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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

• UConn Library
• Literature Review: The What, Why and How-to Guide
• Introduction

Literature Review: The What, Why and How-to Guide — Introduction

• Getting Started
• How to Pick a Topic
• Strategies to Find Sources
• Evaluating Sources & Lit. Reviews
• Tips for Writing Literature Reviews
• Writing Literature Review: Useful Sites
• Citation Resources
• Other Academic Writings

What are Literature Reviews?

So, what is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries." Taylor, D.  The literature review: A few tips on conducting it . University of Toronto Health Sciences Writing Centre.

Goals of Literature Reviews

What are the goals of creating a Literature Review?  A literature could be written to accomplish different aims:

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

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

What kinds of sources require a Literature Review?

• A research paper assigned in a course
• A thesis or dissertation
• A grant proposal
• An article intended for publication in a journal

All these instances require you to collect what has been written about your research topic so that you can demonstrate how your own research sheds new light on the topic.

Types of Literature Reviews

What kinds of literature reviews are written?

Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.

• Example : Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework:  10.1177/08948453211037398  

Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L. K. (2013). Research in Communication Sciences and Disorders . Plural Publishing.

• Example : The effect of leave policies on increasing fertility: a systematic review:  10.1057/s41599-022-01270-w

Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M. C., & Ilardi, S. S. (2003). Handbook of Research Methods in Clinical Psychology . Blackwell Publishing.

• Example : Employment Instability and Fertility in Europe: A Meta-Analysis:  10.1215/00703370-9164737

Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts .  Journal of Advanced Nursing , 53 (3), 311-318.

• Example : Women’s perspectives on career successes and barriers: A qualitative meta-synthesis:  10.1177/05390184221113735

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
• << Previous: Getting Started
• Next: How to Pick a Topic >>
• Last Updated: Sep 21, 2022 2:16 PM
• URL: https://guides.lib.uconn.edu/literaturereview

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

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

Table of Contents

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

How to write a good literature review 

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

What is a literature review?

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

What is the purpose of literature review?

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

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

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

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

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

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

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

Literature review example

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

Literature Review on Climate Change Impacts on Biodiversity:

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

a. Habitat Loss and Species Extinction:

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

b. Range Shifts and Phenological Changes:

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

c. Ocean Acidification and Coral Reefs:

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

d. Adaptive Strategies and Conservation Efforts:

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

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

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

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

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

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

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

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

Conducting a literature review

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

Choose a Topic and Define the Research Question:

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

Decide on the Scope of Your Review:

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

Select Databases for Searches:

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

Conduct Searches and Keep Track:

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

Review the Literature:

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

Organize and Write Your Literature Review:

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

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How to write a literature review faster with Paperpal?

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

Here’s how to use the Research feature:  

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• Cite with Confidence: Paperpal makes it easy to incorporate relevant citations and references into your writing, ensuring your arguments are well-supported by credible sources. This translates to a polished, well-researched literature review. 

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

Frequently asked questions

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

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

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

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

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

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

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

References 

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

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What is a literature review? [with examples]

What is a literature review?

The purpose of a literature review, how to write a literature review, the format of a literature review, general formatting rules, the length of a literature review, literature review examples, frequently asked questions about literature reviews, related articles.

A literature review is an assessment of the sources in a chosen topic of research.

In a literature review, you’re expected to report on the existing scholarly conversation, without adding new contributions.

If you are currently writing one, you've come to the right place. In the following paragraphs, we will explain:

• the objective of a literature review
• how to write a literature review
• the basic format of a literature review

Tip: It’s not always mandatory to add a literature review in a paper. Theses and dissertations often include them, whereas research papers may not. Make sure to consult with your instructor for exact requirements.

The four main objectives of a literature review are:

• Studying the references of your research area
• Summarizing the main arguments
• Identifying current gaps, stances, and issues
• Presenting all of the above in a text

Ultimately, the main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

The format of a literature review is fairly standard. It includes an:

• introduction that briefly introduces the main topic
• body that includes the main discussion of the key arguments
• conclusion that highlights the gaps and issues of the literature

➡️ Take a look at our guide on how to write a literature review to learn more about how to structure a literature review.

First of all, a literature review should have its own labeled section. You should indicate clearly in the table of contents where the literature can be found, and you should label this section as “Literature Review.”

➡️ For more information on writing a thesis, visit our guide on how to structure a thesis .

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, it will be long. If your paper does not depend entirely on references, it will be short.

Take a look at these three theses featuring great literature reviews:

• School-Based Speech-Language Pathologist's Perceptions of Sensory Food Aversions in Children [ PDF , see page 20]
• Who's Writing What We Read: Authorship in Criminological Research [ PDF , see page 4]
• A Phenomenological Study of the Lived Experience of Online Instructors of Theological Reflection at Christian Institutions Accredited by the Association of Theological Schools [ PDF , see page 56]

Literature reviews are most commonly found in theses and dissertations. However, you find them in research papers as well.

There is no set amount of words for a literature review, so the length depends on the research. If you are working with a large amount of sources, then it will be long. If your paper does not depend entirely on references, then it will be short.

No. A literature review should have its own independent section. You should indicate clearly in the table of contents where the literature review can be found, and label this section as “Literature Review.”

The main goal of a literature review is to provide the researcher with sufficient knowledge about the topic in question so that they can eventually make an intervention.

Harvey Cushing/John Hay Whitney Medical Library

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YSN Doctoral Programs: Steps in Conducting a Literature Review

• Biomedical Databases
• Global (Public Health) Databases
• Soc. Sci., History, and Law Databases
• Grey Literature
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• Recommended Books
• Steps in Conducting a Literature Review

What is a literature review?

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

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

Why is it important?

A literature review is important because it:

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

APA7 Style resources

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1. Choose a topic. Define your research question.

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

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

2. Decide on the scope of your review

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

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

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

Make a list of the databases you will search. 

Where to find databases:

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

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

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

Review the literature

Some questions to help you analyze the research:

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

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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Literature Review: The What, Why and How-to Guide: Literature Reviews?

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What is a Literature Review?

So, what is a literature review .

"A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available or a set of summaries." - Quote from Taylor, D. (n.d)."The Literature Review: A Few Tips on Conducting it".

• Citation: "The Literature Review: A Few Tips on Conducting it"

What kinds of literature reviews are written?

Each field has a particular way to do reviews for academic research literature. In the social sciences and humanities the most common are:

• Narrative Reviews: The purpose of this type of review is to describe the current state of the research on a specific research topic and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weaknesses, and gaps are identified. The review ends with a conclusion section that summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.
• Book review essays/ Historiographical review essays : A type of literature review typical in History and related fields, e.g., Latin American studies. For example, the Latin American Research Review explains that the purpose of this type of review is to “(1) to familiarize readers with the subject, approach, arguments, and conclusions found in a group of books whose common focus is a historical period; a country or region within Latin America; or a practice, development, or issue of interest to specialists and others; (2) to locate these books within current scholarship, critical methodologies, and approaches; and (3) to probe the relation of these new books to previous work on the subject, especially canonical texts. Unlike individual book reviews, the cluster reviews found in LARR seek to address the state of the field or discipline and not solely the works at issue.” - LARR

What are the Goals of Creating a Literature Review?

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 
• Baumeister, R.F. & Leary, M.R. (1997). "Writing narrative literature reviews," Review of General Psychology , 1(3), 311-320.

When do you need to write a Literature Review?

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

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

Where I can find examples of Literature Reviews?

Note:  In the humanities, even if they don't use the term "literature review", they may have a dedicated  chapter that reviewed the "critical bibliography" or they incorporated that review in the introduction or first chapter of the dissertation, book, or article.

• UCSB electronic theses and dissertations In partnership with the Graduate Division, the UC Santa Barbara Library is making available theses and dissertations produced by UCSB students. Currently included in ADRL are theses and dissertations that were originally filed electronically, starting in 2011. In future phases of ADRL, all theses and dissertations created by UCSB students may be digitized and made available.

Where to Find Standalone Literature Reviews

Literature reviews are also written as standalone articles as a way to survey a particular research topic in-depth. This type of literature review looks at a topic from a historical perspective to see how the understanding of the topic has changed over time. 

• Find e-Journals for Standalone Literature Reviews The best way to get familiar with and to learn how to write literature reviews is by reading them. You can use our Journal Search option to find journals that specialize in publishing literature reviews from major disciplines like anthropology, sociology, etc. Usually these titles are called, "Annual Review of [discipline name] OR [Discipline name] Review. This option works best if you know the title of the publication you are looking for. Below are some examples of these journals! more... less... Journal Search can be found by hovering over the link for Research on the library website.

