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• v.14(4); 2022 Aug

Narrative Reviews: Flexible, Rigorous, and Practical

Javeed sukhera.

Javeed Sukhera, MD, PhD, FRCPC , is Chair/Chief, Department of Psychiatry, Institute of Living and Hartford Hospital

Introduction

Narrative reviews are a type of knowledge synthesis grounded in a distinct research tradition. They are often framed as non-systematic, which implies that there is a hierarchy of evidence placing narrative reviews below other review forms. 1 However, narrative reviews are highly useful to medical educators and researchers. While a systematic review often focuses on a narrow question in a specific context, with a prespecified method to synthesize findings from similar studies, a narrative review can include a wide variety of studies and provide an overall summary, with interpretation and critique. 1 Examples of narrative review types include state-of-the-art, critical, and integrative reviews, among many others.

Foundations

Narrative reviews are situated within diverse disciplines in the social sciences and humanities. Most forms of narrative reviews align with subjectivist and interpretivist paradigms. These worldviews emphasize that reality is subjective and dynamic. They contrast with the positivist and post-positivist worldviews that are the foundations of systematic reviews: a single reality can be known through experimental research. Unlike systematic reviews, narrative reviews offer researchers the ability to synthesize multiple points of view and harness unique review team perspectives, which will shape the analysis. Therefore, insights gained from a narrative review will vary depending on the individual, organizational, or historical contexts in which the review was conducted. 1 - 5

Why Choose a Narrative Review?

Narrative reviews allow researchers to describe what is known on a topic while conducting a subjective examination and critique of an entire body of literature. Authors can describe the topic's current status while providing insights on advancing the field, new theories, or current evidence viewed from different or unusual perspectives. 3 Therefore, such reviews can be useful by exploring topics that are under-researched as well as for new insights or ways of thinking regarding well-developed, robustly researched fields.

Narrative reviews are often useful for topics that require a meaningful synthesis of research evidence that may be complex or broad and that require detailed, nuanced description and interpretation. 1 See Boxes 1 and 2 for resources on writing a narrative review as well as a case example of a program director's use of a narrative review for an interprofessional education experience. This Journal of Graduate Medical Education (JGME) special review series will continue to use the Case of Dr. Smith to consider the same question using different review methodologies.

Box 1 The Case of Dr. Smith

Dr. Smith, a program director, has been tasked to develop an interprofessional education (IPE) experience for the residency program. Dr. Smith decides that conducting a literature review would be a savvy way to examine the existing evidence and generate a publication useful to others. Using PubMed and a general subject search with “interprofessional education,” Dr. Smith identifies 24 000 matches. Dr. Smith begins to randomly sample the papers and notes the huge diversity of types and approaches: randomized trials, qualitative investigations, critical perspectives, and more.

Dr. Smith decides to do a meta-narrative review, because she notes that there are tensions and contradictions in the ways in which IPE is discussed by different health professions education communities, such as in nursing literature vs in medical journals.

Box 2 Resources

Ferrari R. Writing narrative style literature reviews. Med Writing . 2015;24(4):230-235. doi: 10.1179/2047480615Z.000000000329

Green BN, Johnson CD, Adams A. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Chiropr Med . 2006;5(3):101-117. doi: 10.1016/S0899-3467(07)60142-6

Gregory AT, Denniss AR. An introduction to writing narrative and systematic reviews—tasks, tips and traps for aspiring authors. Heart Lung Circ . 2018;27(7):893-898. doi: 10.1016/j.hlc.2018.03.027

Murphy CM. Writing an effective review article. J Med Toxicol . 2012;8(2):89-90. doi: 10.1007/s13181-012-0234-2

Process and Rigor

While each type of narrative review has its own associated markers of rigor, the following guidelines are broadly applicable to narrative reviews and can help readers critically appraise their quality. These principles may also guide researchers who wish to conduct narrative reviews. When engaging with a narrative review as a reader or a researcher, scholars are advised to be conversant with the following 5 foundational elements of narrative reviews.

Rationale for a Narrative Review

First, scholars should consider the framing of the research question. Does the topic being studied align with the type of knowledge synthesis performed through a narrative review? Authors should have a clear research question and a specific audience target. Authors should also provide a rationale for why a narrative review method was chosen. 6 The manuscript should include the initial research question as well as details about any iterative refinements to the question.

Clarity of Boundaries, Scope, and Definitions

Second, although narrative reviews do not typically involve strict predetermined inclusion or exclusion criteria, scholars should explicitly demarcate the boundaries and scope of their topic. They should also clearly define key terms related to the topic and research question and any definitions used. Authors should elaborate why they chose a particular definition if others were available. As narrative reviews are flexible, the initial scope may change through the review process. In such circumstances, authors should provide reasonable justification for the evolution of inclusion and exclusion criteria and a description of how this affected the literature search.

Justification for Inclusion and Exclusion Criteria

Third, authors of narrative reviews should explain which search terms and databases were included in the synthesis and why. For example, did authors include research studies from a particular database, time frame, or study design? Did they include commentaries or empirical articles? Did they include grey literature such as trade publications, reports, or digital media? Each of the authors' choices should be outlined with appropriate reasoning. 7 Narrative reviews tend to be iterative and involve multiple cycles of searching, analysis, and interpretation. High-quality narrative reviews usually include pivotal or seminal papers that address the phenomenon of interest and other manuscripts that are relevant to the research question.

Reflexivity and a Saturation/Sufficiency Statement

Fourth, narrative reviews should clearly specify any factors that may have shaped the authors' interpretations and analysis. One fundamental distinction between narrative and non-narrative reviews is that narrative reviews explicitly recognize that they may not include all relevant literature on a topic. Since narrative reviews do not aim to be inclusive of all literature addressing the phenomenon of interest, a justification for the selection of manuscripts must be included. Authors should carefully outline how researchers conducted analyses and how they determined that sufficient analysis and interpretation was achieved. This latter concept is similar to considerations of saturation or thematic sufficiency in primary qualitative research. 8

Details on Analysis and Interpretation

Lastly, since several different categories of reviews fall under the narrative review umbrella, the analysis conducted in a narrative review varies by type. Regardless of the type of narrative review carried out, authors should clearly describe how analyses were conducted and provide justification for their approach. Narrative reviews are enhanced when researchers are explicit about how their perspectives and experiences informed problem identification, interpretation, and analysis. Given that authors' unique perspectives shape the selection of literature and its interpretation, narrative reviews may be reproduced, but different authors will likely yield different insights and interpretations.

Distinctive Methods and Subtypes

The narrative review has been commonly framed as an umbrella term that includes several different subtypes of reviews. These narrative medicine subtypes share the goals of deepening an understanding of a topic, while describing why researchers chose to explore and analyze the topic in a specific way.

There are several subtypes of narrative reviews with distinctive methodologies; each offers a unique way of approaching the research question and analyzing and interpreting the literature. This article will describe some common narrative review types that will also be discussed in upcoming JGME special articles on reviews: state-of-the-art , meta-ethnographic , critical , and theory integration reviews.

A state-of-the-art review attempts to summarize the research concerning a specific topic along a timeline of significant changes in understanding or research orientations. By focusing on such turning points in the history of evolving understandings of a phenomenon, state-of-the-art reviews offer a summary of the current state of understanding, how such an understanding was developed, and an idea of future directions. A state-of-the art review seeks to offer a 3-part description: where are we now in our understanding, how did we get here, and where should we go next?

A meta-ethnographic review involves choosing and interpreting qualitative research evidence about a specific topic. Working exclusively with qualitative data, this type of knowledge synthesis aims to generate new insights or new conclusions about a topic. It draws together insights and analyses from existing publications of qualitative research to construct new knowledge that spans across these individual, and often small scale, studies.

A meta-narrative review seeks to explore and make sense of contradictions and tensions within the literature. A meta-narrative review maps how a certain topic is understood in distinct ways, conducts a focused search to describe and compare narratives, and then seeks to make sense of how such narratives are interpreted across different disciplines or historical contexts, as part of the analysis. 9

A critical review is a narrative synthesis of literature that brings an interpretative lens: the review is shaped by a theory, a critical point of view, or perspectives from other domains to inform the literature analysis. Critical reviews involve an interpretative process that combines the reviewer's theoretical premise with existing theories and models to allow for synthesis and interpretation of diverse studies. First, reviewers develop and outline their interpretive theoretical position, which is informed by individual knowledge and experience. Next, a noncomprehensive search is completed to capture and identify dominant themes focused on a research question. 8 , 10

An integrative review typically has 1 of 2 different orientations. Empirical integrative reviews analyze and synthesize publications of evidence-based studies with diverse methodologies. In contrast, theoretical integrative reviews conduct an analysis of the available theories addressing a phenomenon, critically appraise those theories, and propose an advancement in the development of those theories. Both types of integrative reviews follow a multistage approach including problem identification, searching, evaluation, analysis, and presentation. 11

Strengths and Weaknesses

Narrative reviews have many strengths. They are flexible and practical, and ideally provide a readable, relevant synthesis of a diverse literature. Narrative reviews are often helpful for teaching or learning about a topic because they deliver a general overview. They are also useful for setting the stage for future research, as they offer an interpretation of the literature, note gaps, and critique research to date.

