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Literature Reviews

• Qualitative or Quantitative?
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Qualitative researchers TEND to:

Researchers using qualitative methods tend to:

• t hink that social sciences cannot be well-studied with the same methods as natural or physical sciences
• feel that human behavior is context-specific; therefore, behavior must be studied holistically, in situ, rather than being manipulated
• employ an 'insider's' perspective; research tends to be personal and thereby more subjective.
• do interviews, focus groups, field research, case studies, and conversational or content analysis.

Image from https://www.editage.com/insights/qualitative-quantitative-or-mixed-methods-a-quick-guide-to-choose-the-right-design-for-your-research?refer-type=infographics

Qualitative Research (an operational definition)

Qualitative Research: an operational description

Purpose : explain; gain insight and understanding of phenomena through intensive collection and study of narrative data

Approach: inductive; value-laden/subjective; holistic, process-oriented

Hypotheses: tentative, evolving; based on the particular study

Lit. Review: limited; may not be exhaustive

Setting: naturalistic, when and as much as possible

Sampling : for the purpose; not necessarily representative; for in-depth understanding

Measurement: narrative; ongoing

Design and Method: flexible, specified only generally; based on non-intervention, minimal disturbance, such as historical, ethnographic, or case studies

Data Collection: document collection, participant observation, informal interviews, field notes

Data Analysis: raw data is words/ ongoing; involves synthesis

Data Interpretation: tentative, reviewed on ongoing basis, speculative

• Qualitative research with more structure and less subjectivity
• Increased application of both strategies to the same study ("mixed methods")
• Evidence-based practice emphasized in more fields (nursing, social work, education, and others).

Some Other Guidelines

• Guide for formatting Graphs and Tables
• Critical Appraisal Checklist for an Article On Qualitative Research

Quantitative researchers TEND to:

Researchers using quantitative methods tend to:

• think that both natural and social sciences strive to explain phenomena with confirmable theories derived from testable assumptions
• attempt to reduce social reality to variables, in the same way as with physical reality
• try to tightly control the variable(s) in question to see how the others are influenced.
• Do experiments, have control groups, use blind or double-blind studies; use measures or instruments.

Quantitative Research (an operational definition)

Quantitative research: an operational description

Purpose: explain, predict or control phenomena through focused collection and analysis of numberical data

Approach: deductive; tries to be value-free/has objectives/ is outcome-oriented

Hypotheses : Specific, testable, and stated prior to study

Lit. Review: extensive; may significantly influence a particular study

Setting: controlled to the degree possible

Sampling: uses largest manageable random/randomized sample, to allow generalization of results to larger populations

Measurement: standardized, numberical; "at the end"

Design and Method: Strongly structured, specified in detail in advance; involves intervention, manipulation and control groups; descriptive, correlational, experimental

Data Collection: via instruments, surveys, experiments, semi-structured formal interviews, tests or questionnaires

Data Analysis: raw data is numbers; at end of study, usually statistical

Data Interpretation: formulated at end of study; stated as a degree of certainty

This page on qualitative and quantitative research has been adapted and expanded from a handout by Suzy Westenkirchner. Used with permission.

Images from https://www.editage.com/insights/qualitative-quantitative-or-mixed-methods-a-quick-guide-to-choose-the-right-design-for-your-research?refer-type=infographics.

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Chapter 9. Reviewing the Literature

What is a “literature review”.

No researcher ever comes up with a research question that is wholly novel. Someone, somewhere, has asked the same thing. Academic research is part of a larger community of researchers, and it is your responsibility, as a member of this community, to acknowledge others who have asked similar questions and to put your particular research into this greater context. It is not simply a convention or custom to begin your study with a review of previous literature (the “ lit review ”) but an important responsibility you owe the scholarly community.

Too often, new researchers pursue a topic to study and then write something like, “No one has ever studied this before” or “This area is underresearched.” It may be that no one has studied this particular group or setting, but it is highly unlikely no one has studied the foundational phenomenon of interest. And that comment about an area being underresearched? Be careful. The statement may simply signal to others that you haven’t done your homework. Rubin ( 2021 ) refers to this as “free soloing,” and it is not appreciated in academic work:

The truth of the matter is, academics don’t really like when people free solo. It’s really bad form to omit talking about the other people who are doing or have done research in your area. Partly, I mean we need to cite their work, but I also mean we need to respond to it—agree or disagree, clarify for extend. It’s also really bad form to talk about your research in a way that does not make it understandable to other academics.…You have to explain to your readers what your story is really about in terms they care about . This means using certain terminology, referencing debates in the literature, and citing relevant works—that is, in connecting your work to something else. ( 51–52 )

A literature review is a comprehensive summary of previous research on a topic. It includes both articles and books—and in some cases reports—relevant to a particular area of research. Ideally, one’s research question follows from the reading of what has already been produced. For example, you are interested in studying sports injuries related to female gymnasts. You read everything you can find on sports injuries related to female gymnasts, and you begin to get a sense of what questions remain open. You find that there is a lot of research on how coaches manage sports injuries and much about cultures of silence around treating injuries, but you don’t know what the gymnasts themselves are thinking about these issues. You look specifically for studies about this and find several, which then pushes you to narrow the question further. Your literature review then provides the road map of how you came to your very specific question, and it puts your study in the context of studies of sports injuries. What you eventually find can “speak to” all the related questions as well as your particular one.

In practice, the process is often a bit messier. Many researchers, and not simply those starting out, begin with a particular question and have a clear idea of who they want to study and where they want to conduct their study but don’t really know much about other studies at all. Although backward, we need to recognize this is pretty common. Telling students to “find literature” after the fact can seem like a purposeless task or just another hurdle for completing a thesis or dissertation. It is not! Even if you were not motivated by the literature in the first place, acknowledging similar studies and connecting your own research to those studies are important parts of building knowledge. Acknowledgment of past research is a responsibility you owe the discipline to which you belong.

Literature reviews can also signal theoretical approaches and particular concepts that you will incorporate into your own study. For example, let us say you are doing a study of how people find their first jobs after college, and you want to use the concept of social capital . There are competing definitions of social capital out there (e.g., Bourdieu vs. Burt vs. Putnam). Bourdieu’s notion is of one form of capital, or durable asset, of a “network of more or less institutionalized relationships of mutual acquaintance or recognition” ( 1984:248 ). Burt emphasizes the “brokerage opportunities” in a social network as social capital ( 1997:355 ). Putnam’s social capital is all about “facilitating coordination and cooperation for mutual benefit” ( 2001:67 ). Your literature review can adjudicate among these three approaches, or it can simply refer to the one that is animating your own research. If you include Bourdieu in your literature review, readers will know “what kind” of social capital you are talking about as well as what kind of social scientist you yourself are. They will likely understand that you are interested more in how some people are advantaged by their social capital relative to others rather than being interested in the mechanics of how social networks operate.

The literature review thus does two important things for you: firstly, it allows you to acknowledge previous research in your area of interest, thereby situating you within a discipline or body of scholars, and, secondly, it demonstrates that you know what you are talking about. If you present the findings of your research study without including a literature review, it can be like singing into the wind. It sounds nice, but no one really hears it, or if they do catch snippets, they don’t know where it is coming from.

Examples of Literature Reviews

To help you get a grasp of what a good literature review looks like and how it can advance your study, let’s take a look at a few examples.

Reader-Friendly Example: The Power of Peers

The first is by Janice McCabe ( 2016 ) and is from an article on peer networks in the journal Contexts . Contexts presents articles in a relatively reader-friendly format, with the goal of reaching a large audience for interesting sociological research. Read this example carefully and note how easily McCabe is able to convey the relevance of her own work by situating it in the context of previous studies:

Scholars who study education have long acknowledged the importance of peers for students’ well-being and academic achievement. For example, in 1961, James Coleman argued that peer culture within high schools shapes students’ social and academic aspirations and successes. More recently, Judith Rich Harris has drawn on research in a range of areas—from sociological studies of preschool children to primatologists’ studies of chimpanzees and criminologists’ studies of neighborhoods—to argue that peers matter much more than parents in how children “turn out.” Researchers have explored students’ social lives in rich detail, as in Murray Milner’s book about high school students, Freaks, Geeks, and Cool Kids , and Elizabeth Armstrong and Laura Hamilton’s look at college students, Paying for the Party . These works consistently show that peers play a very important role in most students’ lives. They tend, however, to prioritize social over academic influence and to use a fuzzy conception of peers rather than focusing directly on friends—the relationships that should matter most for student success. Social scientists have also studied the power of peers through network analysis, which is based on uncovering the web of connections between people. Network analysis involves visually mapping networks and mathematically comparing their structures (such as the density of ties) and the positions of individuals within them (such as how central a given person is within the network). As Nicholas Christakis and James Fowler point out in their book Connected , network structure influences a range of outcomes, including health, happiness, wealth, weight, and emotions. Given that sociologists have long considered network explanations for social phenomena, it’s surprising that we know little about how college students’ friends impact their experiences. In line with this network tradition, I focus on the structure of friendship networks, constructing network maps so that the differences we see across participants are due to the underlying structure, including each participant’s centrality in their friendship group and the density of ties among their friends. ( 23 )

What did you notice? In her very second sentence, McCabe uses “for example” to introduce a study by Coleman, thereby indicating that she is not going to tell you every single study in this area but is going to tell you that (1) there is a lot of research in this area, (2) it has been going on since at least 1961, and (3) it is still relevant (i.e., recent studies are still being done now). She ends her first paragraph by summarizing the body of literature in this area (after giving you a few examples) and then telling you what may have been (so far) left out of this research. In the second paragraph, she shifts to a separate interesting focus that is related to the first but is also quite distinct. Lit reviews very often include two (or three) distinct strands of literature, the combination of which nicely backgrounds this particular study . In the case of our female gymnast study (above), those two strands might be (1) cultures of silence around sports injuries and (2) the importance of coaches. McCabe concludes her short and sweet literature review with one sentence explaining how she is drawing from both strands of the literature she has succinctly presented for her particular study. This example should show you that literature reviews can be readable, helpful, and powerful additions to your final presentation.

Authoritative Academic Journal Example: Working Class Students’ College Expectations

The second example is more typical of academic journal writing. It is an article published in the British Journal of Sociology of Education by Wolfgang Lehmann ( 2009 ):

Although this increase in post-secondary enrolment and the push for university is evident across gender, race, ethnicity, and social class categories, access to university in Canada continues to be significantly constrained for those from lower socio-economic backgrounds (Finnie, Lascelles, and Sweetman 2005). Rising tuition fees coupled with an overestimation of the cost and an underestimation of the benefits of higher education has put university out of reach for many young people from low-income families (Usher 2005). Financial constraints aside, empirical studies in Canada have shown that the most important predictor of university access is parental educational attainment. Having at least one parent with a university degree significantly increases the likelihood of a young person to attend academic-track courses in high school, have high educational and career aspirations, and ultimately attend university (Andres et al. 1999, 2000; Lehmann 2007a). Drawing on Bourdieu’s various writing on habitus and class-based dispositions (see, for example, Bourdieu 1977, 1990), Hodkinson and Sparkes (1997) explain career decisions as neither determined nor completely rational. Instead, they are based on personal experiences (e.g., through employment or other exposure to occupations) and advice from others. Furthermore, they argue that we have to understand these decisions as pragmatic, rather than rational. They are pragmatic in that they are based on incomplete and filtered information, because of the social context in which the information is obtained and processed. New experiences and information can, however, also be allowed into one’s world, where they gradually or radically transform habitus, which in turn creates the possibility for the formation of new and different dispositions. Encountering a supportive teacher in elementary or secondary school, having ambitious friends, or chance encounters can spark such transformations. Transformations can be confirming or contradictory, they can be evolutionary or dislocating. Working-class students who enter university most certainly encounter such potentially transformative situations. Granfield (1991) has shown how initially dislocating feelings of inadequacy and inferiority of working-class students at an elite US law school were eventually replaced by an evolutionary transformation, in which the students came to dress, speak and act more like their middle-class and upper-class peers. In contrast, Lehmann (2007b) showed how persistent habitus dislocation led working-class university students to drop out of university. Foskett and Hemsley-Brown (1999) argue that young people’s perceptions of careers are a complex mix of their own experiences, images conveyed through adults, and derived images conveyed by the media. Media images of careers, perhaps, are even more important for working-class youth with high ambitions as they offer (generally distorted) windows into a world of professional employment to which they have few other sources of access. It has also been argued that working-class youth who do continue to university still face unique, class-specific challenges, evident in higher levels of uncertainty (Baxter and Britton 2001; Lehmann 2004, 2007a; Quinn 2004), their higher education choices (Ball et al. 2002; Brooks 2003; Reay et al. 2001) and fears of inadequacy because of their cultural outsider status (Aries and Seider 2005; Granfield 1991). Although the number of working-class university students in Canada has slowly increased, that of middle-class students at university has risen far more steeply (Knighton and Mizra 2002). These different enrolment trajectories have actually widened the participation gap, which in tum explains our continued concerns with the potential outsider status Indeed, in a study comparing first-generation working-class and traditional students who left university without graduating, Lehmann (2007b) found that first-generation working-class students were more likely to leave university very early in some cases within the first two months of enrollment. They were also more likely to leave university despite solid academic performance. Not “fitting in,” not “feeling university,” and not being able to “relate to these people” were key reasons for eventually withdrawing from university. From the preceding review of the literature, a number of key research questions arise: How do working-class university students frame their decision to attend university? How do they defy the considerable odds documented in the literature to attend university? What are the sources of information and various images that create dispositions to study at university? What role does their social-class background- or habitus play in their transition dispositions and how does this translate into expectations for university? ( 139 )

What did you notice here? How is this different from (and similar to) the first example? Note that rather than provide you with one or two illustrative examples of similar types of research, Lehmann provides abundant source citations throughout. He includes theory and concepts too. Like McCabe, Lehmann is weaving through multiple literature strands: the class gap in higher education participation in Canada, class-based dispositions, and obstacles facing working-class college students. Note how he concludes the literature review by placing his research questions in context.

Find other articles of interest and read their literature reviews carefully. I’ve included two more for you at the end of this chapter . As you learned how to diagram a sentence in elementary school (hopefully!), try diagramming the literature reviews. What are the “different strands” of research being discussed? How does the author connect these strands to their own research questions? Where is theory in the lit review, and how is it incorporated (e.g., Is it a separate strand of its own or is it inextricably linked with previous research in this area)?

One model of how to structure your literature review can be found in table 9.1. More tips, hints, and practices will be discussed later in the chapter.

Table 9.1. Model of Literature Review, Adopted from Calarco (2020:166)

Embracing Theory

A good research study will, in some form or another, use theory. Depending on your particular study (and possibly the preferences of the members of your committee), theory may be built into your literature review. Or it may form its own section in your research proposal/design (e.g., “literature review” followed by “theoretical framework”). In my own experience, I see a lot of graduate students grappling with the requirement to “include theory” in their research proposals. Things get a little squiggly here because there are different ways of incorporating theory into a study (Are you testing a theory? Are you generating a theory?), and based on these differences, your literature review proper may include works that describe, explain, and otherwise set forth theories, concepts, or frameworks you are interested in, or it may not do this at all. Sometimes a literature review sets forth what we know about a particular group or culture totally independent of what kinds of theoretical framework or particular concepts you want to explore. Indeed, the big point of your study might be to bring together a body of work with a theory that has never been applied to it previously. All this is to say that there is no one correct way to approach the use of theory and the writing about theory in your research proposal.

Students are often scared of embracing theory because they do not exactly understand what it is. Sometimes, it seems like an arbitrary requirement. You’re interested in a topic; maybe you’ve even done some research in the area and you have findings you want to report. And then a committee member reads over what you have and asks, “So what?” This question is a good clue that you are missing theory, the part that connects what you have done to what other researchers have done and are doing. You might stumble upon this rather accidentally and not know you are embracing theory, as in a case where you seek to replicate a prior study under new circumstances and end up finding that a particular correlation between behaviors only happens when mediated by something else. There’s theory in there, if you can pull it out and articulate it. Or it might be that you are motivated to do more research on racial microaggressions because you want to document their frequency in a particular setting, taking for granted the kind of critical race theoretical framework that has done the hard work of defining and conceptualizing “microaggressions” in the first place. In that case, your literature review could be a review of Critical Race Theory, specifically related to this one important concept. That’s the way to bring your study into a broader conversation while also acknowledging (and honoring) the hard work that has preceded you.

Rubin ( 2021 ) classifies ways of incorporating theory into case study research into four categories, each of which might be discussed somewhat differently in a literature review or theoretical framework section. The first, the least theoretical, is where you set out to study a “configurative idiographic case” ( 70 ) This is where you set out to describe a particular case, leaving yourself pretty much open to whatever you find. You are not expecting anything based on previous literature. This is actually pretty weak as far as research design goes, but it is probably the default for novice researchers. Your committee members should probably help you situate this in previous literature in some way or another. If they cannot, and it really does appear you are looking at something fairly new that no one else has bothered to research before, and you really are completely open to discovery, you might try using a Grounded Theory approach, which is a methodological approach that foregrounds the generation of theory. In that case, your “theory” section can be a discussion of “Grounded Theory” methodology (confusing, yes, but if you take some time to ponder, you will see how this works). You will still need a literature review, though. Ideally one that describes other studies that have ever looked at anything remotely like what you are looking at—parallel cases that have been researched.

The second approach is the “disciplined configurative case,” in which theory is applied to explain a particular case or topic. You are not trying to test the theory but rather assuming the theory is correct, as in the case of exploring microaggressions in a particular setting. In this case, you really do need to have a separate theory section in addition to the literature review, one in which you clearly define the theoretical framework, including any of its important concepts. You can use this section to discuss how other researchers have used the concepts and note any discrepancies in definitions or operationalization of those concepts. This way you will be sure to design your study so that it speaks to and with other researchers. If everyone who is writing about microaggressions has a different definition of them, it is hard for others to compare findings or make any judgments about their prevalence (or any number of other important characteristics). Your literature review section may then stand alone and describe previous research in the particular area or setting, irrespective of the kinds of theory underlying those studies.

The third approach is “heuristic,” one in which you seek to identify new variables, hypotheses, mechanisms, or paths not yet explained by a theory or theoretical framework. In a way, you are generating new theory, but it is probably more accurate to say that you are extending or deepening preexisting theory. In this case, having a single literature review that is focused on the theory and the ways the theory has been applied and understood (with all its various mechanisms and pathways) is probably your best option. The focus of the literature reviewed is less on the case and more on the theory you are seeking to extend.

The final approach is “theory testing,” which is much rarer in qualitative studies than in quantitative, where this is the default approach. Theory-testing cases are those where a particular case is used to see if an existing theory is accurate or accurate under particular circumstances. As with the heuristic approach, your literature review will probably draw heavily on previous uses of the theory, but you may end up having a special section specifically about cases very close to your own . In other words, the more your study approaches theory testing, the more likely there is to be a set of similar studies to draw on or even one important key study that you are setting your own study up in parallel to in order to find out if the theory generated there operates here.

If we wanted to get very technical, it might be useful to distinguish theoretical frameworks properly from conceptual frameworks. The latter are a bit looser and, given the nature of qualitative research, often fit exploratory studies. Theoretical frameworks rely on specific theories and are essential for theory-testing studies. Conceptual frameworks can pull in specific concepts or ideas that may or may not be linked to particular theories. Think about it this way: A theory is a story of how the world works. Concepts don’t presume to explain the whole world but instead are ways to approach phenomena to help make sense of them. Microaggressions are concepts that are linked to Critical Race Theory. One could contextualize one’s study within Critical Race Theory and then draw various concepts, such as that of microaggressions from the overall theoretical framework. Or one could bracket out the master theory or framework and employ the concept of microaggression more opportunistically as a phenomenon of interest. If you are unsure of what theory you are using, you might want to frame a more practical conceptual framework in your review of the literature.

Helpful Tips

How to maintain good notes for what your read.

Over the years, I have developed various ways of organizing notes on what I read. At first, I used a single sheet of full-size paper with a preprinted list of questions and points clearly addressed on the front side, leaving the second side for more reflective comments and free-form musings about what I read, why it mattered, and how it might be useful for my research. Later, I developed a system in which I use a single 4″ × 6″ note card for each book I read. I try only to use the front side (and write very small), leaving the back for comments that are about not just this reading but things to do or examine or consider based on the reading. These notes often mean nothing to anyone else picking up the card, but they make sense to me. I encourage you to find an organizing system that works for you. Then when you set out to compose a literature review, instead of staring at five to ten books or a dozen articles, you will have ten neatly printed pages or notecards or files that have distilled what is important to know about your reading.

It is also a good idea to store this data digitally, perhaps through a reference manager. I use RefWorks, but I also recommend EndNote or any other system that allows you to search institutional databases. Your campus library will probably provide access to one of these or another system. Most systems will allow you to export references from another manager if and when you decide to move to another system. Reference managers allow you to sort through all your literature by descriptor, author, year, and so on. Even so, I personally like to have the ability to manually sort through my index cards, recategorizing things I have read as I go. I use RefWorks to keep a record of what I have read, with proper citations, so I can create bibliographies more easily, and I do add in a few “notes” there, but the bulk of my notes are kept in longhand.

What kinds of information should you include from your reading? Here are some bulleted suggestions from Calarco ( 2020:113–114 ), with my own emendations:

• Citation . If you are using a reference manager, you can import the citation and then, when you are ready to create a bibliography, you can use a provided menu of citation styles, which saves a lot of time. If you’ve originally formatted in Chicago Style but the journal you are writing for wants APA style, you can change your entire bibliography in less than a minute. When using a notecard for a book, I include author, title, date as well as the library call number (since most of what I read I pull from the library). This is something RefWorks is not able to do, and it helps when I categorize.

I begin each notecard with an “intro” section, where I record the aims, goals, and general point of the book/article as explained in the introductory sections (which might be the preface, the acknowledgments, or the first two chapters). I then draw a bold line underneath this part of the notecard. Everything after that should be chapter specific. Included in this intro section are things such as the following, recommended by Calarco ( 2020 ):

• Key background . “Two to three short bullet points identifying the theory/prior research on which the authors are building and defining key terms.”
• Data/methods . “One or two short bullet points with information about the source of the data and the method of analysis, with a note if this is a novel or particularly effective example of that method.” I use [M] to signal methodology on my notecard, which might read, “[M] Int[erview]s (n-35), B[lack]/W[hite] voters” (I need shorthand to fit on my notecard!).
• Research question . “Stated as briefly as possible.” I always provide page numbers so I can go back and see exactly how this was stated (sometimes, in qualitative research, there are multiple research questions, and they cannot be stated simply).
• Argument/contributions . “Two to three short bullet points briefly describing the authors’ answer to the central research question and its implication for research, theory, and practice.” I use [ARG] for argument to signify the argument, and I make sure this is prominently visible on my notecard. I also provide page numbers here.

For me, all of this fits in the “intro” section, which, if this is a theoretically rich, methodologically sound book, might take up a third or even half of the front page of my notecard. Beneath the bold underline, I report specific findings or particulars of the book as they emerge chapter by chapter. Calarco’s ( 2020 ) next step is the following:

• Key findings . “Three to four short bullet points identifying key patterns in the data that support the authors’ argument.”

All that remains is writing down thoughts that occur upon finishing the article/book. I use the back of the notecard for these kinds of notes. Often, they reach out to other things I have read (e.g., “Robinson reminds me of Crusoe here in that both are looking at the effects of social isolation, but I think Robinson makes a stronger argument”). Calarco ( 2020 ) concludes similarly with the following:

• Unanswered questions . “Two to three short bullet points that identify key limitations of the research and/or questions the research did not answer that could be answered in future research.”

As I mentioned, when I first began taking notes like this, I preprinted pages with prompts for “research question,” “argument,” and so on. This was a great way to remind myself to look for these things in particular. You can do the same, adding whatever preprinted sections make sense to you, given what you are studying and the important aspects of your discipline. The other nice thing about the preprinted forms is that it keeps your writing to a minimum—you cannot write more than the allotted space, even if you might want to, preventing your notes from spiraling out of control. This can be helpful when we are new to a subject and everything seems worth recording!

After years of discipline, I have finally settled on my notecard approach. I have thousands of notecards, organized in several index card filing boxes stacked in my office. On the top right of each card is a note of the month/day I finished reading the item. I can remind myself what I read in the summer of 2010 if the need or desire ever arose to do so…those invaluable notecards are like a memento of what my brain has been up to!

Where to Start Looking for Literature

Your university library should provide access to one of several searchable databases for academic books and articles. My own preference is JSTOR, a service of ITHAKA, a not-for-profit organization that works to advance and preserve knowledge and to improve teaching and learning through the use of digital technologies. JSTOR allows you to search by several keywords and to narrow your search by type of material (articles or books). For many disciplines, the “literature” of the literature review is expected to be peer-reviewed “articles,” but some disciplines will also value books and book chapters. JSTOR is particularly useful for article searching. You can submit several keywords and see what is returned, and you can also narrow your search by a particular journal or discipline. If your discipline has one or two key journals (e.g., the American Journal of Sociology and the American Sociological Review are key for sociology), you might want to go directly to those journals’ websites and search for your topic area. There is an art to when to cast your net widely and when to refine your search, and you may have to tack back and forth to ensure that you are getting all that is relevant but not getting bogged down in all studies that might have some marginal relevance.

Some articles will carry more weight than others, and you can use applications like Google Scholar to see which articles have made and are continuing to make larger impacts on your discipline. Find these articles and read them carefully; use their literature review and the sources cited in those articles to make sure you are capturing what is relevant. This is actually a really good way of finding relevant books—only the most impactful will make it into the citations of journals. Over time, you will notice that a handful of articles (or books) are cited so often that when you see, say, Armstrong and Hamilton ( 2015 ), you know exactly what book this is without looking at the full cite. This is when you know you are in the conversation.

You might also approach a professor whose work is broadly in the area of your interest and ask them to recommend one or two “important” foundational articles or books. You can then use the references cited in those recommendations to build up your literature. Just be careful: some older professors’ knowledge of the literature (and I reluctantly add myself here) may be a bit outdated! It is best that the article or book whose references and sources you use to build your body of literature be relatively current.

Keep a List of Your Keywords

When using searchable databases, it is a good idea to keep a list of all the keywords you use as you go along so that (1) you do not needlessly duplicate your efforts and (2) you can more easily adjust your search as you get a better sense of what you are looking for. I suggest you keep a separate file or even a small notebook for this and you date your search efforts.

Here’s an example:

Table 9.2. Keep a List of Your Keywords

Think Laterally

How to find the various strands of literature to combine? Don’t get stuck on finding the exact same research topic you think you are interested in. In the female gymnast example, I recommended that my student consider looking for studies of ballerinas, who also suffer sports injuries and around whom there is a similar culture of silence. It turned out that there was in fact research about my student’s particular questions, just not about the subjects she was interested in. You might do something similar. Don’t get stuck looking for too direct literature but think about the broader phenomenon of interest or analogous cases.

