how to write a literature review public health

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Literature Reviews

• Organizing/Synthesizing
• Peer Review
• Ulrich's -- One More Way To Find Peer-reviewed Papers

"Literature review," "systematic literature review," "integrative literature review" -- these are terms used in different disciplines for basically the same thing -- a rigorous examination of the scholarly literature about a topic (at different levels of rigor, and with some different emphases).  

1. Our library's guide to Writing a Literature Review

2. Other helpful sites

• Writing Center at UNC (Chapel Hill) -- A very good guide about lit reviews and how to write them
• Literature Review: Synthesizing Multiple Sources (LSU, June 2011 but good; PDF) -- Planning, writing, and tips for revising your paper

3. Welch Library's list of the types of expert reviews

Doing a good job of organizing your information makes writing about it a lot easier.

You can organize your sources using a citation manager, such as refworks , or use a matrix (if you only have a few references):.

• Use Google Sheets, Word, Excel, or whatever you prefer to create a table
• The column headings should include the citation information, and the main points that you want to track, as shown

Synthesizing your information is not just summarizing it. Here are processes and examples about how to combine your sources into a good piece of writing:

• Purdue OWL's Synthesizing Sources
• Synthesizing Sources (California State University, Northridge)

Annotated Bibliography  

An "annotation" is a note or comment. An "annotated bibliography" is a "list of citations to books, articles, and [other items]. Each citation is followed by a brief...descriptive and evaluative paragraph, [whose purpose is] to inform the reader of the relevance, accuracy, and quality of the sources cited."*

• Sage Research Methods (database) --> Empirical Research and Writing (ebook) -- Chapter 3: Doing Pre-research  
• Purdue's OWL (Online Writing Lab) includes definitions and samples of annotations  
• Cornell's guide * to writing annotated bibliographies  

* Thank you to Olin Library Reference, Research & Learning Services, Cornell University Library, Ithaca, NY, USA https://guides.library.cornell.edu/annotatedbibliography

What does "peer-reviewed" mean?

• If an article has been peer-reviewed before being published, it means that the article has been read by other people in the same field of study ("peers").
• The author's reviewers have commented on the article, not only noting typos and possible errors, but also giving a judgment about whether or not the article should be published by the journal to which it was submitted.

How do I find "peer-reviewed" materials?

• Most of the the research articles in scholarly journals are peer-reviewed.
• Many databases allow you to check a box that says "peer-reviewed," or to see which results in your list of results are from peer-reviewed sources. Some of the databases that provide this are Academic Search Ultimate, CINAHL, PsycINFO, and Sociological Abstracts.

What kinds of materials are *not* peer-reviewed?

• open web pages
• most newspapers, newsletters, and news items in journals
• letters to the editor
• press releases
• columns and blogs
• book reviews
• anything in a popular magazine (e.g., Time, Newsweek, Glamour, Men's Health)

If a piece of information wasn't peer-reviewed, does that mean that I can't trust it at all?

No; sometimes you can. For example, the preprints submitted to well-known sites such as  arXiv  (mainly covering physics) and  CiteSeerX (mainly covering computer science) are probably trustworthy, as are the databases and web pages produced by entities such as the National Library of Medicine, the Smithsonian Institution, and the American Cancer Society.

Is this paper peer-reviewed? Ulrichsweb will tell you.

1) On the library home page , choose "Articles and Databases" --> "Databases" --> Ulrichsweb

2) Put in the title of the JOURNAL (not the article), in quotation marks so all the words are next to each other

3) Mouse over the black icon, and you'll see that it means "refereed" (which means peer-reviewed, because it's been looked at by referees or reviewers). This journal is not peer-reviewed, because none of the formats have a black icon next to it:

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• Literature reviews

Public Health: Literature reviews

Created by health science librarians.

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Section Objective

What is a literature review, clearly stated research question, search terms, searching worksheets, boolean and / or.

• Systematic reviews
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The content in the Literature Review section defines the literature review purpose and process, explains using the PICO format to ask a clear research question, and demonstrates how to evaluate and modify search results to improve the accuracy of the retrieval.

A literature review seeks to identify, analyze and summarize the published research literature about a specific topic.  Literature reviews are assigned as course projects; included as the introductory part of master's and PhD theses; and are conducted before undertaking any new scientific research project.

The purpose of a literature review is to establish what is currently known about a specific topic and to evaluate the strength of the evidence upon which that knowledge is based. A review of a clinical topic may identify implications for clinical practice. Literature reviews also identify areas of a topic that need further research.

A systematic review is a literature review that follows a rigorous process to find all of the research conducted on a topic and then critically appraises the research methods of the highest quality reports. These reviews track and report their search and appraisal methods in addition to providing a summary of the knowledge established by the appraised research.

The UNC Writing Center provides a nice summary of what to consider when writing a literature review for a class assignment. The online book, Doing a literature review in health and social care : a practical guide (2010), is a good resource for more information on this topic.

Obviously, the quality of the search process will determine the quality of all literature reviews. Anyone undertaking a literature review on a new topic would benefit from meeting with a librarian to discuss search strategies. A consultaiton with a librarian is strongly recommended for anyone undertaking a systematic review.

Use the email form on our Ask a Librarian page to arrange a meeting with a librarian.

The first step to a successful literature review search is to state your research question as clearly as possible.

It is important to:

• be as specific as possible
• include all aspects of your question

Clinical and social science questions often have these aspects (PICO):

• People/population/problem  (What are the characteristics of the population?  What is the condition or disease?)
• Intervention (What do you want to do with this patient?  i.e. treat, diagnose)
• Comparisons [not always included]  (What is the alternative to this intervention?  i.e. placebo, different drug, surgery)
• Outcomes  (What are the relevant outcomes?  i.e. morbidity, death, complications)

If the PICO model does not fit your question, try to use other ways to help be sure to articulate all parts of your question. Perhaps asking yourself Who, What, Why, How will help.  

Example Question:  Is acupuncture as effective of a therapy as triptans in the treament of adult migraine?

Note that this question fits the PICO model.

• Population: Adults with migraines
• Intervention: Acupuncture
• Comparison: Triptans/tryptamines
• Outcome: Fewer Headache days, Fewer migraines

A literature review search is an iterative process. Your goal is to find all of the articles that are pertinent to your subject. Successful searching requires you to think about the complexity of language. You need to match the words you use in your search to the words used by article authors and database indexers. A thorough PubMed search must identify the author words likely to be in the title and abstract or the indexer's selected MeSH (Medical Subject Heading) Terms.

Start by doing a preliminary search using the words from the key parts of your research question.

Step #1: Initial Search

Enter the key concepts from your research question combined with the Boolean operator AND. PubMed does automatically combine your terms with AND. However, it can be easier to modify your search if you start by including the Boolean operators.

migraine AND acupuncture AND tryptamines

The search retrieves a number of relevant article records, but probably not everything on the topic.

Step #2: Evaluate Results

Use the Display Settings drop down in the upper left hand corner of the results page to change to Abstract display.

Review the results and move articles that are directly related to your topic to the Clipboard .

Go to the Clipboard to examine the language in the articles that are directly related to your topic.

• look for words in the titles and abstracts of these pertinent articles that differ from the words you used
• look for relevant MeSH terms in the list linked at the bottom of each article

The following two articles were selected from the search results and placed on the Clipboard.

Here are word differences to consider:

• Initial search used acupuncture. MeSH Terms use Acupuncture therapy.
• Initial search used migraine.  Related word from MeSH Terms is Migraine without Aura and Migraine Disorders.
• Initial search used tryptamines. Article title uses sumatriptan. Related word from MeSH is Sumatriptan or Tryptamines.

With this knowledge you can reformulate your search to expand your retrieval, adding synonyms for all concepts except for manual and plaque.

#3 Revise Search

Use the Boolean OR operator to group synonyms together and use parentheses around the OR groups so they will be searched properly. See the image below to review the difference between Boolean OR / Boolean AND.

Here is what the new search looks like:

(migraine OR migraine disorders) AND (acupuncture OR acupuncture therapy) AND (tryptamines OR sumatriptan)

• Search Worksheet Example: Acupuncture vs. Triptans for Migraine
• Search Worksheet
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Literature Review

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What exactly is a Literature Review?

A literature review describes, summarizes and analyzes previously published literature in a field. What you want to do is demonstrate your knowledge and understanding of what the "conversation" about this topic is, identify gaps in the literature, present research pertinent to your ideas and how your research fits in with, changes, elaborates on, etc., the present conversation.

BOOKS - Literature Review and how to write it

BOOKS - Research Methods

Research Methods at a Glance

This information on basic business research methods is in part adapted from the book Field Guide to Nonprofit Program Design, Marketing and Evaluation by Carter McNamara (Call number: HD62.6 .M36). 

Research Methods in General

Research Methods in Public Health

• The Literature Review: A Research Journey This guide from the Harvard School of Education is an introduction to the basics of conducting a literature review.

• How to cite effectively and improve readability of your paper?

Improve your writing

The Academic Phrasebank is a general resource for academic writers. It aims to provide you with examples of some of the phraseological ‘nuts and bolts’ of writing organized according to the main sections of a research paper or dissertation:

• Introducing work  - e.g Evidence suggests that X is among the most important factors for …
• Referring to sources  - e.g. A number of authors have considered the effects of … (Smith, 2003; Jones, 2004).
• Describing methods - e.g. Different methods have been proposed to classify … (Johnson, 2021; Petersen, 2019; Appel, 2017).
• Reporting results - e.g. Interestingly, the X was observed to …
• Discussing findings  - e.g. A strong relationship between X and Y has been reported in the literature.
• Writing conclusions  - e.g. One of the more significant findings to emerge from this study is that …

Additional  examples from Academic Phrasebank are below:

Before explaining these theories, it is necessary to …

In a similar case in America, Smith (2021) identified …

This is exemplified in the work undertaken by Smith (2021) ...

Recent cases reported by Smith  et al . (2021) also support the hypothesis that …

This section has reviewed the three key aspects of …

In summary, it has been shown from this review that …

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Searching the public health & medical literature more effectively: literature review help.

• Getting Started
• Articles: Searching PubMed This link opens in a new window
• More Sources: Databases, Systematic Reviews, Grey Literature
• Organize Citations & Search Strategies
• Literature Review Help
• Need More Help?

Writing Guides, Manuals, etc.

Literature Review Tips Handouts

Write about something you are passionate about!

• About Literature Reviews (pdf)
• Literature Review Workflow (pdf)
• Search Tips/Search Operators
• Quick Article Evaluation Worksheet (docx)
• Tips for the Literature Review Workflow
• Sample Outline for a Literature Review (docx)

Ten simple rules for writing a literature review . Pautasso M. PLoS Comput Biol. 2013;9(7):e1003149. doi:10.1371/journal.pcbi.1003149

Conducting the Literature Search . Chapter 4 of Chasan-Taber L. Writing Dissertation and Grant Proposals: Epidemiology, Preventive Medicine and Biostatistics. New York: Chapman and Hall/CRC, 2014.

A step-by-step guide to writing a research paper, from idea to full manuscript . Excellent and easy to follow blog post by Dr. Raul Pacheco-Vega.

Data Extraction

Data extraction answers the question “what do the studies tell us?”

At a minimum, consider the following when extracting data from the studies you are reviewing ( source ):

• Only use the data elements relevant to your question;
• Use a table, form, or tool (such as Covidence ) for data extraction;
• Test your methods and tool for missing data elements, redundancy, consistency, clarity.

Here is a table of data elements to consider for your data extraction. (From University of York, Centre for Reviews and Dissemination).

Critical Reading

As you read articles, write notes. You may wish to create a table, answering these questions:

• What is the hypothesis?
• What is the method? Rigorous? Appropriate sample size? Results support conclusions?
• What are the key findings?
• How does this paper support/contradict other work?
• How does it support/contradict your own approach?
• How significant is this research? What is its special contribution?
• Is this research repeating existing approaches or making a new contribution?
• What are its strengths?
• What are its weaknesses/limitations?

From: Kearns, H. & Finn, J. (2017) Supervising PhD Students: A Practical Guide and Toolkit . AU: Thinkwell, p. 103.

Submitting to a Journal? First Identify Journals That Publish on Your Topic

Through Scopus

• Visit the  Scopus database.
• Search for recent articles on your research topic.
• Above the results, click “Analyze search results."
• Click in the "Documents per year by source" box.
• On the left you will see the results listed by the number of articles published on your research topic per journal.

Through Web of Science

• Visit the Web of Science database.
• In the results, click "Analyze Results" on the right hand side.
• From the drop-down menu near the top left, choose "Publication Titles."
• Change the "Minimum record count (threshold)," if desired.
• Scroll down for a table of results by journal title.
• JANE (Journal/Author Name Estimator) Use JANE to help you discover and decide where to publish an article you have authored. Jane matches the abstract of your article to the articles in Medline to find the best matching journals (or authors, or articles).
• Jot (Journal Targeter) Jot uses Jane and other data to determine journals likely to publish your article (based on title, abstract, references) against the impact metric of those journals. From Yale University.
• EndNote Manuscript Matcher Using algorithms and data from the Web of Science and Journal Citation Reports, Manuscript Matcher identifies the most relevant and impactful journals to which one may wish to submit a manuscript. Access Manuscript Matcher via EndNote X9 or EndNote 20.
• DOAJ (Directory of Open Access Journals) Journal Lookup Look up a journal title on DOAJ and find information on publication fees, aims and scope, instructions for authors, submission to publication time, copyright, and more.

Writing Help @UCB

Here is a short list of sources of writing help available to UC Berkeley students, staff, and faculty:

• Purdue OWL Excellent collection of guides on writing, including citing/attribution, citation styles, grammar and punctuation, academic writing, and much more.
• Berkeley Writing: College Writing Programs "Our philosophy includes small class size, careful attention to building your critical reading and thinking skills along with your writing, personalized attention, and a great deal of practice writing and revising." Website has a Writing Resources Database .
• Graduate Writing Center, Berkeley Graduate Division Assists graduate students in the development of academic skills necessary to successfully complete their programs and prepare for future positions. Workshops and online consultations are offered on topics such as academic writing, grant writing, dissertation writing , thesis writing , editing, and preparing articles for publication, in addition to writing groups and individual consultations.
• Nature Masterclass on Scientific Writing and Publishing For Postdocs, Visiting Scholars, and Visiting Student Researchers with active, approved appointments, and current UC Berkeley graduate students who are new to publishing or wish to refresh their skills. Part 1: Writing a Research Paper; Part 2: Publishing a Research Paper; Part 3: Writing and Publishing a Review Paper. Offered by Visiting Researcher Scholar and Postdoc Affairs (VSPA) program; complete this form to gain access.

