervention methods. Furthermore, numerous limitations have been associated with first-line, evidence-based treatments for PTSD, including early dropout and worsening of symptoms in survivors of interpersonal trauma [ 66 – 68 ]. In this regard, Trauma Center Trauma Sensitive Yoga (TCTSY) [ 69 ]’, an evidence-based protocol for complex trauma or treatment-resistant PTSD, appears to be a particularly promising therapeutic strategy, drawing specific focus to interoception (i.e., awareness of bodily sensations) and empowerment processes. While there is cumulative qualitative and quantitative evidence demonstrating protocol efficacity compared to conventional psychotherapy modalities [ 70 – 72 ], the use of TCTSY in individuals with chronic pain has not yet been investigated. In addition to trauma specialized treatment, and in line with a recent topical review [ 73 ], the present findings further support the importance of a systems approach to trauma care in pain management and rehabilitation services. Future research is needed to investigate comprehensive models of trauma-informed care based on principals such as safety, collaboration and choice within routine practice as a means to improve patient adherence, pain outcomes and prevent re-traumatization.

Methodological considerations

This systematic review was conducted following recommended guidelines for search strategy as well as quality assessment allowing for a more rigorous process regarding methodological appraisal. Some limitations, however, should be taken into consideration in analyzing key findings. The search was not limited to study design, year of publication or methodological quality. Further, inclusion criteria for chronic pain and trauma factors were generally defined such as to provide a broad overview of the current state of art, limiting therefore conclusive or generalizing evidence regarding subtypes of trauma in relation to specific pain syndromes or phenotypes. Despite the inclusive approach to this review, only a short list of mostly moderate to high quality evidence, was identified, highlighting the preliminary nature of research in this area. Overall, the selected studies used appropriate and validated measurement for childhood trauma, PTSD/CPTSD and chronic pain which included a variety of self-reported as well as physician-based assessment. However, the heterogeneity of tools included in this review, in particular for PTSD/CPTSD, warrants vigilance to generalization of findings. Further, the majority of selected studies used the Childhood Trauma Questionnaire [CTQ; 74 ] as primary measurement for childhood trauma. While this is a validated and widely utilized instrument in the study of childhood trauma history, it provides assessment limited only to childhood maltreatment (i.e., abuse and neglect). Only two studies in this review assessed childhood trauma exposure based on PTSD qualifying stressors following DSM diagnostic criteria. This review recognizes the instability around diagnostic consensus of PTSD/CPTSD proposed by distinct classification models over the past two decades. For example, based on earlier diagnostic and clinical literature [ 22 , 25 ], somatization was typically considered a core feature of DSM DESNOS, but does not appear in the current WHO ICD-11 model of CPTSD. Finally, to the best of our knowledge, there is currently no randomized controlled, longitudinal or case study evidence investigating intervention modalities for PTSD/CPTSD and chronic pain comorbidity in individuals with a history of childhood trauma.

The findings of this systematic review highlight the importance of taking into account childhood trauma, in particular neglect and emotional abuse, in the study of PTSD/CPTSD and chronic pain comorbidity in adults. The long-term impact of childhood trauma was further emphasized by an indirect dose-response relationship associated with increased risk of re-traumatization, higher levels of PTSD and perceived distress later in life when compared to adulthood trauma. This review also included evidence on specific neurophysiological patterns in chronic pain patients with PTSD suggesting differential pain modulation processes following trauma, in particular childhood maltreatment. Only a few selected studies reported on CPTSD and chronic pain comorbidity, providing preliminary evidence on the role of trauma-related physical pain (e.g., pain flashbacks). The need for future research adopting a differential approach has been issued in order to extend current models of comorbidity in relation to pain phenotypes, while also accounting for intersectional disparities. Considering the widespread prevalence of childhood trauma and its long-term and complex impact on both PTSD/CPTSD and pain chronicity later in life, recommendations for clinical practice draw attention to the need for PTSD/CPTSD specialized treatment as well as trauma-informed pain management in routine care.