Read Outside the Canon

Some scholars’ work gets cited by everyone all the time. To some extent, this is a very good thing, as it helps establish the discipline. For example, there are a lot of “Bourdieu scholars” out there (myself included) who draw ideas, concepts, and quoted passages from Bourdieu. This makes us recognizable to one another and is a way of sharing a common language (e.g., where “cultural capital” has a particular meaning to those versed in Bourdieusian theory). There are empirical studies that get cited over and over again because they are excellent studies but also because there is an “echo chamber effect” going on, where knowing to cite this study marks you as part of the club, in the know, and so on. But here’s the problem with this: there are hundreds if not thousands of excellent studies out there that fail to get appreciated because they are crowded out by the canon. Sometimes this happens because they are published in “lower-ranked” journals and are never read by a lot of scholars who don’t have time to read anything other than the “big three” in their field. Other times this happens because the author falls outside of the dominant social networks in the field and thus is unmentored and fails to get noticed by those who publish a lot in those highly ranked and visible spaces. Scholars who fall outside the dominant social networks and who publish outside of the top-ranked journals are in no way less insightful than their peers, and their studies may be just as rigorous and relevant to your work, so it is important for you to take some time to read outside the canon. Due to how a person’s race, gender, and class operate in the academy, there is also a matter of social justice and ethical responsibility involved here: “When you focus on the most-cited research, you’re more likely to miss relevant research by women and especially women of color, whose research tends to be under-cited in most fields. You’re also more likely to miss new research, research by junior scholars, and research in other disciplines that could inform your work. Essentially, it is important to read and cite responsibly, which means checking that you’re not just reading and citing the same white men and the same old studies that everyone has cited before you” ( Calarco 2020:112 ).

Consider Multiple Uses for Literature

Throughout this chapter, I’ve referred to the literature of interest in a rather abstract way, as what is relevant to your study. But there are many different ways previous research can be relevant to your study. The most basic use of the literature is the “findings”—for example, “So-and-so found that Canadian working-class students were concerned about ‘fitting in’ to the culture of college, and I am going to look at a similar question here in the US.” But the literature may be of interest not for its findings but theoretically—for example, employing concepts that you want to employ in your own study. Bourdieu’s definition of social capital may have emerged in a study of French professors, but it can still be relevant in a study of, say, how parents make choices about what preschools to send their kids to (also a good example of lateral thinking!).

If you are engaged in some novel methodological form of data collection or analysis, you might look for previous literature that has attempted that. I would not recommend this for undergraduate research projects, but for graduate students who are considering “breaking the mold,” find out if anyone has been there before you. Even if their study has absolutely nothing else in common with yours, it is important to acknowledge that previous work.

Describing Gaps in the Literature

First, be careful! Although it is common to explain how your research adds to, builds upon, and fills in gaps in the previous research (see all four literature review examples in this chapter for this), there is a fine line between describing the gaps and misrepresenting previous literature by failing to conduct a thorough review of the literature. A little humility can make a big difference in your presentation. Instead of “This is the first study that has looked at how firefighters juggle childcare during forest fire season,” say, “I use the previous literature on how working parents juggling childcare and the previous ethnographic studies of firefighters to explore how firefighters juggle childcare during forest fire season.” You can even add, “To my knowledge, no one has conducted an ethnographic study in this specific area, although what we have learned from X about childcare and from Y about firefighters would lead us to expect Z here.” Read more literature review sections to see how others have described the “gaps” they are filling.

Use Concept Mapping

Concept mapping is a helpful tool for getting your thoughts in order and is particularly helpful when thinking about the “literature” foundational to your particular study. Concept maps are also known as mind maps, which is a delightful way to think about them. Your brain is probably abuzz with competing ideas in the early stages of your research design. Write/draw them on paper, and then try to categorize and move the pieces around into “clusters” that make sense to you. Going back to the gymnasts example, my student might have begun by jotting down random words of interest: gymnasts * sports * coaches * female gymnasts * stress * injury * don’t complain * women in sports * bad coaching * anxiety/stress * careers in sports * pain. She could then have begun clustering these into relational categories (bad coaching, don’t complain culture) and simple “event” categories (injury, stress). This might have led her to think about reviewing literature in these two separate aspects and then literature that put them together. There is no correct way to draw a concept map, as they are wonderfully specific to your mind. There are many examples you can find online.

Ask Yourself, “How Is This Sociology (or Political Science or Public Policy, Etc.)?”

Rubin ( 2021:82 ) offers this suggestion instead of asking yourself the “So what?” question to get you thinking about what bridges there are between your study and the body of research in your particular discipline. This is particularly helpful for thinking about theory. Rubin further suggests that if you are really stumped, ask yourself, “What is the really big question that all [fill in your discipline here] care about?” For sociology, it might be “inequality,” which would then help you think about theories of inequality that might be helpful in framing your study on whatever it is you are studying—OnlyFans? Childcare during COVID? Aging in America? I can think of some interesting ways to frame questions about inequality for any of those topics. You can further narrow it by focusing on particular aspects of inequality (Gender oppression? Racial exclusion? Heteronormativity?). If your discipline is public policy, the big questions there might be, How does policy get enacted, and what makes a policy effective? You can then take whatever your particular policy interest is—tax reform, student debt relief, cap-and-trade regulations—and apply those big questions. Doing so would give you a handle on what is otherwise an intolerably vague subject (e.g., What about student debt relief?).

Sometimes finding you are in new territory means you’ve hit the jackpot, and sometimes it means you’ve traveled out of bounds for your discipline. The jackpot scenario is wonderful. You are doing truly innovative research that is combining multiple literatures or is addressing a new or under-examined phenomenon of interest, and your research has the potential to be groundbreaking. Congrats! But that’s really hard to do, and it might be more likely that you’ve traveled out of bounds, by which I mean, you are no longer in your discipline . It might be that no one has written about this thing—at least within your field— because no one in your field actually cares about this topic . ( Rubin 2021:83 ; emphases added)

Don’t Treat This as a Chore

Don’t treat the literature review as a chore that has to be completed, but see it for what it really is—you are building connections to other researchers out there. You want to represent your discipline or area of study fairly and adequately. Demonstrate humility and your knowledge of previous research. Be part of the conversation.

Supplement: Two More Literature Review Examples

Elites by harvey ( 2011 ).

In the last two decades, there has been a small but growing literature on elites. In part, this has been a result of the resurgence of ethnographic research such as interviews, focus groups, case studies, and participant observation but also because scholars have become increasingly interested in understanding the perspectives and behaviors of leaders in business, politics, and society as a whole. Yet until recently, our understanding of some of the methodological challenges of researching elites has lagged behind our rush to interview them.

There is no clear-cut definition of the term elite, and given its broad understanding across the social sciences, scholars have tended to adopt different approaches. Zuckerman (1972) uses the term ultraelites to describe individuals who hold a significant amount of power within a group that is already considered elite. She argues, for example, that US senators constitute part of the country’s political elite but that among them are the ultraelites: a “subset of particularly powerful or prestigious influentials” (160). She suggests that there is a hierarchy of status within elite groups. McDowell (1998) analyses a broader group of “professional elites” who are employees working at different levels for merchant and investment banks in London. She classifies this group as elite because they are “highly skilled, professionally competent, and class-specific” (2135). Parry (1998:2148) uses the term hybrid elites in the context of the international trade of genetic material because she argues that critical knowledge exists not in traditional institutions “but rather as increasingly informal, hybridised, spatially fragmented, and hence largely ‘invisible,’ networks of elite actors.” Given the undertheorization of the term elite, Smith (2006) recognizes why scholars have shaped their definitions to match their respondents . However, she is rightly critical of the underlying assumption that those who hold professional positions necessarily exert as much influence as initially perceived. Indeed, job titles can entirely misrepresent the role of workers and therefore are by no means an indicator of elite status (Harvey 2010).

Many scholars have used the term elite in a relational sense, defining them either in terms of their social position compared to the researcher or compared to the average person in society (Stephens 2007). The problem with this definition is there is no guarantee that an elite subject will necessarily translate this power and authority in an interview setting. Indeed, Smith (2006) found that on the few occasions she experienced respondents wanting to exert their authority over her, it was not from elites but from relatively less senior workers. Furthermore, although business and political elites often receive extensive media training, they are often scrutinized by television and radio journalists and therefore can also feel threatened in an interview, particularly in contexts that are less straightforward to prepare for such as academic interviews. On several occasions, for instance, I have been asked by elite respondents or their personal assistants what they need to prepare for before the interview, which suggests that they consider the interview as some form of challenge or justification for what they do.

In many cases, it is not necessarily the figureheads or leaders of organizations and institutions who have the greatest claim to elite status but those who hold important social networks, social capital, and strategic positions within social structures because they are better able to exert influence (Burt 1992; Parry 1998; Smith 2005; Woods 1998). An elite status can also change, with people both gaining and losing theirs over time. In addition, it is geographically specific, with people holding elite status in some but not all locations. In short, it is clear that the term elite can mean many things in different contexts, which explains the range of definitions. The purpose here is not to critique these other definitions but rather to highlight the variety of perspectives.

When referring to my research, I define elites as those who occupy senior-management- and board-level positions within organizations. This is a similar scope of definition to Zuckerman’s (1972) but focuses on a level immediately below her ultraelite subjects. My definition is narrower than McDowell’s (1998) because it is clear in the context of my research that these people have significant decision-making influence within and outside of the firm and therefore present a unique challenge to interview. I deliberately use the term elite more broadly when drawing on examples from the theoretical literature in order to compare my experiences with those who have researched similar groups.

”Changing Dispositions among the Upwardly Mobile” by Curl, Lareau, and Wu ( 2018 )

There is growing interest in the role of cultural practices in undergirding the social stratification system. For example, Lamont et al. (2014) critically assess the preoccupation with economic dimensions of social stratification and call for more developed cultural models of the transmission of inequality. The importance of cultural factors in the maintenance of social inequality has also received empirical attention from some younger scholars, including Calarco (2011, 2014) and Streib (2015). Yet questions remain regarding the degree to which economic position is tied to cultural sensibilities and the ways in which these cultural sensibilities are imprinted on the self or are subject to change. Although habitus is a core concept in Bourdieu’s theory of social reproduction, there is limited empirical attention to the precise areas of the habitus that can be subject to change during upward mobility as well as the ramifications of these changes for family life.

In Bourdieu’s (1984) highly influential work on the importance of class-based cultural dispositions, habitus is defined as a “durable system of dispositions” created in childhood. The habitus provides a “matrix of perceptions” that seems natural while also structuring future actions and pathways. In many of his writings, Bourdieu emphasized the durability of cultural tastes and dispositions and did not consider empirically whether these dispositions might be changed or altered throughout one’s life (Swartz 1997). His theoretical work does permit the possibility of upward mobility and transformation, however, through the ability of the habitus to “improvise” or “change” due to “new experiences” (Friedman 2016:131). Researchers have differed in opinion on the durability of the habitus and its ability to change (King 2000). Based on marital conflict in cross-class marriages, for instance, Streib (2015) argues that cultural dispositions of individuals raised in working-class families are deeply embedded and largely unchanging. In a somewhat different vein, Horvat and Davis (2011:152) argue that young adults enrolled in an alternative educational program undergo important shifts in their self-perception, such as “self-esteem” and their “ability to accomplish something of value.” Others argue there is variability in the degree to which habitus changes dependent on life experience and personality (Christodoulou and Spyridakis 2016). Recently, additional studies have investigated the habitus as it intersects with lifestyle through the lens of meaning making (Ambrasat et al. 2016). There is, therefore, ample discussion of class-based cultural practices in self-perception (Horvat and Davis 2011), lifestyle (Ambrasat et al. 2016), and other forms of taste (Andrews 2012; Bourdieu 1984), yet researchers have not sufficiently delineated which aspects of the habitus might change through upward mobility or which specific dimensions of life prompt moments of class-based conflict.

Bourdieu (1999:511; 2004) acknowledged simmering tensions between the durable aspects of habitus and those aspects that have been transformed—that is, a “fractured” or “cleft” habitus. Others have explored these tensions as a “divided” or “fragmented” habitus (Baxter and Britton 2001; Lee and Kramer 2013). Each of these conceptions of the habitus implies that changes in cultural dispositions are possible but come with costs. Exploration of the specific aspects of one’s habitus that can change and generate conflict contributes to this literature.

Scholars have also studied the costs associated with academic success for working-class undergraduates (Hurst 2010; Lee and Kramer 2013; London 1989; Reay 2017; Rondini 2016; Stuber 2011), but we know little about the lasting effects on adults. For instance, Lee and Kramer (2013) point to cross-class tensions as family and friends criticize upwardly mobile individuals for their newly acquired cultural dispositions. Documenting the tension many working-class students experience with their friends and families of origin, they find that the source of their pain or struggle is “shaped not only by their interactions with non-mobile family and friends but also within their own minds, by their own assessments of their social positions, and by how those positions are interpreted by others” (Lee and Kramer 2013:29). Hurst (2010) also explores the experiences of undergraduates who have been academically successful and the costs associated with that success. She finds that decisions about “class allegiance and identity” are required aspects of what it means to “becom[e] educated” (4) and that working-class students deal with these cultural changes differently. Jack (2014, 2016) also argues that there is diversity among lower-income students, which yields varied college experiences. Naming two groups, the “doubly disadvantaged” and the “privileged poor,” he argues that previous experience with “elite environments” (2014:456) prior to college informs students’ ability to take on dominant cultural practices, particularly around engagement, such as help seeking or meeting with professors (2016). These studies shed light on the role college might play as a “lever for mobility” (2016:15) and discuss the pain and difficulty associated with upward mobility among undergraduates, but the studies do not illuminate how these tensions unfold in adulthood. Neither have they sufficiently addressed potential enduring tensions with extended family members as well as the specific nature of the difficulties.

Some scholars point to the positive outcomes upwardly mobile youth (Lehmann 2009) and adults (Stuber 2005) experience when they maintain a different habitus than their newly acquired class position, although, as Jack (2014, 2016) shows, those experiences may vary depending on one’s experience with elite environments in their youth. Researchers have not sufficiently explored the specific aspects of the habitus that upwardly mobile adults change or the conflicts that emerge with family and childhood friends as they reach adulthood and experience colliding social worlds. We contribute to this scholarship with clear examples of self-reported changes to one’s cultural dispositions in three specific areas: “horizons,” food and health, and communication. We link these changes to enduring tension with family members, friends, and colleagues and explore varied responses to this tension based on race.

Further Readings

Bloomberg, Linda Dale, and Marie F. Volpe. 2012. Completing Your Qualitative Dissertation: A Road Map from Beginning to End . 2nd ed. Thousand Oaks, CA: SAGE. In keeping with its general approach to qualitative research, includes a “road map” for conducting a literature review.

Hart, Chris. 1998. Doing a Literature Review: Releasing the Social Science Research Imagination . London: SAGE. A how-to book dedicated entirely to conducting a literature review from a British perspective. Useful for both undergraduate and graduate students.

Machi, Lawrence A., and Brenda T. McEvoy. 2022. The Literature Review: Six Steps to Success . 4th ed. Newbury Park, CA: Corwin. A well-organized guidebook complete with reflection sections to prompt successful thinking about your literature review.

Ridley, Diana. 2008. The Literature Review: A Step-by-Step Guide for Students . London: SAGE. A highly recommended companion to conducting a literature review for doctoral-level students.

The process of systematically searching through pre-existing studies (“literature”) on the subject of research; also, the section of a presentation in which the pre-existing literature is discussed.

Follow-up questions used in a semi-structured interview  to elicit further elaboration.  Suggested prompts can be included in the interview guide  to be used/deployed depending on how the initial question was answered or if the topic of the prompt does not emerge spontaneously.

A tool for identifying relationships among ideas by visually representing them on paper.  Most concept maps depict ideas as boxes or circles (also called nodes), which are structured hierarchically and connected with lines or arrows (also called arcs). These lines are labeled with linking words and phrases to help explain the connections between concepts.  Also known as mind mapping.

The people who are the subjects of an interview-based qualitative study. In general, they are also known as the participants, and for purposes of IRBs they are often referred to as the human subjects of the research.

Introduction to Qualitative Research Methods Copyright © 2023 by Allison Hurst is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License , except where otherwise noted.

How to write a Literature Review: Quantitative vs qualitative method

• Literature review process
• Purpose of a literature review
• Evaluating sources
• Managing sources
• Request a literature search
• Selecting the approach to use

Quantitative vs qualitative method

• Summary of different research methodologies
• Research design vs research methodology
• Diagram: importance of research
• Attributes of a good research scholar

Source : Golafshani, 2003

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Quantitative research: literature review .

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Exploring the literature review 

Literature review model: 6 steps.

Adapted from The Literature Review , Machi & McEvoy (2009, p. 13).

Your Literature Review

Step 2: search, boolean search strategies, search limiters, ★ ebsco & google drive.

1. Select a Topic

"All research begins with curiosity" (Machi & McEvoy, 2009, p. 14)

Selection of a topic, and fully defined research interest and question, is supervised (and approved) by your professor. Tips for crafting your topic include:

• Be specific. Take time to define your interest.
• Topic Focus. Fully describe and sufficiently narrow the focus for research.
• Academic Discipline. Learn more about your area of research & refine the scope.
• Avoid Bias. Be aware of bias that you (as a researcher) may have.
• Document your research. Use Google Docs to track your research process.
• Research apps. Consider using Evernote or Zotero to track your research.

Consider Purpose

What will your topic and research address?

In The Literature Review: A Step-by-Step Guide for Students , Ridley presents that literature reviews serve several purposes (2008, p. 16-17).  Included are the following points:

• Historical background for the research;
• Overview of current field provided by "contemporary debates, issues, and questions;"
• Theories and concepts related to your research;
• Introduce "relevant terminology" - or academic language - being used it the field;
• Connect to existing research - does your work "extend or challenge [this] or address a gap;" 
• Provide "supporting evidence for a practical problem or issue" that your research addresses.

★ Schedule a research appointment

At this point in your literature review, take time to meet with a librarian. Why? Understanding the subject terminology used in databases can be challenging. Archer Librarians can help you structure a search, preparing you for step two. How? Contact a librarian directly or use the online form to schedule an appointment. Details are provided in the adjacent Schedule an Appointment box.

2. Search the Literature

Collect & Select Data: Preview, select, and organize

Archer Library is your go-to resource for this step in your literature review process. The literature search will include books and ebooks, scholarly and practitioner journals, theses and dissertations, and indexes. You may also choose to include web sites, blogs, open access resources, and newspapers. This library guide provides access to resources needed to complete a literature review.

Books & eBooks: Archer Library & OhioLINK

Databases: scholarly & practitioner journals.

Review the Library Databases tab on this library guide, it provides links to recommended databases for Education & Psychology, Business, and General & Social Sciences.

Expand your journal search; a complete listing of available AU Library and OhioLINK databases is available on the Databases  A to Z list . Search the database by subject, type, name, or do use the search box for a general title search. The A to Z list also includes open access resources and select internet sites.

Databases: Theses & Dissertations

Review the Library Databases tab on this guide, it includes Theses & Dissertation resources. AU library also has AU student authored theses and dissertations available in print, search the library catalog for these titles.

Did you know? If you are looking for particular chapters within a dissertation that is not fully available online, it is possible to submit an ILL article request . Do this instead of requesting the entire dissertation.

Newspapers:  Databases & Internet

Consider current literature in your academic field. AU Library's database collection includes The Chronicle of Higher Education and The Wall Street Journal .  The Internet Resources tab in this guide provides links to newspapers and online journals such as Inside Higher Ed , COABE Journal , and Education Week .

Search Strategies & Boolean Operators

There are three basic boolean operators:  AND, OR, and NOT.

Used with your search terms, boolean operators will either expand or limit results. What purpose do they serve? They help to define the relationship between your search terms. For example, using the operator AND will combine the terms expanding the search. When searching some databases, and Google, the operator AND may be implied.

Overview of boolean terms

About the example: Boolean searches were conducted on November 4, 2019; result numbers may vary at a later date. No additional database limiters were set to further narrow search returns.

Database Search Limiters

Database strategies for targeted search results.

Most databases include limiters, or additional parameters, you may use to strategically focus search results.  EBSCO databases, such as Education Research Complete & Academic Search Complete provide options to:

• Limit results to full text;
• Limit results to scholarly journals, and reference available;
• Select results source type to journals, magazines, conference papers, reviews, and newspapers
• Publication date

Keep in mind that these tools are defined as limiters for a reason; adding them to a search will limit the number of results returned.  This can be a double-edged sword.  How? 

• If limiting results to full-text only, you may miss an important piece of research that could change the direction of your research. Interlibrary loan is available to students, free of charge. Request articles that are not available in full-text; they will be sent to you via email.
• If narrowing publication date, you may eliminate significant historical - or recent - research conducted on your topic.
• Limiting resource type to a specific type of material may cause bias in the research results.

Use limiters with care. When starting a search, consider opting out of limiters until the initial literature screening is complete. The second or third time through your research may be the ideal time to focus on specific time periods or material (scholarly vs newspaper).

★ Truncating Search Terms

Expanding your search term at the root.

Truncating is often referred to as 'wildcard' searching. Databases may have their own specific wildcard elements however, the most commonly used are the asterisk (*) or question mark (?).  When used within your search. they will expand returned results.

Asterisk (*) Wildcard

Using the asterisk wildcard will return varied spellings of the truncated word. In the following example, the search term education was truncated after the letter "t."

Explore these database help pages for additional information on crafting search terms.

• EBSCO Connect: Basic Searching with EBSCO
• EBSCO Connect: Searching with Boolean Operators
• EBSCO Connect: Searching with Wildcards and Truncation Symbols
• ProQuest Help: Search Tips
• ERIC: How does ERIC search work?

★ EBSCO Databases & Google Drive

Tips for saving research directly to Google drive.

Researching in an EBSCO database?

It is possible to save articles (PDF and HTML) and abstracts in EBSCOhost databases directly to Google drive. Select the Google Drive icon, authenticate using a Google account, and an EBSCO folder will be created in your account. This is a great option for managing your research. If documenting your research in a Google Doc, consider linking the information to actual articles saved in drive.

EBSCO Databases & Google Drive

EBSCOHost Databases & Google Drive: Managing your Research

This video features an overview of how to use Google Drive with EBSCO databases to help manage your research. It presents information for connecting an active Google account to EBSCO and steps needed to provide permission for EBSCO to manage a folder in Drive.

About the Video:  Closed captioning is available, select CC from the video menu.  If you need to review a specific area on the video, view on YouTube and expand the video description for access to topic time stamps.  A video transcript is provided below.

• EBSCOhost Databases & Google Scholar

Defining Literature Review

What is a literature review.

A definition from the Online Dictionary for Library and Information Sciences .

A literature review is "a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works" (Reitz, 2014). 

A systemic review is "a literature review focused on a specific research question, which uses explicit methods to minimize bias in the identification, appraisal, selection, and synthesis of all the high-quality evidence pertinent to the question" (Reitz, 2014).

Recommended Reading

About this page

EBSCO Connect [Discovery and Search]. (2022). Searching with boolean operators. Retrieved May, 3, 2022 from https://connect.ebsco.com/s/?language=en_US

EBSCO Connect [Discover and Search]. (2022). Searching with wildcards and truncation symbols. Retrieved May 3, 2022; https://connect.ebsco.com/s/?language=en_US

Machi, L.A. & McEvoy, B.T. (2009). The literature review . Thousand Oaks, CA: Corwin Press: 

Reitz, J.M. (2014). Online dictionary for library and information science. ABC-CLIO, Libraries Unlimited . Retrieved from https://www.abc-clio.com/ODLIS/odlis_A.aspx

Ridley, D. (2008). The literature review: A step-by-step guide for students . Thousand Oaks, CA: Sage Publications, Inc.

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

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

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

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

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Qualitative systematic reviews: their importance for our understanding of research relevant to pain

This article outlines what a qualitative systematic review is and explores what it can contribute to our understanding of pain. Many of us use evidence of effectiveness for various interventions when working with people in pain. A good systematic review can be invaluable in bringing together research evidence to help inform our practice and help us understand what works. In addition to evidence of effectiveness, understanding how people with pain experience both their pain and their care can help us when we are working with them to provide care that meets their needs. A rigorous qualitative systematic review can also uncover new understandings, often helping illuminate ‘why’ and can help build theory. Such a review can answer the question ‘What is it like to have chronic pain?’ This article presents the different stages of meta-ethnography, which is the most common methodology used for qualitative systematic reviews. It presents evidence from four meta-ethnographies relevant to pain to illustrate the types of findings that can emerge from this approach. It shows how new understandings may emerge and gives an example of chronic musculoskeletal pain being experienced as ‘an adversarial struggle’ across many aspects of the person’s life. This article concludes that evidence from qualitative systematic reviews has its place alongside or integrated with evidence from more quantitative approaches.

Many of us use evidence of effectiveness for various interventions when working with people in pain. A good systematic review can be invaluable in bringing together research evidence to help inform our practice and help us understand what works. In addition to evidence of effectiveness, understanding how people with pain experience both their pain and their care can help us when we are working with them to provide care that meets their needs. A high-quality qualitative systematic review can also uncover new understandings, often helping illuminate ‘why’ and can help build theory. A qualitative systematic review could answer the question ‘What is it like to have chronic non-malignant pain?’

The purpose of this article is to outline what a qualitative systematic review is and explore what it can contribute to our understanding of pain. A qualitative systematic review brings together research on a topic, systematically searching for research evidence from primary qualitative studies and drawing the findings together. There is a debate over whether the search needs to be exhaustive. 1 , 2 Methods for systematic reviews of quantitative research are well established and explicit and have been pioneered through the Cochrane Collaboration. Methods for qualitative systematic reviews have been developed more recently and are still evolving. The Cochrane Collaboration now has a Qualitative and Implementation Methods Group, including a register of protocols, illustrating the recognition of the importance of qualitative research within the Cochrane Collaboration. In November 2013, an editorial described the Cochrane Collaboration’s first publication of a qualitative systematic review as ‘a new milestone’ for Cochrane. 3 Other editorials have raised awareness of qualitative systematic reviews in health. 4

Noblit and Hare 5 were pioneers in the area of synthesising qualitative data. They describe such reviews as aggregated or as interpretative. The aggregated review summarises the data, and Hannes and Pearson 6 provide a worked example of an aggregation approach. Interpretative approaches, as the name suggests, interpret the data, and from that interpretation, new understandings can develop that may lead to development of a theory that helps us to understand or predict behaviour. Types of interpretative qualitative systematic reviews include meta-ethnography, critical interpretative synthesis, realist synthesis and narrative synthesis. More details about these and other approaches can be found in other papers and books. 1 , 5 , 7 – 11 This article will describe one approach, meta-ethnography, as it was identified as the most frequently used approach, 1 and there are some examples using meta-ethnography that focus on pain. A meta-ethnographic approach can be used with a variety of qualitative methodologies, not only ethnography. The data for a meta-ethnography are the concepts or themes described by the authors of the primary studies.