Such reviews may be useful for providing general background; however, a more comprehensive form of review may be necessary. Narrative reviews do not offer an evidence-based synthesis for focused questions, nor do they offer definitive guideline statements. All types of narrative reviews offer interpretations that are open to critique and will vary depending on the author team or context of the review.

Conclusions

Well-done narrative reviews provide a readable, thoughtful, and practical synthesis on a topic. They allow review authors to advance new ideas while describing and interpreting literature in the field. Narrative reviews do not aim to be systematic syntheses that answer a specific, highly focused question; instead, they offer carefully thought out and rigorous interpretations of a body of knowledge. Such reviews will not provide an exhaustive, comprehensive review of the literature; however, they are useful for a rich and meaningful summary of a topic.

Subject Guides

Literature Review and Evidence Synthesis

• Reviews as Assignments
• Annotated Bibliography

What is a Narrative Literature Review

Narrative review process.

• Integrative Review
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A narrative literature review is an integrated analysis of the existing literature used to summarize a body of literature, draw conclusions about a topic, and identify research gaps.  By understanding the current state of the literature, you can show how new research fits into the larger research landscape.  

A narrative literature review is NOT:  

• Just a summary of sources
• A review of  everything  written on a particular topic
• A research paper arguing for a specific viewpoint - a lit review should avoid bias and highlight areas of disagreements
• A systematic review

Purposes of a narrative literature review:

• Explain the background of research on a topic
• Demonstrate the importance of a topic
• Suggest new areas of research
• Identify major themes, concepts, and researchers in a topic
• Identify critical gaps, points of disagreement, or flawed approaches for a research topic

1. Choose a topic & create a research question

• Use a narrow research question for more focused search results
• Use a question framework such as PICO to develop your research question
• Breakdown your research question into searchable concepts and keywords
• Research skills tutorials : How to choose a topic
• Ask a librarian for assistance

2. Select the sources for searching & develop a search strategy

• Identify databases to search for articles relevant to your topic
• Ask a librarian for recommended databases
• Develop a comprehensive search strategy using keywords, controlled vocabularies and Boolean operators
• Research skills tutorials: How to develop a search strategy

3. Conduct the search

• Use a consistent search strategy between databases
• Document the strategies employed to keep track of which are more successful
• Use a citation manager to organize your search results
• Ask a librarian for help or refer to the Research skills tutorials

4. Review the references

• Review the search results for relevant articles that answer your research question
• Review the bibliography of all relevant articles for additional sources
• Consider developing subfolders in the citation manager to organize sources by topic
• Use interlibrary loan for any articles without full text access

5. Summarize findings

• Synthesize the findings from the articles into a final paper
• The final paper should cover the themes identified in the research, explain any conflicts or disagreements, identify research gaps and potential future research areas, explain how this narrative review fits within the existing research and answer the research question . 

For additional information : 

Hempel. (2020). Conducting your literature review. American Psychological Association .

• Buchholz, & Dickins, K. A. (2023). Literature review and synthesis : a guide for nurses and other healthcare professionals . Springer Publishing Company, LLC.
• Coughlan, Michael, and Patricia Cronin.  Doing a Literature Review in Nursing, Health and Social Care . 2nd edition., SAGE, 2017.
• Nundy, S., Kakar, A., Bhutta, Z.A. (2022). How to Do a Review of the Literature? . In: How to Practice Academic Medicine and Publish from Developing Countries?. Springer, Singapore.  https://doi.org/10.1007/978-981-16-5248-6_18
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Planning For Your Expert Literature Review

Narrative literature reviews.

• Types of Expert Literature Reviews

Further Reading

• Standards and Guidelines
• The Systematic Review Process
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Narrative or traditional literature reviews can take many shapes and forms. They do not need to follow any specific guideline or standard. A narrative literature view may be assigned as part of your coursework or capstone.

A narrative literature review can be a first step to building on other research in the field. After all, if it's a topic that you're interested in, you need to know what's already been done, right?

Your Narrative Literature Review Should Have...

• A clearly defined topic
• A search for relevant literature
• A logical organization structure
• An interpretation and discussion of the selected relevant literature

A common structure for narrative literature reviews is IMRaD, or:

• Introduction
• What is your topic?
• What are you interested in finding out?
• Why did you select this topic?
• How did you look for the literature?
• Where did you look?
• What search terms did you use?
• What kind of literature did you find?
• Did the literature you found change your opinion on the topic?
• Did you find out something new?
• What were the key concepts?
• and Discussion
• Evaluate and summarize the major concepts
• Connect the major concepts to future research potential

While the structure above may be sufficient for your topic, you may also consider using the similar but more robust structure IAMRDC, or:

• Ferrari, R. (2015). Writing narrative style literature reviews. Medical Writing, 24 (4), 230-235. https://doi.org/10.1179/2047480615Z.000000000329
• Sollaci, L. B., & Pereira, M. G. (2004). The introduction, methods, results, and discussion (IMRAD) structure: a fifty-year survey. Journal of the Medical Library Association 92 (3), 364–367. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC442179/

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• Last Updated: Apr 9, 2024 9:52 AM
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Literature Review: Traditional or narrative literature reviews

Traditional or narrative literature reviews.

• Scoping Reviews
• Systematic literature reviews
• Annotated bibliography
• Keeping up to date with literature
• Finding a thesis
• Evaluating sources and critical appraisal of literature
• Managing and analysing your literature
• Further reading and resources

A narrative or traditional literature review is a comprehensive, critical and objective analysis of the current knowledge on a topic. They are an essential part of the research process and help to establish a theoretical framework and focus or context for your research. A literature review will help you to identify patterns and trends in the literature so that you can identify gaps or inconsistencies in a body of knowledge. This should lead you to a sufficiently focused research question that justifies your research.

Onwuegbuzie and Frels (pp 24-25, 2016) define four common types of narrative reviews:

• General literature review that provides a review of the most important and critical aspects of the current knowledge of the topic. This general literature review forms the introduction to a thesis or dissertation and must be defined by the research objective, underlying hypothesis or problem or the reviewer's argumentative thesis.
• Theoretical literature review which examines how theory shapes or frames research
• Methodological literature review where the research methods and design are described. These methodological reviews outline the strengths and weaknesses of the methods used and provide future direction
• Historical literature review which 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.

References and additional resources

Baker, J. D. (2016) The purpose, process and methods of writing a literature review: Editorial . Association of Operating Room Nurses. AORN Journal, 103 (3), 265-269. doi:10.1016/j.aorn.2016.01.016

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Literature Reviews

• Types of reviews
• Getting started

Types of reviews and examples

Choosing a review type.

• 1. Define your research question
• 2. Plan your search
• 3. Search the literature
• 4. Organize your results
• 5. Synthesize your findings
• 6. Write the review
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• Meta-analysis
• Systematized

Definition:

"A term used to describe a conventional overview of the literature, particularly when contrasted with a systematic review (Booth et al., 2012, p. 265).

Characteristics:

• Provides examination of recent or current literature on a wide range of subjects
• Varying levels of completeness / comprehensiveness, non-standardized methodology
• May or may not include comprehensive searching, quality assessment or critical appraisal

Mitchell, L. E., & Zajchowski, C. A. (2022). The history of air quality in Utah: A narrative review.  Sustainability ,  14 (15), 9653.  doi.org/10.3390/su14159653

Booth, A., Papaioannou, D., & Sutton, A. (2012). Systematic approaches to a successful literature review. London: SAGE Publications Ltd.

"An assessment of what is already known about a policy or practice issue...using systematic review methods to search and critically appraise existing research" (Grant & Booth, 2009, p. 100).

• Assessment of what is already known about an issue
• Similar to a systematic review but within a time-constrained setting
• Typically employs methodological shortcuts, increasing risk of introducing bias, includes basic level of quality assessment
• Best suited for issues needing quick decisions and solutions (i.e., policy recommendations)

Learn more about the method:

Khangura, S., Konnyu, K., Cushman, R., Grimshaw, J., & Moher, D. (2012). Evidence summaries: the evolution of a rapid review approach.  Systematic reviews, 1 (1), 1-9.  https://doi.org/10.1186/2046-4053-1-10

Virginia Commonwealth University Libraries. (2021). Rapid Review Protocol .

Quarmby, S., Santos, G., & Mathias, M. (2019). Air quality strategies and technologies: A rapid review of the international evidence.  Sustainability, 11 (10), 2757.  https://doi.org/10.3390/su11102757

Grant, M.J. & Booth, A. (2009). A typology of reviews: an analysis of the 14 review types and associated methodologies.  Health Information & Libraries Journal , 26(2), 91-108. https://www.doi.org/10.1111/j.1471-1842.2009.00848.x

Developed and refined by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), this review "map[s] out and categorize[s] existing literature on a particular topic, identifying gaps in research literature from which to commission further reviews and/or primary research" (Grant & Booth, 2009, p. 97).

