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How to Write a Conclusion for Research Papers (with Examples)

The conclusion of a research paper is a crucial section that plays a significant role in the overall impact and effectiveness of your research paper. However, this is also the section that typically receives less attention compared to the introduction and the body of the paper. The conclusion serves to provide a concise summary of the key findings, their significance, their implications, and a sense of closure to the study. Discussing how can the findings be applied in real-world scenarios or inform policy, practice, or decision-making is especially valuable to practitioners and policymakers. The research paper conclusion also provides researchers with clear insights and valuable information for their own work, which they can then build on and contribute to the advancement of knowledge in the field.

The research paper conclusion should explain the significance of your findings within the broader context of your field. It restates how your results contribute to the existing body of knowledge and whether they confirm or challenge existing theories or hypotheses. Also, by identifying unanswered questions or areas requiring further investigation, your awareness of the broader research landscape can be demonstrated.

Remember to tailor the research paper conclusion to the specific needs and interests of your intended audience, which may include researchers, practitioners, policymakers, or a combination of these.

Table of Contents

What is a conclusion in a research paper, summarizing conclusion, editorial conclusion, externalizing conclusion, importance of a good research paper conclusion, how to write a conclusion for your research paper, research paper conclusion examples.

• How to write a research paper conclusion with Paperpal? 

Frequently Asked Questions

A conclusion in a research paper is the final section where you summarize and wrap up your research, presenting the key findings and insights derived from your study. The research paper conclusion is not the place to introduce new information or data that was not discussed in the main body of the paper. When working on how to conclude a research paper, remember to stick to summarizing and interpreting existing content. The research paper conclusion serves the following purposes: 1

• Warn readers of the possible consequences of not attending to the problem.
• Recommend specific course(s) of action.
• Restate key ideas to drive home the ultimate point of your research paper.
• Provide a “take-home” message that you want the readers to remember about your study.

Types of conclusions for research papers

In research papers, the conclusion provides closure to the reader. The type of research paper conclusion you choose depends on the nature of your study, your goals, and your target audience. I provide you with three common types of conclusions:

A summarizing conclusion is the most common type of conclusion in research papers. It involves summarizing the main points, reiterating the research question, and restating the significance of the findings. This common type of research paper conclusion is used across different disciplines.

An editorial conclusion is less common but can be used in research papers that are focused on proposing or advocating for a particular viewpoint or policy. It involves presenting a strong editorial or opinion based on the research findings and offering recommendations or calls to action.

An externalizing conclusion is a type of conclusion that extends the research beyond the scope of the paper by suggesting potential future research directions or discussing the broader implications of the findings. This type of conclusion is often used in more theoretical or exploratory research papers.

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The conclusion in a research paper serves several important purposes:

• Offers Implications and Recommendations : Your research paper conclusion is an excellent place to discuss the broader implications of your research and suggest potential areas for further study. It’s also an opportunity to offer practical recommendations based on your findings.
• Provides Closure : A good research paper conclusion provides a sense of closure to your paper. It should leave the reader with a feeling that they have reached the end of a well-structured and thought-provoking research project.
• Leaves a Lasting Impression : Writing a well-crafted research paper conclusion leaves a lasting impression on your readers. It’s your final opportunity to leave them with a new idea, a call to action, or a memorable quote.

Writing a strong conclusion for your research paper is essential to leave a lasting impression on your readers. Here’s a step-by-step process to help you create and know what to put in the conclusion of a research paper: 2

• Research Statement : Begin your research paper conclusion by restating your research statement. This reminds the reader of the main point you’ve been trying to prove throughout your paper. Keep it concise and clear.
• Key Points : Summarize the main arguments and key points you’ve made in your paper. Avoid introducing new information in the research paper conclusion. Instead, provide a concise overview of what you’ve discussed in the body of your paper.
• Address the Research Questions : If your research paper is based on specific research questions or hypotheses, briefly address whether you’ve answered them or achieved your research goals. Discuss the significance of your findings in this context.
• Significance : Highlight the importance of your research and its relevance in the broader context. Explain why your findings matter and how they contribute to the existing knowledge in your field.
• Implications : Explore the practical or theoretical implications of your research. How might your findings impact future research, policy, or real-world applications? Consider the “so what?” question.
• Future Research : Offer suggestions for future research in your area. What questions or aspects remain unanswered or warrant further investigation? This shows that your work opens the door for future exploration.
• Closing Thought : Conclude your research paper conclusion with a thought-provoking or memorable statement. This can leave a lasting impression on your readers and wrap up your paper effectively. Avoid introducing new information or arguments here.
• Proofread and Revise : Carefully proofread your conclusion for grammar, spelling, and clarity. Ensure that your ideas flow smoothly and that your conclusion is coherent and well-structured.

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Remember that a well-crafted research paper conclusion is a reflection of the strength of your research and your ability to communicate its significance effectively. It should leave a lasting impression on your readers and tie together all the threads of your paper. Now you know how to start the conclusion of a research paper and what elements to include to make it impactful, let’s look at a research paper conclusion sample.

How to write a research paper conclusion with Paperpal?

A research paper conclusion is not just a summary of your study, but a synthesis of the key findings that ties the research together and places it in a broader context. A research paper conclusion should be concise, typically around one paragraph in length. However, some complex topics may require a longer conclusion to ensure the reader is left with a clear understanding of the study’s significance. Paperpal, an AI writing assistant trusted by over 800,000 academics globally, can help you write a well-structured conclusion for your research paper. 

• Sign Up or Log In: Create a new Paperpal account or login with your details.  
• Navigate to Features : Once logged in, head over to the features’ side navigation pane. Click on Templates and you’ll find a suite of generative AI features to help you write better, faster.  
• Generate an outline: Under Templates, select ‘Outlines’. Choose ‘Research article’ as your document type.  
• Select your section: Since you’re focusing on the conclusion, select this section when prompted.  
• Choose your field of study: Identifying your field of study allows Paperpal to provide more targeted suggestions, ensuring the relevance of your conclusion to your specific area of research. 
• Provide a brief description of your study: Enter details about your research topic and findings. This information helps Paperpal generate a tailored outline that aligns with your paper’s content. 
• Generate the conclusion outline: After entering all necessary details, click on ‘generate’. Paperpal will then create a structured outline for your conclusion, to help you start writing and build upon the outline.  
• Write your conclusion: Use the generated outline to build your conclusion. The outline serves as a guide, ensuring you cover all critical aspects of a strong conclusion, from summarizing key findings to highlighting the research’s implications. 
• Refine and enhance: Paperpal’s ‘Make Academic’ feature can be particularly useful in the final stages. Select any paragraph of your conclusion and use this feature to elevate the academic tone, ensuring your writing is aligned to the academic journal standards. 

By following these steps, Paperpal not only simplifies the process of writing a research paper conclusion but also ensures it is impactful, concise, and aligned with academic standards. Sign up with Paperpal today and write your research paper conclusion 2x faster .  

The research paper conclusion is a crucial part of your paper as it provides the final opportunity to leave a strong impression on your readers. In the research paper conclusion, summarize the main points of your research paper by restating your research statement, highlighting the most important findings, addressing the research questions or objectives, explaining the broader context of the study, discussing the significance of your findings, providing recommendations if applicable, and emphasizing the takeaway message. The main purpose of the conclusion is to remind the reader of the main point or argument of your paper and to provide a clear and concise summary of the key findings and their implications. All these elements should feature on your list of what to put in the conclusion of a research paper to create a strong final statement for your work.

A strong conclusion is a critical component of a research paper, as it provides an opportunity to wrap up your arguments, reiterate your main points, and leave a lasting impression on your readers. Here are the key elements of a strong research paper conclusion: 1. Conciseness : A research paper conclusion should be concise and to the point. It should not introduce new information or ideas that were not discussed in the body of the paper. 2. Summarization : The research paper conclusion should be comprehensive enough to give the reader a clear understanding of the research’s main contributions. 3 . Relevance : Ensure that the information included in the research paper conclusion is directly relevant to the research paper’s main topic and objectives; avoid unnecessary details. 4 . Connection to the Introduction : A well-structured research paper conclusion often revisits the key points made in the introduction and shows how the research has addressed the initial questions or objectives. 5. Emphasis : Highlight the significance and implications of your research. Why is your study important? What are the broader implications or applications of your findings? 6 . Call to Action : Include a call to action or a recommendation for future research or action based on your findings.

The length of a research paper conclusion can vary depending on several factors, including the overall length of the paper, the complexity of the research, and the specific journal requirements. While there is no strict rule for the length of a conclusion, but it’s generally advisable to keep it relatively short. A typical research paper conclusion might be around 5-10% of the paper’s total length. For example, if your paper is 10 pages long, the conclusion might be roughly half a page to one page in length.

In general, you do not need to include citations in the research paper conclusion. Citations are typically reserved for the body of the paper to support your arguments and provide evidence for your claims. However, there may be some exceptions to this rule: 1. If you are drawing a direct quote or paraphrasing a specific source in your research paper conclusion, you should include a citation to give proper credit to the original author. 2. If your conclusion refers to or discusses specific research, data, or sources that are crucial to the overall argument, citations can be included to reinforce your conclusion’s validity.

The conclusion of a research paper serves several important purposes: 1. Summarize the Key Points 2. Reinforce the Main Argument 3. Provide Closure 4. Offer Insights or Implications 5. Engage the Reader. 6. Reflect on Limitations

Remember that the primary purpose of the research paper conclusion is to leave a lasting impression on the reader, reinforcing the key points and providing closure to your research. It’s often the last part of the paper that the reader will see, so it should be strong and well-crafted.

• Makar, G., Foltz, C., Lendner, M., & Vaccaro, A. R. (2018). How to write effective discussion and conclusion sections. Clinical spine surgery, 31(8), 345-346.
• Bunton, D. (2005). The structure of PhD conclusion chapters.  Journal of English for academic purposes ,  4 (3), 207-224.

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Home » Research Summary – Structure, Examples and Writing Guide

Research Summary – Structure, Examples and Writing Guide

Table of Contents

Research Summary

Definition:

A research summary is a brief and concise overview of a research project or study that highlights its key findings, main points, and conclusions. It typically includes a description of the research problem, the research methods used, the results obtained, and the implications or significance of the findings. It is often used as a tool to quickly communicate the main findings of a study to other researchers, stakeholders, or decision-makers.

Structure of Research Summary

The Structure of a Research Summary typically include:

• Introduction : This section provides a brief background of the research problem or question, explains the purpose of the study, and outlines the research objectives.
• Methodology : This section explains the research design, methods, and procedures used to conduct the study. It describes the sample size, data collection methods, and data analysis techniques.
• Results : This section presents the main findings of the study, including statistical analysis if applicable. It may include tables, charts, or graphs to visually represent the data.
• Discussion : This section interprets the results and explains their implications. It discusses the significance of the findings, compares them to previous research, and identifies any limitations or future directions for research.
• Conclusion : This section summarizes the main points of the research and provides a conclusion based on the findings. It may also suggest implications for future research or practical applications of the results.
• References : This section lists the sources cited in the research summary, following the appropriate citation style.