Noblit and Hare 5 outlined the seven steps of a meta-ethnography: (1) getting started, (2) deciding what is relevant, (3) reading the studies, (4) determining how studies are related to each other, (5) translating studies into each other, (6) synthesising translations and (7) expressing the synthesis.

The first three might seem relatively straightforward, although Lee et al. 12 emphasised both the importance and nuances of the reading stage, and Toye et al. 13 discuss the complexities of making quality assessments of qualitative papers and searching for this type of study. You need to understand what data to extract from the papers and how you are going to do this.

You have to first identify what is a concept and what is purely descriptive. Toye et al. 2 describe a process for collaboratively identifying concepts. In determining how studies are related to each other and translating them into each other, the meta-ethnographer compares the concepts found in each study with each other and then groups similar concepts into conceptual themes. Translating studies into each other involves looking at where concepts between studies agree (reciprocal synthesis) and where they do not agree (refutational synthesis). Developing conceptual categories can be challenging as you need to judge the extent to which a concept from one study adequately reflects concepts from other studies and choose one that seems to fit best. This is discussed in more detail in Toye et al. 2 , 13

To synthesise the translation, a line of argument is then developed from the conceptual categories. How the concepts group and relate to each other are developed. This provides an overall interpretation of the findings, ensuring this is grounded in the data from the primary studies. You are aiming to explain, and new concepts and understandings may emerge, which can then go on to underpin development of theory. For example, a qualitative systematic review that explored medicine taking found that ‘resistance’ was a new concept, revealed through meta-ethnography, and this helped understanding of lay responses to medicine taking. 1 Hannes and Macaitis, 14 in a review of published papers, reported that over time, authors have become more transparent about searching and critical appraisal, but that the synthesis element of reviews is often not well described. Being transparent about decisions that are interpretative has its own challenges. Working collaboratively to challenge interpretations and assumptions can be helpful. 2 , 12 The next section will use examples of qualitative systematic reviews from the pain field to illuminate what this type of review can contribute to our understanding of pain.

What can a qualitative systematic review contribute to the field of pain – some examples

Toye et al. 2 , 15 undertook a meta-ethnography to look at patients’ experiences of chronic non-malignant musculoskeletal pain. At the time of this research, no other qualitative systematic reviews had been published in this area. Their review included 77 papers reporting 60 individual studies, resulting from searches of six electronic bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, AMED and HMIC) from inception until February 2012 and hand-searching key journals from 2001 to 2012.

They developed a new concept which they identified as an ‘adversarial struggle’. This struggle took place across five main dimensions: (1) there was a struggle to affirm themselves, where there was a tension between the ‘real me’ (without pain) and ‘not real me’ (me with pain). (2) The present and future were often unpredictable, and construction of time was altered and they struggled to reconstruct themselves in time. (3) People struggled to find an acceptable explanation for their pain and suffering. (4) There was a struggle to negotiate the healthcare system and (5) a struggle for pain to be seen as legitimate, including the need to be believed, and a struggle to know whether to show or hide their pain. Some people were able to move forward with pain. They saw their body as more integrated, they re-defined what was normal, they told people about their pain, they were part of a community of people with pain and they felt more expert on how their pain affected them and what they could do about it.

So, this meta-ethnography highlighted the adversarial nature of having chronic musculoskeletal pain and how this struggle pervaded many different areas of their life. It also illustrated how by showing patients their pain is understood and being alongside the person in pain, they can start to move forward. A short film based on the 77 papers in this meta-ethnography has been made and is available on YouTube. 16 This film was made as an attempt to disseminate the findings of a meta-ethnography in a way that is accessible to a range of people.

Snelgrove and Liossi 17 undertook a meta-ethnography of qualitative research in chronic low back pain (CLBP) using meta-ethnography. They included 33 papers of 28 studies published between 2000 and 2012. They identified three overarching themes of (1) the impact of CLBP on self, (2) relationships with others (health professionals and family and friends) and (3) coping with CLBP. They found that very few successful coping strategies were reported. Like Toye et al., 2 , 15 they also reported disruption to self, distancing their valued self from their painful self, legitimising pain, the struggle to manage daily living and the importance of social relationships alongside negotiation of their care in the health system.

MacNeela et al. 18 also undertook a meta-ethnography of experiences of CLBP. They included 38 articles published between 1994 and 2012 representing 28 studies. They identified four themes: (1) the undermining influence of pain, (2) the disempowering impact on all levels, (3) unsatisfying relationships with healthcare professionals and (4) learning to live with the pain. They reported the findings being dominated by ‘wide-ranging distress and loss’. They discussed the disempowering consequences of pain and a search for help. However, they also highlighted self-determination and resilience and suggested these could offer ‘pathways to endurance’. They emphasised self-management and adaptation, which resonates with the moving forward category reported by Toye et al. 2 , 15

Froud et al. 19 looked at the impact of low back pain on people’s lives. They describe their approach as meta-ethnographic and meta-narrative. They included 49 papers of about 42 studies from inception of databases searched until July 2011. They described five themes: activities, relationships, work, stigma and changing outlook, which they derived from ‘participant-level data’. They described their findings as showing patients wanted to be believed. They highlighted the importance of social factors when developing relevant outcome measures. There are other examples of qualitative systematic reviews relevant to pain. 20 – 23

Different qualitative systematic reviews on a similar subject may come up with overlapping but also some different findings. This could be, for example, because different search periods or different inclusion criteria are used, so different primary studies may be included in different reviews. In addition, undertaking a qualitative systematic review requires researchers to interpret concepts. This interpretation does not need to be a limitation. For example, to ensure rigour and transparency, Toye et al. 24 report a process of collaborative interpretation of concepts among a team of experienced qualitative researchers to ensure individual interpretations were challenged and remained grounded in the original studies. They also published a detailed audit trail of the processes and decisions made. 2 Campbell et al. 1 argue ‘Meta-ethnography is a highly interpretative method requiring considerable immersion in the individual studies to achieve a synthesis. It places substantial demands upon the synthesiser and requires a high degree of qualitative research skill’. It is important to be able to think conceptually when undertaking a meta-ethnography, and it can be a time-consuming process. However, the ability of a meta-ethnography to synthesise a large number of primary research studies, generate new conceptual understandings and thus increase our understanding of patients’ experiences of pain makes it a very useful resource for our evidence-based practice.

The way forward

A register of qualitative systematic reviews would be useful for researchers and clinicians, so there was a clear way of identifying existing qualitative reviews or reviews that are planned or underway. The Cochrane Collaboration does now have a register for protocols of qualitative systematic reviews being undertaken under the aegis of the Cochrane Qualitative and Implementation Methods Group. It would help those wanting to undertake qualitative systematic reviews if reviews that were underway were registered and described more clearly to prevent duplication of effort, for example, using ‘qualitative systematic review’ and the methodological approach used (such as meta-ethnography) in the title and/or abstract. The Toye et al. 2 protocol 25 was accessible on the National Institutes for Health website from 2010. The Snelgrove and Liossi 17 study was done without external funding, so it would be difficult to pick up that it was underway. The MacNeela et al. 18 study was listed on the Irish Research Council for the Humanities and Social Sciences under their Research Development Initiative 2008–2009, but was described as ‘Motivation and Beliefs among People Experiencing Chronic Low Back Pain’, so it was not clearly identified at that stage as a qualitative systematic review. Finally, the Froud et al. 19 award details 26 do not mention qualitative systematic reviews or meta-ethnography. This highlights the difficulty of finding some of these reviews and the importance of a register of both completed and ongoing reviews.

This article has argued that qualitative systematic reviews have their place alongside or integrated with more quantitative approaches. There is an increasing body of evidence from qualitative systematic reviews. They can synthesise primary research, and this can be helpful for the busy practitioner. The methods for these approaches are still developing, and attention to rigour at each stage is crucial. It is important that each stage of the synthesis is reported transparently and that the researchers’ stance is clearly reported. 27 Meta-ethnographies published over the last year 2 , 15 , 17 – 19 have drawn together a wide range of primary studies and shown that people’s lives can be markedly changed by their pain across multiple dimensions of their life.

Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

• Systematic Review
• Open access
• Published: 30 May 2024

Patient experiences: a qualitative systematic review of chemotherapy adherence

• Amineh Rashidi 1 ,
• Susma Thapa 1 ,
• Wasana Sandamali Kahawaththa Palliya Guruge 1 &
• Shubhpreet Kaur 1  

BMC Cancer volume  24 , Article number:  658 ( 2024 ) Cite this article

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Adherence to chemotherapy treatment is recognized as a crucial health concern, especially in managing cancer patients. Chemotherapy presents challenges for patients, as it can lead to potential side effects that may adversely affect their mobility and overall function. Patients may sometimes neglect to communicate these side effects to health professionals, which can impact treatment management and leave their unresolved needs unaddressed. However, there is limited understanding of how patients’ experiences contribute to improving adherence to chemotherapy treatment and the provision of appropriate support. Therefore, gaining insights into patients’ experiences is crucial for enhancing the accompaniment and support provided during chemotherapy.

This review synthesizes qualitative literature on chemotherapy adherence within the context of patients’ experiences. Data were collected from Medline, Web of Science, CINAHL, PsychINFO, Embase, Scopus, and the Cochrane Library, systematically searched from 2006 to 2023. Keywords and MeSH terms were utilized to identify relevant research published in English. Thirteen articles were included in this review. Five key themes were synthesized from the findings, including positive outlook, receiving support, side effects, concerns about efficacy, and unmet information needs. The review underscores the importance for healthcare providers, particularly nurses, to focus on providing comprehensive information about chemotherapy treatment to patients. Adopting recommended strategies may assist patients in clinical practice settings in enhancing adherence to chemotherapy treatment and improving health outcomes for individuals living with cancer.

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Introduction

Cancer can affect anyone and is recognized as a chronic disease characterized by abnormal cell multiplication in the body [ 1 ]. While cancer is prevalent worldwide, approximately 70% of cancer-related deaths occur in low- to middle-income nations [ 1 ]. Disparities in cancer outcomes are primarily attributed to variations in the accessibility of comprehensive diagnosis and treatment among countries [ 1 , 2 ]. Cancer treatment comes in various forms; however, chemotherapy is the most widely used approach [ 3 ]. Patients undergoing chemotherapy experience both disease-related and treatment-related adverse effects, significantly impacting their quality of life [ 4 ]. Despite these challenges, many cancer patients adhere to treatment in the hope of survival [ 5 ]. However, some studies have shown that concerns about treatment efficacy may hinder treatment adherence [ 6 ]. Adherence is defined as “the extent to which a person’s behaviour aligns with the recommendations of healthcare providers“ [ 7 ]. Additionally, treatment adherence is influenced by the information provided by healthcare professionals following a cancer diagnosis [ 8 ]. Patient experiences suggest that the decision to adhere to treatment is often influenced by personal factors, with family support playing a crucial role [ 8 ]. Furthermore, providing adequate information about chemotherapy, including its benefits and consequences, can help individuals living with cancer gain a better understanding of the advantages associated with adhering to chemotherapy treatment [ 9 ].

Recognizing the importance of adhering to chemotherapy treatment and understanding the impact of individual experiences of chemotherapy adherence would aid in identifying determinants of adherence and non-adherence that are modifiable through effective interventions [ 10 ]. Recently, systematic reviews have focused on experiences and adherence in breast cancer [ 11 ], self-management of chemotherapy in cancer patients [ 12 ], and the influence of medication side effects on adherence [ 13 ]. However, these reviews were narrow in scope, and to date, no review has integrated the findings of qualitative studies designed to explore both positive and negative experiences regarding chemotherapy treatment adherence. This review aims to synthesize the qualitative literature on chemotherapy adherence within the context of patients’ experiences.

This review was conducted in accordance with the Joanna Briggs Institute [ 14 ] guidelines for systemic review involving meta-aggregation. This review was registered in PROSPERO (CRD42021270459).

Search methods

The searches for peer reviewed publications in English from January 2006-September 2023 were conducted by using keywords, medical subject headings (MeSH) terms and Boolean operators ‘AND’ and ‘OR’, which are presented in the table in Appendix 1 . The searches were performed in a systematic manner in core databases such including Embase, Medline, PsycINFO, CINAHL, Web of Science, Cochrane Library, Scopus and the Joanna Briggs Institute (JBI). The search strategy was developed from keywords and medical subject headings (MeSH) terms. Librarian’s support and advice were sought in forming of the search strategies.

Study selection and inclusion criteria

The systematic search was conducted on each database and all articles were exported to Endnote and duplicates records were removed. Then, title and abstract of the full text was screened by two independent reviewers against the inclusion criteria. For this review, populations were patients aged 18 and over with cancer, the phenomenon of interest was experiences on chemotherapy adherence and context was considered as hospitals, communities, rehabilitation centres, outpatient clinics, and residential aged care. All peer-reviewed qualitative study design were also considered for inclusion. Studies included in this review were classified as primary research, published in English since 2006, some intervention implemented to improve adherence to treatment. This review excluded any studies that related to with cancer and mental health condition, animal studies and grey literature.

Quality appraisal and data extraction

The JBI Qualitative Assessment and Review Instrument for qualitative studies was used to assess the methodological quality of the included studies, which was conducted by the primary and second reviewers independently. There was no disagreement between the reviews. The qualitative data on objectives, study population, context, study methods, and the phenomena of interest and findings form the included studies were extracted.

Data synthesis

The meta-aggregation approach was used to combine the results with similar meaning. The primary and secondary reviewers created categories based on the meanings and concept. These categories were supported by direct quotations from participants. The findings were assess based on three levels of evidence, including unequivocal, credible, and unsupported [ 15 , 16 ]. Findings with no quotation were not considered for synthesis in this review. The categories and findings were also discussed by the third and fourth reviewers until a consensus was reached. The review was approved by the Edith Cowan University Human Research Ethics Committee (2021–02896).

Study inclusion

A total of 4145 records were identified through a systematic search. Duplicates ( n  = 647) were excluded. Two independent reviewers conducted screening process. The remaining articles ( n  = 3498) were examined for title and abstract screening. Then, the full text screening conducted, yielded 13 articles to be included in the final synthesis see Appendix 2 .

Methodological quality of included studies

All included qualitative studies scored between 7 and 9, which is displayed in Appendix 3 . The congruity between the research methodology and the research question or objectives, followed by applying appropriate data collection and data analysis were observed in all included studies. Only one study [ 17 ] indicated the researcher’s statement regarding cultural or theoretical perspectives. Three studies [ 18 , 19 , 20 ] identified the influence of the researcher on the research and vice-versa.

Characteristics of included studies

Most of studies conducted semi-structured and in-depth interviews, one study used narrative stories [ 19 ], one study used focus group discussion [ 21 ], and one study combined focus group and interview [ 22 ] to collect data. All studies conducted outpatient’s clinic, community, or hospital settings [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. The study characteristics presented in Appendix 4 .

Review findings

Eighteen findings were extracted and synthesised into five categories: positive outlook, support, side effects, concern about efficacy and unmet information needs.

Positive outlook

Five studies discussed the link between positivity and hope and chemotherapy adherence [ 19 , 20 , 23 , 27 , 28 ]. Five studies commented that feeling positive and avoid the negativity and worry could encourage people to adhere in their mindset chemotherapy: “ I think the main thing for me was just keeping a positive attitude and not worrying, not letting myself worry about it ” [ 20 ]. Participants also considered the positive thoughts as a coping mechanism, that would help them to adhere and complete chemotherapy: “ I’m just real positive on how everything is going. I’m confident in the chemo, and I’m hoping to get out of her soon ” [ 23 ]. Viewing chemotherapy as part of their treatment regimen and having awareness of negative consequences of non-adherence to chemotherapy encouraged them to adhere chemotherapy: “ If I do not take medicine, I do not think I will be able to live ” [ 28 ]. Adhering chemotherapy was described as a survivor tool which helped people to control cancer-related symptoms: “ it is what is going to restore me. If it wasn’t this treatment, maybe I wasn’t here talking to you. So, I have to focus in what he is going to give me, life !” [ 27 ]. Similarly, people accepted the medical facts and prevent their life from worsening; “ without the treatment, it goes the wrong way. It is hard, but I have accepted it from the beginning, yes. This is how it is. I cannot do anything about it. Just have to accept it ” [ 19 ].

Finding from six studies contributed to this category [ 20 , 21 , 23 , 24 , 25 , 29 ]. Providing support from families and friends most important to the people. Receiving support from family members enhanced a sense responsibility towards their families, as they believed to survive for their family even if suffered: “ yes, I just thought that if something comes back again and I say no, then I have to look my family and friends in the eye and say I could have prevented it, perhaps. Now, if something comes back again, I can say I did everything I could. Cancer is bad enough without someone saying: It’s your own fault!!” [ 29 ]. Also, emotional support from family was described as important in helping and meeting their needs, and through facilitation helped people to adhere chemotherapy: “ people who genuinely mean the support that they’re giving […] just the pure joy on my daughter’s face for helping me. she was there day and night for me if I needed it, and that I think is the main thing not to have someone begrudgingly looking after you ” [ 20 ]. Another study discussed the role family, friends and social media as the best source of support during their treatment to adhere and continue “ I have tons of friends on Facebook, believe it or not, and it’s amazing how many people are supportive in that way, you know, just sending get-well wishes. I can’t imagine going through this like 10 years ago whenever stuff like that wasn’t around ” [ 23 ]. Receiving support from social workers was particularly helpful during chemotherapy in encouraging adherence to the chemotherapy: “ the social worker told me that love is courage. That was a huge encouragement, and I began to encourage myself ” [ 25 ].

Side effects

Findings from five studies informed this category [ 17 , 21 , 22 , 25 , 26 ]. Physical side effects were described by some as the most unpleasure experience: “ the side effects were very uncomfortable. I felt pain, fatigue, nausea, and dizziness that limited my daily activities. Sometimes, I was thinking about not keeping to my chemotherapy schedule due to those side effect ” [ 17 ]. The impact of side effects affected peoples’ ability to maintain their independence and self-care: “ I couldn’t walk because I didn’t have the energy, but I wouldn’t have dared to go out because the diarrhoea was so bad. Sometimes I couldn’t even get to the toilet; that’s very embarrassing because you feel like you’re a baby ” [ 26 ]. Some perceived that this resulted in being unable to perform independently: “ I was incredibly weak and then you still have to do things and you can’t manage it ” [ 22 ]. These side effect also decreased their quality of life “ I felt nauseated whenever I smelled food. I simply had no appetite when food was placed in front of me. I lost my sense of taste. Food had no taste anymore ” [ 25 ]. Although, the side effects impacted on patients´ leisure and free-time activities, they continued to undertake treatment: “ I had to give up doing the things I liked the most, such as going for walks or going to the beach. Routines, daily life in general were affected ” [ 21 ].

Concern about efficacy

Findings form four studies informed this category [ 17 , 18 , 24 , 28 ]. Although being concerned about the efficacy of the chemotherapy and whether or not chemotherapy treatment would be successful, one participant who undertook treatment described: “the efficacy is not so great. It is said to expect about 10% improvement, but I assume that it declines over time ” [ 28 ]. People were worried that such treatment could not cure their cancer and that their body suffered more due to the disease: “ I was really worried about my treatment effectiveness, and I will die shortly ” [ 17 ]. There were doubts expressed about remaining the cancer in the body after chemotherapy: “ there’s always sort of hidden worries in there that whilst they’re not actually taking the tumour away, then you’re wondering whether it’s getting bigger or what’s happening to it, whether it’s spreading or whatever, you know ” [ 24 ]. Uncertainty around the outcome of such treatment, or whether recovering from cancer or not was described as: “it makes you feel confused. You don’t know whether you are going to get better or else whether the illness is going to drag along further” [ 18 ].

Unmet information needs

Five studies contributed to this category [ 17 , 21 , 22 , 23 , 26 ]. The need for adequate information to assimilate information and provide more clarity when discussing complex information were described. Providing information from clinicians was described as minimal: “they explain everything to you and show you the statistics, then you’re supposed to take it all on-board. You could probably go a little bit slower with the different kinds of chemo and grappling with these statistics” [ 26 ]. People also used the internet search to gain information about their cancer or treatments, “I’ve done it (consult google), but I stopped right away because there’s so much information and you don’t know whether it’s true or not ” [ 21 ]. The need to receive from their clinicians to obtain clearer information was described as” I look a lot of stuff up online because it is not explained to me by the team here at the hospital ” [ 23 ]. Feeling overwhelmed with the volume of information could inhibit people to gain a better understanding of chemotherapy treatment and its relevant information: “ you don’t absorb everything that’s being said and an awful lot of information is given to you ” [ 22 ]. People stated that the need to know more information about their cancer, as they were never dared to ask from their clinicians: “ I am a low educated person and come from a rural area; I just follow the doctor’s advice for my health, and I do not dare to ask anything” [ 17 ].

The purpose of this review was to explore patient’s experiences about the chemotherapy adherence. After finalizing the searches, thirteen papers were included in this review that met the inclusion criteria.

The findings of the present review suggest that social support is a crucial element in people’s positive experiences of adhering to chemotherapy. Such support can lead to positive outcomes by providing consistent and timely assistance from family members or healthcare professionals, who play vital roles in maintaining chemotherapy adherence [ 30 ]. Consistent with our study, previous research has highlighted the significant role of family members in offering emotional and physical support, which helps individuals cope better with chemotherapy treatment [ 31 , 32 ]. However, while receiving support from family members reinforces individuals’ sense of responsibility in managing their treatment and their family, it also instils a desire to survive cancer and undergo chemotherapy. One study found that assuming self-responsibility empowers patients undergoing chemotherapy, as they feel a sense of control over their therapy and are less dependent on family members or healthcare professionals [ 33 ]. A qualitative systematic review reported that support from family members enables patients to become more proactive and effective in adhering to their treatment plan [ 34 ]. This review highlights the importance of maintaining a positive outlook and rational beliefs as essential components of chemotherapy adherence. Positive thinking helps individuals recognize their role in chemotherapy treatment and cope more effectively with their illness by accepting it as part of their treatment regimen and viewing it as a tool for survival. This finding is supported by previous studies indicating that positivity and positive affirmations play critical roles in helping individuals adapt to their reality and construct attitudes conducive to chemotherapy adherence [ 35 , 36 ]. Similarly, maintaining a positive mindset can foster more favourable thoughts regarding chemotherapy adherence, ultimately enhancing adherence and overall well-being [ 37 ].

This review identified side effects as a significant negative aspect of the chemotherapy experience, with individuals expressing concerns about how these side effects affected their ability to perform personal self-care tasks and maintain independent living in their daily lives. Previous studies have shown that participants with a history of chemotherapy drug side effects were less likely to adhere to their treatment regimen due to worsening symptoms, which increased the burden of medication side effects [ 38 , 39 ]. For instance, cancer patients who experienced minimal side effects from chemotherapy were at least 3.5 times more likely to adhere to their treatment plan compared to those who experienced side effects [ 40 ]. Despite experiencing side effects, patients were generally willing to accept and adhere to their treatment program, although one study in this review indicated that side effects made some patients unable to maintain treatment adherence. Side effects also decreased quality of life and imposed restrictions on lifestyle, as seen in another study where adverse effects limited individuals in fulfilling daily commitments and returning to normal levels of functioning [ 41 ]. Additionally, unmet needs regarding information on patients’ needs and expectations were common. Healthcare professionals were considered the most important source of information, followed by consultation with the internet. Providing information from healthcare professionals, particularly nurses, can support patients effectively and reinforce treatment adherence [ 42 , 43 ]. Chemotherapy patients often preferred to base their decisions on the recommendations of their care providers and required adequate information retention. Related studies have highlighted that unmet needs among cancer patients are known factors associated with chemotherapy adherence, emphasizing the importance of providing precise information and delivering it by healthcare professionals to improve adherence [ 44 , 45 ]. Doubts about the efficacy of chemotherapy treatment, as the disease may remain latent, were considered negative experiences. Despite these doubts, patients continued their treatment, echoing findings from a study where doubts regarding efficacy were identified as a main concern for chemotherapy adherence. Further research is needed to understand how doubts about treatment efficacy can still encourage patients to adhere to chemotherapy treatment.

Strengths and limitation

The strength of this review lies in its comprehensive search strategy across databases to select appropriate articles. Additionally, the use of JBI guidelines provided a comprehensive and rigorous methodological approach in conducting this review. However, the exclusion of non-English studies, quantitative studies, and studies involving adolescents and children may limit the generalizability of the findings. Furthermore, this review focuses solely on chemotherapy treatment and does not encompass other types of cancer treatment.

Conclusion and practical implications

Based on the discussion of the findings, it is evident that maintaining a positive mentality and receiving social support can enhance chemotherapy adherence. Conversely, experiencing treatment side effects, concerns about efficacy, and unmet information needs may lead to lower adherence. These findings present an opportunity for healthcare professionals, particularly nurses, to develop standardized approaches aimed at facilitating chemotherapy treatment adherence, with a focus on providing comprehensive information. By assessing patients’ needs, healthcare professionals can tailor approaches to promote chemotherapy adherence and improve the survival rates of people living with cancer. Raising awareness and providing education about cancer and chemotherapy treatment can enhance patients’ understanding of the disease and its treatment options. Utilizing videos and reading materials in outpatient clinics and pharmacy settings can broaden the reach of educational efforts. Policy makers and healthcare providers can collaborate to develop sustainable patient education models to optimize patient outcomes in the context of cancer care. A deeper understanding of individual processes related to chemotherapy adherence is necessary to plan the implementation of interventions effectively. Further research examining the experiences of both adherent and non-adherent patients is essential to gain a comprehensive understanding of this topic.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. on our submission system as well.

World Health Organization. Cancer 2021 [ https://www.who.int/news-room/fact-sheets/detail/cancer .

Klapheke A, Yap SA, Pan K, Cress RDDHSDCA. Sociodemographic disparities in chemotherapy treatment and impact on survival among patients with metastatic bladder cancer. Urologic Oncology: Seminars Original Investigations. 2018;36(6):19–308.

Article   Google Scholar  

Moth EB, Kiely BE, Naganathan V, Martin A, Blinman P. How do oncologists make decisions about chemotherapy for their older patients with cancer? A survey of Australian oncologists. Support Care Cancer. 2018;26(2):451–60.

Article   CAS   PubMed   Google Scholar  

Khamboon T, Pakanta I. Intervention for symptom cluster management of fatigue, loss of appetite, and anxiety among patients with lung cancer undergoing chemotherapy. Asia-Pacific J Oncol Nurs. 2021;8(3):267–75.