Although mapping reviews are sometimes called scoping reviews, the key difference is that mapping reviews focus on a review question, rather than a topic

Mapping reviews are "best used where a clear target for a more focused evidence product has not yet been identified" (Booth, 2016, p. 14)

Mapping review searches are often quick and are intended to provide a broad overview

Mapping reviews can take different approaches in what types of literature is focused on in the search

Cooper I. D. (2016). What is a "mapping study?".  Journal of the Medical Library Association: JMLA ,  104 (1), 76–78. https://doi.org/10.3163/1536-5050.104.1.013

Miake-Lye, I. M., Hempel, S., Shanman, R., & Shekelle, P. G. (2016). What is an evidence map? A systematic review of published evidence maps and their definitions, methods, and products.  Systematic reviews, 5 (1), 1-21.  https://doi.org/10.1186/s13643-016-0204-x

Tainio, M., Andersen, Z. J., Nieuwenhuijsen, M. J., Hu, L., De Nazelle, A., An, R., ... & de Sá, T. H. (2021). Air pollution, physical activity and health: A mapping review of the evidence.  Environment international ,  147 , 105954.  https://doi.org/10.1016/j.envint.2020.105954

Booth, A. (2016). EVIDENT Guidance for Reviewing the Evidence: a compendium of methodological literature and websites . ResearchGate. https://doi.org/10.13140/RG.2.1.1562.9842 . 

Grant, M.J. & Booth, A. (2009). A typology of reviews: an analysis of the 14 review types and associated methodologies.  Health Information & Libraries Journal , 26(2), 91-108.  https://www.doi.org/10.1111/j.1471-1842.2009.00848.x

"A type of review that has as its primary objective the identification of the size and quality of research in a topic area in order to inform subsequent review" (Booth et al., 2012, p. 269).

• Main purpose is to map out and categorize existing literature, identify gaps in literature—great for informing policy-making
• Search comprehensiveness determined by time/scope constraints, could take longer than a systematic review
• No formal quality assessment or critical appraisal

Learn more about the methods :

Arksey, H., & O'Malley, L. (2005) Scoping studies: towards a methodological framework.  International Journal of Social Research Methodology ,  8 (1), 19-32.  https://doi.org/10.1080/1364557032000119616

Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies: Advancing the methodology. Implementation Science: IS, 5, 69. https://doi.org/10.1186/1748-5908-5-69

Example : 

Rahman, A., Sarkar, A., Yadav, O. P., Achari, G., & Slobodnik, J. (2021). Potential human health risks due to environmental exposure to nano-and microplastics and knowledge gaps: A scoping review.  Science of the Total Environment, 757 , 143872.  https://doi.org/10.1016/j.scitotenv.2020.143872

A review that "[compiles] evidence from multiple...reviews into one accessible and usable document" (Grant & Booth, 2009, p. 103). While originally intended to be a compilation of Cochrane reviews, it now generally refers to any kind of evidence synthesis.

• Compiles evidence from multiple reviews into one document
• Often defines a broader question than is typical of a traditional systematic review

Choi, G. J., & Kang, H. (2022). The umbrella review: a useful strategy in the rain of evidence.  The Korean Journal of Pain ,  35 (2), 127–128.  https://doi.org/10.3344/kjp.2022.35.2.127

Aromataris, E., Fernandez, R., Godfrey, C. M., Holly, C., Khalil, H., & Tungpunkom, P. (2015). Summarizing systematic reviews: Methodological development, conduct and reporting of an umbrella review approach. International Journal of Evidence-Based Healthcare , 13(3), 132–140. https://doi.org/10.1097/XEB.0000000000000055

Rojas-Rueda, D., Morales-Zamora, E., Alsufyani, W. A., Herbst, C. H., Al Balawi, S. M., Alsukait, R., & Alomran, M. (2021). Environmental risk factors and health: An umbrella review of meta-analyses.  International Journal of Environmental Research and Public Dealth ,  18 (2), 704.  https://doi.org/10.3390/ijerph18020704

A meta-analysis is a "technique that statistically combines the results of quantitative studies to provide a more precise effect of the result" (Grant & Booth, 2009, p. 98).

• Statistical technique for combining results of quantitative studies to provide more precise effect of results
• Aims for exhaustive, comprehensive searching
• Quality assessment may determine inclusion/exclusion criteria
• May be conducted independently or as part of a systematic review

Berman, N. G., & Parker, R. A. (2002). Meta-analysis: Neither quick nor easy. BMC Medical Research Methodology , 2(1), 10. https://doi.org/10.1186/1471-2288-2-10

Hites R. A. (2004). Polybrominated diphenyl ethers in the environment and in people: a meta-analysis of concentrations.  Environmental Science & Technology ,  38 (4), 945–956.  https://doi.org/10.1021/es035082g

A systematic review "seeks to systematically search for, appraise, and [synthesize] research evidence, often adhering to the guidelines on the conduct of a review" provided by discipline-specific organizations, such as the Cochrane Collaboration (Grant & Booth, 2009, p. 102).

• Aims to compile and synthesize all known knowledge on a given topic
• Adheres to strict guidelines, protocols, and frameworks
• Time-intensive and often takes months to a year or more to complete
• The most commonly referred to type of evidence synthesis. Sometimes confused as a blanket term for other types of reviews

Gascon, M., Triguero-Mas, M., Martínez, D., Dadvand, P., Forns, J., Plasència, A., & Nieuwenhuijsen, M. J. (2015). Mental health benefits of long-term exposure to residential green and blue spaces: a systematic review.  International Journal of Environmental Research and Public Health ,  12 (4), 4354–4379.  https://doi.org/10.3390/ijerph120404354

"Systematized reviews attempt to include one or more elements of the systematic review process while stopping short of claiming that the resultant output is a systematic review" (Grant & Booth, 2009, p. 102). When a systematic review approach is adapted to produce a more manageable scope, while still retaining the rigor of a systematic review such as risk of bias assessment and the use of a protocol, this is often referred to as a  structured review  (Huelin et al., 2015).

• Typically conducted by postgraduate or graduate students
• Often assigned by instructors to students who don't have the resources to conduct a full systematic review

Salvo, G., Lashewicz, B. M., Doyle-Baker, P. K., & McCormack, G. R. (2018). Neighbourhood built environment influences on physical activity among adults: A systematized review of qualitative evidence.  International Journal of Environmental Research and Public Health ,  15 (5), 897.  https://doi.org/10.3390/ijerph15050897

Huelin, R., Iheanacho, I., Payne, K., & Sandman, K. (2015). What’s in a name? Systematic and non-systematic literature reviews, and why the distinction matters. https://www.evidera.com/resource/whats-in-a-name-systematic-and-non-systematic-literature-reviews-and-why-the-distinction-matters/

• Review Decision Tree - Cornell University For more information, check out Cornell's review methodology decision tree.
• LitR-Ex.com - Eight literature review methodologies Learn more about 8 different review types (incl. Systematic Reviews and Scoping Reviews) with practical tips about strengths and weaknesses of different methods.
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The Impact of Malnutrition on the Developing Lung and Long-Term Lung Health: A Narrative Review of Global Literature

• Open access
• Published: 17 May 2024

Cite this article

You have full access to this open access article

• Ramiyya Tharumakunarajah 1 , 5 ,
• Alice Lee 2 , 3 ,
• Daniel B. Hawcutt 2 , 4 ,
• Nicola L. Harman 5 &
• Ian P. Sinha 3  

2 Altmetric

Worldwide, over 2 billion children under the age of 5 experience stunting, wasting, or are underweight. Malnutrition contributes to 45% of all deaths in this age group (approximately 3.1 million deaths) [1]. Poverty, food insecurity, suboptimal feeding practices, climate change, and conflict are all contributing factors. Malnutrition causes significant respiratory problems, including increased risk of respiratory infections, impaired lung function, and increased risk of subsequent adult respiratory disease, including asthma, COPD, and lung cancer. Childhood malnutrition not only has serious consequences for children's health but it also has numerous consequences on wellbeing and educational attainment. Childhood malnutrition is a complex and multifaceted problem. However, by understanding and addressing the underlying causes, and investing in prevention and treatment programs, it is possible to maximize children's health and wellbeing on a global scale. This narrative review will focus on the impact of childhood malnutrition on lung development, the consequent respiratory disease, and what actions can be taken to reduce the burden of malnutrition on lung health.

Avoid common mistakes on your manuscript.

Introduction

There continues to be a global crisis of childhood malnutrition. In 2019, one in three preschool children worldwide were either under or overweight, and one in two children suffer some form of nutritional deficiency [ 2 ]. Malnutrition can be fatal, and contributes to approximately 45% (3.1 million) of all deaths for children under the age of 5 through direct and indirect causal pathways [ 2 ].

The landscape of global childhood malnutrition is changing. While slow progress is being made to address life-threatening severe undernutrition in lower- and middle-income countries (LMICs), families in these regions now also face the chronic double-burden of obesity and stunting [ 3 ]. Children in high-income countries (HICs) also face food insecurity, driving high rates of childhood obesity and increasing rates of hospitalizations for hidden hunger and nutritional deficiencies. Underlying this change is a food system whereby processed, high-calorie, low-nutrient food is widely advertised, more readily available, and cheaper in comparison to fresh produce [ 4 ]. Food production and access to a healthy diet is then further impacted by ‘shocks to the system’ such as the COVID-19 pandemic and subsequent economic recession, conflicts, and climate change events. These issues surrounding the food system are compounded by increasingly sedentary lifestyles.

