critically analyse literature review

• University of Oregon Libraries
• Research Guides

How to Write a Literature Review

• 5. Critically Analyze and Evaluate
• Literature Reviews: A Recap
• Reading Journal Articles
• Does it Describe a Literature Review?
• 1. Identify the Question
• 2. Review Discipline Styles
• Searching Article Databases
• Finding Full-Text of an Article
• Citation Chaining
• When to Stop Searching
• 4. Manage Your References

Critically analyze and evaluate

Tip: read and annotate pdfs.

• 6. Synthesize
• 7. Write a Literature Review

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

• What is the research question?
• What is the primary methodology used?
• How was the data gathered?
• How is the data presented?
• What are the main conclusions?
• Are these conclusions reasonable?
• What theories are used to support the researcher's conclusions?

Take notes on the articles as you read them and identify any themes or concepts that may apply to your research question.

This sample template (below) may also be useful for critically reading and organizing your articles. Or you can use this online form and email yourself a copy .

• Sample Template for Critical Analysis of the Literature

Opening an article in PDF format in Acrobat Reader will allow you to use "sticky notes" and "highlighting" to make notes on the article without printing it out. Make sure to save the edited file so you don't lose your notes!

Some Citation Managers like Mendeley also have highlighting and annotation features.Here's a screen capture of a pdf in Mendeley with highlighting, notes, and various colors:

Screen capture from a UO Librarian's Mendeley Desktop app

• Learn more about citation management software in the previous step: 4. Manage Your References
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• Next: 6. Synthesize >>
• Last Updated: Aug 12, 2024 11:48 AM
• URL: https://researchguides.uoregon.edu/litreview

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Library Guides

Literature reviews: criticality.

• Criticality

Express Critical Analysis

The literature review of a dissertation should include critical analysis. You cannot simply juxtapose the literature you find: you have to  evaluate and draw conclusions from it.  

Paragraph level  

Try expressing your voice in each paragraph of your literature review. Write strong paragraphs. In strong paragraphs your voice can be heard in the topic sentence, development (where you analyse and compare/contrast the sources, sometimes as individual pieces, sometimes in a synthesis) and, even more easily, in the concluding sentence, where you present the "therefore" of the paragraph. 

How to express criticality at the paragraph level:  

Identify the significance of the sources, and why the points they are making are relevant  

Make connections between the sources 

Compare and contrast sources, literatures  

Accept/adopt points made by the sources, with reasons  

Reject the points made by the sources, with reasons (e.g., limitations in the methodology; out of date; limited scope; geographical delimitation) 

Indicate the position you are taking in your own work on the theories and concepts presented by the sources 

Show how limitations in the existing literature create a research gap for you 

Organise the materials, synthesising them in an original way, that sheds new light on the topic.  

To find out more about paragraph writing, check out the Assignment Writing Guides.

Literature review level 

Try to take ownership of the literature review. Remember the purposes of the review (providing background on the subject you are researching and identifying a gap in the existing literature on this subject). Thus, throughout the review:   

Identify the key themes relevant to your subject matter  

Identify the most logical and effective order for your themes 

Relate the sources back to the dissertation's research question 

Shed new light on the topic 

Draw conclusions on the existing literature  

Identify gaps in the literature  

Your literature review should present an argument (which you can recap in the concluding paragraph of the literature review). For instance, 

"The literature says/illustrates/reveals that... there are debates in the literature as of... it can be understood from the literature that... however, there are gaps in the literature... the literature does not specifically address (specific sector/location/population)... there is a lack of independent/recent studies on...  therefore in order to answer the research question(s) (you can repeat the question) this dissertation uses method xyz, as illustrated in the next section (if applicable)". 

Manchester University’s  academic phrase bank  is a great resource for learning new words and phrases. 

Extra Resources

For extra help with all aspects of study skills including how to undertake literature reviews, appointments are available with learning advisors on Engage. 

Appointments are also available with an Academic Engagement Librarian to discuss any issues you might be having with research.

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• Last Updated: Nov 18, 2023 10:56 PM
• URL: https://libguides.westminster.ac.uk/literature-reviews

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• Research Guides

Literature Review: A Self-Guided Tutorial

• 5. Critically analyze and evaluate
• Literature Reviews: A Recap
• Peer Review
• Reading the Literature
• Using Concept Maps
• Developing Research Questions
• Considering Strong Opinions
• 2. Review discipline styles
• Super Searching
• Finding the Full Text
• Citation Searching This link opens in a new window
• When to stop searching
• Citation Management
• Annotating Articles Tip
• How to Review the Literature
• Using a Synthesis Matrix
• 7. Write literature review

Critically analyze and evaluate

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

• What is the research question?
• Why is this work significant?
• What are the major themes and main conclusions?
• What research methods were used?
• What are the main conclusions? Are they reasonable?
• What theories are used to support the researcher's conclusions?

Take notes on the books and articles as you read them and identify any themes or concepts that may apply to your research question. Use the template below as a guide for taking notes.

• Critical Analysis of the Literature: Notes Template Use this template to take notes on books and articles you are reading. Choose File|Make a copy to add an editable copy to your Google Drive.
• << Previous: Annotating Articles Tip
• Next: 6. Synthesize >>
• Last Updated: Jul 30, 2024 4:12 PM
• URL: https://libguides.williams.edu/literature-review

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: .

• 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.

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: 

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. 

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. 

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. 

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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How to write a good literature review 

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

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

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

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

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

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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. 

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• Cite with Confidence: Paperpal makes it easy to incorporate relevant citations and references in 10,000+ styles 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.  

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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Critical Analysis in a Literature Review

• 3-minute read
• 29th June 2015

A literature review is vital to any in-depth research , providing a foundation your work will build upon. Familiarizing yourself with the existing literature allows you to identify current debates in the field, ensuring that your work is up-to-date and addresses significant questions.

But a good literature review will require reading critically. This means deciding whether you agree or disagree with certain viewpoints, arguments and theories, rather than simply describing them.

It also requires being able to spot the flaws and strengths of particular studies, which can in turn help when developing your own ideas. To make sure you do this effectively, it’s worth looking for the following things.

1. Overgeneralizations

One common issue in research is the scope of its application, especially when dealing with limited sample sizes or when a study is generalized too broadly.

The conclusions of a psychological study conducted with all male participants, for instance, may not be applicable in the same way to female subjects.

2. Methodological Limitations

When writing a literature review, ask yourself whether the methods used for particular studies were appropriate.

For example, whether the study used a quantitative, qualitative or mixed-methods research design can make a big difference to the conclusions reached.

3. How Well Explained is the Research?

When reading for a critical literature review, it is important to consider how well written the studies you examine are.

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Does the author explain their methods? Is enough detail provided for any experiments to be replicated? Are sampling, data collection and analysis techniques clearly identified? Does the conclusion follow from the results?

Asking these and similar questions will help you discern between good and bad research.

4. Identify Biases

Another important factor is to consider whether implicit biases might have influenced the research.

The term “confirmation bias,” for example, refers to the tendency to focus on evidence which supports one’s existing beliefs, which can lead to overlooking alternative hypotheses.

5. Challenge Your Own Assumptions

If you come across a study which seems to oppose your hypothesis, consider whether it presents good counterarguments to your own position. If it does, ask yourself whether this affects how you conduct the rest of your research.

The final point here is important because conducting a literature review serves two purposes . The finished literature review will help your reader to understand the background of your research, so critical analysis helps to clarify what your work contributes to the debate.

But comparing different studies and theories for a literature review will also help you to develop a research approach. The better your critical analysis, then, the better prepared you’ll be.

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Methodology

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

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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

• Quick Run-through
• Step 1 & 2

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

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

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

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See an example

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

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

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

Download Word doc Download Google doc

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

For each publication, ask yourself:

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

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

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

Take notes and cite your sources

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

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

As you write, you can follow these tips:

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

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

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

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

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

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

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

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

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

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

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

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

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

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

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

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

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

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Systematic Reviews

• Types of Literature Reviews

What Makes a Systematic Review Different from Other Types of Reviews?

• Planning Your Systematic Review
• Database Searching
• Creating the Search
• Search Filters and Hedges
• Grey Literature
• Managing and Appraising Results
• Further Resources

Reproduced from Grant, M. J. and Booth, A. (2009), A typology of reviews: an analysis of 14 review types and associated methodologies. Health Information & Libraries Journal, 26: 91–108. doi:10.1111/j.1471-1842.2009.00848.x

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Conduct a literature review

What is a literature review.

A literature review is a summary of the published work in a field of study. This can be a section of a larger paper or article, or can be the focus of an entire paper. Literature reviews show that you have examined the breadth of knowledge and can justify your thesis or research questions. They are also valuable tools for other researchers who need to find a summary of that field of knowledge.

Unlike an annotated bibliography, which is a list of sources with short descriptions, a literature review synthesizes sources into a summary that has a thesis or statement of purpose—stated or implied—at its core.

How do I write a literature review?

Step 1: define your research scope.

• What is the specific research question that your literature review helps to define?
• Are there a maximum or minimum number of sources that your review should include?

Ask us if you have questions about refining your topic, search methods, writing tips, or citation management.

Step 2: Identify the literature

Start by searching broadly. Literature for your review will typically be acquired through scholarly books, journal articles, and/or dissertations. Develop an understanding of what is out there, what terms are accurate and helpful, etc., and keep track of all of it with citation management tools . If you need help figuring out key terms and where to search, ask us .

Use citation searching to track how scholars interact with, and build upon, previous research:

• Mine the references cited section of each relevant source for additional key sources
• Use Google Scholar or Scopus to find other sources that have cited a particular work

Step 3: Critically analyze the literature

Key to your literature review is a critical analysis of the literature collected around your topic. The analysis will explore relationships, major themes, and any critical gaps in the research expressed in the work. Read and summarize each source with an eye toward analyzing authority, currency, coverage, methodology, and relationship to other works. The University of Toronto's Writing Center provides a comprehensive list of questions you can use to analyze your sources.

Step 4: Categorize your resources

Divide the available resources that pertain to your research into categories reflecting their roles in addressing your research question. Possible ways to categorize resources include organization by:

• methodology
• theoretical/philosophical approach

Regardless of the division, each category should be accompanied by thorough discussions and explanations of strengths and weaknesses, value to the overall survey, and comparisons with similar sources. You may have enough resources when:

• You've used multiple databases and other resources (web portals, repositories, etc.) to get a variety of perspectives on the research topic.
• The same citations are showing up in a variety of databases.

Additional resources

Undergraduate student resources.

• Literature Review Handout (University of North Carolina at Chapel Hill)
• Learn how to write a review of literature (University of Wisconsin-Madison)

Graduate student and faculty resources

• Information Research Strategies (University of Arizona)
• Literature Reviews: An Overview for Graduate Students (NC State University)
• Oliver, P. (2012). Succeeding with Your Literature Review: A Handbook for Students [ebook]
• Machi, L. A. & McEvoy, B. T. (2016). The Literature Review: Six Steps to Success [ebook]
• Graustein, J. S. (2012). How to Write an Exceptional Thesis or Dissertation: A Step-by-Step Guide from Proposal to Successful Defense [ebook]
• Thomas, R. M. & Brubaker, D. L. (2008). Theses and Dissertations: A Guide to Planning, Research, and Writing

Conducting a Literature Review

• Getting Started
• Developing a Question
• Searching the Literature
• Identifying Peer-Reviewed Resources
• Managing Results

Analyzing the Literature

• Writing the Review

Evidence synthesis and critical appraisal are two distinct but interrelated processes in the field of evidence-based practice and research. Here's a breakdown of the differences between them:

Critical Appraisal:

• Definition : Critical appraisal involves systematically evaluating the quality, relevance, and validity of research studies or evidence sources. It aims to assess the strengths and weaknesses of individual studies to determine their trustworthiness and applicability to a particular research question or clinical scenario.
• Focus : Critical appraisal focuses on examining the methodology, design, data analysis, and results of research studies. It involves assessing factors such as study design, sample size, bias, confounding variables, statistical methods, and generalizability.
• Purpose : The purpose of critical appraisal is to identify high-quality evidence that can inform decision-making in healthcare practice, policy, or research. It helps researchers and practitioners assess the credibility and reliability of evidence sources and make informed judgments about their use in practice.

Evidence Synthesis:

• Definition : Evidence synthesis involves systematically collecting, analyzing, and integrating evidence from multiple sources to generate new knowledge, insights, or conclusions about a particular topic or research question. It aims to aggregate and synthesize findings from individual studies to produce a comprehensive summary of the available evidence.
• Focus : Evidence synthesis encompasses a variety of methods, including systematic reviews, meta-analyses, scoping reviews, and narrative reviews. It focuses on synthesizing data, findings, and conclusions from multiple studies to provide a comprehensive overview of the evidence base on a particular topic.
• Purpose : The purpose of evidence synthesis is to provide stakeholders with a robust and comprehensive summary of the existing evidence on a particular topic or research question. It helps identify patterns, trends, inconsistencies, and gaps in the literature, informing decision-making, guiding policy development, and identifying future research priorities.

In summary, critical appraisal involves assessing the quality and validity of individual research studies, while evidence synthesis involves aggregating and synthesizing findings from multiple studies to generate new knowledge or insights about a particular topic. While they are distinct processes, they are often conducted sequentially, with critical appraisal informing the selection and inclusion of studies in evidence synthesis. Together, critical appraisal and evidence synthesis play essential roles in evidence-based practice and research, 

Critical Appraisal

Conducting a critical appraisal of the literature is crucial for evidence-based practice for several reasons:

• Validity and Reliability: It helps you assess the quality of the evidence you're using, ensuring that you can trust the findings and apply them to your practice confidently.
• Informed Decision-Making : By critically appraising the literature, you can make informed decisions about which studies are most relevant and appropriate to inform your practice, ensuring it's based on the best available evidence.
• Identifying Gaps and Limitations: This process allows you to spot gaps and limitations in the existing literature related to your practice area, helping you refine your clinical questions and design more robust interventions.
• Applicability to Practice: You aim to implement evidence-based practices to improve patient outcomes. Critical appraisal helps you assess how applicable the literature is to your clinical setting, considering factors like patient population and available resources.
• Ethical Considerations: Ethical principles are crucial in healthcare practice. Critical appraisal helps you evaluate whether the studies you're using adhere to these principles, ensuring your practice respects patient autonomy, beneficence, and non-maleficence, and avoids bias.

By conducting a critical appraisal of the literature, you ensure that your evidence-based practice is grounded in high-quality evidence, aligns with ethical standards, and has the potential to positively impact patient care outcomes.

• Centre for Evidence Based Medicine: Critical Appraisal Resources Provides helpful worksheets for critical appraisal of various study types in several languages.
• Critical Appraisal Checklist for Implementation Science, from NYU Langone Health, Health Sciences Library This Implementation Science (IS) critical appraisal checklist is based on the CASP format.
• Critical Appraisal Skills Programme (CASP) Checklists A number of free downloadable checklists to help you more easily and accurately perform critical appraisal across a number of different study types.
• Critical Appraisal Tools from JBI JBI’s critical appraisal tools assist in assessing the trustworthiness, relevance and results of published papers.

Synthesizing the Articles

Literature reviews synthesize large amounts of information and present it in a coherent, organized fashion. In a literature review you will be combining material from several texts to create a new text – your literature review.

You will use common points among the sources you have gathered to help you synthesize the material. This will help ensure that your literature review is organized by subtopic, not by source. This means various authors' names can appear and reappear throughout the literature review, and each paragraph will mention several different authors.

When you shift from writing summaries of the content of a source to synthesizing content from sources, there is a number things you must keep in mind:

• Look for specific connections and or links between your sources and how those relate to your thesis or question.
• When writing and organizing your literature review be aware that your readers need to understand how and why the information from the different sources overlap.
• Organize your literature review by the themes you find within your sources or themes you have identified. 

You can use a synthesis chart to help keep your sources and main ideas organized. Here are some examples:

• Virginia Commonwealth University Literature Matrix
• Johns Hopkins University Literature Review Matrix
• Writing A Literature Review and Using a Synthesis Matrix Tutorial from NC State University

California State University, Northridge. (2017). Literature Review How-To: Synthesizing Sources. Retrieved from https://libguides.csun.edu/literature-review/synthesis.

Things to Think About

Before you begin to analyze and synthesize the articles you have selected, read quickly through each article to get a sense of what they are about. One way to do this is to read the abstract and the conclusion for each article.

It is also helpful at this stage to begin sorting your articles by type of source; this will help you with the next step in the process. Many papers (but not all) fall into one of two categories:

• Primary source: a report by the original researchers of a study.
• Secondary source: a description or summary of research by somebody other than the original author(s), like a review article.

These are a selection of questions to consider while reading each article selected for your literature review. 

Primary Sources:

• Author and Year
• Purpose of Study
• Type of Study
• Data Collection Method
• Major Findings
• Recommendations
• Key thoughts/comments (eg. strengths and weaknesses)

Secondary Sources (ie. reviews)

• Author and year
• Review questions/purpose
• Key definitions
• Review boundaries
• Appraisal criteria
• Synthesis of studies
• Summary/conclusions

Cronin, P., Ryan, F., & Coughlan, M. (2008). Undertaking a literature review: A step-by-step approach. British Journal of Nursing, 17 (1), 38-43. Retrieved from: https://bit.ly/2wLeCge .

When Am I Done?

You are done with your literature review synthesis when :

• You are not finding any new ideas,
• When you encounter the same authors repeatedly, and/or
• When you feel that you have a strong understanding of the topic
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Writing a Critical Review of Literature: A Practical Guide for English Graduate Students

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Literature reviews - research guide

• Critical reading and analysis
• Literature reviews home
• Planning your Review & EBP
• Searching for literature
• Managing your results
• Writing your review
• Systematic literature reviews

Critical reading & analysis

• Critical reading
• Analysing sources

Author analysis

• Journal analysis
• Note taking

A critical reader:​ ​

• Does not believe everything they read​ ​
• Questions what they read​ ​
• Rereads if necessary​ ​
• Understands the influence of style​ ​
• Analyses arguments​ ​
• Discounts arguments that are unsupported or based on faulty reasoning

When reading critically, focus on the purpose of your literature review:

• Think about what you expect from the article or chapter, before reading it
• Skim the abstract, headings, conclusion, and the first sentence of each paragraph
• Focus on the arguments presented rather than facts
• Take notes as you read and start to organise your review around themes and ideas
• Consider using a table, matrix or concept map to identify how the different sources relate to each other
• Note four to six points for each study that summarises the main points and conclusions
• Be as objective as possible

Critical appraisal

Critical appraisal is the process of carefully and syst ematically examining research to judge its credibility, its value and its relevance in a specific context.

The aim of critical appraisal is to understand the strengths, weaknesses, and potential for bias in the research. Validity, applicability, and clinical importance should be considered during critical appraisal to ensure that research evidence is used reliably and efficiently and false conclusions are not drawn.

Why do we need to critically appraise the literature?

Critical appraisal is necessary to:

• Assess benefits and strengths for research against flaws and weaknesses
• Decide whether studies have been undertaken in a way that makes their findings reliable
• Make sense of the result
• Know what these results mean in the context of the clinical decision being made
• Assess the usefulness of  the evidence for clinical decisions

Elements of sources

• Abstract: this is what the author wants the reader to take away from their article - what is the starting point? ​ ​
• Introduction:  provides background and a starting point - how does it guide the reader?​ ​
• Materials and methods:  often overlooked but very important - is the methodology understandable, reproducible, direct and robust?
• What do the tables, figures and legends actually report? ​ ​
• What do you think the data means? Decide before reading the discussion​.
• Discussion:  author draws conclusions – how does this correlate with your conclusions?

Evaluation of sources

Consider the following criteria:

• Is the source up-to-date?​
• Does it consider the latest research on your topic?​
• Is the article relevant to your topic?​
• Is the research methodology comprehensively described?​
• Does the work ultimately contribute in any significant way to an understanding of the subject?
• How reputable is the source?​
• Is the source peer-reviewed?​
• What is the source's impact factor ?
• Is the author from a reputable institution?​
• Have you seen the author cited in other sources?​
• Does the data support the conclusions drawn?​
• Are the author's opinions and conclusions convincing? 
• Are the author's arguments supported by evidence (primary material, case studies, narratives, statistics, recent findings)?​ ​
• Is the article properly referenced?​
• What is the purpose of the article and its intended audience?​
• Can you detect any bias in the content?​
• Is the reporting objective?​
• Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Which of the author's arguments are most/least convincing?​ ​
• Were the objectives achieved? ​ ​
• Hypotheses tested? ​ ​
• How do these results relate to other studies you have found?​ ​
• Do the authors openly discuss any limitations of their study?​ ​
• What else needs be studied in the future?

Interpretation

• Read critically​ ​
• Note 2-4 bullet points for each study that summarises the main points and conclusions​ ​
• Use matrix to analyse findings, relevance and importance of each text​ ​
• Draw attention to studies that are important, influential or that bring a new understanding or method of studying your area of research
• Literature Analysis Worksheet
• Literature Review Matrix

Databases such as Scopus and Web of Science can be used to:

• Locate the papers of a specific author
• Compare the research output of more than one author

The h -index

The h -index is a metric that allows you to compare the publications or research output of authors. This metric is calculated by determining the number of articles (n) written by an author, in the database, that have received the same number or more (n) citations over time. The h -index is a useful metric for comparing rates of publication, as the value is not skewed by a single highly cited paper, nor by a large number of poorly cited papers.

• The h -index is not a static value – if discussing an author’s h-index, you need to specify the date on which the h -index was calculated.
• The h -index is also calculated by other databases/resources and may vary from the h -index given by Scopus – if discussing an author’s h -index, you need to specify the source of the h-index.

See the example below of how an author's  h -index may appear in Scopus.

To locate papers of an author in  Scopus :

• Go to the default Scopus search screen and select Authors tab.
• Enter the author details and affiliation (university). Only include author surname for a comprehensive search. If the author has a common surname, include the first name's initial only.
• The author’s details and the documents that they have written, and which are indexed by Scopus, will be retrieved. Click on the author’s name to see a full list of their publications.

The information about the author will also tell you:

• How many of their publications have been indexed by Scopus
• How many times their publications have been cited
• Which of their publications are most highly cited
• Who they have co-authored papers with
• Their publication and citation trends for the past nine years
• Their h -index

See the Scopus resources below for more help:

• How to search for authors by topic
• How to assess an author's impact
• How to keep track of an author
• How to create citation overviews in Scopus

Web of Science Core Collection

To locate papers of an author in Web of Science Core Collection (WoS CC):

• Go to the default WoS CC search screen and select Researchers tab.
• Enter the author's surname and first name's initial.

The author’s details and the papers that they have written, and which are indexed by WoS CC, will be retrieved. Click on the Publications tab to see a full list of their publications.

• How many of their publications have been indexed by WoS CC

The author's citation report will tell you:

The Measuring research quality and impact guide has more detailed information on author analytics:

• Measuring research quality and impact

Source/journal analysis

Databases such as Scopus and Web of Science  (including CAB Abstracts ) can be used to determine the quality of journals in a discipline or field of research. For more information on journal analytics, please see the relevant section of our guide on Measuring Research Quality & Impact:

• Journal quality & impact (in Measuring research quality & impact guide)

Taking clear, legible notes will help to focus your critical reading and analysis of your literature review sources. When taking notes, avoid plagiarism by:

•  Keeping track of the difference between information from your sources and from your own ideas
•  Providing clear references, including page numbers

Note taking methods

Some effective methods of note-taking include:

• Outlining method. Use headings, sub-headings and bullet points to organize topics
• Cornell method. Use two columns - in one column write your summary of the authors' conclusions and evidence, and in the other column write down your own analysis and other comments
• Charting method. Create a list of topics or points you want to write about - use a column for each one. As you read, add references and make notes in the appropriate column
• Sentence method. Simply write down new ideas and bits of information as a numbered  sentence
• Mapping method. Write down key concepts and terms, with related ideas radiating out from these

You may consider using the matrix below for your note taking and analysis:

Critical reading & analysis checklist

• Does your literature review highlight flaws, gaps, or shortcomings of specific texts or groups of texts?
• Have you identified areas that have not yet been researched or have not yet been researched sufficiently?
• Does the literature demonstrate a change over time or recent developments that make your research relevant now?
• Are you able to discuss research methods used to study this topic and/or related topics?
• Can you clearly state why your research is necessary?
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Literature Reviews

What is a Literature Review?