Garcia ACM, Camargos Junior JB, Sarto KK, Silva Marcelo CAd, Paiva EMC, Nogueira DA, Mills J. Quality of life, self-compassion and mindfulness in cancer patients undergoing chemotherapy: a cross-sectional study. Eur J Oncol Nurs. 2021;51:N.PAG-N.PAG.

Horne R, Chapman SCE, Parham R, Freemantle N, Forbes A, Cooper V. Understanding patients’ adherence-related beliefs about Medicines prescribed for long-term conditions: a Meta-Analytic Review of the necessity-concerns Framework. PLoS ONE. 2013;8(12):e80633.

Article   PubMed   PubMed Central   Google Scholar  

WHO. Adherence to long-term therapies: evidence for action. Geneva, Switzerland: World Health Organisation; 2003.

Google Scholar  

Warby A, Dhillon HM, Kao S, Vardy JL. A survey of patient and caregiver experience with malignant pleural mesothelioma. Support Care Cancer. 2019;27(12):4675–86.

Article   PubMed   Google Scholar  

Arunachalam SS, Shetty AP, Panniyadi N, Meena C, Kumari J, Rani B, et al. Study on knowledge of chemotherapy’s adverse effects and their self-care ability to manage - the cancer survivors impact. Clin Epidemiol Global Health. 2021;11:100765.

Article   CAS   Google Scholar  

Nizet P, Touchefeu Y, Pecout S, Cauchin E, Beaudouin E, Mayol S, et al. Exploring the factors influencing adherence to oral anticancer drugs in patients with digestive cancer: a qualitative study. Support Care Cancer. 2022;30(3):2591–604.

Clancy C, Lynch J, Oconnor P, Dowling M. Breast cancer patients’ experiences of adherence and persistence to oral endocrine therapy: a qualitative evidence synthesis. Eur J Oncol Nurs. 2020;44.

Magalhães B, Fernandes C, Lima L, Martinez-Galiano JM, Santos C. Cancer patients’ experiences on self-management of chemotherapy treatment-related symptoms: A systematic review and thematic synthesis. Eur J Oncol Nurs. 2020;49.

Peddie N, Agnew S, Crawford M, Dixon D, MacPherson I, Fleming L. The impact of medication side effects on adherence and persistence to hormone therapy in breast cancer survivors: a qualitative systematic review and thematic synthesis. Breast. 2021;58:147–59.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ: Br Med J. 2009;339(7716):332–6.

Joanna Briggs Institute. The Joanna Briggs Institute critical appraisal tools for use in JBI systematic reviews. Checklist for qualitative research. 2017.

Zachary M, Kylie P, Craig L, Edoardo A, Alan P. Establishing confidence in the output of qualitative research synthesis: the ConQual approach. BMC Med Res Methodol [Internet]. 2014;14(1):108.

Iskandarsyah A, de Klerk C, Suardi DR, Soemitro MP, Sadarjoen SS, Passchier J. Psychosocial and cultural reasons for Delay in seeking help and Nonadherence to treatment in Indonesian women with breast Cancer: a qualitative study. Health Psychol. 2014;33(3):214–21.

Chircop D, Scerri J. The lived experience of patients with Non-hodgkin’s lymphoma undergoing chemotherapy. Eur J Oncol Nurs. 2018;35:117–21.

Kvåle K, Synnes O. Living with life-prolonging chemotherapy—control and meaning‐making in the tension between life and death. Eur J Cancer Care. 2018;27(1):1.

Staneva AA, Beesley VL, Niranjan N, Gibson AF, Rowlands I, Webb PM. I wasn’t gonna let it stop me: exploring women’s experiences of getting through chemotherapy for ovarian cancer. Cancer Nurs. 2019;42(2):E31–8.

Talens A, Guilabert M, Lumbreras B, Aznar MT, López-Pintor E. Medication Experience and Adherence to Oral Chemotherapy: A Qualitative Study of Patients’ and Health Professionals’ Perspectives. Int J Environ Res Public Health. 2021;18(8).

Dumas L, Lidington E, Appadu L, Jupp P, Husson O, Banerjee S, et al. Exploring older women’s attitudes to and experience of treatment for advanced ovarian cancer: a qualitative phenomenological study. Cancers. 2021;13(6):1207.

Albrecht TA, Keim-Malpass J, Boyiadzis M, Rosenzweig M. Psychosocial experiences of young adults diagnosed with acute leukemia during hospitalization for induction chemotherapy treatment. J Hospice Palliat Nurs. 2019;21(2):167–73.

Beaver K, Williamson S, Briggs J. Exploring patient experiences of neo-adjuvant chemotherapy for breast cancer. Eur J Oncol Nurs. 2016;20:77–86.

Chou J-F, Lu YY. Intraperitoneal chemotherapy: the lived experiences of Taiwanese patients with ovarian cancer. Clin J Oncol Nurs. 2019;23(6):E100–6.

Farrell C, Heaven C. Understanding the impact of chemotherapy on dignity for older people and their partners. Eur J Oncol Nurs. 2018;36:82–8.

Wakiuchi J, Silva Marcon S, de Oliveira DC, Aparecida Sales C. Rebuilding subjectivity from the experience of cancer and its treatment. Revista Brasileira De Enfermagem. 2019;72(1):125–33.

Yagasaki K, Komatsu H, Takahashi T. Inner conflict in patients receiving oral anticancer agents: a qualitative study. BMJ Open [Internet]. 2015; 5(4).

Gassmann C, Kolbe N, Brenner A. Experiences and coping strategies of oncology patients undergoing oral chemotherapy: first steps of a grounded theory study. Eur J Oncol Nurs. 2016;23:106–14.

Tang GX, Yan PP, Yan CL, Fu B, Zhu SJ, Zhou LQ, et al. Determinants of suicidal ideation in gynecological cancer patients. Psycho-oncology. 2016;25(1):97–103.

Oven Ustaalioglu B, Acar E, Caliskan M. The predictive factors for perceived social support among cancer patients and caregiver burden of their family caregivers in Turkish population. Int J Psychiatry Clin Pract. 2018;22(1):63–9.

Levkovich I, Cohen M, Karkabi K. The experience of fatigue in breast Cancer patients 1–12 Month Post-chemotherapy: a qualitative study. Behav Med. 2019;45(1):7–18.

Simchowitz B, Shiman L, Spencer J, Brouillard D, Gross A, Connor M, Weingart SN. Perceptions and experiences of patients receiving oral chemotherapy. Clin J Oncol Nurs. 2010;14(4):447–53.

Rashidi A, Kaistha P, Whitehead L, Robinson S. Factors that influence adherence to treatment plans amongst people living with cardiovascular disease: a review of published qualitative research studies. Int J Nurs Stud 2020;110(103727).

Aydogan U, Doganer YC, Komurcu S, Ozturk B, Ozet A, Saglam K. Coping attitudes of cancer patients and their caregivers and quality of life of caregivers. Indian J Palliat Care. 2016;22(2):150–6.

Langford DJ, Morgan S, Cooper B, Paul S, Kober K, Wright F, et al. Association of personality profiles with coping and adjustment to cancer among patients undergoing chemotherapy. Psycho-oncology. 2020;29(6):1060–7.

Jamie MJ, Pensak NA, Sporn NJ, MacDonald JJ, Lennes IT, Safren SA et al. Treatment satisfaction and adherence to oral chemotherapy in patients with Cancer. J Oncol Pract. 2017;13(2).

Tsai Y-F, Huang W-C, Cho S-F, Hsiao H-H, Liu Y-C, Lin S-F, et al. Side effects and medication adherence of tyrosine kinase inhibitors for patients with chronic myeloid leukemia in Taiwan. Medicine. 2018;97(26):415.

D S, M P, G R, S H. Importance of medication adherence and factors affecting it. IP Int J Compr Adv Pharmacolog. 2020;3(2):69–77.

Bekalu YE, Wudu MA, Gashu AW. Adherence to Chemotherapy and Associated factors among patients with Cancer in Amhara Region, Northeastern Ethiopia, 2022. A cross-sectional study. Cancer Control. 2023;30.

Hsu H-C, Liou W-S, Chiang A-J, Tsai S-Y, Jeang S-R, Wu S-L, et al. Longitudinal perceptions of the side effects of chemotherapy in patients with gynecological cancer. Support Care Cancer. 2017;25(11):3457–64.

Gow K, Rashidi A, Whithead L. Factors influencing medication adherence among adults living with diabetes and comorbidities: a qualitative systematic review. Curr Diab Rep. 2023:1–7.

Rashidi A, Whitehead L, Kaistha P. Nurses’ perceptions of factors influencing treatment engagement among patients with cardiovascular diseases: a systematic review. BMC Nurs. 2021;20(1):251.

Zebrack BJ, Block R, Hayes-Lattin B, Embry L, Aguilar C, Meeske KA, et al. Psychosocial service use and unmet need among recently diagnosed adolescent and young adult cancer patients. Cancer. 2013;119(1):201–14.

Timmers L, Boons CCLM, van den Verbrugghe M, Van Hecke A, Hugtenburg JG. Supporting adherence to oral anticancer agents: clinical practice and clues to improve care provided by physicians, nurse practitioners, nurses and pharmacists. BMC Cancer. 2017;17(1).

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First author (AR) and second author (ST) conceived the review and the second author oversight for all stages of the review provided by the second author. All authors (AR), (ST), (WG) and (SK) undertook the literature search. Data extraction, screening the included papers and quality appraisal were undertaken by all authors (AR), (ST), (WG) and (SK). First and second authors (AR) and (ST) analysed the data and wrote the first draft of the manuscript and revised the manuscript and all authors (AR), (ST), (WG) and (SK) approved the final version of the manuscript.

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Rashidi, A., Thapa, S., Kahawaththa Palliya Guruge, W. et al. Patient experiences: a qualitative systematic review of chemotherapy adherence. BMC Cancer 24 , 658 (2024). https://doi.org/10.1186/s12885-024-12353-z

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Understanding patient-related barriers to hydroxyurea use among adolescent and adult patients with sickle cell disease in Mulago and Kiruddu hospitals, Uganda, a qualitative study

• Priscilla Namaganda 1 ,
• Patience Nantume 2 ,
• Kelvin Roland Mubiru 3 ,
• Adelliine Twimukye 2 &
• Christine Sekaggya Wiltshire 2  

BMC Health Services Research volume  24 , Article number:  666 ( 2024 ) Cite this article

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In 2016, Uganda added Hydroxyurea (HU) to the list of essential drugs to treat sickle cell disease SCD. However, Hydroxyurea utilization has been low for several countries in sub-Saharan Africa. This study examined patient-related barriers to hydroxyurea use among adolescent and adult patients with sickle cell disease in Mulago and Kiruddu hospitals, in Uganda.

To understand the patient-related barriers to hydroxyurea use among adolescent and adult patients with sickle cell disease, we conducted a parallel convergent mixed methods study at outpatient departments of two national referral hospitals in Uganda from October 2022 to January 2023. The cross-sectional mixed-methods study employed both quantitative and qualitative methods. We collected survey data from a systematic sample of 259 participants and conducted individual interviews with a purposive sample of 40 participants (20 adolescents or their caregivers and 20 adult patients with SCD) and interviewed them individually on their knowledge, perceptions, barriers, and facilitators of HU utilization. Descriptive data were analyzed using Stata 16, whereas qualitative data were analyzed thematically using an inductive approach supported by NVivo 12 software. We triangulated data to determine the concordance of qualitative and quantitative data.

The study enrolled 40 participants for qualitative interviews and 259 patients for quantitative, with an average age of 16, over half being female, 46% having secondary education, and 96% unmarried. The prevalence of HU use was 78%. The study identified three themes as follows: Patient barriers at the individual including Inadequate knowledge about HU, Persistent pain, Poor adherence to HU, Poor communication with health care workers, and Psychosocial and emotional challenges. At the facility level, long queues and poor quality of care, drug-related side effects that affect HU, and drug stock-outs were reported. Myths, rumors, and misconceptions about HU, and gender-related barriers were reported to affect HU utilization at a community level. Facilitators for the use of HU and recommendations for improvement. Facilitators included perceived benefits, long duration on HU, information sharing by healthcare workers, availability of complementary drugs, confirmation of diagnosis, and availability of medication at public health facilities or private pharmacies. Patients suggested continuous adherence support, encouragement from healthcare workers, sensitization about benefits and risks, a peer-to-peer approach, and financial support for adolescents and women to start businesses to resolve financial problems.

Implementing the use of HU has been challenging in Uganda and needs improvement. Facilitators to hydroxyurea use have been highlighted, though Patient-identified barriers at individual, facility, and community levels that need to be resolved. The experiences and insights shared by our participants provide invaluable guidance for increasing the uptake of HU. Further studies are needed to establish validated instruments to assess patients’ pain communication and adherence to the HU regimen.

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In Africa, sickle cell disease (SCD) contributes substantially to mortality in children younger than 5 years. The global burden has been quantified, with SCD accounting for 6.4% of the under-5 mortality across all of Africa [ 1 ]. However, in countries with greater sickle allele frequencies and lower childhood mortality rates, such as Uganda, SCD may account for up to 15% of under-5 mortality [ 2 ]. The mortality rate in adult patients with SCD is not known presumably because of a lack of accurate data but is thought to be high as more children with SCD survive into adolescence and adulthood, they are faced with poor access to comprehensive sickle cell care with a continuing risk of complications or death [ 2 ].

Hydroxyurea is one of the approved drugs for treating sickle cell disease [ 3 ]. The mechanism by which hydroxyurea works is rather unknown although its efficacy in the treatment of SCD is generally attributed to its ability to boost the levels of fetal hemoglobin (Hb F, α 2 γ 2 ) hence lowering the concentration of HbS. HbF is protective against clinical severity, and low-percentage HbF is associated with a higher risk of developing Vaso-occlusive complications, organ damage, and early death. Systemic review studies have documented the efficacy of hydroxyurea in adult patients with SCD [ 3 ]. In Uganda, the NOHARM and REACH studies reported a reduction in SCD-related complications with the use of hydroxyurea and appeared to be safe for children with SCD without increased severe malaria, infections, or adverse events [ 4 , 5 ].

Hydroxyurea was added to the list of essential drugs in Uganda in 2016 but it is not readily available [ 6 ].

The number of patients with SCD currently taking hydroxyurea is about 33%; this is undocumented data from patient charts. This low percentage of use could be due to limited access and availability of drugs, practitioners’ low knowledge of HU use, and patients’ fear of drug toxicities. Therefore, this study sought to assess barriers to HU treatment among this cohort of patients and document them. This study focused on knowledge, perceptions, barriers, and facilitators of adolescent and adult patients with sickle cell disease regarding HU because there is minimal data and even the data that is available focuses on children, not adults. Reasons reported by authors in studies done included fear of cancer and other side effects, not wanting to take a medication, not wanting to have required laboratory monitoring, or not thinking the medication would work [ 7 ]. The primary goal and benefit of patient-centered care is to improve individual health outcomes, not just population health outcomes, although population outcomes may also improve [ 8 ]. Not only do patients benefit, but providers and healthcare systems benefit as well, through (a) Improved satisfaction among patients and their families, (b) Enhanced reputation of providers among healthcare consumers, (c) Better morale and productivity among clinicians and ancillary staff, (d) Improved resource allocation, (e) Reduced expenses and increased financial margins throughout the continuum of care [ 8 ].

With greater use of HU for eligible patients, it is expected that fewer patients will be hospitalized for complications of SCD, resulting in a net reduction of national healthcare costs for patients with SCD [ 9 ]. In addition, the broader appropriate use of HU in patients with SCD should improve their quality of life and productivity [ 9 ]. With this information, we can lobby the government and/or donors to avail recourses for continued supply of HU and other resources like laboratory capacity that aid us in giving comprehensive care to patients with SCD. Therefore, we conducted a mixed methods study to identify the knowledge, perceptions, barriers, and facilitators of adolescent and adult patients with sickle cell disease regarding HU and suggest interventions to facilitate HU uptake in Uganda. We hypothesized that there was a relationship between patient-related barriers and hydroxyurea use among patients with SCD.

Study design

From October 2022 to January 2023, we conducted a cross-sectional mixed-methods study (parallel convergent) with qualitative components using a phenomenological approach.

Study setting

The study was conducted at the Sickle cell clinic in Mulago Hospital sickle cell clinic and Kiruddu Hospital, hematology. The Sickle Cell Clinic is an innovation for treating children with SCA with acute pain and other medical complications as outpatients. The Mulago sickle cell clinic attends to children, adolescents, and adult patients with SCD. The Kiruddu clinic attends to adolescent and adult patients with SCD in addition to other hematological conditions. Both Mulago and Kiruddu are national referral hospitals in Uganda and are teaching hospitals for Makerere University, College of Health Sciences. The Mulago SCD clinic cares for more than 300 patients with SCD. The hematology clinic at Kiruddu Hospital cares for 100 to 150 patients with SCD.

Sample size estimation

We purposively selected 40 participants to participate in the qualitative interviews. The actual sample size (40) was determined by how many participants were required to explore all the research questions and to achieve thematic saturation. It was difficult to determine the ideal sample size for achieving these objectives at the early stage of the research. Therefore, the process of participant selection was iterative, involving several rounds of selection and interviews as will be necessary to achieve thematic saturation. Data was collected until no new themes or patterns emerged from participants interviewed participants selected from each study site. 20 individual interviews were carried out in each selected site, making a total of 40 Individual interviews from two study sites. Patients were interviewed to identify the barriers to the use of hydroxyurea through In-depth interviews using an in-depth interview form developed for the study with 20 purposively selected patients per site. The criteria for the selection of patients for in-depth interviews were 10 adults (5 males and 5 females), and 10 adolescents (5 males and 5 females) who have ever missed appointments or drugs from each clinic. Also, their understanding, experiences, and what they had heard regarding using Hydroxyurea were assessed. All the interviews were conducted from the hospital premises and in a language preferred by the participants and audio recorded. All adolescents were interviewed with their caretakers and each caretaker signed a parent-guardian consent form in addition to the adolescent signing an assent form.

Eligibility for HU use was (a) Three or more sickle cell-associated moderate to severe pain crises in 12 months, requiring hospitalization or management at a health facility, (b) Sickle cell-associated pain that interferes with daily activities and quality of life, (c) History of severe and/or recurrent acute chest syndrome, (d) Severe symptomatic chronic anemia that interferes with daily activities or quality of life(severe symptomatic anemia criteria was assessed based on the need for blood transfusion). if participants responded yes to any of the above criteria, they were eligible for HU use. Patients with other sickle cell syndromes – e.g., Hb SC disease, S/ß thalassemia, pregnant, severely ill study, and declined to participate in the study were excluded.

The sample size for quantitative was estimated using Leslie Kish’s (1964) formula for sample size calculation. With a prevalence of HU use at 33.7% as reported by a study done in Oman [ 10 ] and at a 0.05 level of significance, the sample was estimated at 260 participants. The sickle cell clinic at Mulago Hospital runs daily and that at Kiruddu on Thursday of every week. Patients with SCD who came for assessment were screened using a questionnaire developed for the study and each one of them was informed about the study with the help of a research assistant. Patients who are taking HU or have taken HU were recorded. Patients who are not taking HU were assessed to determine if they fit the criteria for starting HU as described above. If participants responded to any of the above criteria, they were enrolled in the study after obtaining informed consent from research assistants. Patients enrolled were asked to fill out a standardized questionnaire with the help of research assistants. Information obtained included (a) demographic i.e. age, gender, address, level of education, religion, and occupation, (b) time when patient joined the clinic, past and current medications, history of SCD-associated complications and history of admissions, (c) status of HU use and reasons for not initiating HU and possible solutions to these challenges.

Study variables

Independent variables.

We collected data on; age, gender, address, level of education, religion, occupation, commonest complications of SCD experienced, indications for HU use, and the common medications used.

Dependent variables

Our outcomes were willingness to use HU, perceptions about HU use, reasons for not initiating HU and possible solutions to these challenges.

Procedures for data collection and instruments

Quantitative data.

We used a systematic sampling method for the survey. For the quantitative objective, all patients with SCD were screened and those who met the inclusion criteria were enrolled in the study. We therefore included every 4th participant in the survey beginning with the 4th adult until the sample size was attained. We used maximum variation purposive sampling to select the participants for the in-depth interviews. For the survey, we used an interviewer-administered semi-structured questionnaire to collect data on the 259 participants using a questionnaire administered by a research assistant. For the 40 individual interviews, we used an interview guide which was used to collect perceptions on HU. Interviews lasted approximately 10–20 min. Data collection occurred over three months and transcription began as data collection was ongoing.

Data quality control

The questionnaire was pre-tested on 5 participants from the same community to ensure that the questions were clear and understandable to participants. The Questionnaires and Interview guide were translated into the local language and then back-translated to English as part of standard operating procedures such that they have retained their meaning. The research assistants were adequately trained for 7 days and routinely supervised while in the field and the data they were collecting by the principal investigator to ensure the correct use of data collection tools and adherence to ethical principles.

To ensure reliability, we set clear research questions to expand on responses. Qualitative data was collected separately from quantitative data (parallel convergence). Codes and qualitative findings were crosschecked to improve reliability. Consensus between two or more observers was done to establish reliability. We used NVivo version 12 software to manage narrative data.

To ensure validity, all transcripts were checked for accuracy and completeness by the interviewers to enhance data validity. Feedback from research participants (member check) after analysis and interpretation was obtained in an organized results dissemination workshop. Documentation of member checks and interpretations that were changed because of member feedback was done. Triangulation combined quantitative (survey) and qualitative data collection methods (in-depth interviews) in this single study. Triangulation of various data collection methods was used. These included questionnaires, Topic guides (In-depth interviews), transcripts, field notes, and Literature review. This was aimed at verifying information, or facts obtained from using other methods.

Data management and analysis

Quantitative data collected were double-entered into the computer using EPI-DATA (version 3.1) software to minimize data entry errors. Data was exported to STATA version 15 for data cleaning and analysis. Data was then backed up and archived using codes to ensure confidentiality. The descriptive characteristics were presented using frequencies and percentages or proportions in tables. Numerical data was summarized using means and standard deviations for normally distributed continuous data or medians and interquartile ranges for continuous but skewed variables. The prevalence of hydroxyurea use among adult patients was calculated as a proportion of adult patients with SCD who have ever used hydroxyurea out of the total number of participants who are eligible for HU use with its 95% confidence intervals.

The Qualitative study was guided by the ethical principles of the Association of Social Anthropologists. These principles included protecting research participants, anticipating harm, avoiding undue intrusion, rights to confidentiality and anonymity, intellectual property rights, and participant involvement in research. Recording and storing participants’ information was done in a manner that facilitated greater confidentiality and anonymity, including the use of pseudonyms to describe participants during interviews, separation of participants’ ID information from their transcripts, storage of participant information in secured locations and password-protected hard drives, removal of participants names in all research dissemination outputs. Research assistants obtained informed consent prior to start of individual interviews. The Individual interviews were conducted in one-to-one and face-to-face format to provide greater privacy and assure participants of confidentiality. We conducted an inductive thematic analysis collected from individual interviews with different respondent categories such as (20 adolescents or their caregivers and 20 adult patients with SCD). The analysis examined meanings, themes, and patterns that manifested texts from the interviews regarding HU use in two hospitals in Uganda. All audio recordings from open-ended questions based on interview guides were transcribed verbatim. Two coders Individually read each transcript line by line and identified key concepts to develop a coding framework. A coding framework based on eight transcripts that were manually reviewed and coded to generate the initial set of codes that were crosschecked iteratively between two coders (AT & PN) for consensus and to improve reliability. All transcripts were imported into NVivo version 12 software for open coding and management of data. An initial codebook was developed, and the revised codes were grouped into categories and identified themes. Illustrative quotations for each emergent theme were selected for the results narration.

283 participants were assessed and 259 were enrolled in the study as shown in the flow chart, Fig.  1 .

Flow chart showing enrolment profile

Characteristics of adults and adolescents

The total sample size was 259, 221 participants were recruited from the Mulago Hospital sickle cell clinic and 38 from Kiruddu Hospital. At the Mulago sickle cell clinic, the average age was 16 years, with 58.5% being female, and 46% having an education level of secondary. At Kiruddu Hospital, the median age was 24, with 71.1% being female, and 48.1% having an education level of secondary. The average cost of transport to and from the hospital was 11,000 Ugx. The average duration of HU use was 24 months. All this is summarized in Table  1 .

Eligibility for HU use

259 participants met the criteria for HU, 202(78.0%) were taking HU, and 57 participants met the criteria for HU use but were not taking HU. Of those that use HU, 92.1% were current users and 7.9% were past users. HU use among eligible patients is shown in Table  2 .

Patient-related barriers to HU use

Painful crisis was the most common indication for HU use reported in 94.6% of participants, followed by chest syndrome (28%), anemia, 19.4%, and avascular necrosis, 24.7%. indication for HU use is summarized in Table  3 above.

Indications for initiating HU use

The study identified three themes as follows: Patient barriers at the individual, facility, and community level as shown in Tables  4 , 5 and 6 , and 7 . Facilitators for the use of HU and recommendations for improvement as displayed in Table  8 .

Individual barriers

Financial constraints.

The most common reason for stopping HU use was lack of affordability reported by 81.2% of participants. This information is summarised in Table  5 below. The major challenge among 19 (48%) participants from qualitative interviews was financial constraints to buy medication, and food and meet the transport costs to access care.

“There are times when I skipped my medicine doses… Sometimes it was due to money; if I didn’t have the money to buy the tablets. Because we are supposed to buy the tablets—sometimes you go to the pharmacy, and they are expensive, yet you don’t have money. You use the little money you must buy some tablets and they get finished, and I have no money to buy more. So, I first miss some days, and a few times I depend on Panadol and Ibuprofen for emergencies. I take it in case I don’t have the medicine not daily—they told me I could take it occasionally if I am constrained financially and unable to buy the medicine”.

-- IDI, 18, female, adult, Mulago.

Most adults and adolescents were not able to pay for prescribed sickle cell drugs and other ailments because they were expensive.

“… There was no money to buy it because a packet is shs.15,000; just one packet… yet buying it is expensive and I have no money. Now I no longer stay with my father; my mother stays home; she does not work. If my father goes to work and takes a long time there, my mother is suffering to buy the medicine. She buys it for shs. 15,000 but it gets finished in a week, so she must look for more shs. 15,000 to buy another dose”. -- IDI, 19, Male, adolescent, Mulago.

Most of the adolescents said they were unemployed and were mainly dependent on their parent’s support, which was sometimes limited:

“If there is transport because I am always at home. Ever since they fired me from my job, I have been at home”. -- IDI, 3 1, female, adolescent, Mulago.