Social Sciences

• Annual Review of Anthropology
• Annual Review of Political Science
• Annual Review of Sociology
• Ethnic Studies Review

Hard science and health sciences:

• Annual Review of Biomedical Data Science
• Annual Review of Materials Science
• Systematic Review From journal site: "The journal Systematic Reviews encompasses all aspects of the design, conduct, and reporting of systematic reviews" in the health sciences.
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Literature Review - what is a Literature Review, why it is important and how it is done

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

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 What is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries. " - Quote from Taylor, D. (n.d) "The literature review: A few tips on conducting it"

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

What are the goals of creating a Literature Review?

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

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

When do you need to write a Literature Review?

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

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

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

What kinds of literature reviews are written?

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

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

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Conducting Health Sciences Review Articles

• Finding Review Articles
• Goals of a Literature Review
• Select Citation Management Software
• Select Databases to Search
• Track Your Searches
• Conduct Searches
• Select Articles to Include in Review
• Extract Information from Articles
• Structure the Review
• Find "fill-in" information
• Select Books
• Systematic Reviews This link opens in a new window
• Writing Tips
• Quick Links

goals of a literature review

Keeping these goals in mind throughout your project will help you stay organized and focused.

A literature review helps the author:

• Understand the scope, history, and present state of knowledge in a specific topic
• Understand application of research concepts such as statistical tests and methodological choices
• Create a research project that complements the existing research or fills in gaps

A literature review helps the reader:

• Understand how your research project fits into the existing knowledge and research in a field
• Understand that a topic is important/relevant to the world and persuade them to keep reading your project
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Conducting a Literature Review: Home

What is a literature review.

A literature review is a body of text that aims to review the critical points of current knowledge on a particular topic. Most often associated with science-oriented literature, such as a thesis, the literature review usually proceeds a research proposal, methodology and results section. Its ultimate goals is to bring the reader up to date with current literature on a topic and forms that basis for another goal, such as the justification for future research in the area. (retrieved from http://en.wikipedia.org/wiki/Literature_review )

Print Resources

Many resources on research methodology include a chapter on literature review. Try these titles:

• SAGE Research Methods "SAGE Research Methods (SRM) is a research tool supported by a newly devised taxonomy that links content and methods terms. It provides the most comprehensive picture available today of research methods (quantitative, qualitative and mixed methods)across the social and behavioural sciences."

There are many resources available on the internet and in print to help you conduct a literature review. For graduate students working on a thesis, the most important resource is your graduate committee chair. Also, if you are an ILR student, don't forget to speak with one of Catherwood's reference librarians. They have subject matter expertise and can help you find research materials, as well as show you relevant databases and resources, including Zotero , an online bibliographic management system. Cornell students can also take advantage of the  John S. Knight Institute for Writing in the Disciplines , which offers a walk-in tutoring Service.

Additional Resources for Writing Literature Reviews

• Library Research at Cornell by Michael Engle Last Updated Jul 17, 2024 9518 views this year
• The Literature Review: A Few Tips on Conducting Writing Advice from the University of Toronto Health Sciences Writing Centre.
• Write a Literature Review Research guide from the University Library, UC Santa Cruz
• Learn How to Write a Review of Literature From the Writing Center at University of Wisconsin - Madison.

Searching the Library Catalog

Conducting a guided keyword search from the  Cornell University Library Catalog , using the terms "research methodology" or "qualitative research" will provide additional results, and adding the term "social sciences" to the search will help narrow the results. You can also use this list of the classification numbers for theses by department . We also offer a finding guide to dissertations and theses that you may find useful!

We also recommend you look through other theses - often your graduate chair will have copies.

• Last Updated: Feb 4, 2021 9:22 AM
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Literature Reviews

• What is a literature review?
• Steps in the Literature Review Process
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support
• Artificial Intelligence (AI) Tools

What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

Librarian Assistance

For help, please contact the librarian for your subject area.  We have a guide to library specialists by subject .

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Literature Reviews (in the Health Sciences)

• Goals of a Literature Review
• Select Citation Management Software
• Select databases to search
• Conduct searches
• Track your searches
• Select articles to include
• Extract information from articles
• Structure your review
• Find "fill-in" information
• Other sources and help

Keeping these goals in mind throughout your project will help you stay organized and focused.

A literature review helps the author:

• Understand the scope, history, and present state of knowledge in a specific topic
• Understand application of research concepts such as statistical tests and methodological choices
• Create a research project that complements the existing research or fills in gaps

A literature review helps the reader:

• Understand how your research project fits into the existing knowledge and research in a field
• Understand that a topic is important/relevant to the world and persuade them to keep reading your project
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What is the Purpose of a Literature Review?

4-minute read

• 23rd October 2023

If you’re writing a research paper or dissertation , then you’ll most likely need to include a comprehensive literature review . In this post, we’ll review the purpose of literature reviews, why they are so significant, and the specific elements to include in one. Literature reviews can:

1. Provide a foundation for current research.

2. Define key concepts and theories.

3. Demonstrate critical evaluation.

4. Show how research and methodologies have evolved.

5. Identify gaps in existing research.

6. Support your argument.

Keep reading to enter the exciting world of literature reviews!

What is a Literature Review?

A literature review is a critical summary and evaluation of the existing research (e.g., academic journal articles and books) on a specific topic. It is typically included as a separate section or chapter of a research paper or dissertation, serving as a contextual framework for a study. Literature reviews can vary in length depending on the subject and nature of the study, with most being about equal length to other sections or chapters included in the paper. Essentially, the literature review highlights previous studies in the context of your research and summarizes your insights in a structured, organized format. Next, let’s look at the overall purpose of a literature review.

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Literature reviews are considered an integral part of research across most academic subjects and fields. The primary purpose of a literature review in your study is to:

Provide a Foundation for Current Research

Since the literature review provides a comprehensive evaluation of the existing research, it serves as a solid foundation for your current study. It’s a way to contextualize your work and show how your research fits into the broader landscape of your specific area of study.  

Define Key Concepts and Theories

The literature review highlights the central theories and concepts that have arisen from previous research on your chosen topic. It gives your readers a more thorough understanding of the background of your study and why your research is particularly significant .

Demonstrate Critical Evaluation 

A comprehensive literature review shows your ability to critically analyze and evaluate a broad range of source material. And since you’re considering and acknowledging the contribution of key scholars alongside your own, it establishes your own credibility and knowledge.

Show How Research and Methodologies Have Evolved

Another purpose of literature reviews is to provide a historical perspective and demonstrate how research and methodologies have changed over time, especially as data collection methods and technology have advanced. And studying past methodologies allows you, as the researcher, to understand what did and did not work and apply that knowledge to your own research.  

Identify Gaps in Existing Research

Besides discussing current research and methodologies, the literature review should also address areas that are lacking in the existing literature. This helps further demonstrate the relevance of your own research by explaining why your study is necessary to fill the gaps.

Support Your Argument

A good literature review should provide evidence that supports your research questions and hypothesis. For example, your study may show that your research supports existing theories or builds on them in some way. Referencing previous related studies shows your work is grounded in established research and will ultimately be a contribution to the field.  

Literature Review Editing Services 

Ensure your literature review is polished and ready for submission by having it professionally proofread and edited by our expert team. Our literature review editing services will help your research stand out and make an impact. Not convinced yet? Send in your free sample today and see for yourself! 

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Frequently asked questions

What is the purpose of a literature review.

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.

Frequently asked questions: Academic writing

A rhetorical tautology is the repetition of an idea of concept using different words.

Rhetorical tautologies occur when additional words are used to convey a meaning that has already been expressed or implied. For example, the phrase “armed gunman” is a tautology because a “gunman” is by definition “armed.”

A logical tautology is a statement that is always true because it includes all logical possibilities.

Logical tautologies often take the form of “either/or” statements (e.g., “It will rain, or it will not rain”) or employ circular reasoning (e.g., “she is untrustworthy because she can’t be trusted”).

You may have seen both “appendices” or “appendixes” as pluralizations of “ appendix .” Either spelling can be used, but “appendices” is more common (including in APA Style ). Consistency is key here: make sure you use the same spelling throughout your paper.

The purpose of a lab report is to demonstrate your understanding of the scientific method with a hands-on lab experiment. Course instructors will often provide you with an experimental design and procedure. Your task is to write up how you actually performed the experiment and evaluate the outcome.

