advantages of traditional literature review

Literature Review: Traditional or narrative literature reviews

Traditional or narrative literature reviews.

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

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

• General literature review that provides a review of the most important and critical aspects of the current knowledge of the topic. This general literature review forms the introduction to a thesis or dissertation and must be defined by the research objective, underlying hypothesis or problem or the reviewer's argumentative thesis.
• Theoretical literature review which examines how theory shapes or frames research
• Methodological literature review where the research methods and design are described. These methodological reviews outline the strengths and weaknesses of the methods used and provide future direction
• Historical literature review which focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.

References and additional resources

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

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Purpose of traditional literature reviews

Literature reviews come in many shapes and sizes, and may be placed in different areas in different theses. However, for most projects, the literature review usually has one overall purpose: to provide a rationale for your research in terms of what has gone before.

The purpose of a traditional literature review is to demonstrate a gap or problem in your field that your research seeks to address. The importance of addressing the gap for your field or discipline must not be assumed but persuasively demonstrated. Indeed, explaining why there is a need for filling the gap helps you to justify your work's value, originality and significance.

To establish your credibility as a scholar, your literature review will typically need to do at least some (if not all) of the following effectively.

• Demonstrate that your research is rigorous and up-to-date by enagaging with seminal and current work
• Summarise relevant bodies of work and evaluate their strengths and weaknesses to demonstrate your critical understanding of the literature.
• Point out gaps in the literature or identify problems / issues remaining to be solved.
• Justify the choice of topic/area of research, to establish the value of the research and the nature of the contribution you expect to make to the research field.
• Highlight key issues essential to your own research.
• Synthesise the main themes and arguments of a particular body of literature.
• Develop an argument in the process of reviewing the literature
• Produce a brief historical survey or other context information in order to situate your research.

The literature review helps you to establish the nature of your contribution to knoweldge. The type of contribution differs from project to project. The list below gives a variety of ways in which different projects can contribute to different fields. Does your project fit into any of these categories?

• Filling a significant gap in the research (could be almost anything).
• Challenging prevailing methodologies, theories or test procedures.
• Continuing an ongoing line of enquiry (common in the experimental sciences).
• Developing new experimental procedures or perhaps a model.
• Developing new products, software or technology (perhaps for industry).
• Using established techniques or approaches in a new context (common in area studies).
• Providing extensive new data (common in field research).
• Producing a portfolio of creative work with an accompanying exegesis.
• Presenting studio work or performance presentations, as in some arts.
• Writing a biography (perhaps in History or English).
• Setting up a comprehensive practical study for professional development purposes.
• Doing a comprehensive analysis of issues in new, and important, policy proposals.
• Documenting a language (perhaps in Linguistics).

Whichever type of contribution you're making, your literature review should establish the need for your contribution.

Placement of traditional literature reviews>>

Literature reviews

Placement of traditional literature reviews

Structuring a literature review

Language of the literature review

Systematic literature reviews

Grounded theory literature reviews

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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How to Conduct a Literature Review: A Guide for Graduate Students

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Traditional or Narrative Reviews

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

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

• General literature review that provides a review of the most important and critical aspects of the current knowledge of the topic. This general literature review forms the introduction to a thesis or dissertation and must be defined by the research objective, underlying hypothesis or problem or the reviewer's argumentative thesis.
• Historical literature review which focus on examining research throughout a period of time, often starting with the first time an issue, concept, theory, phenomena emerged in the literature, then tracing its evolution within the scholarship of a discipline. The purpose is to place research in a historical context to show familiarity with state-of-the-art developments and to identify the likely directions for future research.
• Methodological literature review where the research methods and design are described. These methodological reviews outline the strengths and weaknesses of the methods used and provide future direction
• Theoretical literature review which examines how theory shapes or frames research

References and additional resources

Machi, Lawrence A. & Brenda T. McEvoy (2016), The Literature Review: Six steps to success . 3rd edition.; Thousand Oaks, CA: Corwin. Onwuegbuzie, A. J. & Frels, R. (2016) 7 steps to a comprehensive literature review: A multimodal & cultural approach . London: Sage Publications.

