literature of review and synthesis

The Sheridan Libraries

• Write a Literature Review
• Sheridan Libraries
• Evaluate This link opens in a new window

Get Organized

• Lit Review Prep Use this template to help you evaluate your sources, create article summaries for an annotated bibliography, and a synthesis matrix for your lit review outline.

Synthesize your Information

Synthesize: combine separate elements to form a whole.

Synthesis Matrix

A synthesis matrix helps you record the main points of each source and document how sources relate to each other.

After summarizing and evaluating your sources, arrange them in a matrix or use a citation manager to help you see how they relate to each other and apply to each of your themes or variables.  

By arranging your sources by theme or variable, you can see how your sources relate to each other, and can start thinking about how you weave them together to create a narrative.

• Step-by-Step Approach
• Example Matrix from NSCU
• Matrix Template
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• Next: Integrate >>
• Last Updated: Jul 30, 2024 1:42 PM
• URL: https://guides.library.jhu.edu/lit-review

• University of Oregon Libraries
• Research Guides

How to Write a Literature Review

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

Synthesis Visualization

Synthesis matrix example.

• 7. Write a Literature Review

• Synthesis Worksheet

About Synthesis

Approaches to Synthesis

You can sort the literature in various ways, for example:

How to Begin?

Read your sources carefully and find the main idea(s) of each source

Look for similarities in your sources – which sources are talking about the same main ideas? (for example, sources that discuss the historical background on your topic)

Use the worksheet (above) or synthesis matrix (below) to get organized

This work can be messy. Don't worry if you have to go through a few iterations of the worksheet or matrix as you work on your lit review!

Four Examples of Student Writing

In the four examples below, only ONE shows a good example of synthesis: the fourth column, or  Student D . For a web accessible version, click the link below the image.

Long description of "Four Examples of Student Writing" for web accessibility

• Download a copy of the "Four Examples of Student Writing" chart

Click on the example to view the pdf.

From Jennifer Lim

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• Next: 7. Write a Literature Review >>
• Last Updated: Aug 12, 2024 11:48 AM
• URL: https://researchguides.uoregon.edu/litreview

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Literature Syntheis 101

How To Synthesise The Existing Research (With Examples)

By: Derek Jansen (MBA) | Expert Reviewer: Eunice Rautenbach (DTech) | August 2023

One of the most common mistakes that students make when writing a literature review is that they err on the side of describing the existing literature rather than providing a critical synthesis of it. In this post, we’ll unpack what exactly synthesis means and show you how to craft a strong literature synthesis using practical examples.

This post is based on our popular online course, Literature Review Bootcamp . In the course, we walk you through the full process of developing a literature review, step by step. If it’s your first time writing a literature review, you definitely want to use this link to get 50% off the course (limited-time offer).

Overview: Literature Synthesis

• What exactly does “synthesis” mean?
• Aspect 1: Agreement
• Aspect 2: Disagreement
• Aspect 3: Key theories
• Aspect 4: Contexts
• Aspect 5: Methodologies
• Bringing it all together

What does “synthesis” actually mean?

As a starting point, let’s quickly define what exactly we mean when we use the term “synthesis” within the context of a literature review.

Simply put, literature synthesis means going beyond just describing what everyone has said and found. Instead, synthesis is about bringing together all the information from various sources to present a cohesive assessment of the current state of knowledge in relation to your study’s research aims and questions .

Put another way, a good synthesis tells the reader exactly where the current research is “at” in terms of the topic you’re interested in – specifically, what’s known , what’s not , and where there’s a need for more research .

So, how do you go about doing this?

Well, there’s no “one right way” when it comes to literature synthesis, but we’ve found that it’s particularly useful to ask yourself five key questions when you’re working on your literature review. Having done so,  you can then address them more articulately within your actual write up. So, let’s take a look at each of these questions.

1. Points Of Agreement

The first question that you need to ask yourself is: “Overall, what things seem to be agreed upon by the vast majority of the literature?”

For example, if your research aim is to identify which factors contribute toward job satisfaction, you’ll need to identify which factors are broadly agreed upon and “settled” within the literature. Naturally, there may at times be some lone contrarian that has a radical viewpoint , but, provided that the vast majority of researchers are in agreement, you can put these random outliers to the side. That is, of course, unless your research aims to explore a contrarian viewpoint and there’s a clear justification for doing so. 

Identifying what’s broadly agreed upon is an essential starting point for synthesising the literature, because you generally don’t want (or need) to reinvent the wheel or run down a road investigating something that is already well established . So, addressing this question first lays a foundation of “settled” knowledge.

Need a helping hand?

2. Points Of Disagreement

Related to the previous point, but on the other end of the spectrum, is the equally important question: “Where do the disagreements lie?” .

In other words, which things are not well agreed upon by current researchers? It’s important to clarify here that by disagreement, we don’t mean that researchers are (necessarily) fighting over it – just that there are relatively mixed findings within the empirical research , with no firm consensus amongst researchers.

This is a really important question to address as these “disagreements” will often set the stage for the research gap(s). In other words, they provide clues regarding potential opportunities for further research, which your study can then (hopefully) contribute toward filling. If you’re not familiar with the concept of a research gap, be sure to check out our explainer video covering exactly that .

3. Key Theories

The next question you need to ask yourself is: “Which key theories seem to be coming up repeatedly?” .

Within most research spaces, you’ll find that you keep running into a handful of key theories that are referred to over and over again. Apart from identifying these theories, you’ll also need to think about how they’re connected to each other. Specifically, you need to ask yourself:

• Are they all covering the same ground or do they have different focal points  or underlying assumptions ?
• Do some of them feed into each other and if so, is there an opportunity to integrate them into a more cohesive theory?
• Do some of them pull in different directions ? If so, why might this be?
• Do all of the theories define the key concepts and variables in the same way, or is there some disconnect? If so, what’s the impact of this ?

Simply put, you’ll need to pay careful attention to the key theories in your research area, as they will need to feature within your theoretical framework , which will form a critical component within your final literature review. This will set the foundation for your entire study, so it’s essential that you be critical in this area of your literature synthesis.

If this sounds a bit fluffy, don’t worry. We deep dive into the theoretical framework (as well as the conceptual framework) and look at practical examples in Literature Review Bootcamp . If you’d like to learn more, take advantage of our limited-time offer to get 60% off the standard price.

4. Contexts

The next question that you need to address in your literature synthesis is an important one, and that is: “Which contexts have (and have not) been covered by the existing research?” .

For example, sticking with our earlier hypothetical topic (factors that impact job satisfaction), you may find that most of the research has focused on white-collar , management-level staff within a primarily Western context, but little has been done on blue-collar workers in an Eastern context. Given the significant socio-cultural differences between these two groups, this is an important observation, as it could present a contextual research gap .

In practical terms, this means that you’ll need to carefully assess the context of each piece of literature that you’re engaging with, especially the empirical research (i.e., studies that have collected and analysed real-world data). Ideally, you should keep notes regarding the context of each study in some sort of catalogue or sheet, so that you can easily make sense of this before you start the writing phase. If you’d like, our free literature catalogue worksheet is a great tool for this task.

5. Methodological Approaches

Last but certainly not least, you need to ask yourself the question: “What types of research methodologies have (and haven’t) been used?”

For example, you might find that most studies have approached the topic using qualitative methods such as interviews and thematic analysis. Alternatively, you might find that most studies have used quantitative methods such as online surveys and statistical analysis.

But why does this matter?

Well, it can run in one of two potential directions . If you find that the vast majority of studies use a specific methodological approach, this could provide you with a firm foundation on which to base your own study’s methodology . In other words, you can use the methodologies of similar studies to inform (and justify) your own study’s research design .

On the other hand, you might argue that the lack of diverse methodological approaches presents a research gap , and therefore your study could contribute toward filling that gap by taking a different approach. For example, taking a qualitative approach to a research area that is typically approached quantitatively. Of course, if you’re going to go against the methodological grain, you’ll need to provide a strong justification for why your proposed approach makes sense. Nevertheless, it is something worth at least considering.

Regardless of which route you opt for, you need to pay careful attention to the methodologies used in the relevant studies and provide at least some discussion about this in your write-up. Again, it’s useful to keep track of this on some sort of spreadsheet or catalogue as you digest each article, so consider grabbing a copy of our free literature catalogue if you don’t have anything in place.

Bringing It All Together

Alright, so we’ve looked at five important questions that you need to ask (and answer) to help you develop a strong synthesis within your literature review.  To recap, these are:

• Which things are broadly agreed upon within the current research?
• Which things are the subject of disagreement (or at least, present mixed findings)?
• Which theories seem to be central to your research topic and how do they relate or compare to each other?
• Which contexts have (and haven’t) been covered?
• Which methodological approaches are most common?

Importantly, you’re not just asking yourself these questions for the sake of asking them – they’re not just a reflection exercise. You need to weave your answers to them into your actual literature review when you write it up. How exactly you do this will vary from project to project depending on the structure you opt for, but you’ll still need to address them within your literature review, whichever route you go.

The best approach is to spend some time actually writing out your answers to these questions, as opposed to just thinking about them in your head. Putting your thoughts onto paper really helps you flesh out your thinking . As you do this, don’t just write down the answers – instead, think about what they mean in terms of the research gap you’ll present , as well as the methodological approach you’ll take . Your literature synthesis needs to lay the groundwork for these two things, so it’s essential that you link all of it together in your mind, and of course, on paper.

Psst… there’s more!

This post is an extract from our bestselling short course, Literature Review Bootcamp . If you want to work smart, you don't want to miss this .

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Purdue Online Writing Lab Purdue OWL® College of Liberal Arts

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.

Literature Review Basics

• What is a Literature Review?
• Synthesizing Research
• Using Research & Synthesis Tables
• Additional Resources

Synthesis: What is it?

First, let's be perfectly clear about what synthesizing your research isn't :

• - It isn't  just summarizing the material you read
• - It isn't  generating a collection of annotations or comments (like an annotated bibliography)
• - It isn't  compiling a report on every single thing ever written in relation to your topic

When you  synthesize  your research, your job is to help your reader understand the current state of the conversation on your topic, relative to your research question.  That may include doing the following:

• - Selecting and using representative work on the topic
• - Identifying and discussing trends in published data or results
• - Identifying and explaining the impact of common features (study populations, interventions, etc.) that appear frequently in the literature
• - Explaining controversies, disputes, or central issues in the literature that are relevant to your research question
• - Identifying gaps in the literature, where more research is needed
• - Establishing the discussion to which your own research contributes and demonstrating the value of your contribution

Essentially, you're telling your reader where they are (and where you are) in the scholarly conversation about your project.

Synthesis: How do I do it?

Synthesis, step by step.

This is what you need to do  before  you write your review.

• Identify and clearly describe your research question (you may find the Formulating PICOT Questions table at  the Additional Resources tab helpful).
• Collect sources relevant to your research question.
• Organize and describe the sources you've found -- your job is to identify what  types  of sources you've collected (reviews, clinical trials, etc.), identify their  purpose  (what are they measuring, testing, or trying to discover?), determine the  level of evidence  they represent (see the Levels of Evidence table at the Additional Resources tab ), and briefly explain their  major findings . Use a Research Table to document this step.
• Study the information you've put in your Research Table and examine your collected sources, looking for  similarities  and  differences . Pay particular attention to  populations ,   methods  (especially relative to levels of evidence), and  findings .
• Analyze what you learn in (4) using a tool like a Synthesis Table. Your goal is to identify relevant themes, trends, gaps, and issues in the research.  Your literature review will collect the results of this analysis and explain them in relation to your research question.

Analysis tips

• - Sometimes, what you  don't  find in the literature is as important as what you do find -- look for questions that the existing research hasn't answered yet.
• - If any of the sources you've collected refer to or respond to each other, keep an eye on how they're related -- it may provide a clue as to whether or not study results have been successfully replicated.
• - Sorting your collected sources by level of evidence can provide valuable insight into how a particular topic has been covered, and it may help you to identify gaps worth addressing in your own work.
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• Next: Using Research & Synthesis Tables >>
• Last Updated: Sep 26, 2023 12:06 PM
• URL: https://usi.libguides.com/literature-review-basics

Literature Reviews

• Introduction
• Tutorials and resources
• Step 1: Literature search
• Step 2: Analysis, synthesis, critique
• Step 3: Writing the review

If you need any assistance, please contact the library staff at the Georgia Tech Library Help website . 

Analysis, synthesis, critique

Literature reviews build a story. You are telling the story about what you are researching. Therefore, a literature review is a handy way to show that you know what you are talking about. To do this, here are a few important skills you will need.

Skill #1: Analysis

Analysis means that you have carefully read a wide range of the literature on your topic and have understood the main themes, and identified how the literature relates to your own topic. Carefully read and analyze the articles you find in your search, and take notes. Notice the main point of the article, the methodologies used, what conclusions are reached, and what the main themes are. Most bibliographic management tools have capability to keep notes on each article you find, tag them with keywords, and organize into groups.

Skill #2: Synthesis

After you’ve read the literature, you will start to see some themes and categories emerge, some research trends to emerge, to see where scholars agree or disagree, and how works in your chosen field or discipline are related. One way to keep track of this is by using a Synthesis Matrix .

Skill #3: Critique

As you are writing your literature review, you will want to apply a critical eye to the literature you have evaluated and synthesized. Consider the strong arguments you will make contrasted with the potential gaps in previous research. The words that you choose to report your critiques of the literature will be non-neutral. For instance, using a word like “attempted” suggests that a researcher tried something but was not successful. For example: 

There were some attempts by Smith (2012) and Jones (2013) to integrate a new methodology in this process.

On the other hand, using a word like “proved” or a phrase like “produced results” evokes a more positive argument. For example:

The new methodologies employed by Blake (2014) produced results that provided further evidence of X.

In your critique, you can point out where you believe there is room for more coverage in a topic, or further exploration in in a sub-topic.

Need more help?

If you are looking for more detailed guidance about writing your dissertation, please contact the folks in the Georgia Tech Communication Center .

• << Previous: Step 1: Literature search
• Next: Step 3: Writing the review >>
• Last Updated: Apr 2, 2024 11:21 AM
• URL: https://libguides.library.gatech.edu/litreview

Literature Reviews

• 5. Synthesize your findings
• Getting started
• Types of reviews
• 1. Define your research question
• 2. Plan your search
• 3. Search the literature
• 4. Organize your results

How to synthesize

Approaches to synthesis.

• 6. Write the review
• Artificial intelligence (AI) tools
• Thompson Writing Studio This link opens in a new window
• Need to write a systematic review? This link opens in a new window

Contact a Librarian

Ask a Librarian

In the synthesis step of a literature review, researchers analyze and integrate information from selected sources to identify patterns and themes. This involves critically evaluating findings, recognizing commonalities, and constructing a cohesive narrative that contributes to the understanding of the research topic.

Here are some examples of how to approach synthesizing the literature:

💡 By themes or concepts

🕘 Historically or chronologically

📊 By methodology

These organizational approaches can also be used when writing your review. It can be beneficial to begin organizing your references by these approaches in your citation manager by using folders, groups, or collections.

Create a synthesis matrix

A synthesis matrix allows you to visually organize your literature.

Topic: ______________________________________________

Topic: Chemical exposure to workers in nail salons

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• Next: 6. Write the review >>
• Last Updated: Sep 5, 2024 10:39 AM
• URL: https://guides.library.duke.edu/litreviews

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How to write a literature review

Are you writing a literature review as part of a final year project, dissertation, or thesis, or as a standalone piece of work? This page will work through a process of organising and synthesising your sources and then writing a clear and critical final review.

What is a literature review?

A literature review is an account of the current thinking in a specific area of study. Its purpose is to introduce the reader to what has gone before and often to provide you with a foundation that you can build on with your own research. This traditional form of review is sometimes also referred to as a narrative review.

A literature review will often form a section or chapter of a larger piece of research work, such as a dissertation, thesis, or final year project.  It can also be a standalone piece of work.  

A literature review will usually do some or all of the following:

• Introduce the reader to a specific area of interest.
• Organise relevant sources thematically, starting with the more general, broader themes and narrowing towards the most specific themes.
• Introduce key theories relevant to the area of study.
• Define your understanding of important terms or language used in the research.
• Include only the most relevant, important or influential sources, carefully selected. It is about quality not quantity!
• Identify gaps or limitations in existing research.

Considering a body of scholarship as a whole (or in relation to each of your themes) will allow you to 'synthesise' multiple sources and produce an overall summary.

Developing a literature review will help you to develop a level of expertise in your chosen area. By consulting and including a unique combination of sources, you will be able to formulate an informed and original perspective.  Where relevant, this can drive forward your ongoing research.

Writing a Literature Review workshop: book here

A systematic review is a research methodology, often following a standardised and replicable search method and reporting structure that is specific to your discipline. Visit our guidance on systematic reviews for more information.

Organising your sources

As you encounter more and more relevant sources, you will face an ever-expanding amount of reading for yourself. It would take years to read through all of the literature in a specific field from start to finish.

Academic reading, and particularly the process of 'reading around' a topic, is about selective, or targeted reading. Visit our Reading and understanding information Hub to explore approaches to reading for different purposes.

Creating a Literature Matrix can help you to identify the key things that you want to take away from each source. A literature matrix is a simple spreadsheet where you select column titles to suit the aims of your literature review. Are you interested in the research methodology, the scale of the research, the main conclusions, or something else entirely?

Once you have scanned through a source and pulled out the points you are interested in, you can move onto the next source. Organising your reading in this way will also allow you to identify key themes that are emerging in your reading, which you will be able to use later on to plan your review.

You may want to use a reference management tool to help organise and produce your bibliography. Visit the University of Sheffield Library Reference Management pages here .

Make a copy of our Literature matrix template (Google Sheet) and add/delete columns based on the information you want to collect during your search.  Using a spreadsheet means that you can filter and sort your sources, for example, into chronological order, or alphabetically by author.