How to Write Research Summary

Here are the steps you can follow to write a research summary:

• Read the research article or study thoroughly: To write a summary, you must understand the research article or study you are summarizing. Therefore, read the article or study carefully to understand its purpose, research design, methodology, results, and conclusions.
• Identify the main points : Once you have read the research article or study, identify the main points, key findings, and research question. You can highlight or take notes of the essential points and findings to use as a reference when writing your summary.
• Write the introduction: Start your summary by introducing the research problem, research question, and purpose of the study. Briefly explain why the research is important and its significance.
• Summarize the methodology : In this section, summarize the research design, methods, and procedures used to conduct the study. Explain the sample size, data collection methods, and data analysis techniques.
• Present the results: Summarize the main findings of the study. Use tables, charts, or graphs to visually represent the data if necessary.
• Interpret the results: In this section, interpret the results and explain their implications. Discuss the significance of the findings, compare them to previous research, and identify any limitations or future directions for research.
• Conclude the summary : Summarize the main points of the research and provide a conclusion based on the findings. Suggest implications for future research or practical applications of the results.
• Revise and edit : Once you have written the summary, revise and edit it to ensure that it is clear, concise, and free of errors. Make sure that your summary accurately represents the research article or study.
• Add references: Include a list of references cited in the research summary, following the appropriate citation style.

Example of Research Summary

Here is an example of a research summary:

Title: The Effects of Yoga on Mental Health: A Meta-Analysis

Introduction: This meta-analysis examines the effects of yoga on mental health. The study aimed to investigate whether yoga practice can improve mental health outcomes such as anxiety, depression, stress, and quality of life.

Methodology : The study analyzed data from 14 randomized controlled trials that investigated the effects of yoga on mental health outcomes. The sample included a total of 862 participants. The yoga interventions varied in length and frequency, ranging from four to twelve weeks, with sessions lasting from 45 to 90 minutes.

Results : The meta-analysis found that yoga practice significantly improved mental health outcomes. Participants who practiced yoga showed a significant reduction in anxiety and depression symptoms, as well as stress levels. Quality of life also improved in those who practiced yoga.

Discussion : The findings of this study suggest that yoga can be an effective intervention for improving mental health outcomes. The study supports the growing body of evidence that suggests that yoga can have a positive impact on mental health. Limitations of the study include the variability of the yoga interventions, which may affect the generalizability of the findings.

Conclusion : Overall, the findings of this meta-analysis support the use of yoga as an effective intervention for improving mental health outcomes. Further research is needed to determine the optimal length and frequency of yoga interventions for different populations.

References :

• Cramer, H., Lauche, R., Langhorst, J., Dobos, G., & Berger, B. (2013). Yoga for depression: a systematic review and meta-analysis. Depression and anxiety, 30(11), 1068-1083.
• Khalsa, S. B. (2004). Yoga as a therapeutic intervention: a bibliometric analysis of published research studies. Indian journal of physiology and pharmacology, 48(3), 269-285.
• Ross, A., & Thomas, S. (2010). The health benefits of yoga and exercise: a review of comparison studies. The Journal of Alternative and Complementary Medicine, 16(1), 3-12.

Purpose of Research Summary

The purpose of a research summary is to provide a brief overview of a research project or study, including its main points, findings, and conclusions. The summary allows readers to quickly understand the essential aspects of the research without having to read the entire article or study.

Research summaries serve several purposes, including:

• Facilitating comprehension: A research summary allows readers to quickly understand the main points and findings of a research project or study without having to read the entire article or study. This makes it easier for readers to comprehend the research and its significance.
• Communicating research findings: Research summaries are often used to communicate research findings to a wider audience, such as policymakers, practitioners, or the general public. The summary presents the essential aspects of the research in a clear and concise manner, making it easier for non-experts to understand.
• Supporting decision-making: Research summaries can be used to support decision-making processes by providing a summary of the research evidence on a particular topic. This information can be used by policymakers or practitioners to make informed decisions about interventions, programs, or policies.
• Saving time: Research summaries save time for researchers, practitioners, policymakers, and other stakeholders who need to review multiple research studies. Rather than having to read the entire article or study, they can quickly review the summary to determine whether the research is relevant to their needs.

Characteristics of Research Summary

The following are some of the key characteristics of a research summary:

• Concise : A research summary should be brief and to the point, providing a clear and concise overview of the main points of the research.
• Objective : A research summary should be written in an objective tone, presenting the research findings without bias or personal opinion.
• Comprehensive : A research summary should cover all the essential aspects of the research, including the research question, methodology, results, and conclusions.
• Accurate : A research summary should accurately reflect the key findings and conclusions of the research.
• Clear and well-organized: A research summary should be easy to read and understand, with a clear structure and logical flow.
• Relevant : A research summary should focus on the most important and relevant aspects of the research, highlighting the key findings and their implications.
• Audience-specific: A research summary should be tailored to the intended audience, using language and terminology that is appropriate and accessible to the reader.
• Citations : A research summary should include citations to the original research articles or studies, allowing readers to access the full text of the research if desired.

When to write Research Summary

Here are some situations when it may be appropriate to write a research summary:

• Proposal stage: A research summary can be included in a research proposal to provide a brief overview of the research aims, objectives, methodology, and expected outcomes.
• Conference presentation: A research summary can be prepared for a conference presentation to summarize the main findings of a study or research project.
• Journal submission: Many academic journals require authors to submit a research summary along with their research article or study. The summary provides a brief overview of the study’s main points, findings, and conclusions and helps readers quickly understand the research.
• Funding application: A research summary can be included in a funding application to provide a brief summary of the research aims, objectives, and expected outcomes.
• Policy brief: A research summary can be prepared as a policy brief to communicate research findings to policymakers or stakeholders in a concise and accessible manner.

Advantages of Research Summary

Research summaries offer several advantages, including:

• Time-saving: A research summary saves time for readers who need to understand the key findings and conclusions of a research project quickly. Rather than reading the entire research article or study, readers can quickly review the summary to determine whether the research is relevant to their needs.
• Clarity and accessibility: A research summary provides a clear and accessible overview of the research project’s main points, making it easier for readers to understand the research without having to be experts in the field.
• Improved comprehension: A research summary helps readers comprehend the research by providing a brief and focused overview of the key findings and conclusions, making it easier to understand the research and its significance.
• Enhanced communication: Research summaries can be used to communicate research findings to a wider audience, such as policymakers, practitioners, or the general public, in a concise and accessible manner.
• Facilitated decision-making: Research summaries can support decision-making processes by providing a summary of the research evidence on a particular topic. Policymakers or practitioners can use this information to make informed decisions about interventions, programs, or policies.
• Increased dissemination: Research summaries can be easily shared and disseminated, allowing research findings to reach a wider audience.

Limitations of Research Summary

Limitations of the Research Summary are as follows:

• Limited scope: Research summaries provide a brief overview of the research project’s main points, findings, and conclusions, which can be limiting. They may not include all the details, nuances, and complexities of the research that readers may need to fully understand the study’s implications.
• Risk of oversimplification: Research summaries can be oversimplified, reducing the complexity of the research and potentially distorting the findings or conclusions.
• Lack of context: Research summaries may not provide sufficient context to fully understand the research findings, such as the research background, methodology, or limitations. This may lead to misunderstandings or misinterpretations of the research.
• Possible bias: Research summaries may be biased if they selectively emphasize certain findings or conclusions over others, potentially distorting the overall picture of the research.
• Format limitations: Research summaries may be constrained by the format or length requirements, making it challenging to fully convey the research’s main points, findings, and conclusions.
• Accessibility: Research summaries may not be accessible to all readers, particularly those with limited literacy skills, visual impairments, or language barriers.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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• How to Write Discussions and Conclusions

The discussion section contains the results and outcomes of a study. An effective discussion informs readers what can be learned from your experiment and provides context for the results.

What makes an effective discussion?

When you’re ready to write your discussion, you’ve already introduced the purpose of your study and provided an in-depth description of the methodology. The discussion informs readers about the larger implications of your study based on the results. Highlighting these implications while not overstating the findings can be challenging, especially when you’re submitting to a journal that selects articles based on novelty or potential impact. Regardless of what journal you are submitting to, the discussion section always serves the same purpose: concluding what your study results actually mean.

A successful discussion section puts your findings in context. It should include:

• the results of your research,
• a discussion of related research, and
• a comparison between your results and initial hypothesis.

Tip: Not all journals share the same naming conventions.

You can apply the advice in this article to the conclusion, results or discussion sections of your manuscript.

Our Early Career Researcher community tells us that the conclusion is often considered the most difficult aspect of a manuscript to write. To help, this guide provides questions to ask yourself, a basic structure to model your discussion off of and examples from published manuscripts. 

Questions to ask yourself:

• Was my hypothesis correct?
• If my hypothesis is partially correct or entirely different, what can be learned from the results? 
• How do the conclusions reshape or add onto the existing knowledge in the field? What does previous research say about the topic? 
• Why are the results important or relevant to your audience? Do they add further evidence to a scientific consensus or disprove prior studies? 
• How can future research build on these observations? What are the key experiments that must be done? 
• What is the “take-home” message you want your reader to leave with?

How to structure a discussion

Trying to fit a complete discussion into a single paragraph can add unnecessary stress to the writing process. If possible, you’ll want to give yourself two or three paragraphs to give the reader a comprehensive understanding of your study as a whole. Here’s one way to structure an effective discussion:

Writing Tips

While the above sections can help you brainstorm and structure your discussion, there are many common mistakes that writers revert to when having difficulties with their paper. Writing a discussion can be a delicate balance between summarizing your results, providing proper context for your research and avoiding introducing new information. Remember that your paper should be both confident and honest about the results! 

• Read the journal’s guidelines on the discussion and conclusion sections. If possible, learn about the guidelines before writing the discussion to ensure you’re writing to meet their expectations. 
• Begin with a clear statement of the principal findings. This will reinforce the main take-away for the reader and set up the rest of the discussion. 
• Explain why the outcomes of your study are important to the reader. Discuss the implications of your findings realistically based on previous literature, highlighting both the strengths and limitations of the research. 
• State whether the results prove or disprove your hypothesis. If your hypothesis was disproved, what might be the reasons? 
• Introduce new or expanded ways to think about the research question. Indicate what next steps can be taken to further pursue any unresolved questions. 
• If dealing with a contemporary or ongoing problem, such as climate change, discuss possible consequences if the problem is avoided. 
• Be concise. Adding unnecessary detail can distract from the main findings. 

Don’t

• Rewrite your abstract. Statements with “we investigated” or “we studied” generally do not belong in the discussion. 
• Include new arguments or evidence not previously discussed. Necessary information and evidence should be introduced in the main body of the paper. 
• Apologize. Even if your research contains significant limitations, don’t undermine your authority by including statements that doubt your methodology or execution. 
• Shy away from speaking on limitations or negative results. Including limitations and negative results will give readers a complete understanding of the presented research. Potential limitations include sources of potential bias, threats to internal or external validity, barriers to implementing an intervention and other issues inherent to the study design. 
• Overstate the importance of your findings. Making grand statements about how a study will fully resolve large questions can lead readers to doubt the success of the research. 