• Steps for Creating a Literature Review
• Providing Evidence / Critical Analysis
• Challenges when writing a Literature Review
• Systematic Literature Reviews

A literature review is an academic text that surveys, synthesizes, and critically evaluates the existing literature on a specific topic. It is typically required for theses, dissertations, or long reports and  serves several key purposes:

• Surveying the Literature : It involves a comprehensive search and examination of relevant academic books, journal articles, and other sources related to the chosen topic.
• Synthesizing Information : The literature review summarizes and organizes the information found in the literature, often identifying patterns, themes, and gaps in the current knowledge.
• Critical Analysis : It critically analyzes the collected information, highlighting limitations, gaps, and areas of controversy, and suggests directions for future research.
• Establishing Context : It places the current research within the broader context of the field, demonstrating how the new research builds on or diverges from previous studies.

Types of Literature Reviews

Literature reviews can take various forms, including:

• Narrative Reviews : These provide a qualitative summary of the literature and are often used to give a broad overview of a topic. They may be less structured and more subjective, focusing on synthesizing the literature to support a particular viewpoint.
• Systematic Reviews : These are more rigorous and structured, following a specific methodology to identify, evaluate, and synthesize all relevant studies on a particular question. They aim to minimize bias and provide a comprehensive summary of the existing evidence.
• Integrative Reviews : Similar to systematic reviews, but they aim to generate new knowledge by integrating findings from different studies to develop new theories or frameworks.

Importance of Literature Reviews

• Foundation for Research : They provide a solid background for new research projects, helping to justify the research question and methodology.

Identifying Gaps : Literature reviews highlight areas where knowledge is lacking, guiding future research efforts.

• Building Credibility : Demonstrating familiarity with existing research enhances the credibility of the researcher and their work.

In summary, a literature review is a critical component of academic research that helps to frame the current state of knowledge, identify gaps, and provide  a basis for new research.

The research, the body of current literature, and the particular objectives should all influence the structure of a literature review. It is also critical to remember that creating a literature review is an ongoing process - as one reads and analyzes the literature, one's understanding may change, which could require rearranging the literature review.

Paré, G. and Kitsiou, S. (2017) 'Methods for Literature Reviews' , in: Lau, F. and Kuziemsky, C. (eds.)  Handbook of eHealth evaluation: an evidence-based approach . Victoria (BC): University of Victoria.

Perplexity AI (2024) Perplexity AI response to Kathy Neville, 31 July.       

Royal Literary Fund (2024)  The structure of a literature review.  Available at: https://www.rlf.org.uk/resources/the-structure-of-a-literature-review/ (Accessed: 23 July 2024).

Library Services for Undergraduate Research (2024) Literature review: a definition . Available at: https://libguides.wustl.edu/our?p=302677 (Accessed: 31 July 2024).

Further Reading:

Methods for Literature Reviews

Literature Review (The University of Edinburgh)

Literature Reviews (University of Sheffield)

• How to Write a Literature Review Paper? Wee, Bert Van ; Banister, David ISBN: 0144-1647

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

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

Chapter 9 methods for literature reviews.

Guy Paré and Spyros Kitsiou .

9.1. Introduction

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

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

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

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

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

9.2. Overview of the Literature Review Process and Steps

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

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

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

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

9.3. Types of Review Articles and Brief Illustrations

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

9.3.1. Narrative Reviews

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

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

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

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

9.3.2. Descriptive or Mapping Reviews

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

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

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

9.3.3. Scoping Reviews

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

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

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

9.3.4. Forms of Aggregative Reviews

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

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

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

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

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

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

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

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

9.3.5. Realist Reviews

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

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

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

9.3.6. Critical Reviews

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

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

9.4. Summary

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

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

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

9.5. Concluding Remarks

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

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

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

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• Cite this Page Paré G, Kitsiou S. Chapter 9 Methods for Literature Reviews. In: Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.
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• Introduction
• Overview of the Literature Review Process and Steps
• Types of Review Articles and Brief Illustrations
• Concluding Remarks

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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.

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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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Writing a Literature Review: Read and Analyse the Literature

• Select a Topic
• Search the Literature
• Read and Analyse the Literature
• Write the Review
• Referencing This link opens in a new window

Read the studies you have found

Gathering and reading information to write your literature review is a process that can take a while - but keep the end goal in sight.

• Critically read each source, look for the arguments presented rather than for facts.
• Take notes as you read and start to organise your review around themes and ideas.
• Consider using a table, matrix or concept map to identify how the different sources relate to each other.
• TIP: Read your papers in chronological order, from the earliest publication to the most recent. This will allow you to see how previous research influences and forms the foundation for contemporary research. It will also help you to identify where and when 'breakthroughs' have occurred in the research, and importantly where the gaps are in the research.

Source -  http://www.citewrite.qut.edu.au/write/litreview.jsp

Critical analysis of the studies

Critical analysis is a way or examining the research to assess its validity and relevance. It is an essential step in making sense of the research evidence.

Ask the following questions:

• What are the key terms and concepts?
• How relevant is this article to my specific topic?
• What are the major relationships, trends and patterns?
• How has the author structured the arguments?
• How authoritative and credible is this source?
• What are the differences and similarities between the sources?
• Are there any gaps in the literature that require further study?

Source - http://www.citewrite.qut.edu.au/write/litreview.jsp

Using a Review Matrix

Once you have read and critically appraised your articles, using a review matrix can help you to compare and contrast research, note important information or issues, and track ideas or research over time. There are many methods and matrices to help you synthesize research. You can develop your own matrix or choose from the many examples found online. Any matrix though, should respond to your research area and the types of research you are reviewing.  Below are two common examples.

Critical Appraisal Checklists

• CASP Critical Appraisal Too l Critical Appraisal Skills Programme offers eight free critical appraisal tools designed to help when reading research.
• Critical Appraisal Sheets From the Centre for Evidence-based Medicine.
• Systematic Reviews: Checklists for review articles. From BMJ.
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Home » Literature Review – Types Writing Guide and Examples

Literature Review – Types Writing Guide and Examples

Table of Contents

Literature Review

Definition:

A literature review is a comprehensive and critical analysis of the existing literature on a particular topic or research question. It involves identifying, evaluating, and synthesizing relevant literature, including scholarly articles, books, and other sources, to provide a summary and critical assessment of what is known about the topic.

Types of Literature Review

Types of Literature Review are as follows:

• Narrative literature review : This type of review involves a comprehensive summary and critical analysis of the available literature on a particular topic or research question. It is often used as an introductory section of a research paper.
• Systematic literature review: This is a rigorous and structured review that follows a pre-defined protocol to identify, evaluate, and synthesize all relevant studies on a specific research question. It is often used in evidence-based practice and systematic reviews.
• Meta-analysis: This is a quantitative review that uses statistical methods to combine data from multiple studies to derive a summary effect size. It provides a more precise estimate of the overall effect than any individual study.
• Scoping review: This is a preliminary review that aims to map the existing literature on a broad topic area to identify research gaps and areas for further investigation.
• Critical literature review : This type of review evaluates the strengths and weaknesses of the existing literature on a particular topic or research question. It aims to provide a critical analysis of the literature and identify areas where further research is needed.
• Conceptual literature review: This review synthesizes and integrates theories and concepts from multiple sources to provide a new perspective on a particular topic. It aims to provide a theoretical framework for understanding a particular research question.
• Rapid literature review: This is a quick review that provides a snapshot of the current state of knowledge on a specific research question or topic. It is often used when time and resources are limited.
• Thematic literature review : This review identifies and analyzes common themes and patterns across a body of literature on a particular topic. It aims to provide a comprehensive overview of the literature and identify key themes and concepts.
• Realist literature review: This review is often used in social science research and aims to identify how and why certain interventions work in certain contexts. It takes into account the context and complexities of real-world situations.
• State-of-the-art literature review : This type of review provides an overview of the current state of knowledge in a particular field, highlighting the most recent and relevant research. It is often used in fields where knowledge is rapidly evolving, such as technology or medicine.
• Integrative literature review: This type of review synthesizes and integrates findings from multiple studies on a particular topic to identify patterns, themes, and gaps in the literature. It aims to provide a comprehensive understanding of the current state of knowledge on a particular topic.
• Umbrella literature review : This review is used to provide a broad overview of a large and diverse body of literature on a particular topic. It aims to identify common themes and patterns across different areas of research.
• Historical literature review: This type of review examines the historical development of research on a particular topic or research question. It aims to provide a historical context for understanding the current state of knowledge on a particular topic.
• Problem-oriented literature review : This review focuses on a specific problem or issue and examines the literature to identify potential solutions or interventions. It aims to provide practical recommendations for addressing a particular problem or issue.
• Mixed-methods literature review : This type of review combines quantitative and qualitative methods to synthesize and analyze the available literature on a particular topic. It aims to provide a more comprehensive understanding of the research question by combining different types of evidence.

Parts of Literature Review

Parts of a literature review are as follows:

Introduction

The introduction of a literature review typically provides background information on the research topic and why it is important. It outlines the objectives of the review, the research question or hypothesis, and the scope of the review.

Literature Search

This section outlines the search strategy and databases used to identify relevant literature. The search terms used, inclusion and exclusion criteria, and any limitations of the search are described.

Literature Analysis

The literature analysis is the main body of the literature review. This section summarizes and synthesizes the literature that is relevant to the research question or hypothesis. The review should be organized thematically, chronologically, or by methodology, depending on the research objectives.

Critical Evaluation

Critical evaluation involves assessing the quality and validity of the literature. This includes evaluating the reliability and validity of the studies reviewed, the methodology used, and the strength of the evidence.

The conclusion of the literature review should summarize the main findings, identify any gaps in the literature, and suggest areas for future research. It should also reiterate the importance of the research question or hypothesis and the contribution of the literature review to the overall research project.

The references list includes all the sources cited in the literature review, and follows a specific referencing style (e.g., APA, MLA, Harvard).

How to write Literature Review

Here are some steps to follow when writing a literature review:

• Define your research question or topic : Before starting your literature review, it is essential to define your research question or topic. This will help you identify relevant literature and determine the scope of your review.
• Conduct a comprehensive search: Use databases and search engines to find relevant literature. Look for peer-reviewed articles, books, and other academic sources that are relevant to your research question or topic.
• Evaluate the sources: Once you have found potential sources, evaluate them critically to determine their relevance, credibility, and quality. Look for recent publications, reputable authors, and reliable sources of data and evidence.
• Organize your sources: Group the sources by theme, method, or research question. This will help you identify similarities and differences among the literature, and provide a structure for your literature review.
• Analyze and synthesize the literature : Analyze each source in depth, identifying the key findings, methodologies, and conclusions. Then, synthesize the information from the sources, identifying patterns and themes in the literature.
• Write the literature review : Start with an introduction that provides an overview of the topic and the purpose of the literature review. Then, organize the literature according to your chosen structure, and analyze and synthesize the sources. Finally, provide a conclusion that summarizes the key findings of the literature review, identifies gaps in knowledge, and suggests areas for future research.
• Edit and proofread: Once you have written your literature review, edit and proofread it carefully to ensure that it is well-organized, clear, and concise.

Examples of Literature Review

Here’s an example of how a literature review can be conducted for a thesis on the topic of “ The Impact of Social Media on Teenagers’ Mental Health”:

• Start by identifying the key terms related to your research topic. In this case, the key terms are “social media,” “teenagers,” and “mental health.”
• Use academic databases like Google Scholar, JSTOR, or PubMed to search for relevant articles, books, and other publications. Use these keywords in your search to narrow down your results.
• Evaluate the sources you find to determine if they are relevant to your research question. You may want to consider the publication date, author’s credentials, and the journal or book publisher.
• Begin reading and taking notes on each source, paying attention to key findings, methodologies used, and any gaps in the research.
• Organize your findings into themes or categories. For example, you might categorize your sources into those that examine the impact of social media on self-esteem, those that explore the effects of cyberbullying, and those that investigate the relationship between social media use and depression.
• Synthesize your findings by summarizing the key themes and highlighting any gaps or inconsistencies in the research. Identify areas where further research is needed.
• Use your literature review to inform your research questions and hypotheses for your thesis.

For example, after conducting a literature review on the impact of social media on teenagers’ mental health, a thesis might look like this:

“Using a mixed-methods approach, this study aims to investigate the relationship between social media use and mental health outcomes in teenagers. Specifically, the study will examine the effects of cyberbullying, social comparison, and excessive social media use on self-esteem, anxiety, and depression. Through an analysis of survey data and qualitative interviews with teenagers, the study will provide insight into the complex relationship between social media use and mental health outcomes, and identify strategies for promoting positive mental health outcomes in young people.”

Reference: Smith, J., Jones, M., & Lee, S. (2019). The effects of social media use on adolescent mental health: A systematic review. Journal of Adolescent Health, 65(2), 154-165. doi:10.1016/j.jadohealth.2019.03.024

Reference Example: Author, A. A., Author, B. B., & Author, C. C. (Year). Title of article. Title of Journal, volume number(issue number), page range. doi:0000000/000000000000 or URL

Applications of Literature Review

some applications of literature review in different fields:

• Social Sciences: In social sciences, literature reviews are used to identify gaps in existing research, to develop research questions, and to provide a theoretical framework for research. Literature reviews are commonly used in fields such as sociology, psychology, anthropology, and political science.
• Natural Sciences: In natural sciences, literature reviews are used to summarize and evaluate the current state of knowledge in a particular field or subfield. Literature reviews can help researchers identify areas where more research is needed and provide insights into the latest developments in a particular field. Fields such as biology, chemistry, and physics commonly use literature reviews.
• Health Sciences: In health sciences, literature reviews are used to evaluate the effectiveness of treatments, identify best practices, and determine areas where more research is needed. Literature reviews are commonly used in fields such as medicine, nursing, and public health.
• Humanities: In humanities, literature reviews are used to identify gaps in existing knowledge, develop new interpretations of texts or cultural artifacts, and provide a theoretical framework for research. Literature reviews are commonly used in fields such as history, literary studies, and philosophy.

Role of Literature Review in Research

Here are some applications of literature review in research:

• Identifying Research Gaps : Literature review helps researchers identify gaps in existing research and literature related to their research question. This allows them to develop new research questions and hypotheses to fill those gaps.
• Developing Theoretical Framework: Literature review helps researchers develop a theoretical framework for their research. By analyzing and synthesizing existing literature, researchers can identify the key concepts, theories, and models that are relevant to their research.
• Selecting Research Methods : Literature review helps researchers select appropriate research methods and techniques based on previous research. It also helps researchers to identify potential biases or limitations of certain methods and techniques.
• Data Collection and Analysis: Literature review helps researchers in data collection and analysis by providing a foundation for the development of data collection instruments and methods. It also helps researchers to identify relevant data sources and identify potential data analysis techniques.
• Communicating Results: Literature review helps researchers to communicate their results effectively by providing a context for their research. It also helps to justify the significance of their findings in relation to existing research and literature.

Purpose of Literature Review

Some of the specific purposes of a literature review are as follows:

• To provide context: A literature review helps to provide context for your research by situating it within the broader body of literature on the topic.
• To identify gaps and inconsistencies: A literature review helps to identify areas where further research is needed or where there are inconsistencies in the existing literature.
• To synthesize information: A literature review helps to synthesize the information from multiple sources and present a coherent and comprehensive picture of the current state of knowledge on the topic.
• To identify key concepts and theories : A literature review helps to identify key concepts and theories that are relevant to your research question and provide a theoretical framework for your study.
• To inform research design: A literature review can inform the design of your research study by identifying appropriate research methods, data sources, and research questions.

Characteristics of Literature Review

Some Characteristics of Literature Review are as follows:

• Identifying gaps in knowledge: A literature review helps to identify gaps in the existing knowledge and research on a specific topic or research question. By analyzing and synthesizing the literature, you can identify areas where further research is needed and where new insights can be gained.
• Establishing the significance of your research: A literature review helps to establish the significance of your own research by placing it in the context of existing research. By demonstrating the relevance of your research to the existing literature, you can establish its importance and value.
• Informing research design and methodology : A literature review helps to inform research design and methodology by identifying the most appropriate research methods, techniques, and instruments. By reviewing the literature, you can identify the strengths and limitations of different research methods and techniques, and select the most appropriate ones for your own research.
• Supporting arguments and claims: A literature review provides evidence to support arguments and claims made in academic writing. By citing and analyzing the literature, you can provide a solid foundation for your own arguments and claims.
• I dentifying potential collaborators and mentors: A literature review can help identify potential collaborators and mentors by identifying researchers and practitioners who are working on related topics or using similar methods. By building relationships with these individuals, you can gain valuable insights and support for your own research and practice.
• Keeping up-to-date with the latest research : A literature review helps to keep you up-to-date with the latest research on a specific topic or research question. By regularly reviewing the literature, you can stay informed about the latest findings and developments in your field.

Advantages of Literature Review

There are several advantages to conducting a literature review as part of a research project, including:

• Establishing the significance of the research : A literature review helps to establish the significance of the research by demonstrating the gap or problem in the existing literature that the study aims to address.
• Identifying key concepts and theories: A literature review can help to identify key concepts and theories that are relevant to the research question, and provide a theoretical framework for the study.
• Supporting the research methodology : A literature review can inform the research methodology by identifying appropriate research methods, data sources, and research questions.
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Limitations of Literature Review

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• Quality of sources : The quality of the literature reviewed can vary widely, and not all sources may be reliable or valid.
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• Lack of original data : Literature reviews do not generate new data, but rather rely on the analysis of existing studies.
• Risk of plagiarism: It is important to ensure that literature reviews do not inadvertently contain plagiarism, which can occur when researchers use the work of others without proper attribution.

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• Open access
• Published: 31 August 2024

Incidence of post-extubation dysphagia among critical care patients undergoing orotracheal intubation: a systematic review and meta-analysis

• Weixia Yu 1   na1 ,
• Limi Dan 1   na1 ,
• Jianzheng Cai 1 ,
• Yuyu Wang 1 ,
• Qingling Wang 1 ,
• Yingying Zhang 1 &
• Xin Wang 1  

European Journal of Medical Research volume  29 , Article number:  444 ( 2024 ) Cite this article

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Post-extubation dysphagia (PED) emerges as a frequent complication following endotracheal intubation within the intensive care unit (ICU). PED has been strongly linked to adverse outcomes, including aspiration, pneumonia, malnutrition, heightened mortality rates, and prolonged hospitalization, resulting in escalated healthcare expenditures. Nevertheless, the reported incidence of PED varies substantially across the existing body of literature. Therefore, the principal objective of this review was to provide a comprehensive estimate of PED incidence in ICU patients undergoing orotracheal intubation.

We searched Embase, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science, Technology Journal Database (VIP), and SinoMed databases from inception to August 2023. Two reviewers independently screened studies and extracted data. Subsequently, a random-effects model was employed for meta-statistical analysis utilizing the “meta prop” command within Stata SE version 15.0 to ascertain the incidence of PED. In addition, we performed subgroup analyses and meta-regression to elucidate potential sources of heterogeneity among the included studies.

Of 4144 studies, 30 studies were included in this review. The overall pooled incidence of PED was 36% (95% confidence interval [CI] 29–44%). Subgroup analyses unveiled that the pooled incidence of PED, stratified by assessment time (≤ 3 h, 4–6 h, ≤ 24 h, and ≤ 48 h), was as follows: 31.0% (95% CI 8.0–59.0%), 28% (95% CI 22.0–35.0%), 41% (95% CI 33.0–49.0%), and 49.0% (95% CI 34.0–63.0%), respectively. When sample size was 100 <  N  ≤ 300, the PED incidence was more close to the overall PED incidence. Meta-regression analysis highlighted that sample size, assessment time and mean intubation time constituted the source of heterogeneity among the included studies.

The incidence of PED was high among ICU patients who underwent orotracheal intubation. ICU professionals should raise awareness about PED. In the meantime, it is important to develop guidelines or consensus on the most appropriate PED assessment time and assessment tools to accurately assess the incidence of PED.

Graphical abstract

Introduction

Mechanical ventilation is the most common technological support, being required by 20–40% of adult in ICU [ 1 ]. Orotracheal intubation is the primary way of mechanical ventilation in ICU, which can increase the risk of post-extubation dysphagia (PED) [ 2 , 3 ]. PED is any form of swallowing dysfunction that arises subsequent to extubation following endotracheal intubation, affecting the passage of food from the entrance to the stomach. The occurrence rate of PED within the ICU setting demonstrates considerable variation among different countries [ 4 ]. The incidence varied among countries, including 13.3–61.8% in the United States [ 5 , 6 ], 25.3–43.5% in France, and 23.2–56% in China [ 7 , 8 ], and the incidence ranging from 7 to 80% [ 9 , 10 ]. Significantly, PED standing out as a prominent complication encountered in this particular context. For instance, See et al. have elucidated that patients afflicted with PED face an 11-fold higher risk of aspiration compared to those without PED [ 11 ]. McIntyre et al. have underscored that patients afflicted with PED endure double the length of stay in the ICU and the overall hospitalization period when compared to patients without PED [ 10 ]. Furthermore, it is essential to note that PED emerged as an independent predictor of 28-day and 90-day mortality [ 12 ]. This high incidence of PED places an immense burden not only on patients but also on the broader healthcare system. Therefore, a systematic review and meta-analysis is necessary to explore the incidence of PED in ICU patients. A systematic review and meta-analysis conducted by McIntyre et al. reported that the incidence of PED was 41%, but the main outcomes of their partly included studies was aspiration [ 12 ]. Although aspiration and PED are closely related, not all aspiration is caused by dysphagia. The incidence of aspiration was 8.80%-88.00% in ICU [ 13 , 14 ], so the incidence of PED in that study may be overestimated. Moreover, there has been increasing literature on PED of ICU patients, and a new systematic review and meta-analysis is needed to obtain a more precise estimate of its incidence.

The incidence of PED may indeed vary depending on various covariates, including assessment time, mean intubation time, age and other relevant factors. First, there is no standard time for swallowing function assessment, which spans a range of intervals, including 3 h [ 6 , 9 , 12 ], 4–6 h [ 15 , 16 ], 24 h [ 17 , 18 , 19 ], 48 h [ 20 ], 7 days [ 21 ], and discharge [ 22 ], and the incidence of PED was 80% [ 9 ], 22.62% [ 15 ], 56.06% [ 18 ], and 35.91% [ 20 ], 22.06% [ 21 ], and 28.78% [ 22 ], respectively. Second, the PED is closely tied to the time of orotracheal intubation. Skoretz et al. have demonstrated that the overall incidence of PED in the ICU ranges from 3 to 4%. However, upon re-analysis of patients subjected to orotracheal intubation for more than 48 h, the PED incidence can surge as high as 51% [ 23 ]. Third, the choice of assessment tool to evaluate PED in ICU patients plays a pivotal role. These assessment tools may include Video-fluoroscopic Swallowing Study (VFSS), Fiberoptic Endoscopic Evaluation of Swallowing (FEES), Standardized Swallowing Assessment (SSA), Bedside Swallowing Evaluation (BSE), Gugging Swallowing Screen (GUSS), Post-Extubation Dysphagia Screening Tool (PEDS), Water Swallowing Test (WST) and other assessment tools. FEES and VFSS are considered the gold standards, with a detection rate of approximately 80% [ 9 ]. SSA and BSE exhibit detection rates of 22% and 62%, respectively [ 5 , 15 ]. Finally, age-related changes in laryngeal sensory and motor functions also influence PED risk [ 24 ]. Notably, there may not be a significant difference in the incidence of PED between elderly and young patients within the initial 48 h post-extubation. However, elderly patients exhibit a significantly slower rate of PED recovery compared to their younger counterparts over time (5.0 days vs 3.0 days; p  = 0.006) [ 5 ]. Therefore, it is necessary to explore the potential source of heterogeneity in the incidence of PED in ICU patients from such covariates.