Lung growth and function is influenced by nutritional status throughout the life course, starting with prenatal maternal nutrition. Malnutrition negatively impacts lung function, increases the risk of infective and non-communicable child and adult respiratory diseases, and drives poor disease outcomes [ 5 ]. This narrative review will outline what is meant by malnutrition, the key drivers of childhood malnutrition, and how this affects healthy lung growth and respiratory disease physiology and outcomes. In undertaking this review, we conducted a search of global peer-reviewed literature from online databases, and governmental and third-sector white papers, up to December 2023. Key search terms used were “malnutrition”, “pulmonary”, “development”, “children”, and “pediatric”. This article is based on previously conducted studies and does not contain any new studies with human participants or animals performed by any of the authors.

• Malnutrition

What is malnutrition?

Malnutrition is defined by the World Health Organization (WHO) as a “deficiency or excess in nutrient intake, imbalance of essential nutrients or impaired nutrient utilization”, [ 6 ] which encompasses undernutrition, micro-nutrient related malnutrition, overweight, and obesity [ 7 ].

Undernutrition is malnutrition-caused inadequate calorie intake. It is historically the most common form of malnutrition, particularly in LMICs, [ 8 ] and despite being the focus of many global health campaigns including the Sustainable Development Goals (SDG) Goal 2 “to end hunger”, still poses a significant threat to children’s lives [ 9 ]. Acute episodes of undernutrition drive weight loss, and severe undernutrition causes wasting (low weight for height) [ 6 ] and kwashiorkor (acute edematous malnutrition, driven by a high-cereal, protein-deficient diet in children under the age of 5). Acute severe undernutrition is immediately life-threatening, and children who survive the acute illness are at increased risk of metabolic disorders and increased morbidity and mortality throughout their life-course [ 10 ].

Chronic undernutrition can also cause stunting (low height for age) [ 6 ]. Being shorter is not always a health concern at an individual level, but a comparatively shorter pediatric population reflects systemic problems with chronic childhood undernutrition and is a robust indicator for overall child wellbeing and inequalities within a society [ 11 ]. Stunting is associated with poor neurocognitive outcomes and decreased economic prospects, as well as endocrinopathies and metabolic consequences which confer increased risks of adult obesity and cardiovascular disease [ 12 ]. Stunting is often used as a marker for progress for LMICs but often underused to assess wellbeing in HICs [ 11 ].

Micronutrient deficiency (iron, folate, iodine, vitamin A, and zinc being the most prevalent) [ 13 ] can happen with or without calorie deficiency, leading children to be “over fed but undernourished” [ 14 ]. Lack of diversity in a diet increases the risk of micronutrient deficiency, particularly for families who rely on low-cost food staples to keep their children full. UNICEF’s State of the World’s Children report in 2019 estimated that one in two children world-wide suffer from hidden hunger and micronutrient deficiency [ 2 ].

Obesity is an excessive accumulation of fat that is detrimental to health and is measured as a body mass index (BMI) greater than 30 [ 7 ]. It is the fastest-growing type of malnutrition both in HICs and LMICs [ 15 ]. Increasing obesity rates are now driven by socioeconomic inequality and poverty – changing food landscapes, particularly in urban areas, drive cheap, calorie-dense diets with reduced physical activity and access to green/blue spaces for exercise [ 16 ].

The social and environmental causes of malnutrition

While malnutrition can be a consequence of underlying pathology affecting intake and absorption, as well as causing excessive losses or increased requirements, this review focuses on the social and environmental drivers of poor dietary intake.

Childhood malnutrition is inextricably linked to poverty at both individual household and overall national levels. Every country in the world is affected by a degree of malnutrition, [ 17 ] but countries in the poorest quartile for gross domestic product (GDP) per capita are significantly more likely to face ‘double burden malnutrition’ of wasting/stunting and obesity, with the poorest families within individual countries often carrying this burden [ 3 ]. In 2020, 94% of young children with stunting, 97% of children with wasting, and 75% of overweight children were living in Africa and Asia [ 18 ]. While some progress has been made in reducing the number of undernourished children on these continents, it has been slow, unequal, and likely reversed during the COVID-19 pandemic. Levels of overweight children in these regions have remained static and have increased in many Asian and African countries [ 18 ]. Despite ‘secure’ food supplies with sufficient production and import in many HICs including Europe and North America, many children grow up in food-insecure households and are also at risk of malnutrition, in particular obesity and hidden hunger. In England, almost a quarter of 10 to 11-year-olds are obese. The disparity in obesity prevalence has been gradually widening over 15 years, and children from the most deprived decile are now over twice as likely to be obese as those in the least deprived decile [ 2 , 19 ]. Simultaneously, rates of undernutrition are rising. During the COVID-19 pandemic in 2020, UNICEF launched a campaign to distribute food parcels to hungry children in the UK [ 20 ], the first time in its history [ 19 ]. The number of children and adults admitted to hospital with malnutrition has doubled since 2008 [ 21 ]. Between 2022 and 2023, the prevalence of underweight 10 to 11-year-olds in England was 1.6%, the highest recorded since 2009 [ 22 ].

Socioeconomic deprivation creates barriers to a healthy nutritious diet at every step of the process of providing food for children (Fig.  1 ) [ 19 ]. Inequality at the individual/household level is exacerbated by a food system that is flawed by societal, governmental, and corporate factors, in which healthy food has become more costly, and highly processed food, high in refined sugars and fats and low in nutrients, is widely advertised and easily available [ 3 , 4 ].

A ‘clock/capacity/cost analysis of limitations of a healthy diet’ demonstrating a the steps required in providing a healthy diet and b the time, resources, and financial constraints driven by economic deprivation [ 19 ]

Global warming driven climate changes also impact the food environment from production to distribution. A comparison of recorded temperature anomalies and international data on Food Insecurity Experience Scale found that for every 1 ℃ temperature anomaly, severe global food insecurity increases by 1.4% [ 23 ], and a recent systematic review found a significant correlation between increasing extreme weather events from climate change including droughts and flooding and childhood undernutrition in Africa and Asia [ 24 ].

Nutrition and healthy lung development

Antenatal exposure to nutrition.

The impact of malnutrition on respiratory health starts with antenatal and maternal nutrition. Lung development is a multistage process that begins as early as 4 weeks gestation and continues into early adulthood. Suboptimal maternal nutrition, whether insufficient or excessive, has significant respiratory consequences for offspring [ 25 ].

Intrauterine growth restriction (IUGR) in undernourished mothers is one well-identified mechanism behind this relationship. IUGR affects 10–15% of pregnancies worldwide, and maternal undernutrition prior to and during pregnancy represents the most common maternal etiology of IUGR [ 25 , 26 , 27 ]. Numerous animal studies show that prolonged fetal undernutrition contributes to restriction of lung growth, impaired alveolar function, and reduced pulmonary vascular growth [ 5 , 27 ]. There is longstanding evidence of a correlation between lower birthweight and reduced lung function in later life, initially theorized by the Barker hypothesis [ 28 , 29 ]. More recently, both Dekker et al. and Suresh et al. conducted studies that associated lower birthweight with poor lung function in children and young adults, respectively [ 30 , 31 ]. Chronic antenatal undernutrition associated with IUGR also causes epigenetic changes that impair subsequent lung development through alterations in specific signaling pathways—including transforming growth factor beta and the peroxisome proliferator-activated receptor pathways. These changes may be combatted by increased maternal docosahexaenoic acid (DHA) intake and breastfeeding [ 25 , 27 ].

Maternal obesity also poses a risk to infant respiratory health, and significantly increases risk of preterm birth, itself a separate risk factor for poor respiratory health [ 32 ]. Liu et al. have demonstrated a significant association between childhood asthma and pre-pregnancy obesity or overweight mothers [ 33 ]. Some animal studies have also implicated maternal obesity in the impairment of fetal lung maturation and surfactant production [ 34 , 35 ]. This is particularly pertinent due to a steep increase in maternal obesity, particularly in high- and middle-income countries [ 36 ]. For example, maternal obesity rates have increased from 7.6 to 22.3% between 1989 and 2019 in the UK [ 37 ].

Maternal micronutrient intake is also important for childhood respiratory health. The most common ‘hidden hunger’ of pregnancy is iron deficiency anemia, which affects nearly 50% of pregnancies worldwide [ 38 ]. It is the most common nutrient deficiency globally and is exacerbated during pregnancy [ 39 ]. There are a multitude of poor outcomes that can occur secondary to maternal anemia, including pre-term delivery, neonatal anemia, low birth weight, and neonatal stunting [ 40 ]. Stunting is associated with various respiratory health consequences for children, including poor lung function, asthma, and poorer outcomes for pneumonia [ 41 , 42 , 43 ]. Maternal vitamin E deficiency is also associated with an increased risk of asthma and atopy [ 44 ]. Bedard et al. found that children of mothers who adopted a “Mediterranean diet” during pregnancy were found to have higher small airway function at 8–9 years old compared to those that did not [ 45 ]. Maternal consumption of n3 (DHA and eicosapentaenoic acid—EPA) and n6 fatty acids, particularly during the second trimester, is also associated with reduced risk of asthma and allergic sensitization [ 46 ].

Breast feeding and lung growth

The nutritional, immune, cognitive, and economic benefits of breastfeeding are well established, with the WHO and UNICEF recommendation that children are exclusively breastfed until 6 months of age [ 47 ]. Newer studies have shown potential benefits of breastfeeding on children’s respiratory health as well as those previously demonstrated [ 48 , 49 ].