This downloadable example literature matrix shows how you can lay out your columns.

Synthesising your sources

Once you have a number of sources to work with, you will start to identify key themes emerging. At this point you can start to organise your sources systematically to develop and explore those themes. Can you organise your themes from the broadest to the narrowest and most specific?

A synthesis matrix will help you to identify a thematic structure for your literature review and to understand how the sources that you have found relate to one another. A synthesis matrix is a further spreadsheet that organises your sources by theme and includes a synthesis column, where you can begin to draw out comparisons between the sources. 

Once you have identified a number of sources for each theme in your matrix, you should be able to identify the following:

• Do the sources build on or develop one another? This may be a chronological process.
• Do the sources challenge or contradict one another? Do they reveal a debate within the field?
• Do the sources identify an area of particular interest or a gap in the field?
• Do the sources help to fill in gaps or complete a bigger picture?

Your synthesis column provides an opportunity for you to comment on multiple sources considered as a whole. It is a space for your critical voice and interpretation, which is a key part of writing a successful literature review.

Make a copy of our synthesis matrix (Google Sheet) to organise your themes and plan how the relevant sources can be synthesised.

Download a completed example synthesis matrix from NC State University (PDF, 34Kb)

Visit our Producing a literature review interactive tutorial - for further guidance.

Writing your review

Once you have done the background reading and organised your sources using a synthesis matrix, the job of writing your review is simply about adding flesh to the bones. You will need to write your review as a narrative account, but you can use your matrix as a framework to help you do so.

A literature review will usually follow a simple structure:

• Introduction: what is the overall topic area and how have you broken your review down into themes?
• Theme 1: the broadest, most top-level area (perhaps including some background theory that may have influenced your thinking).
• Theme 2, theme 3, theme 4, etc. Your themes should get progressively more specific and closer to the focus of your research.
• Conclusion: how has this informed your thinking and (if the review is part of a bigger project) what are your research aims and objectives? 

Your review may be broken down by section headings or be a continuous flow with themes clearly separated in a paragraph structure. Each section or paragraph will describe that theme and finish by summarising your overview of a theme (the synthesis part of the matrix above, which includes your critical analysis). 

Our web page How to structure a paragrap h has further guidance to ensure your paragraphs are clear and contain your synthesis and critical analysis.

For advice and feedback on your own review, including referencing, synthesis and academic arguments, please book a writing advisory service appointment.

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

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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

• Quick Run-through
• Step 1 & 2

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

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

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

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

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

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

Download Word doc Download Google doc

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

For each publication, ask yourself:

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

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

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

Take notes and cite your sources

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

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

As you write, you can follow these tips:

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

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

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

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

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

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

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

 Statistics

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

Research bias

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

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

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

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

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

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

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

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

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

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

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

Importance of a Good Literature Review

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

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

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

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

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

Types of Literature Reviews

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

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

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

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

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

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

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

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

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

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

Structure and Writing Style

I.  Thinking About Your Literature Review

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

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

The critical evaluation of each work should consider :

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

II.  Development of the Literature Review

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

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

III.  Ways to Organize Your Literature Review

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

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

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

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

IV.  Writing Your Literature Review

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

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

V.  Common Mistakes to Avoid

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

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

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

Writing Tip

Break Out of Your Disciplinary Box!

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

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

Another Writing Tip

Don't Just Review for Content!

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

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

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

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

Yet Another Writing Tip

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

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

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

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

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Chapter 7: Synthesizing Sources

Learning objectives.

At the conclusion of this chapter, you will be able to:

• synthesize key sources connecting them with the research question and topic area.

7.1 Overview of synthesizing

7.1.1 putting the pieces together.

Combining separate elements into a whole is the dictionary definition of synthesis.  It is a way to make connections among and between numerous and varied source materials.  A literature review is not an annotated bibliography, organized by title, author, or date of publication.  Rather, it is grouped by topic to create a whole view of the literature relevant to your research question.

Your synthesis must demonstrate a critical analysis of the papers you collected as well as your ability to integrate the results of your analysis into your own literature review.  Each paper collected should be critically evaluated and weighed for “adequacy, appropriateness, and thoroughness” ( Garrard, 2017 ) before inclusion in your own review.  Papers that do not meet this criteria likely should not be included in your literature review.

Begin the synthesis process by creating a grid, table, or an outline where you will summarize, using common themes you have identified and the sources you have found. The summary grid or outline will help you compare and contrast the themes so you can see the relationships among them as well as areas where you may need to do more searching. Whichever method you choose, this type of organization will help you to both understand the information you find and structure the writing of your review.  Remember, although “the means of summarizing can vary, the key at this point is to make sure you understand what you’ve found and how it relates to your topic and research question” ( Bennard et al., 2014 ).

As you read through the material you gather, look for common themes as they may provide the structure for your literature review.  And, remember, research is an iterative process: it is not unusual to go back and search information sources for more material.

At one extreme, if you are claiming, ‘There are no prior publications on this topic,’ it is more likely that you have not found them yet and may need to broaden your search.  At another extreme, writing a complete literature review can be difficult with a well-trod topic.  Do not cite it all; instead cite what is most relevant.  If that still leaves too much to include, be sure to reference influential sources…as well as high-quality work that clearly connects to the points you make. ( Klingner, Scanlon, & Pressley, 2005 ).

7.2 Creating a summary table

Literature reviews can be organized sequentially or by topic, theme, method, results, theory, or argument.  It’s important to develop categories that are meaningful and relevant to your research question.  Take detailed notes on each article and use a consistent format for capturing all the information each article provides.  These notes and the summary table can be done manually, using note cards.  However, given the amount of information you will be recording, an electronic file created in a word processing or spreadsheet is more manageable. Examples of fields you may want to capture in your notes include:

• Authors’ names
• Article title
• Publication year
• Main purpose of the article
• Methodology or research design
• Participants
• Measurement
• Conclusions

  Other fields that will be useful when you begin to synthesize the sum total of your research:

• Specific details of the article or research that are especially relevant to your study
• Key terms and definitions
• Strengths or weaknesses in research design
• Relationships to other studies
• Possible gaps in the research or literature (for example, many research articles conclude with the statement “more research is needed in this area”)
• Finally, note how closely each article relates to your topic.  You may want to rank these as high, medium, or low relevance.  For papers that you decide not to include, you may want to note your reasoning for exclusion, such as ‘small sample size’, ‘local case study,’ or ‘lacks evidence to support assertion.’

This short video demonstrates how a nursing researcher might create a summary table.

7.2.1 Creating a Summary Table

  Summary tables can be organized by author or by theme, for example:

For a summary table template, see http://blogs.monm.edu/writingatmc/files/2013/04/Synthesis-Matrix-Template.pdf

7.3 Creating a summary outline

An alternate way to organize your articles for synthesis it to create an outline. After you have collected the articles you intend to use (and have put aside the ones you won’t be using), it’s time to identify the conclusions that can be drawn from the articles as a group.

  Based on your review of the collected articles, group them by categories.  You may wish to further organize them by topic and then chronologically or alphabetically by author.  For each topic or subtopic you identified during your critical analysis of the paper, determine what those papers have in common.  Likewise, determine which ones in the group differ.  If there are contradictory findings, you may be able to identify methodological or theoretical differences that could account for the contradiction (for example, differences in population demographics).  Determine what general conclusions you can report about the topic or subtopic as the entire group of studies relate to it.  For example, you may have several studies that agree on outcome, such as ‘hands on learning is best for science in elementary school’ or that ‘continuing education is the best method for updating nursing certification.’ In that case, you may want to organize by methodology used in the studies rather than by outcome.

Organize your outline in a logical order and prepare to write the first draft of your literature review.  That order might be from broad to more specific, or it may be sequential or chronological, going from foundational literature to more current.  Remember, “an effective literature review need not denote the entire historical record, but rather establish the raison d’etre for the current study and in doing so cite that literature distinctly pertinent for theoretical, methodological, or empirical reasons.” ( Milardo, 2015, p. 22 ).

As you organize the summarized documents into a logical structure, you are also appraising and synthesizing complex information from multiple sources.  Your literature review is the result of your research that synthesizes new and old information and creates new knowledge.

7.4 Additional resources:

Literature Reviews: Using a Matrix to Organize Research / Saint Mary’s University of Minnesota

Literature Review: Synthesizing Multiple Sources / Indiana University

Writing a Literature Review and Using a Synthesis Matrix / Florida International University

 Sample Literature Reviews Grid / Complied by Lindsay Roberts

Select three or four articles on a single topic of interest to you. Then enter them into an outline or table in the categories you feel are important to a research question. Try both the grid and the outline if you can to see which suits you better. The attached grid contains the fields suggested in the video .

Literature Review Table  

Test Yourself

• Select two articles from your own summary table or outline and write a paragraph explaining how and why the sources relate to each other and your review of the literature.
• In your literature review, under what topic or subtopic will you place the paragraph you just wrote?

Image attribution

Literature Reviews for Education and Nursing Graduate Students Copyright © by Linda Frederiksen is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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

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

Table of Contents

What is the purpose of literature review , a. habitat loss and species extinction: , b. range shifts and phenological changes: , c. ocean acidification and coral reefs: , d. adaptive strategies and conservation efforts: .

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

Frequently asked questions 

What is a literature review .

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

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

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

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

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

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

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

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

Literature review example 

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

Literature Review on Climate Change Impacts on Biodiversity:  

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

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

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

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

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

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How to write a good literature review 

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

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

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

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

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

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

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

Conducting a literature review 

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

Choose a Topic and Define the Research Question:  

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

Decide on the Scope of Your Review:  

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

Select Databases for Searches:  

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

Conduct Searches and Keep Track:  

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

Review the Literature:  

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

Organize and Write Your Literature Review:  

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

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How to write a literature review faster with Paperpal?  

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

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

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

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

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

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

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

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

References 

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

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Libraries | Research Guides

Literature reviews, what is a literature review, learning more about how to do a literature review.

• Planning the Review
• The Research Question
• Choosing Where to Search
• Organizing the Review
• Writing the Review

A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

• Sage Research Methods Core This link opens in a new window SAGE Research Methods supports research at all levels by providing material to guide users through every step of the research process. SAGE Research Methods is the ultimate methods library with more than 1000 books, reference works, journal articles, and instructional videos by world-leading academics from across the social sciences, including the largest collection of qualitative methods books available online from any scholarly publisher. – Publisher

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Library Guides

Literature reviews: synthesis.

• Criticality

Synthesise Information

So, how can you create paragraphs within your literature review that demonstrates your knowledge of the scholarship that has been done in your field of study?  

You will need to present a synthesis of the texts you read.  

Doug Specht, Senior Lecturer at the Westminster School of Media and Communication, explains synthesis for us in the following video:  

Synthesising Texts  

What is synthesis? 

Synthesis is an important element of academic writing, demonstrating comprehension, analysis, evaluation and original creation.  

With synthesis you extract content from different sources to create an original text. While paraphrase and summary maintain the structure of the given source(s), with synthesis you create a new structure.  

The sources will provide different perspectives and evidence on a topic. They will be put together when agreeing, contrasted when disagreeing. The sources must be referenced.  

Perfect your synthesis by showing the flow of your reasoning, expressing critical evaluation of the sources and drawing conclusions.  

When you synthesise think of "using strategic thinking to resolve a problem requiring the integration of diverse pieces of information around a structuring theme" (Mateos and Sole 2009, p448). 

Synthesis is a complex activity, which requires a high degree of comprehension and active engagement with the subject. As you progress in higher education, so increase the expectations on your abilities to synthesise. 

How to synthesise in a literature review: 

Identify themes/issues you'd like to discuss in the literature review. Think of an outline.  

Read the literature and identify these themes/issues.  

Critically analyse the texts asking: how does the text I'm reading relate to the other texts I've read on the same topic? Is it in agreement? Does it differ in its perspective? Is it stronger or weaker? How does it differ (could be scope, methods, year of publication etc.). Draw your conclusions on the state of the literature on the topic.  

Start writing your literature review, structuring it according to the outline you planned.  

Put together sources stating the same point; contrast sources presenting counter-arguments or different points.  

Present your critical analysis.  

Always provide the references. 

The best synthesis requires a "recursive process" whereby you read the source texts, identify relevant parts, take notes, produce drafts, re-read the source texts, revise your text, re-write... (Mateos and Sole, 2009). 

What is good synthesis?  

The quality of your synthesis can be assessed considering the following (Mateos and Sole, 2009, p439):  

Integration and connection of the information from the source texts around a structuring theme. 

Selection of ideas necessary for producing the synthesis. 

Appropriateness of the interpretation.  

Elaboration of the content.  

Example of Synthesis

Original texts (fictitious): 

Synthesis: 

Animal experimentation is a subject of heated debate. Some argue that painful experiments should be banned. Indeed it has been demonstrated that such experiments make animals suffer physically and psychologically (Chowdhury 2012; Panatta and Hudson 2016). On the other hand, it has been argued that animal experimentation can save human lives and reduce harm on humans (Smith 2008). This argument is only valid for toxicological testing, not for tests that, for example, merely improve the efficacy of a cosmetic (Turner 2015). It can be suggested that animal experimentation should be regulated to only allow toxicological risk assessment, and the suffering to the animals should be minimised.   

Bibliography

Mateos, M. and Sole, I. (2009). Synthesising Information from various texts: A Study of Procedures and Products at Different Educational Levels. European Journal of Psychology of Education,  24 (4), 435-451. Available from https://doi.org/10.1007/BF03178760 [Accessed 29 June 2021].

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Systematic Literature Reviews: Steps & Resources

Literature review & systematic review steps.

• What are Literature Reviews?
• Conducting & Reporting Systematic Reviews
• Finding Systematic Reviews
• Tutorials & Tools for Literature Reviews

What are Systematic Reviews? (3 minutes, 24 second YouTube Video)

These steps for conducting a systematic literature review are listed below . 

Also see subpages for more information about:

• The different types of literature reviews, including systematic reviews and other evidence synthesis methods
• Tools & Tutorials
• Develop a Focused Question
• Scope the Literature  (Initial Search)
• Refine & Expand the Search
• Limit the Results
• Download Citations
• Abstract & Analyze
• Create Flow Diagram
• Synthesize & Report Results

1. Develop a Focused   Question 

Consider the PICO Format: Population/Problem, Intervention, Comparison, Outcome

Focus on defining the Population or Problem and Intervention (don't narrow by Comparison or Outcome just yet!)

"What are the effects of the Pilates method for patients with low back pain?"

Tools & Additional Resources:

• PICO Question Help
• Stillwell, Susan B., DNP, RN, CNE; Fineout-Overholt, Ellen, PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek, PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M., PhD, RN Evidence-Based Practice, Step by Step: Asking the Clinical Question, AJN The American Journal of Nursing : March 2010 - Volume 110 - Issue 3 - p 58-61 doi: 10.1097/01.NAJ.0000368959.11129.79

2. Scope the Literature

A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature. 

Eligible studies may be located by searching in:

• Background sources (books, point-of-care tools)
• Article databases
• Trial registries
• Grey literature
• Cited references
• Reference lists

When searching, if possible, translate terms to controlled vocabulary of the database. Use text word searching when necessary.

Use Boolean operators to connect search terms:

• Combine separate concepts with AND  (resulting in a narrower search)
• Connecting synonyms with OR  (resulting in an expanded search)

Search:  pilates AND ("low back pain"  OR  backache )

Video Tutorials - Translating PICO Questions into Search Queries

• Translate Your PICO Into a Search in PubMed (YouTube, Carrie Price, 5:11) 
• Translate Your PICO Into a Search in CINAHL (YouTube, Carrie Price, 4:56)

3. Refine & Expand Your Search

Expand your search strategy with synonymous search terms harvested from:

• database thesauri
• reference lists
• relevant studies

Example: 

(pilates OR exercise movement techniques) AND ("low back pain" OR backache* OR sciatica OR lumbago OR spondylosis)

As you develop a final, reproducible strategy for each database, save your strategies in a:

• a personal database account (e.g., MyNCBI for PubMed)
• Log in with your NYU credentials
• Open and "Make a Copy" to create your own tracker for your literature search strategies

4. Limit Your Results

Use database filters to limit your results based on your defined inclusion/exclusion criteria.  In addition to relying on the databases' categorical filters, you may also need to manually screen results.  

• Limit to Article type, e.g.,:  "randomized controlled trial" OR multicenter study
• Limit by publication years, age groups, language, etc.

NOTE: Many databases allow you to filter to "Full Text Only".  This filter is  not recommended . It excludes articles if their full text is not available in that particular database (CINAHL, PubMed, etc), but if the article is relevant, it is important that you are able to read its title and abstract, regardless of 'full text' status. The full text is likely to be accessible through another source (a different database, or Interlibrary Loan).  

• Filters in PubMed
• CINAHL Advanced Searching Tutorial

5. Download Citations

Selected citations and/or entire sets of search results can be downloaded from the database into a citation management tool. If you are conducting a systematic review that will require reporting according to PRISMA standards, a citation manager can help you keep track of the number of articles that came from each database, as well as the number of duplicate records.

In Zotero, you can create a Collection for the combined results set, and sub-collections for the results from each database you search.  You can then use Zotero's 'Duplicate Items" function to find and merge duplicate records.

• Citation Managers - General Guide

6. Abstract and Analyze

• Migrate citations to data collection/extraction tool
• Screen Title/Abstracts for inclusion/exclusion
• Screen and appraise full text for relevance, methods, 
• Resolve disagreements by consensus

Covidence is a web-based tool that enables you to work with a team to screen titles/abstracts and full text for inclusion in your review, as well as extract data from the included studies.

• Covidence Support
• Critical Appraisal Tools
• Data Extraction Tools

7. Create Flow Diagram

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review.  It depicts the number of records identified, included and excluded.  It is best used in conjunction with the PRISMA checklist .