The purpose of this study was to estimate the incidence of PED among ICU patients who underwent orotracheal intubation and investigate potential sources of heterogeneity through the application of subgroup analyses and meta-regression.

This systematic review and meta-analysis was conducted adhering to the guidelines outlined in the Joanna Briggs Institute (JBI) Reviewers’ Manual and followed the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement (PRISMA 2020) [ 25 ] (see Additional file 1: Table S1). In addition, it was registered with PROSPERO under the registration number CRD42022373300.

Eligibility criteria

The study’s eligibility criteria were established in accordance with the PICOS principle. Inclusion criteria as follows: population (P): adult patients (≥ 18 years old) admitted to the ICU who underwent orotracheal intubation. Exposure (E): undergoing orotracheal intubation. Outcome (O): PED. Study design (S): observational study (cohort, case–control, cross-sectional study). In studies where multiple articles were derived from the same sample, only the article providing the most detailed data was included. Patients at high risk of dysphagia (such as those with head and neck cancer, who have undergone head and neck surgery, patients receiving palliative care, esophageal dysfunction, stroke, esophageal cancer and Parkinson’s disease) were excluded. Studies were excluded if they exhibited incomplete original data or data that could not be extracted. Studied were also excluded if their sample sizes fell below 30 participants or the full text was inaccessible.

Data sources and search strategy

Our comprehensive search multiple databases, including Embase, PubMed, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, China Science and Technology Journal Database (VIP), and SinoMed, with the search period encompassing inception to August 18, 2023. Search language was Chinese and English. The limited number of studies retrieved initially, primarily attributed to the inclusion of the qualifier “ICU” in the initial search, prompted us to broaden the scope of our literature search. Consequently, we refined the search strategy by reducing the emphasis on “ICU” during the search process. After a series of preliminary searches, we finalized the search strategy, which combined subject headings and free-text terms while employing Boolean operators to enhance search precision. In addition, a manual hand-search of the reference lists of selected articles was carried out to identify any supplementary studies not originally identified through the electronic search. For a detailed presentation of our complete search strategies across all databases, please refer to Additional file 1: Table S2.

Quality evaluation

The evaluation of the risk of bias within the included studies was conducted by two trained investigators. Cross-sectional study was evaluated by the Agency for Healthcare Research and Quality (AHRQ) tool [ 26 ], which consisted of 11 items, resulting in a maximum score of 11. Scores falling within the ranges of 0–3, 4–7, and 8–11 corresponded to studies of poor, moderate, and high quality, respectively. Cohort study was evaluated by the Newcastle–Ottawa Scale (NOS) tool [ 27 ], which comprised three dimensions and eight items, allowing for a star rating ranging from 2 to 9 stars. In this case, 0–4, 5–6, and 7–9 stars were indicative of study of poor, moderate, and high quality, respectively. Any discrepancies or disagreements between the investigators were resolved through discussion, when necessary, consultation with a third expert specializing in evidence-based practice methodology.

Study selection and data extraction

Bibliographic records were systematically exported into the NoteExpress database to facilitate the screening process and the removal of duplicate citations. Initial screening, based on titles and abstracts, was conducted by two reviewers who possessed specialized training in evidence-based knowledge. To ascertain whether the studies satisfied the predefined inclusion and exclusion criteria, the full texts of potentially relevant articles were acquired. In the event of disagreements between the two reviewers, resolution was achieved through discussion or, when necessary, by enlisting the input of a third reviewer for arbitration.

After confirming the included studies, the two authors independently extracted data from the each paper, including the first author, year of publication, country, study design, ICU type, mean patient age, mean intubation time, assessment time, assessment tool, evaluator, sample size, and the PED event. Any disparities during the process of extracted data were addressed through thorough discussion and consensus-building among the reviewers.

The outcomes of this review were as follows: (1) incidence of PED in patients with orotracheal intubation in the ICU; (2) sources of heterogeneity of PED in patients with orotracheal intubation in ICU.

Statistical analyses

Meta-analysis was conducted using the ‘meta prop’ function from the meta package within STATA/SE (version 15.0, StataCorp, TX, USA). To approximate the normal distribution of the data, incidence estimates were transformed using the “Freeman-Tukey Double Arcsine Transformation”. Heterogeneity was assessed using the I 2 statistic, and pooled analyses of PED were executed employing a random-effects model in the presence of significant heterogeneity ( I 2  ≥ 50%), with fixed-effects models utilized when heterogeneity was non-significant. A significance level of P  < 0.05 was established for all analyses.

Subgroup analyses were undertaken to investigate the potential impact of various factors, including assessment tool (gold standard, SSA, GUSS, BSE, PEDS, WST, and other assessment tools), year of publication (2000–2010, 2011–2015, 2016–2020, 2021–2023), study design (cross-sectional study and cohort study), study quality (moderate quality and high quality), assessment time (≤ 3 h, 4–6 h, ≤ 24 h, ≤ 48 h, and after 48 h post-extubation), mean intubation time (≤ 24 h, 48 – 168 h, and > 168 h), mean patient age (≤ 44 years, 45–59 years, 60–74 years), evaluator (nurses, speech-language pathologist), ICU type (Trauma ICU, Cardiac surgery ICU, Mixed medical and surgical ICU), and sample size ( N  ≤ 100, 100 <  N  ≤ 200, 200 <  N  ≤ 300, N  > 300) on the pooled estimate. In instances where no source of heterogeneity was identified in the subgroup analyse, we conducted meta-regression to further pinpoint the origins of heterogeneity, focusing on assessment time, mean intubation time, mean age, assessment tool, sample size, evaluator, ICU type, study design, study quality and year of publication. Sensitivity analysis by the “leave-one-out method” was employed to evaluate the random-effects model’s stability of the pooled incidence of PED. Publication bias was assessed by funnel plot and “Trim and Full” method.

Certainty of the evidence

The level of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) [ 28 ]. This tool classifies the certainty of evidence into four levels: very low, low, moderate, and high. “High quality” suggests that the actual effect is approximate to the estimate of the effect. On the other hand, “Very low quality” suggests that there is very little confidence in the effect estimate and the reported estimate may be substantially different from what was measured. Two reviewers judged the following aspects: risk of bias, inconsistency, imprecision, indirect evidence, and publication bias. Disagreements were resolved by consensus with the third reviewer.

Study selection

Out of the 4144 studies initially identified, 1280 duplicate studies were removed, and an additional 2864 studies that were deemed irrelevant were excluded based on title and abstract screening. Subsequently, a thorough examination of the full text was conducted for the remaining 122 studies. A manual hand-search of the reference lists of selected articles was 5 studies. Finally, 30 studies were chosen as they met the predetermined inclusion criteria for this systematic review and meta-analysis. The study selection flowchart is shown in Fig.  1 .

Flowchart of study selection

General characteristics of the included studies

The characteristics of the included studies are shown in Table  1 . The total sample size across these studies amounted to 6,228 participants. The earliest study in this review was conducted in 2003 [ 29 ], while the most recent study was conducted in 2023 [ 15 ], with 14 studies published after 2020. The study with the largest sample size was conducted by Schefold et al. [ 12 ], comprising 933 participants, while the study with the smallest sample size was carried out by Yılmaz et al. [ 19 ], including 40 participants. The methods employed to assess the incidence of PED exhibited variability among the studies. Specifically, one study employed VFSS [ 30 ], and four studies relied on FEES [ 9 , 29 , 31 , 32 ], and seven studies utilized SSA assessment tools [ 7 , 15 , 16 , 33 , 34 , 35 , 36 ]. Furthermore, six studies utilized BSE [ 5 , 10 , 17 , 37 , 38 , 39 ], two studies employed WST [ 12 , 40 ], two studies adopted PEDS [ 8 , 18 ], two studies utilized GUSS [ 19 , 41 ], and six studies employed other assessment tools [ 6 , 20 , 21 , 22 , 43 ,, 42 , 43 ] such as ASHA, FOIS, SSQ200, NPS-PED, MASA, and YSP.

Among all the studies, 23 studies recorded the assessment time for PED. Specifically, three studies assessed PED within ≤ 3 h post-extubation [ 6 , 9 , 12 ], four studies conducted assessments at 4–6 h post-extubation [ 15 , 16 , 33 , 36 ], nine studies assessed PED within ≤ 24 h post-extubation [ 7 , 8 , 17 , 18 , 19 , 31 , 34 , 40 , 41 ], three studies assessed PED within ≤ 48 h post-extubation [ 5 , 20 , 37 ], and four studies evaluated PED at > 24 h post-extubation [ 21 , 22 , 29 , 38 ]. In terms of study quality, eight of the included studies were categorized as high quality, while the remainder were deemed of moderate quality (see Additional 1: Tables S3, S4).

Meta-analysis results

Utilizing the random-effects model, the pooled incidence of PED was estimated to be 36% (95% CI 29.0%–44.0%, I 2  = 97.06%, p  < 0.001; Fig.  2 ), indicating a substantial degree of heterogeneity. Despite conducting additional subgroup analyses, the source of this high heterogeneity remained elusive. However, the results of the meta-regression analysis revealed that sample size ( p  < 0.001), assessment time ( p  = 0.027) and mean intubation time ( p  = 0.045) emerged as the significant factor contributing to the heterogeneity.

Overall pooled incidence of PED in ICU

Subgroup analysis of incidence

The subgroup analyses yielded the following incidence rates of PED based on assessment time post-extubation: the incidence of PED within 3 h post-extubation was 31% (95% CI 8.0–59.0), 4–6 h was 28% (95% CI 22.0–35.0, I 2  = 78.56%, p  < 0.001), within 24 h was 41% (95% CI 33.0–49.0, I 2  = 88.99%, p  < 0.001), and within 48 h was 49%. In addition, the incidence of PED beyond 24 h post-extubation was 37% (95% CI 23.0–52.0, I 2  = 91.73%, p  < 0.001) (Additional file 1: Fig. S1). Furthermore, when analyzing studies based on sample size ( N ), the overall incidence of PED was found 51% (95% CI 39.0–63.0, I 2  = 87.11%, p  < 0.001) for studies with N  < 100 participants, 37% (95% CI 31.0–43.0, I 2  = 84.74%, p  < 0.001) for studies with 100 <  N  ≤ 200 participants, 32% (95% CI 20.0–46.0, I 2  = 97.16%, p  < 0.001) for studies with 200 <  N  ≤ 300 participants, and 16% (95% CI 8.0–26.0, I 2  = 97.07%, p  < 0.001) for studies with N  > 300 participants (see Additional file 1: Fig. S2). In addition, further analyses were conducted based on assessment tool, mean intubation time, mean age, ICU type, evaluator, publication year, study design and study quality (see Additional file 1: Figs. S3–S11).

Results of meta-regression analysis

In the meta-regression analysis, we examined PED assessment time, sample size, assessment tools, mean intubation time, mean age, ICU type, evaluator, publication year, study design and study quality as potential covariates to identify the source of heterogeneity (Table  2 ). The univariate meta-regression analysis revealed a statistically significant correlation between incidence and sample size, assessment time and mean intubation time. Bubble plots of meta-regression of covariates were shown in Additional (see Additional file 1: Figs. S12–S22).

Sensitivity analysis

Sensitivity analysis showed that the incidence of PED ranged from 29 to 44% (see Additional file 1: Fig. S23). The marginal variance between these results and the pooled incidence was minimal, suggesting that the result of the pooled incidence being stable and reliable.

Publication bias

In our study, publication bias was detected by the funnel plot (see Additional file 1: Fig. S24). We found that the adjusted effect size was similar to the original effect size ( p  < 0.01) (see Additional file 1: Fig. S25).

The certainty of evidence was very low for all comparisons performed according to the GRADE rating [ 28 ]. Thus, it can be considered that the certainty of the evidence regarding the incidence of PED in this review is very low (Table  3 ).

This systematic review and meta-analysis aimed to estimate the incidence of PED in ICU patients. The study revealed an overall incidence of PED in ICU patients who underwent orotracheal intubation to be 36.0%. This incidence rate was comparable to the incidence of dysphagia resulting from stroke (36.30%) [ 45 ] and aligned with the incidence of PED observed in ICU patients (36%) [ 46 ]. However, it was slightly lower than the 41% reported in the meta-analysis conducted by McIntyre et al. [ 4 ]. The incidence of PED among ICU patients who underwent orotracheal intubation was high, ICU medical professionals, especially nurses should raise awareness about PED. However, the included studies were characterized by diversity and heterogeneity in assessment time and assessment tools signaled the need for obtaining consensus on a range of issues, including assessment time and assessment tools appropriate for ICU.

Sample size

This review identified sample size as a significant source of heterogeneity ( p  < 0.001). Notably, the incidence of PED demonstrated a gradual decrease as the sample size of the studies increased. In larger scale studies, such as those conducted by McIntyre et al. and Schefold et al., simpler assessment tools are employed, allowing for quick completion [ 10 , 12 ]. However, the reliability and validity of some of these tools remain unverified. Conversely, certain studies are conducted by highly trained professionals using the gold standard for PED assessment [ 9 , 29 , 31 ], which, while more accurate, is also time-consuming and costly [ 47 ]. In addition, some ICU patients, due to their unstable conditions, are unable to complete the gold standard assessment, resulting in relatively smaller sample sizes for these studies.

In statistics, sample size is intricately linked to result stability, and the confidence intervals for subgroups with N  < 100 in this study exhibited a wider range, this might diminish the result precision and lead to larger deviations from the true value. However, as the sample size increased to 100 <  N  ≤ 300, the confidence intervals narrowed in comparison to other subgroups. Consequently, when sample size was 100 <  N  ≤ 300, the PED incidence rates were more close with the overall PED rate. According to the central limit theorem, if the sampling method remains consistent, results obtained from larger samples are more stable and closer to the true value [ 48 , 49 ]. It is worth noting that the confidence intervals for the subgroup with N  > 300 in this study were wider and demonstrated a larger divergence from the total PED incidence. Therefore, in future studies, careful consideration of the sample size, based on the detection rate of the assessment tool used, is advisable to ensure both the stability and reliability of the results.

Mean intubation time

This review identified mean intubation time as a significant source of heterogeneity ( p  = 0.045). Variances in mean intubation time among ICU patients undergoing orotracheal intubation can lead to differing degrees of mucosal damage in the oropharynx and larynx [ 2 , 50 ], thereby resulting in varying incidence rates of PED. For instance, Malandraki et al. have reported that prolonged intubation is associated with more than a 12-fold increased risk of moderate/severe dysphagia compared to shorter intubation durations, and this effect is particularly pronounced among elderly patients [ 51 ]. Moreover, studies have demonstrated that ICU patients with extended orotracheal intubation periods leading to PED also exhibit diminished tongue and lip strength, protracted oral food transportation, slower swallowing, and muscle weakness in swallowing-related muscles [ 24 , 46 ]. In view of these findings, ICU medical professionals should routinely evaluate the need for orotracheal intubation, strive to minimize the duration of mechanical ventilation.

PED assessment time

This review identified assessment time as a significant source of heterogeneity ( P  = 0.027). It is important to note that there are currently no established guidelines recommending the optimal timing for the initial assessment of PED in ICU patients who have undergone orotracheal intubation. Consequently, the assessment time varies widely across studies, resulting in PED incidence rates ranging from 28 to 49% among subgroups. Interestingly, the incidence of PED assessed within ≤ 3 h post-extubation appeared lower than that assessed within ≤ 24 h and ≤ 48 h post-extubation. This difference may be attributed to the study by Schefold et al., which featured a shorter intubation duration [ 12 ]. Therefore, the incidence of PED assessed within ≤ 3 h post-extubation in ICU patients with orotracheal intubation may be underestimated. Moreover, it is essential to highlight that some ICU patients, particularly those with severe illnesses and extended intubation time, may face challenges in complying with post-extubation instructions provided by healthcare personnel. Paradoxically, this group of patients is at a higher risk of developing PED, subsequently increasing their susceptibility to post-extubation pneumonia [ 11 ]. ICU professionals should evaluate swallowing function in patients post-extubation; early identification of patients at risk for PED to reduce complications. If PED is identified, nurses should follow-up assessments at multiple time to obtain a thorough comprehension of PED recovery trajectory among PED patients, which can serve as a foundation for determining the timing of clinical interventions accurately.

PED assessment tools

Despite the subgroup analyses and meta-regression results indicating that PED assessment tools did not contribute to the observed heterogeneity, it is important to acknowledge the wide array of assessment tools employed across the studies included in this review. The study’s findings revealed that the results of the GUSS and BSE assessments were most closely aligned with the gold standard screening results. In contrast, the PEDS assessment results tended to be higher than those derived from the gold standard assessment. Furthermore, the results of other assessment tools generally yielded lower incidence rates of PED, possibly attributable to variations in specificity or sensitivity. FEES and VFSS assessments are recognized for their meticulous scrutiny of patients’ swallowing processes, including the detection of food residue and aspiration, which may not be as comprehensively addressed by other assessment methods [ 51 ]. Assessment tools such as BSE, SSA, GUSS, WST, and other clinical methods do not provide direct visualization of the swallowing process. Instead, assessors rely on the observation of overt clinical symptoms during the patient’s initial food or water intake to judge the presence of PED. However, these methods may overlook occult aspiration in patients, potentially resulting in an underestimation of PED incidence. In contrast, PEDS, which primarily assesses patients based on their medical history and plumbing symptoms without screening for drinking or swallowing, may overestimate PED incidence. Considering the varying strengths and limitations of existing assessment tools, ICU professionals select appropriate PED assessment tool based on the characteristics of the critically ill patient. Early and rapid identification of PED, before the use of more complex and expensive assessment tools, minimizes the occurrence of complications in patients.

Strengths and weaknesses

In this study, we conducted a comprehensive analysis of the incidence of PED in ICU patients who underwent orotracheal intubation across various subgroups, revealing a notable degree of heterogeneity among the included studies. In our study, we have expanded the search as much as possible and included a total of 30 papers after screening, half of which were published after 2020. There are several limitations that should be considered when interpreting the results of this meta-analysis. First, there was varied heterogeneity between methodological of the study and estimates of prevalence that may question the appropriateness of calculating pooled prevalence estimates. However, in order to address this heterogeneity, we addressed the heterogeneity with applying a random-effect model and conducting subgroup analysis and meta-regression to explore three sources of heterogeneity. Second, the overall quality of evidence for the incidence of PED was rated as low according to GRADE. Higher quality original studies on the incidence of PED should be performed in the future. As a result, the findings should be interpreted with caution in such cases.

In conclusion, our systematic review and meta-analysis revealed a high incidence of PED among ICU patients who underwent orotracheal intubation. It is also worth noting that the incidence of PED in the ICU may be underestimated. It is expected to increase awareness about the issue of PED among ICU patients. It will be important to develop guidelines or consensus on the most appropriate PED assessment time and assessment tools to accurately assess the incidence of PED.

Relevance to clinical practice

Each year, a substantial number of critically ill patients, ranging from 13 to 20 million, necessitate endotracheal intubation to sustain their lives. Patients undergoing orotracheal intubation are at heightened risk of developing PED. PED has been linked to prolonged hospital and ICU length of stay, increased rates of pneumonia, and all-cause mortality. Early identification of high-risk patients by clinical nurses is critical for reduce patient burden and adverse outcomes.

Early and multiple times assessment: Future investigations should early assess PED in clinical practice, especially within 6 h post-extubation. Furthermore, we suggest for follow-up assessments at multiple time to obtain a thorough comprehension of PED incidence and the recovery trajectory among ICU patients who have undergone orotracheal intubation.

Assessment tool: Considering the varying strengths and limitations of existing assessment tools, ICU professionals should carefully evaluate the characteristics of critically ill patients and select appropriate assessment tools, before the use of more complex and expensive assessment tools.

Routinely evaluate the need for orotracheal intubation: Healthcare professionals should routinely evaluate the need for orotracheal intubation, strive to minimize the duration of mechanical ventilation.

Availability of data and materials

All data related to the present systematic review and meta-analysis are available from the original study corresponding author on reasonable request.

Abbreviations

Confidence interval

• Intensive care unit

Post-extubation dysphagia

Sydney Swallow Questionnaire 200

Water swallowing test

Post-Extubation Dysphagia Screening Tool

Bedside swallow evaluation

The Yale swallow protocol

Mann Assessment of Swallowing Ability

American Speech-Language-Hearing Association

Video Fluoroscopic Swallowing Study

Fiberoptic endoscopic evaluation of swallowing

Gugging swallowing screen

Standardized Swallowing Assessment

Functional Oral Intake Scale

Nurse-performed screening for post-extubation dysphagia

Speech-language pathologists

Events of PED

Preferred Reporting Items for Systematic Reviews and Meta-analyses

International Prospective Register of Systematic Reviews

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Weixia Yu, Limi Dan, Jianzheng Cai, Yuyu Wang, Qingling Wang, Yingying Zhang & Xin Wang

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Weixia Yu, Limi Dan, Jianzheng Cai, and Yuyu Wang developed the original concept of this systematic review and meta-analysis. Weixia Yu, Limi Dan, Jianzheng Cai and Yuyu Wang contributed to the screening of eligible studies, data extraction, and data synthesis. Weixia Yu, Limi Dan, Jianzheng Cai, Yuyu Wang and Qingling Wang drafted the first version of the manuscript. Yingying Zhang, Qingling Wang and Xin Wang prepared the tables and figures. All the authors have edited and contributed for intellectual content. All the authors read and approved the final manuscript and take public responsibility for it.

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Additional file 1: Table S1. PRISMA 2020 Checklist. Table S2. Search strategy. Table S3. Quality evaluation results of the cohort studies. Table S4. Quality evaluation results of the cross-sectional study. Fig. S1. Subgroup analysis of the incidence of PED by assessment time. Fig. S2. Subgroup analysis of the incidence of PED by sample size. Fig. S3. Incidence of PED by assessment tool. Fig. S4. Incidence of PED by mean intubation time. Fig. S5 Incidence of PED by mean age. Fig. S6. Incidence of PED by ICU type. Fig. S7. Incidence of PED by evaluator. Fig. S8. Incidence of PED by year of publication. Fig. S9. Incidence of PED by study design. Fig. S10. Incidence of PED by quality of cohort study. Fig. S11. Incidence of PED by quality of Cross-sectional study. Fig. S12. Bubble plot of meta-regression result for evaluate time as a covariate. Fig. S13. Bubble plot of meta-regression result for sample size as a covariate. Fig. S14. Bubble plot of meta-regression result for assessment tool as a covariate. Fig. S15. Bubble plot of meta-regression result for mean intubation time as a covariate. Fig. S16. Bubble plot of meta-regression result for mean age as a covariate. Fig. S17. Bubble plot of meta-regression result for ICU type as a covariate. Fig. S18. Bubble plot of meta-regression result for evaluator as a covariate. Fig. S19. Bubble plot of meta-regression result for year of publication as a covariate. Fig. S20. Bubble plot of meta-regression result for study design as a covariate. Fig. S21. Bubble plot of meta-regression result for quality of cohort study as a covariate. Fig. S22. Bubble plot of meta-regression result for quality of cross-sectional study as a covariate. Fig. S23. Sensitivity analysis of PED. Fig. S24. Publication bias assessment plot. Fig. S25. Publication bias assessment plot. “Trim and Full test” method.