Supporting information

S1 file. prisma checklist 2020..

https://doi.org/10.1371/journal.pone.0309332.s001

S2 File. List of identified studies in the literature search.

https://doi.org/10.1371/journal.pone.0309332.s002

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• Published: 30 August 2024

A scoping review of stroke services within the Philippines

• Angela Logan 1 , 2 ,
• Lorraine Faeldon 3 ,
• Bridie Kent 1 , 4 ,
• Aira Ong 1 &
• Jonathan Marsden 1  

BMC Health Services Research volume  24 , Article number:  1006 ( 2024 ) Cite this article

Metrics details

Stroke is a leading cause of mortality and disability. In higher-income countries, mortality and disability have been reduced with advances in stroke care and early access to rehabilitation services. However, access to such services and the subsequent impact on stroke outcomes in the Philippines, which is a lower- and middle-income countries (LMIC), is unclear. Understanding gaps in service delivery and underpinning research from acute to chronic stages post-stroke will allow future targeting of resources.

This scoping review aimed to map available literature on stroke services in the Philippines, based on Arksey and O’Malley’s five-stage-process.

Summary of review

A targeted strategy was used to search relevant databases (Focused: MEDLINE (ovid), EMBASE (ovid), Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO (ebsco); broad-based: Scopus; review-based: Cochrane Library, International Prospective Register of Systematic Reviews (PROSPERO), JBI (formerly Joanna Briggs Institute) as well as grey literature (Open Grey, Google scholar). The searches were conducted between 12/2022-01/2023 and repeated 12/2023. Literature describing adults with stroke in the Philippines and stroke services that aimed to maximize well-being, participation and function were searched. Studies were selected if they included one or more of: (a) patient numbers and stroke characteristics (b) staff numbers, qualifications and role (c) service resources (e.g., access to a rehabilitation unit) (d) cost of services and methods of payment) (e) content of stroke care (f) duration of stroke care/rehabilitation and interventions undertaken (g) outcome measures used in clinical practice.

A total of 70 papers were included. Articles were assessed, data extracted and classified according to structure, process, or outcome related information. Advances in stroke services, including stroke ready hospitals providing early access to acute care such as thrombectomy and thrombolysis and early referral to rehabilitation coupled with rehabilitation guidelines have been developed. Gaps exist in stroke services structure (e.g., low number of neurologists and neuroimaging, lack of stroke protocols and pathways, inequity of stroke care across urban and rural locations), processes (e.g., delayed arrival to hospital, lack of stroke training among health workers, low awareness of stroke among public and non-stroke care workers, inequitable access to rehabilitation both hospital and community) and outcomes (e.g., low government insurance coverage resulting in high out-of-pocket expenses, limited data on caregiver burden, absence of unified national stroke registry to determine prevalence, incidence and burden of stroke). Potential solutions such as increasing stroke knowledge and awareness, use of mobile stroke units, TeleMedicine, TeleRehab, improving access to rehabilitation, upgrading PhilHealth and a unified national long-term stroke registry representing the real situation across urban and rural were identified.

This scoping review describes the existing evidence-base relating to structure, processes and outcomes of stroke services for adults within the Philippines. Developments in stroke services have been identified however, a wide gap exists between the availability of stroke services and the high burden of stroke in the Philippines. Strategies are critical to address the identified gaps as a precursor to improving stroke outcomes and reducing burden. Potential solutions identified within the review will require healthcare government and policymakers to focus on stroke awareness programs, primary and secondary stroke prevention, establishing and monitoring of stroke protocols and pathways, sustainable national stroke registry, and improve access to and availability of rehabilitation both hospital and community.

What is already known?

Stroke services in the Philippines are inequitable, for example, urban versus rural due to the geography of the Philippines, location of acute stroke ready hospitals and stroke rehabilitation units, limited transport options, and low government healthcare insurance coverage resulting in high out-of-pocket costs for stroke survivors and their families.

What are the new findings?

The Philippines have a higher incidence of stroke in younger adults than other LMICs, which impacts the available workforce and the country’s economy. There is a lack of data on community stroke rehabilitation provision, the content and intensity of stroke rehabilitation being delivered and the role and knowledge/skills of those delivering stroke rehabilitation, unmet needs of stroke survivors and caregiver burden and strain,

What do the new findings imply?

A wide gap exists between the availability of stroke services and the high burden of stroke. The impact of this is unclear due to the lack of a compulsory national stroke registry as well as published data on community or home-based stroke services that are not captured/published.