Alternative Publishing Formats

Here is some information and tips on getting your research to a broader, or to a specialized, audience

• Creating One-Page Reports One-page reports are a great way to provide a snapshot of a project’s activities and impact to stakeholders. Summarizing key facts in a format that is easily and quickly digestible engages the busy reader and can make your project stand out. From EvaluATE .
• How to write an Op-ed (Webinar) Strategies on how to write sharp op-eds for broader consumption, one of the most important ways to ensure your analysis and research is shared in the public sphere. From the Institute for Research on Public Policy .
• 10 tips for commentary writers From UC Berkeley Media Relations’ 2017 Op-Ed writing workshop.
• Journal of Science Policy and Governance JSPG publishes policy memos, op-eds, position papers, and similar items created by students.
• Writing Persuasive Policy Briefs Presentation slides from a UCB Science Policy Group session.
• 3 Essential Steps to Share Research With Popular Audiences (Inside Higher Ed) How to broaden the reach and increase the impact of your academic writing. Popular writing isn’t a distraction from core research!

The Politics of Citation

"One of the feminist practices key to my teaching and research is a feminist practice of citation."

From The Digital Feminist Collective , this blog post emphasizes the power of citing.

"Acknowledging and establishing feminist genealogies is part of the work of producing more just forms of knowledge and intellectual practice."

Here's an exercise (docx) to help you in determining how inclusive you are when citing.

Additional Resources for Inclusive Citation Practices :

• BIPOC Scientists Citation guide (Rockefeller Univ.).
• Conducting Research through an Anti-Racism Lens (Univ. of Minnesota Libraries).
• cleanBib (Code to probabilistically assign gender and race proportions of first/last authors pairs in bibliography entries).
• Balanced Citer (Python script guesses the race and gender of the first and last authors for papers in your citation list and compares your list to expected distributions based on a model that accounts for paper characteristics).
• Read Black women's work;
• Integrate Black women into the CORE of your syllabus (in life & in the classroom);
• Acknowledge Black women's intellectual production;
• Make space for Black women to speak;
• Give Black women the space and time to breathe.
• CiteASista .
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• Last Updated: May 22, 2024 3:44 PM
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Majority of Youth Are Willing to Answer Questions About Their Sexual Orientation, Gender Identity

Dean’s note: this pride month, reaffirming the dignity of lgbtqia+ populations, literature reviews ..

A literature review is systematic examination of existing research on a proposed topic (1). Public health professionals often consult literature reviews to stay up-to-date on research in their field (1–3). Researchers also frequently use literature reviews as a way to identify gaps in the research and provide a background for continuing research on a topic (1,2). This section will provide an overview of the essential elements needed to write a successful literature review.

Collecting Articles

A literature review is systematic examination of existing research on a proposed topic (1). Public health professionals often consult literature reviews to stay up-to-date on research in their field (1–3). Researchers also frequently use literature reviews as a way to identify gaps in the research and provide a background for continuing research on a topic (1,2).   This section will provide an overview of the essential elements needed to write a successful literature review.

Do not hesitate to reach out to a reference librarian at the BUMC Alumni Medical Library for assistance in collecting your research.

Reviewing the Research

After selecting the articles for your review, read each article and takes notes to keep track of each paper (3). One way to effectively take notes is to create a table listing each article’s research question, methods, results, limitations, etc. Once you have finished reading the articles, critically think about why each one is important to your discussion (1,2,4). Try to group articles based on similar content, such as similar study populations, methods, or results (4). Most literature reviews do not require you to organize your articles in a certain manner; however, you should think about how you would logically tie your articles together so that you are analyzing them, not simply summarizing each article (4).

Organizing your Review

While there is no standard organization for a literature review, literature reviews generally follow this structure (1,3):

• Introduction.  The introduction should identify a research question and relate it to a public health topic. The significance of the public health problem and topic should be described.
• Body.  The body of a literature review should be organized so that the review flows logical from one subtopic to another subtopic. Consider breaking this section into the following sections:
• Methods.  Describe how you obtained your articles. Be sure to include the names of search engines and key words used to generate searches. Detail your inclusion and exclusion criteria (i.e. did not fit your definition of your outcome). Consider creating a flow chart to illustrate your search process.
• Results/Discussion.  Explain what the literature says about your question. What did the studies find? Is their conflicting evidence? What are the limitations of the current studies? What gaps exist in the literature? What are the outstanding research questions? A table of your studies can be a great tool to summarize of the essential information.
• Conclusion.  Review your findings and how they relate to your research questions. Use this space to propose needs in the research, if appropriate.

Collecting articles, reviewing your research, and organizing your review are the first steps toward writing a literature review. Reading examples of peer-reviewed literature reviews is an excellent way to brainstorm how to organize your research and tables.

Additional Resources

The following resources also provide a more in-depth discussion on writing literature reviews:

• Ten Simple Rules for Writing a Literature Review   (requires BU Kerberos Login)
• Handout on Writing Literature Reviews from UNC Writing Center
• Tips for Writing a Public Health Literature Review from Tulane University
• Get the Lit: The Literature Review Video from Texas A&M University Writing Center
• University of North Carolina at Chapel Hill. Literature Reviews [Internet]. The Writing Center. [cited 2014 Jul 15]. Available from: http://writingcenter.unc.edu/handouts/literature-reviews/
• Tips for writing a public health literature review [Internet]. Tulane University School of Public Health and Tropical Medicine 1. Department of Community Health Sciences; [cited 2014 Jul 15]. Available from: http://tulane.edu/publichealth/mchltp/upload/Writing-Lit-review.pdf
• Pautasso M. Ten Simple Rules for Writing a Literature Review. PLoS Comput Biol. 2013 Jul 18;9(7):e1003149.
• Get Lit: The Literature Review [Internet]. 2011 [cited 2014 Jul 15]. Available from: http://www.youtube.com/watch?v=Y1hG99HUaOk&feature=youtube_gdata_player

Public Health: LITERATURE REVIEWS

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This page contains resources to help you with your literature reviews.

To find more resources, search in the  TUC Library Catalog  using a keyword search. For example, if you need information about literature reviews, use the keywords *literature reviews* and you will be presented with many more books--both print and electronic.

RESEARCH METHODOLOGIES

Information about getting started with your research and the various research methods and can be found on the  R esearch Methods  page.  

Information about systematic reviews can be found on the  Systematic Reviews  page. 

WHAT IS A LITERATURE REVIEW? (9:38)

This short video covers all you need to know about what a literature review is and why it is important. It goes over the various steps and gives tips and insight on the process.

HOW TO WRITE A LITERATURE REVIEW: 3-MINUTE STEP-BY-STEP GUIDE (3:04)

HOW TO READ & COMPREHEND SCIENTIFIC RESEARCH ARTICLES (5:03)

This 5-minute video tutorial from the University of Minnesota will give you a brief overview of how to read research articles to get the most understanding of them while saving you time.

BOOKS ON LITERATURE REVEWS

CONTACT ME FOR HELP

HOW TO READ EVIDENCE-BASED MEDICINE PAPERS

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Public Health Research Experiences

• Welcome: Use the Resources
• Choosing a Topic
• Building a Literature Review
• Search Strategies & Tutorials
• Picking Databases
• Checking What You Find
• Zotero: Using a Citation Manager

The Purpose of the Literature Review

More about Literature Reviews

• Literature Reviews: An Overview for Graduate Students From NCSU Libraries, this 9 minute video tutorial (with a transcript) explores the purpose, expectations, and structure of a literature review.
• What Is a Literature Review Describes how literature reviews help both the researcher and the reader. (a section in the book Scientific Inquiry in Social Work )
• Lesson 5.1: Types of Evidence and Literature Reviews (part of chapter 5 in the book The DNP Project Workbook: A Step-by-Step Process for Success )
• Sources Included in a Literature Review (part of Chapter 6 in the book Understanding Nursing Research: Building an Evidence-Based Practice )
• The sections Exploring and Refining Your Question through Accessing Journal Literature (part of Chapter 6 in the book How to Write Your Nursing Dissertation )
• Evaluating the Literature (part of chapter 7 in the book Introduction to Nursing Research: Incorporating Evidence-Based Practice )
• Critically Appraising and Assessing the Quality of the Literature (part of chapter 5 in the book Literature Reviews and Synthesis: A Guide for Nurses and Other Healthcare Professionals )
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• Queen's University Library
• Research Guides

Public Health

• Writing Literature Reviews
• Evidence-Informed Decision Making
• Defining the Question
• Grey Literature
• Appraising Sources

Introduction

The review article, e-books @ bracken, print books @ queen's library locations, relevant articles, bibliography, related guides.

• Systematic Reviews & Other Syntheses

Article Spotlight

Improving the reliability and accessibility of narrative review articles ( Byrne, 2016 ):

• Is the review article required/important?
• Was the conduct of literature searches defined?
• Were literature citations appropriate and balanced?
• Were original references cited?
• Was information summarised correctly?
• Were studies critically evaluated?
• Are there adequate tables/figures/diagrams?
• Will the review help readers entering the field?
• Does the review expand the body of knowledge?

“ The literature review comes in many shapes and sizes. It is widely used across disciplines because it offers a useful snapshot of the state of research on a particular topic. It provides background and helps to frame research questions and findings in empirical articles, theses, or dissertations. A literature review can also stand alone as an article, providing a valuable overview for those with an interest in the topic. Entire journals are devoted to publishing literature reviews. …

Whether a reviewer is writing about biology or sociology, conducting a qualitative or quantitative review, preparing a literature review as a part of another piece of work, or as its own stand-alone article, every good reviewer of literature must successfully filter large amounts of information into a condensed report that allows others to understand what is currently known about a specific topic ” (Pan, 2016).

Purpose:   To summarize and synthesize research that has been done on a particular topic. A review emphasizes important findings in a field and may identify gaps or shortcomings in the research. As it describes and evaluates the studies of others, its primary focus is on what the research has demonstrated through the methodologies and results of study and experimentation.

Audience:   Usually a science journal’s broadest readership because a review is more general in its focus than a research article.

• Introduction  – introduces the topic and its significance and provides a brief preview of the sub-topics or major trends to be covered in the paper.
• Body   – presents a survey of the stages or significant trends in the research. Studies are discussed in groups or clusters often identified with subheadings. To develop the body, the writer must determine criteria for grouping: will studies be clustered according to major advances in the research (chronological development) or areas of consensus or lack of consensus in the field? Will the body highlight similarities and differences in the findings in terms of methods, results, and/or the focus of research studies? *Tips : The body should contain both generalizations about the set of studies under review (written in the present tense) and citations of specific studies (past tense) to identify and verify observed trends. Topic and concluding sentences of paragraphs and/or sections should synthesize research findings and may show differences and similarities or points of agreement/disagreement.
• Conclusion  – provides a final general overview of what is known and what is left to explore in the field This section may discuss practical implications or suggest directions for future research.

Distinguishing Elements:   The review article is largely descriptive in that it identifies trends or patterns in an area of research across studies. However, analysis is required as the writer offers an interpretation of the state of knowledge in the field, perhaps calling attention to an issue in the field, proposing a theory or model to resolve it, or suggesting directions for future research. As well, unlike research papers that feature functional headings related to the IMRAD format, the review article uses topical or content headings to indicate the sections of the review.

From  Types and Conventions of Science Writing  by The Writing Centre at Queen's University.

Pautasso, M. (2013). Ten simple rules for writing a literature review .  PLoS  Computational Biology ,  9 (7),  e1003149 .

• Define a Topic and Audience
• Search and Re-search the Literature
• Take Notes While Reading
• Choose the Type of Review You Wish to Write
• Keep the Review Focused, but Make It of Broad Interest
• Be Critical and Consistent
• Find a Logical Structure
• Make Use of Feedback
• Include Your Own Relevant Research, but Be Objective
• Be Up-to-Date, but Do Not Forget Older Studies

Baker, J. D. (2016). The purpose, process, and methods of writing a literature review . Association of Operating Room Nurses Journal, 103(3), 265-269.

      Specific purposes of literature reviews are to:

• Provide a theoretical framework for the specific topic under study;
• Define relevant or key terms and important variables used for a study or manuscript development;
• Provide a synthesized overview of current evidence for practice to gain new perspectives and support assumptions and opinions presented in a manuscript using research studies, quality improvement projects, models, case studies, and so forth;
• Identify the main methodology and research techniques previously used; and
• Demonstrate the gap (distinguishing what has been done from what needs to be done) in the literature, pointing to the significance of the problem and need for the study or building a case for the quality improvement project to be conducted.

Baker, J. D. (2016).  The purpose, process, and methods of writing a literature review . Association of Operating Room Nurses Journal, 103(3), 265-269.

Byrne, J. A. (2016).  Improving the peer review of narrative literature reviews . Research integrity and peer review, 1(1), 12.

Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Routledge.

Pautasso, M. (2013).  Ten simple rules for writing a literature review . PLoS Computational Biology, 9(7), e1003149.

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Literature Review Overview

What is a Literature Review? Why Are They Important?

A literature review is important because it presents the "state of the science" or accumulated knowledge on a specific topic. It summarizes, analyzes, and compares the available research, reporting study strengths and weaknesses, results, gaps in the research, conclusions, and authors’ interpretations.

Tips and techniques for conducting a literature review are described more fully in the subsequent boxes:

• Literature review steps
• Strategies for organizing the information for your review
• Literature reviews sections
• In-depth resources to assist in writing a literature review
• Templates to start your review
• Literature review examples

Literature Review Steps

Graphic used with permission: Torres, E. Librarian, Hawai'i Pacific University

1. Choose a topic and define your research question

• Try to choose a topic of interest. You will be working with this subject for several weeks to months.
• Ideas for topics can be found by scanning medical news sources (e.g MedPage Today), journals / magazines, work experiences, interesting patient cases, or family or personal health issues.
• Do a bit of background reading on topic ideas to familiarize yourself with terminology and issues. Note the words and terms that are used.
• Develop a focused research question using PICO(T) or other framework (FINER, SPICE, etc - there are many options) to help guide you.
• Run a few sample database searches to make sure your research question is not too broad or too narrow.
• If possible, discuss your topic with your professor. 

2. Determine the scope of your review

The scope of your review will be determined by your professor during your program. Check your assignment requirements for parameters for the Literature Review.

• How many studies will you need to include?
• How many years should it cover? (usually 5-7 depending on the professor)
• For the nurses, are you required to limit to nursing literature?

3. Develop a search plan

• Determine which databases to search. This will depend on your topic. If you are not sure, check your program specific library website (Physician Asst / Nursing / Health Services Admin) for recommendations.
• Create an initial search string using the main concepts from your research (PICO, etc) question. Include synonyms and related words connected by Boolean operators
• Contact your librarian for assistance, if needed.