In contrast, a research paper requires you to independently develop an original argument. It involves more in-depth research and interpretation of sources and data.

A lab report is usually shorter than a research paper.

The sections of a lab report can vary between scientific fields and course requirements, but it usually contains the following:

• Title: expresses the topic of your study
• Abstract: summarizes your research aims, methods, results, and conclusions
• Introduction: establishes the context needed to understand the topic
• Method: describes the materials and procedures used in the experiment
• Results: reports all descriptive and inferential statistical analyses
• Discussion: interprets and evaluates results and identifies limitations
• Conclusion: sums up the main findings of your experiment
• References: list of all sources cited using a specific style (e.g. APA)
• Appendices: contains lengthy materials, procedures, tables or figures

A lab report conveys the aim, methods, results, and conclusions of a scientific experiment . Lab reports are commonly assigned in science, technology, engineering, and mathematics (STEM) fields.

The abstract is the very last thing you write. You should only write it after your research is complete, so that you can accurately summarize the entirety of your thesis , dissertation or research paper .

If you’ve gone over the word limit set for your assignment, shorten your sentences and cut repetition and redundancy during the editing process. If you use a lot of long quotes , consider shortening them to just the essentials.

If you need to remove a lot of words, you may have to cut certain passages. Remember that everything in the text should be there to support your argument; look for any information that’s not essential to your point and remove it.

To make this process easier and faster, you can use a paraphrasing tool . With this tool, you can rewrite your text to make it simpler and shorter. If that’s not enough, you can copy-paste your paraphrased text into the summarizer . This tool will distill your text to its core message.

Revising, proofreading, and editing are different stages of the writing process .

• Revising is making structural and logical changes to your text—reformulating arguments and reordering information.
• Editing refers to making more local changes to things like sentence structure and phrasing to make sure your meaning is conveyed clearly and concisely.
• Proofreading involves looking at the text closely, line by line, to spot any typos and issues with consistency and correct them.

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 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.

Avoid citing sources in your abstract . There are two reasons for this:

• The abstract should focus on your original research, not on the work of others.
• The abstract should be self-contained and fully understandable without reference to other sources.

There are some circumstances where you might need to mention other sources in an abstract: for example, if your research responds directly to another study or focuses on the work of a single theorist. In general, though, don’t include citations unless absolutely necessary.

An abstract is a concise summary of an academic text (such as a journal article or dissertation ). It serves two main purposes:

• To help potential readers determine the relevance of your paper for their own research.
• To communicate your key findings to those who don’t have time to read the whole paper.

Abstracts are often indexed along with keywords on academic databases, so they make your work more easily findable. Since the abstract is the first thing any reader sees, it’s important that it clearly and accurately summarizes the contents of your paper.

In a scientific paper, the methodology always comes after the introduction and before the results , discussion and conclusion . The same basic structure also applies to a thesis, dissertation , or research proposal .

Depending on the length and type of document, you might also include a literature review or theoretical framework before the methodology.

Whether you’re publishing a blog, submitting a research paper , or even just writing an important email, there are a few techniques you can use to make sure it’s error-free:

• Take a break : Set your work aside for at least a few hours so that you can look at it with fresh eyes.
• Proofread a printout : Staring at a screen for too long can cause fatigue – sit down with a pen and paper to check the final version.
• Use digital shortcuts : Take note of any recurring mistakes (for example, misspelling a particular word, switching between US and UK English , or inconsistently capitalizing a term), and use Find and Replace to fix it throughout the document.

If you want to be confident that an important text is error-free, it might be worth choosing a professional proofreading service instead.

Editing and proofreading are different steps in the process of revising a text.

Editing comes first, and can involve major changes to content, structure and language. The first stages of editing are often done by authors themselves, while a professional editor makes the final improvements to grammar and style (for example, by improving sentence structure and word choice ).

Proofreading is the final stage of checking a text before it is published or shared. It focuses on correcting minor errors and inconsistencies (for example, in punctuation and capitalization ). Proofreaders often also check for formatting issues, especially in print publishing.

The cost of proofreading depends on the type and length of text, the turnaround time, and the level of services required. Most proofreading companies charge per word or page, while freelancers sometimes charge an hourly rate.

For proofreading alone, which involves only basic corrections of typos and formatting mistakes, you might pay as little as $0.01 per word, but in many cases, your text will also require some level of editing , which costs slightly more.

It’s often possible to purchase combined proofreading and editing services and calculate the price in advance based on your requirements.

There are many different routes to becoming a professional proofreader or editor. The necessary qualifications depend on the field – to be an academic or scientific proofreader, for example, you will need at least a university degree in a relevant subject.

For most proofreading jobs, experience and demonstrated skills are more important than specific qualifications. Often your skills will be tested as part of the application process.

To learn practical proofreading skills, you can choose to take a course with a professional organization such as the Society for Editors and Proofreaders . Alternatively, you can apply to companies that offer specialized on-the-job training programmes, such as the Scribbr Academy .

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A Comprehensive Review of the Non-operative Management of Traumatic Rib Fractures

• Anesthesia for Trauma (TE Grissom, Section Editor)
• Open access
• Published: 22 August 2024

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• Kaveh Hemati 1 ,
• Andrew T. Gray 1 &
• Ashish Agrawal 1  

Purpose of Review

This review summarizes current literature on the non-operative management of traumatic rib fractures, including risk assessment scores, respiratory therapy, and multimodal and regional analgesia.

Recent Findings

Rib fractures are associated with significant morbidity and mortality, especially in elderly patients. Risk assessment scores, such as the Pain Inspiration Cough (PIC) score, allow for early identification and dynamic assessment of those at risk for ICU admission or increased length of stay. Incentive spirometry is both prognostic and therapeutic for patients with rib fractures, while high flow nasal cannula and non-invasive ventilation strategies lack robust evidence. Multimodal analgesia regimens have been associated with significant reductions in opioid exposure and pain scores. Epidural and regional anesthesia remain common analgesic modalities to decrease unplanned intubation and ICU admission especially in elderly patients.

Optimizing pulmonary hygiene and analgesia regimens remain the primary evidence-based goals of management for patients with rib fractures.

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Introduction

In the United States alone, rib fractures affect over 40,000 people per year, resulting in a cost of over $469 million per year [ 1 ]. Although rib fractures can be atraumatic, most rib fractures are caused by either penetrating or blunt chest trauma. In fact, the most common presenting injury related to blunt chest trauma is rib fractures, occurring in nearly two-thirds of these patients [ 2 , 3 , 4 ]. The clinical importance of rib fractures stems from their association with significant morbidity (48% complication rate) and mortality (22% for older adults) [ 4 , 5 ]. Complications of rib fractures include increased rates of pneumonia, ventilator days, and intensive care unit (ICU) and hospital length of stay (HLOS) [ 6 ]. Patients with an increased number of fractures, older age, and polytrauma have increased morbidity and mortality [ 7 ].

Given the impact rib fractures have on our healthcare system, both in terms of patient morbidity and mortality and the overall burden of hospital care costs, recent studies have aimed to risk stratify patients, identify complications early, and develop management strategies to mitigate the negative effects. In this review, we will examine the associated complications of traumatic rib fractures and summarize evidence and options for risk assessment and triage, respiratory management, and pain management of patients with traumatic rib fractures.

Complications of Rib Fractures

The morbidity and mortality associated with rib fractures can be linked to the direct and indirect effects of the injury on the pulmonary system.

Directly, the significant blunt force required to fracture ribs and the associated energy transfer can result in damage to the underlying tissues, including the pleura and the lung parenchyma. This can lead to sequela such as pneumothorax, hemothorax, or pulmonary contusion [ 8 , 9 ]. Direct damage to the alveolar capillary membrane complex can lead to bleeding and edema, which can impair gas exchange due to intra-pulmonary shunting and reduced compliance. These sequelae can lead to adverse effects on oxygenation and ventilation, which can require higher levels of respiratory support including mechanical ventilation.

Indirectly, rib fractures can cause significant pain that can limit respiratory function and mobility. Pain in the thoracic area may limit chest wall excursion and lead to reduced tidal volumes and an ineffective cough, which contributes to inadequate secretion clearance and atelectasis. In addition, rib fracture pain can reduce the ability of patients to mobilize, further compounding atelectasis [ 10 ]. The limited tidal volumes, atelectasis, and inadequate secretion clearance all contribute to developing pneumonia [ 9 ].