Example from: Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46. https://doi.org/10.1007/s11892-021-01414-3

• PRISMA Flow Diagram Generator (ShinyApp.io, Haddaway et al. )
• PRISMA Diagram Templates  (Word and PDF)
• Make a copy of the file to fill out the template
• Image can be downloaded as PDF, PNG, JPG, or SVG
• Covidence generates a PRISMA diagram that is automatically updated as records move through the review phases

8. Synthesize & Report Results

There are a number of reporting guideline available to guide the synthesis and reporting of results in systematic literature reviews.

It is common to organize findings in a matrix, also known as a Table of Evidence (ToE).

• Reporting Guidelines for Systematic Reviews
• Download a sample template of a health sciences review matrix  (GoogleSheets)

Steps modified from: 

Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach.   Medical Education , 46 (10), 943–952.

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• Next: What are Literature Reviews? >>
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Systematic reviews & evidence synthesis methods.

• Schedule a Consultation / Meet our Team
• What is Evidence Synthesis?
• Types of Evidence Synthesis
• Evidence Synthesis Across Disciplines
• Finding and Appraising Existing Systematic Reviews
• 0. Preliminary Searching
• 1. Develop a Protocol
• 2. Draft your Research Question
• 3. Select Databases
• 4. Select Grey Literature Sources
• 5. Write a Search Strategy
• 6. Register a Protocol
• 7. Translate Search Strategies
• 8. Citation Management
• 9. Article Screening
• 10. Risk of Bias Assessment
• 11. Data Extraction
• 12. Synthesize, Map, or Describe the Results
• Evidence Synthesis Resources & Tools

What are evidence syntheses?

According to the Royal Society, 'evidence synthesis' refers to the process of bringing together information from a range of sources and disciplines to inform debates and decisions on specific issues. They generally include a methodical and comprehensive literature synthesis focused on a well-formulated research question. Their aim is to identify and synthesize all of the scholarly research on a particular topic, including both published and unpublished studies. Evidence syntheses are conducted in an unbiased, reproducible way to provide evidence for practice and policy-making, as well as to identify gaps in the research. Evidence syntheses may also include a meta-analysis, a more quantitative process of synthesizing and visualizing data retrieved from various studies.

Evidence syntheses are much more time-intensive than traditional literature reviews and require a multi-person research team. See this PredicTER tool to get a sense of a systematic review timeline (one type of evidence synthesis). Before embarking on an evidence synthesis, it's important to clearly identify your reasons for conducting one. For a list of types of evidence synthesis projects, see the Types of Evidence Synthesis tab.

How does a traditional literature review differ from evidence synthesis?

One commonly used form of evidence synthesis is a systematic review. This table compares a traditional literature review with a systematic review.

Video: Reproducibility and transparent methods (Video 3:25)

Reporting standards

There are some reporting standards for evidence syntheses. These can serve as guidelines for protocol and manuscript preparation and journals may require that these standards are followed for the review type that is being employed (e.g. systematic review, scoping review, etc).​

• PRISMA checklist Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses.
• PRISMA-P Standards An updated version of the original PRISMA standards for protocol development.
• PRISMA - ScR Reporting guidelines for scoping reviews and evidence maps
• PRISMA-IPD Standards Extension of the original PRISMA standards for systematic reviews and meta-analyses of individual participant data.
• EQUATOR Network The EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network is an international initiative that seeks to improve the reliability and value of published health research literature by promoting transparent and accurate reporting and wider use of robust reporting guidelines. They provide a list of various standards for reporting in systematic reviews.

Video: Guidelines and reporting standards

PRISMA flow diagram

The PRISMA flow diagram depicts the flow of information through the different phases of an evidence synthesis. It maps the search (number of records identified), screening (number of records included and excluded), and selection (reasons for exclusion). Many evidence syntheses include a PRISMA flow diagram in the published manuscript.

See below for resources to help you generate your own PRISMA flow diagram.

• PRISMA Flow Diagram Tool
• PRISMA Flow Diagram Word Template
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How to Synthesize Written Information from Multiple Sources

Shona McCombes

Content Manager

B.A., English Literature, University of Glasgow

Shona McCombes is the content manager at Scribbr, Netherlands.

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Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

On This Page:

When you write a literature review or essay, you have to go beyond just summarizing the articles you’ve read – you need to synthesize the literature to show how it all fits together (and how your own research fits in).

Synthesizing simply means combining. Instead of summarizing the main points of each source in turn, you put together the ideas and findings of multiple sources in order to make an overall point.

At the most basic level, this involves looking for similarities and differences between your sources. Your synthesis should show the reader where the sources overlap and where they diverge.

Unsynthesized Example

Franz (2008) studied undergraduate online students. He looked at 17 females and 18 males and found that none of them liked APA. According to Franz, the evidence suggested that all students are reluctant to learn citations style. Perez (2010) also studies undergraduate students. She looked at 42 females and 50 males and found that males were significantly more inclined to use citation software ( p < .05). Findings suggest that females might graduate sooner. Goldstein (2012) looked at British undergraduates. Among a sample of 50, all females, all confident in their abilities to cite and were eager to write their dissertations.

Synthesized Example

Studies of undergraduate students reveal conflicting conclusions regarding relationships between advanced scholarly study and citation efficacy. Although Franz (2008) found that no participants enjoyed learning citation style, Goldstein (2012) determined in a larger study that all participants watched felt comfortable citing sources, suggesting that variables among participant and control group populations must be examined more closely. Although Perez (2010) expanded on Franz’s original study with a larger, more diverse sample…

Step 1: Organize your sources

After collecting the relevant literature, you’ve got a lot of information to work through, and no clear idea of how it all fits together.

Before you can start writing, you need to organize your notes in a way that allows you to see the relationships between sources.

One way to begin synthesizing the literature is to put your notes into a table. Depending on your topic and the type of literature you’re dealing with, there are a couple of different ways you can organize this.

Summary table

A summary table collates the key points of each source under consistent headings. This is a good approach if your sources tend to have a similar structure – for instance, if they’re all empirical papers.

Each row in the table lists one source, and each column identifies a specific part of the source. You can decide which headings to include based on what’s most relevant to the literature you’re dealing with.

For example, you might include columns for things like aims, methods, variables, population, sample size, and conclusion.

For each study, you briefly summarize each of these aspects. You can also include columns for your own evaluation and analysis.

The summary table gives you a quick overview of the key points of each source. This allows you to group sources by relevant similarities, as well as noticing important differences or contradictions in their findings.

Synthesis matrix

A synthesis matrix is useful when your sources are more varied in their purpose and structure – for example, when you’re dealing with books and essays making various different arguments about a topic.

Each column in the table lists one source. Each row is labeled with a specific concept, topic or theme that recurs across all or most of the sources.

Then, for each source, you summarize the main points or arguments related to the theme.

The purposes of the table is to identify the common points that connect the sources, as well as identifying points where they diverge or disagree.

Step 2: Outline your structure

Now you should have a clear overview of the main connections and differences between the sources you’ve read. Next, you need to decide how you’ll group them together and the order in which you’ll discuss them.

For shorter papers, your outline can just identify the focus of each paragraph; for longer papers, you might want to divide it into sections with headings.

There are a few different approaches you can take to help you structure your synthesis.

If your sources cover a broad time period, and you found patterns in how researchers approached the topic over time, you can organize your discussion chronologically .

That doesn’t mean you just summarize each paper in chronological order; instead, you should group articles into time periods and identify what they have in common, as well as signalling important turning points or developments in the literature.

If the literature covers various different topics, you can organize it thematically .

That means that each paragraph or section focuses on a specific theme and explains how that theme is approached in the literature.

Source Used with Permission: The Chicago School

If you’re drawing on literature from various different fields or they use a wide variety of research methods, you can organize your sources methodologically .

That means grouping together studies based on the type of research they did and discussing the findings that emerged from each method.

If your topic involves a debate between different schools of thought, you can organize it theoretically .

That means comparing the different theories that have been developed and grouping together papers based on the position or perspective they take on the topic, as well as evaluating which arguments are most convincing.

Step 3: Write paragraphs with topic sentences

What sets a synthesis apart from a summary is that it combines various sources. The easiest way to think about this is that each paragraph should discuss a few different sources, and you should be able to condense the overall point of the paragraph into one sentence.

This is called a topic sentence , and it usually appears at the start of the paragraph. The topic sentence signals what the whole paragraph is about; every sentence in the paragraph should be clearly related to it.

A topic sentence can be a simple summary of the paragraph’s content:

“Early research on [x] focused heavily on [y].”

For an effective synthesis, you can use topic sentences to link back to the previous paragraph, highlighting a point of debate or critique:

“Several scholars have pointed out the flaws in this approach.” “While recent research has attempted to address the problem, many of these studies have methodological flaws that limit their validity.”

By using topic sentences, you can ensure that your paragraphs are coherent and clearly show the connections between the articles you are discussing.

As you write your paragraphs, avoid quoting directly from sources: use your own words to explain the commonalities and differences that you found in the literature.

Don’t try to cover every single point from every single source – the key to synthesizing is to extract the most important and relevant information and combine it to give your reader an overall picture of the state of knowledge on your topic.

Step 4: Revise, edit and proofread

Like any other piece of academic writing, synthesizing literature doesn’t happen all in one go – it involves redrafting, revising, editing and proofreading your work.

Checklist for Synthesis

•   Do I introduce the paragraph with a clear, focused topic sentence?
•   Do I discuss more than one source in the paragraph?
•   Do I mention only the most relevant findings, rather than describing every part of the studies?
•   Do I discuss the similarities or differences between the sources, rather than summarizing each source in turn?
•   Do I put the findings or arguments of the sources in my own words?
•   Is the paragraph organized around a single idea?
•   Is the paragraph directly relevant to my research question or topic?
•   Is there a logical transition from this paragraph to the next one?

Further Information

How to Synthesise: a Step-by-Step Approach

Help…I”ve Been Asked to Synthesize!

Learn how to Synthesise (combine information from sources)

How to write a Psychology Essay

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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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This publication is licensed under a Creative Commons License, Attribution-Noncommercial 4.0 International License (CC BY-NC 4.0): see https://creativecommons.org/licenses/by-nc/4.0/

• 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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Advancing middle grade research on critical pedagogy: research synthesis.

1. Introduction

2. materials and methods, 2.1. scope of the literature review.

• How do teachers across content areas use and promote critical and culturally responsive teaching practices?
• What strategies and classroom practices do teachers implement that examine and challenge power relations and center culturally and linguistically diverse students?
• What is the impact of classroom implementation of critical pedagogies on young adolescent learning?
• How do educators and researchers expand the concept of critical pedagogies to include antiracist and anticolonial teaching practices for action?

2.2. Study Selection

• Critical pedagogies AND middle school or junior high or 6th, 7th, and 8th grades, AND teaching strategies or teaching methods or teaching approaches or classroom techniques;
• Antiracist teaching AND middle school or junior high or 6th, 7th, and 8th grades;
• Antiracism or anti-racism or antiracist or antiracist AND middle school or junior high or 6th, 7th, and 8th grades AND education or school or learning or teaching or classroom or education system (later added AND education to further narrow results);
• Culturally responsive teaching or culturally relevant pedagogy or culturally responsive instruction or culturally inclusive AND middle school or junior high or 6th, 7th, and 8th grades or young adolescents;
• Anticolonial or anti-colonial or decolonial AND middle school or junior high or 6th, 7th, and 8th grades or young adolescents AND education or school or learning or teaching or classroom or education system;
• Critical literacy or social justice AND teaching strategies or teaching methods or teaching approaches or classroom techniques AND middle school or junior high or 6th or 7th or 8th.

3.1. Diverse Instructional Practices

3.2. culturally responsive pedagogies, 3.3. decolonial and antiracist strategies, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Walker, A.; Yoon, B.; Pankowski, J. Advancing Middle Grade Research on Critical Pedagogy: Research Synthesis. Educ. Sci. 2024 , 14 , 997. https://doi.org/10.3390/educsci14090997

Walker A, Yoon B, Pankowski J. Advancing Middle Grade Research on Critical Pedagogy: Research Synthesis. Education Sciences . 2024; 14(9):997. https://doi.org/10.3390/educsci14090997

Walker, Amy, Bogum Yoon, and Jennifer Pankowski. 2024. "Advancing Middle Grade Research on Critical Pedagogy: Research Synthesis" Education Sciences 14, no. 9: 997. https://doi.org/10.3390/educsci14090997

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• Volume 14, Issue 9
• Guideline concordant screening and monitoring of extrapyramidal symptoms in patients prescribed antipsychotic medication: a protocol for a systematic literature review and narrative synthesis
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• http://orcid.org/0009-0008-8045-1704 Rebekah Aubry 1 ,
• http://orcid.org/0000-0002-7777-0981 Thomas Hastings 2 , 3 ,
• http://orcid.org/0009-0001-5954-4702 Micheal Morgan 4 ,
• Jacqueline Hastings 5 ,
• Marie Bolton 6 ,
• Maura Grummell 7 ,
• Sinead Killeen 1 ,
• Cathal Coyne 8 ,
• Risa Shorr 9 ,
• http://orcid.org/0000-0003-4877-7233 Marco Solmi 10
• 1 Department of Psychiatry , Lucena Clinic Services , Dublin , Ireland
• 2 Department of Psychiatry , McMaster University , Hamilton , Ontario , Canada
• 3 Department of Psychiatry , University of Toronto , Toronto , Ontario , Canada
• 4 Department of Psychiatry , South Louth CAMHS , Drogheda , Ireland
• 5 School of Medicine , UCD , Dublin , Ireland
• 6 Department of Child and Adolescent Psychiatry , St Vincent's Hospital Fairview , Dublin , Ireland
• 7 Department of Psychiatry , Mater Misericordiae University Hospital , Dublin , Ireland
• 8 Department of Child and Adolescent Psychiatry , West Kildare CAMHS Linn Dara , Abbeylands Clane , Ireland
• 9 Learning Services , Ottawa Hospital , Ottawa , Ontario , Canada
• 10 Ottawa Hospital Research Institute , Ottawa , Ontario , Canada
• Correspondence to Dr Rebekah Aubry; rebekah.aubry{at}sjog.ie

Introduction Given the increasing rates of antipsychotic use in multiple psychiatric conditions, greater attention to the assessment, monitoring and documentation of their side effects is warranted. While a significant degree of attention has been provided to metabolic side effect monitoring, comparatively little is known about how clinicians screen for, document and monitor the motor side effects of antipsychotics (ie, parkinsonism, akathisia, dystonia and dyskinesias, collectively ‘extrapyramidal side effects’, EPS). This review aims to systematically assess the literature for insights into current trends in EPS monitoring practices within various mental health settings globally.

Methods and analysis An electronic search will be performed using the OVID Medline, PubMed, Embase, CINAHL and APA PsycINFO databases for studies published in the last quarter century (1998 to present day). Two independent reviewers will conduct the initial title and abstract screenings, using predetermined criteria for inclusion and exclusion. A third reviewer will resolve disagreements if consensus cannot be reached. If selected for inclusion, full-text data extraction will then be conducted using a pilot-tested data extraction form. Quality assessment will be conducted for all included studies using a modified version of the Quality Improvement Minimum Quality Criteria Set. A narrative synthesis and summary of the data will be provided. All stages of the review process will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Ethics and dissemination Ethical approval is not required. Findings will be peer reviewed, published and shared verbally, electronically and in print with interested clinicians and will also be presented as posters or talks at relevant medical conferences and meetings.

PROSPERO registration number CRD42023482372.

• Systematic Review
• Schizophrenia & psychotic disorders
• Protocols & guidelines

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2024-087632

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STRENGTHS AND LIMITATIONS OF THIS STUDY

The search strategy was developed a priori in collaboration with an experienced health sciences librarian and involves a comprehensive search across five large databases and platforms.

The protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines enhancing replicability and transparency.

Included studies will be rated based on their methodological quality using a modified version of the Quality Improvement Minimum Quality Criteria Set quality assessment tool developed by Hempel et al , which is suitable for the quality assessment of various types of service evaluation studies.

Due to resource constraints, the literature search will be restricted to English-only, peer-reviewed publications, possibly increasing the risk of selection bias and limiting the generalisability of review findings.

Introduction

Second generation antipsychotics (SGAs) are broadly used in clinical practice, not only for the treatment of psychotic and bipolar disorders but also for a variety of other conditions. 1–3 While SGAs are associated with a lower risk of motor side effects (ie, parkinsonism, akathisia, dystonia and dyskinesias, collectively ‘extrapyramidal side effects’, EPSs) than first-generation antipsychotics the rates of EPS remain significant. 4–8 Furthermore, EPSs are associated with impaired quality of life, medication non-adherence, increased morbidity, mortality, caregiver burden, utilisation of healthcare resources and higher medical costs. 8–16 This has resulted in some advocating for ‘better monitoring … to assess their true effect on patients’ quality of life and functioning and to prevent underascertainment’, 17 something especially important in higher risk populations, for instance, children, adolescents and the elderly. 18–20 The most recent American Psychiatric Association’s guidelines (2020) for the treatment of patients with schizophrenia calls for clinical assessment of EPS at baseline or initial assessment, at each subsequent visit as well as an assessment using a ‘structured instrument’ every 6 months in patients at increased risk of tardive dyskinesia and every 12 months for all other patients. 21 In the UK, the National Institute for Health and Care Excellence guidelines recommend assessment of any movement disorders before starting antipsychotic medication as part of baseline investigations and to monitor and record side effects of treatment and their impact on functioning, and the emergence of movement disorders, regularly and systematically throughout treatment and especially during titration. 22 Unfortunately, evidence demonstrates that actual monitoring rates fall far below these standards. 23–25

Rationale for the review

While a significant degree of attention has been provided to metabolic side effect monitoring, with several systematic reviews conducted on the subject, 26 27 comparatively little is known about EPS monitoring practices.