Snippets of Effective Discussions:

Consumer-based actions to reduce plastic pollution in rivers: A multi-criteria decision analysis approach

Identifying reliable indicators of fitness in polar bears

• How to Write a Great Title
• How to Write an Abstract
• How to Write Your Methods
• How to Report Statistics
• How to Edit Your Work

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The conclusion is intended to help the reader understand why your research should matter to them after they have finished reading the paper. A conclusion is not merely a summary of the main topics covered or a re-statement of your research problem, but a synthesis of key points derived from the findings of your study and, if applicable, where you recommend new areas for future research. For most college-level research papers, two or three well-developed paragraphs is sufficient for a conclusion, although in some cases, more paragraphs may be required in describing the key findings and their significance.

Conclusions. The Writing Center. University of North Carolina; Conclusions. The Writing Lab and The OWL. Purdue University.

Importance of a Good Conclusion

A well-written conclusion provides you with important opportunities to demonstrate to the reader your understanding of the research problem. These include:

• Presenting the last word on the issues you raised in your paper . Just as the introduction gives a first impression to your reader, the conclusion offers a chance to leave a lasting impression. Do this, for example, by highlighting key findings in your analysis that advance new understanding about the research problem, that are unusual or unexpected, or that have important implications applied to practice.
• Summarizing your thoughts and conveying the larger significance of your study . The conclusion is an opportunity to succinctly re-emphasize  your answer to the "So What?" question by placing the study within the context of how your research advances past research about the topic.
• Identifying how a gap in the literature has been addressed . The conclusion can be where you describe how a previously identified gap in the literature [first identified in your literature review section] has been addressed by your research and why this contribution is significant.
• Demonstrating the importance of your ideas . Don't be shy. The conclusion offers an opportunity to elaborate on the impact and significance of your findings. This is particularly important if your study approached examining the research problem from an unusual or innovative perspective.
• Introducing possible new or expanded ways of thinking about the research problem . This does not refer to introducing new information [which should be avoided], but to offer new insight and creative approaches for framing or contextualizing the research problem based on the results of your study.

Bunton, David. “The Structure of PhD Conclusion Chapters.” Journal of English for Academic Purposes 4 (July 2005): 207–224; Conclusions. The Writing Center. University of North Carolina; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion. San Francisco Edit, 2003-2008; Conclusions. The Writing Lab and The OWL. Purdue University; Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8.

Structure and Writing Style

I.  General Rules

The general function of your paper's conclusion is to restate the main argument . It reminds the reader of the strengths of your main argument(s) and reiterates the most important evidence supporting those argument(s). Do this by clearly summarizing the context, background, and necessity of pursuing the research problem you investigated in relation to an issue, controversy, or a gap found in the literature. However, make sure that your conclusion is not simply a repetitive summary of the findings. This reduces the impact of the argument(s) you have developed in your paper.

When writing the conclusion to your paper, follow these general rules:

• Present your conclusions in clear, concise language. Re-state the purpose of your study, then describe how your findings differ or support those of other studies and why [i.e., what were the unique, new, or crucial contributions your study made to the overall research about your topic?].
• Do not simply reiterate your findings or the discussion of your results. Provide a synthesis of arguments presented in the paper to show how these converge to address the research problem and the overall objectives of your study.
• Indicate opportunities for future research if you haven't already done so in the discussion section of your paper. Highlighting the need for further research provides the reader with evidence that you have an in-depth awareness of the research problem but that further investigations should take place beyond the scope of your investigation.

Consider the following points to help ensure your conclusion is presented well:

• If the argument or purpose of your paper is complex, you may need to summarize the argument for your reader.
• If, prior to your conclusion, you have not yet explained the significance of your findings or if you are proceeding inductively, use the end of your paper to describe your main points and explain their significance.
• Move from a detailed to a general level of consideration that returns the topic to the context provided by the introduction or within a new context that emerges from the data [this is opposite of the introduction, which begins with general discussion of the context and ends with a detailed description of the research problem]. 

The conclusion also provides a place for you to persuasively and succinctly restate the research problem, given that the reader has now been presented with all the information about the topic . Depending on the discipline you are writing in, the concluding paragraph may contain your reflections on the evidence presented. However, the nature of being introspective about the research you have conducted will depend on the topic and whether your professor wants you to express your observations in this way. If asked to think introspectively about the topics, do not delve into idle speculation. Being introspective means looking within yourself as an author to try and understand an issue more deeply, not to guess at possible outcomes or make up scenarios not supported by the evidence.

II.  Developing a Compelling Conclusion

Although an effective conclusion needs to be clear and succinct, it does not need to be written passively or lack a compelling narrative. Strategies to help you move beyond merely summarizing the key points of your research paper may include any of the following:

• If your essay deals with a critical, contemporary problem, warn readers of the possible consequences of not attending to the problem proactively.
• Recommend a specific course or courses of action that, if adopted, could address a specific problem in practice or in the development of new knowledge leading to positive change.
• Cite a relevant quotation or expert opinion already noted in your paper in order to lend authority and support to the conclusion(s) you have reached [a good source would be from your literature review].
• Explain the consequences of your research in a way that elicits action or demonstrates urgency in seeking change.
• Restate a key statistic, fact, or visual image to emphasize the most important finding of your paper.
• If your discipline encourages personal reflection, illustrate your concluding point by drawing from your own life experiences.
• Return to an anecdote, an example, or a quotation that you presented in your introduction, but add further insight derived from the findings of your study; use your interpretation of results from your study to recast it in new or important ways.
• Provide a "take-home" message in the form of a succinct, declarative statement that you want the reader to remember about your study.

III. Problems to Avoid

Failure to be concise Your conclusion section should be concise and to the point. Conclusions that are too lengthy often have unnecessary information in them. The conclusion is not the place for details about your methodology or results. Although you should give a summary of what was learned from your research, this summary should be relatively brief, since the emphasis in the conclusion is on the implications, evaluations, insights, and other forms of analysis that you make. Strategies for writing concisely can be found here .

Failure to comment on larger, more significant issues In the introduction, your task was to move from the general [the field of study] to the specific [the research problem]. However, in the conclusion, your task is to move from a specific discussion [your research problem] back to a general discussion framed around the implications and significance of your findings [i.e., how your research contributes new understanding or fills an important gap in the literature]. In short, the conclusion is where you should place your research within a larger context [visualize your paper as an hourglass--start with a broad introduction and review of the literature, move to the specific analysis and discussion, conclude with a broad summary of the study's implications and significance].

Failure to reveal problems and negative results Negative aspects of the research process should never be ignored. These are problems, deficiencies, or challenges encountered during your study. They should be summarized as a way of qualifying your overall conclusions. If you encountered negative or unintended results [i.e., findings that are validated outside the research context in which they were generated], you must report them in the results section and discuss their implications in the discussion section of your paper. In the conclusion, use negative results as an opportunity to explain their possible significance and/or how they may form the basis for future research.

Failure to provide a clear summary of what was learned In order to be able to discuss how your research fits within your field of study [and possibly the world at large], you need to summarize briefly and succinctly how it contributes to new knowledge or a new understanding about the research problem. This element of your conclusion may be only a few sentences long.

Failure to match the objectives of your research Often research objectives in the social and behavioral sciences change while the research is being carried out. This is not a problem unless you forget to go back and refine the original objectives in your introduction. As these changes emerge they must be documented so that they accurately reflect what you were trying to accomplish in your research [not what you thought you might accomplish when you began].

Resist the urge to apologize If you've immersed yourself in studying the research problem, you presumably should know a good deal about it [perhaps even more than your professor!]. Nevertheless, by the time you have finished writing, you may be having some doubts about what you have produced. Repress those doubts! Don't undermine your authority as a researcher by saying something like, "This is just one approach to examining this problem; there may be other, much better approaches that...." The overall tone of your conclusion should convey confidence to the reader about the study's validity and realiability.

Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8; Concluding Paragraphs. College Writing Center at Meramec. St. Louis Community College; Conclusions. The Writing Center. University of North Carolina; Conclusions. The Writing Lab and The OWL. Purdue University; Freedman, Leora  and Jerry Plotnick. Introductions and Conclusions. The Lab Report. University College Writing Centre. University of Toronto; Leibensperger, Summer. Draft Your Conclusion. Academic Center, the University of Houston-Victoria, 2003; Make Your Last Words Count. The Writer’s Handbook. Writing Center. University of Wisconsin Madison; Miquel, Fuster-Marquez and Carmen Gregori-Signes. “Chapter Six: ‘Last but Not Least:’ Writing the Conclusion of Your Paper.” In Writing an Applied Linguistics Thesis or Dissertation: A Guide to Presenting Empirical Research . John Bitchener, editor. (Basingstoke,UK: Palgrave Macmillan, 2010), pp. 93-105; Tips for Writing a Good Conclusion. Writing@CSU. Colorado State University; Kretchmer, Paul. Twelve Steps to Writing an Effective Conclusion. San Francisco Edit, 2003-2008; Writing Conclusions. Writing Tutorial Services, Center for Innovative Teaching and Learning. Indiana University; Writing: Considering Structure and Organization. Institute for Writing Rhetoric. Dartmouth College.

Writing Tip

Don't Belabor the Obvious!

Avoid phrases like "in conclusion...," "in summary...," or "in closing...." These phrases can be useful, even welcome, in oral presentations. But readers can see by the tell-tale section heading and number of pages remaining that they are reaching the end of your paper. You'll irritate your readers if you belabor the obvious.

Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8.

Another Writing Tip

New Insight, Not New Information!

Don't surprise the reader with new information in your conclusion that was never referenced anywhere else in the paper. This why the conclusion rarely has citations to sources. If you have new information to present, add it to the discussion or other appropriate section of the paper. Note that, although no new information is introduced, the conclusion, along with the discussion section, is where you offer your most "original" contributions in the paper; the conclusion is where you describe the value of your research, demonstrate that you understand the material that you’ve presented, and position your findings within the larger context of scholarship on the topic, including describing how your research contributes new insights to that scholarship.

Assan, Joseph. "Writing the Conclusion Chapter: The Good, the Bad and the Missing." Liverpool: Development Studies Association (2009): 1-8; Conclusions. The Writing Center. University of North Carolina.

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6 Summary, Conclusions, and Recommendations

• Published: December 2011
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This chapter summarizes the key issues that researchers need to take into consideration when choosing and implementing exploratory factor analysis (EFA) before offering some conclusions and recommendations to help readers who are contemplating the use of EFA in their own research. It reviews the basic assumptions of the common factor model, the general mathematical model on which EFA is based, intended to explain the structure of correlations among a battery of measured variables; the issues that researchers should bear in mind in determining when it is appropriate to conduct an EFA; the decisions to be made in conducting an EFA; and the implementation of EFA as well as the interpretation of data it provides.

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How to Write Summary, Conclusion and Recommendations in a Research

The summary, conclusion and recommendations are the last part of the research work . It is essential to have this in all research work, both qualitative and quantitative . When perusing a research work (thesis or research articles ), the readers go directly to the summary, conclusion, and recommendation and see if they could point out what the dissertation is saying because it is common in this chapter.

