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• What is a Literature Review? | Guide, Template, & Examples

What is a Literature Review? | Guide, Template, & Examples

Published on 22 February 2022 by Shona McCombes . Revised on 7 June 2022.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research.

There are five key steps to writing a literature review:

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

A good literature review doesn’t just summarise sources – it analyses, synthesises, and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

Why write a literature review, examples of literature reviews, step 1: search for relevant literature, step 2: evaluate and select sources, step 3: identify themes, debates and gaps, step 4: outline your literature review’s structure, step 5: write your literature review, frequently asked questions about literature reviews, introduction.

• Quick Run-through
• Step 1 & 2

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

• Demonstrate your familiarity with the topic and scholarly context
• Develop a theoretical framework and methodology for your research
• Position yourself in relation to other researchers and theorists
• Show how your dissertation addresses a gap or contributes to a debate

You might also have to write a literature review as a stand-alone assignment. In this case, the purpose is to evaluate the current state of research and demonstrate your knowledge of scholarly debates around a topic.

The content will look slightly different in each case, but the process of conducting a literature review follows the same steps. We’ve written a step-by-step guide that you can follow below.

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

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

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

Download Word doc Download Google doc

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

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

If you are writing a literature review as a stand-alone assignment, you will have to choose a focus and develop a central question to direct your search. Unlike a dissertation research question, this question has to be answerable without collecting original data. You should be able to answer it based only on a review of existing publications.

Make a list of keywords

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

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

Search for relevant sources

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

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

You can use boolean operators to help narrow down your search:

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

To identify the most important publications on your topic, take note of recurring citations. If the same authors, books or articles keep appearing in your reading, make sure to seek them out.

You probably won’t be able to read absolutely everything that has been written on the topic – you’ll have to evaluate which sources are most relevant to your questions.

For each publication, ask yourself:

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

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

You can find out how many times an article has been cited on Google Scholar – a high citation count means the article has been influential in the field, and should certainly be included in your literature review.

The scope of your review will depend on your topic and discipline: in the sciences you usually only review recent literature, but in the humanities you might take a long historical perspective (for example, to trace how a concept has changed in meaning over time).

Remember that you can use our template to summarise and evaluate sources you’re thinking about using!

Take notes and cite your sources

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

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

You can use our free APA Reference Generator for quick, correct, consistent citations.

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

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

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

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

There are various approaches to organising the body of a literature review. You should have a rough idea of your strategy before you start writing.

Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

If you are writing the literature review as part of your dissertation or thesis, reiterate your central problem or research question and give a brief summary of the scholarly context. You can emphasise the timeliness of the topic (“many recent studies have focused on the problem of x”) or highlight a gap in the literature (“while there has been much research on x, few researchers have taken y into consideration”).

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

As you write, make sure to follow these tips:

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

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

If the literature review is part of your dissertation or thesis, reiterate how your research addresses gaps and contributes new knowledge, or discuss how you have drawn on existing theories and methods to build a framework for your research. This can lead directly into your methodology section.

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

It is often written as part of a dissertation , thesis, research paper , or proposal .

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

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

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

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

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• 04 December 2020
• Correction 09 December 2020

How to write a superb literature review

Andy Tay is a freelance writer based in Singapore.

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Literature reviews are important resources for scientists. They provide historical context for a field while offering opinions on its future trajectory. Creating them can provide inspiration for one’s own research, as well as some practice in writing. But few scientists are trained in how to write a review — or in what constitutes an excellent one. Even picking the appropriate software to use can be an involved decision (see ‘Tools and techniques’). So Nature asked editors and working scientists with well-cited reviews for their tips.

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Correction 09 December 2020 : An earlier version of the tables in this article included some incorrect details about the programs Zotero, Endnote and Manubot. These have now been corrected.

Hsing, I.-M., Xu, Y. & Zhao, W. Electroanalysis 19 , 755–768 (2007).

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Ledesma, H. A. et al. Nature Nanotechnol. 14 , 645–657 (2019).

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Choi, Y. & Lee, S. Y. Nature Rev. Chem . https://doi.org/10.1038/s41570-020-00221-w (2020).

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

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

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

Get science-backed answers as you write with Paperpal's Research feature

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

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

Table of Contents

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

How to write a good literature review 

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

What is a literature review?

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

What is the purpose of literature review?

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

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

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

Find academic papers related to your research topic faster. Try Research on Paperpal  

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

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

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

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

Literature review example

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

Literature Review on Climate Change Impacts on Biodiversity:

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

a. Habitat Loss and Species Extinction:

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

b. Range Shifts and Phenological Changes:

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

c. Ocean Acidification and Coral Reefs:

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

d. Adaptive Strategies and Conservation Efforts:

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

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

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

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

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

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

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

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

Conducting a literature review

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

Choose a Topic and Define the Research Question:

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

Decide on the Scope of Your Review:

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

Select Databases for Searches:

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

Conduct Searches and Keep Track:

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

Review the Literature:

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

Organize and Write Your Literature Review:

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

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How to write a literature review faster with Paperpal?

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

Here’s how to use the Research feature:  

• Ask a question: Get started with a new document on paperpal.com. Click on the “Research” feature and type your question in plain English. Paperpal will scour over 250 million research articles, including conference papers and preprints, to provide you with accurate insights and citations. 
• Review and Save: Paperpal summarizes the information, while citing sources and listing relevant reads. You can quickly scan the results to identify relevant references and save these directly to your built-in citations library for later access. 
• Cite with Confidence: Paperpal makes it easy to incorporate relevant citations and references into your writing, ensuring your arguments are well-supported by credible sources. This translates to a polished, well-researched literature review. 

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

Frequently asked questions

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

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

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

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

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

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

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

References 

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

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How To Write An A-Grade Literature Review

3 straightforward steps (with examples) + free template.

By: Derek Jansen (MBA) | Expert Reviewed By: Dr. Eunice Rautenbach | October 2019

Quality research is about building onto the existing work of others , “standing on the shoulders of giants”, as Newton put it. The literature review chapter of your dissertation, thesis or research project is where you synthesise this prior work and lay the theoretical foundation for your own research.

Long story short, this chapter is a pretty big deal, which is why you want to make sure you get it right . In this post, I’ll show you exactly how to write a literature review in three straightforward steps, so you can conquer this vital chapter (the smart way).

Overview: The Literature Review Process

• Understanding the “ why “
• Finding the relevant literature
• Cataloguing and synthesising the information
• Outlining & writing up your literature review
• Example of a literature review

But first, the “why”…

Before we unpack how to write the literature review chapter, we’ve got to look at the why . To put it bluntly, if you don’t understand the function and purpose of the literature review process, there’s no way you can pull it off well. So, what exactly is the purpose of the literature review?

Well, there are (at least) four core functions:

• For you to gain an understanding (and demonstrate this understanding) of where the research is at currently, what the key arguments and disagreements are.
• For you to identify the gap(s) in the literature and then use this as justification for your own research topic.
• To help you build a conceptual framework for empirical testing (if applicable to your research topic).
• To inform your methodological choices and help you source tried and tested questionnaires (for interviews ) and measurement instruments (for surveys ).

Most students understand the first point but don’t give any thought to the rest. To get the most from the literature review process, you must keep all four points front of mind as you review the literature (more on this shortly), or you’ll land up with a wonky foundation.

Okay – with the why out the way, let’s move on to the how . As mentioned above, writing your literature review is a process, which I’ll break down into three steps:

• Finding the most suitable literature
• Understanding , distilling and organising the literature
• Planning and writing up your literature review chapter

Importantly, you must complete steps one and two before you start writing up your chapter. I know it’s very tempting, but don’t try to kill two birds with one stone and write as you read. You’ll invariably end up wasting huge amounts of time re-writing and re-shaping, or you’ll just land up with a disjointed, hard-to-digest mess . Instead, you need to read first and distil the information, then plan and execute the writing.

Step 1: Find the relevant literature

Naturally, the first step in the literature review journey is to hunt down the existing research that’s relevant to your topic. While you probably already have a decent base of this from your research proposal , you need to expand on this substantially in the dissertation or thesis itself.

Essentially, you need to be looking for any existing literature that potentially helps you answer your research question (or develop it, if that’s not yet pinned down). There are numerous ways to find relevant literature, but I’ll cover my top four tactics here. I’d suggest combining all four methods to ensure that nothing slips past you:

Method 1 – Google Scholar Scrubbing

Google’s academic search engine, Google Scholar , is a great starting point as it provides a good high-level view of the relevant journal articles for whatever keyword you throw at it. Most valuably, it tells you how many times each article has been cited, which gives you an idea of how credible (or at least, popular) it is. Some articles will be free to access, while others will require an account, which brings us to the next method.

Method 2 – University Database Scrounging

Generally, universities provide students with access to an online library, which provides access to many (but not all) of the major journals.

So, if you find an article using Google Scholar that requires paid access (which is quite likely), search for that article in your university’s database – if it’s listed there, you’ll have access. Note that, generally, the search engine capabilities of these databases are poor, so make sure you search for the exact article name, or you might not find it.

Method 3 – Journal Article Snowballing

At the end of every academic journal article, you’ll find a list of references. As with any academic writing, these references are the building blocks of the article, so if the article is relevant to your topic, there’s a good chance a portion of the referenced works will be too. Do a quick scan of the titles and see what seems relevant, then search for the relevant ones in your university’s database.

Method 4 – Dissertation Scavenging

Similar to Method 3 above, you can leverage other students’ dissertations. All you have to do is skim through literature review chapters of existing dissertations related to your topic and you’ll find a gold mine of potential literature. Usually, your university will provide you with access to previous students’ dissertations, but you can also find a much larger selection in the following databases:

• Open Access Theses & Dissertations
• Stanford SearchWorks

Keep in mind that dissertations and theses are not as academically sound as published, peer-reviewed journal articles (because they’re written by students, not professionals), so be sure to check the credibility of any sources you find using this method. You can do this by assessing the citation count of any given article in Google Scholar. If you need help with assessing the credibility of any article, or with finding relevant research in general, you can chat with one of our Research Specialists .

Alright – with a good base of literature firmly under your belt, it’s time to move onto the next step.

Need a helping hand?

Step 2: Log, catalogue and synthesise

Once you’ve built a little treasure trove of articles, it’s time to get reading and start digesting the information – what does it all mean?

While I present steps one and two (hunting and digesting) as sequential, in reality, it’s more of a back-and-forth tango – you’ll read a little , then have an idea, spot a new citation, or a new potential variable, and then go back to searching for articles. This is perfectly natural – through the reading process, your thoughts will develop , new avenues might crop up, and directional adjustments might arise. This is, after all, one of the main purposes of the literature review process (i.e. to familiarise yourself with the current state of research in your field).

As you’re working through your treasure chest, it’s essential that you simultaneously start organising the information. There are three aspects to this:

• Logging reference information
• Building an organised catalogue
• Distilling and synthesising the information

I’ll discuss each of these below:

2.1 – Log the reference information

As you read each article, you should add it to your reference management software. I usually recommend Mendeley for this purpose (see the Mendeley 101 video below), but you can use whichever software you’re comfortable with. Most importantly, make sure you load EVERY article you read into your reference manager, even if it doesn’t seem very relevant at the time.

2.2 – Build an organised catalogue

In the beginning, you might feel confident that you can remember who said what, where, and what their main arguments were. Trust me, you won’t. If you do a thorough review of the relevant literature (as you must!), you’re going to read many, many articles, and it’s simply impossible to remember who said what, when, and in what context . Also, without the bird’s eye view that a catalogue provides, you’ll miss connections between various articles, and have no view of how the research developed over time. Simply put, it’s essential to build your own catalogue of the literature.

I would suggest using Excel to build your catalogue, as it allows you to run filters, colour code and sort – all very useful when your list grows large (which it will). How you lay your spreadsheet out is up to you, but I’d suggest you have the following columns (at minimum):

• Author, date, title – Start with three columns containing this core information. This will make it easy for you to search for titles with certain words, order research by date, or group by author.
• Categories or keywords – You can either create multiple columns, one for each category/theme and then tick the relevant categories, or you can have one column with keywords.
• Key arguments/points – Use this column to succinctly convey the essence of the article, the key arguments and implications thereof for your research.
• Context – Note the socioeconomic context in which the research was undertaken. For example, US-based, respondents aged 25-35, lower- income, etc. This will be useful for making an argument about gaps in the research.
• Methodology – Note which methodology was used and why. Also, note any issues you feel arise due to the methodology. Again, you can use this to make an argument about gaps in the research.
• Quotations – Note down any quoteworthy lines you feel might be useful later.
• Notes – Make notes about anything not already covered. For example, linkages to or disagreements with other theories, questions raised but unanswered, shortcomings or limitations, and so forth.

If you’d like, you can try out our free catalog template here (see screenshot below).

2.3 – Digest and synthesise

Most importantly, as you work through the literature and build your catalogue, you need to synthesise all the information in your own mind – how does it all fit together? Look for links between the various articles and try to develop a bigger picture view of the state of the research. Some important questions to ask yourself are:

• What answers does the existing research provide to my own research questions ?
• Which points do the researchers agree (and disagree) on?
• How has the research developed over time?
• Where do the gaps in the current research lie?

To help you develop a big-picture view and synthesise all the information, you might find mind mapping software such as Freemind useful. Alternatively, if you’re a fan of physical note-taking, investing in a large whiteboard might work for you.

Step 3: Outline and write it up!

Once you’re satisfied that you have digested and distilled all the relevant literature in your mind, it’s time to put pen to paper (or rather, fingers to keyboard). There are two steps here – outlining and writing:

3.1 – Draw up your outline

Having spent so much time reading, it might be tempting to just start writing up without a clear structure in mind. However, it’s critically important to decide on your structure and develop a detailed outline before you write anything. Your literature review chapter needs to present a clear, logical and an easy to follow narrative – and that requires some planning. Don’t try to wing it!

Naturally, you won’t always follow the plan to the letter, but without a detailed outline, you’re more than likely going to end up with a disjointed pile of waffle , and then you’re going to spend a far greater amount of time re-writing, hacking and patching. The adage, “measure twice, cut once” is very suitable here.

In terms of structure, the first decision you’ll have to make is whether you’ll lay out your review thematically (into themes) or chronologically (by date/period). The right choice depends on your topic, research objectives and research questions, which we discuss in this article .

Once that’s decided, you need to draw up an outline of your entire chapter in bullet point format. Try to get as detailed as possible, so that you know exactly what you’ll cover where, how each section will connect to the next, and how your entire argument will develop throughout the chapter. Also, at this stage, it’s a good idea to allocate rough word count limits for each section, so that you can identify word count problems before you’ve spent weeks or months writing!

PS – check out our free literature review chapter template…

3.2 – Get writing

With a detailed outline at your side, it’s time to start writing up (finally!). At this stage, it’s common to feel a bit of writer’s block and find yourself procrastinating under the pressure of finally having to put something on paper. To help with this, remember that the objective of the first draft is not perfection – it’s simply to get your thoughts out of your head and onto paper, after which you can refine them. The structure might change a little, the word count allocations might shift and shuffle, and you might add or remove a section – that’s all okay. Don’t worry about all this on your first draft – just get your thoughts down on paper.

Once you’ve got a full first draft (however rough it may be), step away from it for a day or two (longer if you can) and then come back at it with fresh eyes. Pay particular attention to the flow and narrative – does it fall fit together and flow from one section to another smoothly? Now’s the time to try to improve the linkage from each section to the next, tighten up the writing to be more concise, trim down word count and sand it down into a more digestible read.

Once you’ve done that, give your writing to a friend or colleague who is not a subject matter expert and ask them if they understand the overall discussion. The best way to assess this is to ask them to explain the chapter back to you. This technique will give you a strong indication of which points were clearly communicated and which weren’t. If you’re working with Grad Coach, this is a good time to have your Research Specialist review your chapter.

Finally, tighten it up and send it off to your supervisor for comment. Some might argue that you should be sending your work to your supervisor sooner than this (indeed your university might formally require this), but in my experience, supervisors are extremely short on time (and often patience), so, the more refined your chapter is, the less time they’ll waste on addressing basic issues (which you know about already) and the more time they’ll spend on valuable feedback that will increase your mark-earning potential.

Literature Review Example

In the video below, we unpack an actual literature review so that you can see how all the core components come together in reality.

Let’s Recap

In this post, we’ve covered how to research and write up a high-quality literature review chapter. Let’s do a quick recap of the key takeaways:

• It is essential to understand the WHY of the literature review before you read or write anything. Make sure you understand the 4 core functions of the process.
• The first step is to hunt down the relevant literature . You can do this using Google Scholar, your university database, the snowballing technique and by reviewing other dissertations and theses.
• Next, you need to log all the articles in your reference manager , build your own catalogue of literature and synthesise all the research.
• Following that, you need to develop a detailed outline of your entire chapter – the more detail the better. Don’t start writing without a clear outline (on paper, not in your head!)
• Write up your first draft in rough form – don’t aim for perfection. Remember, done beats perfect.
• Refine your second draft and get a layman’s perspective on it . Then tighten it up and submit it to your supervisor.

Psst… there’s more!

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

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38 Comments

Thank you very much. This page is an eye opener and easy to comprehend.

This is awesome!

I wish I come across GradCoach earlier enough.

But all the same I’ll make use of this opportunity to the fullest.

Thank you for this good job.

Keep it up!

You’re welcome, Yinka. Thank you for the kind words. All the best writing your literature review.

Thank you for a very useful literature review session. Although I am doing most of the steps…it being my first masters an Mphil is a self study and one not sure you are on the right track. I have an amazing supervisor but one also knows they are super busy. So not wanting to bother on the minutae. Thank you.

You’re most welcome, Renee. Good luck with your literature review 🙂

This has been really helpful. Will make full use of it. 🙂

Thank you Gradcoach.

Really agreed. Admirable effort

thank you for this beautiful well explained recap.

Thank you so much for your guide of video and other instructions for the dissertation writing.

It is instrumental. It encouraged me to write a dissertation now.

Thank you the video was great – from someone that knows nothing thankyou

an amazing and very constructive way of presetting a topic, very useful, thanks for the effort,

It is timely

It is very good video of guidance for writing a research proposal and a dissertation. Since I have been watching and reading instructions, I have started my research proposal to write. I appreciate to Mr Jansen hugely.

I learn a lot from your videos. Very comprehensive and detailed.

Thank you for sharing your knowledge. As a research student, you learn better with your learning tips in research

I was really stuck in reading and gathering information but after watching these things are cleared thanks, it is so helpful.

Really helpful, Thank you for the effort in showing such information

This is super helpful thank you very much.

Thank you for this whole literature writing review.You have simplified the process.

I’m so glad I found GradCoach. Excellent information, Clear explanation, and Easy to follow, Many thanks Derek!

You’re welcome, Maithe. Good luck writing your literature review 🙂

Thank you Coach, you have greatly enriched and improved my knowledge

Great piece, so enriching and it is going to help me a great lot in my project and thesis, thanks so much

This is THE BEST site for ANYONE doing a masters or doctorate! Thank you for the sound advice and templates. You rock!

Thanks, Stephanie 🙂

This is mind blowing, the detailed explanation and simplicity is perfect.

I am doing two papers on my final year thesis, and I must stay I feel very confident to face both headlong after reading this article.

thank you so much.

if anyone is to get a paper done on time and in the best way possible, GRADCOACH is certainly the go to area!

This is very good video which is well explained with detailed explanation

Thank you excellent piece of work and great mentoring

Thanks, it was useful

Thank you very much. the video and the information were very helpful.

Good morning scholar. I’m delighted coming to know you even before the commencement of my dissertation which hopefully is expected in not more than six months from now. I would love to engage my study under your guidance from the beginning to the end. I love to know how to do good job

Thank you so much Derek for such useful information on writing up a good literature review. I am at a stage where I need to start writing my one. My proposal was accepted late last year but I honestly did not know where to start

Like the name of your YouTube implies you are GRAD (great,resource person, about dissertation). In short you are smart enough in coaching research work.

This is a very well thought out webpage. Very informative and a great read.

Very timely.

I appreciate.