Several observational studies have concluded that breastfeeding for at least 4 months results in improved lung function at school age, compared to children who are not breastfed [ 48 ]. Dogaru et al. noted that breastfed children of asthmatic mothers have higher forced vital capacity (FVC) and forced expiratory volume (FEV1) measurements in a dose–responsive relationship with duration of breastfeeding compared to those who are not breastfed [ 50 ]. Various potential mechanisms for this have been hypothesized, from a direct effect on lung growth to the suggestion that the physical act of suckling itself encourages structural changes leading to improved lung volumes [ 49 ].

The relationship between breastfeeding and childhood respiratory disease is more conflicting, specifically around asthma. Lodge et al. found there was an association between longer breastfeeding duration and a reduced risk of asthma in 5 to 18-year-olds [ 51 ] whereas other studies have previously found no significant association [ 48 , 52 ].

Despite the WHO and UNICEF recommendation and the recognized benefits of breastfeeding, rates of breastfeeding in HICs such as the UK consistently fall from birth to 6 months. A study conducted in England demonstrated that in 2020, while breastfeeding was initiated in almost 85% of newborns, by 6 weeks only 38% were exclusively breast fed and by 6 months this figure dropped to 18% [ 53 ].

Childhood malnutrition and lung health

Undernutrition represents a significant respiratory health risk for children and has significant consequences throughout childhood [ 54 ]. Being underweight is associated with slow lung growth and reduced alveolarization, resulting in reduced surface area for gas exchange as well as reduced lung function. Undernutrition also compromises immune cell function and mucociliary clearance, which leads to increased risk of developing respiratory tract infections (RTIs), and worse clinical outcomes [ 55 ].

Obesity is also known to have cardiovascular, metabolic, and respiratory consequences, as well as an overall increased risk of mortality. Children who are overweight or obese have an increased risk of asthma and sleep-disordered breathing [ 15 ]. During the COVID-19 pandemic, the most common comorbidity of children admitted to Paediatric Intensive Care Units in the US and Canada was obesity [ 56 ], suggesting that childhood obesity is also associated with worse clinical outcomes in RTIs. In adults, there is a recognized inverse relationship between body mass index (BMI) and FEV1 [ 57 ], however this finding is not always present in children. Dysanapsis—the discrepancy between lung growth and airway caliber defined by reduced FEV1/FVC with normal FEV1 and FVC measurements—is more common in childhood obesity and asthma [ 58 ]. Forno et al. found that airway dysanapsis is more common in overweight and obese children and is associated with more severe disease for children with asthma [ 59 ]. Obesity in children is also associated with sleep-disordered breathing, particularly obstructive sleep apnea syndrome (OSAS). Some studies have reported a prevalence of OSAS from 13 to 59% in obese children compared to 1–2% in children of average-weight children [ 56 , 60 ]. Besides the physical deposits of adipose tissue around the upper airway, another proposed causality of OSAS is leptin resistance. Leptin, released by adipose tissue, is involved in triggering ventilation, and leptin resistance is known to be more present in obesity [ 5 , 61 , 62 ].

Pathophysiological explanations for obesity-induced reduced lung function and respiratory illness include both mechanical processes, such as reduced chest wall compliance, increased airway resistance and low volume breathing resulting in airway hyper-responsiveness, as well as inflammatory processes. Inflammatory cytokines, which are associated with severe asthma symptoms such as interleukin-6 (IL-6), are released from adipose tissue, encourage neutrophilic airway inflammation, and impair immune function [ 56 , 63 ].

The micronutrient deficiency of hidden hunger, either with or without undernutrition, can also impact childhood respiratory health. Vitamin E and A deficiencies, as well as iron, zinc, and selenium seem to have the most specific respiratory consequences [ 44 , 54 , 64 ]. Both antenatal and childhood deficiency of vitamin E and selenium are associated with increased risk of asthma and atopy, whereas optimal intake of dietary carotenoids is linked to a reduced risk of developing asthma and improved ventilatory function [ 44 ]. Zinc, vitamin A, and iron deficiencies are all associated with increased risk with RTIs. Zinc deficiency is common in LMICs, and a 2004 randomized clinical trial performed in India demonstrated that zinc treatment in boys with acute RTIs reduced the severity and duration of their illness [ 64 ]. Vitamin A plays a pivotal role in immune function and in hemoglobin production, and vitamin A deficiency correlates with increased risk of morbidity and mortality from RTIs, in childhood [ 65 ]. Iron-deficient anemia in childhood also increases a child’s risk of RTIs—studies from Nepal, Egypt, Israel, Lebanon, Romania, and India all identify that children with anemia are at 2–4 times higher risk of developing RTIs [ 66 ]. A retrospective cohort study in Ecuador found that children with anemia were more susceptible to the impacts of air pollution, with increased hospitalization for pneumonia [ 67 ].

Another important consideration in malnutrition is its effect on the gut microbiome. The concept of a gut–lung axis has been proposed as an internal communication that has microbial and immune implications and as a result, the gut–lung axis could affect the course of respiratory disease [ 63 , 68 ]. If a healthy gut microbiome is crucial to establishing and maintaining good respiratory health, unhealthy diets and malnutrition can significantly compromise this. A study performed in Bangladesh observed that the gut microbiome of malnourished infants had increased pathogenic species and minimal organism diversity when compared to the microbiome of healthy infants [ 54 ]. It then follows that microbiome changes due to poor nutrition could compromise the gut–lung axis and have respiratory health implications.

Long-term impacts and adult disease

Lung development is an ongoing process which continues into young adulthood with maximum lung function achieved by approximately 22 years old. Lung function subsequently decreases, and the rate of this decline is based on a number of factors, including lifestyle, environment, and smoking [ 69 ]. Therefore, if optimum lung function is not achieved in utero or childhood, adults are more vulnerable to developing respiratory disease at a younger age as any decline will have a significant clinical impact [ 70 ] (see Fig.  2 ).

Lung trajectories in health and disease [ 71 ]

Lopuhaä et al. found that children born during the Dutch famine (1944–1945), whose mothers were exposed to famine in early to mid-gestation, experienced a higher probability of chronic obstructive pulmonary disease (COPD) in adulthood [ 72 ]. A large Australian study demonstrated that RTIs and poorly controlled asthma in childhood, which can be exacerbated by poor nutrition and being underweight, are associated with decline in adult FEV1 and increased risk of COPD [ 73 ]. In addition to increased risk of COPD, more than one meta-analysis has associated reduced lung function with an increased risk of lung cancer [ 74 , 75 ], and a longitudinal study in the UK demonstrated that RTIs under 2 years of age significantly increased risk of early death from respiratory disease, even when adjusted for other respiratory risk factors—demonstrating the extensive impact of childhood exposures on adult lung health [ 76 ].

Malnutrition and respiratory disease outcomes

As previously described, both undernutrition and obesity increase the risk of childhood asthma. Childhood undernutrition is associated with vitamin D deficiency, leptin deficiency, poor lung growth, poor alveolarization, reduced lung function, and increased IL-4 and CD23 + levels. These factors are all posited to be relevant in the development of childhood asthma [ 41 ]. A study based on the European Prospective Investigation into Cancer and nutrition (EPIC) cohort, who were exposed to the Dutch famine during childhood, showed a dose-dependent relationship between exposure to famine and risk of hospitalization with asthma later in life [ 77 ]. A Chinese study also demonstrated that exposure to famine, antenatally and during childhood, increased the risk of asthma and reduced lung function in adulthood, with the highest risk associated with antenatal exposure [ 78 ].

Current evidence suggests that obesity affects both allergic and non-allergic asthma. The provocation of a pro-inflammatory state appears to exaggerate the allergic inflammatory response and the mechanical consequences of an obese habitus are also likely to exacerbate symptoms [ 63 ]. There is also evidence that the presence of insulin resistance alongside obesity is more strongly associated with asthma [ 79 ]. While there are some nutritional factors that are protective from asthma, including longer duration of breastfeeding and adopting a Mediterranean diet [ 63 , 80 ], this protection does not supersede the risk posed by obesity. A 2023 study [ 81 ] showed that exclusively breastfed children who were overweight remained more prone to developing asthma, compared to children who were exclusively breastfed but not overweight.

Respiratory tract infections

Every year, RTIs cause 4.3 million deaths of children under 5 years old, making it the most common cause of childhood mortality in the world [ 82 ]. Malnutrition is proven to increase rates of child mortality from respiratory infection—a 2021 meta-analysis demonstrated that severely underweight children hospitalized with pneumonia were 4.5 times more likely to die than those of healthy weight [ 83 ].

Poor nutrition, particularly poor protein intake, can compromise the innate immune system and impair cytokine release, due to reduced synthetic capacity. Acute illness is often accompanied by reduced food intake, with a negative nitrogen balance (where excreted nitrogen exceeds protein intake) driven by pyrexia. As such, children can become trapped in a vicious cycle, whereby malnutrition drives infection, and infections can perpetuate malnutrition [ 84 ].