Most significantly, complications of rib fractures are higher in patients over 65 years old. While pneumonia and mortality rates increase in all age groups with a greater number of rib fractures, it increases even more in elderly patients [ 11 ]. Pneumonia rates are 31% in older patients versus 17% in younger patients [ 11 ]. Rib fractures are also associated with long-term pain and disability with only approximately 59% of patients returning to work at 6 months after injury [ 12 , 13 ]. Mortality, irrespective of age, has been estimated to be between 10–12%; for patients hospitalized, this rate increases with each additional rib fractured, approaching > 40% if > 6 ribs are fractured [ 8 , 9 , 11 ]. Deaths usually occur because of multi-organ failure provoked by respiratory insufficiency and pneumonia [ 8 , 14 ].

Because of these resulting issues, the primary goals of managing patients with rib fractures are to identify those most at risk of decompensation and to direct efforts at optimizing oxygenation and ventilation, pulmonary hygiene, early mobility, and effective analgesia regimens [ 2 ].

Risk Assessment and Scoring Systems

Although early triage and standardized care pathways have been shown to reduce complications such as length of stay, pneumonia, and mortality, there currently is no single standardized scoring system or care pathway that has widespread use [ 15 , 16 ]. The scoring systems that have been developed are used to assist in the evaluation of patients, guide treatment decisions, and aid in risk stratifying and prognosticating outcomes in patients with rib fractures.

The three most common scoring systems are the Rib Fracture Score (RFS), Chest Trauma Score (CTS), and RibScore (RS). All three scoring systems have been shown to have moderate discrimination for predicting complications and outcomes [ 16 ]. However, these scores provide a one-time static score and do not vary based on changes in the patient’s clinical status. There are dynamic clinical scoring systems, such as the Pain Inspiration Cough (PIC) score, that may be utilized in serial patient assessments to assist with level of care triage and predicting morbidity over time [ 15 , 17 ]. The newer Sequential Clinical Assessment of Respiratory Function (SCARF) score is another dynamic scoring system that is currently utilized by one academic center. Although we do not describe it here, we recognize its potential value as a dynamic scoring system [ 15 ].

Here we describe the common scoring systems that exist (Table  1 ). Although each institution may use different scoring systems, we do recommend the use of a scoring system and/or evidence-based care pathway to guide the management of patients with rib fractures as this has been shown to be associated with reduced mortality [ 4 ].

Rib Fracture Score (RFS)

The RFS was retrospectively developed by analyzing a large population of trauma patients previously studied in the literature [ 18 , 19 ]. It is calculated as the number of total fractures of the ribs (2 breaks in a single rib counts for 2) multiplied by the number sides affected (1 or 2) plus an age factor (51–60 = 1, 61–70 = 2, 71–80 = 3, > 80 = 4), and it was developed to assess the need for respiratory support, mobilization, and pain management [ 16 , 18 ]. Initially, an RFS score > 6 was suggested as a cutoff to have specific care implemented; however, several validation studies have shown a weak correlation between RFS and hospital length of stay (HLOS) and ICU length of stay (ICULOS) [ 16 , 18 , 20 ]. A retrospective cohort study also showed RFS had poor predictive value for mortality, pneumonia, and rate of tracheostomy for all patients with rib fractures [ 16 ]. However, when analyzed by age group, RFS > 8 in patients 65 years and older had higher mortality, higher injury severity scores (ISS), longer HLOS, longer ICULOS, and higher rates of pneumonia [ 16 ]. Although conflicting data exist for RFS, it may be a valuable tool for geriatric patients.

Chest Trauma Score (CTS)

The CTS was developed to identify patients at risk for morbidity and mortality at admission [ 21 ]. It is calculated by the summation of points from several categories: age, number of ribs fractured, number of sides affected, and pulmonary contusion severity defined by a radiologist [ 16 , 21 , 22 ]. The initial study found different cut points to be associated with distinct morbidities: CTS > 7 associated with higher mortality, ICU admission, intubation; CTS > 5 associated with longer HLOS and longer duration of mechanical ventilation. When analyzed by age group, CTS > 6 in patients 65 and older had higher mortality, higher ISS, longer HLOS, longer ICULOS, longer duration of mechanical ventilation, higher rates of tracheostomies, and higher rates of pneumonia [ 16 ]. Although cut points for CTS and associated morbidities have varied, several validation studies confirm that higher CTS scores predict patients at risk for complications from rib fractures, and thus CTS is a valuable tool to guide early implementation of treatment strategies [ 16 , 22 ].

RibScore (RS)

The RS is a radiographic rib fracture score based on chest computed tomography (CT) [ 23 ]. It allocates points for each of six radiographic variables: six or more rib fractures, bilateral fractures, flail chest, three or more severely displaced fractures, fracture of the first rib, and at least one fracture in all segmental locations [ 23 ]. The initial study confirmed associations between each individual RS variable and total RS with pneumonia, respiratory failure, and tracheostomy [ 23 ]. RS of 4 or higher had greater than 90% specificity for pneumonia, respiratory failure, and tracheostomy [ 16 , 23 ]. When an age factor was added, there was interestingly no increased predictability of RS on morbidities. A recent retrospective cohort study found that both geriatric and non-geriatric patients with RS > 1 had higher mortality, higher ISS, longer HLOS, longer ICULOS, longer duration of mechanical ventilation, higher rates of tracheostomies, and higher rates of pneumonia [ 16 ]. Although data exist for the usage of RS in rib fracture patients, it is recommended that RS be used for the selective assessment of severely injured patients with high ISS values given that its specificity increases with higher scores.

Pain Inspiration Cough (PIC) Score

The PIC score was developed by clinicians as an easy-to-implement, dynamic scoring system that could prognosticate and guide management in patients with rib fractures over time [ 17 , 24 ]. The PIC score is calculated from the summation of three individual category scores (pain, inspiration, cough) to obtain a composite score that can range from 3 to 10 [ 17 ]. During its first implementation, a PIC score of 7 or less was associated with a 57% reduction in unanticipated transfer to a higher level of care for respiratory status decline; HLOS was reduced by 0.7 days and discharge to home improved by 13% [ 17 ]. The PIC score has subsequently been adopted by many institutions and continues to be utilized as a dynamic tool that can not only to inform where to admit patients, but also to determine when to downgrade a patient [ 12 , 24 ]. A recent retrospective cohort study found that a PIC score 7 or lower was highly associated with ICU admission and a prolonged HLOS [ 24 ]. Interestingly, the PIC score cutoff of 7 was a moderate independent predictor of ICULOS > 48 h and was not associated with any particular injury pattern or preinjury comorbidity burden [ 24 ]. The developers of the PIC score have recently liberalized their triage criteria for ICU admission (PIC score 5 or lower), but continue to use PIC score of higher than 7 to guide discharge from the ICU [ 25 ]. Although utilized by many institutions currently as a useful dynamic scoring system, there are discrepancies with PIC score cutoffs to determine ICU admission or downgrades to floor and thus further research is necessary to determine optimal cutoffs. However, we do see great value in the use of the PIC score as its ongoing use requires vigilance from care team members including nursing and respiratory therapy, which will only pay dividends in the early detection and mitigation of respiratory failure emergencies.

Monitoring and Respiratory Management

Given that morbidity and mortality associated with rib fractures stem from issues within the pulmonary system, it is prudent to focus on preventing pulmonary complications and addressing them as they arise. To that end, respiratory parameter monitoring and management is key to successfully caring for patients with rib fractures.

Level of Care / Monitoring

All patients with rib fractures admitted to the hospital should have continuous pulse oximetry available regardless of level of care. ICU admission is recommended for older adults (> 65 years) with three or more rib fractures as this lowers morbidity and mortality [ 4 , 26 , 27 , 28 ]. Scoring systems described earlier can be utilized to risk stratify patients who do not meet these criteria, and institution-specific monitoring guidelines should be established based on a patient’s level of care.

Incentive Spirometry (IS)

Bedside assessments using incentive spirometry (IS) are standard of care as IS can be both therapeutic and prognostic. Therapeutically, IS assists with lung expansion and reduces atelectasis. A recent randomized controlled trial demonstrated that the utilization of IS reduced pulmonary complications, including atelectasis, hemothorax, and interventions such as thoracostomy, in patients with traumatic rib fractures [ 29 ].

Prognostically, IS volume is a predictor of complications. A prospective case-series suggested that low IS volume (< 500 ml) at admission was associated with higher rates of acute respiratory failure [ 30 ]. A retrospective study found that the relative risk of pulmonary complications was 3.3 in patients with incentive spirometry volume < 1000 ml after rib fractures [ 31 ]. Given its minimal adverse effects, low cost, and good therapeutic tolerance, we recommend the use of IS for all patients with rib fractures.