When it comes to EPS, its incidence and prevalence in research and naturalistic settings have been thoroughly investigated in numerous studies and reviews. 4–6 28 However, there seems to be a paucity of data about current practices relating to how clinicians screen for, monitor and document EPS in patients prescribed antipsychotics. Gaining a better understanding of current practice may allow for the introduction of effective interventions that help address the existing discrepancy between current practice and best practice.

Aim and objectives

The aim of this review is to systematically assess the literature, seeking insights into current EPS monitoring practices within various mental health settings globally.

Our three main objectives are as follows: (1) to identify the extent to which patients prescribed antipsychotic medication receive guideline concordant monitoring, (2) to gather data on interventions that have been proposed to improve this aspect of care and (3) to identify any existing barriers.

Research questions

In accordance with the aim and objectives outlined above, this review will seek to answer the following questions as regards EPS monitoring for patients who are prescribed antipsychotic medication:

Which guidelines if any are being used to guide current practice and arerecommended standards being met? What screening tools are being used?

What is the frequency of monitoring? Has it improved or worsened over the years?

What interventions have been proposed to improve monitoring standards?

What are some of the possible barriers to adequate monitoring?

Methods and design

All stages of the review process including literature searching, screening, applying inclusion and exclusion criteria and data extraction will be reported and documented in accordance with the Preferred Reporting Items for Systematic Review and Met-Analysis Protocol (PRISMA-P) statement. 29 The PRISMA-P was used to guide the development of the review protocol (see online supplemental file 1 for PRISMA-P checklist). 30 In accordance with the guidelines, this systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the reference number CRD42023482372. Any amendments to the protocol will be reported when publishing the results.

Supplemental material

Inclusion and exclusion criteria (eligibility of studies).

These are grouped under the following seven subsections:

Study design

Study designs aimed at gathering data on current practices relating to EPS documentation and monitoring as well as studies describing interventions developed to improve clinical performance in the area of documentation and monitoring of EPS will be included in the review. Examples of study designs that will be included are as follows:

Clinical audits without intervention.

Clinical audits with completed audit cycles after intervention.

Service evaluations without a quality improvement intervention.

Service evaluations following a quality improvement intervention.

However, the following study design types will be excluded:

Case reports.

Any trial design, including randomized controlled trials(RCTs).

Literature reviews.

Discussion and viewpoint studies.

Grey literature.

Abstract-only publications.

Epidemiological studies of incidence/prevalence of EPS.

Survey designs.

Types of intervention

All types of interventions concerned with the assessment, screening and monitoring of EPS will be included. This will involve gathering data on the types of processes currently used to carry out EPS monitoring and documentation as well as on any proposed interventions aimed at improving EPS documentation and monitoring such as educational interventions, adoption of novel screening instruments, etc.

Study language

This systematic review will be restricted to English language studies only.

Publication dates

Studies published from 1998 to the present will be included, spanning the last 25 years of clinical practice. We consider this sufficiently representative of contemporary trends in practice.

Study population/demographics

The first population of interest includes patients of all ages and genders receiving treatment for one or more mental health conditions and prescribed one or more antipsychotic medications. While it is true that EPS can manifest spontaneously in patients who were never exposed to antipsychotic agents 31 32 or can be caused by substances other than antipsychotics, 33–35 a substantial proportion of reported EPS is attributed to antipsychotic medication. 6 36 37 Moreover, even within cohorts of previously neuroleptic naïve patients, research suggests that dopamine D2 receptor antagonist antipsychotics interact with the disease process in such a way that ‘precipitates’ and ‘accentuates’ movement disorders intrinsic to schizophrenia’. 38 This review will, therefore, focus on patients prescribed antipsychotic medication, as they may be at higher risk of developing severe EPS. In addition, most available guidelines on EPS monitoring specifically refer to patients prescribed antipsychotic medications.

The second population of interest includes the healthcare professionals involved in the care of the patients (eg, nurses, residents, clinicians and pharmacists) and tasked with carrying out EPS monitoring.

Study settings

Studies reporting on EPS monitoring practices in any naturalistic, real-world clinical setting, including inpatient hospitals, day hospitals, outpatient clinics, community settings, etc will be included.

Other phenomena of interest

Where available, data on the views, experiences and behaviours of healthcare professionals and patients involved in the assessment, screening and monitoring of EPS will also be collected.

Patient and public involvement

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

Information sources

Electronic sources.

The literature search was conducted using the following five databases and search platforms: OVID Medline, PubMed, EMBASE, PsycINFO and CINAHL. The initial search covers 25 years and includes studies published between April 1998 and April 2023. These searches will be re-run immediately prior to the final analysis (projected to take place in September 2024) and potential further studies will be retrieved for inclusion, ensuring that the most up-to-date information is presented in the review. The reference lists of all eligible articles will be manually searched to identify any additional relevant citations to ensure a comprehensive search.

Search strategy

Review authors RA and RS (librarian and information specialist with expertise in electronic searching) developed and ran a comprehensive search strategy. A scoping search was undertaken against each database to inform how the search terms were being translated and hence to identify the corresponding text words in each database. Following this, the complete search strategy was tested for its sensitivity to locate the key papers that the researchers are already aware of, along with relevant articles which are consistent with the inclusion criteria just before running the search through all the selected search engines.

The search strategy used variations in text words found in the title, abstract or keyword fields, and relevant focused subject headings to retrieve articles combining the following three search concepts, linked by the Boolean operator ‘AND’:

(1) One or more medication terms: antipsychotic* OR psychotropic* OR haloperidol OR olanzapine OR quetiapine OR risperidone OR cariprazine OR amisulpride OR aripiprazole OR lurasidone etc… (to include full list of antipsychotic medication listed as per the WHO Collaboration Centre for Drug Statistics Methodology ATC classification).

(2) One or more EPS terms: “Extrapyramidal symptom*” OR “Extrapyramidal side effect*” OR “drug-induced movement disorder*” OR ‘Drug-Related Side Effects and Adverse Reactions’ OR ‘movement side effects’ OR Dystonia OR ‘acute dystonia’ OR parkinsonism OR ‘drug-induced parkinsonism’ OR akathisia OR “tardive dyskinesia” OR tremor

(3) One or more terms relating to monitoring, screening, documenting or auditing clinical practice (including screening instruments): ‘Monitoring’ OR ‘Screening’ OR ‘Documenting’ OR ‘Documentation’ OR ‘Assessing’ OR ‘Assessment’ OR ‘Abnormal Involuntary Movement Scale’ OR ‘Extrapyramidal Symptom Rating Scale’ OR ‘Simpson-Angus Scale’ OR ‘Barnes Akathisia Scale’.

The search included all relevant synonyms, truncations and Mesh terms. Full details of search terms used for the OVID Medline search are shown in online supplemental file 2 . A similar search was conducted using the other databases and search platforms. The full search strategy is available on request from the corresponding author.

Study records

Data management.

The search results will be uploaded into web-based, systematic review management software (Covidence). Duplicates will be removed automatically by Covidence software. Authors RA and MM will scan through the results to remove any remaining duplicate records manually. Using Covidence, the initial title and abstract screening, and the full-text review will be logged. All standardised forms will be piloted and revised as needed by the reviewers before starting the review.

Screening and selection process

After identification of articles from searching the electronic databases, titles and abstracts will be screened independently by two review authors according to the predefined eligibility criteria. Disagreements will be resolved by consensus and the opinion of a third reviewer will be sought if necessary. The full-text copies of each potentially relevant study will then be retrieved and screened independently by at least two reviewers including the first author (RA). Consensus will be reached through discussion, and in the event that no consensus can be reached for a study, a third reviewer will arbitrate. All studies not meeting the eligibility criteria will be excluded. The results will be reported using the PRISMA flow diagram.

Data extraction and reporting of results

A standardised data extraction form will be developed to extract all relevant data from included studies. Information to be extracted will be as follows:

Study characteristics: authors, date, settings, country of origin, study design and sample size.

Patient characteristics: demographic data (age, gender, diagnosis, type of antipsychotic prescribed, etc.).

Monitoring characteristics: frequency, use of a structured tool, healthcare professionals involved in monitoring, guidelines followed, etc.

Intervention characteristics: (if study incorporated a preintervention/postintervention design): educational intervention, adoption of a new instrument, etc.

The data extraction form will be piloted on a small random sample (n=3) of the illegible studies to assess its reliability in extracting the targeted study data. Review authors TH, MB and SK will each independently conduct data extraction on the three studies. Review authors RA and MM will then review this extracted data, checking against the full text of the three studies for any discrepancies (eg, errors, omissions or failure to have consensus in any area) and will decide on how to resolve any that may arise. If the above pilot data extraction process is deemed reliable then the review authors TH, MB and SK will each independently conduct data extraction on the remaining studies in the systematic review. Review authors RA and MM will then cross-check the extracted data against the full-text articles in a similar process to that highlighted above.

Additionally, study authors will be contacted if necessary to gain information for clarification purposes and access to raw material when needed.

Critical appraisal of study quality

Authors RA and MM will use the Quality Improvement Minimum Quality Criteria Set (QI-MQCS) developed by Hempel et al to conduct the quality assessment of included studies. 39 Disagreements will be resolved by consensus; the opinion of a third reviewer (MG) will be sought if necessary. The QI-MQCS is a 16-domain, validated, reliable critical appraisal tool that assesses expert-endorsed QI domains for studies that include a QI intervention component. The QI-MQCS will be modified to be suitable for the body of studies included in our review, and in particular, to be able to assess studies with no intervention component, that is, clinical audits and service evaluations with no intervention. This will involve accepting a broader definition of several domains of the appraisal instrument to include studies evaluating existing services or standards in addition to QI intervention. This approach was chosen in the absence of a suitable tool for critical appraisal of service evaluation studies with no intervention component.

The QI-MQCS tool is designed to provide a score for each domain as well as a total score, which is expressed as a percentage of the maximum possible score.

Data synthesis

In this review, the search is expected to reveal heterogeneous studies and meta-analysis of study findings is therefore not a study objective. Therefore, data synthesis will take the form of a structured narrative synthesis of the included studies. The defining characteristic of a narrative synthesis is that it adopts a textual approach to the process of synthesis in order to provide answers to the identified research questions in a structured manner. Study findings pertaining to the following three themes will be examined and synthesised: (1) Data concerning the extent and quality of EPS monitoring being carried out in various mental health settings will be summarised. (2) Following this, details about any potential interventions employed to improve monitoring practices will be synthesised. And finally, (3) Information about any identifiable barriers or facilitators to guideline concordant EPS monitoring will be synthesised and discussed.

Study status

The study is ongoing and is expected to be completed by September 2024.

Proposed value of the systematic review and use of the findings

This systematic review seeks to shed light on the existing patterns of EPS monitoring occurring within various mental health settings. The findings of this systematic review may be of interest to mental health organisations and services as they are expected to provide insights into the potential barriers or facilitators (including possible quality improvement interventions) influencing whether EPS monitoring is carried out in a guideline concordant manner. This may in turn encourage organisations and services to assess their existing EPS monitoring practice and/or lead them to consider the adoption or development of interventions to improve monitoring standards.

Ethics statements

Patient consent for publication.

Not applicable.

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Contributors RA is the author acting as guarantor. The study was conceived by RA, MS, MM and TH. RA and MM developed the eligibility criteria, search strategy, quality assessment strategy and data extraction plan with guidance from MS and RS. RA, TH and MM wrote the manuscript. MS, MB, MM, MG, JH, SK and CC read all drafts of the manuscript, provided feedback and approved the final manuscript. All contributors meet the ICMJE criteria for authorship.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests MS has received honoraria/has been a consultant for AbbVie, Angelini, Lundbeck, Otsuka.

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

Provenance and peer review Not commissioned; externally peer reviewed.

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

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Sources of Sexual Knowledge and Information, and Sexual Attitudes of Men: A Narrative Synthesis of the Literature

• Review Article
• Open access
• Published: 13 September 2024

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• Darlene Mwende Ndasi   ORCID: orcid.org/0000-0003-1704-7342 1 ,
• Victor Fannam Nunfam   ORCID: orcid.org/0000-0002-4572-0904 1 , 2 ,
• Kwadwo Adusei-Asante   ORCID: orcid.org/0000-0002-1343-8234 1 ,
• Madalena Grobbelaar   ORCID: orcid.org/0000-0002-2749-2944 1 &
• Anh Vo Van Ha   ORCID: orcid.org/0000-0002-9495-9292 1 , 2 , 3  

This study sought to synthesise evidence on the sources of sexual knowledge and information and relationship with sexual attitudes of cis men. From a review of existing literature, five categories were obtained from 11 studies and grouped into three syntheses: (1) sources of sexual knowledge and information, (2) sexual attitudes and (3) the relationship between sources of sexual knowledge and information and sexual attitudes. Sex research relation to sexual knowledge and attitudes of cis men is scant across the globe. Men desire reliable sexual information despite peers and online media being more readily available with consequences for sexual attitudes that impact on sexuality of men. We posit that research, sex education, sexological practice and policy intervention are necessary to avail knowledge that provides reliable sexual knowledge and information to men for safe sexual decision making.

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Introduction

The complexity of sexual socialisation and multi-dimensionality of sexual attitudes and influence on sexual behaviour in sub-Saharan Africa has been put on the spotlight since the advent of the unrelenting HIV/AIDS epidemic; citing men to propagate the disease through multiple sexual partnerships and sexual concurrencies reinforced by rigid gender norms and toxic masculinities. The HIV/AIDS plague and sexual health crisis is compounded by widespread ignorance in sexual knowledge and information among men (Amoo et al., 2019 ; Ogolla & Ondia, 2019 ), and complacent sexual attitudes where peers are mostly the sought-after knowledge source to inform sexual decision making (Hodes & Gittings, 2019 ).

Much of peer sources of sexual knowledge and information often involve sexual interaction leaving little chance for informed sexual decision making and when knowledge is accurate such as the comprehension of the importance of consistent condom use, this knowledge does not always translate into practice (Ogolla & Ondia, 2019 ). In Africa, there is also continued debate on the ideal curricula framework for comprehensive sexuality education in schools which is often cited to be established within colonialism to threaten traditional values that are centred on traditional gender roles and heteronormativity (Bhana et al., 2019 ; Gacoin, 2016 ). This is despite the rise in homosexuality, heterosexual anal sex (Baggaley et al., 2013 ), and the rapidly growing culture of gender diversity. Furthermore, sexual violence involving sexual coercion and assaults, and both implicit and explicit violation of sexual consent among men are perverse with sexual permissiveness represented in the practice of multiple sexual partnerships and sexual concurrencies (Kenyon et al., 2018 ). Therefore, understanding the sources of sexual knowledge and relationship with sexual attitudes and sexual behaviours is important for curricula and sexological practice programme development and research policy.

Despite much of the sexuality education research that exists in Africa largely focusing on the sexual socialisation of adolescents, sexual learning is lifelong and the sources of sexual knowledge are different and impact varies (Ballard & Morris, 1998 ; Graf & Patrick, 2015b ; Nunfam & Adjei, 2014 ). Indeed, the sources of sexual knowledge and information have impact on sexual attitudes and sexual behaviours of individuals (Shin et al., 2011 ). Permissive sexual attitudes and sexual double standards often predict sexual risk behaviours and have negative sexual health outcomes (Astle et al., 2022 ; Kirby et al., 2007 ; Nunfam, 2007 ).

Against the backdrop of studies on the extend of risky sexual behaviours, sexual violence among men and traditional gender roles that perpetuate these vices, the extent to which sex research involving acquisition of sexual knowledge and relationship with sexual attitudes of cis men in sub-Saharan Africa is not known. Also, there seems to be no specific systematic review or synthesis especially using mixed method approach (Nunfam et al., 2018 ) that have examined and highlighted the sources of sexual knowledge and information and sexual attitude of men, and how their sexual knowledge influences their sexual attitudes. Given the significance of systematic reviews and synthesis to evidence-centred policy making, it is imperative to conduct this review study in order to gather findings from extant published and unpublished studies.

Hence, this study sought to assess and synthesise the available evidence in literature on the sources of sexual knowledge and information and sexual attitude of men with emphasis on research design, study setting, methodology, and key findings. This mixed methods narrative review is guided by the following research questions: (1) What are the sources of sexual knowledge and information among men? (2) What are the sexual attitudes of men? (3) To what extent do the sources of sexual knowledge and information relate to sexual attitudes?

Materials and Methods

The philosophy of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRSMA) combined with the Joanna Briggs Institute (JBI) framework for systematic review, synthesis and reporting underpinned this study (JBI, 2017 ; Popay et al., 2006 ). Given that the systematic reviews and synthesis provide the foundation for descriptions of patterns, differences and similarities of results within included studies they were utilised on the basis of clearly defined selection criteria (Petticrew & Roberts, 2008 ; Popay et al., 2006 ).

Additionally, the utility of mixed methods was adopted to provide comprehensive understanding to the research questions (Morgan, 1998 ). The narrative synthesis used textual approach based on findings from several studies relating to sources of sexual knowledge, sexual attitudes and relationship between sexual knowledge and information and sexual attitudes among men. The aggregation of empirical studies therefore warrants the synthesis of both qualitative and quantitative evidence (Dixon-Woods et al., 2005 ). Additionally, mixed methods are agreeable with narrative synthesis permitting the mixing of diverse types of evidence from several studies of various characteristics (Gough et al., 2017 ).

Moreover, mixed methods narrative reviews can play a crucial role in identifying gaps and limitations in the extant literature in sex research. For example, a review examining the use of digital technologies in sexual health promotion may reveal a predominance of quantitative studies focused on measuring the impact of online interventions on knowledge or behavioural outcomes, while overlooking the qualitative exploration of users' experiences, preferences, and barriers to engagement (Schneider & Niederberger, 2020 ; Tariq & Woodman, 2013 ).