Micronutrient deficiency is associated with increased risk of RTIs in children. As well as zinc, vitamin A, and iron deficiencies, several studies have implicated vitamin D deficiency in increased risk of RTIs in children [ 85 ]. Another consideration in underweight children is leptin deficiency. Leptin is produced by adipose tissue and has been identified as an important pro-inflammatory hormone within the immune system. Leptin deficiency has been associated with reduced circulating CD4 + T cells, impaired T cell proliferation, and reduced cytokine release, which can contribute to increased susceptibility to infection [ 86 ].

Cystic fibrosis (CF) and bronchiectatic conditions

Malnutrition, particularly undernutrition and micronutrient deficiency, has traditionally been one of the common consequences of cystic fibrosis (CF), due to high energy loss, recurrent infections and malabsorption, and is a significant risk factors for poorer clinical outcomes, with stunting being a significant independent risk factor for mortality in CF [ 87 , 88 ]. Intense nutritional support (enteral or parenteral) is therefore an important management strategy, as optimal nutritional status is associated with improved lung function and reduced mortality [ 89 ]. However, with the introduction of cystic fibrosis transmembrane conductance regulator (CFTR) modulators, and the ability to correct the defective CFTR, the landscape of CF management has shifted. When CFTR modulators are started early, they have the potential to reduce the risk of undernutrition in children [ 90 , 91 ], and a 2023 study found that the prevalence of overweight and obesity among people with CF had increased from 15% in 2001 to 36–40% in 2021 [ 92 ]. So far, there is no evidence that obesity is related to negative outcomes in CF [ 93 ]. Given this rise in obesity and potential impact of CFTR modulators on nutritional status, as well as the role of undernutrition on clinical outcomes (especially considering that not all children with CF will have access to modulators), it is important for pediatricians to consider all forms of malnutrition in the management of their CF patients [ 90 , 94 ].

For patients with bronchiectasis and childhood interstitial lung diseases, optimizing nutritional status also remains a management priority. The prevalence of malnutrition in patients with interstitial lung disease has been reported to be between 9 and 55%, with higher body mass index shown to predict better outcomes [ 95 ]. Fouda et al. demonstrated that a 9-month nutritional intervention program for malnourished patients improved body composition and respiratory symptoms, reduced the number of exacerbations, and need for hospital admission [ 96 ].

Actions to address the socioenvironmental causes of malnutrition

Ending global childhood malnutrition due to socioenvironmental causes is achievable. It would take an estimated $5 billion USD per year to meet global targets for stunting for under 5s [ 97 ], less than the annual marketing budget for some food and beverage companies [ 98 ]. The drivers for poor nutrition are so widespread and deeply engrained in society that upscale large changes are required [ 99 ]. To achieve this, children’s rights to a nutritious diet must be at the forefront of policy, law, and health and social programs to address corporate, governmental, and societal vectors of malnutrition, including policy failings. This includes enshrining the right to food in national laws. The United Nations Convention on the Rights of the Child (UNCRC) comprehensively lays out global child rights, including the importance of combatting malnutrition, protecting every child’s right to access adequate nutritious foods, and protecting them against unhealthy food environments [ 100 ]. Enshrining the UNCRC in domestic laws, and taking a child rights-based approach to malnutrition would ensure accountability at national and international levels.

Interventions targeting childhood malnutrition

Addressing early-years malnutrition starts with maternal health. Bhutta et al. demonstrated that interventions to combat the health effects of malnutrition are effective and can improve morbidity and mortality rates significantly. With effective maternal supplementation of folate and micronutrients, there is a 16% reduction in low birth weight at term. When strategies are implemented to address complementary feeding, food supplementation, micronutrient supplementation, and educational strategies, stunting and mortality by 36 months of age are reduced by 36% and 25%, respectively, with significant economic payoff [ 101 ].

For older children, schools provide an opportunity to address dietary needs. Free school meals are a commonly implemented social safety net and have been proven to improve nutrition. Kristjansson et al.’s meta-analysis of global school meal programs showed that school children receiving a standard meal for 200 days per year gained an additional 0.37 kg, and pre-school children gained 0.54 cm per year [ 102 ]. Abizari et al. also demonstrated that children who participated in a school meals program in Ghana had higher levels of micronutrient adequacy and a 10% reduction in the incidence of anemia [ 103 ].

Food system changes

The need for increased food production itself also presents challenges. It is estimated that food production will have to increase by 50% by 2050 to meet the anticipated demands of a growing population [ 104 ]. Current intensive agricultural practices have been shown to both contribute to climate change and detrimentally affect food production. Implementing agro-food systems that implement sustainable methods, reduce environmental impact, promote inclusive small-scale farming, and utilize technology to improve efficiency would contribute to achieving the SDG aim of eliminating malnutrition by 2030, and will require global and national policy change [ 105 , 106 ].

Despite agreement across various global bodies that tackling childhood malnutrition is a priority, there is a lack of data on several relevant factors, including age-specific dietary intake, feeding challenges, as well as parental perceptions of nutrition. Dietary surveillance on a global scale would allow a comprehensive understanding of varying needs and enable the implementation of targeted interventions. Micha et al. proposed that a central surveillance unit to monitor global dietary trends could present population-specific recommendations as well as support existing regional initiatives [ 107 ]. Existing data sets would lend themselves to this and can be upscaled to optimize data collection. For example, pregnant mothers and children attending health care services typically have regular anthropometrical examinations, but these data are not necessarily widely available, or of consistent quality [ 108 ]. Collecting individual-level quantitative dietary data using Individual Food Consumption Surveys (IFCS) is an effective method of dietary surveillance. Traditionally, IFCS have been collected in HICs, but over the last 20 years, their use has become more common in LMICs. The Food and Agriculture Organization of the United Nations and World Health Organization Global Individual Food consumption data Tool (FAO/WHO GIFT) is a catalogue of these data [ 109 ]. However, while the availability of these data is increasing, it is rarely integrated into healthcare systems. Huybrechts et al. showed that not only were integrated IFCS associated with better response rates and more representative results, they also encouraged evaluation of healthcare policy, guidelines, and public health priorities [ 110 ]. In summary, investments in nutrition data systems would support policy and strategy, as well as monitoring progress of interventions, to address malnutrition on a large scale [ 108 ].

Conclusions

The triple burden of malnutrition—underweight, overweight, and hidden hunger of micronutrient deficiencies—risks healthy lung development, worsens respiratory disease outcomes, and are a significant threat to children’s lives. The consequences are wide-reaching, and include pre-term birth due to maternal malnutrition, a higher risk of mortality from childhood respiratory infections, as well as increased risk of asthma, COPD, and malignancy in adulthood. Most socioeconomically deprived children across the world are disproportionately affected by malnutrition, as families are priced out of nutritious diets in an increasingly unhealthy global agro-food system.

Only by addressing these issues with meaningful structural changes, using a child-rights approach at the corporate, governmental, and societal levels, can children’s nutritional status, and subsequent respiratory health in both childhood and adulthood, be optimized.

Data Availability

All data used are available in the references provided.

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Tharumakunarajah, R., Lee, A., Hawcutt, D.B. et al. The Impact of Malnutrition on the Developing Lung and Long-Term Lung Health: A Narrative Review of Global Literature. Pulm Ther (2024). https://doi.org/10.1007/s41030-024-00257-z

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Socio-cultural beliefs and perceptions influencing diagnosis and treatment of breast cancer among women in Ghana: a systematic review

• Agani Afaya 1 , 2 ,
• Emmanuel Anongeba Anaba 3 ,
• Victoria Bam 4 ,
• Richard Adongo Afaya 5 ,
• Ahmed-Rufai Yahaya 6 ,
• Abdul-Aziz Seidu 7 &
• Bright Opoku Ahinkorah 8  

BMC Women's Health volume  24 , Article number:  288 ( 2024 ) Cite this article

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Breast cancer is currently the most commonly diagnosed cancer in Ghana and the leading cause of cancer mortality among women. Few published empirical evidence exist on cultural beliefs and perceptions about breast cancer diagnosis and treatment in Ghana. This systematic review sought to map evidence on the socio-cultural beliefs and perceptions influencing the diagnosis and treatment of breast cancer among Ghanaian women.

This review was conducted following the methodological guideline of Joanna Briggs Institute and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses. The literature search was conducted in PubMed, CINAHL via EBSCO host , PsycINFO, Web of Science, and Embase. Studies that were conducted on cultural, religious, and spiritual beliefs were included. The included studies were screened by title, abstract, and full text by three reviewers. Data were charted and results were presented in a narrative synthesis form.

After the title, abstract, and full-text screening, 15 studies were included. Three categories were identified after the synthesis of the charted data. The categories included: cultural, religious and spiritual beliefs and misconceptions about breast cancer. The cultural beliefs included ancestral punishment and curses from the gods for wrongdoing leading to breast cancer. Spiritual beliefs about breast cancer were attributed to spiritual or supernatural forces. People had the religious belief that breast cancer is a test from God and they resorted to prayers for healing. Some women perceived that breast cancer is caused by spider bites, heredity, extreme stress, trauma, infections, diet, or lifestyle.

This study adduces evidence of the socio-cultural beliefs that impact on the diagnosis and treatment of breast cancer among women in Ghana. Taking into consideration the diverse cultural and traditional beliefs about breast cancer diagnosis and treatment, there is a compelling need to intensify nationwide public education on breast cancer to clarify the myths and misconceptions about the disease. We recommend the need to incorporate socio-cultural factors influencing breast cancer diagnosis and treatment into breast cancer awareness programs, education, and interventions in Ghana.