The gap in the literature identified in the introduction signifies what the scholars decided to look at, what they finally assert when their study is done. What did it inform them, and what they are teaching us about the matter. Did they get the expected outcomes? If so, why or why not? The thesis is likely to be a very logical and provisional assertion instead of a broad statement.

Almost every research study concludes by encouraging other academics to continue the work by stating that more investigation is necessary on the topic. Nevertheless, please do not confuse this ruling with the thesis; it is merely a tradition. Frequently, the researchers offer detailed information about possible future research that might or can be undertaken in an attempt to make sense of the findings of their research. The following steps will guide in write a good chapter five:

Step 1: Summary

It is now time to go through each section and highlight the critical statements. What information does the reader have to fully comprehend the article’s central argument or inference? Remember that a summary does not necessitate rephrasing every single line of the article. The idea is to identify the main elements while excluding any background knowledge or optional information. A summary of findings reveals and summarises the most critical factors and outcomes of a study, including the best theoretical boundaries and the finality of the substantiation for each result. It tells the reader what has been done, how it has been done, and the study results. An engaging summary of findings allows the readers to see as many or more minor findings and just about relevant data about each result, see effect estimates presented in various ways, and view clarifications of the evidence supplied.

Step 2: Conclusions

After analysing the literature, the conclusion should aid in understanding why the study is essential to them. A conclusion is a synthesis of critical elements, not just a description of the points or a re-statement of the problem statement. For most research studies, one well-developed paragraph suffices as a conclusion. However, a two- or three paragraph conclusion may be considered necessary in some situations. It is vital to include a conclusion in a thesis, journal article or dissertation to inform the readers of the strength and effect of the assertions in the study. Concluding statements in a thesis can also aid in refocusing the reader’s attention on the quality statements and verifiable details of the research. Conclusions can also form a foundation for further research, generate new ideas to address an issue raised in the thesis or propose novel approaches to a problem. Consider the steps below to help you get started when writing the conclusion of your study:

• Restate the research topic.
• Reiterate the thesis (objective of the study).
• Make a summary of the main points.
• Mention the relevance or outcomes.
• Wrap up your thoughts.

Avoidable Issues

• Inability to be concise.
• Inability to make a statement on more significant, more important issues.
• Failure to expose problems leads to adverse outcomes.
• Inability to provide a brief overview of what was observed.
• Failure to align the research aim and objectives.
• Refrain from apologizing.

Step 3: Recommendations

You may have already created suggestions for future studies in the discussion, but the recommendation is a great place to explain, taking into account the potential ramifications of your research results for practice and theory. The recommendations should be premised on the conclusions of the study.

Specific instances

• Predicated on these conclusions, managers should consider… Additional researches could address…
• Further research is necessary to confirm the causative factors of/effects of/relationship between…

Avoid overstating the practicability of the study. If you’re making policy, business, or other policy implications, it’s best to structure them as suggestions instead of instructions. Academic research aims to educate, demonstrate, and explore rather than to instruct.

Make sure not to undermine the research carried out when making recommendations for additional research. Academic research aims to educate, demonstrate, and explore rather than to instruct.

Make sure not to undermine the research carried out when making recommendations for additional research.

Step 4: Recommendations for further study

Future studies may confirm, build on, or supplement your findings, but they should not be considered necessary to accomplish them. Highlight the contributions. Make sure the reader understands how the study has contributed to knowledge in the field in focus.

The suggestions for further study should address other areas that your study did not cover. That is, suggestions for further study should expand on the limitations and scope of your study.

Summary, Conclusion, and Recommendations

• First Online: 01 November 2022

Cite this chapter

• Yasir Alenazi 3  

Part of the book series: New Frontiers in Translation Studies ((NFTS))

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This chapter presents the conclusions reached in this study, acknowledging some limitations and suggestions for further research. The chapter is presented in seven sections. The first section (7.2) provides a brief overview of the research project. The second section (7.3) demonstrates a summary of the major findings based on the research questions and analysis. The third section (7.4) presents the contributions of the study. The fourth section (7.5) offers two pedagogical frameworks as a set of recommendations to improve ESL/EFL teaching/learning with respect to language errors and writing skills. The chapter concludes (sections 7.6 and 7.7) by presenting the limitations of the study and suggesting areas for further research.

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Al-Jabri, S. M. H. (1998). An analysis of lexical errors in written English of Saudi college freshman female students [Unpublished Master’s thesis], Girls College of Education.

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Ellis, R. (2008). The study of second language acquisition . Oxford University Press.

Elmahdi, O. E. H. (2016). Translation problems faced by Saudi EFL learners at university level. English Literature and Language Review, 2 (7), 74–81.

Gass, S., & Selinker, L. (2008). Second language acquisition: An introductory course (3rd ed.). Routledge.

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Javid, C. Z., Farooq, M. U., & Umer, M. (2013). An investigation of Saudi EFL learners’ writing problems: A case study along gender-lines. Kashmir Journal of Language Research, 16 (1), 179.

Khalifa, M. (2015). Problem in translating English and Arabic languages’ structure: A case study of EFL Saudi students in Shaqra University. European Journal of English Language and Literature Studies, 3 (4), 22–34.

Khan, I. (2011). Role of applied linguistics in the teaching of english in Saudi Arabia. Retrieved June 20, 2018, from https://ssrn.com/abstract=2857575

Rahman, M., & Alhaisoni, E. (2013). Teaching English in Saudi Arabia: Prospective and challenges. Academic Research International, 4 (1), 112–118.

Shalaby, A. N., Yahya, N., & El-Komi, M. (2009). Analysis of lexical errors in Saudi college students’ compositions. Journal of the Saudi Association of Languages and Translation, 2 (3), 65–93.

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Alenazi, Y. (2022). Summary, Conclusion, and Recommendations. In: Exploring Lexical Inaccuracy in Arabic-English Translation. New Frontiers in Translation Studies. Springer, Singapore. https://doi.org/10.1007/978-981-19-6390-2_7

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Chapter 4 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

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Hospital performance evaluation indicators: a scoping review

• Shirin Alsadat Hadian   ORCID: orcid.org/0000-0002-1443-1990 1 ,
• Reza Rezayatmand   ORCID: orcid.org/0000-0002-9907-3597 2 ,
• Nasrin Shaarbafchizadeh   ORCID: orcid.org/0000-0001-7104-2214 3 ,
• Saeedeh Ketabi   ORCID: orcid.org/0000-0002-6778-5645 4 &
• Ahmad Reza Pourghaderi   ORCID: orcid.org/0000-0003-2682-2160 5  

BMC Health Services Research volume  24 , Article number:  561 ( 2024 ) Cite this article

336 Accesses

Metrics details

Hospitals are the biggest consumers of health system budgets and hence measuring hospital performance by quantitative or qualitative accessible and reliable indicators is crucial. This review aimed to categorize and present a set of indicators for evaluating overall hospital performance.

We conducted a literature search across three databases, i.e., PubMed, Scopus, and Web of Science, using possible keyword combinations. We included studies that explored hospital performance evaluation indicators from different dimensions.

We included 91 English language studies published in the past 10 years. In total, 1161 indicators were extracted from the included studies. We classified the extracted indicators into 3 categories, 14 subcategories, 21 performance dimensions, and 110 main indicators. Finally, we presented a comprehensive set of indicators with regard to different performance dimensions and classified them based on what they indicate in the production process, i.e., input, process, output, outcome and impact.

The findings provide a comprehensive set of indicators at different levels that can be used for hospital performance evaluation. Future studies can be conducted to validate and apply these indicators in different contexts. It seems that, depending on the specific conditions of each country, an appropriate set of indicators can be selected from this comprehensive list of indicators for use in the performance evaluation of hospitals in different settings.

Peer Review reports

Healthcare is complex [ 1 ] and a key sector [ 2 ] that is now globally faced with problems of rising costs, lack of service efficiency, competition, and equity as well as responsiveness to users [ 3 ]. One estimate by the WHO has shown a yearly waste of approximately 20–40% of total healthcare resources because of inefficiency [ 4 ]. European countries have spent on average 9.6% of their gross domestic product (GDP) on healthcare in 2017 and 9.92% in 2019. Germany, France, and Sweden reported the highest healthcare expenditures in Europe in 2018 (between 10.9% and 11.5% of GDP) [ 5 ]. In the U.S., healthcare spending consumes 18% of the GDP, which is likely to eclipse $6 trillion by 2027 [ 6 ].

Hospitals, as the biggest consumers of health system budgets [ 7 ], are the major part of the health system [ 8 ]. In many countries 50–80% of the health sector budget is dedicated to hospitals [ 8 , 9 ]. As a result, hospital performance analysis is becoming a routine task for every hospital manager. On the one hand, hospital managers worldwide are faced with difficult decisions regarding cost reduction, increasing service efficiency, and equity [ 10 ]. On the other hand, measuring hospital efficiency is an issue of interest among researchers because patients demand high-quality care at lower expenses [ 11 ].

To address the above mentioned need to measure hospital performance, implementing an appropriate hospital performance evaluation system is crucial in any hospital. In doing so, hospital administrators use various tools to analyse and monitor hospital activities [ 1 ], which need well-defined objectives, standards and quantitative indicators [ 12 ]. The latter are used to evaluate care provided to patients both quantitatively and qualitatively and are often related to input, output, processes, and outcomes. These indicators can be used for continuous quality improvement by monitoring, benchmarking, and prioritizing activities [ 13 ]. These parameters are developed to improve health outcomes and to provide comparative information for monitoring and managing and formulating policy objectives within and across health services [ 12 ]. Studies thus far have used their own set of indicators while evaluating hospital performance, which could be context dependent. In addition, those studies have mostly used a limited set of indicators that focus on few dimensions (2–6 dimensions) of hospital performance [ 14 , 15 , 16 , 17 , 18 ].

Therefore, comprehensive knowledge of potential indicators that can be used for hospital performance evaluation is necessary. It would help choose appropriate indicators when evaluating hospital performance in different contexts. It would also help researchers extend the range of analysis to evaluate performance from a wider perspective by considering more dimensions of performance. Although performance is a very commonly used term, it has several definitions [ 19 , 20 ], yet, it is often misunderstood [ 21 ]. Therefore, some researchers have expressed confusion about the related terms and considered them interchangeable. These terms are effectiveness, efficiency, productivity, quality, flexibility, creativity, sustainability, evaluation, and piloting [ 21 , 22 , 23 ]. Thus, this scoping review aimed to categorize and present a comprehensive set of indicators that can be used as a suitable set for hospital performance evaluation at any needed level of analysis, i.e., clinical, para-clinical, logistical, or departmental, and relate those indicators to the appropriate performance dimensions. The uniqueness of this paper is that it provides its readers with a comprehensive collection of indicators that have been used in different performance analysis studies.

Materials and methods

We conducted a scoping review of a body of literature. The scoping review can be of particular use when the topic has not yet been extensively reviewed or has a complex or heterogeneous nature. This type of review is commonly undertaken to examine the extent, range, and nature of research activity in a topic area; determine the value and potential scope and cost of undertaking a full systematic review; summarize and disseminate research findings; and identify research gaps in the existing literature. As a scoping review provides a rigorous and transparent method for mapping areas of research, it can be used as a standalone project or as a preliminary step to a systematic review [ 24 ]. While a systematic review (qualitative or quantitative) usually addresses a narrow topic/scope and is a method for integrating or comparing findings from previous studies [ 25 ].