Very comprehensive and eye opener for me as beginner in postgraduate study. Well explained and easy to understand. Appreciate and good reference in guiding me in my research journey. Thank you

Thank you. I requested to download the free literature review template, however, your website wouldn’t allow me to complete the request or complete a download. May I request that you email me the free template? Thank you.

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.

Handbook of eHealth Evaluation: An Evidence-based Approach [Internet].

Chapter 9 methods for literature reviews.

Guy Paré and Spyros Kitsiou .

9.1. Introduction

Literature reviews play a critical role in scholarship because science remains, first and foremost, a cumulative endeavour ( vom Brocke et al., 2009 ). As in any academic discipline, rigorous knowledge syntheses are becoming indispensable in keeping up with an exponentially growing eHealth literature, assisting practitioners, academics, and graduate students in finding, evaluating, and synthesizing the contents of many empirical and conceptual papers. Among other methods, literature reviews are essential for: (a) identifying what has been written on a subject or topic; (b) determining the extent to which a specific research area reveals any interpretable trends or patterns; (c) aggregating empirical findings related to a narrow research question to support evidence-based practice; (d) generating new frameworks and theories; and (e) identifying topics or questions requiring more investigation ( Paré, Trudel, Jaana, & Kitsiou, 2015 ).

Literature reviews can take two major forms. The most prevalent one is the “literature review” or “background” section within a journal paper or a chapter in a graduate thesis. This section synthesizes the extant literature and usually identifies the gaps in knowledge that the empirical study addresses ( Sylvester, Tate, & Johnstone, 2013 ). It may also provide a theoretical foundation for the proposed study, substantiate the presence of the research problem, justify the research as one that contributes something new to the cumulated knowledge, or validate the methods and approaches for the proposed study ( Hart, 1998 ; Levy & Ellis, 2006 ).

The second form of literature review, which is the focus of this chapter, constitutes an original and valuable work of research in and of itself ( Paré et al., 2015 ). Rather than providing a base for a researcher’s own work, it creates a solid starting point for all members of the community interested in a particular area or topic ( Mulrow, 1987 ). The so-called “review article” is a journal-length paper which has an overarching purpose to synthesize the literature in a field, without collecting or analyzing any primary data ( Green, Johnson, & Adams, 2006 ).

When appropriately conducted, review articles represent powerful information sources for practitioners looking for state-of-the art evidence to guide their decision-making and work practices ( Paré et al., 2015 ). Further, high-quality reviews become frequently cited pieces of work which researchers seek out as a first clear outline of the literature when undertaking empirical studies ( Cooper, 1988 ; Rowe, 2014 ). Scholars who track and gauge the impact of articles have found that review papers are cited and downloaded more often than any other type of published article ( Cronin, Ryan, & Coughlan, 2008 ; Montori, Wilczynski, Morgan, Haynes, & Hedges, 2003 ; Patsopoulos, Analatos, & Ioannidis, 2005 ). The reason for their popularity may be the fact that reading the review enables one to have an overview, if not a detailed knowledge of the area in question, as well as references to the most useful primary sources ( Cronin et al., 2008 ). Although they are not easy to conduct, the commitment to complete a review article provides a tremendous service to one’s academic community ( Paré et al., 2015 ; Petticrew & Roberts, 2006 ). Most, if not all, peer-reviewed journals in the fields of medical informatics publish review articles of some type.

The main objectives of this chapter are fourfold: (a) to provide an overview of the major steps and activities involved in conducting a stand-alone literature review; (b) to describe and contrast the different types of review articles that can contribute to the eHealth knowledge base; (c) to illustrate each review type with one or two examples from the eHealth literature; and (d) to provide a series of recommendations for prospective authors of review articles in this domain.

9.2. Overview of the Literature Review Process and Steps

As explained in Templier and Paré (2015) , there are six generic steps involved in conducting a review article:

• formulating the research question(s) and objective(s),
• searching the extant literature,
• screening for inclusion,
• assessing the quality of primary studies,
• extracting data, and
• analyzing data.

Although these steps are presented here in sequential order, one must keep in mind that the review process can be iterative and that many activities can be initiated during the planning stage and later refined during subsequent phases ( Finfgeld-Connett & Johnson, 2013 ; Kitchenham & Charters, 2007 ).

Formulating the research question(s) and objective(s): As a first step, members of the review team must appropriately justify the need for the review itself ( Petticrew & Roberts, 2006 ), identify the review’s main objective(s) ( Okoli & Schabram, 2010 ), and define the concepts or variables at the heart of their synthesis ( Cooper & Hedges, 2009 ; Webster & Watson, 2002 ). Importantly, they also need to articulate the research question(s) they propose to investigate ( Kitchenham & Charters, 2007 ). In this regard, we concur with Jesson, Matheson, and Lacey (2011) that clearly articulated research questions are key ingredients that guide the entire review methodology; they underscore the type of information that is needed, inform the search for and selection of relevant literature, and guide or orient the subsequent analysis. Searching the extant literature: The next step consists of searching the literature and making decisions about the suitability of material to be considered in the review ( Cooper, 1988 ). There exist three main coverage strategies. First, exhaustive coverage means an effort is made to be as comprehensive as possible in order to ensure that all relevant studies, published and unpublished, are included in the review and, thus, conclusions are based on this all-inclusive knowledge base. The second type of coverage consists of presenting materials that are representative of most other works in a given field or area. Often authors who adopt this strategy will search for relevant articles in a small number of top-tier journals in a field ( Paré et al., 2015 ). In the third strategy, the review team concentrates on prior works that have been central or pivotal to a particular topic. This may include empirical studies or conceptual papers that initiated a line of investigation, changed how problems or questions were framed, introduced new methods or concepts, or engendered important debate ( Cooper, 1988 ). Screening for inclusion: The following step consists of evaluating the applicability of the material identified in the preceding step ( Levy & Ellis, 2006 ; vom Brocke et al., 2009 ). Once a group of potential studies has been identified, members of the review team must screen them to determine their relevance ( Petticrew & Roberts, 2006 ). A set of predetermined rules provides a basis for including or excluding certain studies. This exercise requires a significant investment on the part of researchers, who must ensure enhanced objectivity and avoid biases or mistakes. As discussed later in this chapter, for certain types of reviews there must be at least two independent reviewers involved in the screening process and a procedure to resolve disagreements must also be in place ( Liberati et al., 2009 ; Shea et al., 2009 ). Assessing the quality of primary studies: In addition to screening material for inclusion, members of the review team may need to assess the scientific quality of the selected studies, that is, appraise the rigour of the research design and methods. Such formal assessment, which is usually conducted independently by at least two coders, helps members of the review team refine which studies to include in the final sample, determine whether or not the differences in quality may affect their conclusions, or guide how they analyze the data and interpret the findings ( Petticrew & Roberts, 2006 ). Ascribing quality scores to each primary study or considering through domain-based evaluations which study components have or have not been designed and executed appropriately makes it possible to reflect on the extent to which the selected study addresses possible biases and maximizes validity ( Shea et al., 2009 ). Extracting data: The following step involves gathering or extracting applicable information from each primary study included in the sample and deciding what is relevant to the problem of interest ( Cooper & Hedges, 2009 ). Indeed, the type of data that should be recorded mainly depends on the initial research questions ( Okoli & Schabram, 2010 ). However, important information may also be gathered about how, when, where and by whom the primary study was conducted, the research design and methods, or qualitative/quantitative results ( Cooper & Hedges, 2009 ). Analyzing and synthesizing data : As a final step, members of the review team must collate, summarize, aggregate, organize, and compare the evidence extracted from the included studies. The extracted data must be presented in a meaningful way that suggests a new contribution to the extant literature ( Jesson et al., 2011 ). Webster and Watson (2002) warn researchers that literature reviews should be much more than lists of papers and should provide a coherent lens to make sense of extant knowledge on a given topic. There exist several methods and techniques for synthesizing quantitative (e.g., frequency analysis, meta-analysis) and qualitative (e.g., grounded theory, narrative analysis, meta-ethnography) evidence ( Dixon-Woods, Agarwal, Jones, Young, & Sutton, 2005 ; Thomas & Harden, 2008 ).

9.3. Types of Review Articles and Brief Illustrations

EHealth researchers have at their disposal a number of approaches and methods for making sense out of existing literature, all with the purpose of casting current research findings into historical contexts or explaining contradictions that might exist among a set of primary research studies conducted on a particular topic. Our classification scheme is largely inspired from Paré and colleagues’ (2015) typology. Below we present and illustrate those review types that we feel are central to the growth and development of the eHealth domain.

9.3.1. Narrative Reviews

The narrative review is the “traditional” way of reviewing the extant literature and is skewed towards a qualitative interpretation of prior knowledge ( Sylvester et al., 2013 ). Put simply, a narrative review attempts to summarize or synthesize what has been written on a particular topic but does not seek generalization or cumulative knowledge from what is reviewed ( Davies, 2000 ; Green et al., 2006 ). Instead, the review team often undertakes the task of accumulating and synthesizing the literature to demonstrate the value of a particular point of view ( Baumeister & Leary, 1997 ). As such, reviewers may selectively ignore or limit the attention paid to certain studies in order to make a point. In this rather unsystematic approach, the selection of information from primary articles is subjective, lacks explicit criteria for inclusion and can lead to biased interpretations or inferences ( Green et al., 2006 ). There are several narrative reviews in the particular eHealth domain, as in all fields, which follow such an unstructured approach ( Silva et al., 2015 ; Paul et al., 2015 ).

Despite these criticisms, this type of review can be very useful in gathering together a volume of literature in a specific subject area and synthesizing it. As mentioned above, its primary purpose is to provide the reader with a comprehensive background for understanding current knowledge and highlighting the significance of new research ( Cronin et al., 2008 ). Faculty like to use narrative reviews in the classroom because they are often more up to date than textbooks, provide a single source for students to reference, and expose students to peer-reviewed literature ( Green et al., 2006 ). For researchers, narrative reviews can inspire research ideas by identifying gaps or inconsistencies in a body of knowledge, thus helping researchers to determine research questions or formulate hypotheses. Importantly, narrative reviews can also be used as educational articles to bring practitioners up to date with certain topics of issues ( Green et al., 2006 ).

Recently, there have been several efforts to introduce more rigour in narrative reviews that will elucidate common pitfalls and bring changes into their publication standards. Information systems researchers, among others, have contributed to advancing knowledge on how to structure a “traditional” review. For instance, Levy and Ellis (2006) proposed a generic framework for conducting such reviews. Their model follows the systematic data processing approach comprised of three steps, namely: (a) literature search and screening; (b) data extraction and analysis; and (c) writing the literature review. They provide detailed and very helpful instructions on how to conduct each step of the review process. As another methodological contribution, vom Brocke et al. (2009) offered a series of guidelines for conducting literature reviews, with a particular focus on how to search and extract the relevant body of knowledge. Last, Bandara, Miskon, and Fielt (2011) proposed a structured, predefined and tool-supported method to identify primary studies within a feasible scope, extract relevant content from identified articles, synthesize and analyze the findings, and effectively write and present the results of the literature review. We highly recommend that prospective authors of narrative reviews consult these useful sources before embarking on their work.

Darlow and Wen (2015) provide a good example of a highly structured narrative review in the eHealth field. These authors synthesized published articles that describe the development process of mobile health ( m-health ) interventions for patients’ cancer care self-management. As in most narrative reviews, the scope of the research questions being investigated is broad: (a) how development of these systems are carried out; (b) which methods are used to investigate these systems; and (c) what conclusions can be drawn as a result of the development of these systems. To provide clear answers to these questions, a literature search was conducted on six electronic databases and Google Scholar . The search was performed using several terms and free text words, combining them in an appropriate manner. Four inclusion and three exclusion criteria were utilized during the screening process. Both authors independently reviewed each of the identified articles to determine eligibility and extract study information. A flow diagram shows the number of studies identified, screened, and included or excluded at each stage of study selection. In terms of contributions, this review provides a series of practical recommendations for m-health intervention development.

9.3.2. Descriptive or Mapping Reviews

The primary goal of a descriptive review is to determine the extent to which a body of knowledge in a particular research topic reveals any interpretable pattern or trend with respect to pre-existing propositions, theories, methodologies or findings ( King & He, 2005 ; Paré et al., 2015 ). In contrast with narrative reviews, descriptive reviews follow a systematic and transparent procedure, including searching, screening and classifying studies ( Petersen, Vakkalanka, & Kuzniarz, 2015 ). Indeed, structured search methods are used to form a representative sample of a larger group of published works ( Paré et al., 2015 ). Further, authors of descriptive reviews extract from each study certain characteristics of interest, such as publication year, research methods, data collection techniques, and direction or strength of research outcomes (e.g., positive, negative, or non-significant) in the form of frequency analysis to produce quantitative results ( Sylvester et al., 2013 ). In essence, each study included in a descriptive review is treated as the unit of analysis and the published literature as a whole provides a database from which the authors attempt to identify any interpretable trends or draw overall conclusions about the merits of existing conceptualizations, propositions, methods or findings ( Paré et al., 2015 ). In doing so, a descriptive review may claim that its findings represent the state of the art in a particular domain ( King & He, 2005 ).

In the fields of health sciences and medical informatics, reviews that focus on examining the range, nature and evolution of a topic area are described by Anderson, Allen, Peckham, and Goodwin (2008) as mapping reviews . Like descriptive reviews, the research questions are generic and usually relate to publication patterns and trends. There is no preconceived plan to systematically review all of the literature although this can be done. Instead, researchers often present studies that are representative of most works published in a particular area and they consider a specific time frame to be mapped.

An example of this approach in the eHealth domain is offered by DeShazo, Lavallie, and Wolf (2009). The purpose of this descriptive or mapping review was to characterize publication trends in the medical informatics literature over a 20-year period (1987 to 2006). To achieve this ambitious objective, the authors performed a bibliometric analysis of medical informatics citations indexed in medline using publication trends, journal frequencies, impact factors, Medical Subject Headings (MeSH) term frequencies, and characteristics of citations. Findings revealed that there were over 77,000 medical informatics articles published during the covered period in numerous journals and that the average annual growth rate was 12%. The MeSH term analysis also suggested a strong interdisciplinary trend. Finally, average impact scores increased over time with two notable growth periods. Overall, patterns in research outputs that seem to characterize the historic trends and current components of the field of medical informatics suggest it may be a maturing discipline (DeShazo et al., 2009).

9.3.3. Scoping Reviews

Scoping reviews attempt to provide an initial indication of the potential size and nature of the extant literature on an emergent topic (Arksey & O’Malley, 2005; Daudt, van Mossel, & Scott, 2013 ; Levac, Colquhoun, & O’Brien, 2010). A scoping review may be conducted to examine the extent, range and nature of research activities in a particular area, determine the value of undertaking a full systematic review (discussed next), or identify research gaps in the extant literature ( Paré et al., 2015 ). In line with their main objective, scoping reviews usually conclude with the presentation of a detailed research agenda for future works along with potential implications for both practice and research.

Unlike narrative and descriptive reviews, the whole point of scoping the field is to be as comprehensive as possible, including grey literature (Arksey & O’Malley, 2005). Inclusion and exclusion criteria must be established to help researchers eliminate studies that are not aligned with the research questions. It is also recommended that at least two independent coders review abstracts yielded from the search strategy and then the full articles for study selection ( Daudt et al., 2013 ). The synthesized evidence from content or thematic analysis is relatively easy to present in tabular form (Arksey & O’Malley, 2005; Thomas & Harden, 2008 ).

One of the most highly cited scoping reviews in the eHealth domain was published by Archer, Fevrier-Thomas, Lokker, McKibbon, and Straus (2011) . These authors reviewed the existing literature on personal health record ( phr ) systems including design, functionality, implementation, applications, outcomes, and benefits. Seven databases were searched from 1985 to March 2010. Several search terms relating to phr s were used during this process. Two authors independently screened titles and abstracts to determine inclusion status. A second screen of full-text articles, again by two independent members of the research team, ensured that the studies described phr s. All in all, 130 articles met the criteria and their data were extracted manually into a database. The authors concluded that although there is a large amount of survey, observational, cohort/panel, and anecdotal evidence of phr benefits and satisfaction for patients, more research is needed to evaluate the results of phr implementations. Their in-depth analysis of the literature signalled that there is little solid evidence from randomized controlled trials or other studies through the use of phr s. Hence, they suggested that more research is needed that addresses the current lack of understanding of optimal functionality and usability of these systems, and how they can play a beneficial role in supporting patient self-management ( Archer et al., 2011 ).

9.3.4. Forms of Aggregative Reviews

Healthcare providers, practitioners, and policy-makers are nowadays overwhelmed with large volumes of information, including research-based evidence from numerous clinical trials and evaluation studies, assessing the effectiveness of health information technologies and interventions ( Ammenwerth & de Keizer, 2004 ; Deshazo et al., 2009 ). It is unrealistic to expect that all these disparate actors will have the time, skills, and necessary resources to identify the available evidence in the area of their expertise and consider it when making decisions. Systematic reviews that involve the rigorous application of scientific strategies aimed at limiting subjectivity and bias (i.e., systematic and random errors) can respond to this challenge.

Systematic reviews attempt to aggregate, appraise, and synthesize in a single source all empirical evidence that meet a set of previously specified eligibility criteria in order to answer a clearly formulated and often narrow research question on a particular topic of interest to support evidence-based practice ( Liberati et al., 2009 ). They adhere closely to explicit scientific principles ( Liberati et al., 2009 ) and rigorous methodological guidelines (Higgins & Green, 2008) aimed at reducing random and systematic errors that can lead to deviations from the truth in results or inferences. The use of explicit methods allows systematic reviews to aggregate a large body of research evidence, assess whether effects or relationships are in the same direction and of the same general magnitude, explain possible inconsistencies between study results, and determine the strength of the overall evidence for every outcome of interest based on the quality of included studies and the general consistency among them ( Cook, Mulrow, & Haynes, 1997 ). The main procedures of a systematic review involve:

• Formulating a review question and developing a search strategy based on explicit inclusion criteria for the identification of eligible studies (usually described in the context of a detailed review protocol).
• Searching for eligible studies using multiple databases and information sources, including grey literature sources, without any language restrictions.
• Selecting studies, extracting data, and assessing risk of bias in a duplicate manner using two independent reviewers to avoid random or systematic errors in the process.
• Analyzing data using quantitative or qualitative methods.
• Presenting results in summary of findings tables.
• Interpreting results and drawing conclusions.

Many systematic reviews, but not all, use statistical methods to combine the results of independent studies into a single quantitative estimate or summary effect size. Known as meta-analyses , these reviews use specific data extraction and statistical techniques (e.g., network, frequentist, or Bayesian meta-analyses) to calculate from each study by outcome of interest an effect size along with a confidence interval that reflects the degree of uncertainty behind the point estimate of effect ( Borenstein, Hedges, Higgins, & Rothstein, 2009 ; Deeks, Higgins, & Altman, 2008 ). Subsequently, they use fixed or random-effects analysis models to combine the results of the included studies, assess statistical heterogeneity, and calculate a weighted average of the effect estimates from the different studies, taking into account their sample sizes. The summary effect size is a value that reflects the average magnitude of the intervention effect for a particular outcome of interest or, more generally, the strength of a relationship between two variables across all studies included in the systematic review. By statistically combining data from multiple studies, meta-analyses can create more precise and reliable estimates of intervention effects than those derived from individual studies alone, when these are examined independently as discrete sources of information.

The review by Gurol-Urganci, de Jongh, Vodopivec-Jamsek, Atun, and Car (2013) on the effects of mobile phone messaging reminders for attendance at healthcare appointments is an illustrative example of a high-quality systematic review with meta-analysis. Missed appointments are a major cause of inefficiency in healthcare delivery with substantial monetary costs to health systems. These authors sought to assess whether mobile phone-based appointment reminders delivered through Short Message Service ( sms ) or Multimedia Messaging Service ( mms ) are effective in improving rates of patient attendance and reducing overall costs. To this end, they conducted a comprehensive search on multiple databases using highly sensitive search strategies without language or publication-type restrictions to identify all rct s that are eligible for inclusion. In order to minimize the risk of omitting eligible studies not captured by the original search, they supplemented all electronic searches with manual screening of trial registers and references contained in the included studies. Study selection, data extraction, and risk of bias assessments were performed inde­­pen­dently by two coders using standardized methods to ensure consistency and to eliminate potential errors. Findings from eight rct s involving 6,615 participants were pooled into meta-analyses to calculate the magnitude of effects that mobile text message reminders have on the rate of attendance at healthcare appointments compared to no reminders and phone call reminders.