4. Conduct searches and find relevant literature

• Keep notes as you search - tracking keywords and search strings used in each database in order to avoid wasting time duplicating a search that has already been tried
• Read abstracts and write down new terms to search as you find them
• Check MeSH or other subject headings listed in relevant articles for additional search terms
• Scan author provided keywords if available
• Check the references of relevant articles looking for other useful articles (ancestry searching)
• Check articles that have cited your relevant article for more useful articles (descendancy searching). Both PubMed and CINAHL offer Cited By links
• Revise the search to broaden or narrow your topic focus as you peruse the available literature
• Conducting a literature search is a repetitive process. Searches can be revised and re-run multiple times during the process.
• Track the citations for your relevant articles in a software citation manager such as RefWorks, Zotero, or Mendeley

5. Review the literature

• Read the full articles. Do not rely solely on the abstracts. Authors frequently cannot include all results within the confines of an abstract. Exclude articles that do not address your research question.
• While reading, note research findings relevant to your project and summarize. Are the findings conflicting? There are matrices available than can help with organization. See the Organizing Information box below.
• Critique / evaluate the quality of the articles, and record your findings in your matrix or summary table. Tools are available to prompt you what to look for. (See Resources for Appraising a Research Study box on the HSA, Nursing , and PA guides )
• You may need to revise your search and re-run it based on your findings.

6. Organize and synthesize

• Compile the findings and analysis from each resource into a single narrative.
• Using an outline can be helpful. Start broad, addressing the overall findings and then narrow, discussing each resource and how it relates to your question and to the other resources.
• Cite as you write to keep sources organized.
• Write in structured paragraphs using topic sentences and transition words to draw connections, comparisons, and contrasts.
• Don't present one study after another, but rather relate one study's findings to another. Speak to how the studies are connected and how they relate to your work.

Organizing Information

Options to assist in organizing sources and information :

1. Synthesis Matrix

• helps provide overview of the literature
• information from individual sources is entered into a grid to enable writers to discern patterns and themes
• article summary, analysis, or results
• thoughts, reflections, or issues
• each reference gets its own row
• mind maps, concept maps, flowcharts
• at top of page record PICO or research question
• record major concepts / themes from literature
• list concepts that branch out from major concepts underneath - keep going downward hierarchically, until most specific ideas are recorded
• enclose concepts in circles and connect the concept with lines - add brief explanation as needed

3. Summary Table

• information is recorded in a grid to help with recall and sorting information when writing
• allows comparing and contrasting individual studies easily
• purpose of study
• methodology (study population, data collection tool)

Efron, S. E., & Ravid, R. (2019). Writing the literature review : A practical guide . Guilford Press.

Literature Review Sections

• Lit reviews can be part of a larger paper / research study or they can be the focus of the paper
• Lit reviews focus on research studies to provide evidence
• New topics may not have much that has been published

* The sections included may depend on the purpose of the literature review (standalone paper or section within a research paper)

Standalone Literature Review (aka Narrative Review):

• presents your topic or PICO question
• includes the why of the literature review and your goals for the review.
• provides background for your the topic and previews the key points
• Narrative Reviews: tmay not have an explanation of methods.
• include where the search was conducted (which databases) what subject terms or keywords were used, and any limits or filters that were applied and why - this will help others re-create the search
• describe how studies were analyzed for inclusion or exclusion
• review the purpose and answer the research question
• thematically - using recurring themes in the literature
• chronologically - present the development of the topic over time
• methodological - compare and contrast findings based on various methodologies used to research the topic (e.g. qualitative vs quantitative, etc.)
• theoretical - organized content based on various theories
• provide an overview of the main points of each source then synthesize the findings into a coherent summary of the whole
• present common themes among the studies
• compare and contrast the various study results
• interpret the results and address the implications of the findings
• do the results support the original hypothesis or conflict with it
• provide your own analysis and interpretation (eg. discuss the significance of findings; evaluate the strengths and weaknesses of the studies, noting any problems)
• discuss common and unusual patterns and offer explanations
•  stay away from opinions, personal biases and unsupported recommendations
• summarize the key findings and relate them back to your PICO/research question
• note gaps in the research and suggest areas for further research
• this section should not contain "new" information that had not been previously discussed in one of the sections above
• provide a list of all the studies and other sources used in proper APA 7

Literature Review as Part of a Research Study Manuscript:

• Compares the study with other research and includes how a study fills a gap in the research.
• Focus on the body of the review which includes the synthesized Findings and Discussion

Literature Reviews vs Systematic Reviews

Systematic Reviews are NOT the same as a Literature Review:

Literature Reviews:

• Literature reviews may or may not follow strict systematic methods to find, select, and analyze articles, but rather they selectively and broadly review the literature on a topic
• Research included in a Literature Review can be "cherry-picked" and therefore, can be very subjective

Systematic Reviews:

• Systemic reviews are designed to provide a comprehensive summary of the evidence for a focused research question
• rigorous and strictly structured, using standardized reporting guidelines (e.g. PRISMA, see link below)
• uses exhaustive, systematic searches of all relevant databases
• best practice dictates search strategies are peer reviewed
• uses predetermined study inclusion and exclusion criteria in order to minimize bias
• aims to capture and synthesize all literature (including unpublished research - grey literature) that meet the predefined criteria on a focused topic resulting in high quality evidence

Literature Review Examples

• Breastfeeding initiation and support: A literature review of what women value and the impact of early discharge (2017). Women and Birth : Journal of the Australian College of Midwives
• Community-based participatory research to promote healthy diet and nutrition and prevent and control obesity among African-Americans: A literature review (2017). Journal of Racial and Ethnic Health Disparities

• Vitamin D deficiency in individuals with a spinal cord injury: A literature review (2017). Spinal Cord

Resources for Writing a Literature Review

These sources have been used in developing this guide.

Resources Used on This Page

Aveyard, H. (2010). Doing a literature review in health and social care : A practical guide . McGraw-Hill Education.

Purdue Online Writing Lab. (n.d.). Writing a literature review . Purdue University. https://owl.purdue.edu/owl/research_and_citation/conducting_research/writing_a_literature_review.html

Torres, E. (2021, October 21). Nursing - graduate studies research guide: Literature review. Hawai'i Pacific University Libraries. Retrieved January 27, 2022, from https://hpu.libguides.com/c.php?g=543891&p=3727230

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Good Place to Start: Citation Databases

Interdisciplinary Citation Databases:

A good place to start your research  is to search a research citation database to view the scope of literature available on your topic.

TIP #1: SEED ARTICLE Begin your research with a "seed article" - an article that strongly supports your research topic.  Then use a citation database to follow the studies published by finding articles which have cited that article, either because they support it or because they disagree with it.

TIP #2: SNOWBALLING Snowballing is the process where researchers will begin with a select number of articles they have identified relevant/strongly supports their topic and then search each articles' references reviewing the studies cited to determine if they are relevant to your research.

BONUS POINTS: This process also helps identify key highly cited authors within a topic to help establish the "experts" in the field.

Begin by constructing a focused research question to help you then convert it into an effective search strategy.

• Identify keywords or synonyms
• Type of study/resources
• Which database(s) to search
• Asking a Good Question (PICO)
• PICO - AHRQ
• PICO - Worksheet
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Web Resources

What is a literature review?

A literature review is a comprehensive and up-to-date overview of published information on a subject area. Conducting a literature review demands a careful examination of a body of literature that has been published that helps answer your research question (See PICO). Literature reviewed includes scholarly journals, scholarly books, authoritative databases, primary sources and grey literature.

A literature review attempts to answer the following:

• What is known about the subject?
• What is the chronology of knowledge about my subject?
• Are there any gaps in the literature?
• Is there a consensus/debate on issues?
• Create a clear research question/statement
• Define the scope of the review include limitations (i.e. gender, age, location, nationality...)
• Search existing literature including classic works on your topic and grey literature
• Evaluate results and the evidence (Avoid discounting information that contradicts your research)
• Track and organize references
• How to conduct an effective literature search.
• Social Work Literature Review Guidelines (OWL Purdue Online Writing Lab)

What is PICO?

The PICO model can help you formulate a good clinical question. Sometimes it's referred to as PICO-T, containing an optional 5th factor. 

Seminal Works: Search Key Indexing/Citation Databases

• Google Scholar
• Web of Science

TIP – How to Locate Seminal Works

• DO NOT: Limit by date range or you might overlook the seminal works
• DO: Look at highly cited references (Seminal articles are frequently referred to “cited” in the research)
• DO: Search citation databases like Scopus, Web of Science and Google Scholar

Search Example

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What is a literature review, systematic literature searching, your search strategy, search strategy elements, tools to help you focus your topic.

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Scribbr (2020) How to write a literature review: 3 minute step-by-step guide.   Available at: https://youtu.be/zIYC6zG265E (Accessed: 29 June 2021).

A literature review is a formal search and discussion of the literature published on a topic.  Such reviews have different purposes, some providing an overview as a learning exercise.  Most literature reviews are related to research activity, focus on scholarly and research publications and how this evidence relates to a specific research question or hypothesis.

Machi and McEvoy (2016, p.23) consider the review process as a critical thinking activity:

• Select a topic (Recognize and define a problem);
• Develop tools of argumentation (Create a process for solving the problem);
• Search the literature (Collect and compile information);
• Survey the literature (Discover the evidence and build the argument);
• Critique the literature (Draw conclusions);
• Write the thesis (Communicate and evaluate the conclusions).

Machi, L.A. and McEvoy, B.T. (2016) The literature review: six steps to success.  London; Corwin.

Leite, D., Padilha, M., and Cecatti, J. G. (2019) 'Approaching literature review for academic purposes: The Literature Review Checklist',  Clinics (Sao Paulo, Brazil) ,  74 , e1403.  https://doi.org/10.6061/clinics/2019/e1403

• Systematic literature searching You might be an undergraduate who wants to improve the quality of their searches, a postgraduate deciding on a dissertation topic, or a PhD student conducting a systematic literature review as part of your thesis. Or, you might be a member of staff conducting systematic search as part of your academic work, grant application, or Knowledge Transfer Partnership (KTP) programme. This guide is your practical companion, offering insights and strategies to navigate the intricacies of systematic searching work.

Literature reviews are often conducted as an introduction to a research project.  However, they can also be used to gain an overview of the publications or research or evidence available as an introduction to a topic.

For the latter, you will be expected to develop a systematic search strategy to identify and locate the most relevant material (Aveyard, 2019).  This means including, as part of your text, the keywords and resources used for your review and the decisions made regarding your selection of materials. 

Aveyard, H. (2019) Doing a literature review in health and social care: a practical guide.4th edn. London: Open University Press, McGraw-Hill Education.

Your search strategy incorporates all the decisions made while selecting items for your literature review.

Themes and keywords

• What are the separate elements of your topic/search? 
• Which are the principal key words or search terms for each element? 
• Are there obvious alternative search terms that should be included?  For example, 'international' could also be described as 'global' or 'worldwide'.

Your initial searches on the topic will help you ascertain relevant search terms.

• Which types of material are you including in your review?  This can be restricted to research articles or encompass policy papers, textbooks, reports, conference presentations, blogs and more.
• Which bibliographic resources are most relevant to your topic, and the types of material identified above?  Options include bibliographic databases and Google Scholar (journal and research papers); the library's OneSearch (books, exemplars and more), Google or other general search engines (policy papers, blogs ...).See Specialist Resources for links to CINAHL and other bibliographic services. 

Additional selection criteria

• Does a specific date range for publication apply? 
• Are you only interested in a specific scenario or environment?
• Are you focusing on a specific population?

Please remember:

• Your decision making will be influenced, in part, by the restricted nature of your assignment and related timescale.
• You will be accessing and reading multiple items for each assignment.  Some of these will be relevant throughout our programme, or in other contexts. See the Keeping Track of your Sources page on this guide for advice on noting details methodically.

There are several tools available to help researchers formulate a robust research question or hypothesis.  These may be helpful in refining your topic and developing a search strategy for your assignments.

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Literature Reviews in Public Health: Home

Public health databases.

View the Public Health Research Guide to view suggestions of databases and websites to search for your literature review.

Literature Review Materials

Use this Excel spreadsheet to track your search and keep your literature review organized.

The accompanying PDF file provides detailed guidelines for conducting a comprehensive literature review.

Have questions about using these materials, or suggestions for improving them? Contact Kim Whalen .

• Literature Review Workbook Use this spreadsheet to keep track of your literature search. Last updated 2/6/2018. DrPH and MHA students: contact me for a version of this workbook adapted to your field.
• Steps in Planning and Implementing a Literature Search

Presentation Slides & Recordings

Literature Review presentation materials available for download and personal use.  E-mail Prof Kim Whalen, the librarian for public health, at [email protected] with questions or to schedule a one-on-one conversation.

• Capstone Literature Review Workshop [2018] Library research & writing skills workshop presented on 2/7/2018.
• Capstone Literature Review Workshop [2017] Library research & writing skills workshop presented on 1/31/2017.
• Writing Seminar Presentation 3/29/2016
• Literature Review Workshop 2/16/2016 Slides from PHSA Literature Review Workshop on 2/16/2016.
• 10/27/15 Presentation Slides from class presentation on 10/27/15.

Recommended Reading

These books, available through the library catalog , are recommended for further reading on the literature review process.

Library Faculty

Systematic Review Information

• Systematic Review Search Workbook Use this Excel workbook to document your searches and track results. If you are not conducting a systematic review, use the "Literature Review Workbook" (left).
• EPID 594 Slides 9/7/16 Presentation to EPID 594 course introducing principles & techniques of systematic review searching.
• EPID 594 Slides 9/14/16 Second week's presentation to EPID 594 - searching grey literature and other means of finding evidence.
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What is a Literature Review and Why Do one?

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

The purpose of a literature review is to:

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

Different Approaches to Writing Literature Reviews

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

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

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

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

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

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

Adapted from:  https://writingcenter.unc.edu/tips-and-tools/literature-reviews/ ;  https://libguides.usc.edu/writingguide/literaturereview

What is a Literature Review?

This handout will explain what a literature review is and offer insights into the form and construction of a literature review in the humanities, social sciences, and sciences.

OK. You've got to write a literature review. You dust off a novel and a book of poetry, settle down in your chair, and get ready to issue a "thumbs up" or "thumbs down" as you leaf through the pages. "Literature review" done. Right?

Wrong! The "literature" of a literature review refers to any collection of materials on a topic, not necessarily the great literary texts of the world. "Literature" could be anything from a set of government pamphlets on British colonial methods in Africa to scholarly articles on the treatment of a torn ACL. And a review does not necessarily mean that your reader wants you to give your personal opinion on whether or not you liked these sources.

What is a literature review, then?

A literature review discusses published information in a particular subject area, and sometimes information in a particular subject area within a certain time period.

A literature review can be just a simple summary of the sources, but it usually has an organizational pattern and combines both summary and synthesis. A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information. It might give a new interpretation of old material or combine new with old interpretations. Or it might trace the intellectual progression of the field, including major debates. And depending on the situation, the literature review may evaluate the sources and advise the reader on the most pertinent or relevant.