Non-invasive Oxygenation / High Flow Nasal Canula (HFNC)

High flow nasal canula (HFNC) has had increased usage in adults for the treatment and prevention of hypoxemic respiratory failure, but there is limited data surrounding HFNC specifically in patients with rib fractures. A retrospective study of blunt chest trauma patients admitted to the ICU showed an intubation rate of 18% in patients receiving HFNC and that a delay to first initiation of HFNC was correlated with increased HLOS and ICULOS [ 32 ]. One randomized controlled trial compared the use of HFNC and venturi mask in patients with rib fractures and high-risk features and found no statistically significant difference in those requiring mechanical invasive/non-invasive ventilation or unplanned admission to the ICU [ 33 ]. An observational study compared patients with three or more rib fractures receiving HFNC at any location to a historical control group when HFNC was available only in the ICU and found no significant differences in HLOS, mechanical ventilation, or mortality between the study and control group, but 27% of patients in the study group avoided ICU admission entirely [ 34 ]. Although a paucity of quality evidence exists regarding HFNC and rib fractures, we do recommend its use for hypoxemia as there is low risk and potential benefit.

Non-invasive Ventilation / Continuous Positive Airway Pressure (CPAP)

Non-invasive ventilation, such as continuous positive airway pressure (CPAP), has been more commonly studied than HFNC in the blunt chest trauma population [ 35 , 36 , 37 ]. Historic studies showed that CPAP combined with regional analgesia have decreased rates of pneumonia and that CPAP combined with patient-controlled analgesia have lower mortality rates and decreased nosocomial infection rates compared with mechanical ventilation in patients with blunt chest trauma [ 35 , 36 ]. In a recent randomized study, hypoxemic blunt chest trauma patients assigned to receive CPAP had 40% lower intubation rates and reduced overall HLOS by 7 days compared to patients receiving HFNC [ 36 ]. Given these studies, expert practice guidelines currently recommended the use of non-invasive ventilation for older adults (> 65 years) who have three or more rib fractures [ 4 , 38 ].

Pain Management

Systemic opioid analgesics were historically the mainstay of pain management in patients with rib fractures; however, given the significant adverse effects of opioids (respiratory depression, nausea, tolerance and dependence), the core of pain management has shifted to multimodal therapy [ 9 , 13 ]. Multimodal analgesia regimens rely on synergistic combinations of opioid and non-opioid medications and regional anesthesia in an attempt to decrease doses and reduce adverse drug reactions for any individual medication [ 39 ]. A few retrospective cohort studies of trauma patients demonstrated that the implementation of a multimodal pain regimen was associated with significant reductions in opioid exposure, opioid prescriptions at discharge, and a modest reduction in patient-reported Numerical Rating Scale (NRS) pain scores [ 40 , 41 ]. While some of the evidence shown below for each individual modality may be mixed, we continue to advocate for the use of multimodal regimens for rib fracture patients tailored to the risks and benefits of the local patient population.

Systemic Non-Opioid Analgesics

Acetaminophen.

Acetaminophen has become a mainstay of multimodal analgesia protocols, but there have been few studies to specifically look at its utility in rib fracture patients. In a randomized double-blinded clinical trial in patients with rib fractures, pain severity was compared between those who received intravenous acetaminophen and those who received intravenous morphine, and there were no significant differences in efficacy for relieving rib fracture pain or side effects [ 42 ]. A prospective randomized controlled trial of elderly patients with rib fractures compared oral acetaminophen to intravenous acetaminophen and found no difference in pain reduction scores, mortality, HLOS, or the development of pneumonia [ 43 ].

Non-steroidal Anti-inflammatory Drugs (NSAIDs)

The efficacy of NSAIDs for rib fractures has been infrequently studied. A matched retrospective cohort study suggested oral morphine equivalent (OME) totals were less at 7 days in the intravenous ibuprofen group compared to routine care in rib fracture patients [ 44 ]. Although no new strong evidence exists regarding NSAID efficacy in rib fracture patients, many providers historically have had reservations regarding the usage of NSAIDs for posttraumatic analgesia due to concerns about risks of worsening acute kidney injury (AKI). A recent retrospective cohort study of trauma-induced rib fracture patients found that a short course of NSAID use did not worsen AKI compared to controls and the authors concluded that NSAIDs may be underutilized in severely injured trauma patients. [ 45 ]

Lidocaine: Transdermal and Intravenous

The use of transdermal lidocaine has been mixed, with one study demonstrating no difference in intravenous opioid use or pain scores when comparing 5% lidocaine patch with placebo, while a second study showed significantly lower average pain scores after day 5 and significantly lower total meperidine use in patients who received 5% lidocaine patches compared to placebo [ 46 , 47 ]. Intravenous lidocaine has also been evaluated as an analgesic in rib fracture patients with more success. A single-center, double blinded randomized controlled trial compared intravenous lidocaine plus usual analgesics to placebo plus usual analgesics and found a significant reduction in pain with movement in the lidocaine group [ 47 ]. A retrospective study assessed the ability of intravenous lidocaine to reduce overall opioid use and pain scores in patients with rib fractures; they found a 30% reduction in pain scores amongst intravenous lidocaine patients, although they noted that intravenous lidocaine was less effective in patients with a history of substance abuse [ 48 ].

It has become widely accepted that subanesthetic doses of ketamine produce analgesia and can also increase the effectiveness of opioids [ 49 ]. A recent double-blinded, randomized placebo-controlled trial examined the efficacy of low dose ketamine as a primary mode of analgesia in patients with rib fractures [ 50 ]. The study found that low dose ketamine failed to affect the 24-h numeric pain scores or OME totals; however, a decrease in OME was demonstrated in patients with an ISS greater than 15.

Regional Anesthesia

Many studies have evaluated the efficacy of regional anesthesia modalities on pain reduction and morbidity outcomes, but much of the data has been conflicting. One meta-analysis and a separate systematic review of 32 randomized controlled trials demonstrated that epidural analgesia provided better pain relief than other locoregional modalities; however, there were no differences observed for secondary endpoints such as ICULOS or pulmonary complications [ 7 , 13 ]. The Eastern Association for the Surgery of Trauma and the Chest Wall Injury Society performed a systematic review and meta-analysis on analgesia strategies for older adults with multiple rib fractures and found that epidural and other regional analgesia techniques did not have any effect on pneumonia, HLOS, length of mechanical ventilation, or mortality [ 11 ]. Based on their work, they currently offer no recommendation for or against the use of epidurals or other regional anesthesia techniques in older patients with rib fractures, though multiple other professional societies continue to recommend epidural placement for older adults (> 65 years) with three or more rib fractures when there are no contraindications [ 4 , 26 , 51 ]. Interestingly, a recent large retrospective study examined the effects of timing of regional anesthesia techniques and found that early regional anesthesia (within 24 h) had a decreased incidence of unplanned intubation, ICU admission, and an increased odds of discharge to home when compared to the late regional anesthesia group (after 24 h) in elderly patients with rib fractures. [ 52 ]

Given the inconsistency in data and differing recommendations among trauma societies, we recommend the use of a regional technique in patients with rib fractures, but the choice of that preferred regional technique should be based on local expertise. We typically utilize several different regional anesthesia techniques depending on our patients’ comorbidities, contraindication profiles, and individual provider preference. Examples of regional techniques that are utilized aside from epidurals include erector spinae plane block (ESPB), paravertebral block (PVB), serratus anterior plane block (SAPB), and intercostal nerve block (ICNB) (Fig.  1 ).

An anatomical schematic and an associated series of static ultrasound images that delineate various regional anesthesia blocks that can be used for analgesia for rib fracture patients. ESPB = erector spinae plane block; PVB = paravertebral block; SAPB = serratus anterior plane block; ICNB = intercostal nerve block; T = trapezius; R = rhomboid; ES = erector spinae; LD = latissimus dorsi; SA = serratus anterior; EI = external intercostal; II = internal intercostal; IMI = innermost intercostal; TP = transverse process; PVS = paravertebral space

Neuraxial/Epidural Anesthesia

The mainstay of regional anesthesia for rib fractures has been thoracic epidural anesthesia, and it is generally our first choice at our institution [ 12 ]. However, many trauma patients have contraindications to epidural placement such as anticoagulation or coagulopathy, unstable spine with or without spinal cord injury, and/or hemodynamic instability. [ 12 , 13 , 53 ] In these cases, a newer regional technique can be chosen which can provide benefit with a lower-risk profile.