By highlighting these gaps, mixed methods narrative reviews can inform the design of future research that more effectively integrates both quantitative and qualitative approaches, leading to a more comprehensive understanding of the complex dynamics of human sexuality (Kajamaa et al., 2020 ; Small, 2011 ). Conclusively, the integration of mixed methods narrative reviews in sex research can address a critical need in the extant scholarship by providing a more holistic and nuanced understanding of the multifaceted nature of human sexuality.

Nevertheless, a scoping review was guided by the notion of the Population, Intervention, Comparison/Context Outcome (PICO) (Cooke et al., 2012 ). Therefore, the scope of the study included cis men 18–65 years old, sources of sexual knowledge and information, and sexual attitudes. For each included article, either the sources of sexual knowledge and information or sexual attitudes or both were addressed . The inclusion and exclusion criteria are presented in Table  1 below.

Search Strategy

A systematic search on Google Scholar, Taylor and Francis Online, Web of Science, Elsevier, Springer Nature, Sage, Wiley, and back studies in reference lists of peer reviewed studies published in English between 2012 and 2022 were searched using key words and search terms presented in Table  2 below.

Article screening occurred at the title and abstract stages, followed by a full review of the selected studies. Independent quality assessment of included articles guided by the JBI critical appraisal for systematic reviews was performed by three researchers who resolved differences through consensus. Our search resulted in 528,156 citation after which 527,731 were removed based on screening the title. After excluding most of the citations for various reasons, 425 citations were retained after which their abstracts were screened. Further review of abstracts retrieved 54 articles with 39 being considered for a full review of entire articles. Further, the full review of the 39 papers resulted in a final 10 studies that fully met the inclusion criteria. Another full review of 25 back references was performed with only one study qualifying for inclusion.

Studies were excluded for ambiguity, inappropriate topic and age, transgender men, studies involving reviews, reports, editorials, letters to editors and those which were published before 2012.The screening process and summary of included studies is presented in the PRISMA flow diagram (Page et al., 2021 ) (see Fig.  1 ).

PRISMA flow chart showing summary of included studies

Characteristics of Included Studies

The studies were characteristically heterogenous and from various countries across the globe including, Kenya, China, Vietnam, India and mostly the United States of America (USA). Most of the studies were found in continent of North America and Asia with the least found in South America. The global location of the 11 included studies included USA (36.4%), Asia (36.4%), Africa (18.1%) and South America (19.1%) as illustrated in Fig.  2 . The descriptive characteristics of the included studies were illustrated by author’s name, year in which publication occurred, the location, population, sample size, methods, data analysis and the study conclusions (Table  3 ).

Global location of included studies

Research objectives and methodologies also were used to organise the studies. Studies must have primarily involved only adult cismen aged 18 to 65 years old and not women, adolescents or transgender men primarily focused on sexuality education, any sources of sexual knowledge and information and sexual attitudes, beliefs and perspectives. Data from the included studies were therefore extracted using ‘Population, Intervention, Comparison and Outcome structure’ (Cooke et al., 2012 ).

The population refers to men aged 18–65 years old relating to sources of sexual knowledge and information and how such knowledge relates to or impact broadly on sexuality including sexual decision making. Interventions as presented in the chosen studies (primary) are the various sexual knowledge and information platforms such as school-based sexuality education, peers, parents, media platforms including religious organisations and other professional institutions such as sexual and reproductive health community settings or a combination of all of them to form blended sources. Comparisons involved different geographical locations, sexuality education platforms and their impact on sexual skills, and sexual attitudes. Outcomes relate to how these blended sources of sexual knowledge and information influence sexual attitudes (Hendrick et al., 2006 ), including consent. Both of these aspects have an intrinsic connection to sexual behaviours. The practice of multiple sexual partnerships and sexual concurrencies, modes of condom use, sexual responsibility, birth control, instrumentality and communion are such outcomes. Secondarily, the outcomes involve the skill in utilising sexual knowledge and information and understanding sexual and reproductive health outcomes and overall well-being of men.

The relationship of both the sources of sexual knowledge and information and sexual attitudes can also reflected social norms that may include the endorsement of sexual double standards and masculinity where men influence each other to maintain certain sexual behaviours. All these constitute sexual skills, values and attitudes.

Abstraction of Findings from Included Studies

We based data extraction on the findings of each included articles for categorisation and narrative synthesis using figures and tables where required (JBI, 2017 ; Popay et al., 2006 ). The JBI’s interpretation of degrees of evidence were used to determine the value of extracted data (see Tables 4 and 5 ) (JBI, 2017 ). Three researchers were involved in the data synthesis process and differences were resolved through consensus. Data were synthesised based on the study’s research questions. Data extracted from the 11 included studies are displayed in the following 11 tables (Tables 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ) according to their findings, illustrating the degree of evidence.

Narrative Synthesis and Categorisation of Included Studies

The abstraction of data resulted in 41 findings which were grouped into six categories: (1) type of sexual knowledge and information received, (2) sources of sexual knowledge and information, (3) access and accuracy of sexual knowledge and information, (4) sexual attitudes and (5) Relationship between sexual attitudes and sexual knowledge. The categories were further synthesised into themes as follows: (1) sources of sexual knowledge and information, (2) sexual attitudes and (3) the relationship between sources of sexual knowledge and information and sexual attitudes. Each of the studies addressed some questions and none answered all of the questions.

Synthesis One: Sources of Sexual Knowledge and Information

Synthesis one describes men’s perception on their sources of sexual knowledge and information, the various types of information sought and received, and their accuracy and reliability. This is the outcome of aggregating related categories comprising twenty-three findings that describe the sources of sexual knowledge and information as presented in Figs.  3 and 4 below. Finding from Category One indicates that men accessed sexual knowledge and information from different sources with various degrees of accuracy and reliability. Although men reported peers, online media and the internet to be the most easily accessible sources of sexual knowledge and information, the knowledge obtained as reportedly to be unreliable and not well understood (Graf & Patrick, 2015a ; Kirby et al., 2007 ). Much of the knowledge sought was focused on pregnancy and STIs/HIV/AIDS prevention as well as sexual pleasure which involved the use pornography and condom use mainly in casual relationships (Brown et al., 2017 ). The internet was viewed to be a confidential alternative source and efficiently accessed as soon as required (Ballester-Arnal et al., 2017 ). These sources were accessed as an alternative to school-based sexuality education which was reported to be inadequate, unreliable or completely absent (Bhana et al., 2019 ; Hodes & Gittings, 2019 ). Sexual knowledge from healthcare professionals as a formal source was not widely used.

Type of sexual knowledge and information sought and received

Sources of sexual knowledge and information

However, men reported that this source offered limited knowledge, mostly inadequate, confusing and lacked content to meet the knowledge required by men (Beia et al., 2021 ). The knowledge and information accessed from this source ranged from the correct application of condom use although as relationships became more permanent, men ceased from using condoms. Condoms were used to mainly control pregnancy and STIs with casual hook-ups (Endendijk et al., 2020 ; Garcia et al., 2012 ). Other sought-after knowledge related to sexual consent, in the context of how men treat women in their sexual engagement and sexual scripts (Ballester-Arnal et al., 2017 ; Garcia et al., 2012 ).

Men desired effective sexual knowledge and information, however the school curriculum through which formal education was accessed by all men was reportedly mainly biological and unlikely to be helpful. Few men accessed information from parents, which was mainly related to pregnancy and STI prevention (Bleakley et al., 2009 ; Khurana & Bleakley, 2014 ). Men also sought sexual knowledge and information to base their sexual decision making (Tannenbaum et al., 2016 ).

Synthesis Two: Sexual Attitudes

Synthesis two had only one category (Category Two) constituting eight findings relating to sexual permissiveness, influence of religion on sexual attitudes, causal sex, birth control attitudes toward condom use and safer sexual practices (Cruz, Legall etc.). Men reported to be less likely to engage in sexual hook-ups if they were in stable relationships. Sexual hook-ups were related to more condom use, pornography and safer sexual practices which involved more sexually permissive attitudes towards sex (Bankole et al., 2004 ). Participants with sexual permissiveness also reported multiple sexual partnerships and sexual concurrencies and sexual double standards (Endendijk et al., 2019 ; Vrangalova et al., 2014 ).

Synthesis Three: Relationship Between Sources of Sexual Knowledge and Sexual Attitudes

Synthesis three reflected the relationship between sources of sexual knowledge and sexual attitudes as presented in Figs.  5 , 6 and 7 below. Having sexual knowledge from reliable sources was associated with attitudes towards safe sexual practices and condom use. Information accessed from friends was related to permissive sexual attitudes related to casual hook-ups and use of pornography (Bridges et al., 2016 ; Lewczuk et al., 2022 ; Lo & Wei, 2005 ) Similarly accessing sexual knowledge and information from the internet and online media was related to permissive sexual attitudes involving casual sex and penetrative sexual hook-ups and infidelity (Brown et al., 2017 ; Rasmussen et al., 2018 ). However, sexual permissiveness was also linked to increased condom use (Berer, 2006 ; Evans et al., 2019 ; Hensel et al., 2012 ).

Access and accuracy sexual knowledge and information

Category three-sexual attitudes

Relationship between sources of sexual knowledge and sexual attitude

This is the most recent systematic and narrative synthesis using a mixed methods approach to assess sources of sexual knowledge and information, sexual attitudes and how the two concepts relate to influence on sexual decision making that impact on the sexuality and sexual and reproductive health of cis men. Our first question was to assess the sources of sexual knowledge and information. We found that men accessed various sources and that provided different forms of information used for sexual decision making.

Despite peers continuing to be the most preferred source of sexual knowledge and information among men (Dutt & Manjula, 2017 ; Rahimi-Naghani et al., 2016 ; Shin et al., 2019 ), the internet continues to rapidly provide instant information as required and both peers and online media is trending to replace formal sources of sexual knowledge and information (Daneback et al., 2012 ; Mustanski et al., 2011 ). Formal knowledge and information are obtainable from sexual and reproductive healthcare professionals but often reported as confusing and unreliable (Amoo et al., 2017 ). This trend indicates that men may miss out on reliable knowledge on which to base their sexual decision making as internet and peers are reported to provide unreliable information. This is consistent with earlier studies which suggest that peers and the internet are important sources of sexual knowledge and information (Ballard & Morris, 1998 ; Lo & Wei, 2005 ). Khurana and Bleakley ( 2014 ) and Bleakley et al. ( 2009 ) found that poor sexual knowledge and sexual literacy leads to unsafe and risky sexual behaviours including inconsistent condom use, lack of interest in sexual health screening and multiple and concurrent sexual partnerships (Hodes & Gittings, 2019 ), especially in sub-Saharan Africa where these practices are prevalent despite the HIV/AIDS epidemic (Kenyon et al., 2018 ). The second research question assessed the sexual attitudes of men. Our review found few studies that explored attitudes regarding sexual permissiveness among men. This study found that men with permissive or liberal views on sex, had more sexual hook-up (Braithwaite et al., 2015 ). Permissive sexual attitudes in men are likely to permit sexual double standards that allow men more sexual partners than women (Endendijk et al., 2020 ). However, men with more permissive sexual attitudes had consistent condom use and practiced safer sex than those who had regular or stable sexual partnerships (Emmers-Sommer et al., 2013 ; Endendijk et al., 2020 ). Knowledge and confidence in condom use provide confidence in sexual activity which could enhance liberal or permissive sexual attitudes (Cruz & Etienne, 2012 ; Hensel et al., 2012 ).

Our last question assessed the relationship between the sources of sexual knowledge and sexual attitudes. We found the sources of sexual knowledge influenced the attitudes men had towards sex. Peers were influential towards sexual permissiveness as men engaged in peer casual sexual hook-up from those they sought sexual information (Bhana et al., 2019 ; Hodes & Gittings, 2019 ; Rogers et al., 2019 ). This is consistent with earlier studies that established the role peers in their influence on sexual behaviours and sexual attitudes (Bhana et al., 2019 ; Bleakley et al., 2009 ). As such peer educators can be trained to provide efficient and accurate sexual knowledge and education to men for transformative sexual attitudes that foster safe sexual practices such as consistent condom uses and frequent sexual screening. This is critical for places where HIV/AIDS is still an epidemic such as sub-Saharan Africa and other developing countries where poor access to condoms and lack of accurate knowledge in their use still persists (Bhana et al., 2019 ). Shin et al. ( 2011 ) and Lyu et al. ( 2020 ) suggested that peer education can also effect change in sexual attitudes towards women.

This study contributes important knowledge to the wide body of sex research knowledge and highlights the need to involve cis men in research and policy development practices. Like all studies though, this review has limitations that are important to consider. We evaluated studies from different locations across the globe upon which cultural considerations must be made concerning how men acquire sexual knowledge and social-cultural implications pertaining to sexual attitudes.

In Africa for instance, it is expected men engage in multiple sexual partnerships as the ideal presentation of manhood (Amoo et al., 2019 ). Sexual attitudes towards masculinity in the continent would require transformative sex education in schools and the community from reliable sources for which funding is essential. Such knowledge must provide clear understanding of the consequences and rewards of sexual practices that impact men’s sexual health and that of their partners. This means that peer educators are critical in their ability to influence attitudes towards safe sexual practices by providing accurate and reliable sexuality education in male-friendly environments which also emphasize sexual pleasure.

Sexual pleasure and risk go hand in hand, and as such sexual pleasure is an important component in sexuality education. A multifaceted approach prioritizing both risk reduction and the enhancement of sexual pleasure, comprehensive programs can empower individuals to make informed decisions, practice safer sex, and experience more fulfilling intimate relationships (Melesse et al., 2020 ). For example, erotizing safe sex with condom use in educational programs, workshops and advertisements could be effective in advancing knowledge in sexual risk reduction and emphasizing sexual pleasure (Scott-Sheldon et al., 2006 ).

Implications

Discussions around sexual behavior, sexual health, and even sexual orientation may be perceived as taboo or even shameful, leading to reluctance among participants to engage openly and honestly in research activities. Moreover, cultures have a powerful influence on sexual attitudes. The topic of sexuality, particularly among men, is often shrouded in secrecy and stigma, particularly in many non-western societies (Muraguri et al., 2012 ; Onyango‐Ouma et al., 2009 ). Navigating these cultural sensitivities requires researchers to employ nuanced and empathetic approaches, building trust and rapport with communities and participants. It is also crucial to consider the role of power dynamics, both within the research process and in the broader social context, and how these may impact the willingness of men to share their experiences and perspectives (Khumalo et al., 2021 ).

In addition to cultural considerations, researchers must grapple with the complexities of gender norms and the ways in which they intersect with sexuality (Ndasi, et al., 2022a , 2022b ). In many sub-Saharan African societies for example, traditional gender roles and expectations place significant pressure on men to conform to rigid notions of masculinity, which may inhibit their ability to learn, discuss or seek support for sexual and reproductive health concerns (discuss or seek support for sexual and reproductive health concerns (Agha et al., 2002 ; Reid & Walker, 2005 ).

Moreover, a mixed methods narrative review examining sexuality topics among cis-gender men could integrate large-scale survey data on sexual issues within this population, while also incorporating in-depth interviews that capture the nuanced, lived experiences of individuals navigating issues of identity, stigma, and sexual and reproductive health support programs (Tariq & Woodman, 2013 ). By adopting this holistic approach, we can gain a richer and more nuanced understanding of the multifaceted factors shaping men’s sexuality, which can then serve as a foundation for developing more targeted and effective interventions.

Another implication relates to sexual research policy and practice. Sex research with adult cis men is generally scarce as discovered in this study. It is important to assess trends in sexual attitudes and the sources of knowledge accessed for sexual and reproductive health planning and practices that do not exclude cis men (Bancroft, 2000 ). Such research is also important for school-based sexuality education and curricula development. Nevertheless, other implications relate to sexuality educators, policy makers and sexological practitioners.

Study Limitations

This study focused on studies focusing on cis-gender men which renders it inherently restrictive. The review also involves studies conducted globally therefore the heterogeneity of the review should be viewed with these considerations. The reliance on secondary data from previously published studies is also a limitation for which the evolution of digital media and its impact on sexuality education and changing trends in research on human sexuality may not present current trends.

Conclusions

Conclusively, men require services that are considerate of their sexual needs, culturally relevant and research that puts these needs on the spotlight to avail effective support services that also benefit the sexual health and well-being of their sexual partners and communities. Additionally, is important to understand the connection between sexual knowledge and information with sexual behavior. The interdisciplinary field of sex research and sexual and reproductive health could explore the long-term effects of sources of sexual knowledge and information and sexual attitudes on sexual health outcomes for cis men.

Additionally, the integration of mixed methods approaches, particularly through the use of narrative reviews, can address a significant need in the field of sex research. By drawing on a diverse range of data sources and methodologies, these reviews can provide a more holistic and nuanced understanding of the multifaceted aspects of human sexuality, ultimately contributing to the development of person-centered and effective interventions in this crucial domain in sex research with cis men.

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From ontological to relational: A scoping review of conceptions of dignity invoked in deliberations on medically assisted death

• Isabelle Martineau 1 ,
• Naïma Hamrouni 1 &
• Johanne Hébert 2  

BMC Medical Ethics volume  25 , Article number:  96 ( 2024 ) Cite this article

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Dignity is omnipresent in Western ethics, but it also provokes dissension and controversy. One of the most striking examples is the debate on medically assisted death, where dignity is invoked to support antagonistic positions. While some authors conclude that the concept is useless as an ethical reference, many others invite us to deepen our analysis from a multidimensional perspective, to enrich it and make it useful. This scoping study is intended to provide an overview of the different conceptions of dignity used in the assisted dying debate, to better grasp the multiple facets of the concept.

The Joanna Briggs Institute's JBI Manual for Evidence Synthesis guided the scoping review. Key words were based on the researchers' expertise and were used to identify relevant literature in French and English. Eleven databases covering the last six decades were consulted. Initially, 2,071 references were found in the databases. After excluding duplicates, screening titles, abstracts, and full texts, and after a specific literature search on the concept of relational dignity, 156 papers were found to match the identified inclusion criteria.