What does this review offer?

This review provides a broad overview of existing evidence-base of stroke services in the Philippines. It provides a catalyst for a) healthcare government to address stroke inequities and burden; b) development of future evidence-based interventions such as community-based rehabilitation; c) task-shifting e.g., training non-neurologists, barangay workers and caregivers; d) use of digital technologies and innovations e.g., stroke TeleRehab, TeleMedicine, mobile stroke units.

Peer Review reports

Introduction

In the Philippines, stroke is the second leading cause of death, with a prevalence of 0·9% equating to 87,402 deaths per annum [ 1 , 2 ]. Approximately 500,000 Filipinos will be affected by stroke, with an estimated US$350 million to $1·2 billion needed to meet the cost of medical care [ 1 ]. As healthcare is largely private, the cost is borne out-of-pocket by patients and their families. This provides a major obstacle for the lower socio-demographic groups in the country.

Research on implementation of locally and regionally adapted stroke-services and cost-effective secondary prevention programs in the Philippines have been cited as priorities [ 3 , 4 ]. Prior to developing, implementing, and evaluating future context-specific acute stroke management services and community-based models of rehabilitation, it was important to map out the available literature on stroke services and characteristics of stroke in the Philippines.

The scoping review followed a predefined protocol, established methodology [ 5 ] and is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses Extension for Scoping Reviews Guidelines (PRISMA-ScR) [ 6 , 7 ]. Healthcare quality will be described according to the following three aspects: structures, processes, and outcomes following the Donabedian model [ 8 , 9 ].The review is based on Arksey and O'Malley’s five stages framework [ 5 ].

Stage 1: The research question:

What stroke services are available for adults within the Philippines? The objective was to systematically scope the literature to describe the availability, structure, processes, and outcome of stroke services for adults within the Philippines.

Stage 2: Identifying relevant studies:

The following databases were searched. Focused: MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO; broad-based: Scopus; review-based: Cochrane Library, Prospero, JBI (formerly Joanna Briggs Institute); Grey literature: Herdin, North Grey, Grey matters, MedRxiv, NIHR health technology assessment, Department of Health Philippines, The Kings Fund, Ethos, Carrot2. Additionally, reference lists of full text included studies were searched.

The targeted search strategy, developed in consultation with an information scientist, was adapted for each database (see supplemental data). Search terms were peer reviewed using the PRESS (Peer Review of Electronic Search Strategies) checklist [ 10 ].

The key search concepts from the Population, Concept and Context (PCC) framework were ≥ 18 years with a stroke living in the Philippines ( population ), stroke services aiming to maximize well-being, participation and function following a stroke ( concept ) and stroke services from acute to chronic including those involving healthcare professionals, non-healthcare related personnel or family or friends ( context ). Search tools such as medical subject headings (MESH) and truncation to narrow or expand searches were used. Single and combined search terms were included (see supplemental data). The search was initially conducted over two weeks in December 2022 and re-run in December 2023.

Studies were selected if they described stroke care in the Philippines in terms of one or more of the following: (a) patient numbers and stroke characteristics (b) staff numbers, qualifications and role (c) service resources (e.g., number of beds/access to a rehabilitation unit, equipment used) (d) cost of services and methods of payment (UHC, Insurance, private) (e) content of stroke care (f) duration of stroke care (hours of personnel contact e.g., Therapy hours per day); interventions undertaken (g) outcome measures used in clinical practice.

Additional criteria:

Context: all environments (home, hospital, outpatients, clinic, academic institute).

Date limits: published between 2002 onwards. This is based on the Philippines Community Rehabilitation Guidelines published in 2009 that would suggest that papers earlier than 2002 may not reflect current practice [ 11 ].

Qualitative and quantitative studies including grey literature.

Language: reported in English or Filipino only.

Publication status: no limit because the level of rigor was not assessed.

Type of study: no limit which included conference abstracts, as the level of rigor was not assessed.

Studies were excluded if they were in non-stroke populations or the full text article could not be obtained. Conference abstracts were excluded if there were insufficient data about methods and results.

Searches of databases were performed by one researcher (JM) and searches of grey literature were performed by one researcher (AO). All retrieved articles were uploaded into Endnote X9 software™, and duplicates identified and removed before transferring them to Rayyan [ 12 ] for screening.