Erector Spinae Plane Block (ESPB)

The ESPB is an ultrasound-guided myofascial plane block that targets the plane between the erector spinae muscle group and a transverse process. Used as a single-shot or catheter-based technique, this procedure may allow for local anesthetic to diffuse to both dorsal and ventral rami, which can supply the ribcage. ESBP is becoming more popular given its low risk of complications (spinal cord injury, epidural hematoma, hemodynamic instability) and anticoagulation is not a contraindication according to the joint European Society of Anesthesiology and Intensive Care (ESAIC) and European Society of Regional Anesthesia (ESRA) guidelines [ 54 ]. Although some studies have demonstrated ESPB to have positive outcomes as an effective technique for analgesia in rib fractures, until there is more conclusive evidence, its use should be determined based on the risk profile of a given patient and provider comfort [ 55 , 56 , 57 ].

Paravertebral Block (PVB)

Classically a blind, surface anatomy-based technique, the PVB has more recently been adapted utilizing ultrasound-guidance to facilitate accessing the area alongside a vertebral body near where the spinal nerves emerge from the intervertebral foramen. In the thoracic region, a single-shot or catheter-based technique can allow for local anesthetic to remain localized to the level injected, or it may spread to contiguous levels, the intercostal space, and/or the epidural space, which can produce chest wall analgesia. PVB is a favorable technique for rib fractures given its fewer adverse effects, complications, and contraindications. Although retrospective studies have shown reductions in ICU admission and mortality and improved analgesia, they are an appropriate alternative regional option that can be used in certain circumstances [ 58 ].

Serratus Anterior Plane Block (SAPB)

The SAPB is an ultrasound-guided block that targets the lateral cutaneous branches of the thoracic intercostal nerves. These nerves can be blocked in either the deep or superficial potential spaces that bound the serratus anterior via single shot or catheter-based techniques. SAPB has few complications and contraindications, but there is an increased risk of pneumothorax. One notable advantage of SAPB is that it can be performed with less patient cooperation as it can be performed in the supine position with minimal repositioning. There are few quality studies assessing analgesic efficacy and outcomes in rib fracture patients receiving SAPB; however, SAPB is a reasonable technique to consider in patients who have positioning limitations [ 59 ].

Intercostal Nerve Block (ICNB)

The ICNB can be performed via a landmark-based or ultrasound-guided technique to target the anterior/ventral rami of the T1-T11 spinal nerves. Although catheters can be placed, the single-shot technique is more practical for this regional technique, especially for multiple rib fractures. ICNB is lower risks and fewer contraindications than epidurals; however, there is a higher risk of pneumothorax and vascular damage. Very limited evidence exists regarding ICNB in terms of analgesic efficacy and outcomes in rib fracture patients, though it appears to be a relatively safe technique that can offer single or multiple rib analgesia in specific patients [ 60 ].

Conclusions

Rib fractures are associated with significant morbidity and mortality and are a burden to our healthcare system. Scoring systems should be used to guide the management of patients with rib fractures as they have been shown to decrease morbidity and mortality. Enhancing pulmonary hygiene and analgesia regimens remain the therapeutic target of rib fracture management. IS should be utilized in all patients for its prognostic and therapeutic purposes, and noninvasive ventilation may decrease the rates of pneumonia. Although no specific analgesic modality has been shown to be superior to others, multimodal analgesia regimens combining systemic medications and regional anesthesia techniques should be utilized to enhance pain control.

Data availability

No datasets were generated or analysed during the current study.

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Hemati, K., Gray, A.T. & Agrawal, A. A Comprehensive Review of the Non-operative Management of Traumatic Rib Fractures. Curr Anesthesiol Rep (2024). https://doi.org/10.1007/s40140-024-00645-w

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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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• Published: 23 August 2024

Prevalence of nonalcoholic fatty liver disease in Pakistan: a systematic review and meta-analysis

• Fazal Hassan 1 ,
• Maria Farman 3 ,
• Kauser Aftab Khan 2 ,
• Muhammad Awais 3 &
• Sohail Akhtar 1  

Scientific Reports volume  14 , Article number:  19573 ( 2024 ) Cite this article

Metrics details

• Liver diseases

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver condition globally and the leading cause of liver-related death and morbidity. The goal of this study was to collect current data in order to calculate the pooled prevalence of NAFLD in Pakistan. We conducted a comprehensive literature search on four electronic databases until March 2024 to find studies on the prevalence of NAFLD in Pakistan. Pooled prevalence estimates of NAFLD were obtained using random-effects meta-analytic models. The chi-square test was used to account for study heterogeneity, whereas the I 2 statistic was used to assess inconsistency. The data were stratified by the general population (average risk) and individuals with metabolic diseases (high risk). Two reviewers thoroughly and independently screened, reviewed, and assessed all studies. In total, 468 studies were reviewed, and 34 were included. The pooled NAFLD prevalence in the general population was 29.82% (95% CI 21.39–39.01%; prediction interval: 2.98–68.92%) based on 13 studies. In individuals with metabolic disorders, the prevalence of NAFLD in patients with diabetes, hypertension, and obesity, was 58.47% (95% CI 54.23–62.64%; prediction interval: 38.16–77.40%), 74.08% (95% CI 60.50–85.70%), and 47.43% (95% CI 30.49–64.66%), respectively. There was no evidence of publication bias, although a statistically significant level of heterogeneity was seen among the studies ( I 2 ranged from 57.5 to 98.69%). The findings of this study indicate a substantial prevalence of NAFLD in the population of Pakistan. The Pakistani government must formulate a comprehensive approach and plan aimed at augmenting awareness, control, prevention, and treatment of fatty liver disease.

Prospero Registration no: CRD42022356607.

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Introduction.

Nonalcoholic fatty liver disease (NAFLD) is a commonly occurring chronic liver disease with a global prevalence 1 . This syndrome primarily affects individuals with diabetes and obesity 2 . NAFLD encompasses a continuum of pathological manifestations, beginning with hepatic lipid accumulation and progressing to nonalcoholic steatohepatitis, characterized by varying degrees of necrotic inflammation, cirrhosis, and fibrosis 3 . NAFLD is associated with an increased vulnerability to hepatocellular carcinoma, cardiovascular disorders, and problems related to type 2 diabetes, such as neuropathy and nephropathy 4 , 5 , 6 . The global prevalence of NAFLD affects around 15–20% of women and 30–40% of men worldwide 7 . The prevalence is even higher among individuals with type-2 diabetes, with up to 70% of them being affected 8 . The increasing cases of NAFLD coincide with the rise of obesity in Asia 9 , where it is estimated to affect 29.6% of the population, potentially surpassing Western countries. This is likely due to age, urbanization, growing economies, a sedentary lifestyle, insulin resistance (type-2 diabetes), and poor health awareness 10 . Because of more significant visceral fat deposition, Asians are more prone to obesity-related problems. Despite having a BMI of less than 25 kg/m2, Asians exhibit a notable prevalence of type-2 diabetes and cardiovascular risk factors 11 , 12 .

In Pakistan, the prevalence of NAFLD has been increasing over recent years. This is mostly because of changed lifestyles, urbanization, and changes in diet that lead to a more calorie-dense diet and a less active lifestyle. The high prevalence of type-2 diabetes 13 , 14 , 15 , 16 , obesity 17 , and metabolic syndrome 18 in the population contributes to the increasing burden of NAFLD. Several regional studies have been published on the prevalence of NAFLD in Pakistan, but there is no nationwide data or survey on the prevalence of NAFLD in Pakistan. Therefore, the main purpose of this study is to systematically collect, summarize, synthesize, and quantify the pool prevalence of NAFLD in Pakistan.

The preferred reporting items for systematic reviews and meta-analyses guidelines were followed in this work 19 . The study protocol was registered in the PROSPERO database with the registration number CRD42022356607.

Search strategy

From inception to March 30, 2024, two investigators (F.H. and S.A.) independently performed an electronic literature search in MEDLINE (via PubMed), Web of Science, Embase (via Ovid), Scopus and local databases by using a combination of MeSh terms related to NAFLD in Pakistan. We searched (“NAFLD”, “nonalcoholic fatty liver disease”, “non-alcoholic fatty liver disease” OR “fatty liver” OR “fatty liver*” OR “nonalcoholic steatohepatitis*” OR “steatohepatitis*” OR “liver steatosis*”) AND (“Pakistan” OR “Pakistani”) AND (“prevalence” OR “incidence” OR “epidemiology” OR “frequency”). Furthermore, we carefully examined the reference lists of all relevant original and review papers to find potential new data sources.