Inadequate knowledge

Inadequate knowledge about HU among adolescents and adults by few participants. Generally, most individual participants from qualitative (27, 68%) and quantitative (231 (88.2%) across all age categories had a high level of awareness about hydroxyurea and its related benefits as shown in Table  5 below. For the few adult participants who lacked awareness about Hydroxyurea, it was because health workers did not inform them about it, and some had never started on it.

Because I didn’t know about it [Hydroxyurea]; they had never told me about it. So, the doctors asked me, “Have you ever used hydroxyurea?” and I told them, “I don’t know about it . -- IDI, 22, male, adult, Mulago.

Among adolescents, there was low knowledge about HU due to limited sensitization as they did not receive enough health education. Moreover, they reported rumors, myths, and misconceptions about sickle cell in the community.

“Most times what scares them, they say, “Once you start taking the drug and then stop you die”, it scares them as well—okay, the rumors are so many”. -- IDI, 11, Male, youth, Mulago.

Some participants said there was a lack of awareness about Hydroxyurea in the community because they were not sensitized and had not come across people who swallowed it:

“Community people have not been well oriented about Hydroxyurea benefits by the doctors… they have not heard anyone on it so far”. -- IDI, 16_ adult, Mulago.

Persistent pain affected the use of HU

Nearly half (38%) of the participants who participated in individual interviews reported persistent pain despite taking painkillers as a major challenge that hindered proper adherence.

They used to administer painkillers to me since I had a lot of pain! And if the pain comes, it is so strong; it is severe because at school there is a health facility they would do their best with the painkillers but they had no effect. So, they would bring me here” . -- IDI, 28, female, youth, Mulago.

Some participants said they could hardly walk to the health facility due to severe pain, hence missed appointments and picking drugs.

I missed my appointment because I was sick and bedridden, admitted to the hospital. Huh! I feel pain. There are times I could hardly walk…. -- IDI, 10, female, adult, Mulago.

Poor adherence to HU

43% (17, 43%), mainly adolescents from qualitative interviews reported Poor treatment adherence. They missed taking sickle cell medication on time or stopped it for a month or more. The major reasons for missing drugs were pain, running out of drugs, missed appointments to pick drug refills, and lack of funds to buy drugs when they ran out:

“So, when I swallow it in the morning, it takes like 30 minutes, then I go back to normal. But sometimes I miss doses because the medicine is finished before the people at home bring for me more, because I am not near home. They bring it within one week because they also must look for the money to buy it. -- IDI, 28, female, adolescent, Mulago.

Another reason for poor adherence to sick cell medication was forgetfulness. Some participants said they came back from school tired and slept off while others could be distracted by television:

“We leave preps at around 9 pm and I must wash my uniform, I must do this or that. So after, you are exhausted and you just fall on the bed; maybe you say, “Let me read this and swallow the medicine, then I sleep” but before you realize it, they are ringing the bell to wake students up. So that is when I have forgotten and then I remember”. --IDI, 28, female, adolescent, Mulago.

One participant said they had poor access to medication when traveling due to the loss of a loved one and suffered too much pain. They also missed appointments due to illness and admission.”

“I had lost someone. Sometimes, I would be ill and have a lot of pain. I felt too much pain. I missed a dose… Still, I have ever missed taking a dose that was because of my illness. I was admitted”. --IDI, 9, male, adult, Mulago.

Some participants missed drugs due to academic reasons. They could not leave school during the exam period to pick treatment refills.

“There is a time I missed some appointments that in turn made me miss drugs…I am in boarding school and my appointment was due during my examination period, so I was unable to come”. -- IDI, 19, Male, adolescent, Mulago).

One caretaker said adolescent was tired of swallowing several tablets daily hence missed taking drugs on some days.

“Talking about being fed up with the medicine; sometimes I say[caregiver], “I will give you shs.500 if you[adolescent] swallow the medicine”. So personally, when I noticed that on the weekend, she swallows 2000 mg, I said, “Okay, let us leave Monday” and we went against the doctor’s instructions. So honestly, we gave Monday a break; we don’t swallow medicine because she swallowed 2 tablets on Sunday and 2 tablets on Saturday, so we rested on Monday. We resume swallowing it on Tuesday till Sunday, then we rest on Monday. But eh! She totally didn’t like it! So, we discussed and came to that agreement, so that is how we do it”. -- IDI, 30, female, caregiver, Mulago.

Missed routine clinic visits or appointments affected adherence.

Most participants [ 11 ] missed routine clinic visits or appointments mainly because they lacked money for transport to the health facility. The cost of transport for some participants was Ugx 20,000.

“I have never missed a clinic appointment and you said yes…I missed because my mother did not have money for transport, yet she had debts—she had to work so that she could pay the debt she had”. --IDI, 21, female, adolescent, Mulago.

Missed appointments hindered participant’s access to medical care and routine sickle cell monitoring.

“Ever since we started this medication, they told us not to miss any appointments because she must come back and monitor her progress ever since she started hydroxyurea. I believe we won’t miss it again. Previously, we could buy our own medicine but this time round, we won’t miss clinic appointments again”. -- IDI, 14, caregiver, female, Mulago.

Transport constraints were the major reasons for missed appointments. Some participants said they lived at far-off distances from health facilities.

“Since sometimes I live far away and sometimes there is no money for the transport fare… Because there are times when I am suffering symptoms of the illness and I have no transport to bring me to the health Centre for instance now, I just borrowed the money to bring me here. So, I fall sick and swallow the medicine, then I feel better”. -- IDI, 31, female, adult, Mulago.

Only one participant reported that a busy work schedule hindered appointment-keeping.

“I miss appointments because sometimes I am weak, or sometimes I might be busy. I am healthy, but the work I am doing keeps me busy. That is what usually happens”. -- IDI, 22, male, adult, Mulago.

Psychosocial, and emotional challenges

Some participants said they lacked a positive outlook on life. They emphasized they lacked motivation, zeal, and interest to continue taking HU drugs because they had lost hope for a complete cure for sickle cell:

“Sometimes, we lack the zeal to come since we do not have the hope to get completely cured but if the doctor tells you to keep coming and follows you up and encourages you” --IDI, 10, female, adult, Mulago.

Some participants (n = 11, 28%) were anxious and worried to take drugs for life without stopping as they worried could cause undesirable side effects:

“For us that have used it, we experience the benefits, but also worry about the risks like kidney, failure because those are the crucial body organs! So, we worry about all that” --. IDI, 30, female, adult, Mulago.

Some participants (38%) from individual interviews suffered stress due to severe pain especially when they missed medication. They felt bad when missed sickle cell drugs because it would result in painful episodes.

“What I know is that it [hydroxyurea] prevents the painful episodes or controls it but now if you don’t swallow it, the pain returns and this time it is severe. That is what I’m scared of”. --IDI, 20, male, youth, Mulago.

Perceived drug-related side effects affected

Some participants [ 10 ] experienced drug-related side effects that affected adherence to HU, such as headache, dizziness, Painful erections at night, frequent urination, and eyes turned yellow.

“I would have headaches every single day without a break. So, there was a health worker we asked while I was admitted, and he said this drug does not cause headaches and we ignored the issue. But it was a severe headache; they first stopped me from taking it for some time… And they [doctors] told her to stop taking it for 2 weeks and that’s what she did”. --IDI, 24, female, adolescent, and caregiver, Mulago.

Some participants were anxious and worried about taking drugs for life without stopping as they worried could cause undesirable side effects:

“For us that have used it, we experience the benefits, but also worry about the risks like kidney, failure because those are the crucial body organs! So, we worry about all that”. --. IDI, 30, female, adult, Mulago.

Facility-related barriers

Long queues.

Long queues that led to poor quality of care were also reported in the hospital. Some participants were concerned about doctors who left without attending to them, yet they were in severe pain.

“ Anha! Sometimes you go and they tell you, “The time is up; the doctor is leaving, the patients’ queue was long”, sometimes you go and there is no medicine”. -- IDI, 5, female, adult, Mulago.

Some participants said there was no counseling support at the health facility regarding sickle cell at the health facility:

“Uh, they [doctors] did not support me when I missed my appointment. When I came, I was registered and given treatment. They did not do anything else or give me any form of counseling”. --IDI, 9, male, adult, Mulago .

Drug stock-outs

Drug stock-outs were mainly reported by adults. lack of sickle cell medication and other drugs in public health facilities leads patients to run out of drugs. They were told to buy the prescribed drugs from other private pharmacies to resolve issues of drug stock-outs, yet they could not afford them.

“About a month. Initially, they would give us three or six sachets of medicine. They can give you medicine for a two months or three months dose. Then, I buy the rest in the pharmacy. The challenge is some pharmacies do not have it in stock”. -- IDI, 10, female, adult, Mulago.

Some participants reported a lack of free medication in public hospitals.

“…Because even if you find someone and say, “Please help me with shs. 30,000 to buy medicine” they tell you, “Go to Mulago, medicine is there free of charge!” But they don’t know the problem is you will get there and fail to get it”. -- IDI, 5, female, adult, Mulago.

Poor communication with health providers

One participant said they did not report drug-related side effects they experienced to healthcare workers due to forgetfulness.

“I forgot to tell the health workers about the side effects I suffered. Sometimes I simply forget all about it and ignore it and say, “As long as it [side effect] is over, I continue swallowing…Now these health workers initiated me into that medicine and told me to swallow it. I would never skip a dose. They told me to swallow it from Monday to Friday, then I take a different dose for the weekend, and then it is the same for the following week”. -- IDI, 19, Male, Youth, Mulago.

Community-based barriers

Some participants reported that rumors, myths, and misconceptions were the major concerns about sickle cell in the community.

“Most times what scares them, they say, “Once you start taking the drug and then stop you die”, it scares them as well—okay, the rumors are so many” -- IDI, 11, Male, youth, Mulago.

Some participants said there was limited access to sickle cell medication in their nearby community health facilities:

“One time my leg was in severe pain; I had not yet seen the doctor. So, if the health facility was nearby—at that time I would go to Nakaseke, and they work on me. But now, there are no health workers who handle sickle cell cases in Namuwogga”. -- IDI, 27, female, adult Mulago.

Family disagreements or conflict arises from lack of financial provision by man for woman to take child to hospital:

“Sometimes we get challenges, and it affects the family. We even get disagreements between the mother and father; sometimes you are supposed to take the child and he says, “I have no money! If you can go, then go. If you are unable to go, you will go some other time” yet the appointment date is due. So, those are some of the challenges we experience” -- IDI, 26, female, caregiver Mulago.

Facilitators for the use of HU

Facilitators reported by participants were mainly at the Individual and facility level as displayed in Table  7 .

Individual level

Positive perception of HU among adolescents and adults facilitated its utilization. Hydroxyurea use was described as effective pain relief, symptom control, and good and helpful treatment among most of the qualitative participants (n = 28, 70%). This was because it mainly relieved and prevented painful sickle cell episodes, stroke, and malaria. One participant said she received pain relief having taken hydroxyurea, she also read via a Google search about weight gain benefits related to hydroxyurea’s use.

“I suffered severe pain before you started taking it [Hydroxyurea]. The pain was severe! It was so strong that sometimes I could faint because the pain was overwhelming…So far, it is not a bad medicine; it has helped us to decrease the pain so that it is not severe”. -- IDI, 3, female, adolescent, Kiruddu.

Patients reported that Hydroxyurea use improves quality of life as it reduces opportunistic infection and frequenting of hospitals by patients.

“The medicine can make you not go to the hospital every day because the day I began taking the medicine, I stopped going to the hospital. I stopped having infections. The medicine can protect you from getting sick in the cold. You can do anything even when you do not put on a sweater. You feel better. Even if you feel pain, it is not so much”- . - IDI, 15, adult male, Mulago.

Some participants illustrated the ability to do daily activities or tasks very well after using hydroxyurea. They said they had the energy to wash, cook, and perform house chores. Hydroxyurea uses enhanced mobility as one participant said could travel on long journeys having taken it.

“Initially, my back would hurt whenever I would walk a distance such as from this place to home which is no longer the case. I am better. I can perform my tasks very well. I wash, cook, and do everything very well”. --IDI, 9, male, adult, Mulago.

Participants said hydroxyurea use regulated the blood levels and reduced the level of the disease in the body or the blood.

“It seems when we had just gotten initiated onto hydroxyurea, the body was not yet used to it, so the blood levels were a bit unstable. Because when we initiated her onto hydroxyurea, they first checked her blood levels and all that. When we had just initiated her, her blood levels went down, and they initiated her back onto the drug around 2018 in December. And ever since that time, we have not had challenges with her blood levels, expect just eating lots of avocado to supplement”. -- IDI, 30, female, caregiver, Mulago.

Patients reported that Hydroxyurea use prevents a child from anemia, stroke, and other complications.

“Those [patients in waiting area] I have heard them say that it has worked for them; those I have heard especially while we are seated. They say it was effective for them; if the child had many pain episodes, they reduced. Or if the blood levels were reduced—even my brother; he used to have anemia and the pain was severe but when he started swallowing it, it started to reduce”. --IDI, 24, female, caregiver, Mulago.

Long duration on HU, enhanced patient confidence. Most of the participants were aware of hydroxyurea because they had experienced taking it for more than a year which enhanced their confidence. Duration on medication among most participants was between one to eleven years, few took it for less than a year.

“I started hydroxyurea this year in January; we came for a check-up after I went to school because I’m in boarding. Now usually when you take hydroxyurea—remember it is daily, every day I must— “ . --IDI, 28, female, adolescent, Mulago.

Facility level

Information shared by healthcare workers about HU enhanced its uptake. Health providers prescribed hydroxyurea and shared information about it through health education and seminars. They taught about the benefits and risks, the importance of hydroxyurea, and the need for patients to alert doctors in case they experienced unusual Side effects.

“…for us, we got to learn about the side effects from the doctors. But while we were at the seminar, they taught us that it is under the supervision of the doctors, who check frequently. But when we gather as women, those who know and those who don’t know, they say, “It burns the liver and the kidneys”, others say, “It is expensive”. But since you have some knowledge about it, you are firm and whatever you notice about it, you inform the doctor, “Doctor, I notice my fingers are turning” and they counsel you. Because even if we are taking it, as parents we are worried”. -- IDI, 30, female, adult, Mulago.

Healthcare workers performed testing to confirm the diagnosis of sickle cell before treatment initiation that enhanced treatment prescription. There was only one participant who said was started on treatment after symptom identification such as joint and leg swelling.

“I was then diagnosed with sickle cells. So, they asked them, “What signs have you noticed?” Then they said that they saw my joints and legs swelling. So, they got to understand and prescribe medication”. -- IDI, 10, female, adult, Mulago.

The availability of HU drugs enhanced its uptake. Some participants said they bought sickle cell medication from private pharmacies or clinics whenever drugs were not available at public health facilities.

“They [doctors from public facility] gave me the prescription and told me to buy it. So, I bought and took it from the private pharmacy, it was finished. So, after a while, I bought more medicine, but they told us we had to swallow it every day”. -- IDI, 5, female, adult, Mulago.

Recommendations from participants on how to alleviate barriers to SCD care

The major recommendation to patients was for patients to receive continuous advice and encouragement from healthcare workers. They particularly desired health workers to remind them about perfectly adhering to Hydroxyurea because it reduced the constant attacks and kept them healthy. They could advise them to set up reminders such as alarms for perfect adherence.

“We need to receive advice from the health workers. Sometimes, we lack the zeal to come since we do not have the hope to get completely cured but if the doctor tells you to keep coming and follows you up and encourages you” --IDI, 10, female, adult, Mulago.

Patients need to be told about the benefits of hydroxyurea, so that they may accept its early initiation and follow the doctor’s instructions.

“In order to accept the drug; we must tell them about the advantages of hydroxyurea. And I think we should also give them examples; I don’t know if you the health workers see that—personally, my child; I know that when she started taking hydroxyurea, her health condition became better. I regretted why they didn’t tell me earlier, but I feared it because I heard them say, “Once she gets initiated onto it, she takes it for life” and I would say, “Argh!” I was quite afraid of it. But I realized that in this life, many people are taking medicine daily and it helps them. [Hmmm] Maybe Musawo, the question I want to ask you today is, if the person grows up and gets to the child-bearing age, does she stop taking hydroxyurea”. -- IDI, 26, female, caretaker, Mulago.

Continuous sensitization about the benefits and risks of hydroxyurea, to create awareness.

“Other people need more teaching about the thing, and telling them, “If the child takes it, it will reduce the number of times you come here due to the child’s severe health condition” -. - IDI, 28, female, Youth, Mulago.

Counseling hydroxyurea should be done as well as counseling patients to value life.

“A way of encouraging people is to educate them about how important their health is; he shouldn’t be discouraged because he is neither the first nor last because there are many people out there who are ill, but everyone must believe in themselves so that they are healthy. So, if my parent cares, I also must care for myself to make sure I am healthy for the sake of my parent, instead of saying, “I don’t want to swallow medicine” one must sacrifice! --IDI, 18, female, adult, Mulago.

A peer-to-peer approach using experienced patients encourages patients to support each other and testify about the benefits of adhering to sickle cell treatment.

“…there is a school with children who suffer from sickle cell who are about 10. So, they asked me for advice, “Should we swallow hydroxyurea?” because I have spent 7 years. And I told them, “You swallow it, I also swallow it” I don’t discourage them because I have grown up without hydroxyurea. But I said the young ones know that it is helpful to them, so I cannot tell them about the fingernails turning black. Because I see their fingernails; they are not as black as I teach them different vocational skills in their school and they ask me, “Do you also swallow this medicine?” and I tell them I swallow it. But I do notice them. -- IDI, 27, female, adult Mulago.

Need financial support to start up a business as a source of income for medication to meet transport, food, and other needs.

“I was thinking, since she has finished Senior 6, maybe I could start up a small business for her so that she earns some money. Even if she gets shs. 2000, she saves it for clinic appointments and buying medicine” --IDI, 24, female, youth, Mulago.

Urge patients to drink plenty of water and mind their diet and clothing.

“They [patients] should be cautious of the cold weather by wearing a scarf. You should take water instead of Soda, minute maid [ soft drink] because that is not recommended. You would rather buy passion fruits and make your juice since the other drinks contain acids that are not good. I would rather drink water instead of drinking those other drinks. [Okay! ] You must wear a sweater when it is cold and desist from drinking cold water in the cold weather. You must mix it with hot water to become warm”. -- IDI, 17, female, Mulago.

Health facility based

Healthcare workers should address the fears and rumors about sick cell disease and treatment.

“You should address their fears and the rumors because personally, that is what made me afraid at first” -- IDI, 4, male, adult, Mulago.

Healthcare workers should advise/encourage patients to adhere to sickle cell medication:

“You must encourage the patient just like you would say, “You have to swallow folic acid because it increases the blood in the body, if you miss, then the blood levels reduce yet these cells need blood”. So even for that medicine, he/she must swallow it—so one must swallow it daily just as one did for folic acid” –. - IDI, 22, male, adult, Mulago.

There should be free drugs availed at the health facilities:

“Another thing is medicine is expensive! So, what will encourage us to come is, we should get free medicine if it is there. But the one we used to take was easy to access; if they bring us that medicine and at least we get it, find it here, then I am certain that we won’t miss any clinic appointment. Because when you come, you expect to go back with medicine, all you must do is invest in the transport”. -- IDI, 14, female, caretaker, Mulago.

Healthcare managers should ensure a consistent and sufficient drug supply.

Doctors should do follow-ups of patients and set up reminder mechanisms to adhere to treatment and keep routine clinic visits.

“Now there is a certain lady, they gave it to her and after it got finished, she stopped there claiming, “I thought you must give it to us. It is expensive in the pharmacies, and I thought I had to get it from here. Why would I buy it?” She was like, “Who is buying the medicine? Me? It is expensive! If you are giving it to us, give it to us consistently”. Other people need more teaching about the thing, and telling them, “If the child takes it, it will reduce the number of times you come here due to the child’s severe health condition” -- IDI, 28, female, Youth, Mulago.

Healthcare facilities should plan to offer transport refunds to sickle cell patients, “Support us by giving us money for the transport fare. Sometimes we are unable to afford it”.

“Apart from the government supplying the medicine; maybe about the transport as well. If they can, they could organize for us some transport when we are bringing them here because these children—sometimes we get challenges, and it affects the family. We even get disagreements between the mother and father; sometimes you are supposed to take the child and he says, “I have no money! If you can go, then go. If you are unable to go, you will go some other time” yet the appointment date is due. So, those are some of the challenges we experience”. -- IDI, 26, female, youth, Mulago.

Health facilities should allow credit options for patients who lack funds to buy drugs.

“What I think—okay, is it possible to give the people the drugs today and they pay for it another time; you record it down. I want them [doctors] to give us patients] the medicine on credit then they pay later”. --IDI, 20, male, youth, Mulago.

Financial empowerment for women to support sickle cell children at the family level should be done. Work opportunities or Income generation activity (IGA) for caregivers or sickle cell patients should be identified.

“So, we [women] must hustle even more than men—sometimes we come and there is no medicine completely! …for our children, we should be assisted in that regard, train us in income generation activities to support our children’’ -.

-- IDI, 30, female, adult, Mulago.

Community-based

Extension of sickle cell health services to the communities and local districts should be done to resolve the issue of transport.

“We need health facilities in every district because sickle cell patients are quite a number. In my village I was the only one and the whole world knew that I had the ‘virus’ as they used to call it. [Hmmm] and it hindered the boy who almost married me; they told him, “Don’t bother! That one is going to die”. But now… we need those health facilities”. -- IDI, 27, female, adult Mulago. “…they could put up health facilities in communities with health workers who handle sickle cells because you leave the place in severe pain—one time my leg was in severe pain; I had not yet seen the doctor. So, if the health facility was nearby—at that time I would go to Nakaseke, and they work on me. But now, there are no health workers who handle sickle cell cases in Namuwogga” -. -IDI, 27, female, adult Mulago.

Sensitization of patients and community people about Hydroxyurea should be done.

“Patients should be intensively sensitized about it [hydroxyurea] so that they can understand it very well. They should sensitize them so that they understand very well how effective it is”. -- IDI, 32, female, adult, Mulago.

Government should reduce the price of sickle cell medicine to enhance access for all patients.

“If it is possible—because most times the drugs are not in stock here, so they should reduce on the price or cost of the medicine…reduce the cost of that medicine. Some people cannot even start taking it; they live far away, from where they get the medicine, yet it is also expensive. So, it would hinder him or her from accessing it”. -- IDI, 11, Male, youth, Mulago.

The government should put up sickle cell health facilities in rural areas:

“Government should supply the medicine to the health facilities in the rural areas. Supply the medicine for sickle cell disease because even in the government health facilities; if you want medicine, they tell you it is out of stock because I have ever gone there when my drugs were over”. -- IDI, 13, female, youth, Mulago.

The government could support patients by providing more drugs in the health facility or in our clinic here:

“Government should supply the medicine to the health facilities in the rural areas. Supply the medicine for sickle cell disease because even in the government health facilities; if you want medicine, they tell you it is out of stock because I have ever gone there when my drugs were over” -- IDI, 13, female, youth, Mulago.

There is a need for a collaborative partnership with international or non-governmental organizations to support sickle cell patients:

Now, the government; because I have ever been NTV, talking about this issue. Just like they support our friends with HIV, they should also find international organizations to support us as well. Because HIV is serious, these patients are difficult! At least they could get for us only the capsules. -- IDI, 24, female, youth, Mulago.

The overall prevalence of HU use among participants who qualify for its use was high at 78%. This is the first study in Uganda to document the prevalence of HU use among patients with SCD. A literature search didn’t yield any studies documenting the prevalence of HU use among eligible patients. A Nigerian study that assessed Hydroxyurea utilization as a lesson in Public Health found that 65% of patients assessed were eligible for HU use and zero were using it, 5% of patients had been informed of or were aware of hydroxyurea as a treatment option for sickle cell disease [ 12 ]. In our study, though 88.2% of patients knew HU as treatment for SCD.

The high prevalence use of HU found in our study is unlike what other studies found in Africa, this is not uncommon given the high prevalence of SCD in these regions of the world. The high prevalence of use is explained by policies that encourage treatment of SCD e.g., HU is listed on the essential medicine list informed by the high prevalence of SCD hence it is procured and made available up to national referral hospitals. Patients are reviewed by healthcare workers in national referral hospitals who are experts in their field, and such are up to date with the latest management protocols for SCD, this is a key driver in the high prescription rate of HU.

In this study, patient-related barriers to HU use included financial constraints, poor adherence to sickle cell medication, missed routine clinic visits or appointments, psychosocial and emotional challenges, poor communication with health providers, and drug-related side effects (headaches, dizziness, frequent urination and yellowing of eyes).

To the best of our knowledge, this is the first study to document patient-related barriers to HU use among patients with SCD in Uganda. These barriers are like those reported by a cross-sectional survey done in Nigeria. Among patients and caregivers, barriers included lack of knowledge; perceived side effects; cost; religious beliefs of disease causation; and lack of pediatric formulation [ 13 ]. Another study done in Chicago, USA, looked at barriers to hydroxyurea adherence and health-related quality of life in adolescents and young adults with sickle cell disease, they found participants reported negative beliefs/motivational barriers (32%), recall barriers/forgetfulness (44%), and access barriers/paying for hydroxyurea and/or getting refills on time (32%) [ 14 ]. Another study looked at barriers to the use of hydroxyurea in the management of sickle cell disease in Nigeria, reported side effects profiles as the commonest barrier, reported concern for infertility (52.0%), and safety profile of HU in pregnancy and lactation (48.2%) [ 15 ]. A U.S. regional collaborative report on barriers to hydroxyurea use from the perspectives of providers, individuals with sickle cell disease, and families found providers and patient/caregiver reports about hydroxyurea use were inconsistent with one another; adults 26 years and older were least likely to be on hydroxyurea; and the likelihood of being on hydroxyurea decreased with one or more barriers, they also found that, even for patients on hydroxyurea, challenges to taking the medicine at the right time and forgetting were crucial unintentional barriers to adherence. Intentional barriers such as worry about side effects and “tried and it did not work” were important barriers for young adults and adults [ 16 ].

These barriers are not uncommon or unique since SCD is a chronic disease that requires daily medication. Similar challenges are experienced by other patients with chronic conditions [ 17 ]. Patients are bound to get treatment fatigued leading to poor adherence and missed appointments, get depressed, and sometimes suicidal. SCD is prevalent in the black population most of whom are residing in resource-limited settings like sub-Saharan Africa where finances are a major factor in accessing health care. Even in the US, SCD is prevalent among the black population [ 14 ] and most of these populations experience socioeconomic inequalities in developed countries.

These challenges are correlated in that financial constraints coupled with treatment fatigue led to poor adherence to treatment missed appointments, and psychosocial and emotional intrigue.