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Yu, W., Dan, L., Cai, J. et al. Incidence of post-extubation dysphagia among critical care patients undergoing orotracheal intubation: a systematic review and meta-analysis. Eur J Med Res 29 , 444 (2024). https://doi.org/10.1186/s40001-024-02024-x

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• Prevention and care of adult enterostomy with high output: a scoping review protocol
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• http://orcid.org/0009-0008-0113-2984 Ying Che 1 ,
• Tianming Wang 2 ,
• Caifeng Gao 3 ,
• Fei Sun 1 ,
• Shangke Li 4 ,
• Zhanlin Luo 5
• 1 Research Ward , Gansu Provincial Hospital , Lanzhou , China
• 2 Gansu University Of Chinese Medicine , Lanzhou , China
• 3 Department of radiotherapy , Gansu Provincial People's Hospital , Lanzhou , China
• 4 Gansu Provincial Hospital , Lanzhou , Gansu , China
• 5 Department of radiotherapy , Gansu Provincial Hospital , Lanzhou , Gansu , China
• Correspondence to Professor Zhanlin Luo; lzl120606{at}126.com

Introduction The purpose of this protocol is to investigate the risk factors, critical evaluation contents and preventive measures of high-output enterostomy.

Methods and analysis This scoping review will follow the Joanna Briggs Institute guidelines for scoping reviews. PubMed, EMBASE, CINAHL, the Chinese Biological Literature Database and the Cochrane Library will be searched for relevant literature published from January 2015 to January 2024. The Grading of Recommendations, Assessment, Development and Evaluation and the Risk Of Bias In Non-randomised Studies of Interventions will be used to assess the reliability of the evidence.

Ethics and dissemination As this scoping review involves database searches for literature analysis, informed consent and ethical approval from patients will not be required. The findings will provide essential decision-making information for researchers, clinicians and ostomy nursing staff. The results of the review will be presented at a scientific conference and published in a peer-reviewed journal.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

This protocol will strictly adhere to the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews.

The literature search will include only English and Chinese literature from the past 10 years, potentially limiting the comprehensiveness of the search. However, researchers will broaden the search scope based on the included literature and supplement it by searching grey literature.

The Grading of Recommendations, Assessment, Development and Evaluation and Risk Of Bias In Non-randomised Studies of Interventions tools will be used to grade the quality of the evidence obtained after quality evaluation, ensuring the scientific rigour of the research design and the appropriateness of evidence classification.

To reduce the risk of bias, researchers will triple-check the input data during the process of literature quality evaluation and evidence summarisation.

Introduction

In recent years, with the rapid development of living standards, people’s eating habits and lifestyles have undergone major changes, leading to a continuously increasing trend in the incidence and mortality of malignant tumours such as gastric cancer and colorectal cancer. 1 The treatment of colorectal cancer predominantly involves surgery, and the number of patients undergoing enterostomy is on the rise. 2 Enterostomy requires the removal of the cancerous end of the intestine, extraction of a section of the intestine through the abdominal incision, and its attachment to the abdominal wall skin to form a stoma. 3 As the anal sphincter loses its normal excretion function, patients must use a stoma bag to collect excreta postsurgery. In the USA, approximately 100 000 patients undergo enterostomy annually, with a current total of 1 million enterostomy patients. 4 Despite rapid advancements in surgical techniques, the incidence of high output in enterostomy patients ranges from 23.8% to 31.1% compared with other common surgical procedures. 5 6

Postoperative complications of enterostomy can be categorised into early and advanced complications based on the time of occurrence. Early complications refer to those occurring within the first 30 days postoperation. High output is a prevalent early complication of enterostomy. 7 Typically, the output from an enterostomy ranges from 500 to 2000 mL but varies based on the type of stoma, enteral feedings and other factors. A review of extensive literature reveals ambiguity in the normal output for different types of enterostomies; however, it is widely accepted that an output exceeding 1500 mL per day from a small bowel enterostomy is considered high. 8 Fluid losses postsurgery usually resolve within a few weeks due to adaptive changes in the remaining small intestine. In some patients, high-output enterostomy results from inadequate adaptation or other causes of diarrhoea, such as indigestible food intake, leading to significant water and electrolyte loss, and potentially causing complications like kidney function injury. 9 High output is also the most common reason affecting readmissions of enterostomy patients. 10 Moreover, the quality of life for patients with enterostomy is poor in the early stages due to insufficient knowledge about stoma care and influences such as psychological emotions. 11 Overall, the risk of postoperative complications after enterostomy is lifelong, with high output being a frequent complication. Specialist stoma nurses should proactively focus on complication prevention and provide guidance.

Currently, the literature on preventing high output has not received adequate attention, and there is no consensus to guide precise and effective nursing interventions for preventing high output in enterostomy patients. Monitoring of enterostomy discharge is also often overlooked by patients and clinical ostomy nurses. Additionally, the variable quality of relevant literature can waste medical resources and lead to misleading clinical practices.

Given these issues, it is urgent to determine a comprehensive and effective prevention programme for high output. The scoping review, based on evidence-based concepts, aims to help researchers understand the scope and characteristics of existing evidence and identify gaps in the evidence. Thus, the methods employed in this study were designed to retrieve, summarise and analyse relevant evidence on high output in enterostomy patients, providing an evidence-based foundation for clinical nurses, patients and caregivers to implement enterostomy care and reduce the incidence of high output.

Review questions

What are the risk factors for high output enterostomy?

What are the critical evaluation contents of high-output enterostomy?

What are the main interventions that can effectively prevent high-output enterostomy?

This scoping review will follow the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. 12 13 The study is scheduled to commence in April 2024 and conclude in August 2024. This protocol has been registered with the OSF ( https://doi.org/10.17605/OSF.IO/UF9B7 ).

Patient and public involvement

No patients and the public were involved.

Inclusion criteria

The subjects are patients who have undergone enterostomy (including colostomy, ileostomy, cecostomy, jejunostomy, etc) after a pathological diagnosis of malignant diseases such as stomach and colorectal cancer. The patients are 18 years or older. Enterostomy in children is excluded due to factors such as the thin cuticle of the skin, crying and different ostomy bag management needs. Additionally, children undergoing enterostomy often have various congenital diseases, such as anal absence and Hirschsprung’s disease, which differ significantly from adult enterostomy. Finally, the rehabilitation outcomes for minor enterostomy patients depend on the effectiveness of care provided by primary caregivers, which is a further reason for their exclusion from this study.

Exclusion criteria

The subjects are patients undergoing urostomy.

Conference abstracts, animal experiments or preclinical trial studies and studies without specifying the type of stoma.

Studies where the full text is not available.

Studies with incomplete data and unsuccessful attempts to contact the original authors.

The objective of this scoping review is to search, select and extract evidence for the prevention and care of high-output enterostomy patients. According to the requirements of different databases, appropriate search strategies will be developed, and a literature search will be conducted. The data that meet the inclusion criteria will be analysed. The main contents include (1) risk factors for high-output enterostomy patients; (2) critical evaluation contents of high-output enterostomy, such as symptoms and signs of high output in enterostomy patients and (3) interventions that can effectively prevent and improve high output.

Types of studies

The literature types included in this study encompass randomised controlled trials (RCTs), non-RCTs, cohort studies, case–control studies, cross-sectional studies, observational studies and descriptive studies. Qualitative studies and systematic reviews will also be considered and published in either English or Chinese, from January 2015 to January 2024. This review will include studies on high-output enterostomy conducted in any country or region.

Search strategy

The search for studies related to the prevention of high output in adult enterostomy patients will be conducted through PubMed, EMBASE, CINAHL, the Chinese Biological Literature Database and the Cochrane Library. We will employ the following MeSH terms and/or free-text terms: surgical stomas, enterostomy, ostomy, stoma, ileostomy, jejunostomy, colostomy, high output, fast transit, diarrhoea, risk factor, association, relative risk, factor, influence, correlation, management, treatment, therapy and care.

Additionally, grey literature sources, such as Google Scholar, will be searched to ensure comprehensive evidence incorporation. Grey literature includes materials published by government departments, academic institutions and commercial industries that are non-profit, helping to avoid publication bias. The flow chart of the study diagram is presented in figure 1 , and the detailed search strategy is outlined in online supplemental appendix S1 .

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The flow diagram of the study selection.

Literature screening

The literature screening will be conducted independently and cross-checked by two reviewers (Che Y and Luo ZL). In the event of disagreements, decisions will be discussed in a group meeting. The reviewers will independently use EndNote V.X9 software to remove duplicate entries and initially exclude irrelevant literature by reviewing titles and abstracts. For literature retained after this initial screening, further exclusions will be made by reading the full text to ensure alignment with the study theme, such as research object consistency and intervention plans.

Data extraction and presentation

Two reviewers (Che Y and Luo ZL) will independently extract data, including (1) research design, title, author, year of publication, types of literature, country or region of publication, and publication languages; (2) baseline characteristics of participants: sample size, gender, age, type of enterostomy, characteristics of the research population; (3) intervention details: intervention measures, observation period and (4) primary outcomes: the incidence of high-output enterostomy, enterostomy output volume, the change of output and the factors contributing to high-output enterostomy. There will be no secondary outcome measures.

Strategy for data synthesis

The study design, baseline characteristics of participants and intervention details of this scoping review will be quantitatively summarised in table format. For the incidence of high output in enterostomy, enterostomy output volume, changes in output and factors contributing to high-output enterostomy will be presented in the form of frequency, percentage and descriptive summary.

Quality of evidence

The quality of evidence for outcome indicators will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. 14 The GRADE evaluation criteria include five grading factors: research limitations, inconsistency, indirectness, imprecision and publication bias. The evidence quality will be rated across four levels: high, moderate, low and very low. The default evidence quality for RCTs is high, with one grade reduction to moderate, two reductions to low and three to very low.

For cohort studies, case–control studies and other non-RCTs included in this review, the risk of bias will be assessed using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. 15 ROBINS-I tool divides bias into 7 domains with a total of 33 items: (1) confounding bias; (2) subject selection bias; (3) intervention classification bias; (4) intentional intervention deviation bias; (5) loss of data bias; (6) outcome measurement bias and (7) selective reporting bias. According to the evaluation results of each item, the researcher will make yes (Y), probably yes (PY), no (N), probably no (PN) and no information (NI) answers. ROBINS-I divided the evaluation results into five levels: low risk of bias, moderate risk of bias, high risk of bias, critical risk of bias and no information.

Ethics statements

Patient consent for publication.

Not applicable.

Ethics approval

Since the literature related to the research topic will be obtained by searching the database for analysis in this scoping review, informed consent and ethical approval of patients will not be required. The results of this study will provide decision-making information for researchers, clinicians, and other ostomy nursing staff. The results of the review will be presented at a scientific conference and published in a peer-reviewed journal.

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Contributors All authors in the manuscript contributed substantially to the idea or design of the study and agreed to the manuscript’s publication; YC and SL: literature search and data extraction; YC and FS: quality assessment of systematic reviews and writing of papers; ZL: search literature and quality assessment of systematic reviews; TW and CG: search literature and quality assessment of systematic reviews; YC: design study and data extraction.

Funding This scoping review protocol was supported by Natural Science Foundation of Gansu Province, China (22JR5RA697).

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Infrastructure resilience plays an important role in mitigating the negative impacts of natural hazards by ensuring the continued accessibility and availability of resources. Increasingly, equity is recognized as essential for infrastructure resilience. Yet, after about a decade of research on equity in infrastructure resilience, what is missing is a systematic overview of the state of the art and a research agenda across different infrastructures and hazards. To address this gap, this paper presents a systematic review of equity literature on infrastructure resilience in relation to natural hazard events. In our systematic review of 99 studies, we followed an 8-dimensional assessment framework that recognizes 4 equity definitions including distributional-demographic, distributional-spatial, procedural, and capacity equity. Significant findings show that (1) the majority of studies found were located in the US, (2) interest in equity in infrastructure resilience has been exponentially rising, (3) most data collection methods used descriptive and open-data, particularly with none of the non-US studies using human mobility data, (4) limited quantitative studies used non-linear analysis such as agent-based modeling and gravity networks, (5) distributional equity is mostly studied through disruptions in power, water, and transportation caused by flooding and tropical cyclones, and (6) other equity aspects, such as procedural equity, remain understudied. We propose that future research directions could quantify the social costs of infrastructure resilience and advocate a better integration of equity into resilience decision-making. This study fills a critical gap in how equity considerations can be integrated into infrastructure resilience against natural hazards, providing a comprehensive overview of the field and developing future research directions to enhance societal outcomes during and after disasters. As such, this paper is meant to inform and inspire researchers, engineers, and community leaders to understand the equity implications of their work and to embed equity at the heart of infrastructure resilience plans.

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Introduction.

Infrastructures are the backbones of our societies, connecting people to essential resources and services. At the same time, infrastructure systems such as power, water, and transportation play a pivotal role in determining whether a natural hazard event escalates into a disaster 1 . Driven by the combination of accelerating climate hazards and increasing vulnerability, a 2022 Reuters report indicated that natural hazards caused infrastructure and building losses between $732 and $845 billion dollars internationally 2 . In another report by the World Bank (2019), the direct damage to power and transportation systems had an estimated cost of $18 billion annually 3 . Not only do infrastructure disruptions result in economic losses but they also lead to health issues and a decline in quality of life 4 . Since infrastructure systems secure the accessibility and availability of water, health, and electricity, among other critical services, disruptions of infrastructure exacerbate disasters. For example, the Nepal earthquake (2015) caused the collapse of 262 micro-hydropower plants and 104 hospitals, which further weakened the community’s ability to recover from the hazardous event 5 . Hurricane Maria (2017) in Puerto Rico led to year-long power disruptions which contributed to the 2975 estimated human fatalities 6 . Therefore, infrastructure resilience is becoming increasingly prominent in research, policy, and practice.

The National Infrastructure Advisory Council defined infrastructure resilience as the ability of infrastructure systems, to absorb, adapt, or recover from disruptive events such as natural hazards 7 , 8 . From an engineering viewpoint, infrastructure resilience ensures no significant degradation or loss of system performance in case of a shock (robustness), establishes multiple access channels to infrastructure services (redundancy), effectively mobilizes resources and adapts to new conditions (resourcefulness), and accomplishes these goals in a timely manner (rapidity) 9 . From these origins, infrastructure resilience has evolved to include the complex interactions of technology, policy, social, and governance structures 10 . The United Nations Office for Disaster Risk Reduction discusses the need to use transdisciplinary and systemic methods to guide infrastructure resilience 11 . In their Principles of Resilient Infrastructure report, the principles of infrastructure resilience are to develop understanding and insights (continual learning), prepare for current and future hazards (proactively protected), positively work with the natural environment (environmentally integrated), develop participation across all levels of society (socially engaged), share information and expertise for coordinated benefits (shared responsibility), and address changing needs in infrastructure operations (adaptively transforming) 12 .

Based on the argument of Schlor et al. 13 that “social equity is essential for an urban resilience concept,” we also argue that equity in infrastructure resilience will not only benefit vulnerable populations but also lead to more resilient communities. Equity, in a broad sense, refers to the impartial distribution and just accessibility of resources, opportunities, and outcomes, which strive for fairness regardless of location and social group 14 , 15 . Equity in infrastructure resilience ensures that everyone in the community, regardless of their demographic background, geographic location, level of community status, and internal capabilities, have access to and benefits from infrastructure services. It would also address the limitations of infrastructure resilience, which brings short-term benefits to a specific group of people but ultimately results in long-term disaster impacts 16 . A failure to recognize equity in infrastructure resilience could exacerbate the disaster impact and lock in recovery processes, which in turn, reduces future resilience and leads to a vicious cycle 17 .

Even though infrastructure resilience has important equity impacts, the traditional definition of infrastructure resilience is antithetical to equity. Socially vulnerable populations (such as lower income, minority, indigenous, or rural populations) have traditionally been excluded from the development, maintenance, and planning of infrastructure resilience 18 . For instance, resilience strategies do not conventionally consider the unique needs and vulnerabilities of different communities, leading to inadequate one-size-fits-all solutions 19 . Conventional approaches to restoring infrastructure after hazard events are based on the number of outages, the number of affected customers, and extent of damage within an area, depending on the company preferences, and rarely prioritize the inherent vulnerability of affected individuals and areas 20 . Thereby, those who are most dependent on infrastructure systems may also be most affected by their outages. Several reports, such as National Institute of Standards and Technology 21 , United Nations Office for Project Services 11 , United Nations Office for Disaster Risk Reduction and Coalition for Disaster Resilient Infrastructure 22 , and the Natural Hazards Engineering Research Infrastructure 23 have recognized the importance of considering vulnerable populations in infrastructure resilience.

Furthermore, infrastructure resilience efforts often require significant investment at individual, community, and societal levels 24 . For instance, lower income households may not be able to afford power generators or water tanks to replace system losses 25 , 26 , which means they are more dependent on public infrastructure systems. Wealthier communities may receive more funding and resources for resilience projects due to better political representation and economic importance 27 . Improvements in infrastructure can also lead to gentrification and displacement, as an area perceived with increased safety may raise property values and push out underrepresented residents 28 . Infrastructure resilience may not be properly communicated or usable for all members of the community 29 . Research has also shown an association between vulnerable groups facing more intense losses and longer restoration periods of infrastructure disruptions due to planning biases, inadequate maintenance, and governance structures 18 . Due to the limited tools that translate equity considerations, infrastructure managers, owners, and operators are unlikely to recognize inequities in service provision 20 . Finally, resilience planning can prioritize rapid recovery which may not allow for sufficient time to address the underlying social inequities. This form of resilience planning overlooks the range of systematic disparities evident in infrastructure planning, management, operations, and maintenance in normal times and hazardous conditions 18 .

The field of equity in infrastructure resilience has sparked increasing interest over the last decade. First, researchers have distinguished equal and equitable treatment for infrastructure resilience. As stated by Kim and Sutley 30 , equality creates equivalence at the beginning of a process whereas equity seeks equivalence at the end. Second, the term has been interpreted through other social-economic concepts such as social justice 16 , sustainability 31 , vulnerability 32 , welfare 33 , 34 , and environmental justice 35 . Third, equitable infrastructure is frequently associated with pre-existing inequities such as demographic features 36 , 37 , spatial clusters 38 , 39 , 40 , and political processes 41 . Fourth, studies have proposed frameworks to analyze the relationship of equity in infrastructure resilience 42 , 43 , adapted quantitative and qualitative approaches 44 , 45 , and created decision-making tools for equity in infrastructure resilience 31 , 46 .

Despite a decade of increasing interest in integrating equity into infrastructure resilience, the research gap is to systematically evaluate collective research progress and fundamental knowledge. To address this gap, this paper presents a comprehensive systematic literature review of equity-related literature in the field of infrastructure resilience during natural hazards. The aim is to provide a thorough overview of the current state of art by synthesizing the growing body of literature of equitable thinking and academic research in infrastructure resilience. From there, we aim to identify gaps and establish a research agenda. This review focuses on the intersection of natural hazard events, infrastructure resilience, and equity to answer three overarching research questions. As such, this research is important because it explores the critical but often neglected integration of equity into infrastructure resilience against natural hazards. It provides a comprehensive overview and identifies future research opportunities to improve societal outcomes during and after disasters.

What are the prevailing concepts, foci, methods, and theories in assessing the inequities of infrastructure services in association with natural hazard events?

What are the similarities and differences in studying pathways of equity in infrastructure resilience?

What are the current gaps of knowledge and future challenges of studying equity in infrastructure resilience?

To answer the research questions, the authors reviewed 99 studies and developed an 8-dimensional assessment framework to understand in which contexts and via which methods equity is studied. To differentiate between different equity conceptualizations, the review distinguishes four definitions of equity: distributional-demographic (D), distributional-spatial (S), procedural (P), and capacity (C). In our study, “pathways” explores the formation, examination, and application of equity within an 8-dimensional framework. Following Meerow’s framework of resilience to what and of what? 47 , we then analyze for which infrastructures and hazards equity is studied. Infrastructures include power, water, transportation, communication, health, food, sanitation, stormwater, emergency, and general if a specific infrastructure is not mentioned. Green infrastructure, social infrastructure, building structures, and industrial structures were excluded. The hazards studied include flood, tropical cyclone, drought, earthquake, extreme temperature, pandemic, and general if there is no specific hazard.

The in-depth decadal review aims to bring insights into what aspects are fully known, partially understood, or completely missing in the conversation involving equity, infrastructure resilience, and disasters. The review will advance the academic understanding of equity in infrastructure resilience by highlighting understudied areas, recognizing the newest methodologies, and advising future research directions. Building on fundamental knowledge can influence practical applications. Engineers and utility managers can use these findings to better understand potential gaps in the current approaches and practices that may lead to inequitable outcomes. Community leaders and advocates could also leverage such evidence-based insights for advocacy and bring attention to equity concerns in infrastructure resilience policies and guidelines.

Infrastructure resilience in the broader resilience debate

To establish links across the resilience fields, this section embeds infrastructure resilience into the broader resilience debate including general systems resilience, ecological resilience, social resilience, physical infrastructure resilience, and equity in infrastructure resilience. From the variety of literature in different disciplines, we focus on the definitions of resilience and draw out the applicability to infrastructure systems.

Resilience has initially been explored in ecological systems. Holling 48 defines resilience as the ability of ecosystems to absorb changes and maintain their core functionality. This perspective recognizes that ecosystems do not necessarily return to a single equilibrium state, but can exist in multiple steady states, each with distinct thresholds and tipping points. Building on these concepts, Carpenter et al. 49 assesses the capacity of socioecological systems to withstand disturbances without transitioning to alternative states. The research compares resilience properties in lake districts and rangelands such as the dependence on slow-changing variables, self-organization capabilities, and adaptive capacity. These concepts enrich our understanding of infrastructure resilience by acknowledging the complex interdependencies between natural and built systems. It also points out the different temporal rhythms across fast-paced behavioral and slow-paced ecological and infrastructural change 50 .

Social resilience brings the human and behavioral dimension to the foreground. Aldrich and Meyer focuses on the concept of social capital in defining community resilience by emphasizing the role of social networks and relationships to enhance a community’s ability to withstand and recover from disasters 51 . Aldrich and Meyer argues that social infrastructure is as important as physical infrastructure in disaster resilience. Particularly, the depth and quality of social networks can provide crucial support in times of crisis, facilitate information sharing, expedite resource allocation, and coordinate recovery efforts. Resilience, in this context, is defined as the enhancement and utilization of its social infrastructure through social capital. It revolves around the collective capacity of communities to manage stressors and return to normalcy post-disaster through cooperative efforts.

Since community resilience relies on collaborative networks, which in turn are driven by accessibility, community and social resilience are intricately linked to functioning infrastructures 52 . To understand the relationships, we first examine the systems of systems approach thinking. Vitae Systems of Systems aims to holistically resolve complex environmental and societal challenges 53 . It emphasizes strategic, adaptive, and interconnected solutions crucial for long-term system resilience. Individual systems, each with their capabilities and purposes, are connected in ways such that they can achieve together what they cannot achieve alone. Additionally, Okada 54 also shows how the Vitae Systems of Systems can detect fundamental areas of concern and hotspots of vulnerability. It highlights principles of survivability (live through), vitality (live lively), and conviviality (live together) to build system capacity in the overall community. In the context of infrastructure resilience, these approaches bring context to the development of systems and their interdependencies, rather than focusing on the resilience of individual components in isolation.