But how is a literature review different from an academic research paper?

The main focus of an academic research paper is to develop a new argument, and a research paper will contain a literature review as one of its parts. In a research paper, you use the literature as a foundation and as support for a new insight that you contribute. The focus of a literature review, however, is to summarize and synthesize the arguments and ideas of others without adding new contributions.

Why do we write literature reviews?

Literature reviews provide you with a handy guide to a particular topic. If you have limited time to conduct research, literature reviews can give you an overview or act as a stepping stone. For professionals, they are useful reports that keep them up to date with what is current in the field. For scholars, the depth and breadth of the literature review emphasizes the credibility of the writer in his or her field. Literature reviews also provide a solid background for a research paper's investigation. Comprehensive knowledge of the literature of the field is essential to most research papers.

Who writes these things, anyway?

Literature reviews are written occasionally in the humanities, but mostly in the sciences and social sciences; in experiment and lab reports, they constitute a section of the paper. Sometimes a literature review is written as a paper in itself.

If your assignment is not very specific, seek clarification from your instructor:

• Roughly how many sources should you include?
• What types of sources (books, journal articles, websites)?
• Should you summarize, synthesize, or critique your sources by discussing a common theme or issue?
• Should you evaluate your sources?
• Should you provide subheadings and other background information, such as definitions and/or a history?

Find models

Look for other literature reviews in your area of interest or in the discipline and read them to get a sense of the types of themes you might want to look for in your own research or ways to organize your final review. You can simply put the word "review" in your search engine along with your other topic terms to find articles of this type on the Internet or in an electronic database. The bibliography or reference section of sources you've already read are also excellent entry points into your own research.

Narrow your topic

There are hundreds or even thousands of articles and books on most areas of study. The narrower your topic, the easier it will be to limit the number of sources you need to read in order to get a good survey of the material. Your instructor will probably not expect you to read everything that's out there on the topic, but you'll make your job easier if you first limit your scope.

And don't forget to tap into your professor's (or other professors') knowledge in the field. Ask your professor questions such as: "If you had to read only one book from the 70's on topic X, what would it be?" Questions such as this help you to find and determine quickly the most seminal pieces in the field.

Consider whether your sources are current

Some disciplines require that you use information that is as current as possible. In the sciences, for instance, treatments for medical problems are constantly changing according to the latest studies. Information even two years old could be obsolete. However, if you are writing a review in the humanities, history, or social sciences, a survey of the history of the literature may be what is needed, because what is important is how perspectives have changed through the years or within a certain time period. Try sorting through some other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to consider what is currently of interest to scholars in this field and what is not.

Find a focus

A literature review, like a term paper, is usually organized around ideas, not the sources themselves as an annotated bibliography would be organized. This means that you will not just simply list your sources and go into detail about each one of them, one at a time. No. As you read widely but selectively in your topic area, consider instead what themes or issues connect your sources together. Do they present one or different solutions? Is there an aspect of the field that is missing? How well do they present the material and do they portray it according to an appropriate theory? Do they reveal a trend in the field? A raging debate? Pick one of these themes to focus the organization of your review.

Construct a working thesis statement

Then use the focus you've found to construct a thesis statement. Yes! Literature reviews have thesis statements as well! However, your thesis statement will not necessarily argue for a position or an opinion; rather it will argue for a particular perspective on the material. Some sample thesis statements for literature reviews are as follows:

The current trend in treatment for congestive heart failure combines surgery and medicine.

More and more cultural studies scholars are accepting popular media as a subject worthy of academic consideration.

Consider organization

You've got a focus, and you've narrowed it down to a thesis statement. Now what is the most effective way of presenting the information? What are the most important topics, subtopics, etc., that your review needs to include? And in what order should you present them? Develop an organization for your review at both a global and local level:

First, cover the basic categories Just like most academic papers, literature reviews also must contain at least three basic elements: an introduction or background information section; the body of the review containing the discussion of sources; and, finally, a conclusion and/or recommendations section to end the paper. Introduction: Gives a quick idea of the topic of the literature review, such as the central theme or organizational pattern. Body: Contains your discussion of sources and is organized either chronologically, thematically, or methodologically (see below for more information on each). Conclusions/Recommendations: Discuss what you have drawn from reviewing literature so far. Where might the discussion proceed? Organizing the body Once you have the basic categories in place, then you must consider how you will present the sources themselves within the body of your paper. Create an organizational method to focus this section even further. To help you come up with an overall organizational framework for your review, consider the following scenario and then three typical ways of organizing the sources into a review: You've decided to focus your literature review on materials dealing with sperm whales. This is because you've just finished reading Moby Dick , and you wonder if that whale's portrayal is really real. You start with some articles about the physiology of sperm whales in biology journals written in the 1980's. But these articles refer to some British biological studies performed on whales in the early 18th century. So you check those out. Then you look up a book written in 1968 with information on how sperm whales have been portrayed in other forms of art, such as in Alaskan poetry, in French painting, or on whale bone, as the whale hunters in the late 19th century used to do. This makes you wonder about American whaling methods during the time portrayed in Moby Dick , so you find some academic articles published in the last five years on how accurately Herman Melville portrayed the whaling scene in his novel. Chronological If your review follows the chronological method, you could write about the materials above according to when they were published. For instance, first you would talk about the British biological studies of the 18th century, then about Moby Dick, published in 1851, then the book on sperm whales in other art (1968), and finally the biology articles (1980s) and the recent articles on American whaling of the 19th century. But there is relatively no continuity among subjects here. And notice that even though the sources on sperm whales in other art and on American whaling are written recently, they are about other subjects/objects that were created much earlier. Thus, the review loses its chronological focus. By publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on biological studies of sperm whales if the progression revealed a change in dissection practices of the researchers who wrote and/or conducted the studies. By trend A better way to organize the above sources chronologically is to examine the sources under another trend, such as the history of whaling. Then your review would have subsections according to eras within this period. For instance, the review might examine whaling from pre-1600-1699, 1700-1799, and 1800-1899. Under this method, you would combine the recent studies on American whaling in the 19th century with Moby Dick itself in the 1800-1899 category, even though the authors wrote a century apart.

Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For instance, the sperm whale review could focus on the development of the harpoon for whale hunting. While the study focuses on one topic, harpoon technology, it will still be organized chronologically. The only difference here between a "chronological" and a "thematic" approach is what is emphasized the most: the development of the harpoon or the harpoon technology.

But more authentic thematic reviews tend to break away from chronological order. For instance, a thematic review of material on sperm whales might examine how they are portrayed as "evil" in cultural documents. The subsections might include how they are personified, how their proportions are exaggerated, and their behaviors misunderstood. A review organized in this manner would shift between time periods within each section according to the point made.

Methodological

A methodological approach differs from the two above in that the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the "methods" of the researcher or writer. For the sperm whale project, one methodological approach would be to look at cultural differences between the portrayal of whales in American, British, and French art work. Or the review might focus on the economic impact of whaling on a community. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Once you've decided on the organizational method for the body of the review, the sections you need to include in the paper should be easy to figure out. They should arise out of your organizational strategy. In other words, a chronological review would have subsections for each vital time period. A thematic review would have subtopics based upon factors that relate to the theme or issue.

Sometimes, though, you might need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you. Put in only what is necessary. Here are a few other sections you might want to consider:

Current Situation : Information necessary to understand the topic or focus of the literature review.

History : The chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.

Methods and/or Standards : The criteria you used to select the sources in your literature review or the way in which you present your information. For instance, you might explain that your review includes only peer-reviewed articles and journals.

Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

Once you've settled on a general pattern of organization, you're ready to write each section. There are a few guidelines you should follow during the writing stage as well. Here is a sample paragraph from a literature review about sexism and language to illuminate the following discussion:

However, other studies have shown that even gender-neutral antecedents are more likely to produce masculine images than feminine ones (Gastil, 1990). Hamilton (1988) asked students to complete sentences that required them to fill in pronouns that agreed with gender-neutral antecedents such as "writer," "pedestrian," and "persons." The students were asked to describe any image they had when writing the sentence. Hamilton found that people imagined 3.3 men to each woman in the masculine "generic" condition and 1.5 men per woman in the unbiased condition. Thus, while ambient sexism accounted for some of the masculine bias, sexist language amplified the effect. (Source: Erika Falk and Jordan Mills, "Why Sexist Language Affects Persuasion: The Role of Homophily, Intended Audience, and Offense," Women and Language19:2.

Use evidence

In the example above, the writers refer to several other sources when making their point. A literature review in this sense is just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence to show that what you are saying is valid.

Be selective

Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the review's focus, whether it is thematic, methodological, or chronological.

Use quotes sparingly

Falk and Mills do not use any direct quotes. That is because the survey nature of the literature review does not allow for in-depth discussion or detailed quotes from the text. Some short quotes here and there are okay, though, if you want to emphasize a point, or if what the author said just cannot be rewritten in your own words. Notice that Falk and Mills do quote certain terms that were coined by the author, not common knowledge, or taken directly from the study. But if you find yourself wanting to put in more quotes, check with your instructor.

Summarize and synthesize

Remember to summarize and synthesize your sources within each paragraph as well as throughout the review. The authors here recapitulate important features of Hamilton's study, but then synthesize it by rephrasing the study's significance and relating it to their own work.

Keep your own voice

While the literature review presents others' ideas, your voice (the writer's) should remain front and center. Notice that Falk and Mills weave references to other sources into their own text, but they still maintain their own voice by starting and ending the paragraph with their own ideas and their own words. The sources support what Falk and Mills are saying.

Use caution when paraphrasing

When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. In the preceding example, Falk and Mills either directly refer in the text to the author of their source, such as Hamilton, or they provide ample notation in the text when the ideas they are mentioning are not their own, for example, Gastil's. 

Draft in hand? Now you're ready to revise. Spending a lot of time revising is a wise idea, because your main objective is to present the material, not the argument. So check over your review again to make sure it follows the assignment and/or your outline. Then, just as you would for most other academic forms of writing, rewrite or rework the language of your review so that you've presented your information in the most concise manner possible. Be sure to use terminology familiar to your audience; get rid of unnecessary jargon or slang. Finally, double check that you've documented your sources and formatted the review appropriately for your discipline. 

We consulted these works while writing the original version of this handout. This is not a comprehensive list of resources on the handout's topic, and we encourage you to do your own research to find the latest publications on this topic. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. 

Anson, Chris M. and Robert A. Schwegler, The Longman Handbook for Writers and Readers. Second edition. New York: Longman, 2000.

Jones, Robert, Patrick Bizzaro, and Cynthia Selfe. The Harcourt Brace Guide to Writing in the Disciplines. New York: Harcourt Brace, 1997.

Lamb, Sandra E. How to Write It: A Complete Guide to Everything You'll Ever Write. Berkeley, Calif.: Ten Speed Press, 1998.

Rosen, Leonard J. and Laurence Behrens. The Allyn and Bacon Handbook. Fourth edition. Boston: Allyn and Bacon, 2000.

Troyka, Lynn Quitman. Simon and Schuster Handbook for Writers. Upper Saddle River, N.J.: Prentice Hall, 2002.

Originally written and publised by the The Writing Center, University of North Carolina at Chapel Hill

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What is a literature review?

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So you have been asked to complete a literature review, but what is a literature review?

A literature review is a piece of research which aims to address a specific research question. It is a comprehensive summary and analysis of existing literature. The literature itself should be the main topic of discussion in your review. You want the results and themes to speak for themselves to avoid any bias.

The first step is to decide on a topic. Here are some elements to consider when deciding upon a topic:

• Choose a topic which you are interested in, you will be looking at a lot of research surrounding that area so you want to ensure it is something that interests you. 
• Draw on your own experiences, think about your placement or your workplace.
• Think about why the topic is worth investigating.  

Once you have decided on a topic, it is a good practice to carry out an initial scoping search.

This requires you to do a quick search using  LibrarySearch  or  Google Scholar  to ensure that there is research on your topic. This is a preliminary step to your search to check what literature is available before deciding on your question. 

The research question framework elements can also be used as keywords.

• Think about who the population/ sample group. Are you looking for a particular age group, ethnicity, cultural background, gender, health issue etc.
• What is the intervention/issue you want to know more about? This could be a particular type of medication, education, therapeutic technique etc. 
• Do you have a particular context in mind? This could relate to a community setting, hospital, ward etc. 

It is important to remember that databases will only ever search for the exact term you put in, so don't panic if you are not getting the results you hoped for. Think about alternative words that could be used for each keyword to build upon your search. 

Build your search by thinking about about synonyms, specialist language, spellings, acronyms, abbreviations for each keyword that you have.

Inclusion & Exclusion Criteria

Your inclusion and exclusion criteria is also an important step in the literature review process. It allows you to be transparent in how you have  ended up with your final articles. 

Your inclusion/exclusion criteria is completely dependent on your chosen topic. Use your inclusion and exclusion criteria to select your articles, it is important not to cherry pick but to have a reason as to why you have selected that particular article. 

• Search Planning Template Use this template to plan your search strategy.

Once you have thought about your keywords and alternative keywords, it is time to think about how to combine them to form your search strategy. Boolean operators instruct the database how your terms should interact with one another. 

Boolean Operators

• OR can be used to combine your keywords and alternative terms. For example "Social Media OR Twitter". When using OR we are informing the database to bring articles continuing either of those terms as they are both relevant so we don't mind which appears in our article. 
• AND can be used to combine two or more concepts. For example "Social Media AND Anxiety". When using AND we are informing the database that we need both of the terms in our article in order for it to be relevant.
• Truncation can be used when there are multiple possible word endings. For example Nurs* will find Nurse, Nurses and Nursing. 
• Double quotation marks can be used to allow for phrase searching. This means that if you have two or more words that belong together as a phrase the database will search for that exact phrase rather than words separately.  For example "Social Media"

Don't forget the more ORs you use the broader your search becomes, the more ANDs you use the narrower your search becomes. 

One of the databases you will be using is EBSCOHost Research Databases. This is a platform which searches through multiple databases so allows for a comprehensive search. The short video below covers how to access and use EBSCO. 

A reference management software will save you a lot of time especially when you are looking at lots of different articles. 

We provide support for EndNote and Mendeley. The video below covers how to install and use Mendeley. 

Consider using a research question framework. A framework will ensure that your question is specific and answerable.

There are different frameworks available depending on what type of research you are interested in.

Population - Who is the question focussed on? This could relate to staff, patients, an age group, an ethnicity etc.

Intervention - What is the question focussed on? This could be a certain type of medication, therapeutic technique etc. 

Comparison/Context - This may be with our without the intervention or it may be concerned with the context for example where is the setting of your question? The hospital, ward, community etc?