Other barriers reported were categorized as facility and these included drug stockouts, poor quality of care (referred as few health personnel to attend to them, and lack of counseling services). Community barriers included knowledge gaps and poor access to sickle cell medication in nearby health centers.

These barriers have been reported by other studies, in Nigeria, among clinicians, barriers included limited knowledge of the drug, as well as low self-efficacy to prescribe among physicians and to counsel among nurses; perceived side effects; perceived patient preference for traditional medicine; cost for patient and expense of accompanying laboratory monitoring; and limited availability of the drug and equipment for laboratory monitoring [ 18 ]. Another study in Nigeria reported barriers to hydroxyurea utilization identified by practitioners included safety and toxicity profile (100%), patient compliance (100%), effective follow-up (100%), drug availability (100%), affordability (100%) and specifically concern for reactivation of latent tuberculosis (50%) and carcinogenesis (100%) and teratogenicity (100%) [ 12 ].

In Africa, drug stockouts are a commonality, it is especially more pronounced if the medicine is used for chronic care like HU for SCD as opposed to an acute illness. Government programs support access to life-saving medications for human immunodeficiency virus (HIV), Tuberculosis (TB), and malaria; however, this is not the case for SCD. Advocacy efforts to sustain the continued availability of HU in the SCD treatment program are necessary.

Suggested recommendations by participants included; continuous advice and encouragement from health care workers, continuous sensitization about the benefits and risks of hydroxyurea to create awareness, peer to peer approach using experienced patients to support each other, the need for financial support to start up a business as a source of income for medication to meet transport, food, and other needs, self-motivation and self-love is needed among patients and urge patients to drink plenty of water and mind their diet and clothing.

These recommendations have been suggested by other studies i.e., prospective evaluation of patient’s perceptions of SCD and hydroxyurea in relation to adherence, HRQOL domains, and clinical outcomes is warranted [ 11 ].

Training of sickle cell care providers to attain and maintain competence in the use of hydroxyurea for the treatment of SCD was recommended by the researchers of the study on the level of utilization and provider-related barriers to hydroxyurea use in the treatment of SCD in Jos, Nigeria [ 19 ]. Researchers from an Irish study on the Irish SCD population reported that the smartphone app was expressed by the majority, with daily medication reminders being the most popular feature [ 11 ].

The suggested recommendations by participants are like interventions already in play in other public health programs such as comprehensive HIV treatment and care programs [ 20 ]. Such programs include social economic empowerment activities that equip them with skills for independent income generating for the sustenance of basic care. This allows patients to afford complementary medication, and nutrition and facilitates adherence to clinic appointments [ 21 ]. Such can be adapted into the SCD management program to offset challenges related to finances. With financial empowerment, all the other correlated challenges will be lessened.

Patients recognize the importance of medical information in advancing compliance with treatment. Programs geared towards increasing healthcare knowledge on novel SCD treatments like HU should be promoted. This will trickle down to more quality medication counseling provided to patients which will then lead to medication compliance. Expert patients could be trained to be peer influencers, by equipping them with information, educational, and communication material necessary to empower fellow patients psychosocially. This strategy has been successfully implemented in other public health challenges e.g., HIV and TB [ 22 ].

Other recommendations were health facility-based and these included; Healthcare workers should advise and encourage patients to adhere to sickle cell medication, There should be free drugs availed at the health facilities, Health managers should ensure consistent and sufficient drug supply, Health care workers should create awareness to patients about benefits of sickle cell treatment, Health care workers should offer continuous advice, health education to patients, Health care facilitates should plan to offer transport refund to sickle cell patients, Health facilities should allow credit options for patients who lack funds to buy drugs.

Community-based recommendations included the extension of sickle cell health services to the communities and local districts should be done to resolve the issue of transport, and Sensitization of patients and community people about Hydroxyurea.

Task shifting in terms of personnel and medication is necessary for grassroots accessibility. Such models have been implemented to improve life-saving therapy like ART for HIV-infected patients and disseminated drug delivery models [ 23 ].

National-based recommendations included the government reducing the price of sickle cell medicine to enhance access for all patients, the Government putting up sickle cell health facilities in rural areas, and there is need for a collaborative partnership with international or non-governmental organizations to support sickle cell patients.

Study limitations

This study was carried out at national referral hospitals which have a better supply of medicines and health care experts in the management of SCD, this created selective bias because the quality of care is not generalizable to other health centers in the country. Future research directions should include national surveys to understand the magnitude of the barriers to better government planning in the allocation of resources.

Because of the Cross-sectional nature, of the quantitative section, we were not able to determine causation but could only determine the association between HU use and patient-related barriers to HU use.

Study strengths

The study was conducted at two national referral hospitals that are in the central region of Uganda. This region has one of the highest prevalence of SCD The central region of Uganda is metropolitan with individuals coming in from different parts of Uganda so the SCD population may be representative. The findings of this study are therefore representative of the sickle cell population in Kampala which is the capital city of Uganda.

This is a mixed-method study, so the qualitative aspects of the study helped to explain the results of the quantitative findings. For example, in this study, we now know that lack of affordability is the reason why most patients have never been on HU even if it is indicated or stop using it when they need it.

Implementing the use of HU has been challenging in Uganda and needs improvement. Facilitators to hydroxyurea use have been highlighted, though Patient-identified barriers at individual, facility, and community levels that need to be resolved. The experiences and insights shared by our participants provide invaluable guidance for increasing the uptake of HU. Further studies are needed to establish validated instruments to assess patients’ pain communication and adherence to the HU regimen. The prevalence of HU use among eligible patients is high at 78%.

Data availability

The datasets used and/or analyzed during the current study are available at https://github.com/PNamaganda/Sickle-cell-Data-in-Uganda. Deidentified data and analyzed data for this manuscript are available from the corresponding author upon request.

Modell B, Darlison M. Global epidemiology of hemoglobin disorders and derived service indicators. Bull World Health Organ. 2008;86:480–7.

Article   PubMed   PubMed Central   Google Scholar  

Lanzkron S, Carroll CP, Haywood C Jr. Mortality rates and age at death from sickle cell disease: U.S., 1979–2005. Public Health Rep. 2013;128(2):110–6.

Lanzkron S, Strouse JJ, Wilson R, Beach MC, Haywood C, Park H, Segal JB. Systematic review: Hydroxyurea for the treatment of adults with sickle cell disease. Ann Intern Med. 2008;148(12):939–55.

Opoka RO, Ndugwa CM, Latham TS, Lane A, Hume HA, Kasirye P, et al. Novel use of Hydroxyurea in an African Region with Malaria (NOHARM): a trial for children with sickle cell anemia. Blood. 2017;130:2585–93.

Article   CAS   PubMed   Google Scholar  

Tshilolo L, Tomlinson G, Williams TN, Santos B, Olupot-Olupot P, Lane A et al. Hydroxyurea for children with sickle cell anemia in sub-saharan Africa. N Engl J Med. 2019; 380:121 – 31.6.

Olupot-Olupot P, Wabwire H, Ndila C, Adong R, Ochen L, Amorut D, ... & Williams, TN. Characterizing demographics, knowledge, practices, and clinical care among patients attending sickle cell disease clinics in Eastern Uganda. Wellcome Open Res. 2020. https://www.health.go.ug/2019/12/02/use-of-hydroxyurea-approved-for-sickle-cell-patients/ .

Brandow AM, Panepinto JA. Hydroxyurea use in sickle cell disease: the battle with low prescription rates, poor patient compliance and fears of toxicities. Expert Rev Hematol. 2010;3(3):255–60. https://doi.org/10.1586/ehm.10.22 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract. 2008;20(12):600–7.

Article   PubMed   Google Scholar  

Kang HA, Barner JC, Lawson KA, Rascati K, Mignacca RC. Impact of adherence to hydroxyurea on health outcomes among patients with sickle cell disease. Am J Hematol. 2023;98(1):90–101.

10, Jose J, Elsadek RA, Jimmy B, George P, Hydroxyurea. Pattern of Use, Patient Adherence, and Safety Profile in patients with Sickle Cell Disease in Oman. Oman Med J. 2019;34(4):327–35. https://doi.org/10.5001/omj.2019.64 . PMID: 31360322; PMCID: PMC6642718.

Article   Google Scholar  

Fogarty H, Gaul A, Syed S, et al. Adherence to hydroxyurea, health-related quality of life domains, and attitudes towards a smartphone app among Irish adolescents and young adults with sickle cell disease. Ir J Med Sci. 2022;191:809–16. https://doi.org/10.1007/s11845-021-02588-1) .

Aliyu ZY, Babadoko A, Mamman A. Hydroxyurea utilization in Nigeria, a Lesson in Public Health. Blood. 2007;110(11):80.

Okocha EC, Gyamfi J, Ryan N, Babalola O, Etuk EA, Chianumba R, Nwegbu M, Isa H, Madu AJ, Adegoke S, Nnebe-Agumandu U, Brown B, Peprah E, Nnodu OE. Barriers to therapeutic use of Hydroxyurea for Sickle Cell Disease in Nigeria: a cross-sectional survey. Front Genet. 2022;12:765958. https://doi.org/10.3389/fgene.2021.765958 . PMID: 35126450; PMCID: PMC8807646).

Badawy SM, Thompson AA, Penedo FJ, Lai JS, Rychlik K, Liem RI. Barriers to hydroxyurea adherence and health-related quality of life in adolescents and young adults with sickle cell disease. Eur J Hematol. 2017;98(6):608–14.

Article   CAS   Google Scholar  

Adeyemo TA, Diaku-Akinwunmi IN, Ojewunmi OO, Bolarinwa AB, Adekile AD. Barriers to the use of hydroxyurea in the management of sickle cell disease in Nigeria. Hemoglobin. 2019;43(3):188–92. Epub 2019 Aug 29. PMID: 31462098).

Treadwell MJ, Du L, Bhasin N, Marsh AM, Wun T, Bender MA, Nugent D. Barriers to hydroxyurea use from the perspectives of providers, individuals with sickle cell disease, and families: report from a US regional collaborative. Front Genet. 2022;13:921432.

Foo KM, Sundram M, Legido-Quigley H. Facilitators, and barriers of managing patients with multiple chronic conditions in the community: a qualitative study. BMC Public Health. 2020;20:273. https://doi.org/10.1186/s12889-020-8375-8) .

Adimora I, Akingbola TS, Lansigan F, van Hoff J. Pharmacotherapy interventions and barriers to treatment of Sickle Cell Disease in Ibadan, Nigeria. Blood. 2018;132:3523.

Ofakunrin AOD, Adekola K, Okpe ES, Oguche S, Afolaranmi T, Kanhu P, Sagay AS. Level of utilization and provider-related barriers to hydroxyurea use in the treatment of sickle cell disease in Jos. Nigeria Blood. 2019;134:1029.

Ford N, Ball A, Baggaley R, Vitoria M, Low-Beer D, Penazzato M, Hirnschall G. The WHO public health approach to HIV treatment and care: looking back and looking ahead. Lancet Infect Dis. 2018;18(3):e76–86.

Kennedy CE, Fonner VA, O’Reilly KR, Sweat MD. A systematic review of income generation interventions, including microfinance and vocational skills training, for HIV prevention. AIDS Care. 2014;26(6):659–73. Epub 2013 Oct 9. PMID: 24107189; PMCID: PMC3943565.

Medley A, Kennedy C, O’Reilly K, Sweat M. Effectiveness of peer education interventions for HIV prevention in developing countries: a systematic review and meta-analysis. AIDS Educ Prev. 2009;21(3):181–206. https://doi.org/10.1521/aeap.2009.21.3.181 . PMID: 19519235; PMCID: PMC3927325.

Fulton BD, Scheffler RM, Sparkes SP, et al. Health workforce skill mix and task shifting in low-income countries: a review of recent evidence. Hum Resource Health. 2011;9:1. https://doi.org/10.1186/1478-4491-9-1 .

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Acknowledgements

We acknowledge the patients of Mulago Hospital SCD clinic and Kiruddu Hospital who gave us consent to obtain this information.

This study was funded with funds from Novartis Pharmaceuticals. The funding project had no role in the design of the study and collection, analysis, and interpretation of data and no role in writing the manuscript.

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Namaganda, P., Nantume, P., Mubiru, K.R. et al. Understanding patient-related barriers to hydroxyurea use among adolescent and adult patients with sickle cell disease in Mulago and Kiruddu hospitals, Uganda, a qualitative study. BMC Health Serv Res 24 , 666 (2024). https://doi.org/10.1186/s12913-024-11125-6

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A systematic literature review of empirical research on ChatGPT in education

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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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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

AlAfnan MA, Dishari S, Jovic M, Lomidze K. ChatGPT as an educational tool: opportunities, challenges, and recommendations for communication, business writing, and composition courses. J Artif Intell Technol. 2023. https://doi.org/10.37965/jait.2023.0184 .

Article   Google Scholar  

Ali JKM, Shamsan MAA, Hezam TA, Mohammed AAQ. Impact of ChatGPT on learning motivation. J Engl Stud Arabia Felix. 2023;2(1):41–9. https://doi.org/10.56540/jesaf.v2i1.51 .

Alkaissi H, McFarlane SI. Artificial hallucinations in ChatGPT: implications in scientific writing. Cureus. 2023. https://doi.org/10.7759/cureus.35179 .

Anderson N, Belavý DL, Perle SM, Hendricks S, Hespanhol L, Verhagen E, Memon AR. AI did not write this manuscript, or did it? Can we trick the AI text detector into generated texts? The potential future of ChatGPT and AI in sports & exercise medicine manuscript generation. BMJ Open Sport Exerc Med. 2023;9(1): e001568. https://doi.org/10.1136/bmjsem-2023-001568 .

Ausat AMA, Massang B, Efendi M, Nofirman N, Riady Y. Can chat GPT replace the role of the teacher in the classroom: a fundamental analysis. J Educ. 2023;5(4):16100–6.

Google Scholar  

Baidoo-Anu D, Ansah L. Education in the Era of generative artificial intelligence (AI): understanding the potential benefits of ChatGPT in promoting teaching and learning. Soc Sci Res Netw. 2023. https://doi.org/10.2139/ssrn.4337484 .

Basic Z, Banovac A, Kruzic I, Jerkovic I. Better by you, better than me, chatgpt3 as writing assistance in students essays. 2023. arXiv preprint arXiv:2302.04536 .‏

Baskara FR. The promises and pitfalls of using chat GPT for self-determined learning in higher education: an argumentative review. Prosiding Seminar Nasional Fakultas Tarbiyah dan Ilmu Keguruan IAIM Sinjai. 2023;2:95–101. https://doi.org/10.47435/sentikjar.v2i0.1825 .

Behera RK, Bala PK, Dhir A. The emerging role of cognitive computing in healthcare: a systematic literature review. Int J Med Inform. 2019;129:154–66. https://doi.org/10.1016/j.ijmedinf.2019.04.024 .

Chaka C. Detecting AI content in responses generated by ChatGPT, YouChat, and Chatsonic: the case of five AI content detection tools. J Appl Learn Teach. 2023. https://doi.org/10.37074/jalt.2023.6.2.12 .

Chiu TKF, Xia Q, Zhou X, Chai CS, Cheng M. Systematic literature review on opportunities, challenges, and future research recommendations of artificial intelligence in education. Comput Educ Artif Intell. 2023;4:100118. https://doi.org/10.1016/j.caeai.2022.100118 .

Choi EPH, Lee JJ, Ho M, Kwok JYY, Lok KYW. Chatting or cheating? The impacts of ChatGPT and other artificial intelligence language models on nurse education. Nurse Educ Today. 2023;125:105796. https://doi.org/10.1016/j.nedt.2023.105796 .

Cotton D, Cotton PA, Shipway JR. Chatting and cheating: ensuring academic integrity in the era of ChatGPT. Innov Educ Teach Int. 2023. https://doi.org/10.1080/14703297.2023.2190148 .

Crawford J, Cowling M, Allen K. Leadership is needed for ethical ChatGPT: Character, assessment, and learning using artificial intelligence (AI). J Univ Teach Learn Pract. 2023. https://doi.org/10.53761/1.20.3.02 .

Creswell JW. Educational research: planning, conducting, and evaluating quantitative and qualitative research [Ebook]. 4th ed. London: Pearson Education; 2015.

Curry D. ChatGPT Revenue and Usage Statistics (2023)—Business of Apps. 2023. https://www.businessofapps.com/data/chatgpt-statistics/

Day T. A preliminary investigation of fake peer-reviewed citations and references generated by ChatGPT. Prof Geogr. 2023. https://doi.org/10.1080/00330124.2023.2190373 .

De Castro CA. A Discussion about the Impact of ChatGPT in education: benefits and concerns. J Bus Theor Pract. 2023;11(2):p28. https://doi.org/10.22158/jbtp.v11n2p28 .

Deng X, Yu Z. A meta-analysis and systematic review of the effect of Chatbot technology use in sustainable education. Sustainability. 2023;15(4):2940. https://doi.org/10.3390/su15042940 .

Eke DO. ChatGPT and the rise of generative AI: threat to academic integrity? J Responsib Technol. 2023;13:100060. https://doi.org/10.1016/j.jrt.2023.100060 .

Elmoazen R, Saqr M, Tedre M, Hirsto L. A systematic literature review of empirical research on epistemic network analysis in education. IEEE Access. 2022;10:17330–48. https://doi.org/10.1109/access.2022.3149812 .

Farrokhnia M, Banihashem SK, Noroozi O, Wals AEJ. A SWOT analysis of ChatGPT: implications for educational practice and research. Innov Educ Teach Int. 2023. https://doi.org/10.1080/14703297.2023.2195846 .

Fergus S, Botha M, Ostovar M. Evaluating academic answers generated using ChatGPT. J Chem Educ. 2023;100(4):1672–5. https://doi.org/10.1021/acs.jchemed.3c00087 .

Fink A. Conducting research literature reviews: from the Internet to Paper. Incorporated: SAGE Publications; 2010.

Firaina R, Sulisworo D. Exploring the usage of ChatGPT in higher education: frequency and impact on productivity. Buletin Edukasi Indonesia (BEI). 2023;2(01):39–46. https://doi.org/10.56741/bei.v2i01.310 .

Firat, M. (2023). How chat GPT can transform autodidactic experiences and open education.  Department of Distance Education, Open Education Faculty, Anadolu Unive .‏ https://orcid.org/0000-0001-8707-5918

Firat M. What ChatGPT means for universities: perceptions of scholars and students. J Appl Learn Teach. 2023. https://doi.org/10.37074/jalt.2023.6.1.22 .

Fuchs K. Exploring the opportunities and challenges of NLP models in higher education: is Chat GPT a blessing or a curse? Front Educ. 2023. https://doi.org/10.3389/feduc.2023.1166682 .

García-Peñalvo FJ. La percepción de la inteligencia artificial en contextos educativos tras el lanzamiento de ChatGPT: disrupción o pánico. Educ Knowl Soc. 2023;24: e31279. https://doi.org/10.14201/eks.31279 .

Gilson A, Safranek CW, Huang T, Socrates V, Chi L, Taylor A, Chartash D. How does ChatGPT perform on the United States medical Licensing examination? The implications of large language models for medical education and knowledge assessment. JMIR Med Educ. 2023;9: e45312. https://doi.org/10.2196/45312 .

Hashana AJ, Brundha P, Ayoobkhan MUA, Fazila S. Deep Learning in ChatGPT—A Survey. In   2023 7th international conference on trends in electronics and informatics (ICOEI) . 2023. (pp. 1001–1005). IEEE. https://doi.org/10.1109/icoei56765.2023.10125852

Hirsto L, Saqr M, López-Pernas S, Valtonen T. (2022). A systematic narrative review of learning analytics research in K-12 and schools.  Proceedings . https://ceur-ws.org/Vol-3383/FLAIEC22_paper_9536.pdf

Hisan UK, Amri MM. ChatGPT and medical education: a double-edged sword. J Pedag Educ Sci. 2023;2(01):71–89. https://doi.org/10.13140/RG.2.2.31280.23043/1 .

Hopkins AM, Logan JM, Kichenadasse G, Sorich MJ. Artificial intelligence chatbots will revolutionize how cancer patients access information: ChatGPT represents a paradigm-shift. JNCI Cancer Spectr. 2023. https://doi.org/10.1093/jncics/pkad010 .

Househ M, AlSaad R, Alhuwail D, Ahmed A, Healy MG, Latifi S, Sheikh J. Large Language models in medical education: opportunities, challenges, and future directions. JMIR Med Educ. 2023;9: e48291. https://doi.org/10.2196/48291 .

Ilkka T. The impact of artificial intelligence on learning, teaching, and education. Minist de Educ. 2018. https://doi.org/10.2760/12297 .

Iqbal N, Ahmed H, Azhar KA. Exploring teachers’ attitudes towards using CHATGPT. Globa J Manag Adm Sci. 2022;3(4):97–111. https://doi.org/10.46568/gjmas.v3i4.163 .

Irfan M, Murray L, Ali S. Integration of Artificial intelligence in academia: a case study of critical teaching and learning in Higher education. Globa Soc Sci Rev. 2023;8(1):352–64. https://doi.org/10.31703/gssr.2023(viii-i).32 .

Jeon JH, Lee S. Large language models in education: a focus on the complementary relationship between human teachers and ChatGPT. Educ Inf Technol. 2023. https://doi.org/10.1007/s10639-023-11834-1 .

Khan RA, Jawaid M, Khan AR, Sajjad M. ChatGPT—Reshaping medical education and clinical management. Pak J Med Sci. 2023. https://doi.org/10.12669/pjms.39.2.7653 .

King MR. A conversation on artificial intelligence, Chatbots, and plagiarism in higher education. Cell Mol Bioeng. 2023;16(1):1–2. https://doi.org/10.1007/s12195-022-00754-8 .

Kooli C. Chatbots in education and research: a critical examination of ethical implications and solutions. Sustainability. 2023;15(7):5614. https://doi.org/10.3390/su15075614 .

Kuhail MA, Alturki N, Alramlawi S, Alhejori K. Interacting with educational chatbots: a systematic review. Educ Inf Technol. 2022;28(1):973–1018. https://doi.org/10.1007/s10639-022-11177-3 .

Lee H. The rise of ChatGPT: exploring its potential in medical education. Anat Sci Educ. 2023. https://doi.org/10.1002/ase.2270 .

Li L, Subbareddy R, Raghavendra CG. AI intelligence Chatbot to improve students learning in the higher education platform. J Interconnect Netw. 2022. https://doi.org/10.1142/s0219265921430325 .

Limna P. A Review of Artificial Intelligence (AI) in Education during the Digital Era. 2022. https://ssrn.com/abstract=4160798

Lo CK. What is the impact of ChatGPT on education? A rapid review of the literature. Educ Sci. 2023;13(4):410. https://doi.org/10.3390/educsci13040410 .

Luo W, He H, Liu J, Berson IR, Berson MJ, Zhou Y, Li H. Aladdin’s genie or pandora’s box For early childhood education? Experts chat on the roles, challenges, and developments of ChatGPT. Early Educ Dev. 2023. https://doi.org/10.1080/10409289.2023.2214181 .

Meyer JG, Urbanowicz RJ, Martin P, O’Connor K, Li R, Peng P, Moore JH. ChatGPT and large language models in academia: opportunities and challenges. Biodata Min. 2023. https://doi.org/10.1186/s13040-023-00339-9 .

Mhlanga D. Open AI in education, the responsible and ethical use of ChatGPT towards lifelong learning. Soc Sci Res Netw. 2023. https://doi.org/10.2139/ssrn.4354422 .

Neumann, M., Rauschenberger, M., & Schön, E. M. (2023). “We Need To Talk About ChatGPT”: The Future of AI and Higher Education.‏ https://doi.org/10.1109/seeng59157.2023.00010

Nolan B. Here are the schools and colleges that have banned the use of ChatGPT over plagiarism and misinformation fears. Business Insider . 2023. https://www.businessinsider.com

O’Leary DE. An analysis of three chatbots: BlenderBot, ChatGPT and LaMDA. Int J Intell Syst Account, Financ Manag. 2023;30(1):41–54. https://doi.org/10.1002/isaf.1531 .

Okoli C. A guide to conducting a standalone systematic literature review. Commun Assoc Inf Syst. 2015. https://doi.org/10.17705/1cais.03743 .

OpenAI. (2023). https://openai.com/blog/chatgpt

Perkins M. Academic integrity considerations of AI large language models in the post-pandemic era: ChatGPT and beyond. J Univ Teach Learn Pract. 2023. https://doi.org/10.53761/1.20.02.07 .

Plevris V, Papazafeiropoulos G, Rios AJ. Chatbots put to the test in math and logic problems: A preliminary comparison and assessment of ChatGPT-3.5, ChatGPT-4, and Google Bard. arXiv (Cornell University) . 2023. https://doi.org/10.48550/arxiv.2305.18618

Rahman MM, Watanobe Y (2023) ChatGPT for education and research: opportunities, threats, and strategies. Appl Sci 13(9):5783. https://doi.org/10.3390/app13095783

Ram B, Verma P. Artificial intelligence AI-based Chatbot study of ChatGPT, google AI bard and baidu AI. World J Adv Eng Technol Sci. 2023;8(1):258–61. https://doi.org/10.30574/wjaets.2023.8.1.0045 .

Rasul T, Nair S, Kalendra D, Robin M, de Oliveira Santini F, Ladeira WJ, Heathcote L. The role of ChatGPT in higher education: benefits, challenges, and future research directions. J Appl Learn Teach. 2023. https://doi.org/10.37074/jalt.2023.6.1.29 .

Ratnam M, Sharm B, Tomer A. ChatGPT: educational artificial intelligence. Int J Adv Trends Comput Sci Eng. 2023;12(2):84–91. https://doi.org/10.30534/ijatcse/2023/091222023 .

Ray PP. ChatGPT: a comprehensive review on background, applications, key challenges, bias, ethics, limitations and future scope. Internet Things Cyber-Phys Syst. 2023;3:121–54. https://doi.org/10.1016/j.iotcps.2023.04.003 .

Roumeliotis KI, Tselikas ND. ChatGPT and Open-AI models: a preliminary review. Future Internet. 2023;15(6):192. https://doi.org/10.3390/fi15060192 .

Rudolph J, Tan S, Tan S. War of the chatbots: Bard, Bing Chat, ChatGPT, Ernie and beyond. The new AI gold rush and its impact on higher education. J Appl Learn Teach. 2023. https://doi.org/10.37074/jalt.2023.6.1.23 .

Ruiz LMS, Moll-López S, Nuñez-Pérez A, Moraño J, Vega-Fleitas E. ChatGPT challenges blended learning methodologies in engineering education: a case study in mathematics. Appl Sci. 2023;13(10):6039. https://doi.org/10.3390/app13106039 .