Meta-analyses are regarded as powerful tools for deriving meaningful conclusions. However, there are situations in which it is neither reasonable nor appropriate to pool studies together using meta-analytic methods simply because there is extensive clinical heterogeneity between the included studies or variation in measurement tools, comparisons, or outcomes of interest. In these cases, systematic reviews can use qualitative synthesis methods such as vote counting, content analysis, classification schemes and tabulations, as an alternative approach to narratively synthesize the results of the independent studies included in the review. This form of review is known as qualitative systematic review.

A rigorous example of one such review in the eHealth domain is presented by Mickan, Atherton, Roberts, Heneghan, and Tilson (2014) on the use of handheld computers by healthcare professionals and their impact on access to information and clinical decision-making. In line with the methodological guide­lines for systematic reviews, these authors: (a) developed and registered with prospero ( www.crd.york.ac.uk/ prospero / ) an a priori review protocol; (b) conducted comprehensive searches for eligible studies using multiple databases and other supplementary strategies (e.g., forward searches); and (c) subsequently carried out study selection, data extraction, and risk of bias assessments in a duplicate manner to eliminate potential errors in the review process. Heterogeneity between the included studies in terms of reported outcomes and measures precluded the use of meta-analytic methods. To this end, the authors resorted to using narrative analysis and synthesis to describe the effectiveness of handheld computers on accessing information for clinical knowledge, adherence to safety and clinical quality guidelines, and diagnostic decision-making.

In recent years, the number of systematic reviews in the field of health informatics has increased considerably. Systematic reviews with discordant findings can cause great confusion and make it difficult for decision-makers to interpret the review-level evidence ( Moher, 2013 ). Therefore, there is a growing need for appraisal and synthesis of prior systematic reviews to ensure that decision-making is constantly informed by the best available accumulated evidence. Umbrella reviews , also known as overviews of systematic reviews, are tertiary types of evidence synthesis that aim to accomplish this; that is, they aim to compare and contrast findings from multiple systematic reviews and meta-analyses ( Becker & Oxman, 2008 ). Umbrella reviews generally adhere to the same principles and rigorous methodological guidelines used in systematic reviews. However, the unit of analysis in umbrella reviews is the systematic review rather than the primary study ( Becker & Oxman, 2008 ). Unlike systematic reviews that have a narrow focus of inquiry, umbrella reviews focus on broader research topics for which there are several potential interventions ( Smith, Devane, Begley, & Clarke, 2011 ). A recent umbrella review on the effects of home telemonitoring interventions for patients with heart failure critically appraised, compared, and synthesized evidence from 15 systematic reviews to investigate which types of home telemonitoring technologies and forms of interventions are more effective in reducing mortality and hospital admissions ( Kitsiou, Paré, & Jaana, 2015 ).

9.3.5. Realist Reviews

Realist reviews are theory-driven interpretative reviews developed to inform, enhance, or supplement conventional systematic reviews by making sense of heterogeneous evidence about complex interventions applied in diverse contexts in a way that informs policy decision-making ( Greenhalgh, Wong, Westhorp, & Pawson, 2011 ). They originated from criticisms of positivist systematic reviews which centre on their “simplistic” underlying assumptions ( Oates, 2011 ). As explained above, systematic reviews seek to identify causation. Such logic is appropriate for fields like medicine and education where findings of randomized controlled trials can be aggregated to see whether a new treatment or intervention does improve outcomes. However, many argue that it is not possible to establish such direct causal links between interventions and outcomes in fields such as social policy, management, and information systems where for any intervention there is unlikely to be a regular or consistent outcome ( Oates, 2011 ; Pawson, 2006 ; Rousseau, Manning, & Denyer, 2008 ).

To circumvent these limitations, Pawson, Greenhalgh, Harvey, and Walshe (2005) have proposed a new approach for synthesizing knowledge that seeks to unpack the mechanism of how “complex interventions” work in particular contexts. The basic research question — what works? — which is usually associated with systematic reviews changes to: what is it about this intervention that works, for whom, in what circumstances, in what respects and why? Realist reviews have no particular preference for either quantitative or qualitative evidence. As a theory-building approach, a realist review usually starts by articulating likely underlying mechanisms and then scrutinizes available evidence to find out whether and where these mechanisms are applicable ( Shepperd et al., 2009 ). Primary studies found in the extant literature are viewed as case studies which can test and modify the initial theories ( Rousseau et al., 2008 ).

The main objective pursued in the realist review conducted by Otte-Trojel, de Bont, Rundall, and van de Klundert (2014) was to examine how patient portals contribute to health service delivery and patient outcomes. The specific goals were to investigate how outcomes are produced and, most importantly, how variations in outcomes can be explained. The research team started with an exploratory review of background documents and research studies to identify ways in which patient portals may contribute to health service delivery and patient outcomes. The authors identified six main ways which represent “educated guesses” to be tested against the data in the evaluation studies. These studies were identified through a formal and systematic search in four databases between 2003 and 2013. Two members of the research team selected the articles using a pre-established list of inclusion and exclusion criteria and following a two-step procedure. The authors then extracted data from the selected articles and created several tables, one for each outcome category. They organized information to bring forward those mechanisms where patient portals contribute to outcomes and the variation in outcomes across different contexts.

9.3.6. Critical Reviews

Lastly, critical reviews aim to provide a critical evaluation and interpretive analysis of existing literature on a particular topic of interest to reveal strengths, weaknesses, contradictions, controversies, inconsistencies, and/or other important issues with respect to theories, hypotheses, research methods or results ( Baumeister & Leary, 1997 ; Kirkevold, 1997 ). Unlike other review types, critical reviews attempt to take a reflective account of the research that has been done in a particular area of interest, and assess its credibility by using appraisal instruments or critical interpretive methods. In this way, critical reviews attempt to constructively inform other scholars about the weaknesses of prior research and strengthen knowledge development by giving focus and direction to studies for further improvement ( Kirkevold, 1997 ).

Kitsiou, Paré, and Jaana (2013) provide an example of a critical review that assessed the methodological quality of prior systematic reviews of home telemonitoring studies for chronic patients. The authors conducted a comprehensive search on multiple databases to identify eligible reviews and subsequently used a validated instrument to conduct an in-depth quality appraisal. Results indicate that the majority of systematic reviews in this particular area suffer from important methodological flaws and biases that impair their internal validity and limit their usefulness for clinical and decision-making purposes. To this end, they provide a number of recommendations to strengthen knowledge development towards improving the design and execution of future reviews on home telemonitoring.

9.4. Summary

Table 9.1 outlines the main types of literature reviews that were described in the previous sub-sections and summarizes the main characteristics that distinguish one review type from another. It also includes key references to methodological guidelines and useful sources that can be used by eHealth scholars and researchers for planning and developing reviews.

Typology of Literature Reviews (adapted from Paré et al., 2015).

As shown in Table 9.1 , each review type addresses different kinds of research questions or objectives, which subsequently define and dictate the methods and approaches that need to be used to achieve the overarching goal(s) of the review. For example, in the case of narrative reviews, there is greater flexibility in searching and synthesizing articles ( Green et al., 2006 ). Researchers are often relatively free to use a diversity of approaches to search, identify, and select relevant scientific articles, describe their operational characteristics, present how the individual studies fit together, and formulate conclusions. On the other hand, systematic reviews are characterized by their high level of systematicity, rigour, and use of explicit methods, based on an “a priori” review plan that aims to minimize bias in the analysis and synthesis process (Higgins & Green, 2008). Some reviews are exploratory in nature (e.g., scoping/mapping reviews), whereas others may be conducted to discover patterns (e.g., descriptive reviews) or involve a synthesis approach that may include the critical analysis of prior research ( Paré et al., 2015 ). Hence, in order to select the most appropriate type of review, it is critical to know before embarking on a review project, why the research synthesis is conducted and what type of methods are best aligned with the pursued goals.

9.5. Concluding Remarks

In light of the increased use of evidence-based practice and research generating stronger evidence ( Grady et al., 2011 ; Lyden et al., 2013 ), review articles have become essential tools for summarizing, synthesizing, integrating or critically appraising prior knowledge in the eHealth field. As mentioned earlier, when rigorously conducted review articles represent powerful information sources for eHealth scholars and practitioners looking for state-of-the-art evidence. The typology of literature reviews we used herein will allow eHealth researchers, graduate students and practitioners to gain a better understanding of the similarities and differences between review types.

We must stress that this classification scheme does not privilege any specific type of review as being of higher quality than another ( Paré et al., 2015 ). As explained above, each type of review has its own strengths and limitations. Having said that, we realize that the methodological rigour of any review — be it qualitative, quantitative or mixed — is a critical aspect that should be considered seriously by prospective authors. In the present context, the notion of rigour refers to the reliability and validity of the review process described in section 9.2. For one thing, reliability is related to the reproducibility of the review process and steps, which is facilitated by a comprehensive documentation of the literature search process, extraction, coding and analysis performed in the review. Whether the search is comprehensive or not, whether it involves a methodical approach for data extraction and synthesis or not, it is important that the review documents in an explicit and transparent manner the steps and approach that were used in the process of its development. Next, validity characterizes the degree to which the review process was conducted appropriately. It goes beyond documentation and reflects decisions related to the selection of the sources, the search terms used, the period of time covered, the articles selected in the search, and the application of backward and forward searches ( vom Brocke et al., 2009 ). In short, the rigour of any review article is reflected by the explicitness of its methods (i.e., transparency) and the soundness of the approach used. We refer those interested in the concepts of rigour and quality to the work of Templier and Paré (2015) which offers a detailed set of methodological guidelines for conducting and evaluating various types of review articles.

To conclude, our main objective in this chapter was to demystify the various types of literature reviews that are central to the continuous development of the eHealth field. It is our hope that our descriptive account will serve as a valuable source for those conducting, evaluating or using reviews in this important and growing domain.

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• Cite this Page Paré G, Kitsiou S. Chapter 9 Methods for Literature Reviews. In: Lau F, Kuziemsky C, editors. Handbook of eHealth Evaluation: An Evidence-based Approach [Internet]. Victoria (BC): University of Victoria; 2017 Feb 27.
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In this Page

• Introduction
• Overview of the Literature Review Process and Steps
• Types of Review Articles and Brief Illustrations
• Concluding Remarks

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How to Write Critical Reviews

When you are asked to write a critical review of a book or article, you will need to identify, summarize, and evaluate the ideas and information the author has presented. In other words, you will be examining another person’s thoughts on a topic from your point of view.

Your stand must go beyond your “gut reaction” to the work and be based on your knowledge (readings, lecture, experience) of the topic as well as on factors such as criteria stated in your assignment or discussed by you and your instructor.

Make your stand clear at the beginning of your review, in your evaluations of specific parts, and in your concluding commentary.

Remember that your goal should be to make a few key points about the book or article, not to discuss everything the author writes.

Understanding the Assignment

To write a good critical review, you will have to engage in the mental processes of analyzing (taking apart) the work–deciding what its major components are and determining how these parts (i.e., paragraphs, sections, or chapters) contribute to the work as a whole.

Analyzing the work will help you focus on how and why the author makes certain points and prevent you from merely summarizing what the author says. Assuming the role of an analytical reader will also help you to determine whether or not the author fulfills the stated purpose of the book or article and enhances your understanding or knowledge of a particular topic.

Be sure to read your assignment thoroughly before you read the article or book. Your instructor may have included specific guidelines for you to follow. Keeping these guidelines in mind as you read the article or book can really help you write your paper!

Also, note where the work connects with what you’ve studied in the course. You can make the most efficient use of your reading and notetaking time if you are an active reader; that is, keep relevant questions in mind and jot down page numbers as well as your responses to ideas that appear to be significant as you read.

Please note: The length of your introduction and overview, the number of points you choose to review, and the length of your conclusion should be proportionate to the page limit stated in your assignment and should reflect the complexity of the material being reviewed as well as the expectations of your reader.

Write the introduction

Below are a few guidelines to help you write the introduction to your critical review.

Introduce your review appropriately

Begin your review with an introduction appropriate to your assignment.

If your assignment asks you to review only one book and not to use outside sources, your introduction will focus on identifying the author, the title, the main topic or issue presented in the book, and the author’s purpose in writing the book.

If your assignment asks you to review the book as it relates to issues or themes discussed in the course, or to review two or more books on the same topic, your introduction must also encompass those expectations.

Explain relationships

For example, before you can review two books on a topic, you must explain to your reader in your introduction how they are related to one another.

Within this shared context (or under this “umbrella”) you can then review comparable aspects of both books, pointing out where the authors agree and differ.

In other words, the more complicated your assignment is, the more your introduction must accomplish.

Finally, the introduction to a book review is always the place for you to establish your position as the reviewer (your thesis about the author’s thesis).

As you write, consider the following questions:

• Is the book a memoir, a treatise, a collection of facts, an extended argument, etc.? Is the article a documentary, a write-up of primary research, a position paper, etc.?
• Who is the author? What does the preface or foreword tell you about the author’s purpose, background, and credentials? What is the author’s approach to the topic (as a journalist? a historian? a researcher?)?
• What is the main topic or problem addressed? How does the work relate to a discipline, to a profession, to a particular audience, or to other works on the topic?
• What is your critical evaluation of the work (your thesis)? Why have you taken that position? What criteria are you basing your position on?

Provide an overview

In your introduction, you will also want to provide an overview. An overview supplies your reader with certain general information not appropriate for including in the introduction but necessary to understanding the body of the review.

Generally, an overview describes your book’s division into chapters, sections, or points of discussion. An overview may also include background information about the topic, about your stand, or about the criteria you will use for evaluation.

The overview and the introduction work together to provide a comprehensive beginning for (a “springboard” into) your review.

• What are the author’s basic premises? What issues are raised, or what themes emerge? What situation (i.e., racism on college campuses) provides a basis for the author’s assertions?
• How informed is my reader? What background information is relevant to the entire book and should be placed here rather than in a body paragraph?

Write the body

The body is the center of your paper, where you draw out your main arguments. Below are some guidelines to help you write it.

Organize using a logical plan

Organize the body of your review according to a logical plan. Here are two options:

• First, summarize, in a series of paragraphs, those major points from the book that you plan to discuss; incorporating each major point into a topic sentence for a paragraph is an effective organizational strategy. Second, discuss and evaluate these points in a following group of paragraphs. (There are two dangers lurking in this pattern–you may allot too many paragraphs to summary and too few to evaluation, or you may re-summarize too many points from the book in your evaluation section.)
• Alternatively, you can summarize and evaluate the major points you have chosen from the book in a point-by-point schema. That means you will discuss and evaluate point one within the same paragraph (or in several if the point is significant and warrants extended discussion) before you summarize and evaluate point two, point three, etc., moving in a logical sequence from point to point to point. Here again, it is effective to use the topic sentence of each paragraph to identify the point from the book that you plan to summarize or evaluate.

Questions to keep in mind as you write

With either organizational pattern, consider the following questions:

• What are the author’s most important points? How do these relate to one another? (Make relationships clear by using transitions: “In contrast,” an equally strong argument,” “moreover,” “a final conclusion,” etc.).
• What types of evidence or information does the author present to support his or her points? Is this evidence convincing, controversial, factual, one-sided, etc.? (Consider the use of primary historical material, case studies, narratives, recent scientific findings, statistics.)
• Where does the author do a good job of conveying factual material as well as personal perspective? Where does the author fail to do so? If solutions to a problem are offered, are they believable, misguided, or promising?
• Which parts of the work (particular arguments, descriptions, chapters, etc.) are most effective and which parts are least effective? Why?
• Where (if at all) does the author convey personal prejudice, support illogical relationships, or present evidence out of its appropriate context?

Keep your opinions distinct and cite your sources

Remember, as you discuss the author’s major points, be sure to distinguish consistently between the author’s opinions and your own.

Keep the summary portions of your discussion concise, remembering that your task as a reviewer is to re-see the author’s work, not to re-tell it.

And, importantly, if you refer to ideas from other books and articles or from lecture and course materials, always document your sources, or else you might wander into the realm of plagiarism.

Include only that material which has relevance for your review and use direct quotations sparingly. The Writing Center has other handouts to help you paraphrase text and introduce quotations.

Write the conclusion

You will want to use the conclusion to state your overall critical evaluation.

You have already discussed the major points the author makes, examined how the author supports arguments, and evaluated the quality or effectiveness of specific aspects of the book or article.

Now you must make an evaluation of the work as a whole, determining such things as whether or not the author achieves the stated or implied purpose and if the work makes a significant contribution to an existing body of knowledge.

Consider the following questions:

• Is the work appropriately subjective or objective according to the author’s purpose?
• How well does the work maintain its stated or implied focus? Does the author present extraneous material? Does the author exclude or ignore relevant information?
• How well has the author achieved the overall purpose of the book or article? What contribution does the work make to an existing body of knowledge or to a specific group of readers? Can you justify the use of this work in a particular course?
• What is the most important final comment you wish to make about the book or article? Do you have any suggestions for the direction of future research in the area? What has reading this work done for you or demonstrated to you?

Academic and Professional Writing

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Literature reviews: criticality.

• Criticality

Express Critical Analysis

The literature review of a dissertation should include critical analysis. You cannot simply juxtapose the literature you find: you have to  evaluate and draw conclusions from it.  

Paragraph level  

Try expressing your voice in each paragraph of your literature review. Write strong paragraphs. In strong paragraphs your voice can be heard in the topic sentence, development (where you analyse and compare/contrast the sources, sometimes as individual pieces, sometimes in a synthesis) and, even more easily, in the concluding sentence, where you present the "therefore" of the paragraph. 

How to express criticality at the paragraph level:  

Identify the significance of the sources, and why the points they are making are relevant  

Make connections between the sources 

Compare and contrast sources, literatures  

Accept/adopt points made by the sources, with reasons  

Reject the points made by the sources, with reasons (e.g., limitations in the methodology; out of date; limited scope; geographical delimitation) 

Indicate the position you are taking in your own work on the theories and concepts presented by the sources 

Show how limitations in the existing literature create a research gap for you 

Organise the materials, synthesising them in an original way, that sheds new light on the topic.  

To find out more about paragraph writing, check out the Assignment Writing Guides.

Literature review level 

Try to take ownership of the literature review. Remember the purposes of the review (providing background on the subject you are researching and identifying a gap in the existing literature on this subject). Thus, throughout the review:   

Identify the key themes relevant to your subject matter  

Identify the most logical and effective order for your themes 

Relate the sources back to the dissertation's research question 

Shed new light on the topic 

Draw conclusions on the existing literature  

Identify gaps in the literature  

Your literature review should present an argument (which you can recap in the concluding paragraph of the literature review). For instance, 

"The literature says/illustrates/reveals that... there are debates in the literature as of... it can be understood from the literature that... however, there are gaps in the literature... the literature does not specifically address (specific sector/location/population)... there is a lack of independent/recent studies on...  therefore in order to answer the research question(s) (you can repeat the question) this dissertation uses method xyz, as illustrated in the next section (if applicable)". 

Manchester University’s  academic phrase bank  is a great resource for learning new words and phrases. 

Extra Resources

For extra help with all aspects of study skills including how to undertake literature reviews, appointments are available with learning advisors on Engage. 

Appointments are also available with an Academic Engagement Librarian to discuss any issues you might be having with research.