Outcome - What do you hope to accomplish or improve etc.

Sample - as this is qualitative research sample is preferred over patient so that it is not generalised. 

Phenomenon of Interest - reasons for behaviour, attitudes, beliefs and decisions.

Design - the form of research used. 

Evaluation - the outcomes.

Research type -qualitative, quantitative or mixed methods.  

All frameworks help you to be specific, but don't worry if your question doesn't fit exactly into a framework. 

There are many critical appraisal tools or books you can use to assess the credibility of a research paper but these are a few we would recommend in the library. Your tutor may be able to advise you of others or some that are more suitable for your topic.

Critical Appraisal Skills Programme (CASP)

CASP is a well-known critical appraisal website that has checklists for a wide variety of study types. You will see it frequently used by practitioners.

Understanding Health Research

This is a brand-new, interactive resource that guides you through appraising a research paper, highlighting key areas you should consider when appraising evidence.

Greenhalgh, T. (2014) How to read a paper: The basics of evidence-based medicine . 5 th edn. Chichester: Wiley

Greenhalgh’s book is a classic in critical appraisal. Whilst you don’t need to read this book cover-to-cover, it can be useful to refer to its specific chapters on how to assess different types of research papers. We have copies available in the library!

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How to Conduct a Literature Review (Health Sciences and Beyond)

What is a literature review, traditional (narrative) literature review, integrative literature review, systematic reviews, meta-analysis, scoping review.

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• Systematic Reviews by Roy Brown Last Updated Oct 17, 2023 559 views this year
• Write a Literature Review by John Glover Last Updated Oct 16, 2023 2948 views this year

A literature review provides an overview of what's been written about a specific topic. There are many different types of literature reviews. They vary in terms of comprehensiveness, types of study included, and purpose. 

The other pages in this guide will cover some basic steps to consider when conducting a traditional health sciences literature review. See below for a quick look at some of the more popular types of literature reviews.

For additional information on a variety of review methods, the following article provides an excellent overview.

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies. Health Info Libr J. 2009 Jun;26(2):91-108. doi: 10.1111/j.1471-1842.2009.00848.x. Review. PubMed PMID: 19490148.

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Unleashing the potential of Health Promotion in primary care—a scoping literature review

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Adela Bisak, Martin Stafström, Unleashing the potential of Health Promotion in primary care—a scoping literature review, Health Promotion International , Volume 39, Issue 3, June 2024, daae044, https://doi.org/10.1093/heapro/daae044

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The purpose of this study is to gain a better understanding of the role and extent of health promotion lifestyle interventions targeting adults in primary care, and especially those who are considered overall healthy, i.e. to study the outcomes of research applying salutogenesis. We performed a literature review, with three specific aims. First, to identify studies that have targeted the healthy population in intervention within the primary health care field with health promotion activities. Second, to describe these interventions in terms of which health problems they have targeted and what the interventions have entailed. Third, to assess what these programs have resulted in, in terms of health outcomes. This scoping review of 42 studies, that applied salutogenesis in primary care interventions shows that health promotion targeting healthy individuals is relevant and effective. The PRISMA-ScR guidelines for reporting on scoping review were used. Most interventions were successful in reducing disease-related risks including CVD, CVD mortality, all-cause mortality, but even more importantly success in behavioural change, sustained at follow-up. Additionally, this review shows that health promotion lifestyle interventions can improve mental health, even when having different aims.

This article describes the importance of including healthy individuals in health promotion activities, applying salutogenesis, as there are significant positive health outcomes effects if they participate in health interventions.

The study amplifies that the prevention paradox should always be considered when designing health promotion interventions.

This article shows that the greatest effects when targeting healthy individuals are found in lower all-cause mortality and CVD risks, mainly because these programs manage to lead to long-lasting lifestyle changes.

Health Promotion is, according to Nutbeam and Muscat (2021 , p. 1580), ‘[…] the process of enabling people to increase control over, and to improve their health’. This process entails a comprehensive approach to change on all levels, from structures to individuals, improving health mainly through addressing the social determinants of health.

Whereas the most overarching processes are initiated on a structural level through global and national health policies ( Cross et al ., 2020 ), health promotion strategies are also widely employed in health interventions targeting individuals. It could entail smoking cessation programs, weight loss programs and adolescent alcohol use, just to mention some common health outcome target areas ( Green et al. , 2019 ). Even when deploying health promotion strategies at a national policy level, it is not uncommon that the programs designed to target individuals and groups are more inspired by pathogenesis, rather than salutogenesis ( Nutbeam and Muscat, 2021 ).

A widespread strategy in the latter programs is that individuals are screened for a need to receive an intervention, so-called secondary or indicated prevention programs, where those who report a riskier lifestyle, or test worse on psychometric or biometric indicators are eligible for receiving the intervention, and those not having the same risks are excluded from the program on the premise that they are, based on study protocol definitions, healthy individuals.

Based on the principles of salutogenesis, this is a somewhat inappropriate approach. Within the strategy of health promotion, it is assumed that all people, no matter their level of risk, would find feedback on their health valuable. Those in need of change should receive the necessary resources and tools to change, whereas those who do not have to change should have their lifestyles positively reinforced. In addition, the prevention paradox ( Rose, 1981 ) postulates that it is important to address the majority, as there will be plenty of adverse health outcomes stemming from them. In conventional indicated prevention programs, attention to those who are non-eligible for interventions is, thus, often completely disregarded.

One common arena for such programs is primary health care. There is a wide range of evidence-based programs that have shown efficacy in reducing the health risks among those who have the riskiest lifestyles in relation to, e.g. alcohol use ( Beyer et al ., 2019 ), smoking ( Cantera et al ., 2015 ), depression ( Bortolotti et al ., 2008 ), diabetes ( Galaviz et al ., 2018 ) and cardiovascular diseases ( Álvarez-Bueno et al. , 2015 ). The at-risk groups vary across the different diseases, but a vast majority of patients targeted in the above studies were identified after screening as non-eligible to participate in the intervention in question. From this follows that a large number of individuals do not receive any substantial health information, nor are their health outcomes measured as they are not included in the intervention. From a health promotion perspective, this seems like a lost opportunity. Additionally, this raises the question of whether a healthy population is systematically disadvantaged compared to those individuals at high risk, which might point to some less-known health inequities or disparities ( Braveman, 2006 ) present in primary care.

In order to gain a better understanding of the effects of health promotion as an overall approach, and to understand the implications of the prevention paradox, it would be pertinent to include the non-eligible group in both the feedback loop—mainly offering them structured positive reinforcement—and to subsequently measure their health and attributed lifestyles.

The purpose of this study is to gain a better understanding of the role and extent of health promotion lifestyle interventions targeting adults in primary care, especially those who are considered overall healthy. More precisely we aim to assess to what extent health promotion practices in primary care address healthy individuals, not only those who need to undergo a lifestyle change. In order to do so, we performed a literature review, with three specific aims. First, to identify studies that have only targeted the healthy population, or healthy population in addition to high-risk group in intervention within the primary health care field with health promotion activities. Second, to describe these interventions in terms of which health problems they have targeted and what the interventions have entailed. Third, to assess what the initiatives published in the research literature have resulted in terms of health outcomes.

Due to the width of the topic and study designs we chose to perform a scoping review, with the aim of summarizing and disseminating previous research and identifying research gaps in the literature ( Arksey and O’Malley, 2005 ). The search process was iterative and non-linear, reflecting upon the results from the literature search at each stage and then repeating steps where necessary to cover the literature more comprehensively ( Arksey and O’Malley, 2005 ).

A few terms demand some further definition within the scope of this review . Healthy individual is a fluid term varying across different studies and contexts, yet it is a key concept in this particular study. The term involves those without chronic disease, who are indicated as not being of an elevated risk of developing a disease linked to the health outcome they have been screened for, but they could very well be at risk for diseases beyond the scope of the study they have been examined within. Primary health care may in this review indicates different types of settings from the most common one relating to general practitioners and family doctors to occupational medicine or periodical work-related health check-ups but also dental health care. Health promotion interventions in this study are understood as interventions that aim to keep people healthy longer, by providing positive feedback in relation to current and new health behaviours, rather than controlling health status by medication use.

Search strategy

The search was done across two databases PubMed and Embase, by combining different strings related to keywords ‘health promotion’ and ‘primary care’, while the rest of the strings varied, more specific search queries are available in Supplementary Appendix A . The search was conducted during June and July 2023 and consisted of publications dated between July 2008 and July 2023 (i.e. the last 15 years). Additional studies were identified manually from references of the included articles and by ‘See all similar articles’ option in PubMed and ‘similar records’ in Embase. The article titles were scanned from databases, followed by screening titles and abstracts through the Covidence software, and then finally the full articles were read. Results were filtered for adult humans, defined as age 18–75, abstracts being available and the studies were authored in English.

Articles were included if (i) the population consisted of working-age adults, (ii) the population included those screened as healthy within a whole sample followed by an intervention or interventions ideally at follow-up, (iii) the study focused on primary prevention (iv) the study focused on lifestyle interventions, (v) the study examined lifestyle-related behaviours. Exclusion criteria for papers were (i) focused on children—below the age of 18 or elderly, (ii) addiction behaviours, (iii) excluding healthy individuals from intervention after screening or using them exclusively in the control group, (iv) using only high-risk population as healthy, (v) promoting only mental health, (vi) secondary prevention, (vii) screening is the only intervention, (viii) reviews and study protocols.

After full-text screening, the data charting process for reviewing, sorting and documenting information ( Arksey and O’Malley, 2005 ) was done using Covidence, Data Extraction version 2 recommended for scoping reviews. The Data Extraction Template included columns for article title, author, country in which the study was conducted, methods (aim, design, population description, inclusion and exclusion criteria) intervention description, outcome measures, relevant results, follow-up (yes/no), study setting (primary care, worksite/occupational, population-based), study category (lifestyle, physical activity and diet, cardiovascular disease, alcohol consumption) and a field for additional notes where needed.

Due to great inconsistencies between studies in the design, populations and outcomes, critical appraisal of individual sources of evidence—an optional step in PRISMA-ScR ( Tricco et al ., 2018 ) guideline list was not done, although concerning research aim it would be useful for assessing the quality of evidence. Although exclusion/inclusion criteria were respected, what was considered as ‘healthy’, ‘middle-’ or ‘high-risk population’ differed significantly in studies, due to differences in definition of terms. Moreover, this decision was made as the AMSTAR tool would not be an adequate choice due to the inclusion of a non-randomized design, and although the AMSTAR 2 tool could potentially be used, this review also included several economic evaluations and follow-ups ( Supplementary Table S1 for more details), or indicators differing highly across studies.

For the synthesis of results ( Tricco et al ., 2018 ), the studies were grouped by the type of the outcome—disease, i.e. CVD or lifestyle/behaviour: physical activity and diet or alcohol consumption. Furthermore, the studies were summarized by setting, risk group and follow-up. None of the systematic reviews with similar research aims were detected during the search.

The selection of sources of evidence ( Tricco et al ., 2018 ) was done as described: 353 references were imported for screening, 72 duplicates were removed, 268 studies were screened against title and abstract during which 198 studies were excluded while 69 studies were assessed for full-text eligibility, when 27 studies were excluded: 12 for wrong intervention, 8 for wrong patient population, 4 for wrong study design 1 was not in English, 1 for wrong indication and 1 for wrong setting, after which 42 studies were included. PRISMA of full screening is found in Figure 1 .

PRISMA of full screening strategy.

Lifestyle interventions

A summary of the study setting, samples and the main outcomes of the 42 studies analysed in this scoping review is presented in Supplementary Table S1 .

In general, the intervention studies analysed here had different main strategies, including: individually tailored programs ( Doumas and Hannah, 2008 ; Gram et al ., 2012 ; Watson et al ., 2015 ) risk-based, group-based ( Recio-Rodriguez et al ., 2016 ) or mixed variants ( Matano et al ., 2007 ; Matzer et al ., 2018 ).

Cardiovascular health

We found several different lifestyle interventions targeting CVD risk. There were a set of programs that addressed physical activity in the workplace, which significantly reduced the CVD risk in healthy participants adhering to the program ( Gram et al ., 2012 ; Dalager et al ., 2016 ; Eng et al ., 2016 ; Biffi et al ., 2018 ). In primary care, an observational study by Journath et al . (2020) , showed an association between healthy participant participation in a CVD prevention programme promoting physical activity and a healthy lifestyle with lower risk of CV events (12%), CV mortality (21%) and all-cause mortality (17%) after 20 years of follow-up.

Similarly, we found interventions in primary care settings that led to changes in physical activity and dietary patterns among all participants—not only those at high risk of CVD morbidity and mortality. These studies described generally decreased CVD risks ( Richardson et al ., 2008 ; Buckland et al ., 2009 ; Nguyen et al ., 2012 ; Gibson et al ., 2014 ; Bo et al ., 2016 ; Lidin et al ., 2018 ; Lingfors and Persson, 2019 ), CVD-related mortality ( Blomstedt et al ., 2011 ; Persson et al ., 2015 ; Jeong et al ., 2019 ) and all-cause mortality ( Blomstedt et al ., 2015 ; Bo et al ., 2016 ; Bonaccio et al ., 2019 ).

In a prospective observational study on healthy individuals and those with CVD conducted by Lidin et al . (2018) , the prevalence within the sample at risk of CVD decreased significantly at 12-month follow-up by 15%. In several studies, the changes in health behaviours among the participants showed to be sustained in follow-ups conducted after intervention discontinuation ( Buckland et al ., 2009 ; Gibson et al ., 2014 ; Baumann et al ., 2015 ; Blomstedt et al ., 2015 ; Lidin et al ., 2018 ), while some cardiovascular risk factors, such as salty diets and smoking, showed evidence of significant decrease in a relatively short period ( Nguyen et al ., 2012 ).

Physical activity and diet

In interventions addressing physical activity and diet, it was evident that healthy individuals were more likely to adhere to physical activity interventions ( Dalager et al ., 2016 ; Biffi et al ., 2018 ; Jeong et al ., 2019 ) compared to those with a disease. One community-based walking intervention ( Yang and Kim, 2022 ) affected not only the level of physical activity significantly but also a positive overall change towards a health-promoting lifestyle and decreased perceived stress. Similarly, several mental health measures including general mental health ( Oude Hengel et al ., 2014 ), anxiety and depression ( Gibson et al ., 2014 ) and stress ( Lingfors et al ., 2009 ; Matzer et al ., 2018 ) in participants improved during interventions and at follow-up when targeting physical activity and diet.

Additionally, concerning physical activity and diet outcomes, there were a higher feasibility of uptake among participants in health promotion programs compared to those only receiving standard care in primary care ( Lingfors et al ., 2009 ; Zabaleta-Del-Olmo et al ., 2021 ). Anokye et al. (2014) argued that brief advice intervention was more effective—leading to 466 QALYs gained, compared to standard care—implying greater cost-effectiveness.