Expanding on the notion of social and community resilience, Hay’s applies key concepts of being adaptable and capable of maintaining critical functionalities during disruptions to infrastructure 55 . This perspective introduces the concept of “safe-to-fail” systems, which suggests that planning for resilience should anticipate and accommodate the potential for system failures in a way that minimizes overall disruption and aids quick recovery.

As such, the literature agrees that social, infrastructural, and environmental systems handle unexpected disturbances and continue to provide essential services. While Aldrich’s contribution lies in underscoring the importance of social ties and community networks, Hay expands this into the realm of physical systems by considering access to facilities. Infrastructure systems traditionally adapt and change slowly, driven by rigid physical structures, high construction costs, and planning regulations. In contrast, behavioral patterns are relatively fast-changing, even though close social connections and trust also take time to build. Yet, infrastructures form the backbone that enables—or disrupts—social ties. By adopting resilience principles that enable adaptation across infrastructure and social systems, better preparedness, response, and recovery can be achieved.

Given the dynamic, complex nature of resilience, infrastructure resilience, by extension, should not just be considered through the effective engineering of the built environment. Rather, infrastructure resilience must be considered as an integral part of the multi-layered resilience landscape. Crucial questions that link infrastructure to the broader resilience debate include: How will it be used and by whom? How are infrastructure resilience decisions taken, and whose voices are prioritized? These critical questions necessitate the integration of equity perspectives into the infrastructure resilience discourse.

Equity in infrastructure resilience ensures all community members have equitable access to essential services and infrastructure. In her commentary paper, Cutter 56 examines disaster resilience and vulnerability, challenging the prevalent ambiguity in the definitions of resilience. The paper poses two fundamental questions of “resilience to what?” and “resilience to whom?” . Later, Meerow and Newell 47 expanded on these questions in the context of urban resilience, “for whom, what, where, and why?” . They also stress the need for “resilience politics,” which include understanding of how power dynamics shape resilience policies, creating winners and losers 47 .

In a nutshell, resilience strategies must proactively address systemic inequities. This can also be framed around the concept of Rawls’ Theory of Justice principles, such as equal basic rights and fair equality of opportunity 57 , 58 . Rawls advocates for structuring social and economic inequalities to benefit the least advantaged members of society. In the context of infrastructure resilience, the theory would ensure vulnerable communities, such as lower-income households, have priority in infrastructure restoration. Incorporating Walker’s Theory of Abundant Access, this could also mean prioritizing those most dependent on public transit. Access to public transit, especially in lower-income brackets, allows for greater freedom of movement and connection to other essential facilities in the community like water, food, and health 59 , 60 . At the same time, Casali et al. 61 show that access to infrastructures alone is not sufficient for urban resilience to emerge. Such perspectives integrate physical and social elements of a community to equitably distribute infrastructure resilience benefits. Table 1 summarizes the selected definitions of resilience.

Definitions of equity

Equity in infrastructure resilience ensures that individuals have the same opportunity and access to infrastructure services regardless of differing demographics, spatial regions, involvement in the community, and internal capacity. Equity is a multifaceted concept that requires precise definitions to thoroughly assess and address it within the scope of infrastructure resilience. Based on the literature, our systematic literature review proposes four definitions of equity for infrastructure resilience: distributional-demographic (D), distributional-spatial (S), procedural (P), and capacity (C). Distributional-demographic (D) equity represents accessibility to and functionality of infrastructure services considering the vulnerability of demographic groups 62 . Distributional-spatial (S) equity focuses on the equitable distribution of infrastructure services to all spatial regions 63 . Procedural (P) equity refers to inclusive participation and transparent planning with stakeholders and community members 31 . Capacity equity (C) connect the supporting infrastructure to the hierarchy of needs which recognizes the specific capacities of households 64 .

Distributional-demographic (D) addresses the systemic inequities in communities to ensure those of differing demographic status have equitable access to infrastructure services 37 . The purpose is to equitably distribute the burdens and benefits of services by reducing disparity for the most disadvantaged populations 42 . These groups may need greater support due to greater hardship to infrastructure losses, greater dependency on essential services, and disproportionate losses to infrastructure 43 , 65 , 66 . In addition, they may have differing abilities and need to mitigate service losses 33 . Our research bases distributional-demographic on age for young children and elderly, employment, education, ethnicity, people with disabilities, gender, income, tenure of residence, marginalized populations based on additional demographic characteristics, intergenerational, and general-social inequities 67 .

Distributional-spatial (S) recognizes that the operation and optimizations of the systems may leave certain areas in isolation 68 , 69 , 70 . For example, an equitable access to essential services (EAE) approach to spatial planning can identify these service deserts 46 . Urban and rural dynamics may also influence infrastructure inequities. Rural areas have deficient funding sources compared to urban areas 17 while urban areas may have greater vulnerability due to the interconnectedness of systems 71 . Our research labels distributional-spatial as spatial and urban-rural. Spatial involves spatial areas of extreme vulnerability through spatial regression models, spatial inequity hotspots, and specific mentions of vulnerable areas. Urban-rural references the struggles of urban-rural areas.

Procedural (P) equity ensures the inclusion of everyone in the decision-making process from the collection of data to the influence of policies. According to Rivera 72 , inequities in the disaster recovery and reconstruction process originate from procedural vulnerabilities associated with historical and ongoing power relations. The validity of local cultural identities is often overlooked in the participation process of designing infrastructure 73 . Governments and institutions may have excluded certain groups from the conversation to understand, plan, manage, and diminish risk in infrastructure 74 . As argued by Liévanos and Horne 20 , such utilitarian bureaucratic decision rules can limit the recognition of unequal services and the development of corrective actions. These biases can be present in governmental policies, maintenance orders, building codes, and distribution of funding 30 . Our research labels procedural equity as stakeholder input and stakeholder engagement. Stakeholder input goes beyond collecting responses from interviews and surveys. Rather, researchers will ask for specific feedback and validation on final research deliverables like models, results, and spatial maps, but they are not included in the research planning process. Stakeholder engagement are instances where participants took an active role in the research deliverables to change elements of their community.

Capacity (C) equity is the ability of individuals, groups, and communities to counteract or mitigate the effect of infrastructure loss. As mentioned by Parsons, et al. 75 , equity can be enhanced through a network of adaptive capacities at the household or community level. These adaptive capacities are viewed as an integral part of community resilience 76 . Regarding infrastructure, households can prepare for infrastructure losses and have service substitutes such as power generators or water storage tanks 77 , 78 . It may also include the household’s ability to tolerate disruptions and the ability to perceive risk to infrastructure losses 66 . However, capacity can be limited by people’s social connections, social standing, and access to financial resources and personal capital 79 . Our research categorizes capacity equity as adaptations, access, and susceptibility. Adaptations include preparedness strategies before a disaster as well as coping strategies during and after the disaster. Access includes a quantifiable metric in reaching critical resources which may include but is not limited to vehicles, public transportation, or walking. Susceptibility involves a household internal household capability such as tolerance, suffering, unhappiness, and willingness-to-pay models. Although an important aspect of capability, the research did not include social capital since it is outside the scope of research.

Methods of systematic literature review

Our systematic literature review used the Covidence software 80 , which is a production tool to make the process of conducting systematic reviews more efficient and streamlined 80 . As a web-based platform, it supports the collaborative management of uploaded journal references and processes journals through 4-step screening and analysis including title and abstract screening, full-text screening, data abstraction, and quality assessment. The software also follows the guidelines of PRIMSA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis), which provides a clear, transparent way for researchers to document their findings 81 . PRIMSA includes a 27-item checklist and 4-phase flow diagram of identification, screening, eligibility, and inclusion. Figure 1 summarizes the PRIMSA method we followed during our review process by showing the search criteria and final selected articles at each stage, including identification, screening, eligibility, and inclusion.

The figure shows the 4-step screening process of identification, screening, eligibility, and inclusion as well as the specific search criteria for each step. From the initial 2991 articles, 99 articles were selected.

Identification

The search covered Web of Science and Science Direct due to their comprehensive coverage and interdisciplinary sources. To cover a broad set of possible disasters and infrastructures, our search focused on the key areas of equity (“equit- OR fair- OR justice- OR and access-“), infrastructure (“AND infrastructure system- OR service-”), and disasters (“ AND hazard- OR, cris- OR, disaster- OR”). We limited our search to journal articles published in engineering, social sciences, and interdisciplinary journals during January 2010 to March 2023. Excluding duplicates, the combined results of the search engines resulted in 2991 articles.

The articles were screened on their title and abstract. These had to explicitly mention both an infrastructure system (water, transportation, communication, etc.) and natural hazards (tropical cyclone, earthquake, etc.) The specific criteria for infrastructure and natural hazard is found in the 8-dimension framework. This initial screening process yielded 398 articles for full-text review.

Eligibility

The articles were examined based on the extent of discussion in infrastructure, natural hazard, and equity dimension. Insufficient equity discussion means that the paper did not fall within the distributional-demographic, distributional-spatial, procedural, or capacity forms of equity (98). Studies were also excluded for not directly including equity analysis in the infrastructure system (19). Limited infrastructure focus means that the article may have focused on infrastructure outside the scope of the manuscript such as industrial, green, building, or social infrastructure (74). Limited disaster focus means that the article did not connect to the direct or indirect impacts of disasters on infrastructure systems (45). Wrong study design included literature reviews, opinion pieces, policy papers, and unable to access (56). This stage yielded 99 final articles.

Inclusion and assessment framework

To analyze the 99 articles, we designed an 8-dimensional assessment framework (see Fig. 2 ) to analyze the literature. In Fig. 2 , the visualization focuses on equity, infrastructure, and natural hazards since these are the 3 main dimensions of the systematic literature review. The icons on the bottom are the remaining 5 dimensions which add more analysis and context to the first 3 dimensions. Here, we refer to research question 1: what are the prevailing concepts, foci, methods, and theories, in assessing the inequities of disrupted infrastructure services? The framework distinguished the concepts (equity dimensions, infrastructure system, and natural hazard event), foci (geographical scale, geographic location, temporal scale), methods (nature of study and data collection), and theories (theoretical perspective) (Fig. 2 ). The following details each subquestion:

Equity dimensions, infrastructure type, and hazard event type are the main 3 dimensions while geographical location, geographic scale, temporal, nature of the study, and theoretical perspectives are the remaining 5 dimensions which add more information and context.

How is equity conceptualized and measured? First, we label equity into 4 definitions (DPSC). Second, it summarizes the equity conclusions.

Infrastructure type

Which infrastructure services were most and least commonly studied? This category is divided into power, water, transportation, communication, health, food, sanitation, stormwater, emergency, and general if a specific infrastructure is not mentioned. Studies can include more than one infrastructure service. Green infrastructure, social infrastructure, building structures, and industrial structures were excluded.

Hazard event type

Which hazard events are most or least frequently studied? This category includes flood, tropical cyclone, drought, earthquake, extreme temperature, pandemic, and general if there is no specific hazard. To clarify, tropical cyclones include hurricanes and typhoons while extreme temperatures are coldwaves and heatwaves. It determines which studies are specific to hazards and which can be applied to universal events.

Geographic location

Which countries have studied equity the most and least? This category is at the country scale such as the United States, Netherlands, China, and Australia, among others.

Geographic scale

What geographic unit of scale has been studied to represent equity? Smaller scales of study can reveal greater insights at the household level while larger scales of study can reveal comparative differences between regional communities. It ranges from individual, local, regional, and country as well as project. To clarify, ‘individual’ can include survey respondents, households, and stakeholder experts; ‘local’ is census block groups, census tracts, and ZIP codes equivalent scales; ‘regional’ is counties, municipalities, and cities equivalent; ‘project’ refers to studies that focused on specific infrastructure/ construction projects.

Temporal scale

When did themes and priority of equity first emerge? This category determines when equity in infrastructure research is published and whether these trends are increasing, decreasing, or constant.

Nature of the study

How is data for equity being collected and processed? This category analyzed data types used including conceptual, descriptive, open-data, location-intelligence, and simulation data. To clarify, conceptual refers to purely conceptual frameworks or hypothetical datasets; descriptive refers to surveys, questionnaires, interviews, or field observations performed by the researcher; open-data refers to any open-data source that is easily and freely attainable such as census and flood data; location-intelligence refers to social media, human mobility, satellite and aerial images, visit data, and GIS layers; and finally, simulation data can be developed through simulation models like numerical software, Monte-Carlo, or percolation methods. Second, the data can be processed through quantitative or qualitative methods. Quantitative methods may include correlation, principal component analysis, and spatial regression while qualitative methods may include validation, thematic coding, participatory rural appraisal, and citizen science. We focused on analysis explicitly mentioned in the manuscript. For example, it can be assumed that studies of linear regression discussed correlation analysis and other descriptive statistics in their data processing.

Theoretical perspective

Which theoretical frameworks have been created and used to evaluate equity? This category summarizes the reasoning behind the theoretical frameworks which may have informal or formal names such as a service-gap model, well-being approach, and capability approach.

Based on the 8-dimensional assessment framework, the research first examines the spatiotemporal patterns as well as data and methods to evaluate equity. Then, it investigates the definitions of equity to the intersections with infrastructure and hazards. It concludes with a discussion of theoretical frameworks. We use the term “pathways” to identify how equity is constructed, analyzed, and used in relation to the 8-dimensional framework. For instance, the connection between equity and infrastructure is considered a pathway. By defining specific “pathways,” we are essentially mapping out the routes through which equity interacts with various dimensions of a framework, such as infrastructure. The following analysis directly addresses research question 1 (prevailing concepts, focuses, methods, and theories, in assessing the inequities of disrupted infrastructure services) and research question 2 (similar and different pathways of equity). Supplementary Figures 1A – 12A provide additional context to the research findings and can be found in the Supplementary Information .

Spatiotemporal patterns of equity

Overall, there is an increasing number of publications about equity in infrastructure management (Fig. 3 ). A slight decrease observed in 2021 could be because of the focus on COVID-19 research. Spatially, by far the most studies focus on the US (69), followed by India (3), Ghana (3), and Bangladesh (3) (Fig. 5 ). This surprising distribution seems to contradict the intuition that equity and fairness in infrastructure resilience are certainly global phenonmena. Besides the exact phrasing of the search term, this result can be explained by the focus of this review on the intersection of infrastructure resilience and inequity. For infrastructure resilience, prominent reports, such as the CDRI’s 2023 Global Infrastructure Resilience Report 82 still fail to address it. Even though research has called for increasing consideration of equity and distributive justice in infrastructure and risk assessment, inequity is still all too often viewed as a social and economic risk 83 . At the same time, persistent imbalances in terms of data availability have been shown to shift research interest to the US, especially for data intense studies on urban infrastructures 84 . Finally, efforts to mainstream of equity and fairness across all infrastructures as a part of major transitions may explain why equity discussion is less pronounced in the context of crises. For instance, in Europe, according to the EU climate act (Article 9(1)) 85 , all sectors need to be enabled and empowered to make the transition to a climate-resilient society fair and equitable .

The bar graph shows an overall increasing from 2011 to 2023 in publications about equity in infrastructure resilience during natural hazard events. The pie chart shows that countries in the global north with United States (US), England, Australia, Germany, Taiwan, Norway, South Korea, and Japan and global south with Bangladesh, India, Ghana, Mexico, Mozambique, Brazil, Tanzania, Sri Lanka, Pakistan, Nigeria, Kenya, Nepal, Zimbabwe, Central Asia, and South Africa.

Data and methods to interpret equity

Our Sankey diagram (Fig. 4 ) sketches the distribution of data collection pathways which connects quantitative-qualitative data to data type to scale. Most studies start from quantitative data (120) with fewer using mixed (34) or qualitative (18) data. Quantitative studies use descriptive (58), open-data (50) location-intelligence (36), simulation (19), and conceptual (9). The most prominent spatial scale was local (66) which consisted of census tract, census block group, zip code, and equivalent spatial scale of analysis. This was followed by individual or household scale (64) which largely stems from descriptive data of interviews, surveys, and field observations. Within the context of infrastructure, equity, and hazards, non-US studies did not use human mobility data, a specific type of location-intelligence data. This could be due to limitations in data availability and different security restrictions to these researchers such as the European Union’s General Data Protection Regulation 86 . Increasingly, the application of location-intelligence data was used to supplement the understanding of service disruptions. For example, satellite information 87 , telemetry-based data 37 , and human mobility data 88 were used to evaluate the equitable restoration of power systems and access to critical facilities. Social media quantified public emotions to disruptions 89 , 90 .

The Sankey diagram shows the flow from studies containing quantitative, qualitative, or quantitative–qualitative data to the specific type of data of descriptive, open-data, location-intelligence, simulation, and conceptual to spatial scale of data of local, individual, regional, country, and project.

As shown in Fig. 5 , there are distinct quantitative and qualitative methods to interpret equity. Most quantitative methods were focused on descriptive analysis and linear models which can assume simple relationships within equity dimensions. Simple relationships would assume that dependent variables have a straightforward relationship with independent variables. Regarding quantitative analysis, descriptive statistics were correlation (12), chi-square (6), and analysis of variance (ANOVA) (5) means. Spatial analysis included geographic information system (GIS) (15), Moran’s-I spatial autocorrelation (6), and spatial-regression (5). Variables were also grouped together through principal component analysis (PCA) (9) and Index-Weighting (9). Logit models (13) and Monte-Carlo simulations (7) were used to analyze data. Thus, more complex models are needed to uncover the underlying mechanisms associated with equity in infrastructure. In analyzing quantitative data, most research has focused on using descriptive statistics, linear models, and Moran’s I statistic which have been effective in pinpointing areas with heightened physical and social vulnerability 25 , 91 , 92 .

The quantitative pie chart has geographic information system (GIS), logit model, correlation, index-weighting, principal component analysis (PCA), monte-carlo simulation, chi-square, Moran’s- I spatial autocorrelation, analysis of variance (ANOVA), and spatial regression. The qualitative pie chart has validation, thematic coding, citizen science, sentiment analysis, conceptual analysis, participatory rural appraisal, document analysis, participatory assessment, photovoice, and ethnographic.

However, there has been a less frequent yet insightful use of advanced techniques like machine learning, agent-based modeling, and simulation. For example, Esmalian, et al. 66 employed agent-based modeling to explore how social demographic characteristics impact responses to power outages during Hurricane Harvey. In a similar vein, Baeza, et al. 93 utilized agent-based modeling to evaluate the trade-offs among three distinct infrastructure investment policies: prioritizing high-social-pressure neighborhoods, creating new access in under-served areas, and refurbishing aged infrastructure. Simulation models have been instrumental in understanding access to critical services like water 43 , health care 92 , and transportation 33 . Beyond these practical models, conceptual studies have also contributed innovative methods. Notably, Clark, et al. 94 proposed gravity-weighted models, and Kim and Sutley 30 explored the use of genetic algorithms to measure the accessibility to critical resources. These diverse methodologies indicate a growing sophistication in the field, embracing a range of analytical tools to address the complexities of infrastructure resilience.

Regarding qualitative analysis, the methods included thematic coding (7), validation of stakeholders (9), sentiment (4), citizen science (5), conceptual analysis (3) participatory rural appraisal (2), document analysis (2), participatory assessment (1), photovoice (1), and ethnographic (1). Qualitative methods were used to capture diverse angles of equity, offering a depth and context not provided by quantitative data alone. These methods are effective in understanding capacity equity, such as unexpected strategies and coping mechanisms that would go otherwise unnoticed 95 . Qualitative research can also capture the perspectives and voices of stakeholders through procedural equity. Interviews and focus groups can validate and enhance research frameworks 96 . Working collaboratively with stakeholders, as shown with Masterson et al. 97 can lead to positive community changes in updated planning policies. Qualitative methods can narratively convey the personal hardships of infrastructure losses 98 . This approach recognizes that infrastructure issues are not just technical problems but also deeply intertwined with social, economic, and cultural dimensions.

Interlinkages of equity definitions

As shown in Fig. 6 , the frequency of type of equity was distributional-demographic (90), distributional-spatial (55), capacity (54), and procedural (16). It is notable to reflect on the intersections between the four definitions of equity. Between two linkages, the top three linkages between DC (20), DS (16), and DP (9), which all revealed a connection to distributional-demographic equity. There were comparatively fewer studies linking 3 dimensions except for DSC which had 25 connections. Only 3 studies had 4 connections.

Distributional-demographic had the highest number of studies and the greatest overlap with the remaining equity definitions of capacity, procedural, and distributional-spatial. Only 3 studies overlapped with the four equity definitions.

Distributional-demographic equity was the most studied equity definition. Table 2 shows how pathways of demographic equity relate to the different infrastructure systems and variables within distributional-demographic, including 728 unique pathways. As a reminder, pathways explore equity across an 8-dimensional framework. In this case, the distributional-demographic equity is connected to infrastructure, treating these connections as pathways Pathways with power (165), water (147), and transportation (112) were the most frequent while those with stormwater (23) and emergency (9) services were the least frequent. Referencing demographics, the most pathways were income (148), ethnicity (115), and age (122) while least studied were gender (63), employment (35), marginalized populations (5) and intergenerational (1). Note the abbreviations for Tables 2 and 3 are power (P), water (W), transportation (T), food (F), health (H), sanitation (ST), communication (C), stormwater (SW), emergency (E), and general (G). Regarding distributional-demographic, several research papers showed that lower income and minority households were most studied in comparison to the other demographic variables. Lower-income and minority households faced greater exposure, more hardship, and less tolerance to withstand power, water, transportation, and communication outages during Hurricane Harvey 99 . These findings were replicated in disasters such as Hurricane Florence, Hurricane Michael, COVID-19 pandemic, Winter Storm Uri, and Hurricane Hermine, respectively 65 , 91 , 100 , 101 . Several studies found that demographic vulnerabilities are interconnected and compounding, and often, distributional-demographic equity is a pre-existing inequality condition that is exacerbated by disaster impact 102 . For instance, Stough, et al. 98 identified that respondents with disabilities faced increased struggles due to a lack of resources to access proper healthcare and transportation after Hurricane Katrina. Women were often overburdened by infrastructure loss as they were expected to “pick up the pieces,” and substitute the missing service 103 , 104 . Fewer studies involved indigenous populations, young children, or considered future generations. Using citizen-science methods, Ahmed, et al. 105 studied the struggles and coping strategies of the Santal indigenous group to respond to water losses in drought conditions. Studies normally did not account for the direct infrastructure losses on children and instead concentrated on the impacts on their caretakers 106 ; however, this is likely due to restrictions surrounding research with children. Lee and Ellingwood 107 discussed how, “intergenerational discounting makes it possible to allocate costs and benefits more equitably between the current and future generations” (pg.51) A slight difference in discounting rate can lead to vastly different consequences and benefits for future generations. For example, the study found that insufficient investments in design and planning will only increase the cost and burden of infrastructure maintenance and replacement.