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A systematic literature review of empirical research on ChatGPT in education

• Open access
• Published: 26 May 2024
• Volume 3 , article number  60 , ( 2024 )

Cite this article

You have full access to this open access article

• Yazid Albadarin   ORCID: orcid.org/0009-0005-8068-8902 1 ,
• Mohammed Saqr 1 ,
• Nicolas Pope 1 &
• Markku Tukiainen 1  

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Over the last four decades, studies have investigated the incorporation of Artificial Intelligence (AI) into education. A recent prominent AI-powered technology that has impacted the education sector is ChatGPT. This article provides a systematic review of 14 empirical studies incorporating ChatGPT into various educational settings, published in 2022 and before the 10th of April 2023—the date of conducting the search process. It carefully followed the essential steps outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines, as well as Okoli’s (Okoli in Commun Assoc Inf Syst, 2015) steps for conducting a rigorous and transparent systematic review. In this review, we aimed to explore how students and teachers have utilized ChatGPT in various educational settings, as well as the primary findings of those studies. By employing Creswell’s (Creswell in Educational research: planning, conducting, and evaluating quantitative and qualitative research [Ebook], Pearson Education, London, 2015) coding techniques for data extraction and interpretation, we sought to gain insight into their initial attempts at ChatGPT incorporation into education. This approach also enabled us to extract insights and considerations that can facilitate its effective and responsible use in future educational contexts. The results of this review show that learners have utilized ChatGPT as a virtual intelligent assistant, where it offered instant feedback, on-demand answers, and explanations of complex topics. Additionally, learners have used it to enhance their writing and language skills by generating ideas, composing essays, summarizing, translating, paraphrasing texts, or checking grammar. Moreover, learners turned to it as an aiding tool to facilitate their directed and personalized learning by assisting in understanding concepts and homework, providing structured learning plans, and clarifying assignments and tasks. However, the results of specific studies (n = 3, 21.4%) show that overuse of ChatGPT may negatively impact innovative capacities and collaborative learning competencies among learners. Educators, on the other hand, have utilized ChatGPT to create lesson plans, generate quizzes, and provide additional resources, which helped them enhance their productivity and efficiency and promote different teaching methodologies. Despite these benefits, the majority of the reviewed studies recommend the importance of conducting structured training, support, and clear guidelines for both learners and educators to mitigate the drawbacks. This includes developing critical evaluation skills to assess the accuracy and relevance of information provided by ChatGPT, as well as strategies for integrating human interaction and collaboration into learning activities that involve AI tools. Furthermore, they also recommend ongoing research and proactive dialogue with policymakers, stakeholders, and educational practitioners to refine and enhance the use of AI in learning environments. This review could serve as an insightful resource for practitioners who seek to integrate ChatGPT into education and stimulate further research in the field.

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Avoid common mistakes on your manuscript.

1 Introduction

Educational technology, a rapidly evolving field, plays a crucial role in reshaping the landscape of teaching and learning [ 82 ]. One of the most transformative technological innovations of our era that has influenced the field of education is Artificial Intelligence (AI) [ 50 ]. Over the last four decades, AI in education (AIEd) has gained remarkable attention for its potential to make significant advancements in learning, instructional methods, and administrative tasks within educational settings [ 11 ]. In particular, a large language model (LLM), a type of AI algorithm that applies artificial neural networks (ANNs) and uses massively large data sets to understand, summarize, generate, and predict new content that is almost difficult to differentiate from human creations [ 79 ], has opened up novel possibilities for enhancing various aspects of education, from content creation to personalized instruction [ 35 ]. Chatbots that leverage the capabilities of LLMs to understand and generate human-like responses have also presented the capacity to enhance student learning and educational outcomes by engaging students, offering timely support, and fostering interactive learning experiences [ 46 ].

The ongoing and remarkable technological advancements in chatbots have made their use more convenient, increasingly natural and effortless, and have expanded their potential for deployment across various domains [ 70 ]. One prominent example of chatbot applications is the Chat Generative Pre-Trained Transformer, known as ChatGPT, which was introduced by OpenAI, a leading AI research lab, on November 30th, 2022. ChatGPT employs a variety of deep learning techniques to generate human-like text, with a particular focus on recurrent neural networks (RNNs). Long short-term memory (LSTM) allows it to grasp the context of the text being processed and retain information from previous inputs. Also, the transformer architecture, a neural network architecture based on the self-attention mechanism, allows it to analyze specific parts of the input, thereby enabling it to produce more natural-sounding and coherent output. Additionally, the unsupervised generative pre-training and the fine-tuning methods allow ChatGPT to generate more relevant and accurate text for specific tasks [ 31 , 62 ]. Furthermore, reinforcement learning from human feedback (RLHF), a machine learning approach that combines reinforcement learning techniques with human-provided feedback, has helped improve ChatGPT’s model by accelerating the learning process and making it significantly more efficient.

This cutting-edge natural language processing (NLP) tool is widely recognized as one of today's most advanced LLMs-based chatbots [ 70 ], allowing users to ask questions and receive detailed, coherent, systematic, personalized, convincing, and informative human-like responses [ 55 ], even within complex and ambiguous contexts [ 63 , 77 ]. ChatGPT is considered the fastest-growing technology in history: in just three months following its public launch, it amassed an estimated 120 million monthly active users [ 16 ] with an estimated 13 million daily queries [ 49 ], surpassing all other applications [ 64 ]. This remarkable growth can be attributed to the unique features and user-friendly interface that ChatGPT offers. Its intuitive design allows users to interact seamlessly with the technology, making it accessible to a diverse range of individuals, regardless of their technical expertise [ 78 ]. Additionally, its exceptional performance results from a combination of advanced algorithms, continuous enhancements, and extensive training on a diverse dataset that includes various text sources such as books, articles, websites, and online forums [ 63 ], have contributed to a more engaging and satisfying user experience [ 62 ]. These factors collectively explain its remarkable global growth and set it apart from predecessors like Bard, Bing Chat, ERNIE, and others.

In this context, several studies have explored the technological advancements of chatbots. One noteworthy recent research effort, conducted by Schöbel et al. [ 70 ], stands out for its comprehensive analysis of more than 5,000 studies on communication agents. This study offered a comprehensive overview of the historical progression and future prospects of communication agents, including ChatGPT. Moreover, other studies have focused on making comparisons, particularly between ChatGPT and alternative chatbots like Bard, Bing Chat, ERNIE, LaMDA, BlenderBot, and various others. For example, O’Leary [ 53 ] compared two chatbots, LaMDA and BlenderBot, with ChatGPT and revealed that ChatGPT outperformed both. This superiority arises from ChatGPT’s capacity to handle a wider range of questions and generate slightly varied perspectives within specific contexts. Similarly, ChatGPT exhibited an impressive ability to formulate interpretable responses that were easily understood when compared with Google's feature snippet [ 34 ]. Additionally, ChatGPT was compared to other LLMs-based chatbots, including Bard and BERT, as well as ERNIE. The findings indicated that ChatGPT exhibited strong performance in the given tasks, often outperforming the other models [ 59 ].

Furthermore, in the education context, a comprehensive study systematically compared a range of the most promising chatbots, including Bard, Bing Chat, ChatGPT, and Ernie across a multidisciplinary test that required higher-order thinking. The study revealed that ChatGPT achieved the highest score, surpassing Bing Chat and Bard [ 64 ]. Similarly, a comparative analysis was conducted to compare ChatGPT with Bard in answering a set of 30 mathematical questions and logic problems, grouped into two question sets. Set (A) is unavailable online, while Set (B) is available online. The results revealed ChatGPT's superiority in Set (A) over Bard. Nevertheless, Bard's advantage emerged in Set (B) due to its capacity to access the internet directly and retrieve answers, a capability that ChatGPT does not possess [ 57 ]. However, through these varied assessments, ChatGPT consistently highlights its exceptional prowess compared to various alternatives in the ever-evolving chatbot technology.

The widespread adoption of chatbots, especially ChatGPT, by millions of students and educators, has sparked extensive discussions regarding its incorporation into the education sector [ 64 ]. Accordingly, many scholars have contributed to the discourse, expressing both optimism and pessimism regarding the incorporation of ChatGPT into education. For example, ChatGPT has been highlighted for its capabilities in enriching the learning and teaching experience through its ability to support different learning approaches, including adaptive learning, personalized learning, and self-directed learning [ 58 , 60 , 91 ]), deliver summative and formative feedback to students and provide real-time responses to questions, increase the accessibility of information [ 22 , 40 , 43 ], foster students’ performance, engagement and motivation [ 14 , 44 , 58 ], and enhance teaching practices [ 17 , 18 , 64 , 74 ].

On the other hand, concerns have been also raised regarding its potential negative effects on learning and teaching. These include the dissemination of false information and references [ 12 , 23 , 61 , 85 ], biased reinforcement [ 47 , 50 ], compromised academic integrity [ 18 , 40 , 66 , 74 ], and the potential decline in students' skills [ 43 , 61 , 64 , 74 ]. As a result, ChatGPT has been banned in multiple countries, including Russia, China, Venezuela, Belarus, and Iran, as well as in various educational institutions in India, Italy, Western Australia, France, and the United States [ 52 , 90 ].

Clearly, the advent of chatbots, especially ChatGPT, has provoked significant controversy due to their potential impact on learning and teaching. This indicates the necessity for further exploration to gain a deeper understanding of this technology and carefully evaluate its potential benefits, limitations, challenges, and threats to education [ 79 ]. Therefore, conducting a systematic literature review will provide valuable insights into the potential prospects and obstacles linked to its incorporation into education. This systematic literature review will primarily focus on ChatGPT, driven by the aforementioned key factors outlined above.

However, the existing literature lacks a systematic literature review of empirical studies. Thus, this systematic literature review aims to address this gap by synthesizing the existing empirical studies conducted on chatbots, particularly ChatGPT, in the field of education, highlighting how ChatGPT has been utilized in educational settings, and identifying any existing gaps. This review may be particularly useful for researchers in the field and educators who are contemplating the integration of ChatGPT or any chatbot into education. The following research questions will guide this study:

What are students' and teachers' initial attempts at utilizing ChatGPT in education?

What are the main findings derived from empirical studies that have incorporated ChatGPT into learning and teaching?

2 Methodology

To conduct this study, the authors followed the essential steps of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) and Okoli’s [ 54 ] steps for conducting a systematic review. These included identifying the study’s purpose, drafting a protocol, applying a practical screening process, searching the literature, extracting relevant data, evaluating the quality of the included studies, synthesizing the studies, and ultimately writing the review. The subsequent section provides an extensive explanation of how these steps were carried out in this study.

2.1 Identify the purpose

Given the widespread adoption of ChatGPT by students and teachers for various educational purposes, often without a thorough understanding of responsible and effective use or a clear recognition of its potential impact on learning and teaching, the authors recognized the need for further exploration of ChatGPT's impact on education in this early stage. Therefore, they have chosen to conduct a systematic literature review of existing empirical studies that incorporate ChatGPT into educational settings. Despite the limited number of empirical studies due to the novelty of the topic, their goal is to gain a deeper understanding of this technology and proactively evaluate its potential benefits, limitations, challenges, and threats to education. This effort could help to understand initial reactions and attempts at incorporating ChatGPT into education and bring out insights and considerations that can inform the future development of education.

2.2 Draft the protocol

The next step is formulating the protocol. This protocol serves to outline the study process in a rigorous and transparent manner, mitigating researcher bias in study selection and data extraction [ 88 ]. The protocol will include the following steps: generating the research question, predefining a literature search strategy, identifying search locations, establishing selection criteria, assessing the studies, developing a data extraction strategy, and creating a timeline.

2.3 Apply practical screen

The screening step aims to accurately filter the articles resulting from the searching step and select the empirical studies that have incorporated ChatGPT into educational contexts, which will guide us in answering the research questions and achieving the objectives of this study. To ensure the rigorous execution of this step, our inclusion and exclusion criteria were determined based on the authors' experience and informed by previous successful systematic reviews [ 21 ]. Table 1 summarizes the inclusion and exclusion criteria for study selection.

2.4 Literature search

We conducted a thorough literature search to identify articles that explored, examined, and addressed the use of ChatGPT in Educational contexts. We utilized two research databases: Dimensions.ai, which provides access to a large number of research publications, and lens.org, which offers access to over 300 million articles, patents, and other research outputs from diverse sources. Additionally, we included three databases, Scopus, Web of Knowledge, and ERIC, which contain relevant research on the topic that addresses our research questions. To browse and identify relevant articles, we used the following search formula: ("ChatGPT" AND "Education"), which included the Boolean operator "AND" to get more specific results. The subject area in the Scopus and ERIC databases were narrowed to "ChatGPT" and "Education" keywords, and in the WoS database was limited to the "Education" category. The search was conducted between the 3rd and 10th of April 2023, which resulted in 276 articles from all selected databases (111 articles from Dimensions.ai, 65 from Scopus, 28 from Web of Science, 14 from ERIC, and 58 from Lens.org). These articles were imported into the Rayyan web-based system for analysis. The duplicates were identified automatically by the system. Subsequently, the first author manually reviewed the duplicated articles ensured that they had the same content, and then removed them, leaving us with 135 unique articles. Afterward, the titles, abstracts, and keywords of the first 40 manuscripts were scanned and reviewed by the first author and were discussed with the second and third authors to resolve any disagreements. Subsequently, the first author proceeded with the filtering process for all articles and carefully applied the inclusion and exclusion criteria as presented in Table  1 . Articles that met any one of the exclusion criteria were eliminated, resulting in 26 articles. Afterward, the authors met to carefully scan and discuss them. The authors agreed to eliminate any empirical studies solely focused on checking ChatGPT capabilities, as these studies do not guide us in addressing the research questions and achieving the study's objectives. This resulted in 14 articles eligible for analysis.

2.5 Quality appraisal

The examination and evaluation of the quality of the extracted articles is a vital step [ 9 ]. Therefore, the extracted articles were carefully evaluated for quality using Fink’s [ 24 ] standards, which emphasize the necessity for detailed descriptions of methodology, results, conclusions, strengths, and limitations. The process began with a thorough assessment of each study's design, data collection, and analysis methods to ensure their appropriateness and comprehensive execution. The clarity, consistency, and logical progression from data to results and conclusions were also critically examined. Potential biases and recognized limitations within the studies were also scrutinized. Ultimately, two articles were excluded for failing to meet Fink’s criteria, particularly in providing sufficient detail on methodology, results, conclusions, strengths, or limitations. The review process is illustrated in Fig.  1 .

The study selection process

2.6 Data extraction

The next step is data extraction, the process of capturing the key information and categories from the included studies. To improve efficiency, reduce variation among authors, and minimize errors in data analysis, the coding categories were constructed using Creswell's [ 15 ] coding techniques for data extraction and interpretation. The coding process involves three sequential steps. The initial stage encompasses open coding , where the researcher examines the data, generates codes to describe and categorize it, and gains a deeper understanding without preconceived ideas. Following open coding is axial coding , where the interrelationships between codes from open coding are analyzed to establish more comprehensive categories or themes. The process concludes with selective coding , refining and integrating categories or themes to identify core concepts emerging from the data. The first coder performed the coding process, then engaged in discussions with the second and third authors to finalize the coding categories for the first five articles. The first coder then proceeded to code all studies and engaged again in discussions with the other authors to ensure the finalization of the coding process. After a comprehensive analysis and capturing of the key information from the included studies, the data extraction and interpretation process yielded several themes. These themes have been categorized and are presented in Table  2 . It is important to note that open coding results were removed from Table  2 for aesthetic reasons, as it included many generic aspects, such as words, short phrases, or sentences mentioned in the studies.

2.7 Synthesize studies

In this stage, we will gather, discuss, and analyze the key findings that emerged from the selected studies. The synthesis stage is considered a transition from an author-centric to a concept-centric focus, enabling us to map all the provided information to achieve the most effective evaluation of the data [ 87 ]. Initially, the authors extracted data that included general information about the selected studies, including the author(s)' names, study titles, years of publication, educational levels, research methodologies, sample sizes, participants, main aims or objectives, raw data sources, and analysis methods. Following that, all key information and significant results from the selected studies were compiled using Creswell’s [ 15 ] coding techniques for data extraction and interpretation to identify core concepts and themes emerging from the data, focusing on those that directly contributed to our research questions and objectives, such as the initial utilization of ChatGPT in learning and teaching, learners' and educators' familiarity with ChatGPT, and the main findings of each study. Finally, the data related to each selected study were extracted into an Excel spreadsheet for data processing. The Excel spreadsheet was reviewed by the authors, including a series of discussions to ensure the finalization of this process and prepare it for further analysis. Afterward, the final result being analyzed and presented in various types of charts and graphs. Table 4 presents the extracted data from the selected studies, with each study labeled with a capital 'S' followed by a number.

This section consists of two main parts. The first part provides a descriptive analysis of the data compiled from the reviewed studies. The second part presents the answers to the research questions and the main findings of these studies.

3.1 Part 1: descriptive analysis

This section will provide a descriptive analysis of the reviewed studies, including educational levels and fields, participants distribution, country contribution, research methodologies, study sample size, study population, publication year, list of journals, familiarity with ChatGPT, source of data, and the main aims and objectives of the studies. Table 4 presents a comprehensive overview of the extracted data from the selected studies.

3.1.1 The number of the reviewed studies and publication years

The total number of the reviewed studies was 14. All studies were empirical studies and published in different journals focusing on Education and Technology. One study was published in 2022 [S1], while the remaining were published in 2023 [S2]-[S14]. Table 3 illustrates the year of publication, the names of the journals, and the number of reviewed studies published in each journal for the studies reviewed.

3.1.2 Educational levels and fields

The majority of the reviewed studies, 11 studies, were conducted in higher education institutions [S1]-[S10] and [S13]. Two studies did not specify the educational level of the population [S12] and [S14], while one study focused on elementary education [S11]. However, the reviewed studies covered various fields of education. Three studies focused on Arts and Humanities Education [S8], [S11], and [S14], specifically English Education. Two studies focused on Engineering Education, with one in Computer Engineering [S2] and the other in Construction Education [S3]. Two studies focused on Mathematics Education [S5] and [S12]. One study focused on Social Science Education [S13]. One study focused on Early Education [S4]. One study focused on Journalism Education [S9]. Finally, three studies did not specify the field of education [S1], [S6], and [S7]. Figure  2 represents the educational levels in the reviewed studies, while Fig.  3 represents the context of the reviewed studies.

Educational levels in the reviewed studies

Context of the reviewed studies

3.1.3 Participants distribution and countries contribution

The reviewed studies have been conducted across different geographic regions, providing a diverse representation of the studies. The majority of the studies, 10 in total, [S1]-[S3], [S5]-[S9], [S11], and [S14], primarily focused on participants from single countries such as Pakistan, the United Arab Emirates, China, Indonesia, Poland, Saudi Arabia, South Korea, Spain, Tajikistan, and the United States. In contrast, four studies, [S4], [S10], [S12], and [S13], involved participants from multiple countries, including China and the United States [S4], China, the United Kingdom, and the United States [S10], the United Arab Emirates, Oman, Saudi Arabia, and Jordan [S12], Turkey, Sweden, Canada, and Australia [ 13 ]. Figures  4 and 5 illustrate the distribution of participants, whether from single or multiple countries, and the contribution of each country in the reviewed studies, respectively.

The reviewed studies conducted in single or multiple countries

The Contribution of each country in the studies

3.1.4 Study population and sample size

Four study populations were included: university students, university teachers, university teachers and students, and elementary school teachers. Six studies involved university students [S2], [S3], [S5] and [S6]-[S8]. Three studies focused on university teachers [S1], [S4], and [S6], while one study specifically targeted elementary school teachers [S11]. Additionally, four studies included both university teachers and students [S10] and [ 12 , 13 , 14 ], and among them, study [S13] specifically included postgraduate students. In terms of the sample size of the reviewed studies, nine studies included a small sample size of less than 50 participants [S1], [S3], [S6], [S8], and [S10]-[S13]. Three studies had 50–100 participants [S2], [S9], and [S14]. Only one study had more than 100 participants [S7]. It is worth mentioning that study [S4] adopted a mixed methods approach, including 10 participants for qualitative analysis and 110 participants for quantitative analysis.