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Introduction

Breast cancer is a global public health concern due to its increasing incidence coupled with the high mortality rate among women in low- and high-income countries [ 1 ]. In 2020, it was estimated that 2.3 million breast cancer cases were newly diagnosed with approximately 685,000 deaths globally [ 1 ]. In Ghana, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality among women [ 2 ]. In 2020, breast cancer accounted for approximately 31.8% of all cancer cases in Ghana [ 3 ].

Evidence shows that cultural factors such as conceptualizations of health, illness, beliefs, and values influence breast cancer screening among women in certain populations [ 4 , 5 , 6 ]. Breast cancer screening is reported to be relatively low among women living in Ghana. A nationwide study revealed that only 4.5% of Ghanaian women aged 50 years and older had undergone mammography screening [ 7 ]. The low levels of breast cancer screening lead to undetected breast cancer symptoms, contributing to the late-stage diagnosis of breast cancer and subsequent poorer outcomes and mortality [ 8 ]. There have been low levels of awareness and knowledge about breast cancer among women in Ghana [ 9 ]. Also, there is a lack of understanding of the perceptions and beliefs toward breast cancer diagnosis and treatment in Ghana.

Culture is considered a multidimensional set of shared beliefs and socially transmitted ideologies about the world, which are passed on from generation to generation [ 10 , 11 ]. Cultural beliefs within certain communities across the globe are considered a determinant of health risk perceptions and behaviors in promoting or seeking health care in diverse populations [ 12 ]. In traditional Ghanaian communities, good health is recognized as a suitable relationship between the living and the dead and being in harmony with the individuals’ environment. Thus, disease is conceptualized as a malfunctioning of the body system which is probably due to a lack of harmony with supernatural/ancestral forces [ 13 ]. This belief influences how diseases are treated and the steps taken to manage the disease and ultimately how the disease is experienced [ 13 , 14 ]. Cultural beliefs connected to breast cancer are among the key determinants in women’s decision-making regarding breast cancer screening practices in traditional societies [ 14 , 15 ]. In most Ghanaian communities, breast cancer is believed to be associated with supernatural powers, hence, women seek alternative treatments (healing/prayer camps) first and only report to health facilities in advanced stages of breast cancer [ 16 ].

It is therefore important to consider how socio-cultural factors impact breast cancer diagnosis and treatment because these factors influence cancer care in resource-limited settings. To the best of our knowledge, no review has been conducted in Ghana specifically to address the cultural, religious, and spiritual beliefs influencing timely diagnosis and treatment of breast cancer among women. To fill this gap, this systematic review sought to map evidence on the cultural beliefs and perceptions that influence the timely diagnosis and treatment of breast cancer among women.

This systematic review was conducted following the updated methodological guideline of Joanna Briggs Institute (JBI) [ 17 , 18 ] and reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. The updated JBI methodological guidance regarding conducting a mixed methods systematic review recommends that reviewers use a convergent approach to synthesize and integrate both qualitative and quantitative studies [ 18 ]. Therefore, using a mixed methods systematic review involving both quantitative and qualitative studies was deemed the most appropriate study design because this is the first evidence synthesis on the cultural, religious, and spiritual beliefs that influence breast cancer diagnosis and treatment in Ghana.

Inclusion and exclusion criteria

Studies conducted among women and explored the cultural beliefs and perceptions about breast cancer were included.

Studies that were only limited to Ghanaian communities were included.

Empirical studies published in peer-review journals.

Observational studies, using qualitative and/or quantitative methods were also included.

The exclusion criteria involved review studies, conference papers, editorials and abstracts.

Studies published before 2012 were also excluded.

Search strategy

This review adopted the triple-step search strategy proposed by the JBI for all types of reviews [ 19 ]. The first step involved an initial limited search in PubMed for already existing published research articles on sociocultural beliefs and perceptions about breast cancer in Ghana. The initial limited search ensured the identification of relevant keywords used in developing the preliminary search terms. Step two involved a formal search after finalizing and combining the following keywords (‘breast cancer’, ‘cultural beliefs’, ‘religious beliefs’, ‘traditional beliefs’, ‘perception’, and ‘Ghana’) using Boolean operators. A comprehensive search was conducted in PubMed, CINAHL via EBSCO host , PsycINFO, Web of Science, and Embase from 2012–2022. The final step involved manual tracing of the reference list of studies for additional studies. This was done up to the point of saturation where no new information emanated from the subsequent manual search of articles.

Study selection

Following the searches, the identified records were exported into EndNote 2020 reference manager for duplicate removal. After the duplicate removal, the reviewers ensured consistency in screening through the following process: (1) joint screening by two reviewers was conducted until they felt confident to start independent screening, (2) independent blinded screening of titles/abstracts followed by a meeting and discussion of discrepancies and (3) repetition of step 2 until an acceptable agreement was met. Following the screening of the titles/abstracts, full-text review was conducted following a two-step process. The first step involved two reviewers who screened all the articles identified after the title/abstract screening. Thereafter, two independent reviewers assessed the full-text articles for inclusion or exclusion. In the course of the full-text screening, any disagreements that emerged were discussed for consensus. Throughout the screening of the abstracts, full-texts, and data extraction, the reviewers regularly met to discuss and solve emerging issues.

Data extraction

A data extraction form was developed in line with the aim of this review. Two authors independently extracted the relevant information from the included articles. The following information was extracted from the articles: first author’s name, year of publication, study location, study type, aim, study population, and key findings. Disagreements during the data extraction process were resolved by a discussion and where a resolution was not reachable, the last author resolved it through further adjudication. Study selection and data extraction were conducted manually.

Data analysis

A convergent integrated approach [ 20 ] was employed to transform the data into narrative form because the extracted information was from quantitative and qualitative studies. The analysis followed JBI recommendation where we qualitized quantitative data for data transformation because this is less prone to error when codified than when qualitative data is given numerical values. Qualitizing entails taking data from quantitative studies, translating or converting it into textual descriptions so that it can be integrated with qualitative data, and providing a narrative interpretation of the quantitative results [ 18 ]. Following the convergent synthesis of the transformed data, the reviewers undertook repeated, detailed examination of the assembled data to identify categories on the basis of similarity in meaning [ 18 ]. Out of these, three categories were derived from the analysis.

Assessment of methodological quality

Using the Mixed Methods Appraisal Tool (MMAT)  version 2018, two researchers (AA and RAA) evaluated each included study’s quality separately [ 21 ]. After discussing disagreements between the two reviewers (AA and RAA), BOA helped to forge a consensus. Methodological quality standards for evaluating research using mixed methodologies, quantitative, and qualitative approaches are included in the MMAT. The MMAT assesses the suitability of the research objective, study design, technique, participant recruitment, data collection, data analysis, results presentation, author comments, and conclusions. Hong et al. [ 21 ] discourages the overall quality scoring of the included studies, therefore, the methodological quality of the studies was evaluated using the recommended guidelines.

Flow Chart of evidence selection

Literature search

Our search yielded a total of 176 records from the electronic databases. After duplicates were automatically removed through the EndNote ( n  = 76), 100 records were reviewed independently by two authors based on the title and abstract. Records that did not meet the inclusion ( n  = 75) were removed after holding discussions to identify discrepancies in the review process. Thereafter, full texts of the remaining 25 articles were assessed for eligibility. Hand-search of the included study references yielded no results. In total, we included 15 studies [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]. The article selection process is shown in the PRISMA flow diagram (Fig.  1 ).

Characteristics of the included studies and quality

The majority of the studies [ 22 , 23 , 24 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ] were conducted in the southern part of Ghana where there are better health infrastructures compared to the northern part of Ghana. Eight of the included studies were qualitative while the rest employed quantitative study designs. The summary of the characteristics of the 15 studies is shown in Table  1 . The appraisal of the included studies was assessed using the MMAT. All the studies were included, and none were excluded due to poor methodological quality. All 15 studies met the screening criteria and provided clear research questions. The studies included clearly stated and described research design, and target population, and used appropriate measurements.

Cultural beliefs

Breast cancer is believed by some sections of Ghanaians to be a curse or a punishment from the lesser gods for sins committed by the individual [ 22 ]. Some women believed that an extra-marital immoral lifestyle provokes God’s retribution for breast cancer development [ 29 ]. Some people believed that it is an ancestral punishment for the woman’s refusal to give birth in order to continue the ancestral lineage [ 23 ] and because of this, they are given spiritual babies to suckle the breast which then causes cancer [ 23 ]. It is also believed some women have been pronounced cursed due to some wrongdoings [ 25 ]. Due to the cultural belief, some women prayed to their ancestors so that traditional medicine will heal them of the breast cancer [ 26 ].

“…when it started, my uncles came to my aid, they took me to the village to see a “Tim Lana” (referring to a traditional healer). He was very good. He told me everything about my problem. So, there was no need for visiting the hospital…” [ 36 ].