The literature highlights the stark confrontation between two dominant conceptions of dignity: ontological and autonomist. However, a lesser-known conceptualization of dignity integrates these two perspectives, underlining the relational and social dimensions of dignity. As a result, dignity emerges as a dynamic, experiential, and dialogical concept, that modulates itself according to circumstances. This raises the possibility of breaking through the binary debate and questioning the current frameworks that define dignity.

Conclusions

This multidimensional conceptualization of dignity could lead to a more complete and nuanced understanding of the concept, as well as open richer normative horizons regarding the issue of medically assisted death.

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There is no question that Western liberal societies place tremendous value on the concept of human dignity. Indeed, it is striking to note just how often dignity is brought up in everyday language, political and legal discourse [ 1 ], normative ethical arguments [ 2 , 3 ] and the principles underlying professional practices such as nursing [ 4 ]. Thus Rigaux [ 5 ] described a “contemporary explosion” or “overheating” of deliberations on dignity, as witnessed by the reams of related literature. This does not mean, however, that there is any consensus on the interpretation or meaning of dignity. In fact, the definition of dignity and its use are the subject of considerable controversy.

Of all the contemporary issues in the Western world involving the concept of dignity, surely, one of the most patent examples is the controversial issue of legalization and decriminalization of medically assisted death. Footnote 1 In the fierce debate on dignity [ 6 , 7 , 8 , 9 , 10 ], many authors point to the paradoxical use of the concept to support contradictory positions on the practices of euthanasia and assisted suicide [ 7 , 9 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. This antilogy is certainly not without bearing on the position of the many authors who bemoan the multivocity, ambiguity, lack of clarity and “plasticity” of dignity and the lack of consensus regarding its content [ 3 , 4 , 7 , 8 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ], or who go so far as to deem it outright meaningless [ 33 ]. Therefore, some even suggest eliminating references to dignity in all ethical and clinical reflections and adhering to concepts such as respect for autonomy or respect for the individual, which they find to be more effective guides [ 34 , 35 , 36 , 37 ], especially in regard to end-of-life issues, including medically assisted death [ 32 ].

However, these exhortations to ignore the concept of dignity have led to several arguments reasserting its relevance. While some authors point out or deplore the polysemy of the term ‘‘dignity’’ [ 5 , 38 ], for others, the many ways in which dignity has been conceptualized can be a source of fecundity, and an incentive to pursue discussion on the topic [ 1 , 39 ]. Although it is wishful thinking and inappropriate to seek an unequivocal definition of dignity [ 40 , 41 , 42 ], due to its complexity and even its ambiguity, we argue it is essential to explore and better understand its multiple facets and interpretations, and to study them more in depth so that dignity may ultimately prove a useful concept in normative ethics and bioethics [ 1 , 3 , 9 , 16 , 43 , 44 ].

This analysis of the term of dignity and its various uses is even more worthwhile in the specific context of euthanasia and medically assisted suicide, since it seems, according to some, to provide a language within which conflicting values and rights appear to cohabitate [ 1 ]. Moreover, since the concern for dying with dignity is unanimously espoused both by proponents and opponents of medically assisted death [ 11 , 13 , 15 , 39 , 42 , 45 ], if it is better conceptualized, dignity could become a “nodal point” [ 39 ], thus furthering ethical reflection on the issue. At least, this is what Muders [ 33 , 42 ] proposed when he urged us to enrich the concept of human dignity so that it could play a useful role in applied ethics, including in the specific case of medically assisted death. He writes:

although assisted death is still a prominent topic in bioethics, the relevance of human dignity for this debate has not yet found the adequate, multifaceted treatment it deserves, namely a treatment that assembles all important perspectives and positions, examines the arguments that may be enhanced by it, and enriches the yet undertheorized role it currently holds in this debate  ([ 42 ], p.3) .

This is the framework for this scoping review, which aims to explore the various conceptions and uses of the term of dignity in the debate surrounding medically assisted death. This method of analysis is particularly helpful in examining the scope of a complex subject based on vast quantities of heterogeneous literature [ 46 , 47 , 48 ]. It will also make it possible to map the key elements related to the concept [ 46 , 48 , 49 ], highlight potential avenues in future research to enrich ethical reflection, and perhaps even contribute to the treatment of the issues of dignity, medically assisted death, euthanasia, and medically assisted suicide.

Primary question

In the debate on medically assisted death in the past sixty years in North America, Europe, and Australia, what are the main conceptions of dignity, and which ones seem to open up new possibilities?

Subquestions

What are the conceptions on which the practice of medically assisted death is based?

What are the conceptions on which criticism of the practice is based?

Should some of these conceptions be revisited in an effort to enrich the debate?

Review method

A scoping review was conducted based on Joanna Briggs Institute’s 2020 version of the JBI Manual for Evidence Synthesis [ 47 ]. The manual is available at https://jbi-global-wiki.refined.site/space/MANUAL/4687342/Chapter+11%3A+Scoping+reviews .

Research strategy

First, one of the members of the research team, who assisted a committee of Quebec experts exploring the eligibility of incompetent patients for medically assisted death, identified the references relevant to the question of dignity. These documents served as a springboard for reflection. Then, keywords adapted to the specific characteristics of each database were identified with the help of a research librarian (see Table  1 ).

The team subsequently conducted systematic research in eleven databases, two specializing in philosophy, four in biomedical science and five in social sciences and the humanities (Philosopher’s Index, Religion & Philosophy Collection [RPC], CINAHL with Full Text [EBSCOhost], MEDLINE, Cochrane, PubMed, Sociological abstract, SocINDEX, Cairn, JSTOR and Érudit); two multidisciplinary databases [Repère and Scopus]; and two others including grey literature [Google Scholar and Santécom]. The literature review took place between September 2021 and April 2022 and was updated in March 2023.

The Boolean operators “OR” and “AND” were used for text searches in Abstract/Title/Keyword, crossing the following two concepts:

Concept 1: (dignit* OR dignified OR dignif* OR “perceived dignit*” OR “dignity loss” OR “loss of dignity” OR indignit*) AND (conception OR perception OR definition

Concept 2: (Euthanas* OR “right to die” OR “assisted suicide” OR “medical* assisted suicide” OR “medically assisted death” OR “hasten death” OR death OR dying OR “droit à la mort” OR “aide médicale à mourir” OR “suicide assisté”)

Research criteria

Since the goal was to determine the scope and construct a map of the conceptions of dignity related to medically assisted death, the inclusion criteria were intentionally broad. The literature had to (1) have been published since 1960, (2) be published in English or French, and (3) take one of the following forms: experimental, quasi-experimental, evaluation, observational or qualitative protocols; joint studies; philosophical analyses and reflections; trials; or grey literature. The target population was (1) adults and (2) those capable of consenting to assisted in dying. The exclusion criteria were as follows: (1) references published before 1960, (2) were published in a language other than English or French, and (3) were social media or mass media publications.

Selection of references

Initially, 2,071 references were in the databases (for an example, see Fig.  1 ). The reference management software EndNote was used and deleted 187 entries. Thus, 1,884 references were imported into Covidence for the purpose of screening the titles and abstracts. The software program deleted an additional 223 duplicate entries. The remaining 1,661 references were subsequently analyzed in parallel by two members of the research team. A third member made the final decision in the case of disagreement. Thus, with an interrater agreement of 81%, 1,327 references were rejected. Another 122 articles were deleted after discussion within the team. Of these, 110 made only marginal reference to assisted death. The other 12 references were either published in a language other than English or French, were unavailable or were proven to be duplicates. In the end, 212 references were exported to NVivo (R 1.6) for full screening (Fig.  2 ). A few book chapters (37) were also extracted and treated individually. Eighteen references (including 13 from a single collection) were imported on the recommendation of two external experts in the field of assisted death: an ethicist and a jurist. In a March 2023 update, 6 references were added. Finally, during the process, the research team noted what appeared to be the emergence of a literature on “relational dignity”. Although writings embracing a relational conception of dignity were still marginal, the team deemed it pertinent to perform a specific search on this concept, using the same databases. This additional search provided 3 more references. After a full analysis of the literature, 119 references were rejected because they did not meet the selection criteria. In the end, 156 references were codified using NVivo (R 1.6), which made it possible to answer the study’s primary question involving the identification of the different conceptions of dignity used in the debate on medically assisted death.

Example of search strategies

Flow diagram

To codify the references, the principal investigator iteratively developed a grid of typologies of dignity based on the initial readings and the selection of references by title/abstract. After approval by the other two members of the research team, the final version of the grid was adopted.

Charting the data

The majority (51%) of the references included (Additional file 1) were from North America: 51/156 from the United States, 26/156 from Canada, including from Quebec, and 2/156 from both countries. Approximately 41% (64/156) of the included documents were written by Europeans. Of these, 16/156 were from France, 13/156 from the United Kingdom, 7/156 from Germany, 6/156 from Belgium, 5/156 from the Netherlands, and 5/156 from Switzerland. In addition to the five references by Australian authors, two literature reviews were included although they were from Iran and Singapore since almost all of the included documents were written in the West. Additionally, although only 25 of the references were published before 2000, more than 60% (95/156) were published after 2010, testifying to the growing interest in the subject.

Apart from a few framework documents, such as reports of commissions or expert committees, almost all the literature analyzed (134/156, or 86%) comprised reflective or analytical works. Many of them were in the field of philosophy, ethics, or bioethics. Only 7/156 of the documents were scientific literature reviews, three of which were systematic reviews. In addition, six studies were identified, of which only two were specifically aimed at exploring conceptions of dignity from the point of view of people at the end of life [ 14 ] or the elderly [ 50 ]. This vast, heterogeneous collection of literature raises a variety of questions about the nature and function of dignity. For example, what is it that justifies the concept of human dignity? Should it be understood in absolute or in relative and subjective terms [ 27 ]? Can it be considered the basis for human rights [ 51 , 52 ]? More generally speaking, as McCrudden suggested [ 1 ], there are basically two levels in the debates surrounding dignity: the foundational level, or the grounding of the concept, and its ability to provide a guide for human action. By circumscribing the literature to what is relevant to assisted death, we can provide a general overview of the conceptions of dignity employed in discussions on the subject, starting with those whose use, whether to oppose or support euthanasia or assisted suicide, is easiest to define.

Conceptions of dignity that argue against assisted death

Dignity from an ontological perspective, different terms.

Without question, according to the terminology used by several authors, ontological dignity [ 25 , 27 , 30 , 38 , 41 , 51 , 53 , 54 , 55 , 56 , 57 ], that is, a dignity inherent to the human being qua human being, is the most common conception of dignity evoked in the literature on medically assisted death, essentially among those who oppose it. Footnote 2 Other terms are used in a similar fashion, including human dignity [ 4 , 11 , 16 , 19 , 22 , 28 , 38 , 44 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 ]; intrinsic dignity (sometimes referred to as “intrinsic human dignity”) [ 12 , 13 , 15 , 22 , 23 , 25 , 28 , 30 , 38 , 39 , 74 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 ]; inherent dignity [ 9 , 27 , 28 , 53 , 64 , 65 , 75 , 76 , 81 , 83 , 87 , 88 ]; basic or fundamental dignity [ 9 , 17 , 25 , 30 , 51 , 52 , 60 , 75 , 78 , 81 ]; absolute dignity [ 13 , 22 , 27 , 28 , 38 , 53 , 68 , 89 , 90 ]; universal dignity [ 13 , 27 , 28 , 52 , 60 ]; and, finally, objective dignity [ 13 , 15 , 22 , 25 , 51 , 89 , 91 ]. Although some of these terms are at times used differently (for example, human dignity, which is not always understood in the ontological sense Footnote 3 ), overall, the different formulations affirm the idea of unique value [ 92 ] and are recognized as applying to every human being, not because of what they “have” but because of what they “are” [ 20 ] “by virtue of their very existence” [ 53 , 54 ], in other words, unconditional human dignity [ 27 ].

This idea of the inherent dignity of every human being, “indissolubly attached” to the “human family” [ 27 ], has a long tradition [ 66 ]. It can be found as far back as in the writings of Cicero [ 80 , 93 , 94 , 95 ], who alluded to dignity in relation to human beings’ unique ability to learn and contemplate [ 3 ] as well as reason [ 94 ]. Seneca and, more broadly, the Stoic philosophers of ancient Greece, often associated human dignity with the possession of reason [ 74 , 80 ]. However, other groundings for ontological dignity have also been postulated. Specifically, from a religious, and especially Judeo-Christian viewpoint, the unique value of humans is predicated on the fact that they were created in God’s image ( Imago Dei ) [ 3 , 5 , 9 , 12 , 17 , 25 , 28 , 32 , 39 , 56 , 63 , 69 , 73 , 74 , 95 , 96 ]. Although dignity is not an exclusively religious concept [ 65 , 85 , 88 , 95 ], Christian thought, by combining the Stoic notion of rationality and the idea that human beings were created in God’s image, has made ontological dignity a key element of its theology and ethics [ 80 , 85 ] and led to its wide dissemination. It is therefore unsurprising to hear that critics say that dignity has too much of a religious connotation to guide ethical reflection [ 3 , 5 ]. Nevertheless, some authors point out that there are also secular foundations for intrinsic dignity in legal, political, and human rights related arguments [ 85 ]. Many authors mention the determining role of the Universal Declaration of Human Rights published in 1948, which contributed to the rather recent promotion of the concept of dignity, particularly in ethics, bioethics, and law [ 3 , 5 , 12 , 18 , 22 , 25 , 27 , 28 , 34 , 38 , 51 , 53 , 54 , 63 , 65 , 80 , 83 , 97 , 98 ]. At any rate, regardless of its foundation or justification, in ontological terms, dignity admits of neither degree nor relativity; for it is given at the same time as humanity, and refers to the latter's absolute value, its intangibility [ 97 ]. As it does not depend on the gaze of others, (ontological) dignity cannot be conferred or taken away by human decision because it is inalienable and unavailable [ 23 , 25 , 52 , 64 , 69 , 85 , 97 ]. No one can waive their dignity since no one has the power to exile themselves from humanity [ 97 ]. Similarly, no condition or situation can alter it or cause a person to lose it, whether through illness, old age, suffering or even imminent death [ 23 , 39 , 53 , 54 , 62 , 78 , 85 , 99 , 100 ]. Therein lies its connection to respect for human life.

Dignity and sanctity of human life

Ontological dignity applies not only to certain human attributes, such as reason but also, to the entire being, including the physical body. As such, human life has value, independent of any judgment [ 9 , 77 , 78 , 91 , 101 , 102 ], and that justifies its inviolability and respect [ 28 ]. This explains the often-postulated connection between dignity and the sanctity of human life [ 23 , 39 , 69 , 71 , 74 , 101 ]. Obviously, the sanctity of human life can be understood from a religious perspective, where life is considered a gift from God [ 35 , 63 , 99 ], which humans cannot simply manipulate as they please without it being an insult to the sanctity of life or a usurpation of divine authority [ 8 , 99 , 103 ]. This approach clearly leads to an argument against medically assisted death. However, like the concept of ontological dignity, to which it is related, the sanctity of human life is not strictly a religious or Christian idea [ 61 , 89 ]. Some interpretations go so far as to suggest that respect for it may include putting an end to life when it loses its meaning [ 89 ], but these are few and far between.

Conceptions of dignity that argue in favor of assisted death

Dignity from an autonomous perspective.

The second perspective on dignity, copiously used in the debate on medically assisted death, could be referred to as “dignity/autonomy,” as described by Landheer-Cieslak [ 79 ]. In our view, this term can be used as an umbrella notion covering several concepts, such as relative dignity [ 12 , 25 , 39 , 63 , 68 ], contingent dignity [ 39 , 63 , 74 ], subjective dignity [ 3 , 11 , 12 , 15 , 22 , 39 , 60 , 75 , 79 , 80 , 82 , 89 , 91 , 104 ], experienced dignity [ 25 , 80 ], phenomenological dignity  [ 25 ], personal dignity [ 4 , 9 , 11 , 17 , 20 , 22 , 52 , 57 , 58 , 60 , 68 , 73 , 76 , 88 , 105 , 106 , 107 , 108 , 109 ], individual dignity [ 76 , 87 , 110 ] and dignity as freedom [ 38 , 53 , 87 , 97 ] . Despite the nuances in the definitions of these various terms and in the way they are used, they share the same general meaning. More specifically, in arguments in favor of assisted death, these variants support the idea that it is exclusively up to the person concerned to define the conditions under which they can live and die with dignity [ 15 , 89 , 105 , 111 ]. Footnote 4 These are subjective forms of dignity based on an assessment by the person, who feels that they have dignity or that they are losing it [ 27 , 80 ]. In concrete terms, from this perspective, in the case of physical or mental deterioration as a result of a severe illness, for example, a person who deems that they are no longer living with dignity should be able to choose to die [ 24 , 67 , 89 , 93 , 112 , 113 , 114 , 115 , 116 ]. This choice is seen as ensuring dignity, both because it allows the person to escape from a life they deem void of dignity [ 117 ] and that impedes “authentic human freedom” [ 112 ], and because it embodies the exercise of free existential choice [ 115 , 117 , 118 ]. Here, dignity is clearly associated with freedom [ 89 , 117 ] in the sense of self-determination [ 119 ].

While it is possible to trace the concept of dignity as freedom all the way back to Pico della Mirandola (1463‒1494) [ 3 , 80 ], the concept of subjective dignity or dignity as autonomy is more modern [ 9 , 53 , 70 ]. Some authors associate it with Descartes [ 27 , 39 ], who advocated for autonomy and mastery [ 12 ] and who is thought to have inspired the postmodern idea of moral and political emancipation [ 27 ]. Others refer to Kant [ 3 , 70 , 101 , 116 ], although as we shall see below, the reading of Kant is open to disagreement. In any case, several authors embrace this perspective, according to which individual autonomy is the foundation of dignity or, at the very least, is closely related to it [ 90 , 104 , 111 , 112 , 120 , 121 , 122 , 123 , 124 ]. In fact, in Western society and from a more global perspective, the terms “autonomy” and “dignity” are so often used together [ 20 , 29 , 35 , 57 , 67 ], or even combined, that they are sometimes considered synonyms [ 11 , 34 ]. According to some authors, the Anglo-Saxon philosophical, political, legal, and bioethical traditions are undoubtedly responsible for the importance of individual autonomy in this conceptualization of dignity [ 10 , 57 , 119 , 125 ].