3.1.5 Participants’ familiarity with using ChatGPT

The reviewed studies recruited a diverse range of participants with varying levels of familiarity with ChatGPT. Five studies [S2], [S4], [S6], [S8], and [S12] involved participants already familiar with ChatGPT, while eight studies [S1], [S3], [S5], [S7], [S9], [S10], [S13] and [S14] included individuals with differing levels of familiarity. Notably, one study [S11] had participants who were entirely unfamiliar with ChatGPT. It is important to note that four studies [S3], [S5], [S9], and [S11] provided training or guidance to their participants before conducting their studies, while ten studies [S1], [S2], [S4], [S6]-[S8], [S10], and [S12]-[S14] did not provide training due to the participants' existing familiarity with ChatGPT.

3.1.6 Research methodology approaches and source(S) of data

The reviewed studies adopted various research methodology approaches. Seven studies adopted qualitative research methodology [S1], [S4], [S6], [S8], [S10], [S11], and [S12], while three studies adopted quantitative research methodology [S3], [S7], and [S14], and four studies employed mixed-methods, which involved a combination of both the strengths of qualitative and quantitative methods [S2], [S5], [S9], and [S13].

In terms of the source(s) of data, the reviewed studies obtained their data from various sources, such as interviews, questionnaires, and pre-and post-tests. Six studies relied on interviews as their primary source of data collection [S1], [S4], [S6], [S10], [S11], and [S12], four studies relied on questionnaires [S2], [S7], [S13], and [S14], two studies combined the use of pre-and post-tests and questionnaires for data collection [S3] and [S9], while two studies combined the use of questionnaires and interviews to obtain the data [S5] and [S8]. It is important to note that six of the reviewed studies were quasi-experimental [S3], [S5], [S8], [S9], [S12], and [S14], while the remaining ones were experimental studies [S1], [S2], [S4], [S6], [S7], [S10], [S11], and [S13]. Figures  6 and 7 illustrate the research methodologies and the source (s) of data used in the reviewed studies, respectively.

Research methodologies in the reviewed studies

Source of data in the reviewed studies

3.1.7 The aim and objectives of the studies

The reviewed studies encompassed a diverse set of aims, with several of them incorporating multiple primary objectives. Six studies [S3], [S6], [S7], [S8], [S11], and [S12] examined the integration of ChatGPT in educational contexts, and four studies [S4], [S5], [S13], and [S14] investigated the various implications of its use in education, while three studies [S2], [S9], and [S10] aimed to explore both its integration and implications in education. Additionally, seven studies explicitly explored attitudes and perceptions of students [S2] and [S3], educators [S1] and [S6], or both [S10], [S12], and [S13] regarding the utilization of ChatGPT in educational settings.

3.2 Part 2: research questions and main findings of the reviewed studies

This part will present the answers to the research questions and the main findings of the reviewed studies, classified into two main categories (learning and teaching) according to AI Education classification by [ 36 ]. Figure  8 summarizes the main findings of the reviewed studies in a visually informative diagram. Table 4 provides a detailed list of the key information extracted from the selected studies that led to generating these themes.

The main findings in the reviewed studies

4 Students' initial attempts at utilizing ChatGPT in learning and main findings from students' perspective

4.1 virtual intelligent assistant.

Nine studies demonstrated that ChatGPT has been utilized by students as an intelligent assistant to enhance and support their learning. Students employed it for various purposes, such as answering on-demand questions [S2]-[S5], [S8], [S10], and [S12], providing valuable information and learning resources [S2]-[S5], [S6], and [S8], as well as receiving immediate feedback [S2], [S4], [S9], [S10], and [S12]. In this regard, students generally were confident in the accuracy of ChatGPT's responses, considering them relevant, reliable, and detailed [S3], [S4], [S5], and [S8]. However, some students indicated the need for improvement, as they found that answers are not always accurate [S2], and that misleading information may have been provided or that it may not always align with their expectations [S6] and [S10]. It was also observed by the students that the accuracy of ChatGPT is dependent on several factors, including the quality and specificity of the user's input, the complexity of the question or topic, and the scope and relevance of its training data [S12]. Many students felt that ChatGPT's answers were not always accurate and most of them believed that it requires good background knowledge to work with.

4.2 Writing and language proficiency assistant

Six of the reviewed studies highlighted that ChatGPT has been utilized by students as a valuable assistant tool to improve their academic writing skills and language proficiency. Among these studies, three mainly focused on English education, demonstrating that students showed sufficient mastery in using ChatGPT for generating ideas, summarizing, paraphrasing texts, and completing writing essays [S8], [S11], and [S14]. Furthermore, ChatGPT helped them in writing by making students active investigators rather than passive knowledge recipients and facilitated the development of their writing skills [S11] and [S14]. Similarly, ChatGPT allowed students to generate unique ideas and perspectives, leading to deeper analysis and reflection on their journalism writing [S9]. In terms of language proficiency, ChatGPT allowed participants to translate content into their home languages, making it more accessible and relevant to their context [S4]. It also enabled them to request changes in linguistic tones or flavors [S8]. Moreover, participants used it to check grammar or as a dictionary [S11].

4.3 Valuable resource for learning approaches

Five studies demonstrated that students used ChatGPT as a valuable complementary resource for self-directed learning. It provided learning resources and guidance on diverse educational topics and created a supportive home learning environment [S2] and [S4]. Moreover, it offered step-by-step guidance to grasp concepts at their own pace and enhance their understanding [S5], streamlined task and project completion carried out independently [S7], provided comprehensive and easy-to-understand explanations on various subjects [S10], and assisted in studying geometry operations, thereby empowering them to explore geometry operations at their own pace [S12]. Three studies showed that students used ChatGPT as a valuable learning resource for personalized learning. It delivered age-appropriate conversations and tailored teaching based on a child's interests [S4], acted as a personalized learning assistant, adapted to their needs and pace, which assisted them in understanding mathematical concepts [S12], and enabled personalized learning experiences in social sciences by adapting to students' needs and learning styles [S13]. On the other hand, it is important to note that, according to one study [S5], students suggested that using ChatGPT may negatively affect collaborative learning competencies between students.

4.4 Enhancing students' competencies

Six of the reviewed studies have shown that ChatGPT is a valuable tool for improving a wide range of skills among students. Two studies have provided evidence that ChatGPT led to improvements in students' critical thinking, reasoning skills, and hazard recognition competencies through engaging them in interactive conversations or activities and providing responses related to their disciplines in journalism [S5] and construction education [S9]. Furthermore, two studies focused on mathematical education have shown the positive impact of ChatGPT on students' problem-solving abilities in unraveling problem-solving questions [S12] and enhancing the students' understanding of the problem-solving process [S5]. Lastly, one study indicated that ChatGPT effectively contributed to the enhancement of conversational social skills [S4].

4.5 Supporting students' academic success

Seven of the reviewed studies highlighted that students found ChatGPT to be beneficial for learning as it enhanced learning efficiency and improved the learning experience. It has been observed to improve students' efficiency in computer engineering studies by providing well-structured responses and good explanations [S2]. Additionally, students found it extremely useful for hazard reporting [S3], and it also enhanced their efficiency in solving mathematics problems and capabilities [S5] and [S12]. Furthermore, by finding information, generating ideas, translating texts, and providing alternative questions, ChatGPT aided students in deepening their understanding of various subjects [S6]. It contributed to an increase in students' overall productivity [S7] and improved efficiency in composing written tasks [S8]. Regarding learning experiences, ChatGPT was instrumental in assisting students in identifying hazards that they might have otherwise overlooked [S3]. It also improved students' learning experiences in solving mathematics problems and developing abilities [S5] and [S12]. Moreover, it increased students' successful completion of important tasks in their studies [S7], particularly those involving average difficulty writing tasks [S8]. Additionally, ChatGPT increased the chances of educational success by providing students with baseline knowledge on various topics [S10].

5 Teachers' initial attempts at utilizing ChatGPT in teaching and main findings from teachers' perspective

5.1 valuable resource for teaching.

The reviewed studies showed that teachers have employed ChatGPT to recommend, modify, and generate diverse, creative, organized, and engaging educational contents, teaching materials, and testing resources more rapidly [S4], [S6], [S10] and [S11]. Additionally, teachers experienced increased productivity as ChatGPT facilitated quick and accurate responses to questions, fact-checking, and information searches [S1]. It also proved valuable in constructing new knowledge [S6] and providing timely answers to students' questions in classrooms [S11]. Moreover, ChatGPT enhanced teachers' efficiency by generating new ideas for activities and preplanning activities for their students [S4] and [S6], including interactive language game partners [S11].

5.2 Improving productivity and efficiency

The reviewed studies showed that participants' productivity and work efficiency have been significantly enhanced by using ChatGPT as it enabled them to allocate more time to other tasks and reduce their overall workloads [S6], [S10], [S11], [S13], and [S14]. However, three studies [S1], [S4], and [S11], indicated a negative perception and attitude among teachers toward using ChatGPT. This negativity stemmed from a lack of necessary skills to use it effectively [S1], a limited familiarity with it [S4], and occasional inaccuracies in the content provided by it [S10].

5.3 Catalyzing new teaching methodologies

Five of the reviewed studies highlighted that educators found the necessity of redefining their teaching profession with the assistance of ChatGPT [S11], developing new effective learning strategies [S4], and adapting teaching strategies and methodologies to ensure the development of essential skills for future engineers [S5]. They also emphasized the importance of adopting new educational philosophies and approaches that can evolve with the introduction of ChatGPT into the classroom [S12]. Furthermore, updating curricula to focus on improving human-specific features, such as emotional intelligence, creativity, and philosophical perspectives [S13], was found to be essential.

5.4 Effective utilization of CHATGPT in teaching

According to the reviewed studies, effective utilization of ChatGPT in education requires providing teachers with well-structured training, support, and adequate background on how to use ChatGPT responsibly [S1], [S3], [S11], and [S12]. Establishing clear rules and regulations regarding its usage is essential to ensure it positively impacts the teaching and learning processes, including students' skills [S1], [S4], [S5], [S8], [S9], and [S11]-[S14]. Moreover, conducting further research and engaging in discussions with policymakers and stakeholders is indeed crucial for the successful integration of ChatGPT in education and to maximize the benefits for both educators and students [S1], [S6]-[S10], and [S12]-[S14].

6 Discussion

The purpose of this review is to conduct a systematic review of empirical studies that have explored the utilization of ChatGPT, one of today’s most advanced LLM-based chatbots, in education. The findings of the reviewed studies showed several ways of ChatGPT utilization in different learning and teaching practices as well as it provided insights and considerations that can facilitate its effective and responsible use in future educational contexts. The results of the reviewed studies came from diverse fields of education, which helped us avoid a biased review that is limited to a specific field. Similarly, the reviewed studies have been conducted across different geographic regions. This kind of variety in geographic representation enriched the findings of this review.

In response to RQ1 , "What are students' and teachers' initial attempts at utilizing ChatGPT in education?", the findings from this review provide comprehensive insights. Chatbots, including ChatGPT, play a crucial role in supporting student learning, enhancing their learning experiences, and facilitating diverse learning approaches [ 42 , 43 ]. This review found that this tool, ChatGPT, has been instrumental in enhancing students' learning experiences by serving as a virtual intelligent assistant, providing immediate feedback, on-demand answers, and engaging in educational conversations. Additionally, students have benefited from ChatGPT’s ability to generate ideas, compose essays, and perform tasks like summarizing, translating, paraphrasing texts, or checking grammar, thereby enhancing their writing and language competencies. Furthermore, students have turned to ChatGPT for assistance in understanding concepts and homework, providing structured learning plans, and clarifying assignments and tasks, which fosters a supportive home learning environment, allowing them to take responsibility for their own learning and cultivate the skills and approaches essential for supportive home learning environment [ 26 , 27 , 28 ]. This finding aligns with the study of Saqr et al. [ 68 , 69 ] who highlighted that, when students actively engage in their own learning process, it yields additional advantages, such as heightened motivation, enhanced achievement, and the cultivation of enthusiasm, turning them into advocates for their own learning.

Moreover, students have utilized ChatGPT for tailored teaching and step-by-step guidance on diverse educational topics, streamlining task and project completion, and generating and recommending educational content. This personalization enhances the learning environment, leading to increased academic success. This finding aligns with other recent studies [ 26 , 27 , 28 , 60 , 66 ] which revealed that ChatGPT has the potential to offer personalized learning experiences and support an effective learning process by providing students with customized feedback and explanations tailored to their needs and abilities. Ultimately, fostering students' performance, engagement, and motivation, leading to increase students' academic success [ 14 , 44 , 58 ]. This ultimate outcome is in line with the findings of Saqr et al. [ 68 , 69 ], which emphasized that learning strategies are important catalysts of students' learning, as students who utilize effective learning strategies are more likely to have better academic achievement.

Teachers, too, have capitalized on ChatGPT's capabilities to enhance productivity and efficiency, using it for creating lesson plans, generating quizzes, providing additional resources, generating and preplanning new ideas for activities, and aiding in answering students’ questions. This adoption of technology introduces new opportunities to support teaching and learning practices, enhancing teacher productivity. This finding aligns with those of Day [ 17 ], De Castro [ 18 ], and Su and Yang [ 74 ] as well as with those of Valtonen et al. [ 82 ], who revealed that emerging technological advancements have opened up novel opportunities and means to support teaching and learning practices, and enhance teachers’ productivity.

In response to RQ2 , "What are the main findings derived from empirical studies that have incorporated ChatGPT into learning and teaching?", the findings from this review provide profound insights and raise significant concerns. Starting with the insights, chatbots, including ChatGPT, have demonstrated the potential to reshape and revolutionize education, creating new, novel opportunities for enhancing the learning process and outcomes [ 83 ], facilitating different learning approaches, and offering a range of pedagogical benefits [ 19 , 43 , 72 ]. In this context, this review found that ChatGPT could open avenues for educators to adopt or develop new effective learning and teaching strategies that can evolve with the introduction of ChatGPT into the classroom. Nonetheless, there is an evident lack of research understanding regarding the potential impact of generative machine learning models within diverse educational settings [ 83 ]. This necessitates teachers to attain a high level of proficiency in incorporating chatbots, such as ChatGPT, into their classrooms to create inventive, well-structured, and captivating learning strategies. In the same vein, the review also found that teachers without the requisite skills to utilize ChatGPT realized that it did not contribute positively to their work and could potentially have adverse effects [ 37 ]. This concern could lead to inequity of access to the benefits of chatbots, including ChatGPT, as individuals who lack the necessary expertise may not be able to harness their full potential, resulting in disparities in educational outcomes and opportunities. Therefore, immediate action is needed to address these potential issues. A potential solution is offering training, support, and competency development for teachers to ensure that all of them can leverage chatbots, including ChatGPT, effectively and equitably in their educational practices [ 5 , 28 , 80 ], which could enhance accessibility and inclusivity, and potentially result in innovative outcomes [ 82 , 83 ].

Additionally, chatbots, including ChatGPT, have the potential to significantly impact students' thinking abilities, including retention, reasoning, analysis skills [ 19 , 45 ], and foster innovation and creativity capabilities [ 83 ]. This review found that ChatGPT could contribute to improving a wide range of skills among students. However, it found that frequent use of ChatGPT may result in a decrease in innovative capacities, collaborative skills and cognitive capacities, and students' motivation to attend classes, as well as could lead to reduced higher-order thinking skills among students [ 22 , 29 ]. Therefore, immediate action is needed to carefully examine the long-term impact of chatbots such as ChatGPT, on learning outcomes as well as to explore its incorporation into educational settings as a supportive tool without compromising students' cognitive development and critical thinking abilities. In the same vein, the review also found that it is challenging to draw a consistent conclusion regarding the potential of ChatGPT to aid self-directed learning approach. This finding aligns with the recent study of Baskara [ 8 ]. Therefore, further research is needed to explore the potential of ChatGPT for self-directed learning. One potential solution involves utilizing learning analytics as a novel approach to examine various aspects of students' learning and support them in their individual endeavors [ 32 ]. This approach can bridge this gap by facilitating an in-depth analysis of how learners engage with ChatGPT, identifying trends in self-directed learning behavior, and assessing its influence on their outcomes.

Turning to the significant concerns, on the other hand, a fundamental challenge with LLM-based chatbots, including ChatGPT, is the accuracy and quality of the provided information and responses, as they provide false information as truth—a phenomenon often referred to as "hallucination" [ 3 , 49 ]. In this context, this review found that the provided information was not entirely satisfactory. Consequently, the utilization of chatbots presents potential concerns, such as generating and providing inaccurate or misleading information, especially for students who utilize it to support their learning. This finding aligns with other findings [ 6 , 30 , 35 , 40 ] which revealed that incorporating chatbots such as ChatGPT, into education presents challenges related to its accuracy and reliability due to its training on a large corpus of data, which may contain inaccuracies and the way users formulate or ask ChatGPT. Therefore, immediate action is needed to address these potential issues. One possible solution is to equip students with the necessary skills and competencies, which include a background understanding of how to use it effectively and the ability to assess and evaluate the information it generates, as the accuracy and the quality of the provided information depend on the input, its complexity, the topic, and the relevance of its training data [ 28 , 49 , 86 ]. However, it's also essential to examine how learners can be educated about how these models operate, the data used in their training, and how to recognize their limitations, challenges, and issues [ 79 ].

Furthermore, chatbots present a substantial challenge concerning maintaining academic integrity [ 20 , 56 ] and copyright violations [ 83 ], which are significant concerns in education. The review found that the potential misuse of ChatGPT might foster cheating, facilitate plagiarism, and threaten academic integrity. This issue is also affirmed by the research conducted by Basic et al. [ 7 ], who presented evidence that students who utilized ChatGPT in their writing assignments had more plagiarism cases than those who did not. These findings align with the conclusions drawn by Cotton et al. [ 13 ], Hisan and Amri [ 33 ] and Sullivan et al. [ 75 ], who revealed that the integration of chatbots such as ChatGPT into education poses a significant challenge to the preservation of academic integrity. Moreover, chatbots, including ChatGPT, have increased the difficulty in identifying plagiarism [ 47 , 67 , 76 ]. The findings from previous studies [ 1 , 84 ] indicate that AI-generated text often went undetected by plagiarism software, such as Turnitin. However, Turnitin and other similar plagiarism detection tools, such as ZeroGPT, GPTZero, and Copyleaks, have since evolved, incorporating enhanced techniques to detect AI-generated text, despite the possibility of false positives, as noted in different studies that have found these tools still not yet fully ready to accurately and reliably identify AI-generated text [ 10 , 51 ], and new novel detection methods may need to be created and implemented for AI-generated text detection [ 4 ]. This potential issue could lead to another concern, which is the difficulty of accurately evaluating student performance when they utilize chatbots such as ChatGPT assistance in their assignments. Consequently, the most LLM-driven chatbots present a substantial challenge to traditional assessments [ 64 ]. The findings from previous studies indicate the importance of rethinking, improving, and redesigning innovative assessment methods in the era of chatbots [ 14 , 20 , 64 , 75 ]. These methods should prioritize the process of evaluating students' ability to apply knowledge to complex cases and demonstrate comprehension, rather than solely focusing on the final product for assessment. Therefore, immediate action is needed to address these potential issues. One possible solution would be the development of clear guidelines, regulatory policies, and pedagogical guidance. These measures would help regulate the proper and ethical utilization of chatbots, such as ChatGPT, and must be established before their introduction to students [ 35 , 38 , 39 , 41 , 89 ].

In summary, our review has delved into the utilization of ChatGPT, a prominent example of chatbots, in education, addressing the question of how ChatGPT has been utilized in education. However, there remain significant gaps, which necessitate further research to shed light on this area.

7 Conclusions

This systematic review has shed light on the varied initial attempts at incorporating ChatGPT into education by both learners and educators, while also offering insights and considerations that can facilitate its effective and responsible use in future educational contexts. From the analysis of 14 selected studies, the review revealed the dual-edged impact of ChatGPT in educational settings. On the positive side, ChatGPT significantly aided the learning process in various ways. Learners have used it as a virtual intelligent assistant, benefiting from its ability to provide immediate feedback, on-demand answers, and easy access to educational resources. Additionally, it was clear that learners have used it to enhance their writing and language skills, engaging in practices such as generating ideas, composing essays, and performing tasks like summarizing, translating, paraphrasing texts, or checking grammar. Importantly, other learners have utilized it in supporting and facilitating their directed and personalized learning on a broad range of educational topics, assisting in understanding concepts and homework, providing structured learning plans, and clarifying assignments and tasks. Educators, on the other hand, found ChatGPT beneficial for enhancing productivity and efficiency. They used it for creating lesson plans, generating quizzes, providing additional resources, and answers learners' questions, which saved time and allowed for more dynamic and engaging teaching strategies and methodologies.