Healthier lifestyles were also maintained at the follow-up. Reduction in risk factors was found to be sustained in follow-ups at 12 months ( Gibson et al ., 2014 ) or improvements in dietary outcomes over 5 years ( Baumann et al ., 2015 ), and sustained lower blood pressure over 6 years ( Eng et al ., 2016 ).

Several interventions promoting physical activity in primary care settings showed significant results in increasing it in all patients, not only in those with chronic disease diagnosis ( Robroek et al ., 2010 ; Gram et al ., 2012 ; Hardcastle et al ., 2012 ; Viester et al ., 2015 ; Byrne et al ., 2016 ; Dalager et al ., 2016 ; Eng et al ., 2016 ; Recio-Rodriguez et al ., 2016 ; Biffi et al ., 2018 ; Matzer et al ., 2018 ; Yang and Kim, 2022 ), and similar patterns were also found concerning a change towards a healthier diet ( Lingfors et al ., 2009 ; Wendel-Vos et al ., 2009 ; Robroek et al ., 2010 ; Baumann et al ., 2015 ; Viester et al ., 2015 ; Bo et al ., 2016 ; Byrne et al ., 2016 ; Kosendiak et al ., 2021 ).

There was disagreement among the above studies in relation to the effectiveness of these interventions among healthy individuals. For example, in the case of implementing a Mediterranean diet, one report argued that a healthy diet should be prioritized, indicating significant hazard ratios (HR) of attaining a Mediterranean diet for all-cause mortality (HR = 0.83), CV mortality (HR = 0.75) and CV events (HR = 0.79) among low-risk individuals ( Bo et al ., 2016 ). Others, however, claimed that there was no evidence of healthier participants being more susceptible to changes in physical activity and diet ( Robroek et al ., 2010 ).

Alcohol consumption

Interventions aimed at decreasing alcohol consumption were divided between those being most effective in high-risk drinkers ( Doumas and Hannah, 2008 ; Kirkman et al ., 2018 ), and both moderate and low-risk drinkers ( Matano et al ., 2007 ). These interventions were, at large, seen as cost-saving ( Watson et al ., 2015 ) and feasible in primary care ( Neuner-Jehle et al ., 2013 ). Some studies found a sustained decrease in alcohol consumption in those adhering to the interventions, compared to the control groups at 1 ( Pemberton et al ., 2011 ) and 4 months after the intervention ( Kirkman et al ., 2018 ), whereas others failed to find a significant difference between groups.

Intervention setting

The interventions took place in primary care settings, though these were either in community-based or occupational settings. The findings suggested that there were some discrepancies between these different settings.

When it comes to a community-based setting, the difference is made between interventions conducted on a sample of those visiting primary health care or a sample representative for a population of one community—town, or region. Primary care community-based studies tended to either include participants who were primary care visitors with a long follow-up period, or interventions conducted in primary care clinic centres with a shorter follow-up period, most often using experimental design, sampling individuals living in the community that did not necessarily had an intention to seek care ( Richardson et al ., 2008 ; Hardcastle et al ., 2012 ; Nguyen et al ., 2012 ; Grunfeld et al ., 2013 ; Baumann et al ., 2015 ; Bo et al ., 2016 ; Lidin et al ., 2018 ; Zabaleta-Del-Olmo et al ., 2021 ).

Overall, the community-based studies were conducted on a sample representative for a population of a smaller community ( Kosendiak et al ., 2021 ; Yang and Kim, 2022 ), region ( Lingfors et al ., 2009 ; Wendel-Vos et al ., 2009 ; Gibson et al ., 2014 ; Persson et al ., 2015 ; Bonaccio et al ., 2019 ; Jeong et al ., 2019 ; Lingfors and Persson, 2019 ; Journath et al ., 2020 ) or a country ( Buckland et al ., 2009 ; Blomstedt et al ., 2011 ; Neuner-Jehle et al ., 2013 ), often followed by a longer follow-up period. Finally, some studies were evaluations of previous interventions ( Richardson et al ., 2008 ; Anokye et al ., 2014 ).

Worksite interventions comprised of different occupational roles, often including several of those in the same sample ( Eng et al ., 2016 ), or segmenting based on how physically active the occupation was, e.g. office workers ( Dalager et al ., 2016 ), construction workers ( Gram et al ., 2012 ; Oude Hengel et al ., 2014 ; Viester et al ., 2015 ), sailors ( Hjarnoe and Leppin, 2013 ), farmers ( van Doorn et al ., 2019 ) or simply more active individuals ( Biffi et al ., 2018 ). This had the implication that approaches to intervention differed widely across the studies.

Several interventions were conducted online using a web-based interface, while others were in a professional setting ( Matano et al ., 2007 ; Doumas and Hannah, 2008 ; Robroek et al ., 2010 ; Pemberton et al ., 2011 ; Khadjesari et al ., 2014 ) or in some cases community-based ( Recio-Rodriguez et al ., 2016 ; Kirkman et al ., 2018 ).

Categorization of risk among participants

Many studies applied specific risk criteria based on the participants’ morbidity risks: including groups of low, middle, high risk ( Persson et al ., 2015 ; Bo et al ., 2016 ; Lingfors and Persson, 2019 ), low and high risk ( Baumann et al ., 2015 ), middle and high risk ( Gibson et al ., 2014 ). While some did not distinguish between risk groups ( Wendel-Vos et al ., 2009 ; Blomstedt et al ., 2011 ; Byrne et al ., 2016 ; Journath et al ., 2020 ). In some studies, however, the protocol included mixed populations of those who were healthy and those who had a chronic disease ( Anokye et al ., 2014 ; Bonaccio et al ., 2019 ). Finally, different studies came up with their own meaning of ‘healthy individual’ or ‘healthy population’ based on the health problem they addressed, i.e. having a sedentary lifestyle or high alcohol consumption. Other criteria for being a part of a healthy population were having a high risk for a disease, one or several risks but not the disease itself, or being above a reference value without having a diagnosis.

Ethical implications of healthy controls

Some interventions were screening-result-based, meaning that there was a difference in the treatment of those with good health and those with some complications. In other words, although not excluding healthy individuals, the study protocol included healthy individuals partially receiving full treatment, in the intervention. Studies that excluded those who were healthy from the sample after screening or used them as a control group were excluded from this review. However, some included studies had a healthy control group. Overall, the studies included in this review did not discuss the ethical implications of including healthy populations as controls, or when that was the case, the ethical impact of excluding healthy participants from an intervention.

This scoping review speaks not only of the role and extent of health promotion for healthy individuals in primary care but also of the importance and effects it has on population health. The results showing the association of lifestyle interventions with CVD risk show great implications for future use in primary care, different contexts and feasibility. Physical activity interventions were additionally found to be related to some improvements in mental health.

Interventions aimed at alcohol consumption were found successful in decreasing the amount of drinking sustainably, while the main discussion was based on whether they should be aimed at high-risk only, or at middle- and low-risk drinkers as well, due to mixed results in said groups. The majority of interventions were based in a worksite setting, meaning that this context might be useful for tackling the issue. This approach showed that outcomes might be beneficial even when not reaching the primary goal. Examples of this are findings showing that although not reducing CVD risk, changes in health behaviours were sustained in follow-up ( Baumann et al ., 2015 ), less drastic changes decreasing CVD risk in the healthy population ( Buckland et al ., 2009 ) and beneficial effects of physical activity intervention on worker’s health without an overall increase in physical activity ( McEachan et al ., 2011 ). Finally, in most cases, as mentioned, changes in health behaviours were associated with changes in CVD risk.

Some interventions showed that health promotion benefits could be even bigger ( Bo et al ., 2016 ) or that adherence is higher in healthy participants ( Dalager et al ., 2016 ; Biffi et al ., 2018 ; Jeong et al ., 2019 ), while other authors disagree ( Robroek et al ., 2010 ). This could be traced to the topic of prioritising primary care for healthy, versus only those at high risk/ already with a disease—secondary care approach according to this review definitions. Designing interventions only for high-risk can make them less successful in healthy participants, as displayed in a study by Blomstedt et al . (2011) where self-rated health decreased in 21% of the good baseline health participants at the 10-year follow-up. Furthermore, from the Rose’s (1981) term of prevention paradox—a great benefit for the population can be almost non-existent for an individual, while if we only focus on high-risk cases, many individuals at low-risk can mean worse health outcomes compared to a small number at high-risk ( Rose, 2001 ). In other words, by focusing only on high-risk population, the downsides are care that can be less efficient, less feasible, more expensive and lead to worse health outcomes. This choice should not be exclusive, as excluding either populations can cause ethical concerns. However, this article gives priority to early prevention, by health promotion for healthy individuals in primary care. Additionally, if it is shown that ‘ Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure… ’ ( Stange et al. , 2023 ), different treatment of those who are currently healthy presents an obstacle worth mentioning for achieving health equity in primary care. Furthermore, the role of promoting health to healthy populations and their inclusion in interventions is crucial for improving population health in the future.

Articles focusing on smoking cessation, alcoholism, substance misuse interventions were excluded from this scoping review as they represent addictions and are therefore different from lifestyle interventions. Originally, oral health and dental care interventions were to be included, but there were not enough studies matching the scoping review inclusion requirements.

As expected, the process of finding articles appropriate for inclusion was challenging. Even when the inclusion criteria, at first glance, were satisfied, most studies we came across had excluded healthy participants from the sample after screening for being asymptomatic or not having enough risk factors. They were, however, often a part of a control group, and usually received standard care or no care at all. This approach puts healthy individuals in a vulnerable position, by not addressing their needs to change lifestyles that eventually could contribute to an early death or becoming unwell. Our findings suggest that interventions that include healthy individuals could improve quality of life and health status both at the population and individual levels.

Due to studies using different risk criteria, as well as including many study designs and topics, it was hard to make general conclusions. Nevertheless, as a scoping review, we mapped the area of research by identifying the gaps in the evidence base, and summarizing and disseminating research findings ( Arksey and O’Malley, 2005 ), instead of appraising the quality of evidence in different studies.

Concerning the above, a big research gap was detected in studies focusing on, or even including healthy populations. Furthermore, there is a lack of a coherent or comprehensive methodology in assessing the effects of what is considered health promotion, which calls for a more specific approach and a clear definition of the term. Additionally, the question of intervention staff skills should be raised. Is it necessary that health promotion interventions should be conducted by clinically trained professionals or, innovatively, by staff trained in the topic at hand when possible? Another aspect that is important to problematize is whether it is ethical to exclude healthy individuals in health promotion intervention studies even if they would benefit from participating if included? Furthermore, if healthy individuals are systematically discriminated ( Braveman, 2006 ), receive worse treatment and have the risk of worse health outcomes in the future, it is critical to include them in interventions for achieving better health of populations. This has great practical implications for primary care. Similarly, from a cost-benefit perspective, research should address if excluding healthy individuals might affect the cost-effectiveness of health promotion interventions.

An apparent limitation within this review is the culturally uniform sample of studies. Most studies that we were able to identify were a result of research in the global north, with a strong emphasis on either North America or the EU. Only two studies were from less affluent settings in Southeast Asia ( Nguyen et al ., 2012 ; Bo et al ., 2016 ). Given that the findings suggest that these interventions are cost-effective and do not require substantial investments, these programs could have great potential in low-resource settings if more systematically researched.

This scoping review of 42 studies applying salutogenesis in primary care interventions shows that health promotion targeting healthy individuals is relevant and effective. Most interventions were successful in reducing disease-related risks including CVD, CVD mortality, all-cause mortality, but even more importantly success in behavioural change, sustained at follow-up. Additionally, this review shows that health promotion lifestyle interventions can improve mental health, even when having different aims.

Supplementary material is available at Health Promotion International online.

A.B. performed the literature search, performed most of the data analysis and was the major contributor in writing the Methods and Results sections of the manuscript. M.S. formulated the research questions and scope of the study. He gave considerable input to the data analysis, gave input on all sections of the study—including writing and editing—and was the main author of the Introduction and Discussion. Both authors read and approved the final manuscript.

We would like to express our gratitude to Maria Björklund, librarian, at the Faculty of Medicine Library, Lund University at CRC in Malmö, who assisted us in the literature search.

A.B.’s contribution was in part funded by a scholarship she received from the Faculty of Medicine and in part by internal funds at the Division of Social Medicine and Global Health, Lund University, the latter also funded M.S.’s contribution.

The data underlying this article are available in the article and in its online supplementary material.

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• Open access
• Published: 03 June 2024

Interventions to increase vaccination in vulnerable groups: rapid overview of reviews

• Gill Norman 1 , 2 , 3 ,
• Maartje Kletter 3 &
• Jo Dumville 3  

BMC Public Health volume  24 , Article number:  1479 ( 2024 ) Cite this article

Metrics details

Groups which are marginalised, disadvantaged or otherwise vulnerable have lower uptake of vaccinations. This differential has been amplified in COVID-19 vaccination compared to (e.g.) influenza vaccination. This overview assessed the effectiveness of interventions to increase vaccination in underserved, minority or vulnerable groups.

In November 2022 we searched four databases for systematic reviews that included RCTs evaluating any intervention to increase vaccination in underserved, minority or vulnerable groups; our primary outcome was vaccination. We used rapid review methods to screen, extract data and assess risk of bias in identified reviews. We undertook narrative synthesis using an approach modified from SWiM guidance. We categorised interventions as being high, medium or low intensity, and as targeting vaccine demand, access, or providers.

We included 23 systematic reviews, including studies in high and low or middle income countries, focused on children, adolescents and adults. Groups were vulnerable based on socioeconomic status, minority ethnicity, migrant/refugee status, age, location or LGBTQ identity. Pregnancy/maternity sometimes intersected with vulnerabilities. Evidence supported interventions including: home visits to communicate/educate and to vaccinate, and facilitator visits to practices (high intensity); telephone calls to communicate/educate, remind/book appointments (medium intensity); letters, postcards or text messages to communicate/educate, remind/book appointments and reminder/recall interventions for practices (low intensity). Many studies used multiple interventions or components.

There was considerable evidence supporting the effectiveness of communication in person, by phone or in writing to increase vaccination. Both high and low intensity interventions targeting providers showed effectiveness. Limited evidence assessed additional clinics or targeted services for increasing access; only home visits had higher confidence evidence showing effectiveness. There was no evidence for interventions for some communities, such as religious minorities which may intersect with gaps in evidence for additional services. None of the evidence related to COVID-19 vaccination where inequalities of outcome are exacerbated.

Prospero registration

CRD42021293355

Peer Review reports

Inequity in vaccination is a recognised public health issue which has been amplified by the COVID-19 pandemic.