Stage 3: study selection

The title and abstract were selected using eligibility criteria. Two pairs of researchers independently screened abstracts and titles;(Databases: JM and AL and grey literature by AO and LF). Where a discrepancy existed for title and abstract screening, the study was automatically included for full text review and discussed among reviewers.

Two reviewers (JM and AL) undertook full-text screening of the selected studies. Discrepancies were resolved through consensus discussions without the need for a third reviewer. There were no discrepancies that required a third reviewer. Reason for exclusion were documented according to pre-determined eligibility criteria. References of included full text articles were screened by each reviewer independently and identified articles were subjected to the same screening process as per the PRISMA-ScR checklist (Fig.  1 ).

PRISMA-ScR flow diagram

Stage 4: Charting the data

Two reviewers independently extracted the data using a piloted customized and standardized data extraction form including (1) Structure: financial (e.g., costs, insurance, government funding), resources (structure and number of stroke facilities, staff (number, profession/specialism, qualifications etc.), stroke characteristics (2) Process: duration of care, content of stroke care within acute, secondary care, community, outcome measures used; (3) Outcome: survival, function, patient satisfaction, cost (admission and interventions), and (4) year of publication, geographical location (including if Philippines only or multiple international locations) and type of evidence (e.g., policy, review, observational, experimental, clinical guidelines). Critical appraisal of included studies was not undertaken because the purpose of the review was to map available evidence on stroke services available within the Philippines.

Stage 5: Collating, summarising and reporting the results

The search identified 351 records from databases and registers. A total of 70 records are included and reasons for non-inclusion are summarized in Fig.  1 .

Study descriptors

The characteristics of included studies are shown in Supplementary Material Table 1. Of the 70 included studies, 36 were observational with most being based on a retrospective review of case notes ( n  = 31), two were audits, eight were surveys or questionnaires, four were consensus opinion and/or guideline development, three were randomized controlled trial (RCT) or feasibility RCT, 1 was a systematic review, two were policy and guidelines, 11 were narrative reviews or opinion pieces, two were case series or reports and one was an experimental study.

Of the 70 studies, 32 (45.7%) were based in a single tertiary hospital site. There were only three papers based in the community (4.3%). Papers that were opinion pieces or reviews were classified as having a national focus. Of the 22 papers classified as having a national focus, 10 (45.5%) were narrative reviews/ opinion pieces (Table 1 ).

The primary focus of the research studies (excluding the 11 narrative reviews and 2 policy documents) were classified as describing structure ( n  = 8, 14%); process ( n  = 21,36.8%) or outcomes ( n  = 29, 49.2%). The structure of acute care was described in seven studies out of eight studies ( n  = 7/8 87.5%) whilst neurosurgery structures were described in one out of eight studies (12.5%). Acute care processes were described in 11 out of 21 studies ( n  = 11/21 52.3%) whilst rehabilitation processes were described in six out of 21 studies (28.6%), with three out of 21 studies primarily describing outcome measurement (14.3%). The primary focus of the outcomes were stroke characteristics (25 out of 28 papers, 89.2%) in terms of number of stroke (prevalence), mortality or severity of stroke. Measures of stroke quality of life were not reported. Healthcare professional knowledge was described in two studies ( n  = 2/28 7.1%) whilst risk factors for stroke were described in one study ( n  = 1/28, 3.6%). Carer burden was described in one study ( n  = 1/28, 3.6%).

A summary of the findings is presented in Table 2 .

This scoping review describes the available literature on stroke services within the Philippines across the lifespan of an adult (> 18 years) with a stroke. The review has identified gaps in information about structures, processes and outcomes as well as deficits in provision of stroke services and processes as recommended by WHO. These included a low number of specialist clinicians including neurologists, neuro-radiographers and neurosurgeons. The high prevalence of stroke suggests attention and resources need to focus on primary and secondary prevention. Awareness of stroke is low, especially in terms of what a stroke is, the signs/symptoms and how to minimize risk of stroke [ 25 ]. Barriers exist, such as lack of healthcare resources, maldistribution of health facilities, inadequate training on stroke treatment among health care workers, poor stroke awareness, insufficient government support and limited health insurance coverage [ 22 ].