Distributional-spatial equity was the second most studied aspect, which includes spatial grouping and urban-rural designation, particularly given the rise of open-data and location-intelligence data with spatial information. Table 3 shows the pathways of spatial equity connected to different infrastructures and variables. In total, 109 unique pathways were found with spatial (83) and urban-rural (26) characteristics. Power (27), transportation (22), water (16), and health (15) systems were the most frequent pathways with stormwater (4), emergency (2), and communication (3) the least frequent. Urban-rural studies on communication and emergency services are entirely missing. Distributional-spatial equity studies, including spatial inequities and urban-rural dynamics, were often linked with distributional-demographic equity. For example, Logan and Guikema 46 defined “access rich” and “access poor” to measure different sociodemographic populations’ access to essential facilities. White populations had less distance to travel to open supermarkets and service stations in North Carolina 46 . Esmalian et al. 108 found that higher income areas had a lower number of stores in their areas, but they still had better access to grocery stores in Harris County, Texas. This could be because higher income areas live in residential areas, but they have the capability to travel further distances and visit more stores. Vulnerable communities could even be indirectly impacted by spatial spillover effects from neighboring areas 26 . Regarding urban-rural struggles, Pandey et al. 17 argued that inequities emerge when urban infrastructure growth lags with respect to the urban population while rural areas face infrastructure deficits. Rural municipalities had fewer resources, longer restoration times, and less institutional support to mitigate infrastructure losses 95 , 109 , 110 .

Capacity was the third most studied dimension and had 150 unique pathways to adaptations (54), access (43), and susceptibility (53). In connecting to infrastructure systems, power (29), water (27), transportation (25), and food (22) had the greatest number of pathways. There were interesting connections between different infrastructures and variables of capacity. Access was most connected to food (11), transportation (10), and health systems (10). Adaptations were most connected to water (15) and power (12) systems. This highlights how capacity equity is reflected differently to infrastructure losses. Capacity equity was often connected with distributional-equity since different sociodemographic groups have varying adaptations to infrastructure losses 78 . For example, Chakalian, et al. 106 found that white respondents were 2.5 more likely to own a power generator while Kohlitz et al. 95 found that poorer households could not afford rainwater harvesting systems. These behaviors may also include tolerating infrastructure disruptions 111 , cutting back on current resources 112 , or having an increased suffering 113 . The capabilities approach offers a valuable perspective on access to infrastructure services 94 . It recognizes the additional time and financial resources that certain groups may need to access the same level of services, especially if travel networks are disrupted 114 , 115 and travel time is extended 33 . In rural regions, women, children, and lower income households often reported traveling further distances for resources 105 , 116 . These disparities are often influenced by socioeconomic factors, emphasizing the need for a nuanced understanding on how different communities are affected by and respond to infrastructure losses. As such, building capacity is not just increasing the preparedness of households but also accommodating infrastructure systems to ensure equitable access, such as the optimization of facility locations 69 .

Procedural was the least studied equity definition with only 26 unique pathways, involving stakeholder input and stakeholder engagement. Pathways to communication and emergency systems were not available. The greatest number of pathways were water services to stakeholder input (7) and stormwater services to stakeholder engagement (4). Stakeholder input can assist researchers in validating and improving their research deliverables. This approach democratizes the decision-making process and enhances the quality and relevance of research and planning outcomes. For instance, the involvement of local experts and residents in Tanzania through a Delphi process led to the development of a more accurate and locally relevant social resilience measurement tool 117 . Stakeholder engagement, such as citizen science methods, can incorporate environmental justice communities into the planning process, educate engineers and scientists, and collect reliable data which can be actively incorporated back to the community 118 , 119 , 120 . Such participatory approaches, including citizen science, allow for a deeper understanding of community needs and challenges. In Houston, TX, the success of engaging high school students in assessing drainage infrastructure exemplified how community involvement can yield significant, practical data 119 . The data was approximately 74% accurate to trained inspectors, which were promising results for communities assessing their infrastructure resilience 119 . In a blend of research and practice, Masterson, et al. 97 illustrated the practical application of procedural equity. By interweaving equity in their policy planning, Rockport, TX planners added accessible services and upgrades to infrastructure for lower-income and racial-ethnic minority neighborhoods, directly benefiting underserved communities.

Pathways between equity, hazard, and infrastructure

For the hazards, tropical cyclones (34.6%) and floods (30.8%) make up over half of the studied hazards (Supplementary Figure 2A ) while power (21.2%), water (19.2%), transportation (15.4%), and health (12.0%) were the most frequently studied infrastructure services (Supplementary Figure 3A ). A pathway is used to connect equity to different dimensions of the framework, in this case, equity to infrastructure to hazard (Fig. 7 ). When considering these pathways, distributional-demographic (270) had the most pathways followed by capacity (175), distributional-spatial (140), and procedural (28). The most common pathway across all infrastructure services was a tropical cyclone and flooding with distributional-demographic equity (Supplementary Figures 6A – 8A ). As shown in Fig. 7 , tropical cyclone (229) and flood (192) had the most pathways while extreme temperatures (20) and pandemic (14) had the least. Although pandemic is seemingly the least studied, it is important to note that most of these studies were post COVID-19. Power (120), transportation (107), and water (104) had the most pathways whereas sanitation (33), communication (27), stormwater (21), and emergency (14) had the least pathways. The figure shows specific gaps in the literature. Whereas the other three equity definitions had connections to each hazard event, procedural equity only had connections to tropical cyclone, flood, general, and drought. There were only pathways from health infrastructure to tropical cyclone, flood, general, earthquake, and pandemic. There were 106 pathways connecting equity to general hazards, which may suggest the need to look at the impacts of specific hazards to equity in infrastructure resilience.

The Sankey diagram shows the flow from the different types of equity, or equity definitions, of distributional-demographic (D), capacity (C), distributional-spatial (S), and procedural (P) to hazard of tropical cyclone, flood, general, drought, earthquake, extreme temperature, and pandemic to infrastructure of power, transportation, water, health, food, communication, general, stormwater, emergency, and sanitation.

Research frameworks

Regarding research question 2, this research aims to understand frameworks of equity in infrastructure resilience. As an exploration of the frameworks. we found common focus areas of adaptations, access, vulnerability, validation, and welfare economics (Table 4 ). The full list of frameworks can be found in the online database that was uploaded in DesignSafe Data Depot. Supplementary Information .

Adaptations

Household adaptations included the ability to prepare before a disaster as well as coping strategies during and after the disaster. Esmalian et al. 111 developed a service gap model based on survey data of residents affected by Hurricane Harvey. Lower-income households were less likely to own power generators, which could lead to an inability to withstand power outages 111 . To understand household adaptations, Abbou et al. 78 asked residents of Los Angeles, California about their experiences in electrical and water losses. The study showed that when compared to men, women used more candles and flashlights. People with higher education, regardless of gender, were more likely to use power generators. In a Pressure and Release model, Daramola et al. 112 examined the level of preparedness to natural hazards in Nigeria. The study found that rural residents tended to use rechargeable lamps while urban areas used generators, likely due to the limited availability of electricity systems. Approximately 73% of participants relied on chemist shops to cope with constrained access to health facilities.

Other frameworks focused on the accessibility to resources. Clark et al. 94 developed the social burden concept which uses resources, conversion factors, capabilities, and functioning into a travel cost method to access critical resources. In an integrated physical-social vulnerability model, Dong et al. 92 calculated disrupted access to hospitals in Harris County, Texas. Logan and Guikema 46 integrated spatial planning, diverse vulnerabilities, and community needs into EAE services. In the case study of Willimgton, North Carolina, they showed how lower-income households had fewer access to grocery stores. In a predictive recovery monitoring spatial model, Patrascu and Mostafavi 26 found that the percentage of Black and Asian subpopulations were significant features to predict recovery of population activity, or the visits to essential services in a community.

Vulnerability

Several of the infrastructure resilience frameworks were grounded in social vulnerability assessments. For instance, Toland et al. 43 created a community vulnerability assessment based on an earthquake scenario that resulted in the need for emergency food and water resources. Using GIS, Oswald and Mohammed developed a transportation justice threshold index that integrated social vulnerability into transportation understanding 121 . In a Disruption Tolerance Index, Esmalian et al. 25 showed how demographic variables are connected with disproportionate losses in power and transportation losses.

Additional studies were based on stakeholder input and expert opinion. Atallah et al. 36 established an ABCD roadmap for health services which included acute life-saving services, basic institutional aspects for low-resource settings, community-driven health initiatives, and disease specific interventions. Health experts were instrumental in providing feedback for the ABCD roadmap. Another example is the development of the social resilience tool for water systems validated by experts and community residents by Sweya et al. 117 . To assess highway resilience, Hsieh and Feng had transportation experts score 9 factors including resident population, income, employment, connectivity, dependency ratio, distance to hospital, number of substitutive links, delay time in substitutions, and average degenerated level of services 122 .

Welfare economics

Willingness-to-pay (WTP) models reveal varied household investments in infrastructure resilience. Wang et al. 123 showed a wide WTP range, from $15 to $50 for those unaffected by disruptions to $120–$775 for affected, politically liberal individuals. Islam et al. 124 found households with limited access to safe drinking water were more inclined to pay for resilient water infrastructure. Stock et al. 125 observed that higher-income households showed greater WTP for power and transportation resilience, likely due to more disposable income and expectations for service quality. These findings highlight the need to consider economic constraints in WTP studies to avoid misinterpreting lower income as lower willingness to invest. Indeed, if a study does not adequately account for a person’s economic constraints, the findings may incorrectly interpret a lower ability to pay as a lower willingness to pay.

In terms of policy evaluation for infrastructure resilience, studies like Ulak et al. 126 prioritized equitable power system recovery for different ethnic groups, favoring network renewal over increasing response crews. Baeza et al. 93 noted that infrastructure decisions are often swayed by political factors rather than technical criteria. Furthermore, Lee and Ellingwood 107 introduced a method for intergenerational discounting in civil infrastructure, suggesting more conservative designs for longer service lives to benefit future generations. These studies underscore the complex factors influencing infrastructure resilience policy, including equity, political influence, and long-term planning.

This systematic review is the first to explore how equity is incorporated into infrastructure resilience against natural hazards. By systematically analyzing the existing literature and identifying key gaps, the paper enhances our understanding of equity in this field and outlines clear directions for future research. This study is crucial for understanding the fundamental knowledge that brings social equity to the forefront of infrastructure resilience. Table 5 summarizes the primary findings of this systematic review of equity in infrastructure resilience literature, including what the studies are currently focusing on and the research gaps and limitations.

Our findings show a great diversity of frameworks and methods depending on the context, in which equity is applied (Table 5 ). Moreover, we identify a lack of integrative formal and analytical tools. Therefore, a clear and standard framework is needed to operationalize inequity across infrastructures and hazards; what is missing are analytical tools and approaches to integrate equity assessment into decision-making.

Referring to question 3, we will further explore the current gaps of knowledge and future challenges of studying equity in infrastructure resilience. In elaborating on the gaps identified in our review, we propose that the next era of research questions and objectives should be (1) monitoring equity performance with improved data, (2) weaving equity in computational models, and (3) integrating equity into decision-making tools. Through principles of innovation, accountability, and knowledge, such objectives would be guided by moving beyond distributional equity, recognizing understudied gaps of equity, and inclusion of all geographic regions, and by extension stakeholders (Fig. 8 ).

The figure demonstrates that previous research has focused on detecting and finding evidence of disparity in infrastructure resilience in hazard events. It supports that the next phase of research will monitor equity performance with improved data, weave equity in computational models, and integrate equity in decision making tools in order to move beyond social and spatial distributions, recognize understudied gaps of equity, and include all geographic regions.

The first research direction is the monitoring equity performance with improved data at more granular scales and greater representation of impacted communities. Increased data availability provides researchers, stakeholders, and community residents with more detailed and accurate assessment of infrastructure losses. Many studies have used reliable, yet inherently approximate data sources, for infrastructure service outages. These sources include human mobility, satellite, points-of-interest visitation, and telemetry-based data (such as refs. 69 , 100 ). Private companies are often reluctant to share utility and outage data with researchers 127 . Thus, we encourage the shift towards transparent and open datasets from utility companies in normal times and outage events. This aligns with open-data initiatives such as Open Infrastructure Outage Data Initiative Nationwide (ODIN) 128 , Invest in Open Infrastructure 129 , and Implementing Act on a list of High-Value Datasets 130 . Transparency in data fosters an environment of accountability and innovation to uphold equity standards in infrastructure resilience 131 . An essential aspect of this transparency involves acknowledging and addressing biases that may render certain groups ‘invisible’ within datasets. These digitally invisible populations may well be among the most vulnerable, such as unhoused people that may not have a digital footprint yet are very vulnerable to extreme weather 132 . Gender serves as a poignant example of such invisibility. Historical biases and societal norms often result in gender disparities being perpetuated in various facets of infrastructure design and resilience planning 133 . Women are frequently placed in roles of caregiving responsibilities, such as traveling to reach water (as shown in refs. 105 , 116 , 134 ) or concern over the well-being of family members (as shown in refs. 103 , 135 ), which have been overlooked or marginalized in infrastructure planning processes.

If instances of social disparities are uncovered, researchers and practitioners could collaboratively cultivate evidence-based recommendations to manage infrastructure resilience. At the same time, approaches for responsible data management need to be developed that protect privacy of individuals, especially marginalized and vulnerable groups 136 . There is a trade-off between proper representation of demographic groups and ensuring the privacy of individuals 45 , 67 . Despite this, very few studies call into question the fairness of the data collection in capturing the multifaceted aspects of equity 137 , or the potential risks to communities as described in the EU’s forthcoming Artificial Intelligence Act 138 .

By extension, addressing the problem of digitally invisible populations and possible bias, Gharaibeh et al. 120 also emphasizes that equitable data should represent all communities in the study area. Choices about data collection and storage can directly impact the management of public services, by extension the management of critical information 139 . For example, a significant problem with location-intelligence data collection is properly representing digitally invisible populations as these groups are often marginalized in the digital space leading to gaps in data 132 , 140 . Human mobility data, a specific type of location-intelligence data derived from cell phone pinpoint data, illustrates this issue. Vulnerable groups may not afford or have frequent access to cell phones, resulting in a skewed understanding of population movements 141 . However, other studies have shown that digital platforms can be empowering for marginalized populations to express sentiments of cultural identity and tragedies through active sharing and communication 142 . Ultimately, Hendricks et al. 118 recommend a “triangulation of data sources,” to integrate quantitative and qualitative data, which would mitigate potential data misrepresentation and take advantage of the online information. Moving ahead, approaches need to be developed for fair, privacy-preserving, and unbiased data collection that empowers especially vulnerable communities. At the same time, realizing that data gaps especially in infrastructure-poor regions may not be easy to address, we also follow Casali et al. 84 in calling for synthetic approaches and models that work on sparse data.

Few studies, such as refs. 45 , 66 , have created computational models to capture equity-infrastructure-hazards interactions, which are initial attempts to quantify both the social impacts and the physical performance of infrastructure. This is echoed in the work of Soden et al. 143 which found only ~28% of studies undertake a quantitative evaluation of differential impacts experienced in disasters. To enhance analytical and computational methods in supporting equitable decision-making, it is imperative for future studies to comprehensively integrate social dimensions of infrastructure resilience. Therefore, the next research direction is the intentional weaving of equity in computational models. Where the majority of studies used descriptive statistics and non-linear modeling, complex computational models—such as agent-based simulations—offer the advantage of capturing the nonlinear interactions of equity in infrastructure systems. These tools also allow decision-makers to gain insights into the emergence of complex patterns over time. These simulation models can then be combined with specific metrics that measure infrastructural or social implications. Metrics might include susceptibility curves 144 , social burden costs estimates 94 , or social resilience assessment 76 . Novel metrics for assessing adaptive strategies, human behaviors, and disproportionate impacts (such as 113 ) could also be further quantified through empirical deprivation costs for infrastructure losses 145 . These metrics also are a stepping-stone for formalizing and integrating equity into decision-making tools.

Another research direction is the integration of equity into decision-making tools. Key performance indicators and monitoring systems are essential for clarifying equity processes and outcomes and creating tangible tools for infrastructure planners, managers, engineers, and policy-makers. In particular, the literature discussed the potential for using equity in infrastructure resilience to direct infrastructure investments (such as refs. 93 , 126 , 146 ). Infrastructure resilience requires significant upfront investment and resource allocations, which generally favors wealthier communities. Communities may hold social, cultural, and environmental values that are not properly quantified in infrastructure resilience 147 . Since traditional standards of cost-benefit analyses used by infrastructure managers and operators primarily focus on monetary gains or losses, they would not favorably support significant investments to mitigate the human impacts of infrastructure losses on those most vulnerable 148 . This limitation also delays investments and leads to inaction in infrastructure resilience, resulting in unnecessary loss of services and social harm, potentially amplifying inequities, and furthering societal fragmentation. To bridge this gap, we propose to measure the social costs of infrastructure service disruptions as a way to determine the broad benefits of resilience investments 147 .

As the literature review found, several studies are following a welfare economics approach to quantify social costs associated with infrastructure losses such as the evaluation of policies (such as ref. 93 ) and willingness-to-pay models (such as ref. 125 ). Such economic functions are preliminary steps in quantifying equity as a cost measure; however, these models must avoid misinterpreting lower income as a lower willingness to invest. Lee and Ellingwood 107 proposed using intergenerational discounting rate; however, it is important to recognize the flexibility of options for future generations 149 . Teodoro et al. 149 points to the challenges of using (fixed) discount rates and advocate for a procedural justice-based approach that maximizes flexibility and adaptability. Further research is needed to quantify the social costs of infrastructure disruptions and integrate them into infrastructure resilience assessments, such as calculating the deprivation costs of service losses for vulnerable populations.

Our review shows that certain demographic groups such as indigenous populations, persons with disabilities, and intergenerational equity issues have not been sufficiently studied 150 . This aligns with the conclusions of Seyedrezaei et al. 151 , who found that the majority of studies about equity in the built-environment focused on lower-income and minority households. Indigenous populations face significant geographical, cultural, and linguistic barriers that make their experiences with disrupted infrastructure services distinct from those of the broader population 152 .

Even though intergenerational justice issues have increasingly sparked attention on the climate change discussion, intergenerational equity issues in infrastructure resilience assessments have received limited attention. We argue that intergenerational equity warrants special attention as infrastructure systems have long life cycles that span across multiple generations, and ultimately the decisions on the finance, restoration, and new construction will have a significant impact on the ability of future generations to withstand the impact of stronger climate hazard events. Non-action may lead to tremendous costs in the long run 149 . It is the responsibility of current research to understand the long-term effects of equity in infrastructure management to mitigate future losses and maintain the flexibility of future generations. As a means of procedural justice, these generations should have the space to make choices, instead of being locked in by today’s decisions. Future studies should develop methods to measure and integrate intergenerational inequity in infrastructure resilience assessments.

Given the specific search criteria and focus on equity, infrastructure, and natural hazard, we found a major geographic focus on the United States. Large portions of the global north and global south were not included in the analysis. This could be due to the search criteria of the literature review; however, it is important to recognize potential geographic areas that are isolated from the academic studies on infrastructure resilience. Different infrastructure challenges (e.g., intermittent services) are present through data availability in the region. A dearth of studies on equitable infrastructure resilience could contribute to greater inequity in those regions due to the absence of empirical evidence and proper methodological solutions. This aligns with other findings on sustainable development goals and climate adaptation broadly 153 . Global research efforts, along with common data platforms, standards and methods (see above), that include international collaborations among researchers across the global north and global south regions can bridge this gap and expand the breadth of knowledge and solutions for equitable infrastructure resilience.

Finally, while significant attention has been paid to distributional demographic and spatial inequity issues 151 , there remain several underutilized definitions of equity. Procedural and capacity equity hold the greatest potential for people to feel more included in the infrastructure resilience process. Instead of depending directly on the infrastructure systems, individual households can adapt to disrupted periods through substituted services and alternative actions (such as ref. 78 ). To advance procedural equity in infrastructure resilience, citizen-science research or participatory studies can begin by empowering locals to understand and monitor their resilience (such as ref. 76 ) or failures in their infrastructure systems (such as ref. 120 ). As referenced by Masterson and Cooper 154 , the ladder of citizen power can serve as a framework for how to ethically engage with community partners for procedural equity. The ladder, originally developed by Arnstein 155 , includes non-participation, tokenism, and citizen power. Table 3 shows that most research falls into non-participation: survey data and information are extracted without any community guidance. Limited studies that have branched into community involvement still stay restricted in the tokenism step, such as models that are validated by stakeholders or receive expert opinions on their conceptual models. Future studies should expand inquiries regarding the procedural and capacity dimension of equity in infrastructure resilience assessments and management. For instance, research could map out where inequities occur in the decision-making process and targeted spatial regions as well as allocate of resources for infrastructure resilience. It could also continue pursuing inclusive methodologies such as participatory action research and co-design processes. It should investigate effective methods to genuinely integrate different stakeholders and community members from conception through evaluation of research.

Although the primary audience of the literature review is academic scholars and fellow researchers, the identified gaps are of importance for practitioners, governmental agencies, community organizations, and advocates. By harnessing the transformative power of equity, studies in infrastructure resilience can transcend its traditional role and develop equity-focused data, modeling, and decision-making tools which considers everyone in the community. The integration of equity aspects within the framework of infrastructure resilience not only enhances the resilience of infrastructure systems but also contributes to the creation of inclusive and resilient communities. Infrastructure resilience would not just be a shield against adversity but also a catalyst for positive social and environmental change.

Data availability

The created excel database which includes information on the key parts of the 8-dimensional equity framework will be uploaded to DesignSafe-CI.

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Acknowledgements

This material is based in part upon work supported by the National Science Foundation under Grant CMMI-1846069 (CAREER) and the support of the National Science Foundation Graduate Research Fellowship. We would like to thank the contributions of our undergraduate students: Nhat Bui, Shweta Kumaran, Colton Singh, and Samuel Baez.

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Coleman, N., Li, X., Comes, T. et al. Weaving equity into infrastructure resilience research: a decadal review and future directions. npj Nat. Hazards 1 , 25 (2024). https://doi.org/10.1038/s44304-024-00022-x

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Challenges in coffee fermentation technologies: bibliometric analysis and critical review

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• Valeria Hurtado Cortés   nAff1 ,
• Andrés Felipe Bahamón Monje   ORCID: orcid.org/0000-0002-2620-148X 1 ,
• Jaime Daniel Bustos Vanegas   nAff1 &
• Nelson Gutiérrez Guzmán   nAff1  

Advancements in coffee processing technologies have led to improved efficiency in field operations, but challenges still exist in their practical implementation. Various alternatives and solutions have been proposed to enhance processing efficiency and address issues related to safety, standardization, and quality improvement in coffee production. A literature review using SciMAT and ScientoPy software highlighted advancements in fermentation tanks and the emergence of novel fermentation methodologies. However, these innovations lack sufficient scientific evidence. Researchers are now focusing on systematic approaches, such as controlled fermentations and evaluating the influence of microorganisms and process conditions on sensory attributes and coffee composition. Brazil is the leader in coffee bean fermentation research, but the number of published papers in the field has recently decreased. Despite this, efforts continue to improve process control and optimize product quality. The study emphasizes the need for further innovation in coffee fermentation technologies to increase efficiency, sustainability, and profitability while minimizing environmental impact. Implementing these advancements promises a more sustainable and quality-driven future for the coffee industry.

Avoid common mistakes on your manuscript.

Introduction

Coffee is a crucial agricultural product and a popular beverage globally. Its growing popularity has led to the need for improved processes to enhance cup quality. The coffee fruit, also known as almond or green coffee, is composed of five layers that protect the endosperm. These layers, known as pulp, mucilage, parchment, and epidermis, form the endosperm and are subjected to roasting to form the flavor and aroma of the coffee drink.