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

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

Chapter 9 methods for literature reviews.

Guy Paré and Spyros Kitsiou .

9.1. Introduction

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

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

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

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

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

9.2. Overview of the Literature Review Process and Steps

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

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

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

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

9.3. Types of Review Articles and Brief Illustrations

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

9.3.1. Narrative Reviews

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

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

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

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

9.3.2. Descriptive or Mapping Reviews

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

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

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

9.3.3. Scoping Reviews

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

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

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

9.3.4. Forms of Aggregative Reviews

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

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

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

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

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

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

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

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

9.3.5. Realist Reviews

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

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

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

9.3.6. Critical Reviews

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

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

9.4. Summary

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

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

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

9.5. Concluding Remarks

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

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

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

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

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Traditional reviews vs. systematic reviews

Posted on 3rd February 2016 by Weyinmi Demeyin

Millions of articles are published yearly (1) , making it difficult for clinicians to keep abreast of the literature. Reviews of literature are necessary in order to provide clinicians with accurate, up to date information to ensure appropriate management of their patients. Reviews usually involve summaries and synthesis of primary research findings on a particular topic of interest and can be grouped into 2 main categories; the ‘traditional’ review and the ‘systematic’ review with major differences between them.

Traditional reviews provide a broad overview of a research topic with no clear methodological approach (2) . Information is collected and interpreted unsystematically with subjective summaries of findings. Authors aim to describe and discuss the literature from a contextual or theoretical point of view. Although the reviews may be conducted by topic experts, due to preconceived ideas or conclusions, they could be subject to bias.

Systematic reviews are overviews of the literature undertaken by identifying, critically appraising and synthesising results of primary research studies using an explicit, methodological approach(3). They aim to summarise the best available evidence on a particular research topic.

The main differences between traditional reviews and systematic reviews are summarised below in terms of the following characteristics: Authors, Study protocol, Research question, Search strategy, Sources of literature, Selection criteria, Critical appraisal, Synthesis, Conclusions, Reproducibility, and Update.

Traditional reviews

• Authors: One or more authors usually experts in the topic of interest
• Study protocol: No study protocol
• Research question: Broad to specific question, hypothesis not stated
• Search strategy: No detailed search strategy, search is probably conducted using keywords
• Sources of literature: Not usually stated and non-exhaustive, usually well-known articles. Prone to publication bias
• Selection criteria: No specific selection criteria, usually subjective. Prone to selection bias
• Critical appraisal: Variable evaluation of study quality or method
• Synthesis: Often qualitative synthesis of evidence
• Conclusions: Sometimes evidence based but can be influenced by author’s personal belief
• Reproducibility: Findings cannot be reproduced independently as conclusions may be subjective
• Update: Cannot be continuously updated

Systematic reviews

• Authors: Two or more authors are involved in good quality systematic reviews, may comprise experts in the different stages of the review
• Study protocol: Written study protocol which includes details of the methods to be used
• Research question: Specific question which may have all or some of PICO components (Population, Intervention, Comparator, and Outcome). Hypothesis is stated
• Search strategy: Detailed and comprehensive search strategy is developed
• Sources of literature: List of databases, websites and other sources of included studies are listed. Both published and unpublished literature are considered
• Selection criteria: Specific inclusion and exclusion criteria
• Critical appraisal: Rigorous appraisal of study quality
• Synthesis: Narrative, quantitative or qualitative synthesis
• Conclusions: Conclusions drawn are evidence based
• Reproducibility: Accurate documentation of method means results can be reproduced
• Update: Systematic reviews can be periodically updated to include new evidence

Decisions and health policies about patient care should be evidence based in order to provide the best treatment for patients. Systematic reviews provide a means of systematically identifying and synthesising the evidence, making it easier for policy makers and practitioners to assess such relevant information and hopefully improve patient outcomes.

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THE INFORMATION IS VERY MUCH VALUABLE, A LOT IS INDEED EXPECTED IN ORDER TO MASTER SYSTEMATIC REVIEW

Thank you very much for the information here. My question is : Is it possible for me to do a systematic review which is not directed toward patients but just a specific population? To be specific can I do a systematic review on the mental health needs of students?