Inclusion and exclusion

For inclusion, studies had to meet the following criteria: (1) the studies should be cross-sectional or longitudinal in nature and reflect the prevalence of NAFLD, or the prevalence can be calculated using the data provided. (2) Only studies that reported the prevalence of NAFLD in Pakistan were included. We excluded articles if (1) they were focused mainly on individuals younger than 18 years; (2) research was conducted on a Pakistani population but outside of Pakistan; (3) they were case reports, letters to editors, perspectives, communications, reviews, or reports of studies; (4) there were duplicate studies found within and across the databases; and (5) studies lacked sufficient data.

Data extraction

Two authors (F.H. and S.A.) independently extracted the data from individual studies, with disagreements being resolved by discussion and mutual consensus between the two investigators. A standardized data extraction form using Microsoft Excel was used to collect information on the first author’s surname, geographical location, publication year, survey period, study design, setting (urban vs rural), data collection timing, median or mean age of the participants, and proportion of females, as well as the number of participants with NAFLD.

Data analysis

To account the expected between-study heterogeneity, the prevalence of NAFLD was combined across studies, systematically using models with random effects. We generated pooled proportions using DerSimonian and Laird random effects models and stabilized the variances of the raw proportions before combining the data 20 . The findings of the meta-analyses are displayed in forest plots, which illustrate the prevalence proportions together with their corresponding 95% confidence intervals for each individual study as well as the overall random-effects pooled estimate. Statistical software R (ver. 4.3.3) with two packages (‘ meta ’ and ‘ metafor ’) was used to conduct the analysis. In pooled studies, we utilized the I 2 index to measure between-study heterogeneity 21 . We investigated publication bias visually with funnel plots and statistically with Begg-Mazumdar 22 and Egger linear regression 23 tests. To evaluate the probable sources of heterogeneity, subgroup analysis, and univariable meta-regression were performed. We did not create a multivariable meta-regression model due to the limited number of observations. The R 2 statistic was employed to quantitatively assess the extent to which factors in meta-regression models accounted for the overall between-study heterogeneity. To investigate the influence of individual studies on the overall effect size, sensitivity analyses were conducted by systematically removing each study in a sequential manner 24 . Using the Cohen kappa coefficient, we evaluated inter-rater agreement for article inclusion and methodological quality 25 .

Our database searches yielded 468 potentially relevant articles. 196 study titles and abstracts were evaluated after removing duplicates Fig. 1 . We evaluated 63 full-text papers for eligibility criteria, 29 were removed from the meta-analysis. Screening titles and abstracts (Kappa = 0.81) and entire texts (Kappa = 0.83) had strong inter-rater reliability.

PRISMA flow chart of the prevalence of NAFLD in Pakistan.

Study characteristics

The study characteristics and quality rating of all 34 selected studies 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 are presented in (Table 1 ). In total, 12995 participants were included. The selected articles were published between 2008 and 2024, with the majority (89%) being published within the last decade. The study encompassed a range of sample sizes, from 51 to 2007 participants. The median sample size was 202 participants, with an interquartile range of 132–202 participants. The age range of participants was documented in a total of 33 studies, with the reported average ages spanning from 23 to 58 years. A total of 17 studies 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 55 , 56 , 57 (50%) were conducted in Punjab province, 8 studies 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 (24%) in Sindh, and 7 26 , 27 , 28 , 29 , 30 , 31 , 58 (21%) in Khyber Pakhtunkhwa while one 59 study was conducted in Baluchistan. In addition, one 32 study was conducted nationwide. 13 26 , 33 , 35 , 36 , 41 , 42 , 43 , 44 , 46 , 49 , 55 , 58 , 59 of the total number of studies reviewed were determined to have a low risk of bias, while 21 27 , 28 , 29 , 30 , 31 , 32 , 34 , 37 , 38 , 39 , 40 , 45 , 47 , 48 , 50 , 51 , 52 , 53 , 54 , 56 , 57 were determined to have a moderate risk. There was no high risk of bias in any of the studies.

NAFLD prevalence in the general population

The NAFLD prevalence in the general population was assessed in 13 studies, encompassing a total of 8461 participants (Table 2 ). The NAFLD prevalence ranged from 13.73% (95% CI 8.70–20.21%) to 60.84% (95% CI 58.00–63.64%). The pooled NAFLD prevalence in the general population was 29.82% (95% CI 21.39–39.01%; prediction interval: 2.98–68.92%) with significant heterogeneity ( I 2  = 98.9%, p < 0.001) Fig. 2 . The Egger linear regression test (t = 0.65, p-value = 0.65), Begg-Mazumdar test (z = 1.29, p-value = 0.1970), and the visual evaluation of the funnel plot Fig. 3 collectively indicate the absence of publication bias in the conducted meta-analysis. The findings of the sensitivity analysis demonstrated that the pooled NAFLD prevalence ranged from 27.33% (95% CI 19.87–35.50%) to 31.40% (95% CI 22.63–40.89%) when each study was systematically excluded (Supplementary file S1 ). The results revealed no significant impact on the pooled outcome when any individual study was excluded systematically. This suggests that our meta-analysis is statistically robust and stable.

Forest plot of the prevalence of NAFLD in general population in Pakistan.

Funnel plot of the prevalence of NAFLD in general population in Pakistan.

When the data were stratified into different publication years, the pooled NAFLD prevalence estimates were found to be 23.83 (95% CI 14.49–36.65%) for the period between 2008 and 2014, and 35.30% (95% CI 22.61–49.14%) for the period between 2015 and 2024. When the data was stratified by gender, the pooled prevalence estimates were found to be (26.68%; 95% CI 15.63–39.41%) in the female group and 27.82% (95% CI 14.13–43.98%) in the male group. Regarding the geographical distribution, the pooled prevalence estimates were found to be 25.38% (95% CI 18.07–33.46%) in the Khyber Pakhtunkhwa province, 30.26% (95% CI 11.87–52.74%) in Sindh, and 34.03 (95% CI 21.33–48.02%) in the Punjab.

The meta-regression analysis indicated that there was no significant association in the prevalence estimations based on the year of publication (slope = 0.0052; 95% CI −0.0165–0.0270; p-value = 0.6392), baseline survey year (slope = 0.0053; 95% CI −0.0328–0.0222; p-value = 0.7065), average age (slope = 0.0056, 95% CI −0.0072–0.0185; p-value = 0.3900), and methodological quality (slope = −0.0006, 95% CI −0.0250–00.0238; p-value = 0.9640).

NAFLD prevalence in individuals with metabolic disorders

The prevalence of NAFLD in individuals with diabetes was assessed in 23 studies, encompassing a total of 4534 patients. The NAFLD prevalence in patients with diabetes ranged from 40.84% (95% CI 34.83–47.06%) to 78.74% (95% CI 70.60–85.50%). The pooled NAFLD prevalence in the individuals with diabetes was 58.47% (95% CI 54.23–62.64%; prediction interval: 38.17–77.40%) with significant heterogeneity (I 2  = 88.0%, p < 0.01) Fig. 4 . Egger linear regression test (t = 0.98, p-value = 0.34), Begg-Mazumdar (0.50, p-value = 0.58) and the visual evaluation of the funnel plot collectively Fig. 5 indicate the absence of publication bias in the conducted meta-analysis. The findings of the sensitivity analysis demonstrated that the pooled NAFLD prevalence ranged from 57.54% (95% CI 52.84–62.16%) to 59.32% (95% CI 55.24–63.34%) when each study was systematically excluded. The sensitivity analysis findings indicate that the inclusion or exclusion of any individual study did not have a significant impact on the overall effect seen in our meta-analysis (see Supplementary file S2 ). This suggests that our meta-analysis is statistically robust and stable. Furthermore, the NAFLD prevalence in obese people was 74.08% (95% CI 60.50–85.70%; prediction interval: 12.73–100.00%) while the NAFLD prevalence in hypertensive patients was (47.43; 95% CI 30.49–64.66; prediction interval: 1.20–97.20%).

Forest plot the prevalence of the NAFLD in patients with diabetes in Pakistan.

Funnel plot of the prevalence of NAFLD in diabetes patients.