Sallam M, Salim NA, Barakat M, Al-Tammemi AB. ChatGPT applications in medical, dental, pharmacy, and public health education: a descriptive study highlighting the advantages and limitations. Narra J. 2023;3(1): e103. https://doi.org/10.52225/narra.v3i1.103 .

Salvagno M, Taccone FS, Gerli AG. Can artificial intelligence help for scientific writing? Crit Care. 2023. https://doi.org/10.1186/s13054-023-04380-2 .

Saqr M, López-Pernas S, Helske S, Hrastinski S. The longitudinal association between engagement and achievement varies by time, students’ profiles, and achievement state: a full program study. Comput Educ. 2023;199:104787. https://doi.org/10.1016/j.compedu.2023.104787 .

Saqr M, Matcha W, Uzir N, Jovanović J, Gašević D, López-Pernas S. Transferring effective learning strategies across learning contexts matters: a study in problem-based learning. Australas J Educ Technol. 2023;39(3):9.

Schöbel S, Schmitt A, Benner D, Saqr M, Janson A, Leimeister JM. Charting the evolution and future of conversational agents: a research agenda along five waves and new frontiers. Inf Syst Front. 2023. https://doi.org/10.1007/s10796-023-10375-9 .

Shoufan A. Exploring students’ perceptions of CHATGPT: thematic analysis and follow-up survey. IEEE Access. 2023. https://doi.org/10.1109/access.2023.3268224 .

Sonderegger S, Seufert S. Chatbot-mediated learning: conceptual framework for the design of Chatbot use cases in education. Gallen: Institute for Educational Management and Technologies, University of St; 2022. https://doi.org/10.5220/0010999200003182 .

Book   Google Scholar  

Strzelecki A. To use or not to use ChatGPT in higher education? A study of students’ acceptance and use of technology. Interact Learn Environ. 2023. https://doi.org/10.1080/10494820.2023.2209881 .

Su J, Yang W. Unlocking the power of ChatGPT: a framework for applying generative AI in education. ECNU Rev Educ. 2023. https://doi.org/10.1177/20965311231168423 .

Sullivan M, Kelly A, McLaughlan P. ChatGPT in higher education: Considerations for academic integrity and student learning. J ApplLearn Teach. 2023;6(1):1–10. https://doi.org/10.37074/jalt.2023.6.1.17 .

Szabo A. ChatGPT is a breakthrough in science and education but fails a test in sports and exercise psychology. Balt J Sport Health Sci. 2023;1(128):25–40. https://doi.org/10.33607/bjshs.v127i4.1233 .

Taecharungroj V. “What can ChatGPT do?” analyzing early reactions to the innovative AI chatbot on Twitter. Big Data Cognit Comput. 2023;7(1):35. https://doi.org/10.3390/bdcc7010035 .

Tam S, Said RB. User preferences for ChatGPT-powered conversational interfaces versus traditional methods. Biomed Eng Soc. 2023. https://doi.org/10.58496/mjcsc/2023/004 .

Tedre M, Kahila J, Vartiainen H. (2023). Exploration on how co-designing with AI facilitates critical evaluation of ethics of AI in craft education. In: Langran E, Christensen P, Sanson J (Eds).  Proceedings of Society for Information Technology and Teacher Education International Conference . 2023. pp. 2289–2296.

Tlili A, Shehata B, Adarkwah MA, Bozkurt A, Hickey DT, Huang R, Agyemang B. What if the devil is my guardian angel: ChatGPT as a case study of using chatbots in education. Smart Learn Environ. 2023. https://doi.org/10.1186/s40561-023-00237-x .

Uddin SMJ, Albert A, Ovid A, Alsharef A. Leveraging CHATGPT to aid construction hazard recognition and support safety education and training. Sustainability. 2023;15(9):7121. https://doi.org/10.3390/su15097121 .

Valtonen T, López-Pernas S, Saqr M, Vartiainen H, Sointu E, Tedre M. The nature and building blocks of educational technology research. Comput Hum Behav. 2022;128:107123. https://doi.org/10.1016/j.chb.2021.107123 .

Vartiainen H, Tedre M. Using artificial intelligence in craft education: crafting with text-to-image generative models. Digit Creat. 2023;34(1):1–21. https://doi.org/10.1080/14626268.2023.2174557 .

Ventayen RJM. OpenAI ChatGPT generated results: similarity index of artificial intelligence-based contents. Soc Sci Res Netw. 2023. https://doi.org/10.2139/ssrn.4332664 .

Wagner MW, Ertl-Wagner BB. Accuracy of information and references using ChatGPT-3 for retrieval of clinical radiological information. Can Assoc Radiol J. 2023. https://doi.org/10.1177/08465371231171125 .

Wardat Y, Tashtoush MA, AlAli R, Jarrah AM. ChatGPT: a revolutionary tool for teaching and learning mathematics. Eurasia J Math, Sci Technol Educ. 2023;19(7):em2286. https://doi.org/10.29333/ejmste/13272 .

Webster J, Watson RT. Analyzing the past to prepare for the future: writing a literature review. Manag Inf Syst Quart. 2002;26(2):3.

Xiao Y, Watson ME. Guidance on conducting a systematic literature review. J Plan Educ Res. 2017;39(1):93–112. https://doi.org/10.1177/0739456x17723971 .

Yan D. Impact of ChatGPT on learners in a L2 writing practicum: an exploratory investigation. Educ Inf Technol. 2023. https://doi.org/10.1007/s10639-023-11742-4 .

Yu H. Reflection on whether Chat GPT should be banned by academia from the perspective of education and teaching. Front Psychol. 2023;14:1181712. https://doi.org/10.3389/fpsyg.2023.1181712 .

Zhu C, Sun M, Luo J, Li T, Wang M. How to harness the potential of ChatGPT in education? Knowl Manag ELearn. 2023;15(2):133–52. https://doi.org/10.34105/j.kmel.2023.15.008 .

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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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A systematic review is designed to be transparent and replicable. Therefore, systematic reviews are considered reliable tools in scientific research and clinical practice. They synthesize the results using multiple primary studies by using strategies that minimize bias and random errors. Depending on the research question and the objectives of the research, the reviews can either be qualitative or quantitative. Qualitative reviews deal with understanding concepts, thoughts, or experiences. Quantitative reviews are employed when researchers want to test or confirm a hypothesis or theory. Let’s look at some of the differences between these two types of reviews.

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Differential attainment in assessment of postgraduate surgical trainees: a scoping review

• Rebecca L. Jones 1 , 2 ,
• Suwimol Prusmetikul 1 , 3 &
• Sarah Whitehorn 1  

BMC Medical Education volume  24 , Article number:  597 ( 2024 ) Cite this article

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Introduction

Solving disparities in assessments is crucial to a successful surgical training programme. The first step in levelling these inequalities is recognising in what contexts they occur, and what protected characteristics are potentially implicated.

This scoping review was based on Arksey & O’Malley’s guiding principles. OVID and Embase were used to identify articles, which were then screened by three reviewers.

From an initial 358 articles, 53 reported on the presence of differential attainment in postgraduate surgical assessments. The majority were quantitative studies (77.4%), using retrospective designs. 11.3% were qualitative. Differential attainment affects a varied range of protected characteristics. The characteristics most likely to be investigated were gender (85%), ethnicity (37%) and socioeconomic background (7.5%). Evidence of inequalities are present in many types of assessment, including: academic achievements, assessments of progression in training, workplace-based assessments, logs of surgical experience and tests of technical skills.

Attainment gaps have been demonstrated in many types of assessment, including supposedly “objective” written assessments and at revalidation. Further research is necessary to delineate the most effective methods to eliminate bias in higher surgical training. Surgical curriculum providers should be informed by the available literature on inequalities in surgical training, as well as other neighbouring specialties such as medicine or general practice, when designing assessments and considering how to mitigate for potential causes of differential attainment.

Peer Review reports

Diversity in the surgical workforce has been a hot topic for the last 10 years, increasing in traction following the BlackLivesMatter movement in 2016 [ 1 ]. In the UK this culminated in publication of the Kennedy report in 2021 [ 2 ]. Before this the focus was principally on gender imbalance in surgery, with the 2010 Surgical Workforce report only reporting gender percentages by speciality, with no comment on racial profile, sexuality distribution, disability occurrence, or socioeconomic background [ 3 ].

Gender is not the only protected characteristic deserving of equity in surgery; many groups find themselves at a disadvantage during postgraduate surgical examinations [ 4 ] and at revalidation [ 5 ]. This phenomenon is termed ‘differential attainment’ (DA), in which disparities in educational outcomes, progression rates, or achievements between groups with protected characteristics occur [ 4 ]. This may be due to the assessors’ subconscious bias, or a deficit in training and education before assessment.

One of the four pillars of medical ethics is “justice”, emphasising that healthcare should be provided in a fair, equitable, and ethical manner, benefiting all individuals and promoting the well-being of society as a whole. This applies not only to our patients but also to our colleagues; training should be provided in a fair, equitable, and ethical manner, benefiting all. By applying the principle of justice to surgical trainees, we can create an environment that is supportive, inclusive, and conducive to professional growth and well-being.

A diverse consultant body is crucial for providing high-quality healthcare to a diverse patient population. It has been shown that patients are happier when cared for by a doctor with the same ethnic background [ 6 ]. Takeshita et al. [ 6 ] proposed this is due to a greater likelihood of mutual understanding of cultural values, beliefs, and preferences and is therefore more likely to cultivate a trusting relationship, leading to accurate diagnosis, treatment adherence and improved patient understanding. As such, ensuring that all trainees are justly educated and assessed throughout their training may contribute to improving patient care by diversifying the consultant body.

Surgery is well known to have its own specific culture, language, and social rules which are unique even within the world of medicine [ 7 , 8 ]. Through training, graduates develop into surgeons, distinct from other physicians and practitioners [ 9 ]. As such, research conducted in other medical domains is not automatically applicable to surgery, and behavioural interventions focused on reducing or eliminating bias in training need to be tailored specifically to surgical settings.

Consequently, it’s important that the surgical community asks the questions:

Does DA exist in postgraduate surgical training, and to what extent?

Why does DA occur?

What groups or assessments are under-researched?

How can we apply this knowledge, or acquire new knowledge, to provide equity for trainees?

The following scoping review hopes to provide the surgical community with robust answers for future of surgical training.

Aims and research question

The aim of this scoping review is to understand the breadth of research about the presence of DA in postgraduate surgical education and to determine themes pertaining to causes of inequalities. A scoping review was chosen to provide a means to map the available literature, including published peer-reviewed primary research and grey literature.

Following the methodological framework set out by Arksey and O’Malley [ 10 ], our research was intended to characterise the literature addressing DA in HST, including Ophthalmology, Obstetrics & Gynaecology (O&G). We included literature from English-language speaking countries, including the UK and USA.

Search strategy

We used search terms tailored to our target population characteristics (e.g., gender, ethnicity), concept (i.e., DA) and context (i.e., assessment in postgraduate surgical education). Medline and Embase were searched with the assistance of a research librarian, with addition of synonyms. This was conducted in May 2023, and was exported to Microsoft Excel for further review. The reference lists of included articles were also searched to find any relevant data sources that had yet to be considered. In addition, to identify grey literature, a search was performed for the term “differential attainment” and “disparity” on the relevant stakeholders’ websites (See supplemental Table 1 for full listing). Stakeholders were included on the basis of their involvement in governance or training of surgical trainees.

Study selection

To start we excluded conference abstracts that were subsequently published as full papers to avoid duplications ( n  = 337). After an initial screen by title to exclude obviously irrelevant articles, articles were filtered to meet our inclusion and exclusion criteria (Table  1 ). The remaining articles ( n  = 47) were then reviewed in their entirety, with the addition of five reports found in grey literature. Following the screening process, 45 studies were recruited for scoping review (Fig.  1 ).

Charting the data

The extracted data included literature title, authors, year of publication, country of study, study design, population characteristic, case number, context, type of assessment, research question and main findings (Appendix 1). Extraction was performed initially by a single author and then subsequently by a second author to ensure thorough review. Group discussion was conducted in case of any disagreements. As charting occurred, papers were discovered within reference lists of included studies which were eligible for inclusion; these were assimilated into the data charting table and included in the data extraction ( n  = 8).

Collating, summarizing and reporting the results

The included studies were not formally assessed in their quality or risk of bias, consistent with a scoping review approach [ 10 ]. However, group discussion was conducted during charting to aid argumentation and identify themes and trends.

We conducted a descriptive numerical summary to describe the characteristics of included studies. Then thematic analysis was implemented to examine key details and organise the attainment quality and population characteristics based on their description. The coding of themes was an iterative process and involved discussion between authors, to identify and refine codes to group into themes.

We categorised the main themes as gender, ethnicity, country of graduation, individual and family background in education, socioeconomic background, age, and disability. The number of articles in each theme is demonstrated in Table  2 . Data was reviewed and organised into subtopics based on assessment types included: academic achievement (e.g., MRCS, FRCS), assessments for progression (e.g., ARCP), workplace-based assessment (e.g., EPA, feedback), surgical experience (e.g., case volume), and technical skills (e.g., visuo-spatial tasks).

PRISMA flow diagram

44 articles defined the number of included participants (89,399 participants in total; range of participants across individual studies 16–34,755). Two articles reported the number of included studies for their meta-analysis (18 and 63 included articles respectively). Two reports from grey literature did not define the number of participants they included in their analysis. The characteristics of the included articles are displayed in Table  2 .

Growth in published literature on differential attainment over the past 40 years

Academic achievement

In the American Board of Surgery Certifying Exam (ABSCE), Maker [ 11 ] found there to be no significant differences in terms of gender when comparing those who passed on their first attempt and those who did not in general surgery training, a finding supported by Ong et al. [ 12 ]. Pico et al. [ 13 ] reported that in Orthopaedic training, Orthopaedic In-Training Examination (OITE) and American Board of Orthopaedic Surgery (ABOS) Part 1 scores were similar between genders, but that female trainees took more attempts in order to pass. In the UK, two studies reported significantly lower Membership of the Royal College of Surgeons (MRCS) pass rates for female trainees compared to males [ 4 , 14 ]. However, Robinson et al. [ 15 ] presented no significant gender differences in MRCS success rates. A study assessing Fellowship of the Royal College of Surgeons (FRCS) examination results found no significant gender disparities in pass rates [ 16 ]. In MRCOG examination, no significant gender differences were found in Part 1 scores, but women had higher pass rates and scores in Part 2 [ 17 ].

Assessment for Progression

ARCP is the annual process of revalidation that UK doctors must perform to progress through training. A satisfactory progress outcome (“outcome 1”) allows trainees to advance through to the next training year, whereas non-satisfactory outcomes (“2–5”) suggest inadequate progress and recommends solutions, such as further time in training or being released from the training programme. Two studies reported that women received 60% more non-satisfactory outcomes than men [ 16 , 18 ]. In contrast, in O&G men had higher non-satisfactory ARCP outcomes without explicit reasons for this given [ 19 ].

Regarding Milestone evaluations based from the US Accreditation Council for Graduate Medical Education (ACGME), Anderson et al. [ 20 ] reported men had higher ratings of knowledge of diseases at postgraduate year 5 (PGY-5), while women had lower mean score achievements. This was similar to another study finding that men and women had similar competencies at PGY-1 to 3, and that it was only at PGY-5 that women were evaluated lower than men [ 21 ]. However, Kwasny et al. [ 22 ] found no difference in trainers’ ratings between genders, but women self-rated themselves lower. Salles et al. [ 23 ] demonstrated significant improvement in scoring in women following a value-affirmation intervention, while this intervention did not affect men.

Workplace-based Assessment

Galvin et al. [ 24 ] reported better evaluation scores from nurses for PGY-2 male trainees, while females received fewer positive and more negative comments. Gerull et al. [ 25 ] demonstrated men received compliments with superlatives or standout words, whereas women were more likely to receive compliments with mitigating phrases (e.g., excellent vs. quite competent).

Hayward et al. [ 26 ] investigated assessment of attributes of clinical performance (ethics, judgement, technical skills, knowledge and interpersonal skills) and found similar scoring between genders.

Several authors have studied autonomy given to trainees in theatre [ 27 , 28 , 29 , 30 , 31 ]. Two groups found no difference in level of granted autonomy between genders but that women rated lower perceived autonomy on self-evaluation [ 27 , 28 ]. Other studies found that assessors consistently gave female trainees lower autonomy ratings, but only in one paper was this replicated in lower performance scores [ 29 , 30 , 31 ].

Padilla et al. [ 32 ] reported no difference in entrustable professional activity assessment (EPA) levels between genders, yet women rated themselves much lower, which they regarded as evidence of imposter syndrome amongst female trainees. Cooney et al. [ 33 ] found that male trainers scored EPAs for women significantly lower than men, while female trainers rated both genders similarly. Conversely, Roshan et al. [ 34 ] found that male assessors were more positive in feedback comments to female trainees than male trainees, whereas they also found that comments from female assessors were comparable for each gender.

Surgical Experience

Gong et al. [ 35 ] found significantly fewer cataract operations were performed by women in ophthalmology residency programmes, which they suggested could be due to trainers being more likely to give cases to male trainees. Female trainees also participated in fewer robotic colorectal procedures, with less operative time on the robotic console afforded [ 36 ]. Similarly, a systematic review highlighted female trainees in various specialties performed fewer cases per week and potentially had limited access to training facilities [ 37 ]. Eruchalu et al. [ 38 ] found that female trainees performed fewer cases, that is, until gender parity was reached, after which case logs were equivalent.

Technical skills

Antonoff et al. [ 39 ] found higher scores for men in coronary anastomosis skills, with women receiving more “fail” assessments. Dill-Macky et al. [ 40 ] analysed laparoscopic skill assessment using blinded videos of trainees and unblinded assessments. While there was no difference in blinded scores between genders, when comparing blinded and unblinded scores individually, assessors were less likely to agree on the scores of women compared to men. However, another study about laparoscopic skills by Skjold-Ødegaard et al. [ 41 ] reported higher performance scores in female residents, particularly when rated by women. The lowest score was shown in male trainees rated by men. While some studies showed disparities in assessment, several studies reported no difference in technical skill assessments (arthroscopic, knot tying, and suturing skills) between genders [ 42 , 43 , 44 , 45 , 46 ].

Several studies investigated trainees’ abilities to complete isolated tasks associated with surgical skills. In laparoscopic tasks, men were initially more skilful in peg transfer and intracorporeal knot tying than women. Following training, the performance was not different between genders [ 47 ]. A study on microsurgical skills reported better initial visual-spatial and perceptual ability in men, while women had better fine motor psychomotor ability. However, these differences were not significant, and all trainees improved significantly after training [ 48 ]. A study by Milam et al. [ 49 ] revealed men performed better in mental rotation tasks and women outperformed in working memory. They hypothesised that female trainees would experience stereotype threat, fear of being reduced to a stereotype, which would impair their performance. They found no evidence of stereotype threat influencing female performance, disproving their hypothesis, a finding supported by Myers et al. [ 50 ].

Ethnicity and country of graduation

Most papers reported ethnicity and country of graduation concurrently, for example grouping trainees as White UK graduates (WUKG), Black and minority ethnicity UK graduates (BME UKG), and international medical graduates (IMG). Therefore, these areas will be addressed together in the following section.

When assessing the likelihood of passing American Board of Surgery (ABS) examinations on first attempt, Yeo et al. [ 51 ] found that White trainees were more likely than non-White. They found that the influence of ethnicity was more significant in the end-of-training certifying exam than in the start-of-training qualifying exam. This finding was corroborated in a study of both the OITE and ABOS certifying exam, suggesting widening inequalities during training [ 52 ].

Two UK-based studies reported significantly higher MRCS pass rates in White trainees compared to BMEs [ 4 , 14 ]. BMEs were less likely to pass MRCS Part A and B, though this was not true for Part A when variations in socioeconomic background were corrected for [ 14 ]. However, Robinson et al. [ 53 ] found no difference in MRCS pass rates based on ethnicity. Another study by Robinson et al. [ 15 ] demonstrated similar pass rates between WUKGs and BME UKGs, but IMGs had significantly lower pass rates than all UKGs. The FRCS pass rates of WUKGs, BME UKGs and IMGs were 76.9%, 52.9%, and 53.9%, respectively, though these percentages were not statistically significantly different [ 16 ].

There was no difference in MRCOG results based on ethnicity, but higher success rates were found in UKGs [ 19 ]. In FRCOphth, WUKGs had a pass rate of 70%, higher than other groups of trainees, with a pass rate of only 45% for White IMGs [ 52 ].

By gathering data from training programmes reporting little to no DA due to ethnicity, Roe et al. [ 54 ] were able to provide a list of factors they felt were protective against DA, such as having supportive supervisors and developing peer networks.

Assessment for progression

RCOphth [ 55 ] found higher rates of satisfactory ARCP outcomes for WUKGs compared to BME UKGs, followed by IMGs. RCOG [ 19 ] discovered higher rates of non-satisfactory ARCP outcomes from non-UK graduates, particularly amongst BMEs and those from the European Economic Area (EEA). Tiffin et al. [ 56 ] considered the difference in experience between UK graduates and UK nationals whose primary medical qualification was gained outside of the UK, and found that the latter were more likely to receive a non-satisfactory ARCP outcome, even when compared to non-UK nationals.

Woolf et al. [ 57 ] explored reasons behind DA by conducting interview studies with trainees. They investigated trainees’ perceptions of fairness in evaluation and found that trainees felt relationships developed with colleagues who gave feedback could affect ARCP results, and might be challenging for BME UKGs and IMGs who have less in common with their trainers.

Workplace-based assessment

Brooks et al. [ 58 ] surveyed the prevalence of microaggressions against Black orthopaedic surgeons during assessment and found 87% of participants experienced some level of racial discrimination during workplace-based performance feedback. Black women reported having more racially focused and devaluing statements from their seniors than men.

Surgical experience

Eruchalu et al. [ 38 ] found that white trainees performed more major surgical cases and more cases as a supervisor than did their BME counterparts.

Dill-Macky et al. [ 40 ] reported no significant difference in laparoscopic surgery assessments between ethnicities.

Individual and family background in education

Two studies [ 4 , 16 ] concentrated on educational background, considering factors such as parental occupation and attendance of a fee-paying school. MRCS part A pass rate was significantly higher for trainees for whom Medicine was their first Degree, those with university-educated parents, higher POLAR (Participation In Local Areas classification group) quintile, and those from fee-paying schools. Higher part B pass rate was associated with graduating from non-Graduate Entry Medicine programmes and parents with managerial or professional occupations [ 4 ]. Trainees with higher degrees were associated with an almost fivefold increase in FRCS success and seven times more scientific publications than their counterparts [ 16 ].

Socioeconomic background

Two studies used Index of Multiple Deprivation quintile, the official measure of relative deprivation in England based on geographical areas for grading socioeconomic level. The area was defined at the time of medical school application. Deprivation quintiles (DQ) were calculated, ranging from DQ1 (most deprived) to DQ5 (least deprived) [ 4 , 14 ].

Trainees with history of less deprivation were associated with higher MRCS part A pass rate. More success in part B was associated with history of no requirement for income support and less deprived areas [ 4 ]. Trainees from DQ1 and DQ2 had lower pass rates and higher number of attempts to pass [ 14 ]. A general trend of better outcomes in examination was found from O&G trainees in less deprived quintiles [ 19 ].

Trainees from DQ1 and DQ2 received significantly more non-satisfactory ARCP outcomes (24.4%) than DQ4 and DQ5 (14.2%) [ 14 ].

Trainees who graduated at age less than 29 years old were more likely to pass MRCS than their counterparts [ 4 ].

Authors [ 18 , 56 ] found that older trainees received more non-satisfactory ARCP outcomes. Likewise, there was higher percentage of non-satisfactory ARCP outcomes in O&G trainees aged over 45 compared with those aged 25–29 regardless of gender [ 19 ].

Trainees with disability had significantly lower pass rates in MRCS part A compared to candidates without disability. However, the difference was not significant for part B [ 59 ].

What have we learnt from the literature?

It is heartening to note the recent increase in interest in DA (27 studies in the last 4 years, compared to 26 in the preceding 40) (Fig.  2 ). The vast majority (77%) of studies are quantitative, based in the US or UK (89%), focus on gender (85%) and relate to clinical assessments (51%) rather than examination results. Therefore, the surgical community has invested primarily in researching the experience of women in the USA and UK.

Interestingly, a report by RCOG [ 19 ] showed that men were more likely to receive non-satisfactory ARCP outcomes than women, and a study by Rushd et al. [ 17 ] found that women were more likely to pass part 2 of MRCOG than men. This may be because within O&G men are the “out-group” (a social group or category characterised by marginalisation or exclusion by the dominant cultural group) as 75% of O&G trainees are female [ 60 ].

This contrasts with other specialities in which men are the in-group and women are seen to underperform. Outside of O&G, in comparison to men, women are less likely to pass MRCS [ 4 , 14 ], receive satisfactory ARCP outcome [ 16 , 18 ], or receive positive feedback [ 24 ], whilst not performing the same number of procedures as men [ 34 , 35 ]. This often leads to poor self-confidence in women [ 32 ], which can then worsen performance [ 21 ].

It proves difficult to comment on DA for many groups due to a lack of evidence. The current research suggests that being older, having a disability, graduate entry to medicine, low parental education, and living in a lower socioeconomic area at the time of entering medical school are all associated with lower MRCS pass rates. Being older and having a lower socioeconomic background are also associated with non-satisfactory ARCP outcomes, slowing progression through training.

These characteristics may provide a compounding negative effect – for example having a previous degree will automatically make a trainee older, and living in a lower socioeconomic area makes it more likely their parents will have a non-professional job and not hold a higher degree. When multiple protected characteristics interact to produce a compounded negative effect for a person, it is often referred to as “intersectional discrimination” or “intersectionality” [ 61 ]. This is a concept which remains underrepresented in the current literature.

The literature is not yet in agreement over the presence of DA due to ethnicity. There are many studies that report perceived discrimination, however the data for exam and clinical assessment outcomes is equivocal. This may be due to the fluctuating nature of in-groups and out-groups, and multiple intersecting characteristics. Despite this, the lived experience of BME surgeons should not be ignored and requires further investigation.

What are the gaps in the literature?

The overwhelming majority of literature exploring DA addresses issues of gender, ethnicity or country of medical qualification. Whilst bias related to these characteristics is crucial to recognise, studies into other protected characteristics are few and far between. The only paper on disability reported striking differences in attainment between disabled and non-disabled registrars [ 59 ]. There has also been increased awareness about neurodiversity amongst doctors and yet an exploration into the experience of neurodiverse surgeons and their progress through training has yet to be published [ 62 ].