The scoping review also highlighted areas where further work is needed, for example, descriptions and research into the frequency, intensity, and content of rehabilitation services especially in the community setting and the outcome measures used to monitor recovery and impairment. PARM published stroke rehabilitation clinical practice guidelines in 2012, which incorporated an innovative approach to contextualize Western clinical practice guidelines for stroke care to the Philippines [ 42 ]. Unfortunately, availability and equitable access to evidence-based rehabilitation for people with stroke in the Philippines pose significant challenges because of multiple factors impacting the country (e.g., geographical, social, personal, environmental, educational, economic, workforce) [ 25 , 40 , 43 ].

The number of stroke survivors with disability has not been reported previously, thus, the extent and burden of stroke from acute to chronic is unknown. The recent introduction of a national stroke registry across public and private facilities may provide some of this data [ 82 ]. The project started in 2021 and captures data on people hospitalized for transient ischemic attack or stroke in the Philippines. National stroke registries have been identified as a pragmatic solution to reduce the global burden of stroke [ 83 ] through surveillance of incidence, prevalence, and outcomes (e.g., death, disability) of, and quality of care for, stroke, and prevalence of risk factors. For the Philippine government to know the full impact and burden of stroke nationally, identify areas for improvement and make meaningful changes for the benefit of Filipinos, the registry would need to be compulsory for all public and private facilities and include out of hospital data. This will require information technology, trained workforces for data capture, monitoring and sharing, as well as governance and funding [ 83 ].

This scoping review has generated a better understanding of the published evidence focusing on availability of stroke services in the Philippines, as well as the existing gaps through the lens of Donabedian’s Structure , Process and Outcome framework. The findings have helped to inform a wider investigation of current stroke service utilization conducted using survey and interview methods with stroke survivors, carers and key stakeholders in the Philippines, and drive forward local, regional and national policy and service changes.

Conclusions

This scoping review describes the existing evidence-based relating to structure, processes and outcomes of stroke services for adults within the Philippines. The review revealed limited information in certain areas, such as the impact of stroke on functional ability, participation in everyday life, and quality of life; the content and intensity of rehabilitation both in the hospital or community setting; and the outcome measures used to evaluate clinical practice. Developments in stroke services have been identified however, a wide gap exists between the availability of stroke services and the high burden of stroke in the Philippines. Strategies are critical to address the identified gaps as a precursor to improving stroke outcomes and reducing burden. Potential solutions identified within the review will require a comprehensive approach from healthcare policymakers to focus on stroke awareness programs, primary and secondary prevention, establishing and monitoring of stroke protocols and pathways, implementation of a compulsory national stroke registry, use of TeleRehab, TeleMedicine and mobile stroke units and improve access to and availability of both hospital- and community-based stroke rehabilitation. Furthermore, changes in PhilHealth coverage and universal credit to minimize catastrophic out-of-pocket costs.

Limitations

Although a comprehensive search was undertaken, data were taken from a limited number of located published studies on stroke in the Philippines. This, together with data from databases and grey literature, may not reflect the current state of stroke services in the country.

Availability of data and materials

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

We acknowledge the TULAY collaborators: Dr Roy Francis Navea, Dr Myrna Estrada, Dr Elda Grace Anota, Dr Maria Mercedes Barba, Dr June Ann De Vera, Dr Maria Elena Tan, Dr Sarah Buckingham and Professor Fiona Jones. We are grateful to Lance de Jesus and Dr Annah Teves, Research Assistants on the TULAY project, for their contribution to some of the data extraction.

This research was funded by the NIHR Global Health Policy and Systems Research Programme (Award ID: NIHR150244) in association with UK aid from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK’s Department of Health and Social Care.

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Conceptualisation, methodology and setting search terms, AL, LF, AO, JM, BK. Searches and screening, AL, JM, LF, AO. Data extraction, AL, LF, AO, JM, LdJ, AT. Original draft preparation, AL, JM. All authors provided substantive intellectual and editorial revisions and approved the final manuscript.

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Logan, A., Faeldon, L., Kent, B. et al. A scoping review of stroke services within the Philippines. BMC Health Serv Res 24 , 1006 (2024). https://doi.org/10.1186/s12913-024-11334-z

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