However, the review also pointed out negative impacts. The results revealed that overuse of ChatGPT could decrease innovative capacities and collaborative learning among learners. Specifically, relying too much on ChatGPT for quick answers can inhibit learners' critical thinking and problem-solving skills. Learners might not engage deeply with the material or consider multiple solutions to a problem. This tendency was particularly evident in group projects, where learners preferred consulting ChatGPT individually for solutions over brainstorming and collaborating with peers, which negatively affected their teamwork abilities. On a broader level, integrating ChatGPT into education has also raised several concerns, including the potential for providing inaccurate or misleading information, issues of inequity in access, challenges related to academic integrity, and the possibility of misusing the technology.

Accordingly, this review emphasizes the urgency of developing clear rules, policies, and regulations to ensure ChatGPT's effective and responsible use in educational settings, alongside other chatbots, by both learners and educators. This requires providing well-structured training to educate them on responsible usage and understanding its limitations, along with offering sufficient background information. Moreover, it highlights the importance of rethinking, improving, and redesigning innovative teaching and assessment methods in the era of ChatGPT. Furthermore, conducting further research and engaging in discussions with policymakers and stakeholders are essential steps to maximize the benefits for both educators and learners and ensure academic integrity.

It is important to acknowledge that this review has certain limitations. Firstly, the limited inclusion of reviewed studies can be attributed to several reasons, including the novelty of the technology, as new technologies often face initial skepticism and cautious adoption; the lack of clear guidelines or best practices for leveraging this technology for educational purposes; and institutional or governmental policies affecting the utilization of this technology in educational contexts. These factors, in turn, have affected the number of studies available for review. Secondly, the utilization of the original version of ChatGPT, based on GPT-3 or GPT-3.5, implies that new studies utilizing the updated version, GPT-4 may lead to different findings. Therefore, conducting follow-up systematic reviews is essential once more empirical studies on ChatGPT are published. Additionally, long-term studies are necessary to thoroughly examine and assess the impact of ChatGPT on various educational practices.

Despite these limitations, this systematic review has highlighted the transformative potential of ChatGPT in education, revealing its diverse utilization by learners and educators alike and summarized the benefits of incorporating it into education, as well as the forefront critical concerns and challenges that must be addressed to facilitate its effective and responsible use in future educational contexts. This review could serve as an insightful resource for practitioners who seek to integrate ChatGPT into education and stimulate further research in the field.

Data availability

The data supporting our findings are available upon request.

Abbreviations

• Artificial intelligence

AI in education

Large language model

Artificial neural networks

Chat Generative Pre-Trained Transformer

Recurrent neural networks

Long short-term memory

Reinforcement learning from human feedback

Natural language processing

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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The paper is co-funded by the Academy of Finland (Suomen Akatemia) Research Council for Natural Sciences and Engineering for the project Towards precision education: Idiographic learning analytics (TOPEILA), Decision Number 350560.

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YA contributed to the literature search, data analysis, discussion, and conclusion. Additionally, YA contributed to the manuscript’s writing, editing, and finalization. MS contributed to the study’s design, conceptualization, acquisition of funding, project administration, allocation of resources, supervision, validation, literature search, and analysis of results. Furthermore, MS contributed to the manuscript's writing, revising, and approving it in its finalized state. NP contributed to the results, and discussions, and provided supervision. NP also contributed to the writing process, revisions, and the final approval of the manuscript in its finalized state. MT contributed to the study's conceptualization, resource management, supervision, writing, revising the manuscript, and approving it.

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See Table  4

The process of synthesizing the data presented in Table  4 involved identifying the relevant studies through a search process of databases (ERIC, Scopus, Web of Knowledge, Dimensions.ai, and lens.org) using specific keywords "ChatGPT" and "education". Following this, inclusion/exclusion criteria were applied, and data extraction was performed using Creswell's [ 15 ] coding techniques to capture key information and identify common themes across the included studies.

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Albadarin, Y., Saqr, M., Pope, N. et al. A systematic literature review of empirical research on ChatGPT in education. Discov Educ 3 , 60 (2024). https://doi.org/10.1007/s44217-024-00138-2

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• Published: 28 May 2024

Towards personalized medicine: a scoping review of immunotherapy in sepsis

• Marleen A. Slim 1 , 2   na1 ,
• Niels van Mourik 1 , 2   na1 ,
• Lieke Bakkerus 3 ,
• Katherine Fuller 4 ,
• Lydia Acharya 4 ,
• Tatiana Giannidis 4 ,
• Joanna C. Dionne 4 , 5 , 6 , 7 ,
• Simon J. W. Oczkowski 4 , 5 , 6 ,
• Mihai G. Netea 3 ,
• Peter Pickkers 8 ,
• Evangelos J. Giamarellos-Bourboulis 9 ,
• Marcella C. A. Müller 1 ,
• Tom van der Poll 2 , 10 ,
• W. Joost Wiersinga 2 , 10 ,
• in collaboration with the ImmunoSep Consortium ,
• Alexander P. J. Vlaar 1   na2 &
• Lonneke A. van Vught 1 , 2   na2  

Critical Care volume  28 , Article number:  183 ( 2024 ) Cite this article

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Despite significant progress in our understanding of the pathophysiology of sepsis and extensive clinical research, there are few proven therapies addressing the underlying immune dysregulation of this life-threatening condition. The aim of this scoping review is to describe the literature evaluating immunotherapy in adult patients with sepsis, emphasizing on methods providing a “personalized immunotherapy” approach, which was defined as the classification of patients into a distinct subgroup or subphenotype, in which a patient’s immune profile is used to guide treatment. Subgroups are subsets of sepsis patients, based on any cut-off in a variable. Subphenotypes are subgroups that can be reliably discriminated from other subgroup based on data-driven assessments. Included studies were randomized controlled trials and cohort studies investigating immunomodulatory therapies in adults with sepsis. Studies were identified by searching PubMed, Embase, Cochrane CENTRAL and ClinicalTrials.gov, from the first paper available until January 29th, 2024. The search resulted in 15,853 studies. Title and abstract screening resulted in 1409 studies (9%), assessed for eligibility; 771 studies were included, of which 282 (37%) were observational and 489 (63%) interventional. Treatment groups included were treatments targeting the innate immune response, the complement system, coagulation and endothelial dysfunction, non-pharmalogical treatment, pleiotropic drugs, immunonutrition, concomitant treatments, Traditional Chinese Medicine, immunostimulatory cytokines and growth factors, intravenous immunoglobulins, mesenchymal stem cells and immune-checkpoint inhibitors. A personalized approach was incorporated in 70 studies (9%). Enrichment was applied using cut-offs in temperature, laboratory, biomarker or genetic variables. Trials often showed conflicting results, possibly due to the lack of patient stratification or the potential influence of severity and timing on immunomodulatory therapy results. When a personalized approach was applied, trends of clinical benefit for several interventions emerged, which hold promise for future clinical trials using personalized immunotherapy.

Despite a global decrease in sepsis burden, sepsis still causes almost 20% of all deaths worldwide [ 1 ]. Over the past few decades, significant progress has been made in the understanding of the pathophysiology of sepsis [ 2 ], however, treatment is still limited to tackling the pathogens and providing supportive care. To date, limited proven therapies address the underlying mechanisms of this life-threatening condition.

The host response to infection can be dysregulated in multiple ways, resulting in a highly heterogeneous clinical presentation, treatment response, and prognosis [ 3 ]. The pathophysiology of sepsis involves dysregulation of the inflammatory response, but also catabolic, metabolic and immune-suppressive features can be present, together resulting in failure to return to homeostasis [ 3 , 4 , 5 ]. Modulating these various immune responses to infection represents a promising treatment option. Reason for the numerous failed clinical trials [ 4 , 5 , 6 ] could be the use of “one-size-fits-all” approaches, suggesting that personalized immunomodulatory treatment tailored to an individual patient’s immune profile may be a more successful treatment approach. The first step towards implementation of such a personalized strategy is providing a structured and in-depth overview of currently available evidence on immunotherapy in sepsis. The aim of this scoping review is to describe and summarize the literature evaluating immunotherapy in adult patients with sepsis, and to evaluate methods by which a personalized immunotherapy approach has been studied so far.

In line with our previously published protocol [ 7 ], studies were identified by searching PubMed, Embase, Cochrane CENTRAL and ClinicalTrials.gov from the first paper available until Janaury 29th, 2024. Inclusion criteria were: 1) randomized controlled trials (RCTs) or cohort studies (including case control studies and observational cohorts); 2) investigating immunomodulatory therapies; in 3) adult (≥ 16 years) patients with sepsis, 4) written in English or Dutch. We included studies that addressed therapies with a potential or hypothesized immunomodulatory effect (see Supplementary Methods). Exclusion criteria were: 1) case reports or systematic reviews; 2) animal studies; and 3) studies in healthy volunteers. We deviated from the previously publish protocol [ 7 ] by not including studies investigating coronavirus disease 2019 (COVID-19), since immunomodulatory treatments and patient stratification in COVID-19 is explored in a recently published review [ 8 ]. The full search strategies, screening and data extraction can be found in the Supplementary Methods. The results are organized in two steps. First, separating observational from interventional studies; and subsequently into treatment groups [ 3 ]. Ongoing trials are reported separately. The text in the main paper focusses on randomized controlled trials and studies applying a personalized approach; an overview of observational studies and non-randomized interventional studies not using a personalized approach can be found in the supplement. We defined a personalized approach as the classification of patients into a distinct subgroup or subphenotype. Subgroups are subsets of patients with the same disease or syndrome, based on any cut-off in temperature, laboratory, biomarker or genetic variables. In particular, subgroups based on age, sex or use of certain interventions (mechanical ventilation or vasopressors) were not considered subgroups for a personalized approach. Subphenotypes are subgroups that can be reliably discriminated from other subgroup based on data-driven assessments including machine learning techniques [ 9 ]. The use of disease severity scores was not considered as personalized. Individualized interventions were not included, since this review focused on personalized treatments, defined as applying specific treatment at subgroup or subphenotype level, and not at an individualized or patient level.

Study characteristics

The search resulted in 15,853 studies, including 43 studies identified through manual searching for the results of protocols, abstracts and registered studies. Our search was completed on January 29th, 2024. Title and abstract screening resulted in 1409 studies that were assessed for eligibility (Fig.  1 ). In total, 282 observational studies and 489 interventional studies were included (Figs.  1 and 2 ), of which 70 (9%) applied a personalized approach. Figure  2 depicts a timeline with an overview of the included studies in this review divided by study design, treatment group and year of publication. Figure  3 depicts an overview of all interventions discussed in this review in order to summarize all treatments that have been studied in the research field of immunotherapy in sepsis. Treatments in bold are discussed in the text and in the supplement, treatment not in bold can be found in the supplement.

Flow diagram for study selection. RCT, randomized controlled trial

Overview of the included studies. Overview of the included studies in this review A divided per treatment strategy, study design and treatment group and B divided per year, study design and treatment group demonstrated from the earliest to the latest studies overtime. RCT, Randomized controlled trial

Overview of all immunomodulatory treatments studies in adult patients with sepsis. Immunomodulatory treatments investigated in sepsis patients either modulate excessive inflammation (top op panel, in red) or aim at immune stimulation (bottom of panel, blue), furthermore there are combinations of these treatment strategies (bottom of panel, in grey) or treatments not fitting into these categories (bottom of panel, in green). All treatments displayed in this figure are included in this review; the treatments in bold are discussed in the text and in the supplement, treatment not in bold can be found in the supplement. Abbreviations: Ab, antibody; ACE, angiotensin-converting-enzyme; anti-PD-1, anti-programmed cell death protein 1; G(M)-CSF, granulocyte(-macrophage) colony-stimulating factor; Ig, immunoglobulin; IL, interleukin; L-NAME, L-NG-Nitro arginine methyl ester; NSAID, non-steroidal anti-inflammatory drugs; (r)a, (receptor) antagonist; TLR, toll-like receptor; TNF(r), tumor necrosis factor (receptor)

Strategies modulating excessive inflammation

Innate immune response.

Since excessive activation of the innate immune response causes host response dysregulation leading to sepsis, there is a clear rationale to study blocking innate immune activation [ 3 ]. Treatments targeting the innate immune response were studied in 11 (15%) observational studies, 5 (7%) non-randomized interventional studies and 57 (78%) RCTs (Supplementary Table  2 ). Treatments most studied were anti-tumor necrosis factor (TNF)α antibodies (Abs) (n = 17, 23%), anti-endotoxin Abs (n = 14, 19%) and interleukin (IL)-1 receptor antagonists (ra) (n = 10, 14%),

RCTs without a personalized approach

Since 1981, RCTs studying anti-endotoxin strategies, including antiserum raised in volunteers immunized with heat-killed mutant E coli J5 (murine E5)) and humanized (HA-1A) antibodies directed against the lipid-A part of endotoxin, have been published almost without positive results. Two studies showed a lower mortality in patients with gram-negative bacteremia (30% vs. 49%, n = 197, respectively, 22% vs. 39%, n = 212) [ 10 , 11 ]. However it has been stated that the results should be interpreted cautiously [ 12 ], since this effect was restricted to gram-negative bacteremia and patients most likely to benefit are difficult to identify, and none of the other anti-endotoxin trials showed similar results (Supplementary Table  2 ). Since 2007, inhibiting Toll-like receptor-4 (TLR4) has been examined using eritoran (a synthetic lipid A antagonist blocking lipopolysaccharide (LPS) from binding at the cell surface MD2-TLR4 receptor) or TAK-242 (a small molecule-inhibitor specific for TLR4) [ 3 ]. Neither was found to be effective in large RCTs in severe sepsis patients [ 13 , 14 ]. Since 1995, anti-TNFα Abs were examined in several trials yielding disappointing results [ 15 , 16 ]. In the 1990s, Anakinra, a recombinant human IL-1RA, was studied in 6 RCTs, without effect on mortality (Supplementary Table  2 ).

Studies with a personalized approach

In a retrospective RCT subgroup analysis, showing no survival benefit of anti-TNFα Ab CB0006 in 80 unselected severe sepsis patients, the patients with increased entry TNF-levels appeared to benefit from the high dose anti-TNF Ab (survival rate 86%, n = 7) [ 17 ]. When the anti-TNF Ab afelimomab was studied in a phase-III trial including sepsis patients using stratification, only patients with IL-6 levels > 1000 pg/mL had a reduced 28-day mortality (44% vs. 48%, n = 998) [ 18 ]. In a similar trial [ 19 ], sepsis patients with IL-6 levels > 1000 pg/mL were randomized to receive either afelimomab or placebo, without mortality effect (54% vs. 58%, n = 446). One of the RCTs [ 20 ] studying anakinra in 696 sepsis patients, failed to demonstrate a mortality reduction, however in a post-hoc analysis [ 21 ] treatment with anakinra provided a 30% decrease of 28-day mortality in patients who, at the start of treatment, had both liver dysfunction and disseminated intravascular coagulation which were interpreted by the authors as traits of macrophage activation. Another post-hoc analysis of this RCT showed that patients with higher baseline IL-1 levels showed mortality reduction compared to patients with lower IL-1 [ 22 ]. In an RCT examining IL-11 therapy in patients with thrombocytopenia, a less extensive inflammatory response and lower mortality was observed (31% vs. 14%, n = 105) [ 23 ]. In an RCT with patients treated with nangibotide, a triggering receptor expressed on myeloid cells-1 (TREM-1) inhibitor, grouped according to sTREM-1 concentrations at baseline, no improvement in sequential organ failure assessment (SOFA) score was seen [ 24 ].

Non-pharmacological treatments

The primary non-pharmacological immunotherapy treatment studied in sepsis is blood purification, which may be beneficial through removal of endotoxin, altering cytokine levels, mobilization of cytokines from local tissues, or through more complex processes of immune modulation [ 25 ]. Non-pharmacological treatments were studied in 63 (36%) observational studies, 51 (29%) non-randomized interventional studies and 59 (34%) RCTs (Supplementary Table  3 ). Treatments most studies were blood purification (n = 111, 64%), blood filtration (n = 47, 27%) and plasma treatments (e.g. plasma filtration or exchange, n = 12, 7%).

The clinical effects of these studies are mixed. For instance, while in the EUPHAS trial Polymyxin B hemoperfusion reduced 28-day mortality in 64 patients with severe abdominal sepsis (32% vs. 53%, aHR 0.36; 95% CI 0.16, 0.80) [ 26 ], the ABDOMIX trial in peritonitis-induced septic shock did not show a reduction in 28-day mortality (28% vs. 20%, n = 243) [ 27 ].

The EUPHRATES trial, a multicenter RCT including 450 patients using enrichment by including patients with endotoxin activity assay (EAA) levels ≥ 0.6, did not find improvement in 28-day survival when applying Polymyxin B hemoperfusion [ 28 ]. The trial showed that in some septic shock patients the burden of endotoxin activity was extreme (EAA ≥ 0.9). Therefore, a post-hoc analysis of the EUPHRATES trial was conducted in only patients with EAA of 0.6–0.89, not leading to better survival rates [ 29 ]. In a retrospective study using the EUPHRATES trial Polymyxin B hemoadsorption was associated with higher 28-day survival in patients with PT-INR > 1.4 or lactate > 3 mmol/L (68% vs. 52%, p  = 0.02) [ 30 ]. Cytokine adsorption and endotoxin hemoabsorption were studied in two observational studies including patients with septic shock and IL-6 ≥ 1000 ng/l, one study found an increased hazard of death of 1.82 (95% CI, 1.03–3.2) compared to a matched control group [ 31 ]; the other compared survivors and non-survivors and concluded that this treatment could be beneficial when applied early after onset of shock [ 32 ].

Complement system

The rationale for studying complement inhibitors is that excessive complement system activation contributes to sepsis-induced organ failure and death [ 33 ], which has been studied in 4 RCTs (Supplementary Table  4 ).

Treatment with complement (C)1-inhibitors infusion was studied in three RCTs and associated with reduced all-cause mortality (12% vs. 45% in control, n = 61) [ 34 ]. Furthermore, a phase-IIa trial on a monoclonal Anti-C5a antibody in 72 severe sepsis and septic shock patients demonstrated a dose-dependent neutralization of C5a. Complement inhibition was not studied in trials using a personalized approach.

Coagulation and endothelial dysfunction

The rationale for studies aiming at coagulation pathways and endothelial dysfunction in sepsis patients is that disseminated intravascular coagulation (DIC) and loss of endothelial barrier integrity are both key phenomena in the pathogenesis of sepsis [ 2 ]. Studies aiming at coagulation pathways and endothelial dysfunction were studied in 103 (62%) observational studies, 9 (5%) non-randomized interventional studies and 55 (33%) RCTs (Supplementary Table  5 ). The most studied treatment interventions were activated protein C (APC; n = 77, 46%), antithrombin (n = 25, 15%) and soluble thrombomodulin (n = 19, 11%).

RCT without a personalized approach

In PROWESS, a large phase-III trial in severe sepsis patients, a beneficial effect on 28-day mortality of APC was observed (25% vs. 31%, n = 1690) along with an increased risk of bleeding (3.5% versus 2.0%) [ 35 ]. In patients with septic shock, however, the phase-III PROWES-SHOCK trial did not show mortality reduction from treatment with APC (26% vs. 24%, n = 1697) [ 36 ]. Even though antithrombin therapy resulted in improvement of DIC [ 37 , 38 ], it did not result in a decreased mortality in patients with severe sepsis or septic shock (39% vs. 39%, n = 2314) [ 39 ]. In the SCARLET trial soluble thrombomodulin did not reduce mortality in unselected sepsis patient (27% vs. 29%, n = 800) [ 40 ].