Dignity, integrity, and identity

From the perspective of dignity as autonomy, a particularly influential conception is that grounded in respecting a person’s integrity and identity. This vision is part of a narrative or biographical approach to dignity [ 65 , 116 , 126 ], and its most well-known version was described by the American liberal philosopher and jurist Ronald Dworkin in the early 1990s [ 96 ]. According to this approach, human life, from beginning to end, revolves around critical interests. These interests give life coherence and shape, and ensure the person’s integrity, thereby preserving their identity [ 127 ]. Respect for human dignity is based on respect for these critical interests. From the narrative perspective, death is seen as the final chapter in a person’s life [ 128 ] or as the final act of existence, and, since everything is intensified at that point in time, the manner of death can affect the overall character of the person’s life [ 116 , 126 , 127 ]. In other words, when the circumstances of a person’s death go against their convictions regarding their critical interests, it is like a story, says Dworkin, “whose bad ending mars what went before” ([ 127 ], p. 27). As a result, to maintain the integrity and coherence of their life, to show consideration of the values that provide coherence and are at the very core of their self-identity, a person may choose to die and avoid ending their life in a manner that, in their opinion, would betray or be inconsistent with the pursuit of their critical interests [ 127 ]. This person is making sure they die with dignity, since their death will be in line [ 70 ] with the values they have always lived by [ 128 ] and will preserve the integrity of their life until the day they die [ 96 ].

The abovementioned approach contributes to the argument in favor of legalizing medically assisted death for those who ask for it [ 109 , 116 , 128 ] and, as such, it supports the argument made by certain advocacy organizations [ 11 , 45 , 129 ]. Moreover, various official documents granting access to medically assisted death in Quebec, Canada and elsewhere, including reports from advisory boards and other experts, judgments, and legal analyses, are directly or indirectly partly based on Dworkinian theory. In brief, they take up the idea that, to preserve dignity, it is up to the person approaching death to determine what aligns with the aspirations and values (religious or secular, philosophical, etc.) that have guided them up to now and to be able to make their choices accordingly. Footnote 5 Some of the documents go so far as to talk about the right to die [ 12 , 13 , 20 , 32 , 35 , 51 , 67 , 76 , 107 , 130 , 131 , 132 , 133 , 134 ].

The Kantian conception of dignity: Conflicting interpretations and impasse

The Kantian conception is another conception of dignity that cannot be overlooked in the debate on medically assisted death, although it is not without its detractors. It is most often invoked by those who oppose medically assisted death and who ground their opposition in a ontological conception of dignity. For these authors, the fact that Kant’s view is that human beings have absolute value, above all price [ 12 , 18 , 88 , 97 ], which requires that they be treated as an “end in themself,” conforms to this vision of dignity [ 5 , 12 , 22 , 27 , 39 , 54 , 66 , 72 , 74 , 78 , 80 , 84 , 96 , 100 ]. Moreover, although the Kantian view of dignity was not initially religious, theologians, especially Catholics, but also other Christians, integrated it into their doctrine [ 85 ] and into their argument against euthanasia and assisted suicide. Several authors cite Kant’s categorical opposition to suicide [ 5 , 12 , 31 , 41 , 66 , 78 , 95 , 96 , 135 , 136 , 137 ]. By extension, several of them conclude that the Kantian perspective opposes assisted death [ 32 , 41 , 78 ].

However, this widespread interpretation is on the other hand criticized by others [ 70 , 121 , 135 , 136 , 137 , 138 , 139 , 140 ], especially by those who emphasize the importance, in the Kantian view, of rationality, moral autonomy or agency, and personal autonomy Footnote 6 ), as the foundations of dignity [ 3 , 70 , 101 , 116 , 119 , 121 , 125 , 135 , 141 ]. Some of these authors point out that the opportunity to autonomously choose to hasten one’s death to “die in dignity” is consistent with respecting a person’s moral agency and status as a rational being [ 116 , 121 , 140 ]. According to these authors, this is especially true since the end-of-life process, prior to natural death, can alter the rationality (practice) and moral agency upon which, in this view, dignity is based [ 58 , 116 , 119 ]. Some authors go even further, postulating that prohibiting medically assisted death could even run counter to Kantian thought. Footnote 7 For example, according to Lossignol and Dumitrescu [ 68 ], refusing someone the right to die as they wish under the pretext of respecting their dignity (in the ontological sense) is manipulative. In their view, this amounts to using the person as a means to an end decided by others who oppose assisted death (e.g. caregivers), which also conflicts with the Kantian principle of non-instrumentalization.

Given these divergent and deeply conflicting interpretations of the Kantian perspective, when it comes to debating the issue of medically assisted death and the role dignity plays in it, some analysts conclude that the concept is ambiguous [ 74 ] and of no use in furthering reflection. In its report End-of-Life Decision Making , the Royal Society of Canada Expert Panel states that “the influential Kantian approach to ethics does not provide an unequivocal ethical guidance and justification on the issue of assisted dying” [ 32 ], suggesting that the divide between the different Kantian interpretations can only lead to an impasse on the subject.

Minority views on dignity and their ambiguous role in medically assisted death

In addition to the conceptions previously discussed, the literature addresses a few other, lesser-known views of dignity. One of them can be termed dignity as a virtue or flourishing dignity , based on the Aristotelian tradition, and essentially refers to dignified conduct or a dignified nature, admirable for its virtue [ 20 , 38 , 52 , 70 , 74 , 77 , 78 , 84 , 85 , 86 , 88 , 96 , 126 , 136 ]. There is also dignity as status or attributed dignity , which is based on the value conferred on a person by others according to a certain scale [ 52 , 78 , 85 , 86 , 99 , 135 ]. Many authors also cite the etymological meaning of the Latin word dignus and the Roman concept of dignitas , which essentially refers to a recognized value, deserving of honor, respect, or esteem [ 3 , 5 , 10 , 12 , 51 , 58 , 70 , 72 , 86 , 101 , 113 , 135 ].

These conceptions, like some of those found sparingly in the literature (e.g., dignity as decency [ 38 , 53 , 54 , 97 ] and esthetic decency [ 9 ], etc.), do not play a clearly defined role in the debate on medically assisted death. In a way similar to Kantian’s interpretations of dignity, because of divergent readings of his philosophy, these conceptions (of dignity as virtue, as status or decency) can be used to argue against or in favor of the practice. In addition, many of these definitions of dignity overlap, which makes it difficult, if not impossible, to provide a clear and exhaustive overview of the different terms. For example, Van Brussel [ 74 ] used external dignity to cover everything to do with a person’s conduct (dignity as a virtue ), social status ( attributed dignity ) and self-identify ( narrative dignity ), although the latter appears to be somehow better described as internal than external. Given all of this, it is easy to understand why some authors believe that the concept of dignity is too “vague” [ 16 ] and not of much use in regard to ethical reflection.

Relational dignity: a relatively unexplored conception

Although it remains relatively marginal, another conception of dignity articulated in discussions on medically assisted death is that of “relational dignity”. In fact, many authors, including those who endorse the dominant conceptions of dignity, already mention the influence of relational or social elements in the experience of dignity, even if they do not make these elements central to their definition of the concept [ 3 , 19 , 24 , 25 , 39 , 53 , 54 , 57 , 61 , 65 , 77 , 78 , 90 , 92 , 93 , 104 , 109 , 114 , 121 , 122 , 124 , 126 , 128 , 142 , 143 , 144 , 145 ]. For example, some address the impact of other people's perceptions (particularly those of family and friends) on a person’s sense of dignity, especially when the person is ill and dependent [ 10 , 19 , 21 , 25 , 73 , 82 , 83 , 95 ]. Others evoke the inexorable interdependence of human beings, sometimes criticizing the contemporary social tendency to value personal autonomy (in the sense of independence) and individualism [ 20 , 44 , 57 , 62 , 75 , 88 , 92 , 108 , 146 , 147 ] or self-sufficiency [ 71 , 73 ]. Regarding this social or collective point of view, several authors mention how the prevailing culture, societal values or the state and its laws tend (or have the power) to shape the way dignity is conceived in the context of end-of-life choices, and medically assisted death [ 8 , 9 , 10 , 13 , 16 , 25 , 26 , 28 , 50 , 69 , 71 , 73 , 76 , 82 , 92 , 95 , 106 , 124 , 125 , 126 , 141 , 148 , 149 , 150 , 151 , 152 , 153 , 154 ]. Authors of religious persuasion, such as Daly [ 16 ], Schirrmacher [ 71 ] and Engelhardt [ 106 ], are particularly critical in this respect. Others note the influence of messages conveyed by the media about end-of-life choices [ 74 , 142 ].

In terms of research on the desire to hasten death, a few studies have been conducted among sick patients and seniors [ 14 , 50 , 75 , 155 ], as well as some conceptual and discursive analyses [ 4 , 10 ] and various literature reviews [ 30 , 57 , 108 , 156 ]. They empirically confirm the importance of the relational dimension in the way people come to experience a sense of dignity or, conversely, the loss of a sense of their own dignity. For example, the fear of dependence and having to be reliant on others [ 155 ] or of being seen as a burden, both by loved ones and by society at large, tends to undermine the sense of dignity of sick patients, the elderly and people approaching the end of life, and to affect their perception of their identity [ 50 , 57 , 75 ]. Apprehension of losing one’s dignity could be experienced through encounters with others and, therefore, the experience of dignity is no longer merely a personal issue, but an intersubjective issue [ 83 ] as well as a social and structural one. However, few authors explicitly discuss the conception of relational dignity [ 3 , 10 , 28 , 50 , 56 , 80 , 110 ]. Moreover, among those who do, there seems a lack of conceptual and theoretical normative underpinnings. Care ethicist Carlo Leget [ 80 ] appears to be an exception to the rule, advancing a relational conception of dignity (he uses the term “social/relational dignity"), his perspective being based on the research of psychiatrist and expert in palliative care Harvey Chochinov [ 14 ], philosopher Paul Ricoeur’s “little ethics,” and the ethics of care . This conception of dignity is notable in that it places the relational dimension at its heart, while at the same time connecting it to the conceptions of dignity usually encountered in the debate on assisted dying.

Groundings and possible connections with subjective and ontological dignity

Like some care ethicists, including Berenice Fisher and Joan Tronto, Leget [ 80 ] emphasizes how a person’s moral conceptions are defined based on the social practices in their surroundings. Thus, the understanding of dignity a person acquires and, by extension, the view they have of their own dignity will be vastly different if they are raised in a culture that values intrinsic dignity or in one that considers it a metaphysical aberration [ 80 ]. Based on Ricoeur’s work, Leget argues that self-respect and one’s perception of one’s own dignity, which go hand in hand with a “good life,” depend heavily on the recognition of others. They are therefore closely linked to attitudes of respect and care, which ensure the cohesion of communities and make personal fulfillment possible. Thus, for Leget [ 80 ], social/relational dignity “genealogically” and “systematically” generates subjective dignity , since the former, through manifestations of recognition, is the basis for the latter. This dynamic can be seen not only in communities but also at the heart of interpersonal relationships. This was clearly demonstrated by the research that led to Chochinov’s dignity therapy , a palliative intervention that helps heighten the sense of dignity of patients near the end of life. According to Leget [ 80 ], ontological or intrinsic dignity serves as a “counterfactual” moral landmark in the cultural landscape, thereby helping create or consolidate institutions that ensure a certain amount of stability and continuity in communities. Leget’s perspective [ 80 ], in which relational dignity is part of a tripartite model along with the subjective and intrinsic conceptions of dignity, does not appear, however, to have made its way into the literature on medically assisted death. In contrast, as this review has shown so far, the literature reveals a persistent gap between the two main conceptions of dignity involved in the discussion.

Dignity and assisted death: a persistent debate between two conceptions

Counterarguments.

Different conceptions of dignity have evolved outside the two main perspectives (ontological dignity and dignity as autonomy) solicited in the dialog on medically assisted death. However, the literature review shows not only how dominant these two perspectives are, but also how much they tend to be used on opposite sides of the debate. In this sense, the concept of dignity appears to stall more than advance the dialog between proponents and opponents of medically assisted death. Burnier [ 157 ] laments the “duologue,” the dichotomous thinking that dismisses the other party’s perspective, tending to evacuate the polysemy of the concept. It is true that the counterarguments on both sides of the debate are often rather mordant.

On the one hand, opponents and critics of euthanasia and assisted suicide condemn several aspects of the conception of dignity as autonomy. In general, they criticize the promotion of individualism [ 145 , 146 ], akin to subjectivism [ 27 , 77 , 102 ], which rejects the interdependence inherent to the human condition [ 6 , 28 , 39 , 62 , 65 , 92 , 136 , 147 , 158 ]; undermines the general sense of the social and community life [ 19 , 38 , 97 , 143 ]; and, in the case of people in a position of dependence, can contribute to intensifying the feeling of being a burden [ 11 , 13 , 19 , 50 , 71 , 73 , 105 , 124 , 148 , 158 , 159 ]. More specifically, and perhaps as a criticism of the narrative conception of dignity, they condemn the idea of a dualistic anthropology that seems to give priority to the life of the mind, notably by prioritizing self-determination, the exercise of personal autonomy and freedom, and by depreciating mere biological human life, limited to an instrumental role [ 53 , 54 , 77 , 78 , 88 ] . In their view, the Dworkinian notions of identity and integrity are based on an illusion, that of human independence and absolute, limitless control over one’s own life [ 44 , 65 , 69 , 73 , 92 , 158 ]. They find it even more incongruous in the socioeconomic context in which, for years, the range of options has constantly been reduced due to resources scarcity and utilitarian-guided governmental cuts in health care [ 57 , 160 ], which have a more significant impact on those on the margins of society, whose needs are the greatest [ 11 , 149 , 150 ].

Additionally, many critics point to what they consider to be a fundamental contradiction. While respect for autonomy and dignity is the main argument used to support the right to medically assisted death in the case of a person who is suffering, these critics believe that some of the mechanisms for regulating the practice not only contradict this principle, but also promote discrimination. For example, in countries that sanction medically assisted death, access to the practice requires that a third person (often a physician) certifies that the person meets the MAID eligibility criteria. As a result, the evaluation of the life and dignity of the person who is requesting to die becomes a shared responsibility. Some authors interpret this as a sort of “heteroevaluation” or “heterodetermination” that goes against respect for a person’s autonomy and calls into question the purported neutrality of the third-party evaluator. In their view, the latter's involvement contributes to categorizing, or at least confirming, certain lives as unworthy [ 6 , 28 , 38 , 77 , 78 , 82 , 91 , 92 , 124 , 151 ]. Moreover, in the case of adults capable of exercising autonomy, these authors question the implementation of criteria (e.g., suffering or terminal illness) restricting access to assisted death [ 39 ] because, in addition to seeming discriminatory [ 78 ], these criteria appear to encourage a substantial evaluation (by a third party) of the person’s reasons for wanting to die [ 134 ]. Some critics also point out that, ironically, the procedures for obtaining approval for medically assisted death and the intervention itself (especially in the case of euthanasia) give physicians undue power and contribute to the medicalization of death [ 57 , 131 ]. Whereas the initial objective, as many proponents of medically assisted death point out, was to support the autonomy (or the dignity as autonomy) of persons approaching the end of life by promoting freedom from medical power and futile medical care [ 13 , 39 , 69 , 77 , 112 , 122 , 132 , 133 , 150 ].

On the other hand, many supporters of medically assisted death strongly criticize the conception of ontological dignity and the role it plays in the debate. To them, the idea of “everlasting” dignity appears to contradict, or reject, the experience of people nearing the end of life, while the sense or fear of losing their dignity is one of the main reasons why people request medically assisted death [ 4 , 14 , 24 , 59 , 94 , 136 , 144 , 155 , 161 , 162 , 163 , 164 ]. The seriously ill, for whom dignity is an invaluable possession, experience that sense or fear very keenly [ 10 , 11 , 14 , 24 , 27 , 83 ]. The conditions frequently identified by authors as potential threats to a sense of dignity include physical and mental decline and, more broadly, suffering [ 13 , 20 , 39 , 94 , 112 , 115 , 117 , 132 , 136 , 164 ]. In particular, situations in which a human being is so dependent that they are incapable of expressing and carrying out their wishes or making key choices, according to their conceptions and personal values, and are therefore subject to heteronomy [ 79 ], are often described as unbearable, undignified, subhuman and “worse than death” [ 13 , 21 , 67 , 111 , 112 , 116 , 118 , 122 , 123 , 132 , 147 , 159 , 161 , 164 ]. On the other hand, elements such as decision-making ability, self-determination [ 12 , 30 , 113 ] and physical control [ 30 , 35 ], especially when it comes to basic human needs (e.g., elimination), are crucial for materially preserving a person’s view of themself and their sense of dignity [ 10 , 30 , 73 ]. Considering these concrete and physical realities, which demand compassion, ontological dignity may be too abstract a concept, real only in an intellectual sense, and somewhat disconnected from these experiences [ 11 , 27 , 80 , 94 ].