The processing of coffee fruit involves stages to preserve the quality of the almond, which is then subjected to roasting. The types of processing include dry, semi-dry, and wet (de Melo Pereira et al. 2015 ). Dry processing involves pulping, fermentation, washing, drying, threshing, and roasting. Semi-dry processing involves mechanical removal of the exocarp and part of the mucilage, while wet processing involves drying and threshing.

Green coffee, obtained after processing, varies according to agro-climatological characteristics, species, variety, processing type, and post-harvest operations. Control of these operations is essential to preserve grain quality and maintain the consistency of its sensory profile.

Coffee fermentation is a metabolic process that converts sugars into energy and compounds through the action of enzymes in mucilage (Silva et al. 2013 ). This process involves the pulped coffee mass being kept in closed containers for 12 to 72 h to remove the mesocarp (mucilage) attached to the parchment. The mucilage, composed of simple sugars and a pectic substrate, is degraded into alcohols and organic acids by microorganisms, such as yeasts and bacteria (Correa et al. 2014 ; Pereira et al. 2016b ).

Coffee fermentation is a metabolic process that converts sugars into energy and compounds through the action of enzymes in mucilage. This process involves the pulped coffee mass being kept in closed containers for 12 to 72 h to remove the mesocarp (mucilage) attached to the parchment. The mucilage, composed of simple sugars and a pectic substrate, is degraded into alcohols and organic acids by microorganisms, such as yeasts and bacteria (Bressani et al. 2021b ).

Metabolites diffuse through parchment and endosperm, potentially causing exosmosis during fermentation until chemical potential equilibrium is achieved. The decrease in pH causes mucilage degradation, which can be removed by washing with water. Controlled fermentation can produce beverages with special aromas and flavors, such as sweet, citrus, and fruity.

Mucilage removal can be performed using mechanical or enzymatic methods, such as mechanical abrasion in ELMU-type mucilage removal machines and enzymes like Ultrazym 100, Irgazim 100, Benefax, and Cofepec. Recent research has revealed that the microbial degradation process during fermentation leads to physical and chemical changes in almonds, impacting the sensory characteristics of the resulting drink (da Mota et al. 2020 ; Elhalis et al. 2021 ).

Factors affecting reaction rates during coffee fermentation include temperature, water availability, fermentation time, and fruit maturity index. Devices designed for the operation must allow control and measurement of these factors to standardize the process.

This article shows the advances achieved over time with the technologies and methods used in the fermentation of coffee, taking into account the improvement in the processes of safety, standardization and quality of coffee. A bibliographic analysis of research focused on technologies and representative authors with related publications, among other aspects, was carried out. All with the purpose of observing the progress in the fermentation process with the objective of continuing researching and looking for solutions to obtain efficient and quality processing.

Search methodology

A bibliometric analysis was conducted on coffee bean fermentation publications to identify trends, emerging research directions, and relationships with fermenters and process variables, using Scopus database and ScientoPy and SciMAT software.

Databases, keywords and search criteria

This study analyzed data from the Scopus database on coffee, bean, and fermentation from 2001 to 2022, focusing on top countries, document types, and institutions, and downloaded in .CSV format for ScientoPy and SciMAT software.

Analysis using ScientoPy software

The downloaded data from Scopus were then loaded and processed with ScientoPy and the pre-processing results are presented in Table  1 . The journals and keywords categories were analyzed with the software to know the most relevant issues, total documents published by journal and keywords and evolution of them in the period from 2001 to 2022.

Analysis using SciMAT software

The data was preprocessed in modules “Knowledge base” and “Group sets” to remove duplicates and related keywords. The analysis was set to three periods (2001–2017, 2018–2020, and 2021–2022) and parameters were selected in “Analysis” to create evolution maps, strategic diagrams, and clusters.

Search results

Trends in publications over time.

The search for 231 documents from 2001 to 2022 revealed a stable trend in published documents. Between 2012 and 2022, there was a decrease in publications (Fig.  1 A and B). The top five countries were Brazil, followed by Indonesia, China, South Korea, and Colombia (Fig.  1 C). The majority of documents were articles, with a small percentage of reviews. The Universidade Federal de Lavras leads the list with 26 publications on the search topic, followed by Brazilian Universidade Federal do Parana (Fig.  1 -D). Indonesian institutions Hasanuddin University and Universitas Sylah Kuala also appear in the top 10. Nestlé S.A. ranks sixth in the top ten.

Documents published in the search topic (Graphs extracted from Scopus online database). ( A ) Documents published by year ( B ) Documents published by type ( C ) Documents published by country ( D ) Documents published by institution

There is no clear trend in the number of publications in the top 10 journals over time. Food Research International and IOP Conference Series: Earth and Environmental Science had the largest publications in 2020 and 2021 respectively. The evolution of the top 10 keywords is showed in Fig.  2 . This graph corroborates the main terms used and shows an increase over time of this words. After “Coffee”, which is a general term, “Fermentation” term has the highest number of documents published in the period analyzed, but according to the percentage of documents published in the last year 2021–2022 graph, “coffee fermentation” had the highest value (42.1%) in comparison to the other terms, which indicates that in the last year, this topic has had a higher relative growth.

Keywords in research related to the search topic ( A ) Cloud diagram of the top 1000 words ( B ) Evolution graph of the top 10 words

Although in general the interest in the fermentation process of coffee remains constantly growing, the topics addressed are diverse, which can be evidenced in the variety of key terms that the search throws up. Figure  2 -A shows the cloud of words specifically related to the fermentation process, such as types of fermentation, process control, variables involved, and fermenters. In relation to the latter, only two specific terms about it appear in the cloud, “bioreactors” and “bioreactor”; and some terms related with variables, control process or devices such as “controlled fermentation”, “temperature distribution”, ohmic technology”, “ohmic heating”.

Besides, some differences are obtained with the processing of data in SciMAT (Table  2 ), since this tool allows groups conformations in similar words and documents not related with the topic, however, words like “Fermentation” and “Coffee” remains as main terms, which is expected since these are general terms. Respect to the journals, the results are similar with some exceptions.

Topic evolution map and strategic diagram and cluster’s network

Figure  3 shows the graphs generated by SciMAT from the analysis of the data associated with the search string. According to the evolution map (Figs.  3 -1), for period 2001–2017 it can be observed nine main terms: “bacteria”, “coffee aroma”, “metabolomics”, “arabica”, “fungal fermentations”, “beverages”, “microorganisms”, “types of fermentation”, and “coffee”. In the period 2018–2020, the number of relevant terms increase to eleven, and only “microorganisms”, “coffee” and “type of fermentation” terms remain. New terms are included such as “classification”, “genetics”, “bacillus”, “yeast”, “seeds”, “sensory analysis” and “volatiles”. With respect to period 2020–2022, “bioreactors and process variables” term appears for the first time and there are new terms, for instance, analytical techniques as “spectrometry” and “chromatography”.

( 1 ) Evolution map of the relevant terms regarding the search topic in the documents reported from 2001 to 2022, and relevant relationships on evolution map. The color lines represent the main associations found, and ( 2 ) Strategic diagram associated with topic of interest for period ( A ) 2001–2017, ( B ) 2018–2020, ( C ) 2021–2022. ( 3 ) Cluster of terms associated with topic of interest for period ( A ) 2001–2017, ( B ) 2018–2020, ( C ) 2021–2022

With respect to the relevant associations shown on the evolution map (Figs.  3 -1), it is possible to observe terms associated with the study of microorganisms (relationships highlighted in red), such as bacteria, especially of the genus Bacillus, fungal fermentation, mainly related to yeasts, and lactic acid fermentation. These terms, in turn, present associations with parameters such as sensory analysis and volatiles. The latter is related to “bioreactor and process variables” in the last period. The term “bioreactor and process variables” is backward associated with “coffee”, a general term, and “types of fermentation”, which, in turn, is associated with “coffee aroma” (relationships highlighted in blue). These associations are anticipated due to the disparate processing methodologies, where the conditions of the process, the utilization of starter cultures, the type of microorganisms employed, and the generation of organic acids that contribute to alterations in the volatile and aroma profiles of roasted coffee are implicated (da Mota et al. 2020 ). Additionally the control of process variable offered by bioreactors has recently shown to contribute to the production of coffee with higher sensory quality and reproducibility (de Carvalho Neto et al. 2018 ).

The strategic diagrams and cluster networks for each period are presented in Fig.  3 (2) and (3). The volume of the spheres is proportional to the number of published documents associated with each theme. The upper-right quadrant is motor-themes, with terms in the upper-left quadrant being highly development and isolated themes. The lower-left quadrant is emerging or declining themes, while the lower-right quadrant is transversal and general. In the first period, “beverages”, “metabolomics”, and “fungal fermentation” are motor themes, while “types of fermentation” is an emergent theme. In the second period, “types of fermentation” remains an emergent theme, with “yeast” added to this category. In the third period, “coffee” is less frequent, with more specific topics such as “bacillus”, “genetics”, and “classification” as motor themes (Elhalis et al. 2021 ). For the period 2020–2022, “volatiles” and “metabolomics” are motor themes, related to research on volatiles and metobolites generated in process fermentation (Elhalis et al. 2021 ; Prakash et al. 2022 ). “Types of fermentation” and “coffee” are tranversal themes, while “lactic acid fermentation” is an emergent theme. “Bioreactors and process variables” is an isolated theme for this period.

Figure  3 (3) displays clusters of terms related to bioreactors and process variables control. The volume of spheres is proportional to the number of documents corresponding to each keyword, and the thickness of the link between two spheres is proportional to the equivalence index between these words. For the period 2001–2017, “bioreactor and process variables” is slightly related to “microorganisms”, “drying process”, “plant seed”, and “mucilage”. For the second period, “volatile” term shows a slight relationship with “bioreactor and process variables”, which in turn is associated with “coffee beans”. The main associations with “bioreactor and process variables” may be with “microorganisms” and “volatile”.

As regards the period 2021–2022 (Figs.  3 - (3) -C), strong bonds are observed between “Bioreactor and process variables”, “Food supply” and “Agriculture”, since the fermentation process is usually on-farm process, although efforts have been made to the process control (Martinez et al. 2017 ; de Carvalho Neto et al. 2018 ). Slight associations are seen with more specific terms such as “Liquid media”, “Enzymes”, “UV-VIS-Spectrophotometry” and “Biochemical analysis”. These terms are directly related to the fermentation process and its monitoring, whereby those relationships are expected.

Coffee fermentation methodologies

Scientific publications related to coffee fermentation devices were searched in the Web of Science, Scopus, and Science Direct databases. Published patents, as well as devices developed by different companies in the sector, were also included in the review. The evolution and characteristics of the devices and their impact on the quality and sensory profile of the coffee were tabulated and summarized in tables.

Table  3 presents various methods for controlling coffee fermentation, focusing on temperature, processing time, and microorganism addition. These parameters affect the grain’s physical-chemical composition and sensory profile. Fermentation times range from 12 h to several days, with low temperatures slowing microbial kinetics and requiring several days for pH to reach 3.8. Mass transfer between mucilage and grain layers occurs mainly through diffusion, leading to more complex profiles in long-time fermentation.

Evolution of technologies for coffee fermentation

Coffee fermentation devices are containers that allow the product volume to be maintained under homogeneous conditions during the process. Fermentation can be done dry or submerged, with the latter ensuring that all grains are in contact with an equal volume of oxygen. Most producers follow this method for a more homogeneous fermentation. Initially, pulped coffee was fermented in vat-type tanks made of wood, cement, or brick, which were plastered or enameled with cement or covered with baked clay veneers. The floor was built with a slope of 6 to 8% and a width-to-height ratio of 1:1.5 to facilitate leachate drainage and product removal. The final processing time was determined based on producer experience, such as the hole and touch test, which is subjective and prone to errors.

Producers have noticed that fermentation under certain conditions can result in heterogeneous coffee products with sour and fermented flavors due to the difficulty in controlling process variables. To improve sanitary conditions, Cenicafé and other manufacturers have developed high-density polyethylene vat-type tanks, which are lightweight, easy to handle, and clean. Cenicafé in Colombia has successfully maintained a stabilized process with less washing water consumption using Ecomill ® technology in stainless steel and high-density polyethylene. These systems incorporate cylindrical fermentation tanks with inverted cone-shaped bases and 60° horizontal inclination, allowing coffee to flow out by gravity.

Widyotomo, S., and Yusi, Y. ( 2013 ) evaluated the fermentation of cherry coffee in a horizontal type fermenter with electrical resistance and agitation (Fig.  4 -4-A). Working at 50% capacity (20 kg/batch), temperatures between 20 and 40 °C and times between 6 and 18 h, the authors defined optimal operating conditions at 25 °C and 12 h of processing. In an attempt to remove the mucilage using low temperatures to reduce the consumption of washing water, Bressani et al. ( 2020 ) evaluated a cold fermenter prototype. Temperatures close to 2 °C managed to denature the structure of the mucilage and then it was removed mechanically (Fig.  4 -4-B). In Brazil, some private companies have developed commercial prototypes for fermentation control. The Palinialves company developed a rotating cylinder (Fig.  4 -4-C) with a galvanized sheet, steel or stainless steel structure with internal blades and rpm control for a homogeneous mix. The system is completely sealed and has a relief valve for pressure control and temperature sensors. Its maximum capacity is 10,000 L. The Campotech company with the support of Embrapa and the Instituto Federal do Sul de Minas, developed a device for the controlled fermentation of 1,250 L of cherry or pulped coffee. The device, in the form of a vertical cylinder and conical base, has a helical agitation and temperature control systems for heating or cooling the coffee mass (Fig.  4 -4-D).

( 1 ) Vat-type tank for fermentation of pulped coffee. ( 2 ) High-density polyethylene vat-type tanks for coffee fermentation. ( A ) Cenicafé ( B ) Rotoplast ® . ( 3 ) Fermentation tank in Ecomill ® Technology. ( A ) 1,000 to 1,500 kg load capacity. ( B ) 2,000 to 6,000 kg load capacity. ( 4 ) Closed systems for coffee fermentation. ( A ) Widyotomo, S., & Yusi, Y. 2013 , ( B ) Correa et al. 2014 , ( C ) Palinialves, ( D ) CampoTech – Jacu Digital

Final remarks

Colombia, with over a century of coffee production experience, has limited knowledge in developing innovative fermentation prototypes. The fermentation process for washed coffees was once considered unimportant, focusing only on removing mucilage to reduce drying time. This neglect of safety and quality has led to issues with materials like concrete, majolica, wood, and cement. Technological advances in the last decade have led to the use of safe materials like high-density polyethylene and stainless steel in fermenters. Prototype fermenters or bioreactors with variable control systems and mechanical agitation have been developed in countries like Peru, Brazil, Chile, Spain, Indonesia, and Colombia. However, these high-cost technologies remain inaccessible to most producers. The industry has developed solutions such as helical-type central agitators and rotating drums, both with high energy consumption. A strategy is being evaluated for mixing through the recirculation of leachate, which requires less energy than the entire coffee mass. However, the impact of this methodology on the process quality has not been scientifically evaluated (Widyotomo and Yusianto 2013 ).

Conclusions

A bibliometric analysis of the literature on coffee fermentation indicates a growing interest and progress in research and development of technologies to improve sensory quality, safety, efficiency, and sustainability. Improvements in fermentation tanks have been identified in terms of materials, designs, and the incorporation of accessories such as digital sensors. Innovations in fermentation methodologies and a more scientific approach by researchers in this field have also been observed.

Moreover, the analysis indicates that issues related to coffee bean fermentation are undergoing constant evolution, with Brazil emerging as a leading contributor in this field. Despite a decline in the number of published papers over the past three years, research is focused on the design of controlled fermentations and the evaluation of the influence of microorganisms and process conditions on the sensory quality and composition of coffee. Nevertheless, it is observed that prototypes designed to regulate process variables, such as agitation and temperature, are costly and may be inaccessible to small-scale producers.

Collectively, these findings indicate that the integration of innovative technologies, enhanced methodologies, and a rigorous scientific approach is transforming the coffee industry towards enhanced efficiency, safety, and sustainability, with the potential to benefit both producers and consumers globally.

Data availability

Not applicable.

Code availability

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Project financed by the Ministry of Science and Technology of Colombia (Minciencias). Project of the General System of Royalties BPIN No. 2020000100460.

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Valeria Hurtado Cortés, Jaime Daniel Bustos Vanegas & Nelson Gutiérrez Guzmán

Present address: Facultad de Ingeniería, Grupo de Investigación Agroindustria USCO, Universidad Surcolombiana, Centro Surcolombiano de Investigación en Café – CESURCAFÉ, Avenida Pastrana Borrero Carrera 1a, Neiva, 410001, Huila, Colombia

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Facultad de Ingeniería, Grupo de Investigación Agroindustria USCO, Universidad Surcolombiana, Centro Surcolombiano de Investigación en Café – CESURCAFÉ, Avenida Pastrana Borrero Carrera 1a, Neiva, 410001, Huila, Colombia

Andrés Felipe Bahamón Monje

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The writing and formatting of the article was done by Valeria Hurtado, Jaime Bustos and Andrés Bahamon, the revision and acceptance was reviewed by Jaime Bustos and Nelson Gutierrez.

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Cortés, V.H., Bahamón Monje, A.F., Bustos Vanegas, J.D. et al. Challenges in coffee fermentation technologies: bibliometric analysis and critical review. J Food Sci Technol (2024). https://doi.org/10.1007/s13197-024-06054-5

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DOI : https://doi.org/10.1007/s13197-024-06054-5

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Parametric analysis of criticaltable buckling in composite laminate structures under mechanical and thermal loads: a finite element and machine learning approach.

1. Introduction

2. literature review, 3. finite element method, 3.1. geometry and modeling, 3.2. boundary conditions and meshing, 4. machine learning approach, 4.1. regression models, 4.2. design and implementation, 5. finite element results and analysis, 5.1. mesh independence test, 5.2. validation of simulation model, 5.3. total deformation, 5.4. effect of parameters, 5.4.1. quasi-isotropic, 5.4.2. angle-ply, 5.4.3. cross-ply, 5.4.4. balanced, 6. machine learning model evaluation and results.

• Linear regression, as a fundamental and interpretable model, serves well as a baseline and is suitable for linear or linearized relationships. Its strength lies in providing clear interpretations of coefficients, aiding in understanding feature impact.
• Decision trees excel at capturing nonlinear relationships and interactions in the data, making them suitable for complex scenarios. They are robust to outliers and handle diverse data types without extensive preprocessing.
• Random forests, by combining multiple decision trees, effectively address overfitting and generalize well, especially in high-dimensional or noisy data. They offer robustness to outliers and missing values while requiring minimal hyperparameter tuning.
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6.1. Hyperparameter Tuning (Grid Search)

• Learning rate: [0.1, 0.5, 1.0];
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6.2. Machine Learning Result Matrix

7. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Ahmed, O.S.; Ali, J.S.M.; Aabid, A.; Hrairi, M.; Yatim, N.M. Parametric Analysis of Criticaltable Buckling in Composite Laminate Structures under Mechanical and Thermal Loads: A Finite Element and Machine Learning Approach. Materials 2024 , 17 , 4367. https://doi.org/10.3390/ma17174367

Ahmed OS, Ali JSM, Aabid A, Hrairi M, Yatim NM. Parametric Analysis of Criticaltable Buckling in Composite Laminate Structures under Mechanical and Thermal Loads: A Finite Element and Machine Learning Approach. Materials . 2024; 17(17):4367. https://doi.org/10.3390/ma17174367

Ahmed, Omar Shabbir, Jaffar Syed Mohamed Ali, Abdul Aabid, Meftah Hrairi, and Norfazrina Mohd Yatim. 2024. "Parametric Analysis of Criticaltable Buckling in Composite Laminate Structures under Mechanical and Thermal Loads: A Finite Element and Machine Learning Approach" Materials 17, no. 17: 4367. https://doi.org/10.3390/ma17174367

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• Open access
• Published: 30 August 2024

Barriers in providing quality end-of-life care as perceived by nurses working in critical care units: an integrative review

• Yousef Saleh Rubbai 1 , 2 ,
• Mei Chan Chong 1 ,
• Li Yoong Tang 1 ,
• Khatijah Lim Abdullah 3 ,
• Walid Theib Mohammad 6 ,
• Samira Mohajer   ORCID: orcid.org/0000-0001-7118-1783 1 , 4 &
• Mohammad Namazinia   ORCID: orcid.org/0000-0003-2198-7556 5  

BMC Palliative Care volume  23 , Article number:  217 ( 2024 ) Cite this article

Metrics details

Despite increasing interest in quality end-of-life care (EOLC), critically ill patients often receive suboptimal care. Critical care nurses play a crucial role in EOLC, but face numerous barriers that hinder their ability to provide compassionate and effective care.

An integrative literature review was conducted to investigate barriers impacting the quality of end-of-life care. This review process involved searching database like MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, EBSCO, and ScienceDirect up to November 2023. Search strategies focused on keywords related to barriers in end-of-life care and critical care nurses from October 30th to November 10th, 2023. The inclusion criteria specified full-text English articles published between 2010 and 2023 that addressed barriers perceived by critical care nurses. This integrative review employs an integrated thematic analysis approach, which combines elements of deductive and inductive analysis, to explore the identified barriers, with coding and theme development overseen by the primary and secondary authors.

Out of 103 articles published, 11 articles were included in the review. There were eight cross-sectional descriptive studies and three qualitative studies, which demonstrated barriers affecting end-of-life care quality. Quality appraisal using the Mixed Method Appraisal Tool was completed by two authors confirmed the high credibility of the selected studies, indicating the presence of high-quality evidence across the reviewed articles. Thematic analysis led to the three main themes (1) barriers related to patients and their families, (2) barriers related to nurses and their demographic characteristics, and (3) barriers related to health care environment and institutions.

This review highlights barriers influencing the quality of end of life care perceived by critical care nurses and the gaps that need attention to improve the quality of care provided for patients in their final stages and their fsmilies within the context of critical care. This review also notes the need for additional research to investigate the uncover patterns and insights that have not been fully explored in the existing literature to enhance understanding of these barriers. This can help to inform future research, care provision, and policy-making. Specifically, this review examines how these barriers interact, their cumulative impact on care quality, and potential strategies to overcome.

Peer Review reports

Introduction

It was estimated that 56.8 million people, including 25.7 million at the end of life, need palliative care; however, only about 14% of people who need palliative care currently receive it [ 1 ]. The need for acute care settings increased in response to life-threatening emergencies and the acute exacerbation of diseases [ 2 , 3 ]. These settings were developed to meet the need for providing optimal health care, saving patient lives and decreasing the rate of mortality using advanced technology [ 2 , 4 ]. Caring in intensive care units sometimes involves withholding or withdrawing treatments that have lasted a lifetime, and in these cases, the role of ICU nurses goes from providing life-saving measures to end-of-life care [ 5 ]. Care at the end of a life is a special kind of health care for individuals and families who are living with a life-limiting illness [ 6 ]. End-of-life care (EOLC) includes a crucial component of intensive care nurses’ work; nurses are in a unique position to cooperate with families to provide care for patients at the end of their lives [ 7 , 8 , 9 , 10 43 ].