In a predefined subgroup analyzing patients with severe protein C deficiency from the PROWESS-SHOCK, APC treatment did not result in differences in 28-day mortality (28.7% vs 30.8%, n = 673) [ 36 ]. However, in a retrospective cohort study in 48 patients with severe sepsis and elevated troponin, treatment with APC did improve intensive care unit (ICU)-mortality (30% vs. 72%, n = 48) [ 41 ]. A post hoc analysis of the SCARLET trial showed that patients with higher baseline thrombin generation biomarker levels showed reduced mortality when treated with recombinant human soluble thrombomodulin [ 42 ]. A study using coagulation phenotypes as a secondary analysis of multicenter registries on sepsis patients admitted to the ICU, demonstrated that in one in four phenotypes, the one with high fibrinogen/fibrin-degradation-products and D-Dimer, treatment with thrombomodulin was associated with lower mortality (adjusted risk difference -18%, 95% CI -29%,-7%, n = 323) [ 43 ]. Antithrombin supplementation therapy only reduced in-hospital mortality in sepsis patients with very low anthithrombin activity (HR 0.603, 95% CI 0.368, 0.988) [ 44 ]. When applying molecular phenotypes previously identified in acute respiratory distress syndrome (ARDS) different treatment response to activated protein C were found, with survival benefit in the hyperinflammatory and harm in the hypoinflammatory phenotype [ 45 ].

Pleiotropic drugs

Pleiotropic drugs refer to substances exerting effects other than for which it was initially developed. Corticosteroids (n = 89, 57%) and antibiotics (n = 18, 12%, mainly macrolides are known for their immunomodulatory effect [ 46 , 47 ]) are the primary pleotropic drugs used in sepsis (Supplementary Table  6 ). Pleiotropic drugs were studied in 64 (41%) observational studies, 6 (4%) non-randomized interventional studies and 85 (55%) RCTs.

Corticosteroids have been studied in sepsis patients in over 30 RCTs with contradicting results. In septic shock patients receiving hydrocortisone plus fludrocortisone compared to placebo, mortality was lower (43% vs. 49%, n = 1241) [ 48 ], however hydrocortisone alone in septic shock patients undergoing mechanical ventilation did not result in the same effect (28% vs. 29%, n = 3658) [ 49 ]. A recently published RCT showed a lower 28-day mortality among ~ 800 patients with severe community-acquired pneumonia treated in the ICU with hydrocortisone (12% vs. 6%) [ 50 ]. In an RCT in sepsis patients receiving vasopressors those who received intravenous vitamin C had a higher risk of death or persistent organ dysfunction (44.5% vs 38.5%, n = 872) [ 51 ]. Trials investigating the combination of vitamin C, thiamine, and hydrocortisone did not find positive results on ventilator-free-days [ 52 ] or mortality SPS:refid::bib53|bib54(53, 54). Treatment with clarithromycin, next to standard-of-care antimicrobial treatment, resulted in contradicting findings, the latest large trial did, however, found an association with a decreased 90-day mortality compared to placebo (43% vs. 60%, n = 200) [ 55 ].

In an RCT including patients with severe community-acquired pneumonia and C-reactive protein (CRP) > 150 mg/L methylprednisolone led to reduced treatment failure (development of shock, need for mechanical ventilation or death) compared to placebo (31% vs. 13%, n = 60) [ 56 ]. Increased mortality was observed in patients with sepsis response signature-(SRS)2 endotype compared to SRS1 in patients treated with hydrocortisone (n = 176, OR 7.9, 95% CI 1.6, 39.9) [ 57 ]. When assigning patients to two previously identified gene expression-based endotypes, corticosteroid exposure may be associated with increased mortality among septic shock endotype A patients (OR 3.1, 95% CI, 1.0 – 9.6, n = 97) [ 58 ]. When gene expression scores used to identify the immune state of shock patients; patients with the prevalent immune-adaptive state may be harmed by hydrocortisone [ 59 ]. Expression of GLCCI1 was associated with decreased time to shock reversal, and the expression of BHSD1 was associated with increased time to shock reversal (n = 494, HR 3.81 vs. 0.64 and HR 0.55 vs. 1.32, respectively) [ 60 ]. In two cohorts with > 1200 and > 2500 patients, studying the use of machine learning for corticosteroid treatment decision showed positive results [ 61 , 62 ]. Another cohort study employing machine learning identified interferon (IFN)γ/IL10 as a theranostic marker; a low serum IFNγ/IL10 ratio predicted increased survival in the hydrocortisone group whereas a high ratio predicted better survival in the placebo group [ 63 ]. One post-hoc analysis of an RCT examined the effect of simvastatin in sepsis-induced ARDS in patients with high baseline IL-18, which was associated with a higher survival probability (39% vs. 24%, n = 511) [ 64 ].

Immunonutrition, concomitant treatments and traditional chinese medicine

See the Supplementary Results for the studies regarding immunonutrition (Supplementary Table  7 ), concomitant treatments (Supplementary Table  8 ) and Traditional Chinese Medicine (Supplementary Table  9 ).

Strategies aiming at immune stimulation

Immunostimulatory cytokines and growth factors.

Immunostimulatory cytokines and growth factors have been studied in 2 (8%) observational studies, 7 (28%) interventional non-RCTs and 16 (64%) RCTs (Supplementary Table  10 ). Treatments most studies were granulocyte-colony stimulating factor (G-CSF) (n = 11, 44%) and granulocyte–macrophage colony-stimulating factor (GM-CSF) (n = 7, 28%).

Six RCTs investigating G-CSF did not show an effect on mortality (Supplementary Table  10 ). Even though likewise no survival benefit was found for GM-CSF, one RCT did demonstrate improved respiratory function (n = 18) [ 65 ].

Three RCTs studied biomarker-guided (human leukocyte antigen DR (HLA-DR) < 8000) GM-CSF treatment; one trial resulted in a shorter time of mechanical ventilation (148 ± 103 h vs. 207 ± 58 h, n = 38) [ 66 ]; another in decreased indoleamine 2,3-dioxygenase levels, possibly due to an improved antibacterial defense (35.4 ± 21.0 vs 21.6 ± 9.9 (baseline vs day 9), n = 36) [ 67 ]; another had no effect on the prevention on ICU-acquired infections (11% vs 11%, n = 98) [ 68 ]. In an RCT studying intramuscular recombinant human IL-7 (CYT107) in 27 patients with severe lymphopenia, CYT107 reversed the loss of CD4+ and CD8+ cells [ 69 ].

Intravenous immunoglobulins

Immunoglobulins can opsonize and neutralize pathogens and toxins resulting in immunostimulation and reduced inflammation. Immunoglobulins have been studied in 17 (41%) observational studies, 4 (10%) interventional non-RCTs and 20 (49%) RCTs (Supplementary Table  11 ).

RCTs without a personalized approach RCTs on immunoglobulins demonstrate contradicting results concerning improving patient outcome and decreasing mortality (Supplementary Table  11 ). For example, two RCTs on immunoglobulin (Ig)G demonstrated a lower mortality from septic shock in one trial (38% vs. 67%, n = 62) [ 70 ]; while no mortality reduction was seen in another trial (37% vs. 39%, n = 653) [ 71 ].

Studies with a personalized approach In an observation study intravenous immunoglobulins (IVIG) administration in patients with sepsis and low serum IgG levels was associated with improved prognosis (OR 0.15; 95%CI, 0.04–0.54; n = 87) [ 72 ]. In sepsis patients with neutropenia, polyclonal immunoglobulin M-enriched immunoglobulins led to a decrease in endotoxin levels in survivors, in non-survivors this was not seen [ 73 ]. In a post-hoc RCT analysis, a reduction of all-cause mortality was observed in pneumosepsis patients with high CRP and low IgM levels when administered trimodulin (polyclonal antibody) (reduction of 25%, n = 92) [ 74 ]. In an RCT studying the use of IVIG, IGMA had no effect on 28-day mortality in neutropenic patients (26% vs. 28%, n = 211) [ 75 ].

Mesenchymal stem cells

Mesenchymal stem cells enhance bacterial clearance and modulate the immune response. Mesenchymal stem cells have been studied in 1 (17%) observational study, 4 (67%) non-randomized interventional studies and 1 (17%) RCT (Supplementary Table  12 ).

RCTs with a personalized approach

One RCT showed that mesenchymal stem cells are safe and attributed to the faster hemodynamic stabilization in 30 patients with neutropenia [ 76 ].

Immune-checkpoint inhibitors

Immune-checkpoint inhibitors have been studied in 1 (33%) non-randomized interventional study and 2 (67%) RCTs (Supplementary Table  13 ).

Studies with a personalized approach Immune-checkpoint inhibitors, like anti-programmed death (PD)-1 antibodies, while not yet proven to enhance survival, also appear safe and could improve immune recovery in one non-randomized interventional study and two RCTs with patients with absolute lymphocyte count ≤ 1.1 × 10 3 cells/μL [ 77 , 78 , 79 ].

Combination of therapies and other therapies

See the Supplementary Results for studies investigating combination of therapies (Supplementary Table  14 ) and treatments that could not be classified into the previously mentioned treatment groups (Supplementary Table  15 ).

Ongoing trials

A search on ClinicalTrials.gov yielded 78 sepsis studies, reflecting ongoing research across the entire immunotherapy spectrum (Supplementary Table  16 ). Notably, sixteen studies (21%) implement a personalized approach. For the RCTs (n = 14) applying a personalized approach see Table  1 . One of these trials, employing a double-dummy design, is studying the impact of precision immunotherapy on sepsis phenotypes like hyperinflammation (using very high ferritin levels as a marker for macrophage activation-like syndrome (MALS)) and immunoparalysis (using low expression of HLA-DR on monocytes as marker of immunoparalysis) [ 80 ]. Patients, stratified by biomarkers are assigned to receive either placebo or active immunotherapy as an adjunct to standard care. The active treatments include anakinra for MALS and interferon-gamma for immunoparalysis.

This scoping review provides a comprehensive overview of immunomodulatory treatments investigated in adult patients with sepsis, highlighting studies with a personalized treatment approach. Our results show that trials often showed conflicting results. Possibly due to the lack of patient stratification, requiring the need to confirm positive findings in large multicenter populations or the potential influence of severity and timing on immunomodulatory therapy results. Several immunomodulatory treatments described in this review suggest possible efficacy, laying the groundwork for future trials to demonstrate their effectiveness. If a personalized approach is applied, clinical benefits of treatment appear to emerge in several studies. This emphasizes the need to decipher different host response endo-/phenotypes for the intervention to modulate.

Over 700 studies investigating immunotherapy in patients with sepsis have been performed and despite this body of evidence, the 2021 surviving sepsis campaign guidelines only include intravenous hydrocortisone as an immunomodulatory treatment for patients with vasopressor refractory septic shock [ 81 ]. Perhaps patient stratification might be the way forward, in which we have witnessed notable advancements in recent years, including therapies targeted by biomarker measurements. For instance, the ratio of IFN-γ to IL-10 has been used to guide corticosteroid therapy decisions [ 63 ], while HLA-DR levels on monocytes and plasma IL-10 concentrations have been used for stratification of treatment with either GM-CSF or IFN-γ [ 82 ]. In ongoing and upcoming sepsis trials, an increase in patient stratification has been observed. The personalized approach most applied is a cut-off value for inflammatory markers such as IL-6 or procalcitonin. Two studies use more complex stratification methods. One is the ImmunoSep trial (NCT04990232) which uses biomarker stratification to identify patients with either hyperinflammation or immunoparalysis [ 80 ]. Another example is the RECORDS trial, which aims at defining endotypes in sepsis adults associated with responsiveness to corticosteroids [ 83 ]. This multicenter, placebo-controlled, biomarker-guided, adaptive Bayesian design basket trial will randomly assign 1800 adults to a biomarker stratum to identify resistant or sensitive sepsis to corticosteroid treatment. In our opinion, using biomarker-based protocols for patient stratification will be the way forward in sepsis research.

The strengths of this review include the systematic search and comprehensive inclusion of all studies investigating immunomodulatory treatments in sepsis, including studies on immunonutrition, Traditional Chinese Medicine and concomitant treatments. Furthermore, it gives an extensive overview of studies that used a personalized approach, which can be used as the foundation for new study designs and aims. A few limitations should be mentioned. Given that the objective of this review was to provide a comprehensive overview of all studies examining immunomodulatory treatments in sepsis, a scoping review was considered the most suitable approach. Consequently, a risk of bias assessment was not conducted [ 84 ]. Although inevitable, different criteria for sepsis have been used over time [ 85 ], leading to heterogeneity in the population included. In this review treatments are considered personalized when a subgroup of subphenotype was selected based on biological characteristics possibly making the patient benefit more from a specific treatment, however, the is no uniform definition for ‘personalized medicine’. Since no qualitative methods such as qualitative text analysis, evidence maps or evidence gap maps, were deployed, no information on the research gaps in the field could be given. Due to the extensive body of evidence, we refrained from reporting cohort studies in a structured manner in the main text. Even though these observational studies and non-randomized interventional studies were included in the supplementary materials, not discussing them in the main text of the paper could be perceived as selective reporting bias. Lastly, since the search yielded a large amount of studies there was only limited possibility for in-depth description of important trials, including descriptions of the different dosages given.

Conclusions

Decades of extensive investigation into immunomodulatory treatments has led to over 700 studies investigating these treatment for sepsis, with often conflicting results. The lack of therapeutic efficacy appears to be related to the difficulty to enroll the right patients for the intervention. Since it is highly unlikely that one single immunomodulatory treatment will be universally effective in all sepsis patients, a personalized approach seems the way forward. To date, only a small proportion of studies have looked into enrichment strategies in sepsis, and for several interventions the therapeutic efficacy appears to emerge when a personalized approach was used. Patient stratification will play a pivotal role in the identification of patients that may benefit from targeted immunotherapy.

Availability of data and materials

Not applicable.

Abbreviations

Activated protein C

Acute respiratory distress syndrome

Coronavirus disease 2019

C-reactive protein

Disseminated intravascular coagulation

Endotoxin activity assay

Granulocyte-colony stimulating factor

Granulocyte–macrophage colony-stimulating factor

Human leukocyte antigen DR

Intensive care unit

Interleukin

(Intravenous) immunoglobulins

Lipopolysaccharide

Macrophage activation-like syndrome

Programmed death-1

Receptor antagonists

Randomized controlled trial

Sequential organ failure assessment

Toll-like receptor

Tumor necrosis factor

Triggering receptor expressed on myeloid cells-1

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Acknowledgements

Authors would like to gratefully thank Mrs. Faridi van Etten-Jamaludin (Medical Library, Amsterdam UMC, location AMC), who helped as an academic librarian to build the search equations, to search the databases and to exclude the duplicates and Maartje Kunen for help in the preparation of the figures.

the ImmunoSep Consortium

Bart-Jan Kullberg: [email protected]; Aline de Nooijer: [email protected]; Frank van de Veerdonk: [email protected]; Jaap ten Oever: [email protected]; Jacobien Hoogerwerf: [email protected]; Marlies Hulscher: [email protected]; Mihai Netea: [email protected]; Anke Oerlemans: [email protected]; Peter Pickkers: [email protected]; Athanasios Ziogas: [email protected]; Julie Swillens: [email protected]; Lisa van de Berg: [email protected]; Lieke Bakkerus: [email protected]; Nynke Bos: [email protected]; Matthijs Kox: [email protected]; Leda Estratiou: [email protected]; Evangelos Giamarellos-Bourboulis: [email protected]; Antigoni Kotsaki: [email protected]; Antonakos Nikolaos : [email protected]; Gregoriadis Spyros: [email protected]; Thierry Calandra: [email protected]; Sylvain Meylan : [email protected]; Tiia Snaka: [email protected]; Thierry Roger: [email protected]; Michael Bauer: [email protected]; Frank Brunkhorst: [email protected]; Frank Bloos: [email protected]; Sebastian Weis: [email protected]; Willy Hartman: [email protected]; Tom van der Poll: [email protected]; Marleen Slim : [email protected]; Niels van Mourik: [email protected]; Lonneke van Vught: [email protected]; Alexander Vlaar: [email protected]; Marcela Muller: [email protected]; Joost Wiersinga : [email protected]; Mihaela Lupse: [email protected]; Grigore Santamarean: [email protected]; Thomas Rimmele: [email protected]; Filippo Conti : [email protected]; Guillaume Monneret: [email protected]; Anna Aschenbrenner: [email protected]; Joachim Schultze: [email protected]; Martina van Uelft : [email protected]; Christoph Bock: [email protected]; Robert terHorst: [email protected]; Irit Gat-Viks: [email protected]; Einat Ron: [email protected]; Gal Yunkovitz: [email protected]; Sophie Ablott: [email protected]; Estelle Peronnet: [email protected]; Margaux Balezeaux: [email protected]; Adrien Saliou: [email protected]; Julie Hart: [email protected].

MAS, NvM, LB, MGN, PP, EJG-B, TvdP, WJW and APJV are supported by the European Commission (Horizon 2020, ImmunoSep, Grant No. 847422).

Author information

Marleen A. Slim and Niels van Mourik have contributed equally to this manuscript.

Alexander P.J. Vlaar and Lonneke A. van Vught have contributed equally to this manuscript.

Authors and Affiliations

Department of Intensive Care Medicine, Amsterdam University Medical Center, Meibergdreef 9, Room G3-220, 1105 AZ, Amsterdam, The Netherlands

Marleen A. Slim, Niels van Mourik, Marcella C. A. Müller, Alexander P. J. Vlaar & Lonneke A. van Vught

Center for Experimental and Molecular Medicine, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands

Marleen A. Slim, Niels van Mourik, Tom van der Poll, W. Joost Wiersinga & Lonneke A. van Vught

Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands

Lieke Bakkerus & Mihai G. Netea

Department of Medicine, McMaster University, Hamilton, Canada

Katherine Fuller, Lydia Acharya, Tatiana Giannidis, Joanna C. Dionne & Simon J. W. Oczkowski

The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, Research Institute St. Joseph’s Healthcare Hamilton, Hamilton, Canada

Joanna C. Dionne & Simon J. W. Oczkowski

Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada

Division of Gastroenterology, McMaster University, Hamilton, ON, Canada

Joanna C. Dionne

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MAS, TvdP, WJW, APJV and LAvV initiated the project, MAS and NvM lead the project. MAS, NvM, JCD, SJWO, MGN, MCAM, APJV and LAvV contributed to the conception and design of the study. JCD and SJWO helped as methodologists to design the study and present the results. All authors contributed to the acquisition of data, or the analysis and interpretation of the data; MAS, NvM, LB, KF, LA, TG, JCD, SJWO and LAvV drafted the manuscript. All authors provided critical revision of the article and provided final approval of the version submitted for publication.

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SJWO has received travel support from Fisher & Paykel Healthcare. MGN is a scientific founder of TTxD, Lemba and Biotrip. PP has received travel reimbursements and consulting fees from AM-Pharma, Adrenomed, EBI Paion, Sphingotec, and 4Teen4. EJG-B has received honoraria from Abbott Products Operations AG, bioMérieux, Brahms GmbH, GSK, InflaRx GmbH, Sobi and Xbiotech Inc; independent educational grants from Abbott Products Operations, bioMérieux Inc, InflaRx GmbH, Johnson & Johnson, MSD, UCB, Swedish Orphan Biovitrum AB; and funding from the Horizon 2020 European Grants ImmunoSep and RISCinCOVID and the Horizon Health grant EPIC-CROWN-2 (granted to the Hellenic Institute for the Study of Sepsis). WJW reports a project grants from EU, Amsterdam UMC and NOW/ZonMW and receives ad hoc consulting fees from GSK, Pfizer, Sobi, AstraZeneca paid to the institution. APJV receives consultant fees from InflaRx paid to the institution. LAvV was supported by the Netherlands Organisation  for  Health Research  and  Development ZonMW (Nederlandse Organisatie voor Wetenschappelijk Onderzoek NWO) VENI grant 09150161910033.