Hi Rosemary, I wonder whether it would be useful for you to look at Module 1 of the Cochrane Interactive Learning modules. This is a free module, open to everyone (you will just need to register for a Cochrane account if you don’t already have one). This guides you through conducting a systematic review, with a section specifically around defining your research question, which I feel will help you in understanding your question further. Head to this link for more details: https://training.cochrane.org/interactivelearning

I wonder if you have had a search on the Cochrane Library as yet, to see what Cochrane systematic reviews already exist? There is one review, titled “Psychological interventions to foster resilience in healthcare students” which may be of interest: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013684/full You can run searches on the library by the population and intervention you are interested in.

I hope these help you start in your investigations. Best wishes. Emma.

La revisión sistemática vale si hay solo un autor?

HI Alex, so sorry for the delay in replying to you. Yes, that is a very good point. I have copied a paragraph from the Cochrane Handbook, here, which does say that for a Cochrane Review, you should have more than one author.

“Cochrane Reviews should be undertaken by more than one person. In putting together a team, authors should consider the need for clinical and methodological expertise for the review, as well as the perspectives of stakeholders. Cochrane author teams are encouraged to seek and incorporate the views of users, including consumers, clinicians and those from varying regions and settings to develop protocols and reviews. Author teams for reviews relevant to particular settings (e.g. neglected tropical diseases) should involve contributors experienced in those settings”.

Thank you for the discussion point, much appreciated.

Hello, I’d like to ask you a question: what’s the difference between systematic review and systematized review? In addition, if the screening process of the review was made by only one author, is still a systematic or is a systematized review? Thanks

Hi. This article from Grant & Booth is a really good one to look at explaining different types of reviews: https://onlinelibrary.wiley.com/doi/10.1111/j.1471-1842.2009.00848.x It includes Systematic Reviews and Systematized Reviews. In answer to your second question, have a look at this Chapter from the Cochrane handbook. It covers the question about ‘Who should do a systematic review’. https://training.cochrane.org/handbook/current/chapter-01

A really relevant part of this chapter is this: “Systematic reviews should be undertaken by a team. Indeed, Cochrane will not publish a review that is proposed to be undertaken by a single person. Working as a team not only spreads the effort, but ensures that tasks such as the selection of studies for eligibility, data extraction and rating the certainty of the evidence will be performed by at least two people independently, minimizing the likelihood of errors.”

I hope this helps with the question. Best wishes. Emma.

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The value and purpose of the traditional qualitative literature review

Affiliation.

• 1 School of Social Work, University of Connecticut, 1798 Asylum Ave., West Hartford, CT 06117, USA. [email protected]
• PMID: 21082469
• DOI: 10.1080/15433710903344116

Both meta-analysis and traditional literature or narrative reviews strive to compile a great deal of information in an accessible and succinct manner. In recent years, social work researchers have been turning toward meta-analysis to identify issues in large areas of research. In order for meta-analysis to be a rigorous and objective source of information there are a certain set of assumptions that must be met about how to carry out the process of including and excluding various studies. However, when these assumptions are not met, the information provided can be misleading. Traditional literature reviews continue to offer a valid and important way to identify existing patterns and gaps in social work research. In fact, because they draw not only on quantitative (as does meta-analysis) but also qualitative studies their reach may often be broader. This paper examines the strengths, weaknesses and utility of both practices in social work research today.

• Meta-Analysis as Topic*
• Qualitative Research
• Research Design*
• Review Literature as Topic*
• Social Work*

Types of Literature Reviews : Home

• Health Science Information Consortium
• University Health Network - New
• Types of Literature Reviews

Need More Help?

• Knowledge Synthesis Support
• Literature Search Request
• The Right Review for You - Workshop Recording (YouTube) 27min video From UHN Libraries Recorded Nov 2021
• The Screening Phase for Reviews Tutorial This tutorial presents information on the screening process for systematic reviews or other knowledge syntheses, and contains a variety of resources for successfully preparing to complete this important research stage.
• Workshops Find more UHN Libraries workshops, live and on-demand, and other learning opportunities helpful for knowledge synthesis projects.