The implications of being LGBTQ + in surgical training have not been recognised nor formally addressed in the literature. Promisingly, the experiences of LGBTQ + medical students have been recognised at an undergraduate level, so one can hope that this will be translated into postgraduate education [ 63 , 64 ]. While this is deeply entwined with experiences of gender discrimination, it is an important characteristic that the surgical community would benefit from addressing, along with disability. To a lesser extent, the effect of socioeconomic background and age have also been overlooked.

Characterising trainees for the purpose of research

Ethnicity is deeply personal, self-defined, and may change over time as personal identity evolves, and therefore arbitrarily grouping diverse ethnic backgrounds is unlikely to capture an accurate representation of experiences. There are levels of discrimination even within minority groups; colourism in India means dark-skinned Indians will experience more discrimination than light-skinned Indians, even from those within in their own ethnic group [ 65 ]. Therefore, although the studies included in the scoping review accepted self-definitions of ethnicity, this is likely not enough to fully capture the nuances of bias and discrimination present in society. For example, Ellis et al. [ 4 ] grouped participants as “White”, “Mixed”, “Asian”, “Black” and “Other”, however they could have also assigned a skin tone value such as the NIS Skin Colour Scale [ 66 ], thus providing more detail.

Ethnicity is more than genetic heritage; it is also cultural expression. The experience of an IMG in UK postgraduate training will differ from that of a UKG, an Indian UKG who grew up in India, and an Indian UKG who grew up in the UK. These are important distinctions which are noted in the literature (e.g. by Woolf et al., 2016 [ 57 ]) however some do not distinguish between ethnicity and graduate status [ 15 ] and none delve into an individual’s cultural expression (e.g., clothing choice) and how this affects the perception of their assessors.

Reasons for DA

Despite the recognition of inequalities in all specialties of surgery, there is a paucity of data explicitly addressing why DA occurs. Reasons behind the phenomenon must be explored to enable change and eliminate biases. Qualitative research is more attuned to capturing the complexities of DA through observation or interview-based studies. Currently most published data is quantitative, and relies on performance metrics to demonstrate the presence of DA while ignoring the causes. Promisingly, there are a gradually increasing number of qualitative, predominantly interview-based, studies (Fig.  2 ).

To create a map of DA in all its guises, an analysis of the themes reported to be contributory to its development is helpful. In our review of the literature, four themes have been identified:

Training culture

In higher surgical training, for there to be equality in outcomes, there needs to be equity in opportunities. Ellis et al. [ 4 ] recognised that variation in training experiences, such as accessibility of supportive peers and senior role models, can have implications on attainment. Trainees would benefit from targeted support at times of transition, such as induction or at examinations, and it may be that currently the needs of certain groups are being met before others, reinforcing differential attainment [ 4 ].

Experience of assessment

Most literature in DA relates to the presence (or lack of) an attainment gap in assessments, such as ARCP or MRCS. It is assumed that these assessments of trainee development are objective and free of bias, and indeed several authors have described a lack of bias in these high-stakes examinations (e.g., Ong et al., 2019 [ 12 ]; Robinson et al., 2019 [ 53 ]). However, in some populations, such as disabled trainees, there are differences in attainment [ 59 ]. This is demonstrated despite legislation requiring professional bodies to make reasonable adjustments to examinations for disabled candidates, such as additional time, text formatting amendments, or wheelchair-accessible venues [ 67 ]. Therefore it would be beneficial to investigate the implementation of these adjustments across higher surgical examinations and identify any deficits.

Social networks

Relationships between colleagues may influence DA in multiple ways. Several studies identified that a lack of a relatable and inspiring mentor may explain why female or BME doctors fail to excel in surgery [ 4 , 55 ]. Certain groups may receive preferential treatment due to their perceived familiarity to seniors [ 35 ]. Robinson et al. [ 15 ] recognised that peer-to-peer relationships were also implicated in professional development, and the lack thereof could lead to poor learning outcomes. Therefore, a non-discriminatory culture and inclusion of trainees within the social network of training is posited as beneficial.

Personal characteristics

Finally, personal factors directly related to protected characteristics have been suggested as a cause of DA. For example, IMGs may perform worse in examinations due to language barriers, and those from disadvantaged backgrounds may have less opportunity to attend expensive courses [ 14 , 16 ]. Although it is impossible to exclude these innate deficits from training, we may mitigate their influence by recognising their presence and providing solutions.

The causes of DA may also be grouped into three levels, as described by Regan de Bere et al. [ 68 ]: macro (the implications of high-level policy), meso (focusing on institutional or working environments) and micro (the influence of individual factors). This can intersect with the four themes identified above, as training culture can be enshrined at both an institutional and individual level, influencing decisions that relate to opportunities for trainees, or at a macro level, such as in the decisions made on nationwide recruitment processes. These three levels can be used to more deeply explore each of the four themes to enrich the discovery of causes of DA.

Discussions outside of surgery

Authors in General Practice (e.g., Unwin et al., 2019 [ 69 ]; Pattinson et al., 2019 [ 70 ]), postgraduate medical training (e.g., Andrews, Chartash, and Hay, 2021 [ 71 ]), and undergraduate medical education (e.g., Yeates et al., 2017 [ 72 ]; Woolf et al., 2013 [ 73 ]) have published more extensively in the aetiology of DA. A study by Hope et al. [ 74 ] evaluating the bias present in MRCP exams used differential item functioning to identify individual questions which demonstrated an attainment gap between male and female and Caucasian and non-Caucasian medical trainees. Conclusions drawn about MRCP Part 1 examinations may be generalisable to MRCS Part A or FRCOphth Part 1: they are all multiple-choice examinations testing applied basic science and usually taken within the first few years of postgraduate training. Therefore it is advisable that differential item functioning should also be applied to these examinations. However, it is possible that findings in some subspecialities may not be generalisable to others, as training environments can vary profoundly. The RCOphth [ 55 ] reported that in 2021, 53% of ophthalmic trainees identified as male, whereas in Orthopaedics 85% identified as male, suggesting different training environments [ 5 ]. It is useful to identify commonalities of DA between surgical specialties and in the wider scope of medical training.

Limitations of our paper

Firstly, whilst aiming to provide a review focussed on the experience of surgical trainees, four papers contained data about either non-surgical trainees or medical students. It is difficult to draw out the surgeons from this data and therefore it is possible that there are issues with generalisability. Furthermore, we did not consider the background of each paper’s authors, as their own lived experience of attainment gap could form the lens through which they commented on surgical education, colouring their interpretation. Despite intending to include as many protected characteristics as possible, inevitably there will be lived experiences missed. Lastly, the experience of surgical trainees outside of the English-speaking world were omitted. No studies were found that originated outside of Europe or North America and therefore the presence or characteristics of DA outside of this area cannot be assumed.

Experiences of inequality in surgical assessment are prevalent in all surgical subspecialities. In order to further investigate DA, researchers should ensure all protected characteristics are considered - and how these interact - to gain insight into intersectionality. Given the paucity of current evidence, particular focus should be given to the implications of disability, and specifically neurodiversity, in progress through training as they are yet to be explored in depth. In defining protected characteristics, future authors should be explicit and should avoid generalisation of cultural backgrounds to allow authentic appreciation of attainment gap. Few authors have considered the driving forces between bias in assessment and DA, and therefore qualitative studies should be prioritised to uncover causes for and protective factors against DA. Once these influences have been identified, educational designers can develop new assessment methods that ensure equity across surgical trainees.

Data availability

All data provided during this study are included in the supplementary information files.

Abbreviations

Accreditation Council for Graduate Medical Education

American Board of Orthopaedic Surgery

American Board of Surgery

American Board of Surgery Certifying Exam

Annual Review of Competence Progression

Black, Asian, and Minority Ethnicity

Council on Resident Education in Obstetrics and Gynecology

Differential Attainment

Deprivation Quintile

European Economic Area

Entrustable Professional Activities

Fellowship of The Royal College of Ophthalmologists

Fellow of the Royal College of Surgeons

General Medical Council

Higher Surgical Training

International Medical Graduate

In-Training Evaluation Report

Member of the Royal College of Obstetricians and Gynaecologists

Member of the Royal College of Physicians

Member of the Royal College of Surgeons

Obstetrics and Gynaecology

Orthopaedic In-Training Examination

Participation In Local Areas

Postgraduate Year

The Royal College of Ophthalmologists

The Royal College of Obstetricians and Gynaecologists

The Royal College of Surgeons of England

United Kingdom Graduate

White United Kingdom Graduate

Joseph JP, Joseph AO, Jayanthi NVG, et al. BAME Underrepresentation in Surgery Leadership in the UK and Ireland in 2020: An Uncomfortable Truth. The Bulletin of the Royal College of Surgeons of England. 2020; 102 (6): 232–33.

Royal College of Surgeons of England. The Royal College – Our Professional Home. An independent review on diversity and inclusion for the Royal College of Surgeons of England. Review conducted by Baroness Helena Kennedy QC. RCS England. 2021.

Sarafidou K, Greatorex R. Surgical workforce: planning today for the workforce of the future. Bull Royal Coll Surg Engl. 2011;93(2):48–9. https://doi.org/10.1308/147363511X552575 .

Article   Google Scholar  

Ellis R, Brennan P, Lee AJ, et al. Differential attainment at MRCS according to gender, ethnicity, age and socioeconomic factors: a retrospective cohort study. J R Soc Med. 2022;115(7):257–72. https://doi.org/10.1177/01410768221079018 .

Hope C, Humes D, Griffiths G, et al. Personal Characteristics Associated with Progression in Trauma and Orthopaedic Specialty Training: A Longitudinal Cohort Study.Journal of Surgical Education 2022; 79 (1): 253–59. doi:10.1016/j.jsurg.2021.06.027.

Takeshita J, Wang S, Loren AW, et al. Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open. 2022; 3(11). doi:10.1001/jamanetworkopen.2020.24583.

Katz, P. The Scalpel’s Edge: The Culture of Surgeons. Allyn and Bacon, 1999.

Tørring B, Gittell JH, Laursen M, et al. (2019) Communication and relationship dynamics in surgical teams in the operating room: an ethnographic study. BMC Health Services Research. 2019;19, 528. doi:10.1186/s12913-019-4362-0.

Veazey Brooks J & Bosk CL. (2012) Remaking surgical socialization: work hour restrictions, rites of passage, and occupational identity. Social Science & Medicine. 2012;75(9):1625-32. doi: 10.1016/j.socscimed.2012.07.007.

Arksey H & OʼMalley L. Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology. 2005;8(1), 19–32.

Maker VK, Marco MZ, Dana V, et al. Can We Predict Which Residents Are Going to Pass/Fail the Oral Boards? Journal of Surgical Education. 2012;69 (6): 705–13.

Ong TQ, Kopp JP, Jones AT, et al. Is there gender Bias on the American Board of Surgery general surgery certifying examination? J Surg Res. 2019;237:131–5. https://doi.org/10.1016/j.jss.2018.06.014 .

Pico K, Gioe TJ, Vanheest A, et al. Do men outperform women during orthopaedic residency training? Clin Orthop Relat Res. 2010;468(7):1804–8. https://doi.org/10.1007/s11999-010-1318-4 .

Vinnicombe Z, Little M, Super J, et al. Differential attainment, socioeconomic factors and surgical training. Ann R Coll Surg Engl. 2022;104(8):577–82. https://doi.org/10.1308/rcsann.2021.0255 .

Robinson DBT, Hopkins L, James OP, et al. Egalitarianism in surgical training: let equity prevail. Postgraduate Medical Journal. 2020;96 (1141), 650–654. doi:10.1136/postgradmedj-2020-137563.

Luton OW, Mellor K, Robinson DBT, et al. Differential attainment in higher surgical training: scoping pan-specialty spectra. Postgraduate Medical Journal. 2022;99(1174),849–854. doi:10.1136/postgradmedj-2022-141638.

Rushd S, Landau AB, Khan JA, Allgar V & Lindow SW. An analysis of the performance of UK medical graduates in the MRCOG Part 1 and Part 2 written examinations. Postgraduate Medical Journal. 2012;88 (1039), 249–254. doi:10.1136/postgradmedj-2011-130479.

Hope C, Lund J, Griffiths G, et al. Differences in ARCP outcome by surgical specialty: a longitudinal cohort study. Br J Surg. 2021;108. https://doi.org/10.1093/bjs/znab282.051 .

Royal College of Obstetricians and Gynaecologists. Report Differential Attainment 2019. https://www.rcog.org.uk/media/jscgfgwr/differential-attainment-tef-report-2019.pdf [Last accessed 28/12/23].

Anderson JE, Zern NK, Calhoun KE, et al. Assessment of Potential Gender Bias in General Surgery Resident Milestone Evaluations. JAMA Surgery. 2022;157 (12), 1164–1166. doi:10.1001/jamasurg.2022.3929.

Landau SI, Syvyk S, Wirtalla C, et al. Trainee Sex and Accreditation Council for Graduate Medical Education Milestone Assessments during general surgery residency. JAMA Surg. 2021;156(10):925–31. https://doi.org/10.1001/jamasurg.2021.3005 .

Kwasny L, Shebrain S, Munene G, et al. Is there a gender bias in milestones evaluations in general surgery residency training? Am J Surg. 2021;221(3):505–8. https://doi.org/10.1016/j.amjsurg.2020.12.020 .

Salles A, Mueller CM & Cohen GL. A Values Affirmation Intervention to Improve Female Residents’ Surgical Performance. Journal of Graduate Medical Education. 2016;8 (3), 378–383. doi:10.4300/JGME-D-15-00214.1.

Galvin S, Parlier A, Martino E, et al. Gender Bias in nurse evaluations of residents in Obstetrics and Gynecology. Obstet Gynecol. 2015;126(7S–12S). https://doi.org/10.1097/AOG.0000000000001044 .

Gerull KM, Loe M, Seiler K, et al. Assessing gender bias in qualitative evaluations of surgical residents. Am J Surg. 2019;217(2):306–13. https://doi.org/10.1016/j.amjsurg.2018.09.029 .

Hayward CZ, Sachdeva A, Clarke JR. Is there gender bias in the evaluation of surgical residents? Surgery. 1987;102(2):297–9.

Google Scholar  

Cookenmaster C, Shebrain S, Vos D, et al. Gender perception bias of operative autonomy evaluations among residents and faculty in general surgery training. Am J Surg. 2021;221(3):515–20. https://doi.org/10.1016/j.amjsurg.2020.11.016 .

Olumolade OO, Rollins PD, Daignault-Newton S, et al. Closing the Gap: Evaluation of Gender Disparities in Urology Resident Operative Autonomy and Performance.Journal of Surgical Education.2022;79 (2), 524–530. doi.org/10.1016/j.jsurg.2021.10.010.

Chen JX, Chang EH, Deng F, et al. Autonomy in the Operating Room: A Multicenter Study of Gender Disparities During Surgical Training. Journal of Graduate Medical Education. 2021;13(5), 666–672. doi: 10.4300/JGME-D-21-00217.1.

Meyerson SL, Sternbach JM, Zwischenberger JB, & Bender EM. The Effect of Gender on Resident Autonomy in the Operating room. Journal of Surgical Education. 2017. 74(6), e111–e118. doi.org/10.1016/j.jsurg.2017.06.014.

Hoops H, Heston A, Dewey E, et al. Resident autonomy in the operating room: Does gender matter? The AmericanJournalofSurgery. 2019; 217(2), 301–305. doi.org/10.1016/j.amjsurg.2018.12.023.

Padilla EP, Stahl CC, Jung SA, et al. Gender Differences in Entrustable Professional Activity Evaluations of General Surgery Residents. Annals of Surgery. 2022;275 (2), 222–229. doi:10.1097/SLA.0000000000004905.

Cooney CM, Aravind P, Hultman CS, et al. An Analysis of Gender Bias in Plastic Surgery Resident Assessment. Journal of Graduate Medical Education. 2021;13 (4), 500–506. doi:10.4300/JGME-D-20-01394.1.

Roshan A, Farooq A, Acai A, et al. The effect of gender dyads on the quality of narrative assessments of general surgery trainees. The American Journal of Surgery. 2022; 224 (1A), 179–184. doi.org/10.1016/j.amjsurg.2021.12.001.

Gong D, Winn BJ, Beal CJ, et al. Gender Differences in Case Volume Among Ophthalmology Residents. Archives of Ophthalmology. 2019;137 (9), 1015–1020. doi:10.1001/jamaophthalmol.2019.2427.

Foley KE, Izquierdo KM, von Muchow MG, et al. Colon and Rectal Surgery Robotic Training Programs: An Evaluation of Gender Disparities. Diseases of the Colon and Rectum. 2020; 63(7), 974–979. doi.org/10.1097/DCR.0000000000001625.

Ali A, Subhi Y, Ringsted C et al. Gender differences in the acquisition of surgical skills: a systematic review. Surgical Endoscopy. 2015;29 (11), 3065–3073. doi:10.1007/s00464-015-4092-2.

Eruchalu CN, He K, Etheridge JC, et al. Gender and Racial/Ethnic Disparities in Operative Volumes of Graduating General Surgery Residents.The Journal of Surgical Research. 2022; 279, 104–112. doi.org/10.1016/j.jss.2022.05.020.

Antonoff MB, Feldman H, Luc JGY, et al. Gender Bias in the Evaluation of Surgical Performance: Results of a Prospective Randomized Trial. Annals of Surgery. 2023;277 (2), 206–213. doi:10.1097/SLA.0000000000005015.

Dill-Macky A, Hsu C, Neumayer LA, et al. The Role of Implicit Bias in Surgical Resident Evaluations. Journal of Surgical Education. 2022;79 (3), 761–768. doi:10.1016/j.jsurg.2021.12.003.

Skjold-Ødegaard B, Ersdal HL, Assmus J et al. Comparison of Performance Score for Female and Male Residents in General Surgery Doing Supervised Real-Life Laparoscopic Appendectomy: Is There a Norse Shield-Maiden Effect? World Journal of Surgery. 2021;45 (4), 997–1005. doi:10.1007/s00268-020-05921-4.

Leape CP, Hawken JB, Geng X, et al. An investigation into gender bias in the evaluation of orthopedic trainee arthroscopic skills. Journal of Shoulder and Elbow Surgery. 2022;31 (11), 2402–2409. doi:10.1016/j.jse.2022.05.024.

Vogt VY, Givens VM, Keathley CA, et al. Is a resident’s score on a videotaped objective structured assessment of technical skills affected by revealing the resident’s identity? American Journal of Obstetrics and Gynecology. 2023;189 (3), 688–691. doi:10.1067/S0002-9378(03)00887-1.

Fjørtoft K, Konge L, Christensen J et al. Overcoming Gender Bias in Assessment of Surgical Skills. Journal of Surgical Education. 2022;79 (3), 753–760. doi:10.1016/j.jsurg.2022.01.006.

Grantcharov TP, Bardram L, Funch-Jensen P, et al. Impact of Hand Dominance, Gender, and Experience with Computer Games on Performance in Virtual Reality Laparoscopy. Surgical Endoscopy 2003;17 (7): 1082–85.

Rosser Jr JC, Rosser LE & Savalgi RS. Objective Evaluation of a Laparoscopic Surgical Skill Program for Residents and Senior Surgeons. Archives of Surgery. 1998; 133 (6): 657–61.

White MT & Welch K. Does gender predict performance of novices undergoing Fundamentals of Laparoscopic Surgery (FLS) training? The American Journal of Surgery. 2012;203 (3), 397–400. doi:10.1016/j.amjsurg.2011.09.020.

Nugent E, Joyce C, Perez-Abadia G, et al. Factors influencing microsurgical skill acquisition during a dedicated training course. Microsurgery. 2012;32 (8), 649–656. doi:10.1002/micr.22047.

Milam LA, Cohen GL, Mueller C et al. Stereotype threat and working memory among surgical residents. The American Journal of Surgery. 2018;216 (4), 824–829. doi:10.1016/j.amjsurg.2018.07.064.

Myers SP, Dasari M, Brown JB, et al. Effects of Gender Bias and Stereotypes in Surgical Training: A Randomized Clinical Trial. JAMA Surgery. 2020; 155(7), 552–560. doi.org/10.1001/jamasurg.2020.1127.

Yeo HL, Patrick TD, Jialin M, et al. Association of Demographic and Program Factors With American Board of Surgery Qualifying and Certifying Examinations Pass Rates. JAMA Surgery 2020; 155 (1): 22–30. doi:0.1001/jamasurg.2019.4081.

Foster N, Meghan P, Bettger JP, et al. Objective Test Scores Throughout Orthopedic Surgery Residency Suggest Disparities in Training Experience. Journal of Surgical Education 2021;78 (5): 1400–1405. doi:10.1016/j.jsurg.2021.01.003.

Robinson DBT, Hopkins L, Brown C, et al. Prognostic Significance of Ethnicity on Differential Attainment in Core Surgical Training (CST). Journal of the American College of Surgeons. 2019;229 (4), e191. doi:10.1016/j.jamcollsurg.2019.08.1254.

Roe V, Patterson F, Kerrin M, et al. What supported your success in training? A qualitative exploration of the factors associated with an absence of an ethnic attainment gap in post-graduate specialty training. General Medical Council. 2019. https://www.gmc-uk.org/-/media/documents/gmc-da-final-report-success-factors-in-training-211119_pdf-80914221.pdf [Last accessed 28/12/23].

Royal College of Ophthalmologists. Data on Differential attainment in ophthalmology and monitoring equality, diversity, and inclusion: Recommendations to the RCOphth. London, Royal College of Ophthalmologists. 2022. https://www.rcophth.ac.uk/wp-content/uploads/2023/01/Differential-Attainment-Report-2022.pdf [Last accessed 28/12/23].

Tiffin PA, Orr J, Paton LW, et al. UK nationals who received their medical degrees abroad: selection into, and subsequent performance in postgraduate training: a national data linkage study. BMJ Open. 2018;8:e023060. doi: 10.1136/bmjopen-2018-023060.

Woolf K, Rich A, Viney R, et al. Perceived causes of differential attainment in UK postgraduate medical training: a national qualitative study. BMJ Open. 2016;6 (11), e013429. doi:10.1136/bmjopen-2016-013429.

Brooks JT, Porter SE, Middleton KK, et al. The Majority of Black Orthopaedic Surgeons Report Experiencing Racial Microaggressions During Their Residency Training. Clinical Orthopaedics and Related Research. 2023;481 (4), 675–686. doi:10.1097/CORR.0000000000002455.

Ellis R, Cleland J, Scrimgeour D, et al. The impact of disability on performance in a high-stakes postgraduate surgical examination: a retrospective cohort study. Journal of the Royal Society of Medicine. 2022;115 (2), 58–68. doi:10.1177/01410768211032573.

Royal College of Obstetricians & Gynaecologists. RCOGWorkforceReport2022. Available at: https://www.rcog.org.uk/media/fdtlufuh/workforce-report-july-2022-update.pdf [Last accessed 28/12/23].

Crenshaw KW. On Intersectionality: Essential Writings. Faculty Books. 2017; 255.

Brennan CM & Harrison W. The Dyslexic Surgeon. The Bulletin of the Royal College of Surgeons of England. 2020;102 (3): 72–75. doi:10.1308/rcsbull.2020.72.

Toman L. Navigating medical culture and LGBTQ identity. Clinical Teacher. 2019;16: 335–338. doi:10.1111/tct.13078.

Torales J, Castaldelli-Maia JM & Ventriglio A. LGBT + medical students and disclosure of their sexual orientation: more than in and out of the closet. International Review of Psychiatry. 2022;34:3–4, 402–406. doi:10.1080/09540261.2022.2101881.

Guda VA & Kundu RV. India’s Fair Skin Phenomena. SKINmed. 2021;19(3), 177–178.

Massey D & Martin JA. The NIS skin color scale. Princeton University Press. 2003.

Intercollegiate Committee for Basic Surgical Examinations.AccessArrangementsandReasonableAdjustmentsPolicyforCandidateswithaDisabilityorSpecificLearningdifficulty. 2020. https://www.intercollegiatemrcsexams.org.uk/-/media/files/imrcs/mrcs/mrcs-regulations/access-arrangements-and-reasonable-adjustments-january-2020.pdf [Last accessed 28/12/23].

Regan de Bere S, Nunn S & Nasser M. Understanding differential attainment across medical training pathways: A rapid review of the literature. General Medical Council. 2015. https://www.gmc-uk.org/-/media/documents/gmc-understanding-differential-attainment_pdf-63533431.pdf [Last accessed 28/12/23].

Unwin E, Woolf K, Dacre J, et al. Sex Differences in Fitness to Practise Test Scores: A Cohort Study of GPs. The British Journal of General Practice: The Journal of the Royal College of General Practitioners. 2019; 69 (681): e287–93. doi:10.3399/bjgp19X701789.

Pattinson J, Blow C, Sinha B et al. Exploring Reasons for Differences in Performance between UK and International Medical Graduates in the Membership of the Royal College of General Practitioners Applied Knowledge Test: A Cognitive Interview Study. BMJ Open. 2019;9 (5): e030341. doi:10.1136/bmjopen-2019-030341.

Andrews J, Chartash D & Hay S. Gender Bias in Resident Evaluations: Natural Language Processing and Competency Evaluation. Medical Education. 2021;55 (12): 1383–87. doi:10.1111/medu.14593.

Yeates P, Woolf K, Benbow E, et al. A Randomised Trial of the Influence of Racial Stereotype Bias on Examiners’ Scores, Feedback and Recollections in Undergraduate Clinical Exams. BMC Medicine 2017;15 (1): 179. doi:10.1186/s12916-017-0943-0.

Woolf K, McManus IC, Potts HWW et al. The Mediators of Minority Ethnic Underperformance in Final Medical School Examinations. British Journal of Educational Psychology. 2013; 83 (1): 135–59. doi:10.1111/j.2044-8279.2011.02060.x.

Hope D, Adamson K, McManus IC, et al. Using Differential Item Functioning to Evaluate Potential Bias in a High Stakes Postgraduate Knowledge Based Assessment. BMC Medical Education. 2018;18 (1): 64. doi:10.1186/s12909-018-1143-0.

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Rebecca L. Jones, Suwimol Prusmetikul & Sarah Whitehorn

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RJ, SP and SW conceived the study. RJ carried out the search. RJ, SP and SW reviewed and appraised articles. RJ, SP and SW extracted data and synthesized results from articles. RJ, SP and SW prepared the original draft of the manuscript. RJ and SP prepared Figs. 1 and 2. All authors reviewed and edited the manuscript and agreed to the final version.

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Jones, R.L., Prusmetikul, S. & Whitehorn, S. Differential attainment in assessment of postgraduate surgical trainees: a scoping review. BMC Med Educ 24 , 597 (2024). https://doi.org/10.1186/s12909-024-05580-2

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Received : 27 February 2024

Accepted : 20 May 2024

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DOI : https://doi.org/10.1186/s12909-024-05580-2

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