In our study, we used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist following the methods outlined by Arksey and O’Malley [ 26 ] and Tricco [ 27 ]. A systematic search for published and English-language literature on hospital performance evaluation models was conducted, using three databases, i.e., PubMed, Scopus, and Web of Science, from 2013 to January 2023. Initially, the identified keywords were refined and validated by a team of experts. Then, a combination of vocabularies was identified by the authors through a brainstorming process. The search strategy was formulated using Boolean operators. The title and abstract of the formulas were searched in the online databases. The search query for each database is presented in Table  1 .

In the screening process, relevant references related to hospital performance evaluation were screened and abstracted into researcher-developed Microsoft® Excel forms by dual independent reviewers and conflicting information was provided by other reviewers.

The inclusion criteria were as follows: focused only on the hospital setting, available full text and written in English. We excluded studies that focused on health organization indicators, not specifically on hospital indicators; articles without appropriate data (only focused on models and not indicators; or qualitative checklist questionnaires); and articles that focused only on clinical or disease-related indicators, not hospital performance dimensions, and provided very general items as indicators, not the domains of the indicators themselves. Then, a PRISMA-ScR Checklist was used to improve transparency in our review [ 28 ].

To extract the data, researcher-developed Microsoft® Excel forms (data tables) were designed. The following data were subsequently extracted into Microsoft®Excel for synthesis and evaluation: title, author, article year, country, indicator category, study environment (number of hospitals studied), study time frame, indicator name, number of indicators, indicator level (hospital level, department level), evaluation perspective (performance, productivity, efficiency, effectiveness, quality, cost, safety, satisfaction, etc. ) , study type (quantitative or qualitative), indicator subtype (input (structure), process, output (result), outcome and impact), and other explanations. To create a descriptive summary of the results that address the objectives of this scoping review, numerical summarization was also used.

The purpose of creating the main category and the evaluation perspective section was to develop them and create new categories, which focused on the type of indicators related to the performance term. For example, in the “Category” section, the names of the departments or wards of the hospital (such as hospital laboratories, pharmacies, clinical departments, and warehouses) and in the “Evaluation perspective” section, various terms related to the evaluation of hospital performance were extracted. These two types were used after extracting their information under the title “performance dimension”.

The indicators’ levels were collected to determine the level of performance evaluation with the relevant index. Some indicators were used to evaluate the performance of the entire hospital, some were used to evaluate the performance of hospital departments, and some were used to evaluate the performance at the level of a specific project. For example, several indicators (such as bed occupancy ratio, length of stay, and waiting time) were used to evaluate the performance of the entire hospital, and other indicators (such as laboratory department indicators, energy consumption indicators, and neonatal department indicators) were used only to measure the performance of specific departments. This sections were used under the title “category”. The “category” and “indicator’s name” sections were defined according to the results of the “subcategory” section.

The subtypes of indicators (input (structure), process, output(result), outcome and impact) were defined based on the chain model, and each of the selected indicators was linked to it (Appendix 1 ). As a result of the chain model, inputs were used to carry out activities, activities led to the delivery of services or products (outputs). The outputs started to bring about change (outcomes), and eventually, this (hopefully) contributed to the impact [ 29 ]. The classification of the set of input, process, output, outcome and impact indicators was such that readers could access these categories if necessary according to their chosen evaluation models. The term was used under the title “Indicators by types”.

The type of study was considered quantitative or qualitative for determining whether an indicator was able to perform calculations. In this way, readers can choose articles that use quantitative or qualitative indicators to evaluate hospital performance.

We included 91 full-text studies (out of 7475) in English published between 2013 and January 2023 (Fig.  1 ), approximately 40% of which were published between 2020 and 2023. More than 20% of the retrieved studies were conducted in Iran and USA.

Study selection and data abstraction

Study characteristic

As shown in Table  2 , in 85% of the reviewed studies, a number of hospitals (1 to 3828 hospitals, 13,221 hospitals in total) were evaluated. More than 90% of the studies used a quantitative approach. In more than 70% of the studies, hospital evaluation occurred at the department level, which can also be divided into three levels: administrative, clinical ward, and paramedical department. In addition, the administrative departments consist of 13 departments, including financial management [ 48 , 55 , 61 , 67 , 68 , 80 , 83 , 109 , 113 ], supply chain management and warehouse [ 15 , 43 , 84 ], value-based purchasing [ 33 , 85 ], human resource management [ 97 , 101 ], medical equipment [ 32 , 87 ], health information management department [ 90 ], information systems [ 106 ], nutritional assessment [ 93 ], energy management [ 30 , 45 , 92 ], facility management [ 52 , 53 ], building sustainability and resilience [ 35 ], research activities [ 44 ], and education [ 107 ].

The clinical wards consisted of 8 wards, namely, emergency departments (EDs) [ 16 , 39 , 56 , 57 , 69 , 70 , 89 ], surgery departments [ 58 , 62 , 63 , 91 , 102 ], intensive care units (ICUs) [ 47 , 64 , 65 ], operating rooms (ORs) [ 38 , 88 , 108 ], surgical intensive care units (SICUs) [ 111 ], obstetrics and gynecology department [ 59 ], neonatal intensive care units (NICUs) [ 74 , 103 ] and quality of care [ 18 , 31 , 40 , 50 , 72 , 92 , 95 , 112 ] indicators. The paramedical departments consisted of 3 departments, pharmacy [ 60 , 76 , 98 ], laboratory and blood bank [ 37 , 42 , 43 , 49 ], and outpatient assessment [ 86 ] indicators.

With regard to data categorization, firstly, a total of 1204 indicators in 91 studies were extracted and after detailed examination, 43 indices (such as hospital ownership, level of care, admission process, and personal discipline) were removed due to their generality and impossibility of calculation in the hospital environment. Then, 1161 performance indicators were entered in this research and were categorized based on the performance criteria (more details about the indicators can be found in Appendix 1 ). Secondly, 145 functional dimensions, including divisions based on different departments and units of the hospital, were defined according to several focus group discussions with 5 health experts. Then, re-categorization and functional summarization were performed, after which 21 performance dimensions were finalized.

As shown in Table  4 , the 21 performance dimensions were divided into three parts: category, subcategory, and related indicators. Additionally, according to the hospital levels, there were three categories: ‘organizational management’, ‘clinical management’, and ‘administrative management’. Then, according to the type of indicators, fifteen subcategories were defined for the 110 selected main indicators.

Performance dimensions

The ‘productivity’ dimension focuses on indicators reflecting the macro-performance of the hospital, considering that this index is more effective and efficient. The ‘efficiency’ dimension focuses on general performance indicators for the optimal use of resources to create optimal output in the hospital. The ‘effectiveness’ dimension is a general performance indicator with an outcome view. The ‘speed’ dimension focuses on the indicators that show attention to the service delivery time and the speed of the procedures. The ‘development’ dimension focuses on matters related to employees’ and students’ training and related training courses. In terms of ‘safety’ dimension, there were issues related to patient safety, unwanted and harmful events, and hospital infections.

The “quality of work life” dimension emphasizes matters related to personnel volume and work conditions. The ‘quality’ dimension is related to the quality of service provided in different parts of the hospital and possible complications in improving the quality of services. The ‘satisfaction’ dimension focuses on the satisfaction of patients, employees, and their complaints. The ‘innovation’ dimension relates to the research process and its output. The ‘appropriateness’ dimension involves proper service from clinical departments, pharmaceutical services, and patient treatment. The ‘evaluation’ dimension focuses on the indicators related to the assessment scores of the para-clinical departments of the hospital.

The ‘profitability’ dimension focuses on the overall output indicators for income and profitability. The ‘cost’ dimension focuses on indicators related to general expenditures and the average cost per bed and patient and budgeting. The ‘economy’ dimension is related to financial rates and their indicators. The ‘coherence’ dimension emphasizes the indicators related to the continuity of the service delivery process. The ‘patient-centeredness’ dimension focuses on the indicators related to the patient’s experience of the facility, environment, treatment processes, communications, and relevant support for the patient. The ‘equity’ dimension studies indicators related to social and financial justice and life expectancy. The ‘relationship’ dimension evaluates the process of consultations and discussions required during the patients’ care provided by the treatment team. The ‘sustainability’ dimension focuses on indicators related to energy standards. The ‘flexibility’ dimension focuses on the hospital’s response to the crisis.

According to Table  4 , most studies focused on ‘efficiency’, ‘productivity’, ‘safety’ and ‘effectiveness’ as performance dimensions in 54, 53, 38 and 37 studies, respectively (40–70% of studies). In the ‘efficiency’ subcategory, resource management, supportive unit assessment, and human resource management indicators were the first to third most common indicators used in 26, 23 and 22 studies, respectively (approximately 25% of the studies).

In addition, for the ‘efficiency’ dimension, ‘medical staff numbers’, ‘emergency department bed numbers’, and ‘nonmedical staff numbers’ were reported in 16, 13, and 11 studies, respectively (between 20 and 30% of the studies). For the ‘productivity’ subcategory, ‘bed utilization rate’ and ‘service delivery and treatment’ were reported in 50% and 20% of the studies, respectively (46 and 19 out of 91).

Additionally, for the ‘productivity’ dimension, the ‘length of stay’ indicator was used more than others and reported in approximately 80% of the studies (43 out of 53), followed by the ‘bed occupancy rate’ in approximately 40% of the studies (21 out of 53). The ‘bed turnover ratio’ and ‘hospitalization rate’ were also reported in 12 studies. Furthermore, for ‘safety’ dimensions, all indicators were in the ‘patient safety’ subcategory, which has been reported in 38 studies, and ‘complications’, ‘accidents or adverse events’, and ‘incidents or errors rates’ were the most concentrated indicators by researchers in 13, 12, and 11 studies, respectively. The performance dimension of ‘effectiveness’ was presented in 37 studies (40%), with only two indicators, ‘mortality rate’ in 29 studies and ‘readmission rate’ in 23 studies.

Performance categories

Considering the three categories shown in Table  4 , ‘organizational management’ indicators were more commonly used among the other two categories (‘clinical’ and ‘administrative’) and were present in more than 85% of the studies (78 out of 91). Two categories, ‘clinical management’ and ‘administrative management’, were reported in 62 and 51 studies, respectively.

Performance subcategories

Considering the 14 subcategories shown in Table  4 , both the ‘bed utilization rate’ and ‘patient safety’ indicators were mentioned in 46 studies and were more common among the other subcategories. The second most common indicator of the ‘financial management’ subcategory was reported in 38 studies. At the third level, both the ‘human resource management’ and ‘time management’ indicators were presented in 31 studies. The ‘paramedical’ subcategory indicators were presented in less than 10% of the studies [ 60 , 96 , 97 , 98 , 106 , 113 ].