This overview uses rapid but rigorous methods to systematically review evidence from over 20 systematic reviews of interventions for increasing vaccination in marginalised, disadvantaged or otherwise vulnerable groups.

We identify and evaluate evidence for low, medium and high intensity interventions targeting pull factors (increasing demand for vaccination); push factors (increasing access to vaccination); and vaccination providers.

We highlight the gaps in evidence for key interventions to improve access, for COVID-19 vaccination and for groups such as religious minorities.

Comparatively low vaccination rates in underserved groups are a recognised UK public health issue. Impacted groups include those who are socio-economically disadvantaged, people from black and minority ethnic backgrounds, and other groups who are marginalised, disadvantaged or otherwise vulnerable [ 1 ].

These known issues in vaccination inequalities were amplified during the COVID-19 pandemic. There is recent evidence that inequities in COVID-19 vaccination rates are even greater than in influenza vaccination, where vulnerability to disease may be similarly distributed in older people and those with pre-existing conditions. For example, in communities across Greater Manchester, a city-region with approximately 2.8 million people and considerable population diversity, inequality of vaccination relative to white British residents was greater for all except one of 16 minority ethnic groups for the first dose of COVID-19 vaccine than it was for influenza vaccination [ 2 ].

People from minoritised and disadvantaged groups are disproportionately likely to experience negative outcomes from COVID-19 infection, including hospitalisation, intensive care unit admission, and death [ 3 ]. Given that inequality of vaccination is disproportionately concentrated among those at greatest risk from the disease, the need for interventions which can address vaccination inequity is particularly acute in the context of COVID-19 vaccination campaigns, including annual booster campaigns for older or clinically vulnerable people. Learning, however, is also relevant to wider vaccination campaigns.

A 2015 overview of reviews identified 15 systematic reviews of strategies for so-called vaccine hesitancy, but few interventions which specifically targeted those who were labelled vaccine hesitant [ 4 ]. Most of the included reviews also focused on childhood vaccination campaigns. This review is now substantially out of date, particularly in the context of the COVID-19 pandemic, and the exacerbation of vaccination inequity seen in its early stages. Our preparatory work highlighted further relevant literature and reinforced the need for a new systematic overview of reviews focused on interventions to reduce vaccination inequalities in underserved groups.

This rapid overview of reviews was undertaken to identify and assess the evidence for effectiveness of interventions to increase vaccination in underserved, minority or vulnerable groups.

The protocol for this overview of reviews was registered on Prospero: CRD42021293355 [ 5 ]. We adapted appropriate rapid systematic review methods for this rapid overview and reported it following PRIOR reporting guidelines where possible [ 6 ].

Inclusion criteria

We included systematic reviews which contained randomised controlled trials (RCTs) of interventions for increasing vaccination in groups of people who were considered to be underserved, minoritised or otherwise vulnerable in the context of the vaccination activities investigated. We did not otherwise limit eligibility and accepted authors’ definitions of these groups. We did however consider older age to be a source of vulnerability as well as groups which may be marginalised based on ethnicity, socioeconomic status, place of residence, faith, or LGBTQ + identity. We treated pregnancy/maternity as an additional vulnerability but not itself as a sufficient reason to consider populations vulnerable (so we included interventions targeted at pregnant women/new mothers eligible for other reasons, but not interventions for all pregnant women or families with young children).

Systematic reviews were defined as reviews which included as a minimum: a systematic search; specific inclusion criteria; and an identifiable set of included studies. We only included English-language reviews; reviews in other languages would have been noted but not extracted. We included reviews that contained RCTs evaluating any intervention aimed at increasing vaccination rates in groups of interest, even if reviews were not exclusively aimed at these groups. Interventions could be delivered in any clinical or community setting and in any country, although we considered the relevance of settings in our synthesis. We included any comparator including alternative interventions, no intervention, or provision of usual healthcare/standard vaccination campaigns.

Our primary outcome was vaccination, broadly defined as we anticipated a range of reported measures. In the absence of evidence for vaccinations we would have considered measures such as willingness/intention to vaccinate and knowledge about vaccinations.

We searched the Cochrane Database of Systematic Reviews, Ovid Medline, Ovid Embase and Ebsco CINAHL from inception to 25 November 2022 (updating an initial search in December 2021) without language or date restrictions. For search strategies see supplementary information (Appendix 1 ). We also checked references of included studies. Search results were deduplicated using Endnote X20 [ 7 ].

Selection of studies

We used Rayyan to screen search records [ 8 ]. To increase rapidity, 10% of titles and abstracts were screened in duplicate by two independent researchers for calibration and consistency. Remaining citations were single screened with a second researcher consulted in cases of uncertainty; disagreements were resolved through discussion. Full texts were obtained for all potentially eligible studies. After initial single screening of these full texts, all reviews which were not clearly included or excluded were screened by a second independent researcher; because of the nuanced nature of the inclusion criteria in relation to vulnerable groups this was most reviews. All relevant reviews were included; overlap in included studies was managed post-inclusion.

Data extraction and assessment of risk of bias

We piloted a bespoke Microsoft Excel data extraction form on a small sample of reviews. After this one researcher extracted the data and a second was consulted in cases of uncertainty. Extraction focused on review and study level data and key review findings. Some reviews contained only a portion of studies eligible for our overview e.g. some included reviews contained RCTs and non-RCTs or RCTs assessing irrelevant interventions or populations. In these cases, only relevant data were extracted. We extracted the following: number and size of relevant RCTs and their intervention characteristics; vaccination types; participants and vulnerabilities; outcome data; results of quality appraisal, risk of bias and/or GRADE assessment (Grading of Recommendations Assessment, Development and Evaluation) [ 9 ].

We assessed risk of bias in reviews using ROBIS; one researcher performed the assessments and a second checked these [ 10 ].

Data synthesis

We followed recommendations of the Synthesis Without Metanalysis (SWiM) approach in the synthesis of data, adapted to our rapid overview of reviews [ 11 ]. We developed the following framework to support narrative synthesis of finding, (this is an expansion and codification of the approach planned in the protocol).

We focused on the primary outcome of vaccination (including vaccination, completion of vaccination schedules, and being up to date with vaccinations); outcomes such as willingness/intention to vaccinate or knowledge about vaccination were considered indirectly relevant.

We first adapted the approach of Ward 2012 [ 12 ] and grouped interventions into three sets based on type and purpose of the intervention: interventions to increase demand for vaccination (targeting pull factors); interventions to increase access to vaccination (targeting push factors); and interventions targeting vaccination providers. We considered that interventions which were primarily provider-focused would also fall into the other two categories for their impact on patients but considered that the provider focus was important to consider separately. Within these sets of interventions we then followed Thomas 2018 [ 13 ], and considered the intensity of the intervention delivery as: high intensity (e.g. home visits); medium intensity (e.g. telephone calls); or low intensity (e.g. text messages). This intensity categorisation was based on resource requirements for providers rather than possible patient perception re the intensity of receiving the intervention. When interventions were multi-component or multi-level we noted this. Two researchers agreed on groupings by intervention purpose and intensity and resolved disagreements through discussion.

We mapped RCT overlap between reviews using GROOVE and paid particular attention to this issue of overlapping primary studies for interventions where contributing reviews showed overlap, in order to reduce the risk of double weighting data [ 14 ].

We considered differences in findings between the countries where studies were undertaken, particularly noting whether the studies were undertaken in high income countries or in low or middle income countries (LMIC). This included consideration of the specific populations and groups targeted.

Assessing confidence in synthesised findings

We assessed confidence in findings using a GRADE-informed approach [ 9 ]. One researcher made judgements and consulted a second in cases of uncertainty. We made initial judgements for each intervention in each review then considered evidence across the overview, taking into account overlapping data [ 14 ]. We assigned greatest confidence to interventions where there was consistent evidence for effectiveness from reviews with low risk of bias, which provided either GRADE assessment or reported evidence from larger RCTs that were described in reviews as well-conducted with clearly reported effect estimates. There is necessarily more subjectivity and estimation in these judgements than in GRADE because of often incomplete information; a formal GRADE judgement would overstate our certainty about evidence quality [ 9 ]. We have used the terms “higher, medium and lower confidence” to denote these judgements.

Results of the search

We identified 674 records following deduplication and assessed 88 full texts. We included 23 reviews [ 13 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 ]. (Fig.  1 ). Sixty-five full texts were excluded for the following reasons: not a systematic review; a review protocol; an earlier version of a Cochrane review; not relevant to interventions to improve vaccination-related outcomes; did not include any relevant RCTs. An excluded studies list is available on request.

Flow diagram for records identified for the review

Characteristics of included reviews

Characteristics of included reviews are summarised in Tables  1 and 2 . Reviews were published between 1998 and 2022; most were recent with nine published in 2021 or 2022 and 17 since 2017. Fifteen reviews included studies from high income countries and eighteen included either adults or adolescents (Table  1 ). Eleven reviews looked at multiple types of vaccination (of which five focused on childhood vaccinations); six reviews looked at influenza vaccination, five at HPV vaccination and one at hepatitis B vaccination (Table  2 ).

Underserved groups represented included

Low socioeconomic status (9 reviews).

Ethnic minority or first nations people (10 reviews).

Migrant or refugee status (2 reviews).

Age (9 reviews).

Location (6 reviews).

LGBTQ identity (1 review).

Other (6 reviews).

These vulnerabilities co-occurred in many studies; in three reviews socioeconomic status, age or ethnic minority status co-occurred with the additional vulnerability of pregnancy/maternity (Table  2 ). We did not identify any reviews with RCTs targeting faith groups.

Risk of bias

The ROBIS assessment found that nine reviews had low, six unclear, and eight high overall risk of bias (Fig.  2 ; Table  2 ). Full responses to signalling questions are available on request.

Summary of ROBIS assessments for included reviews

Mapping of included RCTs using GROOVE identified 16 pairs of reviews with moderate (six), high (five) or very high (five) overlap (Fig.  3 ) [ 14 ]. Nineteen individual reviews contributed to the overlap; three reviews overlapped at least moderately with three other reviews and seven with two other reviews. Nine reviews [ 16 , 19 , 20 , 21 , 24 , 26 , 27 , 29 , 32 ] were linked through the three reviews with the highest number of overlaps [ 20 , 24 , 26 ]. Because overlap was substantive we were careful to consider evidence from individual RCTs, and pay particular attention to overlap for interventions in reviews with highest overlap, which included home visiting and various educational and communication interventions.

Summary of GROOVE assessment of overlapping RCTs in included review

Effectiveness of interventions

Unless otherwise stated, all interventions are compared with usual care, the outcome is vaccination, and effects favour interventions. Where we have medium rather than higher confidence this is because of combinations of concerns around one or more of: reporting, study quality, inconsistency of results or limited numbers of participants. We have reported reviews’ GRADE assessments where these were available. Full documentation of evidence for interventions is in Supplementary Information (Appendix 2 ). Below we summarise narratively interventions for which we have higher or medium confidence, grouped by intervention intensity, purpose and type. For interventions where we have lower confidence see Tables  3 and 4 . Table  3 summarises all interventions where evidence identified a benefit of the intervention; Table  4 summarises those interventions where current evidence did not identify a benefit.

High-intensity interventions: increasing demand for vaccination

Home visits for communication or education.

We have higher confidence that home visits for the purposes of communication by health professionals, lay health workers, volunteers and students increase vaccination in underserved groups (11 reviews) [ 13 , 18 , 19 , 20 , 23 , 24 , 25 , 26 , 28 , 32 , 35 ]. We drew primarily on evidence from Cochrane reviews finding moderate certainty evidence in, respectively, influenza vaccinations for older adults; [ 13 ] and childhood vaccinations in economically disadvantaged families being visited by lay healthcare workers; [ 26 ] the evidence was broadly consistent across the other reviews, which included a variety of vulnerable groups. Home visits were also the highest intensity component of interventions using escalating intensity of reminders, and were used in multicomponent interventions; both were effective for disadvantaged children and adolescents. Evidence for home visits compared with postal reminders was inconsistent [ 20 ].

We have medium confidence that community volunteers or pharmacists advocating for vaccination may increase vaccination in some underserved groups [ 31 , 32 ]. Each review contained a single relevant medium-sized or large RCT in different groups (older adults and children in urban/disadvantaged groups respectively).

Community partnership and outreach

We have medium confidence in the effectiveness of community partnership and outreach within multicomponent interventions (four reviews). This includes outreach as part of a multicomponent intervention; [ 28 ] lay health workers leading focus groups (groups cascade information to the community; moderate certainty evidence); [ 20 ] and community involvement in motivating vaccine acceptance [ 32 ], and ensuring relevance of reminders [ 18 ].

School and other non-home-based in person educational interventions

Eight reviews contributed evidence for varied interventions [ 16 , 18 , 19 , 21 , 29 , 32 , 34 , 36 ]. We have medium or lower confidence in this evidence. Reviews found school-based interventions do not currently have clear evidence of effectiveness in impacting vaccination in underserved groups [ 16 , 18 ]. Educational sessions delivered to adults in a range of settings including English as a second language (ESL) classes [ 36 ] and community venues showed mixed results, with some RCTs reporting benefits. Interventions in LMIC contexts found positive effects from interventions targeting parents (pictorial information or redesigned vaccination cards alongside a verbal educational message) [ 19 , 32 ], or brief interventions for adolescents [ 29 ]. Evidence from high income contexts primarily related to HPV vaccination for adolescent girls in the US and mostly did not show evidence of an effect [ 16 , 18 , 21 , 34 ]. RCTs in two reviews found benefits in increasing vaccination via interventions for mother-daughter dyads in minority ethnic communities [ 21 , 34 ].

High intensity interventions: increasing access to vaccination

Home visits for vaccination.

We have higher confidence that vaccination during home visits (delivered by health care professionals, students or community healthcare workers) increases vaccination compared to standard care (invitations to clinic) [ 13 , 19 , 32 ]. Most evidence comes from the Cochrane review in influenza vaccination for older adults, (high certainty GRADE assessment based on two RCTs) [ 13 ], but there is also evidence from childhood vaccination in LMIC.

Using different/additional locations or services or staff to deliver vaccinations

We have medium confidence in effectiveness of additional clinics as part of a “four pillars” multicomponent intervention [ 18 ]. We found no evidence for them as standalone interventions. We also have medium confidence in using routine/general clinic visits to vaccinate within a multilevel, multicomponent intervention [ 28 ]. For both interventions our confidence is reduced because the impact of the availability component cannot be isolated. Using group visits of participants to clinics may also be effective (moderate certainty evidence from a Cochrane review including one RCT) [ 13 ]. We have medium confidence in pharmacist-initiated vaccination programmes involving use of pharmacy-based services and/or delivery by pharmacy staff [ 22 , 31 , 35 ].

Provider focused interventions

Facilitators for healthcare professionals.