According to subgroup meta-analysis, the prevalence of NAFLD among patients with diabetes was found to be 56.54% (95% CI 48.08–64.82%) between 2008 and 2018, and 59.74% (95% CI 55.23–64.17%) between 2019 and 2024. When looking at gender differences, the prevalence was 63.17% (95% CI 49.98–75.45%) among females and 53.90% (95% CI 47.39–60.36%) among males. Geographically, the prevalence varied with 54.80% (95% CI 50.10–60.83%) in Khyber Pakhtunkhwa, 55.30% (95% CI 46.73–63.72%) in Baluchistan, 59.97% (95% CI 53.51–66.27%) in Punjab, and 60.20% (95% CI:53.51–66.27%) in Sindh.

The meta-regression analysis indicated that there was no significant association in the prevalence estimations based on the year of publication (slope = 0.0035; 95% CI −0.0089–0.0159; p-value = 0.5810), baseline survey year (slope = 0.0008; 95% CI 0.0036–0.0053; p-value = 0.7169), average age (slope = 0.0026, 95% CI 0.0060–0.0113; p-value = 0.5494), and methodological quality (slope = 0.0676, 95% CI −0.0375–0.1728; p-value = 0.2075).

NAFLD is an increasingly important cause of morbidity, disability, and mortality worldwide. Addressing the root cause of NAFLD is imperative to alleviate the burden of diseases associated with excessive caloric intake and metabolic dysfunction from a societal perspective 7 , 8 . The rise in obesity and its associated comorbidities, such as NAFLD, in Pakistan can be attributed to significant shifts in the lifestyle patterns of the Pakistani population. The primary objective of this research was to collect information about the prevalence of NAFLD and the risk factors that are associated with NAFLD in Pakistan. This meta-analysis is expected to contribute to the mitigation of NAFLD and its associated problems by providing valuable information that can support public health initiatives. The pooled NAFLD prevalence in general (low risk) population was 29.82%, which is comparable with the similar meta-analysis conducted on South Asia 60 (26.9%) and global level 61 (30.01%). The prevalence of NAFLD in patients with metabolic disease (high-risk population) is significantly higher than the general population. The NAFLD pooled prevalence in patients with diabetes was found to be 61.22%. The results are in line with the recent meta-analysis 60 (59.69%) and the neighboring country India 62 (57%). The pooled prevalence of NAFLD in patients with diabetes higher than the recent meta-analysis on South Asian (54.1%) 60 .

The data stratification revealed interesting patterns. The prevalence of NAFLD appeared to increase over time, with estimates of 23.83% for the period between 2008 and 2014, and 35.30% for the period between 2015 and 2024. This increasing trend might reflect changes in lifestyle factors, diagnostic criteria, or increased awareness of NAFLD over the years. Furthermore, there were also notable disparities in gender and geographic factors. The prevalence estimates obtained from pooling the data were slightly higher in males (27.82%) than in females (26.68%). Geographically, there were noticeable differences in prevalence rates among different provinces. The highest prevalence was seen in Punjab (34.03%), followed by Sindh (30.27%) and Khyber Pakhtunkhwa (25.38%).

The subgroup analyses revealed that the prevalence of NAFLD in patients with metabolic disease was highest in obese population 74.08% (95% CI 60.50–85.70%), followed by patients with diabetes 58.47% (95% CI 54.23–62.64%) and hypertension patients 47.43% (95% CI 30.49–64.66%). The patients with diabetes are twice as likely to get fatty liver as compared to the general Pakistani population. This is because elevated glucose levels in individuals with diabetes or prediabetes contribute to an increased availability of substrates for triglyceride synthesis 58 . Furthermore, the diminished secretion of very low-density lipoprotein, a condition often associated with insulin resistance, exacerbates the buildup of fat in the liver 63 .

There are several limitations to our meta-analyses that should be considered when interpreting the findings. Firstly, the meta-analytical component of this investigation was constrained by substantial heterogeneity observed among the studies, which could not be investigated or elucidated through subgroup analysis or meta-regression. However, this is a recognized characteristic of meta-analyses concerning prevalence rates 64 . Secondly, most of the studies did not have a nationally representative sample, as they were based in a single center. As such, larger studies across multiple centers are needed to investigate true prevalence. The low number of included studies set in the low and high-risk populations is also a limitation of this study as we were unable to use multivariable meta-regression models to check the significance of risk factors combined. In addition, it is important to note that our analysis solely relied on published reports, so excluding the potential insights that could have been derived from the unpublished grey literature. This omission may have implications for the overall findings and conclusions of our study. Nevertheless, despite these limitations, this is the first meta-analysis to provide pooled prevalence of NAFLD in Pakistan. Prior to commencing the study, we published a protocol delineating our technique and methodology, and we utilized scientific and statistical methodologies to gather and aggregate data. We conducted subgroup studies and random effect meta-regression analyses to assess several factors that could influence our estimate.

The prevalence of NAFLD in Pakistan from 2008 to 2024 is thoroughly described in this study. This study suggests that while the pooled NAFLD prevalence in the general population was 29.02%, the prevalence among patients with diabetes is almost double, at 58.70%. With the rising prevalence of NAFLD in Pakistan, the government should implement diabetes management initiatives nationwide. The Pakistani government should develop a comprehensive plan and strategy to enhance knowledge about fatty liver, as well as to improve its control, prevention, and treatment, thereby reducing the prevalence of the disease in the country.

Data availability

All data are included in this manuscript and presented in Table 1 .

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Conceptualization: S.A. and F.H., Investigation: S.A., F.H. and K.A.K., Methodology: M.A. and S.A, Writing—original draft: F.H., M.F., K.A.K., M.A., Writing and editing: S.A. All authors reviewed the manuscript.

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Hassan, F., Farman, M., Khan, K.A. et al. Prevalence of nonalcoholic fatty liver disease in Pakistan: a systematic review and meta-analysis. Sci Rep 14 , 19573 (2024). https://doi.org/10.1038/s41598-024-70481-9

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Received : 26 May 2024

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DOI : https://doi.org/10.1038/s41598-024-70481-9

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Visions, paradigms, and anomalies of urban transport.

1. Introduction

2. automobility city, 2.1. the vision, 2.2. the paradigm.

• Extensive road networks from the city center to the rural areas, often with multiple lanes and multi-level road intersections that are well connected, allowing for easy access to various parts of the area.
• Large parking lots, including multi-level parking structures and dedicated parking zones, are strategically located near commercial areas, industrial zones, and public spaces.
• Wide streets and boulevards are prevalent, mainly auto-oriented and often neglecting the needs of pedestrians, cyclists, and public transport users. The intersections are carefully designed with traffic signals, turning lanes, and other features to optimize traffic flow.
• The emphasis on automobiles may result in limited public transport infrastructure. While some bus routes or other modes of transit may exist, they might not be as extensive or well-developed as in other urban models.
• Commercial and business districts are often aligned along major road arteries, making them easily accessible by car. Shopping centers, malls, and office complexes may be strategically positioned for convenient automotive access.

2.3. Anomalies

3. multimodality city, 3.1. the vision, 3.2. the paradigm.

• The transport modes physically and operationally with mobility hubs;
• The information systems of service providers with real-time information to passengers on various modes regarding connectivity options, routes, schedules, and payment solutions, such as smart cards, to allow for seamless access and payment across different modes.

3.3. The Anomalies

4. accessible city, 4.1. the vision.

• improve mobility impacts with active transport;
• end car dependence in urban transport;
• create more livable public spaces;
• foster responsible lifestyles and economies;
• ensure the health and well-being of everyone;
• encourage community cohesion;
• avoid an obesogenic environment [ 57 ].

4.2. The Paradigm

• Plan Velo Act 2 aims to make Paris entirely bikeable by 2026, with an investment of 250 million euros. It includes adding 130 km of bike-safe pathways, teaching children to ride bikes in schools, and encouraging cycling tourism.
• Street Code is a new ‘code de la rue’ introduced to help cyclists, cars, and pedestrians share the roads. It includes rules such as respecting pedestrian priority, not encroaching on bus lanes or bike paths, and obeying traffic lights and signs.
• Low-traffic zones ban through traffic in four central districts to give priority to cyclists, pedestrians, and public transport, creating a less-polluted and safer city.

4.3. Anomalies

5. conclusions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Filippi, F. Visions, Paradigms, and Anomalies of Urban Transport. Future Transp. 2024 , 4 , 938-967. https://doi.org/10.3390/futuretransp4030045

Filippi F. Visions, Paradigms, and Anomalies of Urban Transport. Future Transportation . 2024; 4(3):938-967. https://doi.org/10.3390/futuretransp4030045

Filippi, Francesco. 2024. "Visions, Paradigms, and Anomalies of Urban Transport" Future Transportation 4, no. 3: 938-967. https://doi.org/10.3390/futuretransp4030045

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