Performance indicators

According to the indicator columns in Table  3 , the most used indicators in reviewed studies were the length of stay, mortality rate, and readmission rate in 47%, 32%, and 25% of studies, respectively. Bed occupancy rate and non-personnel costs were reported in 23% of studies. Additionally, among the 110 indicators, 16 indicators, namely, the lab cancellation rate, exam-physician ratios, number of coded diagnoses, number of medical records, laboratory sample/report intervals, medical information request time, safety standards in the archives, nutritional risk screening, imaging quality control failures, errors in medical reports, average impact factor, nutritional measures, laboratory scoring, imaging inspection, discharge process and emergency response rate, were reported in less than 1% of the studies.

The classification of the indicators in Table  4 was performed based on the chain model, which included the input, process, output, outcome and impact. The assignment of the indicators to each category was performed according to the experts’ opinions. For instance, the number of publications by academic member of an academic hospital and the average impact factor of those publications were considered outcome indicators. As depicted in the Table  4 , most studies (80%) focused more on output indicators. Additionally, fifteen studies focused on introducing and extracting some of the input, process, output, outcome and impact indicators; among those, only one study [ 96 ] has examined the input, process, output and impact indicators simultaneously.

Additionally, in approximately 42% (36 out of 91) of the studies, the indicators’ definitions, formulas, or descriptions have been illustrated, while less than 10% of the studies have defined measuring units, standard or benchmark units for all studied indicators [ 15 , 43 , 45 , 51 , 52 , 57 , 67 ].

Overall, nine studies related to hospital performance evaluation were conducted using systematic review methodologies (five systematic reviews [ 16 , 29 , 30 , 56 , 113 ], two literature reviews [ 79 , 80 ], one narrative review [ 98 ] and one brief review [ 92 ]). Most of these studies focused on extracting performance indicators from one or more hospital departments (e.g., the emergency department) [ 16 , 56 ], hospital laboratory and radiology information systems [ 106 ], supply chain performance [ 29 ], resources and financial results and activity [ 113 ], hospital water consumption [ 30 ], and the pharmaceutical sector [ 98 ]. Other reviews included a three-step process to review, evaluate and rank these hospital indicators in a systematic approach [ 16 ], or to evaluate performance indicator models to create an interactive network and visualize the causal relationships between performance indicators [ 79 ]; moreover, some have focused on the importance of indicators to ensure adequate coverage of the relevant areas of health care services to be evaluated [ 92 ].

Only one scoping review aimed to identify current assessments of hospital performance and compared quality measures from each method in the context of the six qualitative domains of STEEEP (safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness) of the Institute of Medicine (IOM) in accordance with Donabedian’s framework and formulating policy recommendations [ 115 ].

In addition, 21 studies divided performance indicators into 2 to 6 dimensions of performance. Also, the reviewed studies included 2–40 indicators in zero [ 29 , 30 , 98 ] to 6 domains [ 34 ]. Moreover, none of the studies have tried to comprehensively summarize and categorize the performance indicators in several categories, focusing on all the indicators reflecting the performance of the entire hospital organization, or the indicators of administrative units or clinical departments.

In this scoping review, a unique set of hospital performance evaluation indicators related to the various performance dimensions was categorized from 91 studies over the past ten years.

Similarly, in a study, 19 performance dimensions, 32 sub-dimensions, and 138 indicators were extracted from only six studies. Those dimensions were described by all studies included in the review, but only three studies specified the relevant indicators, and the list provided for all possible indicators was not comprehensive. Also, despite current review, there was no classification of indicators based on the hospital levels: managerial, clinical, or organizational levels [ 116 ]. Another study has similarly investigated the performance evaluation indicators of the hospital in such a way that among 42 studies, 111 indicators were presented in the four categories: input, output, outcome, and impact. But, there was no classification of indicators based on performance dimensions and hospital levels [ 117 ].

In this study, the importance of categorized indicators, for the first time to our knowledge, was determined based on their frequency of use in the published literature (Appendix 2 ). The ‘Organizational management’ indicators were the most common compared with the other two categories (‘clinical’ and ‘administrative’). It could be because of the fact that the indicators such as ‘bed occupancy rate’, ‘average length of stay’, ‘mortality rate’, ‘hospital infection rate’, and ‘patient safety’ are easier to be registered in hospital software compared to other indicators, and also they better reflect the overall performance of hospital. Thus, researchers are more interested in using these indicators.

Considering 14 subcategories, indicators related to three subcategories i.e. bed utilization, patient safety and financial management are the most frequent used indicators for hospital performance evaluation. It reflects the need of hospital managers to increase the profitability of hospital in one hand, and to control cost on the other hand. As a results, researchers have paid special attention to ‘cost income’, ‘profitability’, ‘economic’, etc., as indicators for evaluating hospital performance.

When considering indicators by type, more studies have focused on output indicators, while input indicators were the least common used. This might be because of the fact that at hospital level, it is difficult for managers to change those inputs such as ‘beds’, ‘human resources’, ‘equipment and facilities’. In addition, due to the complexity of interdepartmental relationships in hospitals, process indicators seemed to provide more variety for analysis than input indicators, so they were more often used. As mentioned above, output indicators were the most used indicators for hospital performance evaluation due to their ease of calculation and interpretation.

The main purpose of this paper was to identify a comprehensive set of indicators that can be used to evaluate hospital performance in various hospital settings by being distilled into a smaller and more related set of indicators for every hospital or department setting. future studies could be designed to validate each set of indicators in any specific context. In addition, they could investigate the relationship between the indicators and their outcomes of interest and the performance dimension each could address. This will enable hospital managers to build their own set of indicators for performance evaluation both at organization or at department level. Also it should be mentioned that.

Although some previous studies have provided definitions for each indicator and determined the standard criteria for them, this was not done in this study because the focus of this study was to provide a collection of all the indicators used in hospital performance evaluation, which resulted in the identification of more than a thousand indicators without limiting to specific country or context. So while preparing a smaller set of indicators, specific conditions of each country, such as the type of health system and its policy, the type of financing system, and the structure of services, should be taken into account to select appropriate indicators.

In addition, although it is important to examine the scope of each article to compare the list of indicators and the relationships between the dimensions of the hospital in terms of size and type and between the number and type of selected indicators, this was considered beyond the scope of this review due to the high number of indicators, which made the abovementioned investigations impossible. Future studies could do that while working with a smaller set of indicators.

This review aimed to categorize and present a comprehensive set of indicators for evaluating overall hospital performance in a systematic way. 1161 hospital performance indicators were drawn from 91 studies over the past ten years. They then were summarized into 110 main indicators, and categorized into three categories: 14 subcategories, and 21 performance dimensions This scoping review also highlighted the most frequent used indicators in performance evaluation studies which could reflect their importance for that purpose. The results of this review help hospital managers to build their own set of indicators for performance evaluation both at organization or at department level with regard to various performance dimensions.

As the results of this review was not limited to any specific country or context, specific conditions of each country, such as the type of health system and its policy, the type of financing system, and the structure of services, should be taken into account while selecting appropriate indicators as a smaller set of indicators for hospital performance evaluation in specific context.

Availability of data and materials

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

Abbreviations

Gross domestic product

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews

Emergency departments

Intensive care unit

Operating room

Surgical intensive care unit

Neonatal intensive care unit

Readmission rate

Quality Control

Medication use evaluation

safety, timeliness, effectiveness, efficiency, equity, and patient-centeredness

Institute of Medicine

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Acknowledgements

The authors are grateful for the support of the Vice Chancellor for Research of Isfahan University of Medical Sciences.

The present article is part of the result of a doctoral thesis approved by Isfahan University of Medical Sciences with code 55657 (IR.MUI.NUREMA.REC.1401.005), without financial source.

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Shirin Alsadat Hadian and Reza Rezayatmans and Saeedeh Ketabi: Study conceptualization and design. Acquisition of data: Shirin Alsadat Hadian, Reza Rezayatmand. Analysis and interpretation of data: Shirin Alsadat Hadian, Reza Rezayatmand, Nasrin Shaarbafchizadeh, Saeedeh Ketabi. Drafting of the manuscript: Shirin Alsadat Hadian, Reza Rezayatmand. Critical revision of the manuscript for important intellectual content: Reza Rezayatmand, Nasrin Shaarbafchizadeh, Saeedeh Ketabi, Ahmad Reza Pourghaderi.

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Hadian, S.A., Rezayatmand, R., Shaarbafchizadeh, N. et al. Hospital performance evaluation indicators: a scoping review. BMC Health Serv Res 24 , 561 (2024). https://doi.org/10.1186/s12913-024-10940-1

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Sexual and reproductive health implementation research in humanitarian contexts: a scoping review

• Alexandra Norton 1 &
• Hannah Tappis 2  

Reproductive Health volume  21 , Article number:  64 ( 2024 ) Cite this article

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Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on appropriate methods and analytical frameworks is limited.

A scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Peer-reviewed papers published from 2013 to 2022 were identified through relevant systematic reviews and a literature search of Pubmed, Embase, PsycInfo, CINAHL and Global Health databases. Papers that presented primary quantitative or qualitative data pertaining to a sexual and reproductive health intervention in a humanitarian setting were included.

Seven thousand thirty-six unique records were screened for inclusion, and 69 papers met inclusion criteria. Of these, six papers explicitly described the use of an implementation research framework, three citing use of the Consolidated Framework for Implementation Research. Three additional papers referenced other types of frameworks used in their evaluation. Factors cited across all included studies as helping the intervention in their presence or hindering in their absence were synthesized into the following Consolidated Framework for Implementation Research domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process.

This review found a wide range of methodologies and only six of 69 studies using an implementation research framework, highlighting an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

Plain English summary

Three hundred thirty-nine million people globally were in need of humanitarian assistance in 2023, and meeting the health needs of crisis-affected populations is a growing challenge. One in four people living in humanitarian contexts are women and girls of reproductive age, and provision of sexual and reproductive health care is considered to be essential within a humanitarian response. Implementation research can help to better understand how real-world contexts affect health improvement efforts. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on how best to do so is limited. This scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Of 69 papers that met inclusion criteria for the review, six of them explicitly described the use of an implementation research framework. Three used the Consolidated Framework for Implementation Research, a theory-based framework that can guide implementation research. Three additional papers referenced other types of frameworks used in their evaluation. This review summarizes how factors relevant to different aspects of implementation within the included papers could have been organized using the Consolidated Framework for Implementation Research. The findings from this review highlight an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

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Over the past few decades, the field of public health implementation research (IR) has grown as a means by which the real-world conditions affecting health improvement efforts can be better understood. Peters et al. put forward the following broad definition of IR for health: “IR is the scientific inquiry into questions concerning implementation – the act of carrying an intention into effect, which in health research can be policies, programmes, or individual practices (collectively called interventions)” [ 1 ].

As IR emphasizes real-world circumstances, the context within which a health intervention is delivered is a core consideration. However, much IR implemented to date has focused on higher-resource settings, with many proposed frameworks developed with particular utility for a higher-income setting [ 2 ]. In recognition of IR’s potential to increase evidence across a range of settings, there have been numerous reviews of the use of IR in lower-resource settings as well as calls for broader use [ 3 , 4 ]. There have also been more focused efforts to modify various approaches and frameworks to strengthen the relevance of IR to low- and middle-income country settings (LMICs), such as the work by Means et al. to adapt a specific IR framework for increased utility in LMICs [ 2 ].