Advanced technology in critical care units has led to improved nursing care in many areas, such as End-Of-Life-Care (EOLC) [ 11 ]. This type of care has moved towards enhancing comfort and reducing patients’ suffering [ 12 ]. As EOLC involves enhancing the physical, emotional, and spiritual quality of life for critically ill patients, traditional measures are now challenged as advanced technology has revolutionized nursing care through innovations such as adjustable beds and pressure-relieving mattresses, which help optimize patient comfort, and advanced communication technologies, for example, video conferencing facilitating communication between patients, families, and healthcare providers, allowing for ongoing support, counseling, and decision-making discussions throughout the end-of-life journey. Therefore, quality EOLC has become a significant concern for healthcare decision-makers, healthcare providers, researchers, patients, and families [ 13 ]. Despite the increased interest and demand in providing good EOLC, this care is still limited In the critical care and does not meet the recommended standards [ 14 ]. Critical Care Nurses spend more time with patients compared to other members of the multidisciplinary team. They serve as implementers, educators, and coordinators in end-of-life care. Their role in delivering EOLC is essential as they are presumably prepared to provide this care and meet patients and their family’s needs, including pain control, management of physical, emotional, spiritual, and social needs, and communication with patients and their families [ 15 ]. Therefore, it is important to look into the factors that impede the provision of quality end-of-life care from their perspectives. Many barriers affecting the provision of EOLC in critical care areas have been reported in the literature [ 13 , 16 , 17 ].

End-of-life care (EOLC) involves caring for and managing terminally ill patients and families. The quality of EOLC in critical care units has been evaluated based on factors such as patient/family involvement in decision-making, professional communication between health professionals and patients/families, care quality, support types, illness and symptom management, spirituality, and organizational support for critical care nurses [ 18 ]. Furthermore, working in a critical care unit environment is stressful and emotionally taxing for health professionals such as nurses. Carers of terminally ill patients may experience distressing emotions such as helplessness, loss of power, sadness, and hopelessness [ 18 ]. These feelings make it difficult to provide optimal end-of-life care. Additionally, nurses focus on managing symptoms, disease prognosis, treatment options, and physical aspects, but in fact, caring in critical care units follows a universal and holistic model. Previous research has shown that patients and families are not receiving adequate care at the end of life.

Researchers categorized factors that affect EOLC into barriers and challenges [ 13 ]. Barriers have been classified into three categories: patient and family-related, nurses and other health care workers’ related, and health care institutions’ related [ 16 , 17 ].

Barriers related to communication between health care providers and patients and families and characteristics of critical care nurses, including nurses’ age, gender, educational level, and end-of-life care training, significantly affect providing good EOLC [ 19 , 20 , 21 , 22 , 23 ]. this integrative review aims to go beyond merely identifying and categorizing barriers. By synthesizing results from a wide range of studies, the review seeks to uncover patterns and insights that have not been fully explored in the existing literature to enhance understanding of these barriers. This can help to inform future research, care provision, and policy-making. Specifically, this review will examine how these barriers interact, their cumulative impact on care quality, and potential strategies to overcome Despite the fact that EOLC is decisive to patient care, appropriate provision of this service is still lacking in several aspects. In the ICUs, EOLC must be considered an essential factor. However, owing to the existing practices of nurses, the adequate delivery of EOLC tends to bear various inefficiencies.

Nurses and other healthcare staff seem to come across multiple barriers that hinder their ability to offer effective care to critically ill patients. Considering the given dearth of research in this context, we intend to present a comprehensive insight into the issue. In this review, we focused on EOLC provided by critical care nurses, who were defined as nurses dealing with patients suffering from acute health problems due to injury, surgery, or exacerbated chronic diseases and need close monitoring in units such as intensive care units (surgical, medical, and pediatric) and cardiac care units. Due to the importance of exploring these barriers in determining the quality of EOLC, this integrative review paper was conducted to examine and highlight evidence from the literature on these barriers that affect the provision of quality EOLC. This paper explores and identifies current published peer-reviewed studies addressing barriers that affect the quality of EOLC as perceived by critical care nurses. This integrative review seeks to answer the following question: What barriers affect the quality of end-of-life care perceived by nurses working in critical care units?

An integrative review design was the most suitable method to explore and produce a new understanding from various types of literature (experimental, non-experimental, and theoretical) to enhance understanding of the phenomenon under investigation (i.e., EOLC). This method also facilitated nursing science by informing further research, care provision, and policy-making. It also highlights strengths, weaknesses, limitations, and gaps in knowledge, and supports what is already known about theories relevant to our topic [ 24 ]. Therefore, this design helps meet this review’s purposes.

Search strategies

The search process involved four phases which were developed by the first author (YR) and validated by two expert authors (MCC and KLA) as follows: (1) identifying the problems related to the research question, (2) conducting a systematic literature search, (3) screening the articles to develop themes, and (4) performing critical analysis to develop the themes.

From October 30, 2023, to November 10, 2023, electronic literature searches were conducted using major databases such as MEDLINE, Cochrane, CINAHL, EBSCO, and ScienceDirect.

Search methods were defined using the MeSH (Medical Subject Headings) descriptors of the keywords “end-of-life care,” “barriers,” and “critical care nurses.” Additionally, the reference lists of all identified articles were manually searched for additional studies. The operators used in this search included “AND” and “OR,” as well as the truncation tools of each database. A refined search was performed with terms such as “critical care nurses’ perceptions” OR “opinions” AND “quality end-of-life care” OR “quality of death and dying.” Subsequently, terms like “barriers” OR “obstacles” OR “challenges” AND “quality end-of-life care” OR “quality of death and dying” were employed. Finally, the descriptors “critical care nurses’ perceptions,” “barriers,” and “quality end-of-life care” were used (Fig.  1 ).

PRISMA search flow diagram

Inclusion and exclusion criteria

The inclusion criteria for this search to select relevant articles were as follows: (1) Full-text articles, (2) Papers published in the English language from 2010 to 2023, and (3) Articles that specifically describe the barriers perceived by critical care nurses that affect the quality of end-of-life care.

Intervention studies and studies that describe barriers to providing quality end-of-life care from other perspectives, such as physicians and patients’ families were excluded. For the studies who included nurses and other health care workers within the context of critical care, the researchers included the results that relevant to nurses and excluded the others.

Data extraction

The data extraction and analysis were carried out to collect and consolidate the data from the selected studies into a standard format relevant to the research field. The extracted data included specific descriptions of the settings, populations, study methods, and outcome measures (Table  31 ). Two authors (YSR and KLA) independently extracted the data and reached an agreement after discussion with the third author (MCC).

Included and excluded studies

Following the review process, the authors made the final decision on studies that met the study criteria. Out of a total of 103 articles, 9 duplicates were removed. The abstracts of the remaining 94 articles were initially found to be somewhat relevant to the research topic. However, after examining the articles in terms of research methodology and results, 36 articles that matched the selection criteria for this study were ultimately chosen. The full text of the 36 articles was reexamined based on the title first for suitability. Subsequently, the abstracts of the studies were reviewed, leading to the exclusion of 23 articles for various reasons, leaving 13 studies for further consideration in this study. However, two articles were disqualified as they did not contain a specific research methodology or reviewed literature papers; they relied solely on theoretical information. This step resulted in the inclusion of 11 research articles in this integrative review of the literature (Table  1 ).

Quality appraisal

To ensure the methodology’s quality and avoid bias in the design, highly credible and respected search engines were adopted to select peer-reviewed studies according to the inclusion criteria in this review. The articles chosen in this review were categorized into two sections based on study design and research methodology: quantitative and qualitative studies. These were evaluated manually and independently for each study, with any disagreements resolved by two experts (KLA, Professor, and MCC, Associate Professor) who have experience in research methodology, using the Mixed Methods Appraisal Tool (MMAT) version 2018 [ 25 ]. This tool includes specific criteria for evaluating the quality of quantitative, qualitative, and mixed-method studies. The MMAT consists of a checklist of five research components for each type of study with a rating scale including “Yes,” “No,” and “Can’t tell.” The overall results suggest that the evidence quality across the ten studies was high (Table  2 ).

Data synthesis

Thematic analysis in this review involves a systematic process of coding and theme development, using both inductive and deductive approaches. This method ensures a comprehensive synthesis of diverse data sources, providing valuable insights into the research topic [ 24 , 26 ]. Thematic analysis was employed for all studies to investigate the subject of interest. The coding for the themes in this review followed the six recommended phases: Familiarizing with the data; making initial codes; searching for themes; reviewing themes and making a thematic plan; defining and naming themes; generating the final picture of the report [ 24 ]. The coding was conducted by the primary author (YSR) and confirmed by the three secondary authors (LH, SM, and LY). Any discrepancies were discussed and resolved through consensus.

Search outcomes

The search process yielded a total of 103 articles. All articles resulting from the search process were independently reviewed by all authors in this study for the research process, purpose, methodology, tools, main findings, recommendations, and limitations.

Characteristics of included studies

Eight cross-sectional descriptive studies and three qualitative studies were selected, which were conducted in the following countries: two from the USA [ 27 , 28 ] and a single study from each of the following countries: Saudi Arabia [ 22 ], Jordan [ 29 ], Egypt [ 12 ], Malaysia [ 13 ], Scotland [ 30 ], Poland [ 31 ], Hong Kong [ 32 ], South Africa [ 33 ], and China [ 34 ].

In this comprehensive analysis of 11 studies, a diverse range of methodologies and findings were examined across different countries and healthcare settings. The studies included a mix of quantitative and qualitative approaches, with sample sizes varying from small convenience samples to larger cohorts. Key barriers to providing End of Life Care (EOLC) were identified, such as challenges in communication with families, lack of support from managers, and insufficient training in EOLC. The studies highlighted the importance of addressing these barriers to improve the quality of care provided by nurses in critical care settings. Notably, demographic characteristics and their impact on EOLC provision were not consistently addressed across the studies, indicating a potential area for further research and exploration in this field (Table  31 ).

The thematic analysis of included studies revealed several key themes and sub-themes related to barriers in End of Life Care (EOLC). These themes encompassed various aspects, including challenges related to patients and their families, healthcare institutions and the environment, as well as barriers specific to nurses. Communication and collaboration between patients, nurses, and families included issues such as seeking updates about patient status, misunderstandings about life-saving measures, misunderstanding poor prognosis, troubled family dynamics, and conflicts within families regarding life support decisions [ 22 , 34 ]. Additionally, barriers related to Institution Policy and procedures highlighted concerns such as insufficient standard procedures, communication challenges in decision-making, inadequate ICU design, inappropriate staffing policies, and deficiencies in rooms, supplies, and noise control. Furthermore, barriers associated with nurses encompassed their emotional experiences and socio-demographic characteristics [ 12 ] (Table  4 ).

Among the results of the selected articles on nurses’ perceptions of barriers affecting quality EOLC, three main themes were identified: (1) Communication and collaboration between patients, nurses, and families (2) Institution Policy and procedural barriers, and (3) barriers related to nurses and their demographics. An overlap in some of these areas, such as the themes addressing barriers related to patients and their families, was identified [ 11 , 22 , 35 ]. This overlap indicates a high level of consensus between the authors in identifying the barriers affecting the quality of end-of-life care.

Communication and collaboration between patients, nurses, and families

After reviewing the existing body of literature in this domain, it was observed that some familial factors had been largely perceived as prominent barriers to providing EOLC by the nurses. Although some authors concluded family issues as the highest-ranking concern for nurses in providing quality EOLC, there were variations in the type of barriers they encountered [ 11 , 28 , 35 ]. For example, continuous requests for updates on patients’ status from their families were identified as the top-rated barrier affecting the quality of EOLC from the perspective of critical care nurses. In addition, family misunderstandings about life-saving measures, as well as doubts and uncertainties regarding prognosis, resulted in a lack of time for nurses to provide quality EOLC, as they spent significant time explaining these matters [ 29 ]. Similarly, continuous phone calls from family members seeking updates on patients’ conditions were ranked highest (M = 4.23) among barriers affecting EOLC [ 28 ]. Additionally, dealing with distressed family members also received the highest total mean score (M = 3.3) [ 13 ]. On the contrary, another study found that out of 70 nurses, the practice of calling nurses for updates on patients’ conditions had the lowest impact on EOLC practice (62.2%), while misunderstanding about life-saving measures (65.7%) played a crucial role in determining the quality of EOLC [ 36 ]. The study concluded that the primary barrier related to patients and their families was the lack of understanding among family members about what life-saving measures entailed. Similarly, another source also reported consistent findings indicating that families often did not accept poor prognoses for patients and struggled to grasp the significance of life-saving measures [ 22 ].

Furthermore, previous studies have indicated that barriers affecting EOLC and thereby the quality of care include the presence of family members with patients, inadequate communication with patients’ families, lack of involvement in discussions about patient care decisions, conflicts among family members regarding decisions to cease or continue life support treatment, and unrealistic expectations regarding prognosis [ 22 , 30 , 37 ].

Communication and collaboration among doctors and nurses are vital in designing an effective healthcare plan for patients. However, inadequate and inappropriate collaboration and support, such as conflicting opinions, disagreements, and insufficient cooperation between them, can lead to various difficulties that may result in poor patient care [ 22 ]. Research scholars who have conducted studies in this area have acknowledged that agreement between nurses and physicians regarding care directions for patients at the end of life is one of the most critical barriers to enhancing the quality of EOLC [ 29 ].

Similarly, another study found that poor communication between nurses and physicians resulted in inappropriate decision-making and disagreement about care plans, which subsequently impacted the quality of care [ 13 ]. Additionally, inadequate and poor communication between nurses and other healthcare teams diverted attention from the goal of care [ 28 ].

Failures in communication between nurses and other healthcare providers can lead to misunderstandings of care messages, which can affect EOLC practices [ 30 ]. It also highlighted the lack of communication and cooperation between doctors and other healthcare team members; nurses emphasized the need for a communication training course [ 11 ].

Good communication between nurses and physicians and consideration of nurses’ opinions were found to enhance the quality of EOLC [ 12 ]. Furthermore, educating critical care nurses about communication and collaboration skills was reported as crucial for improving the quality of EOLC [ 13 ].

Barriers related to nurses

The given three sub-themes were identified regarding the impact of nurses-related barriers and the influence of some of their demographic factors on the quality of EOLC:

Lack of opportunities for training and education.

Emotional and psychological issue.

Nurses’ socio -demographic factors.

Lack of opportunities for training and education

It was reported that critical care nurses were not adequately prepared to provide EOLC; nurses needed to increase their knowledge about cultural aspects, ethical issues, skills, communication, and training regarding the continuity of care and the management of physical and psychosocial symptoms [ 11 , 13 , 28 ]. Furthermore, nurses who did not participate in any EOLC training course perceived more barriers to delivering quality EOLC than those who had participated in introductory training courses [ 13 , 28 ]. Attia et al. [ 12 ]. reported that 60% of critical care nurses perceived that they had received poor education and training concerning family grieving, symptom management, and quality EOLC. Furthermore, Holms et al. [ 30 ]. found that all participants acknowledged that they had received very little formal education and training on EOLC, particularly those who worked in intensive care. In a study by Jordan et al. [ 37 ], nurses emphasized that EOLC education is essential during the orientation period before starting their ICU jobs.

Emotional and psychological issue

Five articles in this review have studied the effect of nurses’ feelings and emotions as barriers to providing quality EOLC [ 11 , 13 , 28 , 30 , 37 ]. Nurses stated that they feel sad when they cannot help the patients to die peacefully, and they lack emotional support, considering this one of the main barriers to providing EOLC [ 11 ]. Staff morale distress was reported repeatedly during interviews with ICU nurses about their experience of EOLC. This feeling of despair is accompanied by many causes, such as lack of staff experience, poor communication, inadequate training about EOLC, lack of a suitable environment, and lack of support from senior staff [ 30 ]. Nurses acknowledged that they felt like they were participating in decisions to withdraw or withhold life-sustaining treatment, resulting in conflicting emotions and feeling helpless in advocating for the patients with mixed feelings of sadness, grief, anger, and frustration [ 37 ]. Lastly, Crump et al. [ 28 ] and Omar Daw Hussin et al. [ 13 ] observed that critical care nurses received inadequate emotional support from managers and experts within healthcare institutions, which affects the quality of EOLC they provide.

Nurses’ socio -demographic factors

It has been identified that some socio-demographic characteristics of nurses also play a significant role in shaping their opinions regarding perceived barriers. For example, age, education, experience in the field, and other similar factors profoundly impact their perceptions of the barriers to providing EOLC. A study by Omar Daw Hussin et al. [ 13 ] revealed that nurses ( n  = 553) aged 21–30 years old had the highest mean total score for barrier factors to provide quality EOLC compared to other age groups. This was also higher in diploma holders than in nurses with certificates and bachelor’s degrees. Regarding years of experience as critical care nurses, they found that nurses with minimal years of experience (1–10 years) had the highest mean total score for difficulties. Similarly, Chan et al. [ 38 ] found that nurses’ age, qualifications, and experience in caring for patients at EOL were significantly associated with their perceived barriers. Nurses’ distress in intensive care units was linked to various factors, one of which is the lack of experience in providing EOLC, as reported by Holms et al. [ 30 ].

Institution Policy and procedural barriers

Healthcare facilities and the surrounding environment where patients stay have a significant influence on their quick recovery, mental and physical health, as well as health progress [ 11 ]. Therefore, healthcare institutions ought to establish a healthy environment for patients’ well-being. However, in the current review, it was understood that nurses identified a group of barriers related to hospital settings, such as the insufficiency of standard procedures pertaining to EOLC in place at the institution, inappropriate staffing policies in the ICU, lack of rooms prepared for EOLC, insufficient supplies to assist families in EOLC, and a noisy environment with bright lights in patients’ rooms [ 11 ]. Likewise, researchers concluded that intensive care unit nurses face time constraints due to heavy workloads; they also reported that intensive care units have poor designs that interrupt patients’ privacy and affect the provision of quality EOLC [ 12 , 28 ]. Previous studies identified a lack of EOLC rules and guidelines governing the provision of quality EOLC in critical care units, such as limited visiting hours, guiding preferred care pathways, and excessive paperwork burdens [ 12 , 13 , 30 ].

In this section, we discuss the results of this review on the barriers to providing quality end-of-life care derived from the literature and compare them with the results of previous studies.

The themes emerging from the data helped us understand that some familial factors play a decisive role in hindering timely and effective EOLC provision to patients. Our findings are consistent with Beckstrand et al. [ 36 ] and Friedenberg et al. [ 39 ], who also found that families’ lack of understanding or insufficient understanding of the life-saving measures performed for patients often contributes to delayed EOLC provision, due to their ambiguous opinions and uncertainty about the treatment given. Additionally, before taking any action, barriers related to other factors such as cultural aspects, not covered in this paper, should not be disregarded as they may have a significant influence on the outcomes.

There was agreement among all the authors in this review that communication and collaboration issues were at the forefront of factors that affect the quality of EOLC.in critical care setings, poor communication and collaboration between nurses and physicians makes nurses perceive their roles as secondary in the decision-making process. Additionally, critical care nurses also noted that interrupted communication leads to misunderstandings and conflicts in decision-making, diverting them from the goal of EOLC. It was also agreed that communication breakdown and conflicts in decision-making among healthcare teams impact the quality of care for patients with chronic end-stage diseases [ 40 ].

Reviewing the selected studies made us aware that nurses perceived inadequate training and education about EOLC significantly impacts their practice in delivering quality EOLC. The nurses also acknowledged the importance of receiving training and education regarding EOLC, such as symptom management, dealing with grieving families, and communication skills during the orientation period before starting their work in critical care units. Therefore, critical care nurses need to enhance their knowledge about cultural aspects, ethical issues, communication skills, and training related to the continuity of care and the management of physical and psychosocial symptoms [ 36 ].

Apart from training issues, we found that the feeling of not being able to provide proper care to some patients, consistent distress due to increased workload, or managing patients with critical conditions such as prolonging unavoidable death could be attributed to their deteriorating mental health, which they perceive as a barrier to offering EOLC. These results were also supported by Calvin et al. [ 41 ], who found that novice cardiac care unit nurses expressed more fear and discomfort while caring for dying patients and communicating with their families.

This review further shows that healthcare organizations lack policies and guidelines that govern EOLC, such as staffing policies and scheduling visiting hours, leading to a shortage of nurses, increased workload, and decreased presence of family members with their patients. This lack of policies was also indicated in their study [ 36 ]. Critical care units in this review have a poor design that challenges nurses when providing EOLC and interrupts patient privacy. This is consistent with Sheward et al. [ 42 ], who found that the poor design of critical care units may compromise patients’ confidentiality and affect the provision of quality EOLC.

In summary, our findings revealed that some familial factors play a decisive role in hindering timely and effective EOLC provision to patients. Moreover, nurses perceived that inadequate training and education about EOLC significantly impact their practice in providing good EOLC. Therefore, these aspects of our results are confirmed by broader literature, as evidenced before. The ceuurent review highlights the importance of enhancing family communication throught the needs for conducting education and training programs among health care profesionals in crirical care settings about communication skills. Additionally, healthcare organizations lack policies and guidelines that lead to a shortage of nurses, increased workload, and decreased family members’ presence with their patients, governing EOLC. Thus, this integrative review addresses the question of what barriers affect the quality of end-of-life care as perceived by nurses working in critical care units. Combining diverse methodologies can lead to inadequate rigor, imprecision, bias, flawed analysis, synthesis, and deductions. Therefore, there is a need for future studies to further refine the key indicators.

Strengths and limitations

The selected studies were conducted in several countries, which may enhance the generalizability of the study findings. The limitations of this review study are that it focused mainly on descriptive and non-experimental studies. Additionally, the assessment of quality appraisal for selected studies was subjective to the authors according to MMAT, which could affect the studies’ appraisal. The selection of only English articles may introduce bias regarding barriers beyond EOLC in countries where English is not commonly spoken.

The review indicated that healthcare organizations must provide critical care nurses with evidence-based pathways and guidelines to guide them in providing EOLC, increase emotional support from nursing managers and supervisors, and improve critical care settings design. Further studies need to be conducted on the barriers that affect the quality of EOLC and suggestions to overcome these barriers at the level of patients and families, nurses, physicians, other healthcare providers, and healthcare organizations to enhance teamwork and collaboration and improve the quality of EOLC.

This review also calls for additional research to be conducted to explore the barriers that affect the quality of end-of-life care. These studies should investigate barriers at multiple levels, including those affecting patients and families, nurses, physicians, other healthcare providers, and healthcare organizations. By identifying and understanding these barriers, recommendations can be made to overcome them, ultimately enhancing teamwork, collaboration, and the overall quality of end-of-life care.

International implications for practice

Many tools can be easily used to assess barriers to end-of-life care in critical care settings. We recommend monitoring and evaluating them regularly among nurses because they are significantly linked to the quality of end-of-life care. Furthermore, we advise to assess the quality of end-of-life care from patients and their families perspectives and provide them with greif and emotional support if they are unable to contribute in providing feedback that help in assissing the quality of end-of- life care. Refreshing training and education courses about end-of-life care aspects are significantly associated with the quality of care. We advise nursing management to conduct such courses for critical care nurses periodically. In general, there is an opportunity for improvement in terms of the quality of end-of-life care in critical care settings. As the critical care unit is part of a larger institution, it is worthwhile for the hospital’s management to adjust their policies regarding staffing, ICU design, visiting hours, and provide evidence-based guidelines so they can enhance the quality of end-of-life care.

Data availability

The data used to support the findings of this study are included within the article.

Abbreviations

End-Of-Life-Care

Mixed Method Appraisal Tool

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YSR and KLA set up the search strategy, with the verification of MCC. MCC, LYT, WTM analyzed results. All authors wrote and approved the final manuscript. SM, MN provided critical review and significant revision of the manuscript for important intellectual content, proof-read, and supervised the preparation of the manuscript.

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Rubbai, Y.S., Chong, M.C., Tang, L.Y. et al. Barriers in providing quality end-of-life care as perceived by nurses working in critical care units: an integrative review. BMC Palliat Care 23 , 217 (2024). https://doi.org/10.1186/s12904-024-01543-y

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Received : 17 August 2023

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DOI : https://doi.org/10.1186/s12904-024-01543-y

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