How to Choose Your Review Method

TREAD* Lightly and Consider...

• Available T ime for conducting your review
• Any R esource constraints within which you must deliver your review
• Any requirements for specialist E xpertise in order to complete the review
• The requirements of the A udience for your review and its intended purpose
• The richness, thickness and availability of D ata within included studies

* Booth A, Sutton A, Papaioannou D.  Systematic approaches to a successful literature review.  2nd edition.  Los Angeles, CA:  Sage, 2016.  (p.36)

How do I write a Review Protocol?

• What is a Protocol? (UofT)
• Guidance on Registering a Review with PROSPERO

Writing Resources

• Advice on Academic Writing (University of Toronto)
• How to write a great research paper using reporting guidelines (EQUATOR Network)
• Instructions to Authors in the Health Sciences
• Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly work in Medical Journals (ICMJE)
• Writing resources guide (BMC)

What is a Literature Review?

A literature review provides an overview of what's been written about a specific topic. It is a generic term. There are many different types of literature reviews which can cover a wide range of subjects at various levels of completeness and comprehensiveness. Choosing the type of review you wish to conduct will depend on the purpose of your review, and the time and resources you have available.

This page will provide definitions of some of the most common review types in the health sciences and links to relevant reporting guidelines or methodological papers.

Grant MJ, Booth A. A typology of reviews: an analysis of 14 review types and associated methodologies . Health Information & Libraries Journal . 2009 Jun 1;26(2):91-108. 

• Summary of Five Types of Reviews Table summarizing the characteristics, guidelines etc. of 5 common types of review article.

Traditional (Narrative) Review

Traditional (narrative) literature reviews provide a broad overview of a research topic with no clear methodological approach. Information is collected and interpreted unsystematically with subjective summaries of findings. Authors aim to describe and discuss the literature from a contextual or theoretical point of view. Although the reviews may be conducted by topic experts, due to preconceived ideas or conclusions, they could be subject to bias. This sort of literature review can be appropriate if you have a broad topic area, are working on your own, or have time constraints.

Agarwal S, Charlesworth M, Elrakhawy M. How to write a narrative review . Anaesthesia . 2023;78(9):1162-1166. doi:10.1111/anae.16016

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

Ferrari R. Writing narrative style literature reviews . Medical Writing. 2015 Dec 1;24(4):230-5.

Greenhalgh T, Thorne S, Malterud K. Time to challenge the spurious hierarchy of systematic over narrative reviews ? European journal of clinical investigation . 2018;48:e12931.

Knowledge Synthesis

Literature reviews using systematic methods fall under the knowledge synthesis umbrella. Knowledge synthesis can be defined as “…the contextualization and integration of research findings of individual research studies within the larger body of knowledge on the topic. A synthesis must be reproducible and transparent in its methods, using quantitative and/or qualitative methods. It could take the form of a systematic review, follow the methods developed by the Cochrane Collaboration, result from a consensus conference or expert panel or synthesize qualitative or quantitative results. Realist syntheses, narrative syntheses, meta-analyses, meta-syntheses and practice guidelines are all forms of synthesis.” (Canadian Institutes of Health Research. (2016, July 28). Knowledge Translation. Retrieved April 26, 2018, from http://www.cihr-irsc.gc.ca/e/29418.htm l. )

Grimshaw J. A Guide to Knowledge Synthesis [Internet]. CIHR. Canadian Institutes of Health Research; 2010.

Canadian Institutes of Health Research. Synthesis Resources [Internet]. CIHR. Canadian Institutes of Health Research; 2013.

Booth A, Noyes J, Flemming K, Gerhardus A, Wahlster P, van der Wilt, Gert Jan, et al.  Structured methodology review identified seven (RETREAT) criteria for selecting qualitative evidence synthesis approaches . Journal of clinical epidemiology. 2018;99:41-52.