Spiritual and religious beliefs

Some studies in Greater Accra, Tamale, and Kumasi indicated that breast cancer was a spiritual attack from humans or family members that sought to kill them while some believe it emanated from evil forces [ 29 , 31 , 36 ]. Participants in some studies indicated that breast cancer is attributed to some spiritual or supernatural forces [ 32 , 33 , 36 ] and can only be cured through spiritual means [ 33 ]. Due to the spiritual beliefs, some women went to traditional healers for treatment [ 26 , 36 ]. A study in the northern part of Ghana revealed that women who suffer from breast cancer are witches and have used their breasts for ritual purposes [ 25 ] while in the southern part of Ghana some participants believed that breast cancer is caused by witches [ 22 ]. For example, a narration from a participant stated:

“I believe my condition is spiritual and I realized it is coming from my mother’s side” [ 31 ].

“The problem is that my disease is a spiritual attack, so it has to be treated spiritually; the hospital drugs cannot get this out of me…” [ 36 ].

Some studies in the southern and northern part of Ghana stated that participants had a religious belief that the disease was a test from God and resulted in prayers for healing [ 31 , 36 ] and also believed that God had the supernatural powers to miraculously melt the breast lump [ 29 , 32 ] and completely cure them [ 32 ]. Some women also believed that it was their fate to get breast cancer [ 36 ]. Due to these religious beliefs some women had to resort to prayer camps for healing which leads to delay in diagnosis and treatment of breast cancer [ 26 ].

Misconceptions about breast cancer

Some women perceived that breast cancer is caused by spider bites [ 24 ], heredity, extreme stress [ 22 , 32 ], trauma, infections [ 22 ], diet, or lifestyle [ 22 , 35 ]. Some perceived risk factors of breast cancer as stated by some women included non-breastfeeding women, obesity, or overweight [ 25 , 30 , 33 ], and contraceptive use [ 30 ]. Some women had the perception that male health practitioners would not be allowed to examine or see their breasts while some preferred male doctors to examine their breasts [ 27 ]. A study in Accra conducted among female nonmedical students revealed that suckling the breast by a male caused breast cancer [ 28 ]. It is also perceived that putting money in the brassieres could be a possible cause of breast cancer among females [ 23 , 35 ]. A study by Iddrisu et al. [ 31 ] and Agbokey [ 23 ] revealed that breast cancer is a disgraceful disease, dangerous, and a fast killer. Some people also believed that breast cancer can be cured [ 27 , 32 ] by herbal treatment or medicine [ 25 ] while some believed that it is not curable [ 27 ]. Some people also believed that breast cancer was contagious and transmissible and avoided sharing equipment with breast cancer survivors [ 31 ]. A breast cancer survivor narrated:

“…my mum believes the disease can be transmitted so she does not allow me to eat with my son. I have separate bowls, spoons, and cups from that of the family…” [ 31 ].

This study reviews the existing literature on socio-cultural beliefs influencing the timely diagnosis and treatment of breast cancer among women, and this revealed diverse cultural, spiritual, and religious beliefs across the regions of Ghana. The current findings emphasize critical issues that lead to misguidance and share ignorance about breast cancer and its treatment among a section of Ghanaian communities which is rooted in their personal beliefs. Cultural beliefs are key in the decision-making process for the treatment of ailments depending on their knowledge level about the condition. This could probably lead to making the right decision or the wrong treatment decision. The diverse cultural, spiritual, and religious beliefs about breast cancer could affect the health seeking behavior of women diagnosed with breast cancer within the Ghanaian communities.

Consistent with a systematic review findings [ 13 ] it is believed that breast cancer emanates as a result of supernatural forces, curses, and punishment from lesser gods/ancestors for wrongdoings. Though not all Africans hold this traditional belief in ancestral spirits, some believe that health and illness are in the hands of a higher power such as God or Allah [ 13 ]. Hence, in most African communities it is common practice to seek traditional medicine for the treatment of diseases which is in line with their beliefs [ 37 ]. Due to the cultural/traditional belief systems and practices, most women report to health facilities with advanced stages of breast cancer which adversely impacts the breast cancer diagnosis and treatment [ 36 ]. Most women resort to traditional or spiritual healing because this method of treatment combines body, soul, and spirit. In some African settings, traditional healers are trusted to treat diseases including cancer because women believe they look for both scientific and metaphysical causes of the disease. It is possible that breast cancer patients who combine both traditional and modern methods of treatment may experience treatment interference. This dual approach can impact treatment effectiveness and lead to adverse effects or complications. The provision of culturally sensitive care by recognizing unique cultural, religious, and social beliefs and practices is of paramount importance for early detection and treatment of breast cancer among women [ 38 , 39 , 40 ]. Globally, women’s cultural beliefs and perceptions towards breast cancer should be examined to optimize timely breast cancer diagnosis and treatment.

Religious fanaticism coupled with lack of knowledge about the disease condition could impede the utilization of medical treatment, especially when religious beliefs impact negatively on people’s health-seeking behaviors [ 36 ]. A study in Nigeria revealed that religious beliefs about breast cancer were observed to be a barrier to breast cancer screening among women [ 41 ]. This review found that some women in the southern part of Ghana believed that breast cancer was a test from God and resorted to prayers because they believed that God had supernatural powers to heal them from the disease. Though religious beliefs are considered to be a source of spiritual strength and help people to cope with the disease, the religious misconceptions, and mistaken beliefs are thought to contribute to delayed heath-seeking attitudes and lack of breast cancer screening among women [ 42 ]. In the current review, it was reported that some women stayed in prayer camps for almost one year seeking healing and later reported to health facilities with advanced breast cancer which has dire consequences on the survival rate of women. Efforts to sensitize women and religious leaders about the early presentation of breast disease to health facilities for diagnosis and treatment would be key to reduce the number of breast cancer cases detained in religious camps. It is also imperative for religious bodies to discuss health related issues including breast cancer to create much awareness about the condition.

This review identified varied perceptions of breast cancer where breast cancer has been attributed to spider bites and putting money in the brassieres among others. Some believed that breast cancer was a contagious and transmissible disease. These findings show poor knowledge level among women concerning breast cancer. Even though in this review most women had heard or were aware of breast cancer, the varied perceptions about breast cancer suggests low knowledge level of breast cancer. The low knowledge level of breast cancer among women have been associated with late presentation of breast cancer to health facilities [ 40 ]. Women presenting to health facilities with advanced stage breast cancer have been associated with low survival rate in the African region as compared to high income countries [ 43 ]. A study conducted in Ghana revealed that the breast cancer survival rate among women was below 50% which was probably due to late presentation and lack of breast cancer screening [ 44 ]. We recommend intensification of public health education campaigns on breast cancer in order to improve women’s knowledge of the disease which will subsequently enhance early presentation, diagnosis, and treatment.

Implication for policy and practice

Metaphors such as spider bites, supernatural forces, witchcraft, and many other beliefs are associated with breast cancer in Ghana which impact the understanding of the disease and whether or not to seek medical treatment. Therefore, culturally sensitive intervention programs targeted at improving breast cancer awareness among women, religious and traditional leaders are imperative. These intervention programs could entail community engagement, workshops, or educational materials tailored to address specific cultural beliefs and misconceptions.

Taking into consideration the diverse cultural beliefs about breast cancer, there is a compelling need for nationwide public education on breast cancer to clarify the myths and misconceptions about the disease. The education program should be culturally tailored to address the myths and misconceptions. It is important that considerations are given to these issues, not only focusing on how these issues affect women’s lives post-treatment but also on how these issues can be resolved to improve diagnosis and treatment of the disease. We recommend that socio-cultural factors influencing breast cancer diagnosis and treatment should be incorporated into breast cancer awareness programs, education, and intervention programs in Ghana. We believe these would help inform women and encourage them to report to health facilities early with breast cancer symptoms to initiate timely diagnosis and treatment to improve the outcomes of the disease in Ghana.

Further research is required to explore appropriate and effective multidimensional culturally sensitive intervention research that integrates cultural beliefs and breast cancer treatment especially, in different Ghanaian communities.

Strengths and limitations of the study

This study has several strengths, one major strength is the extensive and comprehensive search in various electronic databases following the methodological guideline of JBI and reported in accordance with the PRISMA guidelines. Also, the inclusion of both qualitative and quantitative studies, allowed for a more comprehensive understanding of the socio-cultural beliefs influencing breast cancer diagnosis and treatment in Ghana.

The review considered only published studies and possibly may have overlooked unpublished or gray literature that could contribute to a more comprehensive understanding of the subject matter. Most of the studies were concentrated in the southern part of Ghana and therefore the results might not represent all the regions in Ghana.

This study adduces evidence on the socio-cultural beliefs that impact diagnosis and treatment of breast cancer among women in Ghana. As policy makers, clinicians and other stakeholders strive to improve breast cancer diagnosis and treatment, there is a need to address the socio-cultural beliefs to improve breast cancer outcomes in Ghana and potentially reduce breast cancer-related mortality.

Data availability

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

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AA, and EAA conceived the study, analyzed and wrote the methods section. AA, VB and RAA conducted the literature search and wrote the background. AA, RAA, and RY screened the included articles and extracted the data. AA, AS and BOA conducted literature search and discussed the results. All the authors reviewed and provided intellectual content and modification. All the authors reviewed and approved the final draft of the manuscript.

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Afaya, A., Anaba, E.A., Bam, V. et al. Socio-cultural beliefs and perceptions influencing diagnosis and treatment of breast cancer among women in Ghana: a systematic review. BMC Women's Health 24 , 288 (2024). https://doi.org/10.1186/s12905-024-03106-y

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