Another criticism of ontological dignity is that it is too strongly affiliated with religious metaphysics [ 3 , 20 , 32 , 35 ], especially because of its relationship with the principle of the sanctity of human life [ 90 ]. Consequently, some authors associate it with perfectionist and paternalistic aims [ 39 , 51 , 103 , 104 , 112 , 120 ], or with the imposition of moral norms removed from what they see as actual human experience [ 68 ]. For the critics of ontological dignity, this perspective is irreconcilable with the political liberalism of pluralistic and democratic occidental societies [ 35 , 76 , 82 ] where the emphasis is placed on personal autonomy and morality [ 19 , 112 , 119 , 120 , 134 ]. It is up to the individual alone, not society or the state Footnote 8 to determine their own vision of a good life [ 132 ]. From this perspective, the ontological conception of dignity should give way to a subjective conception of dignity, a conception based on what patients themselves have to say about the matter [ 68 , 104 ].

The gap between the main conceptions of dignity

In recent years, in more and more places, the century-old ban on assisted death based on the sanctity of human life and intrinsic dignity has been giving way to a more liberal approach to medically assisted death Under this view, as we saw previously, where dignity is reconceptualised in such a way as to support freedom of choice and respect for moral and personal autonomy [ 13 , 27 , 74 , 87 , 119 , 120 , 130 , 132 ]. This trend is apparent in Anglo-Saxon countries, including the United States, England, Australia, and Canada [ 32 , 76 , 87 , 123 , 165 ], as well as in countries such as Germany [ 134 ], France [ 38 ], Spain [ 120 ] and Belgium [ 112 ]. This evolving situation brings the public debate on euthanasia and assisted suicide back to the fore. In this context, some authors note that proponents and opponents are still confronting each other, as the “combat” or “controversy” continues [ 12 , 21 , 38 , 157 , 166 ], and each side is trying to delegitimize the other’s arguments, including its different interpretation of the concept of dignity. These seemingly irreconcilable views prompt some authors to conclude that the concept has been instrumentalized to support the ideological goals of both sides [ 18 , 80 , 137 ]. Some authors bemoan the impasse in a debate where both sides are rigid and immovable [ 17 ], and some believe that dignity is being employed like an empty slogan [ 12 , 21 , 25 , 28 , 34 , 39 , 84 , 91 , 143 , 146 ] or a rhetorical element used as a conversation stopper [ 55 , 65 , 95 , 138 , 140 ].

In this context, following his analysis of the Consultative Commission discussions that preceded the legalization of medical aid in dying in Quebec, Burnier [ 12 ] urges us to move beyond such binary and polarized discourse. Many others agree [ 17 , 33 ]. This is even more important since the two main perspectives in the debate could each have moral legitimacy [ 109 ] and be incorporated into a single theory of dignity [ 33 ].

Dominant views on dignity and the desire to overcome the impasse

This scoping review is limited to the literature on dignity in the context of medically assisted death. Most of the texts reviewed are philosophical, reflective and argumentative. Many of them refer to the underlying conceptions of dignity that support the two principal stances on medically assisted death (for and against), and often provide justification for one or the other. As previously discussed, the two predominant conceptions of dignity (dignity as autonomy and ontological dignity) are different but important angles from which to shed light on the issue of medically assisted death [ 108 ]. But, as we have just seen, they tend to be placed in opposition to each other, which ultimately leads the debate into an impasse. The question is: what strategies can be employed to move beyond this binary discourse?

Claiming the relational dimension of dignity

To begin with, in order to distance ourselves from the fragmented perspectives on dignity, as some authors suggest, it might be useful to identify the elements that unify the various approaches to the concept of dignity [ 80 ]. On closer examination, our review of the different conceptions of dignity almost systematically highlights the principle of respect as a fundamental element. In the literature reviewed, this principle takes two forms: self-respect and respect from others [ 73 , 93 , 95 ]. Self-respect refers to the positive perception we have of ourselves, which also sustains self-esteem or even fuels pride [ 14 , 101 , 113 ]. It is therefore associated with subjective dignity or dignity as autonomy [ 39 , 75 , 80 , 93 , 113 ]. Respect from others concerns the way in which others, society as a whole or institutions perceive and treat people [ 93 ].

Respect from others is all the more important because, according to some, it is an essential condition for maintaining self-respect [ 116 ]. To illustrate, in the early stages of human development, self-respect or a sense of subjective dignity is initially reflected by the image mirrored by one’s parents. Subsequently this self-respect must be continually nurtured through interpersonal relationships throughout one’s life [ 10 ]. In fact, reciprocal recognition (i.e., seeing oneself in others) is fundamental to establishing any relationship, and underpins personal and social self-determination [ 61 , 95 ]. Indeed, some argue that this mutual recognition is essential not only for defining oneself, but also for shaping one's social world [ 61 ]. In ethical terms, this mutual recognition can contribute to self-respect by opening up an intersubjective space of shared validation, where individuals can assess their conduct and perceive themselves in an honorable light through the eyes of others [ 95 ]. We believe that this process, where self-respect is developed and the individual defined through a dialogical dynamic between “self and other,” holds very great promise for understanding and appreciating the inherently relational dimension of dignity.

Respect (both self-respect and respect from others), and its relationality, plays a fundamental role in various conceptions of dignity. Recognizing this commonality can serve as an initial step for building bridges between approaches to dignity seen as fundamentally opposed. Nevertheless, the relational conception of dignity is still insufficiently explored and would warrant greater attention in future discussions.

A multidimensional view of dignity worth exploring

The multidimensional perspective on dignity articulated by Leget stands out in our review as particularly interesting. This approach aims to integrate the concerns of both traditional conceptions of dignity (both subjective/autonomist and ontological) and, drawing on Ricoeur’s work [ 167 ], emphasizes the “social and relational” dimension of dignity, a focus recently highlighted by care ethicists and feminist philosophers. In fact, Leget, building on Ricoeurian and relational care ethics, proposes a multidimensional conception of dignity not to challenge traditional views or resolve debates but rather aims to provide a possible way out of the ongoing conflict between them and to circumvent the impasse. While this scoping review does not claim that this approach is the key to the debate (which would require further philosophical and argumentative study to verify), it appears worthy of further exploration for three reasons.

The first idea worth considering about this multidimensional conception of dignity is its overlap with the concerns of ethical and feminist philosophers. Indeed, since the late 1990s, ethical and feminist philosophers have highlighted the deeply relational dimension of human life. And they have emphasized the (potentially oppressive) socio-cultural contexts within which individual preferences and choices are formed, shaped, directed, exercised, or constrained. In recent decades, several feminist philosophers have also emphasized the central role that “others” play in identity formation and self-perception. Namely, we can think of philosopher Margaret Urban Walker [ 168 ], who is rethinking the notion of dignity by advocating for a conception she describes as “humanized,” which is to be understood in a “fully relational” sense. She argues that an adequate understanding of dignity should not be limited to recognizing attributes of agency and rationality in human subjects (i.e., confined to seeing human dignity solely as the full and free exercise of rational attributes). In fact, for her, dignity should also consider “The relations and responses […] that join us in what human beings recognize as particularly modes of connection […] in and through which we learn responses, responsibilities, and feelings that embody appropriate acknowledgments” ([ 168 ], p. 177). That is why she suggests that dignity is an “interpersonally effective standing” ([ 168 ], p. 179). Just as Leget talks about dignity as an “intersubjective category,” it seems inconceivable to Walker to conceptualize it independently of its deeply relational dimension.

The second idea worth considering concerning Leget’s multidimensional conception of dignity is its “synergistic” quality. Indeed, for Leget, dignity should be conceived as the product of a synergy between three fundamental dimensions: (1) the subjective dimension, (2) the intrinsic dimension, and (3) the social/relational dimension of dignity. Although each of these dimensions has its own gaps and limitations when considered in isolation, conceiving them as interconnected and synergistic would, in his view, mitigate their specific weaknesses and provide a more precise and complete understanding of dignity.

The third significant aspect of Leget’s multidimensional conception of dignity is its recognition of the dynamic and fluid nature of dignity. This intuition, often overlooked by traditional conceptions of dignity, is supported by empirical studies. Indeed, some authors working on medically assisted death show that the sense of one’s own dignity is dynamic, unstable, and vulnerable. It evolves over time and varies according to individual and collective contexts. For example, in their analysis of qualitative studies, Rodríguez-Prat and Leeuwen [ 57 ] observed that the feeling of dignity among people who wish to hasten their death is influenced by several factors, including social (or relational), as well as physical, psychological, and spiritual factors, which in turn are further shaped by the experience of severe illness. At the societal level, the ontological or intrinsic notion of dignity, typically regarded as stable and a moral benchmark [ 9 ], is also described by Leget [ 80 ] as dynamic and unstable. He argues that dignity is vulnerable, and subject to being undermined or contested (he precises that conceptions of intrinsic dignity "are as vulnerable as their authority or plausibility is" ([ 80 ], p. 949).

Arguing that “[c]oncepts like dignity are powerful tools to organize the world we live in” ([ 80 ], p. 950), Leget analyzes what he calls “dying with dignity” through the lens of care ethics, applying his multidimensional conception of dignity in practice. He concludes that “dying with dignity should refer to a situation in which both the dying person is supported in his or her self-esteem and those surrounding the dying person act out of solicitude upholding an attitude of respect ” ([ 80 ], p. 952), our emphasis). Dignity, which is not conceived outside the intersubjective space, is “constituted and upheld by people who are interrelated in caring relationships” ([ 80 ], p. 952). Again, Leget aligns with Walker [ 168 ], for whom dignity, as an ideal of human interaction, recognition, and concern, has “a normative power.” We find these ideas particularly compelling when considering medically assisted death, as they suggest that the phenomenon extends well beyond individual choices [ 149 ] and also engages ethical considerations that clearly impact society as a whole.

Social issues to be clarified in relation to the ordinary concept of dignity

From a societal perspective, enhancing our comprehension of dignity in the context of medically assisted death is crucial, given its omnipresence in the public space and discussions, debates, and media coverage [ 74 , 142 ]. Among other things, the ordinary concept of dignity and common discourses on dignity—specifically the ones surrounding dying with dignity —makes dignity a tool for constructing ways of thinking and acting [ 10 ]. However, similar to other practical language tools, the term "dignity" can be misleading, or even be harmful if it is used in a way that has a negative effect on specific categories of already oppressed or marginalized people [ 80 ].

In this context, some studies highlight several issues affecting severely ill or elderly people: the stigma and exclusion they experience their apprehension of becoming a burden or losing control over their lives, the belief that such a life is not worth living, and the link between these factors and the desire to hasten death [ 30 , 57 , 75 , 155 ]. Such studies point to unresolved questions and underscore the need for further research at the theoretical, argumentative, and empirical level. How significantly do prevailing views on the nature of dignity at the end of life shape the self-perceptions of gravely ill individuals and influence their consideration of assisted dying? Is it possible that these people have internalized negative stereotypes that portray dependency, vulnerability, and old age as undignified states of being [ 75 ]? Does the prevalent conception of dignity, when closely associated with control, inevitably result in choosing to hasten death [ 10 , 169 ]? Does this preclude the possibility of considering other perspectives and making different choices? Could it be that the high value Western societies place on autonomy, independence and self-sufficiency actually undermines those who are no longer autonomous, stripping them of their identity [ 14 ] and, consequently, of their dignity? Such questions deserve further research and debate.

Recommendations

Like some authors, we postulate the importance of identifying and examining the ideas, frameworks and influences that, in our societies, define the contours of dignity and associated concepts such as dependence and vulnerability [ 75 , 92 , 170 ]. We could achieve this by exploring the understanding of dignity held by those who are considering medically assisted death, while also highlighting the prevalent ideas and discourses in the collective space. In this respect, Leget’s [ 80 ] multifaceted conception seems to us an interesting tool to explore. Especially since this approach doesn't seem to have been really taken up yet. First and foremost, this exercise would help us better understand the subtleties of the construction, experience and understanding of dignity, allowing us to break away from what some authors condemn as the dominance of narrow and uniform discourse on what constitutes a “good death” [ 169 ]. Second, the analysis would fuel and elevate the discussion on medically assisted death above the current binary discourse and disembodied theoretical debate. This approach is even more relevant since medically assisted death is still one of the most socially and politically controversial issues in North America and Europe [ 39 ]. Additionally, considering the small number of empirical studies identified in this Scoping Review, there seems to be a need for more empirical data about conceptions of dignity as embraced by individuals themselves, irrespective of the different theoretical approaches review here. For example, in Quah et al.’s [ 156 ] systematic review of “Stakeholder Perspectives of Dignity and Assisted Dying” between 2001 and 2021 of the 663 references initially reviewed, 88 were selected, and only 13 specifically addressed the patients’ point of view on medically assisted death. Of these, only 4 were studies conducted among patients.

Limitations

This review was limited to references in English and French, which inevitably limit its scope. In addition, our focus was put on a Western perspective of dignity and was therefore necessarily colored by dominant Western values. This choice, since the debate surrounding medically assisted death is most prevalent in North America, Europe or Australia, have necessarily resulted in the neglect of other perspectives nourished in other cultures. For example, discussions based on Confucian [ 171 , 172 ] or Buddhist [ 173 ] ethics were not considered, although they would probably have provided complementary points of view. Future comparative analyses by culture could be beneficial.

Although, as Muders [ 42 ] asserts, dignity has not yet found its rightful place, and the multifaceted analysis it deserves in the debate on medically assisted death, the avenues for reflection proposed by Leget [ 80 ] could help remedy these shortcomings. By taking a more in-depth look at the relational aspect of dignity without ignoring its other, more “traditional” dimensions, we could come to a more comprehensive and nuanced conception of the concept that might, as Dige [ 17 ] hopes, make room for normatively richer positions on an issue as sensitive for our societies as medically assisted death.

Availability of data and materials

No datasets were generated or analysed during the current study.

In this paper, the term «medically assisted death» refers both to euthanasia, known in Quebec and Canada as ‘‘Medical Aid in Dying’’ (MAID), and to assisted suicide, which is legalized in some American states and in Switzerland, for example, and which in Canada is also covered by the term ‘‘Medical Aid in Dying’’. All terms will be used interchangeably in this article.

However, a minority of authors differ. For instance, authors such as Kuře [ 20 ] or Ferry [ 61 ] consider that human or ontological dignity does not necessarily imply an absolute ban on all forms of assisted death. In this vein, Reichstein [ 110 ] goes so far as to assert that intrinsic dignity can justify medically assisted death.

The expression "human dignity" carries a broad range of meanings, and apart from more religious perspectives, it is not necessarily synonymous with "ontological and inalienable dignity". For example, many authors simply use it as a generic term to evoke the value inherent to human beings. It can then refer not only to ontological, intrinsic or inalienable dignity but also, to other conceptions (such as subjective and relative dignity), be linked to certain human attributes (e.g. reason), or, in the legal field, be claimed as the foundation of human rights [ 3 , 7 , 9 , 12 , 13 , 17 , 24 , 25 , 31 , 39 , 41 , 42 , 51 , 53 , 54 , 76 , 77 , 78 , 85 , 87 , 88 , 90 , 94 , 95 , 96 , 101 , 109 , 110 , 116 , 124 , 125 , 126 , 132 , 134 , 140 ].

Although this generalization is indeed possible, variations are nonetheless noted in the literature using these expressions. For some authors, contingent dignity is more of a "socially attributed" dignity, which can be attached to action, position or social rank, or be conferred y virtue of a dignified character [ 124 , 138 , 140 ]. Moreover, according to Landheer-Cieslak [ 79 ], dignity/autonomy is constitutive of dignity/subjective, which also includes dignity/safety. For her, the first two expressions must therefore be understood as synonymous. Personal dignity can also take on different meanings. Gormally [ 77 ] and Lee and George [ 81 ], for example, refer to it in the sense of what Kass [ 52 ] calls "full human dignity", i.e., human dignity that unfolds through choices that enable fulfillment in objective common goods. Others conceive of it, or use it in a way that evokes human or intrinsic dignity [ 78 , 154 ]. Still, others see it as the foundation of a "right to respect" [ 65 ], or associate it with a sense of worth [ 73 , 88 ], without supporting the choice of medically assisted death. Conversely, for some, personal dignity is a subjective term that should support (according to legal developments) the choice to decide when to die [ 76 ].

Obviously, the choice of an assisted death remains within the limits of the eligibility criteria established by the law of the state concerned. These may, however, gradually evolve, as is the case in Canada and Quebec.

Moral autonomy or agency can be understood as the capacity to give oneself the moral law, rather than conforming blindly to the injunctions of others. Personal autonomy, on the other hand, refers to the capacity to form, revise and pursue one's own conception of the good life (regardless of the moral content of this life plan).

Among others, Dige [ 17 ] reports the following quotation which, in his view, justifies an (exceptional) openness to suicide and, therefore, in our context, to medical aid in dying: "If a man can preserve his life in no other way than by dishonouring his humanity, he ought rather to sacrifice it. (…) what matters is that, so long as he lives, he should live honourably, and not dishonour the dignity of humanity" (Kant, 1997), In Lectures on Ethics. New York: Cambridge University Press. Kerstein [ 139 ], for his part, suggests an "unorthodox" reading of Kant in which, morally, the prohibition on treating the rational being as a means permits assisted death, while admitting that this nevertheless entails the disappearance of the person, who remains ultimately the source of absolute dignity.

From a political liberalism perspective, the religious ban on assisted dying can be embraced as a principle guiding personal life and choices but cannot serve as a foundation for common law in a secular state.

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Acknowledgements

The authors would like to thank Didier Dupont for his invaluable support in using N-Vivo, and Marie-Josée Lauzière for her help with the literature search.

The first author (IM) received funding for this work from: the Social Sciences and Humanities Research Council of Canada (Joseph-Armand Bombardier Canada Graduate Scholarships) and from the MES-Universities program’s doctoral scholarship for emerging nursing professors, with RRSIQ university counterpart allocation. The second author (NM) holds a Canada Research Chair.

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Martineau, I., Hamrouni, N. & Hébert, J. From ontological to relational: A scoping review of conceptions of dignity invoked in deliberations on medically assisted death. BMC Med Ethics 25 , 96 (2024). https://doi.org/10.1186/s12910-024-01095-z

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DOI : https://doi.org/10.1186/s12910-024-01095-z

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