Within LMIC settings, the centrality of context to a health intervention’s impact is of particular relevance in humanitarian settings, which present a set of distinct implementation challenges [ 5 ]. Humanitarian responses to crisis situations operate with limited resources, under potential security concerns, and often under pressure to relieve acute suffering and need [ 6 ]. Given these factors, successful implementation of a particular health intervention may require different qualities than those that optimize intervention impact under more stable circumstances [ 7 ]. Despite increasing recognition of the need for expanded evidence of health interventions in humanitarian settings, the evidence base remains limited [ 8 ]. Furthermore, despite its potential utility, there is not standardized guidance on IR in humanitarian settings, nor are there widely endorsed recommendations for the frameworks best suited to analyze implementation in these settings.

Sexual and reproductive health (SRH) is a core aspect of the health sector response in humanitarian settings [ 9 ]. Yet, progress in addressing SRH needs has lagged far behind other services because of challenges related to culture and ideology, financing constraints, lack of data and competing priorities [ 10 ]. The Minimum Initial Service Package (MISP) for SRH in Crisis Situations is the international standard for the minimum set of SRH services that should be implemented in all crisis situations [ 11 ]. However, as in other areas of health, there is need for expanded evidence for planning and implementation of SRH interventions in humanitarian settings. Recent systematic reviews of SRH in humanitarian settings have focused on the effectiveness of interventions and service delivery strategies, as well as factors affecting utilization, but have not detailed whether IR frameworks were used [ 12 , 13 , 14 , 15 ]. There have also been recent reviews examining IR frameworks used in various settings and research areas, but none have explicitly focused on humanitarian settings [ 2 , 16 ].

Given the need for an expanded evidence base for SRH interventions in humanitarian settings and the potential for IR to be used to expand the available evidence, a scoping review was undertaken. This scoping review sought to identify IR approaches that have been used in the last ten years to evaluate SRH interventions in humanitarian settings.

This review also sought to shed light on whether there is a need for a common framework to guide research design, analysis, and reporting for SRH interventions in humanitarian settings and if so, if there are any established frameworks already in use that would be fit-for-purpose or could be tailored to meet this need.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews was utilized to guide the elements of this review [ 17 ]. The review protocol was retrospectively registered with the Open Science Framework ( https://osf.io/b5qtz ).

Search strategy

A two-fold search strategy was undertaken for this review, which covered the last 10 years (2013–2022). First, recent systematic reviews pertaining to research or evaluation of SRH interventions in humanitarian settings were identified through keyword searches on PubMed and Google Scholar. Four relevant systematic reviews were identified [ 12 , 13 , 14 , 15 ] Table 1 .

Second, a literature search mirroring these reviews was conducted to identify relevant papers published since the completion of searches for the most recent review (April 2017). Additional file 1 includes the search terms that were used in the literature search [see Additional file 1 ].

The literature search was conducted for papers published from April 2017 to December 2022 in the databases that were searched in one or more of the systematic reviews: PubMed, Embase, PsycInfo, CINAHL and Global Health. Searches were completed in January 2023 Table 2 .

Two reviewers screened each identified study for alignment with inclusion criteria. Studies in the four systematic reviews identified were considered potentially eligible if published during the last 10 years. These papers then underwent full-text review to confirm satisfaction of all inclusion criteria, as inclusion criteria were similar but not fully aligned across the four reviews.

Literature search results were exported into a citation manager (Covidence), duplicates were removed, and a step-wise screening process for inclusion was applied. First, all papers underwent title and abstract screening. The remaining papers after abstract screening then underwent full-text review to confirm satisfaction of all inclusion criteria. Title and abstract screening as well as full-text review was conducted independently by both authors; disagreements after full-text review were resolved by consensus.

Data extraction and synthesis

The following content areas were summarized in Microsoft Excel for each paper that met inclusion criteria: publication details including author, year, country, setting [rural, urban, camp, settlement], population [refugees, internally displaced persons, general crisis-affected], crisis type [armed conflict, natural disaster], crisis stage [acute, chronic], study design, research methods, SRH intervention, and intervention target population [specific beneficiaries of the intervention within the broader population]; the use of an IR framework; details regarding the IR framework, how it was used, and any rationale given for the framework used; factors cited as impacting SRH interventions, either positively or negatively; and other key findings deemed relevant to this review.

As the focus of this review was on the approach taken for SRH intervention research and evaluation, the quality of the studies themselves was not assessed.

Twenty papers underwent full-text review due to their inclusion in one or more of the four systematic reviews and meeting publication date inclusion criteria. The literature search identified 7,016 unique papers. After full-text screening, 69 met all inclusion criteria and were included in the review. Figure  1 illustrates the search strategy and screening process.

Flow chart of paper identification

Papers published in each of the 10 years of the review timeframe (2013–2022) were included. 29% of the papers originated from the first five years of the time frame considered for this review, with the remaining 71% papers coming from the second half. Characteristics of included publications, including geographic location, type of humanitarian crisis, and type of SRH intervention, are presented in Table  3 .

A wide range of study designs and methods were used across the papers, with both qualitative and quantitative studies well represented. Twenty-six papers were quantitative evaluations [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 ], 17 were qualitative [ 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 ], and 26 used mixed methods [ 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 ]. Within the quantitative evaluations, 15 were observational, while five were quasi-experimental, five were randomized controlled trials, and one was an economic evaluation. Study designs as classified by the authors of this review are summarized in Table  4 .

Six papers (9%) explicitly cited use of an IR framework. Three of these papers utilized the Consolidated Framework for Implementation Research (CFIR) [ 51 , 65 , 70 ]. The CFIR is a commonly used determinant framework that—in its originally proposed form in 2009—is comprised of five domains, each of which has constructs to further categorize factors that impact implementation. The CFIR domains were identified as core content areas influencing the effectiveness of implementation, and the constructs within each domain are intended to provide a range of options for researchers to select from to “guide diagnostic assessments of implementation context, evaluate implementation progress, and help explain findings.” [ 87 ] To allow for consistent terminology throughout this review, the original 2009 CFIR domains and constructs are used.

Guan et al. conducted a mixed methods study to assess the feasibility and effectiveness of a neonatal hepatitis B immunization program in a conflict-affected rural region of Myanmar. Guan et al. report mapping data onto the CFIR as a secondary analysis step. They describe that “CFIR was used as a comprehensive meta-theoretical framework to examine the implementation of the Hepatitis B Virus vaccination program,” and implementation themes from multiple study data sources (interviews, observations, examination of monitoring materials) were mapped onto CFIR constructs. They report their results in two phases – Pre-implementation training and community education, and Implementation – with both anchored in themes that they had mapped onto CFIR domains and constructs. All but six constructs were included in their analysis, with a majority summarized in a table and key themes explored further in the narrative text. They specify that most concerns were identified within the Outer Setting and Process domains, while elements identified within the Inner Setting domain provided strength to the intervention and helped mitigate against barriers [ 70 ].

Sarker et al. conducted a qualitative study to assess provision of maternal, newborn and child health services to Rohingya refugees residing in camps in Cox’s Bazar, Bangladesh. They cite using CFIR as a guide for thematic analysis, applying it after a process of inductive and deductive coding to index these codes into the CFIR domains. They utilized three of the five CFIR domains (Outer Setting, Inner Setting, and Process), stating that the remaining two domains (Intervention Characteristics and Characteristics of Individuals) were not relevant to their analysis. They then proposed two additional CFIR domains, Context and Security, for use in humanitarian contexts. In contrast to Guan et al., CFIR constructs are not used nor mentioned by Sarker et al., with content under each domain instead synthesized as challenges and potential solutions. Regarding the CFIR, Sarker et al. write, “The CFIR guided us for interpretative coding and creating the challenges and possible solutions into groups for further clarification of the issues related to program delivery in a humanitarian crisis setting.” [ 51 ]

Sami et al. conducted a mixed methods case study to assess the implementation of a package of neonatal interventions at health facilities within refugee and internally displaced persons camps in South Sudan. They reference use of the CFIR earlier in the study than Sarker et al., basing their guides for semi-structured focus group discussions on the CFIR framework. They similarly reference a general use of the CFIR framework as they conducted thematic analysis. Constructs are referenced once, but they do not specify whether their application of the CFIR framework included use of domains, constructs, or both. This may be in part because they then applied an additional framework, the World Health Organization (WHO) Health System Framework, to present their findings. They describe a nested approach to their use of these frameworks: “Exploring these [CFIR] constructs within the WHO Health Systems Framework can identify specific entry points to improve the implementation of newborn interventions at critical health system building blocks.” [ 65 ]

Three papers cite use of different IR frameworks. Bolan et al. utilized the Theoretical Domains Framework in their mixed methods feasibility study and pilot cluster randomized trial evaluating pilot use of the Safe Delivery App by maternal and newborn health workers providing basic emergency obstetric and newborn care in facilities in the conflict-affected Maniema province of the Democratic Republic of the Congo (DRC). They used the Theroetical Domains Framework in designing interview questions, and further used it as the coding framework for their analysis. Similar to the CFIR, the Theoretical Domains Framework is a determinant framework that consists of domains, each of which then includes constructs. Bolan et al. utilized the Theoretical Domains Framework at the construct level in interview question development and at the domain level in their analysis, mapping interview responses to eight of the 14 domains [ 83 ]. Berg et al. report using an “exploratory design guided by the principles of an evaluation framework” developed by the Medical Research Council to analyze the implementation process, mechanisms of impact, and outcomes of a three-pillar training intervention to improve maternal and neonatal healthcare in the conflict-affected South Kivu province of the DRC [ 67 , 88 ]. Select components of this evaluation framework were used to guide deductive analysis of focus group discussions and in-depth interviews [ 67 ]. In their study of health workers’ knowledge and attitudes toward newborn health interventions in South Sudan, before and after training and supply provision, Sami et al. report use of the Conceptual Framework of the Role of Attitudes in Evidence-Based Practice Implementation in their analysis process. The framework was used to group codes following initial inductive coding analysis of in-depth interviews [ 72 ].

Three other papers cite use of specific frameworks in their intervention evaluation [ 19 , 44 , 76 ]. As a characteristic of IR is the use of an explicit framework to guide the research, the use of the frameworks in these three papers meets the intention of IR and serves the purpose that an IR framework would have in strengthening the analytical rigor. Castle et al. cite use of their program’s theory of change as a framework for a mixed methods evaluation of the provision of family planning services and more specifically uptake of long-acting reversible contraception use in the DRC. They describe use of the theory of change to “enhance effectiveness of [long-acting reversible contraception] access and uptake.” [ 76 ] Thommesen et al. cite use of the AAAQ (Availability, Accessibility, Acceptability and Quality) framework in their qualitative study assessing midwifery services provided to pregnant women in Afghanistan. This framework is focused on the “underlying elements needed for attainment of optimum standard of health care,” but the authors used it in this paper to evaluate facilitators and barriers to women accessing midwifery services [ 44 ]. Jarrett et al. cite use of the Centers for Disease Control and Prevention’s (CDC) Guidelines for Evaluating Public Health Surveillance Systems to explore the characteristics of a population mobility, mortality and birth surveillance system in South Kivu, DRC. Use of these CDC guidelines is cited as one of four study objectives, and commentary is included in the Results section pertaining to each criteria within these guidelines, although more detail regarding use of these guidelines or the authors’ experience with their use in the study is not provided [ 19 ].