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Slim, M.A., van Mourik, N., Bakkerus, L. et al. Towards personalized medicine: a scoping review of immunotherapy in sepsis. Crit Care 28 , 183 (2024). https://doi.org/10.1186/s13054-024-04964-6

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Barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with psychosis: a scoping review protocol

• Cláudia C. Gonçalves   ORCID: orcid.org/0000-0001-6767-0920 1 ,
• Zoe Waters 2 ,
• Shae E. Quirk 1 ,
• Peter M. Haddad 1 , 3 ,
• Ashleigh Lin 4 ,
• Lana J. Williams 1 &
• Alison R. Yung 1 , 5  

Systematic Reviews volume  13 , Article number:  143 ( 2024 ) Cite this article

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The prevalence of psychosis has been shown to be disproportionately high amongst sexual and gender minority individuals. However, there is currently little consideration of the unique needs of this population in mental health treatment, with LGBTQA+ individuals facing barriers in accessing timely and non-stigmatising support for psychotic experiences. This issue deserves attention as delays to help-seeking and poor engagement with treatment predict worsened clinical and functional outcomes for people with psychosis. The present protocol describes the methodology for a scoping review which will aim to identify barriers and facilitators faced by LGBTQA+ individuals across the psychosis spectrum in help-seeking and accessing mental health support.

A comprehensive search strategy will be used to search Medline, PsycINFO, Embase, Scopus, LGBTQ+ Source, and grey literature. Original studies of any design, setting, and publication date will be included if they discuss barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with experiences of psychosis. Two reviewers will independently screen titles/abstracts and full-text articles for inclusion in the review. Both reviewers will then extract the relevant data according to pre-determined criteria, and study quality will be assessed using the Joanna Briggs Institute (JBI) critical appraisal checklists. Key data from included studies will be synthesised in narrative form according to the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews.

The results of this review will provide a comprehensive account of the current and historical barriers and facilitators to mental healthcare faced by LGBTQA+ people with psychotic symptoms and experiences. It is anticipated that the findings from this review will be relevant to clinical and community services and inform future research. Findings will be disseminated through publication in a peer-reviewed journal and presented at conferences.

Scoping review registration

This protocol is registered in Open Science Framework Registries ( https://doi.org/10.17605/OSF.IO/AT6FC ).

Peer Review reports

The prevalence of psychotic disorders in the general population has been estimated to be around 0.27–0.75% [ 1 , 2 ], with the lifetime prevalence of ever having a psychotic experience being estimated at 5.8% [ 3 ]. However, rates of psychotic symptoms and experiences are disproportionately high amongst LGBTQA+ populations, with non-heterosexual individuals estimated to be 1.99–3.75 times more likely to experience psychosis than their heterosexual peers [ 4 , 5 , 6 , 7 ]. Additionally, it has been estimated that transgender or gender non-conforming (henceforth trans) individuals are 2.46–49.7 times more likely than their cisgender peers (i.e. individuals whose gender identity is the same as their birth registered sex) to receive a psychotic disorder diagnosis [ 8 , 9 ]. The increased rates of psychotic experiences noted amongst gender and sexual minorities may be explained by evidence indicating that LGBTQA+ people are also exposed to risk factors for psychosis at a far greater rate than members of the general population, such as childhood adversity [ 10 , 11 , 12 ], minority stress [ 13 ], discrimination [ 14 ], and stigma [ 15 , 16 ]. Furthermore, there is added potential for diagnostic biases leading to over-diagnosing psychosis in gender diverse individuals, whose gender expression and dysphoria may be pathologized by mental health service providers [ 8 ].

Despite these concerning statistics, there is very little research examining the experiences of LGBTQA+ people with psychosis, and limited consideration of the unique needs these individuals may have in accessing and engaging with mental health services. While timely access to treatment has consistently been associated with better symptomatic and functional outcomes for people with psychosis [ 17 , 18 ], there are often delays to treatment initiation which are worsened for LGBTQA+ individuals [ 19 , 20 ]. These individuals face additional barriers to accessing adequate mental health support compared to cisgender/heterosexual people [ 19 ] and may need to experiment with several mental health services before finding culturally competent care [ 20 ]. This in turn may lead to longer duration of untreated psychosis. Additionally, there seems to be a lack of targeted support for this population from healthcare providers, with LGBTQA+ individuals with serious mental health concerns reporting higher rates of dissatisfaction with psychiatric services than their cisgender and heterosexual counterparts [ 7 , 14 , 21 ]. However, the extent of these differences varies across contexts [ 22 ], potentially due to improved education around stigma and LGBTQA+ issues within a subset of mental health services.

Nonetheless, stigma remains one of the highest cited barriers to help-seeking for mental health problems, particularly with regard to concerns around disclosure [ 23 ], which can be particularly challenging for people experiencing psychosis [ 24 , 25 ]. Stigma stress in young people at risk for psychosis is associated with less positive attitudes towards help-seeking regarding both psychiatric medication and psychotherapy [ 26 ], potentially partly due to fears of judgement and being treated differently by service providers [ 27 ]. This issue may be compounded for people who also belong to minoritized groups [ 23 , 28 ], particularly as LGBTQA+ individuals have reported experiencing frequent stigma and encountering uninformed staff when accessing mental healthcare [ 7 , 29 ]. Furthermore, stigma-fuelled hesitance to access services may be heightened for trans people [ 30 ] whose identities have historically been pathologized and conflated with experiences of psychosis [ 31 ].

Even when individuals manage to overcome barriers to access support, there are added challenges to maintaining adequate treatment engagement. In a large online study, half of trans and nearly one third of LGB participants reported having stopped using mental health services in the past because of negative experiences related to their gender identity or sexuality [ 20 ]. This can be particularly problematic as experiences of stigma predict poorer medication adherence in psychosis [ 32 ] which subsequently multiplies the risk for relapse and suicide [ 33 ]. While no research to date has explored non-adherence rates in people with psychosis who are LGBTQA+, concerns around suicidality are heightened for individuals who are gender and sexuality diverse [ 34 , 35 , 36 ].

Generally, there is rising demand for mental healthcare that specifically addresses the needs of gender and sexual minority individuals and promotes respect for diversity, equity, and inclusion [ 29 , 37 ]. This is particularly salient as positive relationships with staff are associated with better medication adherence for people with psychosis [ 38 ] and healthcare providers with LGBTQA+-specific mandates have demonstrated higher satisfaction rates for LGBTQA+ individuals [ 20 ]. Mental health services need to adapt treatment options to acknowledge minority stress factors for those with stigmatised identities and, perhaps more importantly, how these intersect and interact to increase inequalities in people from minoritized groups accessing and benefiting from treatment [ 37 , 39 ].

Additionally, gender affirming care needs to be recognised as an important facet of mental health treatment for many trans individuals, as it is associated with positive outcomes such as improvements in quality of life and psychological functioning [ 40 , 41 , 42 ] and reductions in psychiatric symptom severity and need for subsequent mental health treatment [ 8 , 43 ]. While there are additional barriers in access to gender affirming care for individuals with psychosis, this treatment has shown success in parallel with treatment to address psychosis symptom stabilisation [ 19 , 44 ]. The importance of affirmation is echoed by the finding that many negative experiences of LGBTQA+ participants with mental health services could be avoided simply by respecting people’s pronouns and using gender-neutral language [ 20 ].

To ensure timely access to appropriate treatment for LGBTQA+ people with psychosis, there is a need for improved understanding of the factors which challenge and facilitate help-seeking and engagement with mental health support. A preliminary search of Google Scholar, Medline, the Cochrane Database of Systematic Reviews, and PROSPERO was conducted and revealed no existing or planned reviews exploring benefits and/or obstacles to mental health treatment specific to this population. Therefore, the proposed review seeks to comprehensively search and appraise the existing literature to identify and summarise a range of barriers and facilitators to adequate mental health support faced by LGBTQA+ people with experiences of psychosis. This will allow for the mapping of the types of evidence available and identification of any knowledge gaps. Moreover, we hope to guide future decision-making in mental healthcare to improve service accessibility for LGBTQA+ individuals with psychosis and to set the foundations for future research that centres this marginalised population. Based on published guidance [ 45 , 46 , 47 ], a scoping review methodology was identified as the most appropriate approach to address these aims.

Selection criteria

This scoping review protocol has been developed in compliance with the JBI Manual for Evidence Synthesis [ 48 ] and, where relevant, the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist [ 49 ] (see Additional file 1). In the event of protocol amendments, the date, justification, and description for each amendment will be provided.

Due to the limited literature around the topic of this review, any primary original study design, setting, and publication date will be considered for inclusion. Publications written in English will be included, and articles in other languages may be considered pending time and cost constraints around translation. Publications will be excluded if the full text is not available upon request from authors.

The PCC (Population, Concept, Context) framework was used to develop the inclusion criteria for this scoping review:

This review will include individuals of any age who are LGBTQA+ and have had experiences of psychosis. For the purposes of this review, ‘LGBTQA+ individuals’ will be broadly defined as any individual that is not heterosexual and/or cisgender or anyone who engages in same-gender sexual behaviour. Studies may include participants who are cisgender and heterosexual if they separately report outcomes for LGBTQA+ individuals. Within this review, the term ‘psychosis’ includes (i) any diagnosis of a psychotic disorder, such as schizophrenia spectrum disorders, mood disorders with psychotic features, delusional disorders, and drug-induced psychotic disorders, (ii) sub-threshold psychotic symptoms, such as those present in ultra-high risk (UHR), clinical high risk (CHR), or at risk mental state (ARMS) individuals, and (iii) any psychotic-like symptoms or experiences. Studies may include participants with multiple diagnoses if they separately report outcomes for individuals on the psychosis spectrum.

This review will include publications which discuss potential barriers and/or facilitators to mental health help-seeking and/or engagement with mental health treatment. ‘Barriers’ will be operationalised as any factors which may delay or prevent individuals from accessing and engaging with appropriate mental health support. These may include lack of mental health education, experienced or internalised stigma, experiences of discrimination from health services, and lack of inclusivity in health services. ‘Facilitators’ will be operationalised as any factors which may promote timely help-seeking and engagement with sources of support. These may include improved access to mental health education, positive sources of social support, and welcoming and inclusive services. Mental health help-seeking will be broadly defined as any attempt to seek and access formal or informal support to address a mental health concern related to experiences of psychosis (e.g. making an initial appointment with a service provider, seeking help from a friend). Mental health treatment engagement will be broadly defined as adherence and active participation in the treatment that is offered by a source of support (e.g. attending scheduled appointments, taking medication as prescribed, openly communicating with service providers).

This review may include research encompassing any setting in which mental healthcare is provided. This is likely to include formal healthcare settings such as community mental health teams or inpatient clinics as well as informal settings such as LGBTQA+ spaces or informal peer support. Studies will be excluded if they focus exclusively on physical health treatment.

Search strategy

Database searches will be conducted in Medline, PsycINFO, Embase, Scopus, and LGBTQ+ Source. The full search strategy for this protocol is available (see Additional file 2). This strategy has been collaboratively developed and evaluated by a scholarly services health librarian. Searches will include subject headings relevant to each database and title/abstract keywords relating to three main concepts: (i) LGBTQA+ identity, (ii) experiences of psychosis, and (iii) mental health treatment. Keywords for each concept will be combined using the Boolean operator ‘OR’, and the three concepts will be combined using ‘AND’. This search strategy was appropriately translated for each of the selected databases. There will be no limitations on language or publication date at this stage to maximise the breadth of the literature captured. Publications returned from these searches will be exported to EndNote. Searches will be re-run prior to the final analysis to capture any newly published studies.

The database searches will be supplemented by searching the grey literature as per the eligibility criteria detailed above. These may include theses and dissertations, conference proceedings, reports from mental health services, and policy documents from LGBTQA+ groups. Google and Google Scholar will be searched using a combination of clauses for psychosis (Psychosis OR psychotic OR schizophrenia OR schizoaffective), treatment (treatment or “help-seeking”), and queer identity. The latter concept will have three clauses for three separate searches, with one including broad queer identity (LGBT), one specific to non-heterosexual individuals (gay OR lesbian OR homosexual OR bisexual OR queer OR asexual), and one specific to trans individuals (transgender OR transsexual OR transexual OR “non-binary” OR “gender minority”). Additionally, reference lists and citing literature will be manually searched for each paper included in the review to capture any articles and policy documents not previously identified.

Data selection

Search results will be imported into Covidence using EndNote, and duplicates will be eliminated. Titles and abstracts will be screened by the first and second authors according to pre-defined screening criteria, which will be discussed by the authors and piloted prior to screening. These criteria will consider whether the articles included LGBTQA+ participants with experiences of psychosis (as operationalised above) in relation to mental health help-seeking and/or treatment. Full texts of relevant articles will then be obtained and screened by the first and second reviewer in accordance with the full inclusion and exclusion criteria after initial piloting to maximise inter-rater reliability. Decisions on inclusion and exclusion will be blinded and recorded on Covidence. Potential discrepancies will be resolved through discussion, and when consensus cannot be reached, these will be resolved by the supervising author. The process of study selection will be documented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram [ 50 ].

Data extraction

Data extraction will be performed independently by two reviewers using Covidence. Prior to beginning final extraction, both reviewers will independently pilot the extraction tool using a sample of five included studies and discuss any necessary changes. Information extracted is planned to include the following: title, author name(s), year of publication, country in which the study was conducted, study design, sample size, population of focus (i.e. sexual minorities, gender minorities, or both), sample demographics (i.e. age, gender identity, and sexual orientation), setting (e.g. early intervention service, community mental health team, etc.), psychosis characteristics (e.g. diagnoses included, severity of symptoms, etc.), type of treatment (e.g. cognitive behavioural therapy, antipsychotic medication, etc.), and any barriers and/or facilitators identified according to the aforementioned operationalised definitions. Disagreements will be resolved through discussion between the two reviewers and, when necessary, final decisions will be made by a senior supervisor. Once extracted, information will be recorded in Excel. Lead authors of papers will be contacted by the primary review author in cases where there is missing or insufficient data.

Quality assessment

Due to the expected heterogeneity in the types of studies that may be included in this review (e.g. qualitative studies, randomised controlled trials, case control studies, case reports), the relevant revised Joanna Briggs Institute (JBI) critical appraisal checklists [ 51 ] will be used to assess risk of bias and study quality for each study design. Two reviewers will independently use these checklists to assess each paper that is included following the full-text screening. If there are discrepancies in article ratings, these will be resolved through discussion between the two authors. If no consensus is reached, discrepancies will be resolved by a senior supervisor. In line with the scoping nature of this review, low-quality studies will not be excluded from the synthesis.

Evidence synthesis

Data from included studies will be synthesised using a narrative synthesis approach in accordance with the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews [ 52 ]. A preliminary descriptive synthesis will be conducted by tabulating the extracted data elements from each study alongside quality assessment results and developing an initial description of the barriers and facilitators to (1) accessing and (2) engaging with mental health support that are identified in the literature. This initial synthesis will then be interrogated and refined to contextualise these barriers and facilitators in the setting, population, and methodology of each study to form the basis for an interpretative synthesis.

This review will not use a pre-existing thematic framework to categorise barriers and facilitators as it is expected that the factors identified will not neatly fit into existing criteria. Instead, these will be conceptualised according to overarching themes as interrelated factors, so that potentially complex interactions between barriers and facilitators within and across relevant studies may be explored through concept mapping. If most of the studies included are qualitative, there may also be scope for a partial meta-synthesis. To avoid oversimplifying the concept of ‘barriers and facilitators’ (see criticism by Bach-Mortensen & Verboom [ 53 ]), this data synthesis will be followed by a critical reflection of the findings through the lens of the socio-political contexts which may give rise to the barriers and facilitators identified, exploring the complexities necessary for any changes to be implemented in mental health services.

If the extracted data indicate that gender minority and sexual minority individuals experience unique or different barriers and/or facilitators to each other, these population groups will be analysed separately as opposed to findings being generalised across the LGBTQA+ spectrum. Furthermore, if there is scope to do so, analyses may be conducted to investigate how perceived barriers and facilitators for this population may have changed over time (i.e. according to publication date) as definitions of psychosis evolve and LGBTQA+ individuals gain visibility in clinical services.

The proposed review will add to the literature around mental health treatment for LGBTQA+ people with psychosis. It will provide a thorough account of the barriers and facilitators to accessing and engaging with support faced by this population and may inform future research and clinical practice.

In terms of limitations, this review will be constrained by the existing literature and may therefore not be sufficiently comprehensive in reflecting the barriers and facilitators experienced by subgroups within the broader LGBTQA+ community. Additionally, although broad inclusion criteria are necessary to capture the full breadth of research conducted in this topic, included studies are likely to be heterogeneous and varied in terms of their methodology and population which may complicate data synthesis.

Nonetheless, it is anticipated that the findings from this review will provide the most comprehensive synthesis to date of the issues driving low help-seeking and treatment engagement in people across the psychosis spectrum who are LGBTQA+. This review will likely also identify gaps in the literature which may inform avenues for future research, and the factors identified in this review will be considered in subsequent research by the authors.

Additionally, findings will be relevant to healthcare providers that offer support to people with psychosis who may have intersecting LGBTQA+ identities as well as LGBTQA+ organisations which offer support to LGBTQA+ people who may be experiencing distressing psychotic experiences. These services are likely to benefit from an increased awareness of the factors which may improve or hinder accessibility for these subsets of their target populations. Therefore, results from this review may inform decision-making around the implementation of service-wide policy changes.

The findings of this review will be disseminated through the publication of an article in a peer-reviewed journal and presented at relevant conferences in Australia and/or internationally. Additionally, the completed review will form part of the lead author’s doctoral thesis.

Availability of data and materials

Not applicable for this protocol.

Abbreviations

• At risk mental state

Clinical high risk for psychosis

Joanna Briggs Institute

Lesbian, gay, and bisexual

Lesbian, gay, bisexual, transgender, queer or questioning, asexual or aromantic, and more

Population, Concept, Context

Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols

Ultra-high risk for psychosis

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Acknowledgements

The authors would like to acknowledge the support of Ms Olivia Larobina, Scholarly Services Librarian (STEMM) at Deakin University, in the development of the search strategy.

CCG is funded by a Deakin University Postgraduate Research (DUPR) Scholarship. ZW is funded by a University of Western Australia Research Training Program (RTP) Scholarship. AL is supported by a National Health and Medical Research Council (NHMRC) Emerging Leaders Fellowship (2010063). LJW is supported by a NHMRC Emerging Leaders Fellowship (1174060). ARY is supported by a NHMRC Principal Research Fellowship (1136829). The funding providers had no role in the design and conduct of the study, or in the preparation, review, or approval of this manuscript.

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Cláudia C. Gonçalves, Shae E. Quirk, Peter M. Haddad, Lana J. Williams & Alison R. Yung

Telethon Kids Institute, University of Western Australia, Perth, WA, 6009, Australia

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CCG is the guarantor. CCG conceptualised the review, developed the study design, and drafted the manuscript. CCG, ZW, and SQ collaborated with OL (Scholarly Services Librarian) to develop the search strategy. All authors critically reviewed the manuscript. All authors read and approved the final manuscript.

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Correspondence to Cláudia C. Gonçalves .

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In the last 3 years, PMH has received honoraria for lecturing from Janssen, NewBridge Pharmaceuticals, and Otsuka and royalties from edited textbooks (Cambridge University Press, Oxford University Press).

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Supplementary Information

Additional file 1. prisma-p 2015 checklist. completed prisma-p checklist for this systematic review protocol., 13643_2024_2566_moesm2_esm.docx.

Additional file 2. Search Strategy. Detailed search strategy for this systematic review, including search terms and relevant controlled vocabulary terms for each included database.

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Gonçalves, C.C., Waters, Z., Quirk, S.E. et al. Barriers and facilitators to mental health treatment access and engagement for LGBTQA+ people with psychosis: a scoping review protocol. Syst Rev 13 , 143 (2024). https://doi.org/10.1186/s13643-024-02566-5

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Received : 04 July 2023

Accepted : 17 May 2024

Published : 30 May 2024

DOI : https://doi.org/10.1186/s13643-024-02566-5

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