We have higher confidence that facilitator involvement with healthcare practices increases vaccination; this is based on moderate certainty evidence from a Cochrane review of influenza vaccination for older adults [ 13 ]. . Two cluster RCTs targeted several goals using multiple strategies over 12 to 18 months, including practice visits by facilitators and approaches such as baseline audit, ongoing feedback, consensus building, and follow-up. One study also used educational materials for professionals and patients. Both these studies showed increased numbers of eligible older people vaccinated, a smaller study of a facilitated educational group plus audit did not find a clear effect [ 13 ].

Medium-intensity interventions: increasing demand for vaccination

Telephone calls for communication and education.

We have higher confidence that the following increase vaccination: telephone calls to remind people about booked appointments, deliver reminders about booking appointments, and provide information about vaccination processes (six reviews) [ 13 , 16 , 18 , 26 , 28 , 35 ]. We have medium confidence in the effectiveness of using phone calls to adolescents as well as their parents; and for telephone calls as part of multicomponent interventions [ 16 , 18 , 28 ], including targeted phone calls and phone calls in an intervention with escalating intensity of reminders [ 18 ].

Medium-intensity interventions: increasing access to vaccination

Included reviews did not report on medium intensity interventions primarily aiming to increase access to vaccination; however some provider-focused interventions (e.g. changing provider systems to allow use of routine visits for vaccination) are likely to have increased access to vaccination.

Medium-intensity interventions: provider-focused interventions

Case management.

We have medium confidence in case management within a multicomponent intervention: this included feedback on missed opportunities to vaccinate, tracking, triage and flagging of vaccination status [ 18 , 28 ].

Routine visits

Using routine visits to vaccinate: We have medium confidence in using routine visits to healthcare providers or clinics to vaccinate as part of a multicomponent intervention for childhood vaccinations [ 28 ], and lower confidence as a stand-alone intervention in older adults [ 35 ].

Low-intensity interventions: increasing demand for vaccination

Various methods involving written material for communication and education were used. Both texts and postal communications were used as stand-alone interventions and as part of multicomponent or escalating intensity interventions, where it is harder to determine their impact [ 18 , 26 ]. These multicomponent or escalating interventions showed evidence of effectiveness; we summarise evidence for different delivery methods here.

Text messages

We have higher confidence that single or multiple text message reminders to attend or book appointments (multiple trials in seven reviews) increase vaccination [ 16 , 17 , 18 , 19 , 27 , 28 , 33 ]. Text messages for appointment reminders may be more effective than postal communication [ 18 ]. Unlike phone calls and postal communication there was limited evidence for an impact of text messages in older populations, where risk of digital exclusion may be higher. Evidence for effectiveness of different types of text messages such as using different messages or interactivity is limited (Table  4 ).

Emails, online messages, mass media and videos

We have medium confidence that individually tailored reminder emails are effective [ 27 ], although there is less evidence for email and online messages than other forms of written messaging, with most examples being elements of wider communication strategies [ 16 , 27 , 28 ]. We only had lower confidence in assessments of video-based messaging [ 16 , 17 , 27 , 29 , 34 ], online messages [ 27 ], and mass media [ 29 , 36 ]. In each case the evidence comprised single studies with limitations of reporting, power and study methods.

Postal communication reminders

We have higher confidence that postal reminders to attend or book appointments, and for providing information about vaccination are effective (six reviews). Postcards and letters were the most used; [ 13 , 16 , 18 , 26 , 28 , 30 ] postcards were identified as particularly effective [ 13 ]. Personalised letters may be more effective than generic ones [ 28 ]. We have medium confidence in evidence for sending letters in an appropriate community language (e.g. Spanish for US Hispanic communities) [ 27 ], and for use of postcards designed to use (accessible) “universal language” [ 18 ].

Written material given in person

We have medium confidence that brief paper-based information given in person increase vaccination (three reviews). This included redesigned immunisation cards with the next appointment date in large print, with or without a short verbal intervention; use of pictorial information cards as an additional intervention during home visits; [ 19 , 32 ] and providing a pamphlet of information with or without a short verbal intervention [ 17 ].

Low intensity interventions: increasing access to vaccination

Included reviews did not report on low intensity interventions aiming to increase access to vaccination.

Low intensity interventions: provider-focused interventions

Centralised systems.

We have higher confidence in the effectiveness of centralised reminder/recall systems compared to practice-based reminder/recall systems in increasing the number of children up to date on vaccinations [ 18 , 33 ].

We have higher confidence in reminders to physicians to vaccinate [ 13 ], and medium confidence in the use of computerised reminders to providers to vaccinate (four reviews) [ 16 , 18 , 33 , 35 ]. These are reminders which are sent or flagged to health care professionals to alert them to the need to vaccinate, rather than reminders to patients to attend for vaccination.

Personalised electronic health records

These were not evaluated as a standalone intervention, but we have medium confidence that their use, together with their electronic messaging features, to educate, send reminders and schedule appointments may increase vaccination relative to control groups with only record access or with no access, including where postal reminders were used [ 15 ].

Other low intensity approaches

There is low to moderate certainty evidence from the Cochrane review in influenza vaccination for older people that the following may be effective: payments to physicians; reminding physicians to vaccinate all patients; posters in clinics presenting vaccination rates and encouraging competition between doctors; chart reviews and benchmarking to rates achieved by the top 10% of physicians [ 13 ].

Summary of the evidence

We identified 23 systematic reviews which included RCTs of interventions to increase vaccination in vulnerable groups. Of these 18 reviews were published after the 2015 overview of reviews identified in our scoping work [ 4 ]. In this overview we have summarised randomised evidence for high, medium and low intensity examples of interventions to increase demand for vaccination; interventions to increase access to vaccination; and provider-focused interventions.

The best represented interventions targeted vaccination demand. We had higher confidence in the effectiveness of high, medium and low intensity communication interventions: home visits, telephone calls and text messages respectively. We had higher confidence in home visits for vaccination but medium confidence in evidence for other interventions for increasing access, including additional clinics. We did not identify patient-focused medium or low intensity interventions to increase access to vaccination. However there were provider-focused interventions which would likely have increased access, such as changing systems to allow vaccination on routine or unrelated visits. For provider-focused interventions we had higher confidence in facilitator visits to practices (high intensity incorporating lower intensity components) and centralised reminder/recall systems (low intensity), and medium confidence in case management (moderate intensity). Where interventions did not show evidence of an effect we typically had lower confidence in the evidence.

Strengths and limitations: review process

We searched multiple databases using a strategy designed by an information specialist and updated the search in November 2022 to capture rapidly developing literature in the context of the COVID-19 pandemic. We have surveyed the literature published since then to further contextualise the relevance of the review. We limited our overview to reviews published in English, but the eight identified reviews in other languages would have been excluded for other reasons. We undertook this overview rapidly to inform work to increase vaccination uptake among vulnerable groups in Greater Manchester. We therefore did not screen all records in duplicate, but we used duplicate screening for a sample of records and for all records where there was uncertainty; two reviewers evaluated most full text records because decisions were nuanced; and we checked samples of data extraction. Two researchers agreed risk of bias and confidence assessments and undertook ROBIS assessments independently. We prespecified our synthesis approach to categorising interventions and strength of evidence and informed this using GROOVE mapping of overlap between reviews.

While our approach to categorising evidence was based on those of other reviews [ 12 , 13 ], it was necessarily subjective to some degree. We partially mitigated this by having two reviewers involved in the categorisation process and discussing disagreements within the review team. However, many interventions will contain elements of more than one category even when they are not multicomponent. In particular interventions which involve providers sending recalls or reminders to patients can be conceived of as both intended to increase demand for vaccination (targeting pull factors) and as provider focused. Categorisation of these was based on the intervention description and whether the focus was on the communication with the patient or the providers’ systems to enable these. We acknowledge that this distinction is to some degree arbitrary. Finally we recognise that our categorisation of intensity is based, as in the review that used it previously [ 13 ], on the resource implications of the intervention for providers. While it is less resource intensive to send text messages than to make phone calls to patients, patients may experience (for example) a series of repeated and tailored text messages as a more intensive intervention than a single generic phone call. The patient experience of intervention intensity is outside the scope of this work but would be worth exploring further.

Our dependence the conduct and reporting of included reviews limited us in multiple respects. In some reviews information was extremely limited and we did not have capacity to directly check relevance of primary studies for study design, intervention, population and outcomes if this was not apparent. In one review, we were unsure how many relevant RCTs were included [ 30 ]. This may have led to exclusion of some relevant evidence. Overlap between reviews means evidence missed in one review may be identified elsewhere. We also did not have capacity to check risk of bias assessments or conduct them where they were absent; lack of assessments reduced our confidence in evidence.

Strengths and limitations: scope of review

We limited this overview to randomised evidence and so did not include specific interventions only evaluated by non-randomised studies, and some included interventions are only represented by small numbers of RCTs or RCTs with small numbers of participants. We are conscious that some important interventions, such as the class of societal interventions identified in Thomas (2018), have thereby been excluded entirely [ 13 ]. This decision also meant that we included only very limited evidence for people from LGBTQ + communities; only one review included relevant RCTs [ 27 ]. We accept that limitation to RCTs is also likely to have excluded interventions which are evaluated in other ways, which can be appropriate research designs in the context of the work, often in partnership with a community, which is being undertaken. We have undertaken such work ourselves in Greater Manchester [ 37 ], informed in part by this review, and would suggest that reading our review in the context of reports of this work – which may be found in the grey as much as the published literature – would be appropriate.

We have not identified RCT evidence not included in a systematic review indexed by 2022; this is a necessary constraint in a review of reviews. However, we updated the Medline search in April 2024 to assess the impact of this cutoff on the review. A large number of reviews published or indexed after December 2022 evaluated vaccination uptake and barriers and facilitators to this in both general populations and minority or otherwise vulnerable groups in the context of COVID-19 vaccination programmes. However, only three reviews would have been eligible for inclusion in out review [ 38 , 39 , 40 ].

The most substantive evidence was supplied by a review of behaviour change techniques in minority ethnic populations. This included ten RCTs and reported that across all study designs and multiple target vaccines the most commonly used intervention functions were education, persuasion and enablement. Effective interventions were multicomponent and tailored to the target population, while awareness raising and community organisation involvement were also associated with positive effects [ 39 ]. We suggest that this review be read in conjunction with our overview. Two other reviews each included a small number of relevant RCTs. One contained a single relevant RCT relating to willingness to receive COVID-19 vaccination among black and minority ethnic people in the UK and explored the effectiveness of exposure to different forms of written information [ 40 ]. Another contained two relevant RCTs targeting influenza vaccination in older adults with or without additional markers of vulnerability or marginalisation [ 38 ]. While we would include these reviews in an update of this overview we do not consider that they are likely to substantively change our findings.

We also identified very limited evidence relating to financial incentives for vaccination, this was always part of a wider intervention, and we did not deal with it separately. Free vaccination was evaluated but is not included because our overview was undertaken to inform COVID-19 vaccination work in the UK where universal free vaccination was available.

We excluded several recent scoping reviews, which may be more up to date than systematic reviews. The most substantive is a Cochrane scoping review of interventions for COVID-19 vaccine hesitancy [ 41 ]. This was not limited to minoritised or vulnerable groups although some included studies focused on them. Of the 61 completed studies identified, none were systematic reviews and 45 were RCTs; these focused on online communication interventions posing hypothetical decision-making scenarios. Thirty-five ongoing studies (29 RCTs) mainly evaluated education or communication interventions. An update or subsequent systematic review may identify completed trials relevant to our overview.

Applicability

Identified evidence relates to specific groups and its transferability to other marginalised or vulnerable groups is not evidenced. A substantial amount of the evidence comes from people who are vulnerable due to older age. We did not identify any evidence relating to minoritised faith groups. Some evidence related to people from minority ethnic groups, who may also be members of minority faith groups, but interventions were not targeted on this basis and most evidence related to African or Hispanic Americans who are often members of majority faiths. We therefore did not find evidence for interventions such as women-only vaccination sessions targeted at Muslim or Orthodox Jewish communities.

Conclusions and further research

Considerable evidence supports the probable effectiveness of communication in person, by phone or in writing to increase vaccination; this includes evidence from a Cochrane review with an overall GRADE assessment of moderate certainty. Both high and low intensity interventions targeting providers showed increases in vaccination compared to standard care. However, our overview highlighted the comparatively very limited evidence assessing key strategies to increase access, such as additional clinics or targeted services for increasing access. Only the very high intensity intervention of home visits had higher confidence evidence showing effectiveness. None of the evidence related to COVID-19 vaccination where inequalities of outcome are exacerbated.

There was no evidence for interventions for religious minority communities; this may intersect with gaps in evidence for additional services. Systematic reviews looking specifically at interventions targeting these communities may be needed. We identified very limited evidence for online messaging, video messaging or mass media messaging. Following the COVID-19 pandemic these approaches are not yet well-represented in systematic reviews and a systematic review of primary evidence for these types of communication may also be warranted.

We identified many reviews of barriers and facilitators for vaccination, often relevant to vulnerable or minoritised groups. We also identified several reviews of vaccination programmes. Both sets of reviews would be of interest to those designing interventions to increase vaccination uptake. We did not identify overviews of reviews in either area and there may be merit in undertaking these. We identified multiple, often overlapping reviews in a rapidly growing research field. It may therefore be useful to establish a living systematic review of trials, and to encourage trialists to collaborate actively with the reviewers.

Data availability

All data were previously published; full search strategies and data coding used to support the synthesis are provided in supplementary material or in the main text. Additional data are available on request.

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Acknowledgements

The authors are grateful to Sophie Bishop for designing and implementing the search strategy.

This research was funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration Greater Manchester (ARC-GM); (funding award NIHR200174). The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.

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Gill Norman

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Gill Norman, Maartje Kletter & Jo Dumville

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GN screened studies, extracted data, assessed risk of bias and wrote the first draft of the protocol and the manuscript. MK screened studies, extracted data, assessed risk of bias, contributed substantively to drafting the protocol, and edited and commented substantively on the manuscript. JD had the idea for the review, contributed substantively to drafting the protocol and designing the synthesis, provided input and advice at each stage of the review, and edited and commented substantively on the manuscript.

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Correspondence to Gill Norman .

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This is a systematic review of previously published data and as such did not require ethical approval or participant consent.

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Supplementary Material 1 Appendix 1

: Full search strategies

Supplementary Material 2 Appendix 2

: Documentation of evidence for interventions

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Norman, G., Kletter, M. & Dumville, J. Interventions to increase vaccination in vulnerable groups: rapid overview of reviews. BMC Public Health 24 , 1479 (2024). https://doi.org/10.1186/s12889-024-18713-5

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Received : 14 July 2023

Accepted : 25 April 2024

Published : 03 June 2024

DOI : https://doi.org/10.1186/s12889-024-18713-5

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