Overall, 22 of the 69 papers either explicitly or implicitly identified IR as relevant to their work. Nineteen papers include a focus on feasibility (seven of which did not otherwise identify the importance of exploring questions concerning implementation), touching on a common outcome of interest in implementation research [ 89 ].

While a majority of papers did not explicitly or implicitly use an IR framework to evaluate their SRH intervention of focus, most identified factors that facilitated implementation when they were present or served as a barrier when absent. Sixty cite factors that served as facilitators and 49 cite factors that served as barriers, with just three not citing either. Fifty-nine distinct factors were identified across the papers.

Three of the six studies that explicitly used an IR framework used the CFIR, and the CFIR is the only IR framework that was used by multiple studies. As previously mentioned, Means et al. put forth an adaptation of the CFIR to increase its relevance in LMIC settings, proposing a sixth domain (Characteristics of Systems) and 11 additional constructs [ 2 ]. Using the expanded domains and constructs as proposed by Means et al., the 59 factors cited by papers in this review were thematically grouped into the six domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process. Within each domain, alignment with CFIR constructs was assessed for, and alignment was found with 29 constructs: eight of Means et al.’s 11 constructs, and 21 of the 39 standard CFIR constructs. Three factors did not align with any construct (all fitting within the Outer Setting domain), and 14 aligned with a construct label but not the associated definition. Table 5 synthesizes the mapping of factors affecting SRH intervention implementation to CFIR domains and constructs, with the construct appearing in italics if it is considered to align with that factor by label but not by definition.

Table 6 lists the CFIR constructs that were not found to have alignment with any factor cited by the papers in this review.

This scoping review sought to assess how IR frameworks have been used to bolster the evidence base for SRH interventions in humanitarian settings, and it revealed that IR frameworks, or an explicit IR approach, are rarely used. All four of the systematic reviews identified with a focus on SRH in humanitarian settings articulate the need for more research examining the effectiveness of SRH interventions in humanitarian settings, with two specifically citing a need for implementation research/science [ 12 , 13 ]. The distribution of papers across the timeframe included in this review does suggest that more research on SRH interventions for crisis-affected populations is taking place, as a majority of relevant papers were published in the second half of the review period. The papers included a wide range of methodologies, which reflect the differing research questions and contexts being evaluated. However, it also invites the question of whether there should be more standardization of outcomes measured or frameworks used to guide analysis and to facilitate increased comparison, synthesis and application across settings.

Three of the six papers that used an IR framework utilized the CFIR. Guan et al. used the CFIR at both a domain and construct level, Sarker et al. used the CFIR at the domain level, and Sami et al. did not specify which CFIR elements were used in informing the focus group discussion guide [ 51 , 65 , 70 ]. It is challenging to draw strong conclusions about the applicability of CFIR in humanitarian settings based on the minimal use of CFIR and IR frameworks within the papers reviewed, although Guan et al. provides a helpful model for how analysis can be structured around CFIR domains and constructs. It is worth considering that the minimal use of IR frameworks, and more specifically CFIR constructs, could be in part because that level of prescriptive categorization does not allow for enough fluidity in humanitarian settings. It also raises questions about the appropriate degree of standardization to pursue for research done in these settings.

The mapping of factors affecting SRH intervention implementation provides an example of how a modified CFIR framework could be used for IR in humanitarian contexts. This mapping exercise found factors that mapped to all five of the original CFIR domains as well as the sixth domain proposed by Means et al. All factors fit well within the definition for the selected domain, indicating an appropriate degree of fit between these existing domains and the factors identified as impacting SRH interventions in humanitarian settings. On a construct level, however, the findings were more variable, with one-quarter of factors not fully aligning with any construct. Furthermore, over 40% of the CFIR constructs (including the additional constructs from Means et al.) were not found to align with any factors cited by the papers in this review, also demonstrating some disconnect between the parameters posed by the CFIR constructs and the factors cited as relevant in a humanitarian context.

It is worth noting that while the CFIR as proposed in 2009 was used in this assessment, as well as in the included papers which used the CFIR, an update was published in 2022. Following a review of CFIR use since its publication, the authors provide updates to construct names and definitions to “make the framework more applicable across a range of innovations and settings.” New constructs and subconstructs were also added, for a total of 48 constructs and 19 subconstructs across the five domains [ 90 ]. A CFIR Outcomes Addendum was also published in 2022, based on recommendations for the CFIR to add outcomes and intended to be used as a complement to the CFIR determinants framework [ 91 ]. These expansions to the CFIR framework may improve applicability of the CFIR in humanitarian settings. Several constructs added to the Outer Setting domain could be of particular utility – critical incidents, local attitudes, and local conditions, each of which could help account for unique challenges faced in contexts of crisis. Sub-constructs added within the Inner Setting domain that seek to clarify structural characteristics and available resources would also be of high utility based on mapping of the factors identified in this review to the original CFIR constructs. As outcomes were not formally included in the CFIR until the 2022 addendum, a separate assessment of implementation outcomes was not undertaken in this review. However, analysis of the factors cited by papers in this review as affecting implementation was derived from the full text of the papers and thus captures content relevant to implementation determinants that is contained within the outcomes.

Given the demonstrated need for additional flexibility within an IR framework for humanitarian contexts, while not a focus of this review, it is worth considering whether a different framework could provide a better fit than the CFIR. Other frameworks have differing points of emphasis that would create different opportunities for flexibility but that do not seem to resolve the challenges experienced in applying the CFIR to a humanitarian context. As one example, the EPIS (Exploration, Preparation, Implementation, Sustainment) Framework considers the impact of inner and outer context on each of four implementation phases; while the constructs within this framework are broader than the CFIR, an emphasis on the intervention characteristics is missing, a domain where stronger alignment within the CFIR is also needed [ 92 ]. Alternatively, the PRISM (Practical, Robust Implementation and Sustainability Model) framework is a determinant and evaluation framework that adds consideration of context factors to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) outcomes framework. It has a stronger emphasis on intervention aspects, with sub-domains to account for both organization and patient perspectives within the intervention. While PRISM does include aspects of context, external environment considerations are less robust and intentionally less comprehensive in scope, which would not provide the degree of alignment possible between the Characteristics of Systems and Outer Setting CFIR domains for the considerations unique to humanitarian environments [ 93 ].

Reflecting on their experience with the CFIR, Sarker et al. indicate that it can be a “great asset” in both evaluating current work and developing future interventions. They also encourage future research of humanitarian health interventions to utilize the CFIR [ 51 ]. The other papers that used the CFIR do not specifically reflect on their experience utilizing it, referring more generally to having felt that it was a useful tool [ 65 , 70 ]. On their use of an evaluation framework, Berg et al. reflected that it lent useful structure and helped to identify aspects affecting implementation that otherwise would have gone un-noticed [ 67 ]. The remaining studies that utilized an IR framework did not specifically comment on their experience with its use [ 72 , 83 ]. While a formal IR framework was not engaged by other studies, a number cite a desire for IR to contribute further detail to their findings [ 21 , 37 ].

In their recommendations for strengthening the evidence base for humanitarian health interventions, Ager et al. speak to the need for “methodologic innovation” to develop methodologies with particular applicability in humanitarian settings [ 7 ]. As IR is not yet routinized for SRH interventions, this could be opportune timing for the use of a standardized IR framework to gauge its utility. Using an IR framework to assess factors influencing implementation of the MISP in initial stages of a humanitarian response, and interventions to support more comprehensive SRH service delivery in protracted crises, could lend further rigor and standardization to SRH evaluations, as well as inform strategies to improve MISP implementation over time. Based on categorizing factors identified by these papers as relevant for intervention evaluation, there does seem to be utility to a modified CFIR approach. Given the paucity of formal IR framework use within SRH literature, it would be worth conducting similar scoping exercises to assess for explicit use of IR frameworks within the evidence base for other health service delivery areas in humanitarian settings. In the interim, the recommended approach from this review for future IR on humanitarian health interventions would be a modified CFIR approach with domain-level standardization and flexibility for constructs that may standardize over time with more use. This would enable use of a common analytical framework and vocabulary at the domain level for stakeholders to describe interventions and the factors influencing the effectiveness of implementation, with constructs available to use and customize as most appropriate for specific contexts and interventions.

This review had a number of limitations. As this was a scoping review and a two-part search strategy was used, the papers summarized here may not be comprehensive of those written pertaining to SRH interventions over the past 10 years. Papers from 2013 to 2017 that would have met this scoping review’s inclusion criteria may have been omitted due to being excluded from the systematic reviews. The review was limited to papers available in English. Furthermore, this review did not assess the quality of the papers included or seek to assess the methodology used beyond examination of the use of an IR framework. It does, however, serve as a first step in assessing the extent to which calls for implementation research have been addressed, and identify entry points for strengthening the science and practice of SRH research in humanitarian settings.

With one in 23 people worldwide in need of humanitarian assistance, and financing required for response plans at an all-time high, the need for evidence to guide resource allocation and programming for SRH in humanitarian settings is as important as ever [ 94 ]. Recent research agenda setting initiatives and strategies to advance health in humanitarian settings call for increased investment in implementation research—with priorities ranging from research on effective strategies for expanding access to a full range of contraceptive options to integrating mental health and psychosocial support into SRH programming to capturing accurate and actionable data on maternal and perinatal mortality in a wide range of acute and protracted emergency contexts [ 95 , 96 ]. To truly advance guidance in these areas, implementation research will need to be conducted across diverse humanitarian settings, with clear and consistent documentation of both intervention characteristics and outcomes, as well as contextual and programmatic factors affecting implementation.

Conclusions

Implementation research has potential to increase impact of health interventions particularly in crisis-affected settings where flexibility, adaptability and context-responsive approaches are highlighted as cornerstones of effective programming. There remains significant opportunity for standardization of research in the humanitarian space, with one such opportunity occurring through increased utilization of IR frameworks such as a modified CFIR approach. Investing in more robust sexual and reproductive health research in humanitarian contexts can enrich insights available to guide programming and increase transferability of learning across settings.

Availability of data and materials

The datasets analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Availability, Accessibility, Acceptability and Quality

Centers for Disease Control and Prevention

Consolidated Framework for Implementation Research

Democratic Republic of the Congo

Exploration, Preparation, Implementation, Sustainment

• Implementation research

Low and middle income country

Minimum Initial Service Package

Practical, Robust Implementation and Sustainability Model

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Reach, Effectiveness, Adoption, Implementation, Maintenance

• Sexual and reproductive health

World Health Organization

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Norton, A., Tappis, H. Sexual and reproductive health implementation research in humanitarian contexts: a scoping review. Reprod Health 21 , 64 (2024). https://doi.org/10.1186/s12978-024-01793-2

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