Kastner M, Tricco AC, Soobiah C, et al. What is the most appropriate knowledge synthesis method to conduct a review? Protocol for a scoping review . BMC Medical Research Methodology . 2012;12:114. doi:10.1186/1471-2288-12-114.

Kastner M, Antony J, Soobiah C, Straus SE, Tricco AC. Conceptual recommendations for selecting the most appropriate knowledge synthesis method to answer research questions related to complex evidence . Journal of Clinical Epidemiology . 2016;73:43-49.

Knowledge Synthesis Support at UHN

Common Types of Knowledge Syntheses

• Systematic Reviews
• Meta-Analysis
• Scoping Reviews
• Rapid or Restricted Reviews
• Clinical Practice Guidelines
• Realist Reviews
• Mixed Methods Reviews
• Qualitative Synthesis
• Narrative Synthesis

A systematic review attempts to identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a given research question. Researchers conducting systematic reviews use explicit methods aimed at minimizing bias, in order to produce more reliable findings that can be used to inform decision making. (See Section 1.2 in the Cochrane Handbook for Systematic Reviews of Interventions .)

A systematic review is not the same as a traditional (narrative) review or a literature review. Unlike other kinds of reviews, systematic reviews must be as thorough and unbiased as possible, and must also make explicit how the search was conducted. Systematic reviews may or may not include a meta-analysis.

On average, a systematic review project takes a year. If your timelines are shorter, you may wish to consider other types of synthesis projects or a traditional (narrative) review. See suggested timelines for a Cochrane Review for reference.

Systematic Review Overview (UHN)

Systematic Review Overview workshop recording (UHN)

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

Greyson D, Rafferty E, Slater L, et al. Systematic review searches must be systematic, comprehensive, and transparent: a critique of Perman et al. BMC public health . 2019;19:153.

Ioannidis J. P. (2016). The Mass Production of Redundant, Misleading, and Conflicted Systematic Reviews and Meta-analyses . The Milbank quarterly , 94 (3), 485-514.

A subset of systematic reviews. Meta-analysis is a technique that statistically combines the results of quantitative studies to provide a more precise effect of the results.

"..a form of knowledge synthesis that addresses an exploratory research question aimed at mapping key concepts, types of evidence, and gaps in research related to a defined area or field by systematically searching, selecting and synthesizing existing knowledge." (Colquhoun, HL et al., 2014)

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

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

Colquhoun, H. L., Levac, D., O'Brien, K. K., Straus, S., Tricco, A. C., Perrier, L., . . . Moher, D. (2014). Scoping reviews: Time for clarity in definition, methods, and reporting . Journal of Clinical Epidemiology , 67(12), 1291-1294. doi:10.1016/j.jclinepi.2014.03.013.

Peters MD, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews . Int.J.Evid Based.Healthc . 2015 Sep;13(3):141-146.

Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil, H. Chapter 11: Scoping Reviews (2020 version). In: Aromataris E, Munn Z (Editors). JBI Manual for Evidence Synthesis , JBI, 2020.

Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation . Ann Intern Med . [Epub ahead of print ] doi: 10.7326/M18-0850.

“…a type of knowledge synthesis in which systematic review processes are accelerated and methods are streamlined to complete the review more quickly than is the case for typical systematic reviews. Rapid reviews take an average of 5–12 weeks to complete, thus providing evidence within a shorter time frame required for some health policy and systems decisions.” (Tricco AC et al., 2017)

Ganann R, Ciliska D, Thomas H. Expediting systematic reviews: methods and implications of rapid reviews . Implementation Science : IS . 2010;5:56. doi:10.1186/1748-5908-5-56.

Langlois EV, Straus SE, Antony J, King VJ, Tricco AC. Using rapid reviews to strengthen health policy and systems and progress towards universal health coverage . BMJ Global Health . 2019;4:e001178.

Tricco AC, Langlois EV, Straus SE, editors. Rapid reviews to strengthen health policy and systems: a practical guide . Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.

Watt A, Cameron A, Sturm L, Lathlean T , Babidge W, Blamey S, et al. Rapid reviews versus full systematic reviews: An inventory of current methods and practice in health technology assessment . International Journal of Technology Assessment in Health Care . 2008;24(2):133-9.

“Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Source: Institute of Medicine. (1990). Clinical Practice Guidelines: Directions for a New Program, M.J. Field and K.N. Lohr (eds.) Washington, DC: National Academy Press. Page 38.

–Disclosure of any author conflicts of interest

AGREE Reporting Checklist

Alonso-Coello, P., Oxman, A. D., Moberg, J., Brignardello-Petersen, R., Akl, E. A., Davoli, M., ... & Guyatt, G. H. (2016). GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines . BMJ , 353 , i2089.

Pawson R, Greenhalgh T, Harvey G, Walshe K. Realist review - a new method of systematic review designed for complex policy interventions . Journal of Health Services Research & Policy . 2005;10:21-34.

Rycroft-Malone J, McCormack B, Hutchinson AM, et al. Realist synthesis: illustrating the method for implementation research . Implementation science : IS . 2012;7:33.

Wong G, Greenhalgh T, Westhorp G, Pawson R. Realist methods in medical education research: what are they and what can they contribute? Medical Education . 2012;46(1):89-96.

"Mixed-methods systematic reviews can be defined as combining the findings of qualitative and quantitative studies within a single systematic review to address the same overlapping or complementary review questions." (Harden A, 2010)

Harden A.   Mixed-Methods Systematic Reviews: Integrating quantitative and qualitative findings .   NCDDR:FOCUS. 2010.

Lizarondo L, Stern C, Apostolo J, et al. Five common pitfalls in mixed methods systematic reviews: lessons learned . J Clin Epidemiol . 2022;148:178-183. doi:10.1016/j.jclinepi.2022.03.014

Pluye P, Hong QN. Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews . Annual review of public health . 2014;35:29-45.

Pearson A, White H, Bath-Hextall F, Salmond S, Apostolo J, Kirkpatrick P. A mixed-methods approach to systematic reviews . International journal of evidence-based healthcare . 2015;13:121-131.

The Joanna Briggs Institute 2014 Reviewers Manual: Methodology for JBI Mixed Methods Systematic Reviews .

There are various methods for integrating the results from qualitative studies. "Systematic reviews of qualitative research have an important role in informing the delivery of evidence-based healthcare. Qualitative systematic reviews have investigated the culture of communities, exploring how consumers experience, perceive and manage their health and journey through the health system, and can evaluate components and activities of health services such as health promotion and community development." (Lockwood C et al., 2015)

Booth A, Noyes J, Flemming K, Gerhardus A, Wahlster P, van der Wilt, Gert Jan, et al. Structured methodology review identified seven (RETREAT) criteria for selecting qualitative evidence synthesis approaches . Journal of clinical epidemiology. 2018;99:41-52.

Ring N, Jepson R, Ritchie K. Methods of synthesizing qualitative research studies for health technology assessment . International Journal of Technology Assessment in Health Care . 2011;27:384-390.

Lockwood C, Munn Z, Porritt K. Qualitative research synthesis: methodological guidance for systematic reviewers utilizing meta-aggregation . International journal of evidence-based healthcare . 2015;13:179-187.

France EF, Cunningham M, Ring N, et al. Improving reporting of meta-ethnography: The eMERGe reporting guidance . Journal of advanced nursing . 2019.

Barnett-Page E, Thomas J. Methods for the synthesis of qualitative research: a critical review . BMC Med Res Methodol . 2009;9:59. Published 2009 Aug 11. doi:10.1186/1471-2288-9-59.

Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews . BMC Med Res Methodol . 2008;8:45. Published 2008 Jul 10. doi:10.1186/1471-2288-8-45

Lewin S, Booth A, Glenton C, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series . Implementation science : IS . 2018;13:2.

"Narrative synthesis refers to an approach to the systematic review and synthesis of findings from multiple studies that relies primarily on the use of words and text to summarise and explain the findings of the synthesis. Whilst narrative synthesis can involve the manipulation of statistical data, the defining characteristic is that it adopts a textual approach to the process of synthesis to ‘tell the story’ of the findings from the included studies." (Popay J, 2006)

Tricco AC, Soobiah C, Antony J, et al. A scoping review identifies multiple emerging knowledge synthesis methods, but few studies operationalize the method . Journal of Clinical Epidemiology . 2016;73:19-28.

Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews . Lancaster: ESRC Research Methods Programme; 2006.

Snilstveit B, Oliver S, Vojtkova M. Narrative approaches to systematic review and synthesis of evidence for international development policy and practice . Journal of development effectiveness . 2012 Sep 1;4(3):409-29. 

Lucas PJ, Baird J, Arai L, Law C, Roberts HM. Worked examples of alternative methods for the synthesis of qualitative and quantitative research in systematic reviews . BMC medical research methodology . 2007 Dec;7(1):4.

Ryan R. Cochrane Consumer sand Communication Review Group. Cochrane Consumers and Communication Review Group: data synthesis and analysis . June 2013.

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The Systematic Literature Review: Advantages and Applications in Nonprofit Scholarship

• Research Papers
• Published: 28 September 2021
• Volume 33 , pages 1256–1262, ( 2022 )

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• Beth Gazley   ORCID: orcid.org/0000-0002-7352-4476 1  

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Voluntary and nonprofit sector studies are relatively young and still seeking common intellectual ground. One vehicle for accomplishing this task is the systematic literature review (SLR). SLRs approach knowledge generation through a rules-driven comprehensive process for finding and analyzing prior knowledge. SLRs support the voluntary sector’s current emphasis on data transparency in publication. They also support the growth of voluntary sector empiricism by offering a greater claim to reliability and generalizability of findings. Finally, they support goals of inclusiveness and knowledge unification that are important to the voluntary sector academy, its funders, and its constituents. This explanatory article draws on examples from the nonprofit and voluntary sector to describe the rationale and methods of the SLR.

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Data Availabilty

There is no data, therefore the data-sharing statement is not applicable.

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Gazley, B. The Systematic Literature Review: Advantages and Applications in Nonprofit Scholarship. Voluntas 33 , 1256–1262 (2022). https://doi.org/10.1007/s11266-021-00410-1

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Advantages and disadvantages of literature review

This comprehensive article explores some of the advantages and disadvantages of literature review in research. Reviewing relevant literature is a key area in research, and indeed, it is a research activity in itself. It helps researchers investigate a particular topic in detail. However, it has some limitations as well.

What is literature review?

In order to understand the advantages and disadvantages of literature review, it is important to understand what a literature review is and how it differs from other methods of research. According to Jones and Gratton (2009) a literature review essentially consists of critically reading, evaluating, and organising existing literature on a topic to assess the state of knowledge in the area. It is sometimes called critical review.

A literature review is a select analysis of existing research which is relevant to a researcher’s selected topic, showing how it relates to their investigation. It explains and justifies how their investigation may help answer some of the questions or gaps in the chosen area of study (University of Reading, 2022).

A literature review is a term used in the field of research to describe a systematic and methodical investigation of the relevant literature on a particular topic. In other words, it is an analysis of existing research on a topic in order to identify any relevant studies and draw conclusions about the topic.

A literature review is not the same as a bibliography or a database search. Rather than simply listing references to sources of information, a literature review involves critically evaluating and summarizing existing research on a topic. As such, it is a much more detailed and complex process than simply searching databases and websites, and it requires a lot of effort and skills.

Advantages of literature review

Information synthesis

A literature review is a very thorough and methodical exercise. It can be used to synthesize information and draw conclusions about a particular topic. Through a careful evaluation and critical summarization, researchers can draw a clear and comprehensive picture of the chosen topic.

Familiarity with the current knowledge

According to the University of Illinois (2022), literature reviews allow researchers to gain familiarity with the existing knowledge in their selected field, as well as the boundaries and limitations of that field.

Creation of new body of knowledge

One of the key advantages of literature review is that it creates new body of knowledge. Through careful evaluation and critical summarisation, researchers can create a new body of knowledge and enrich the field of study.

Answers to a range of questions

Literature reviews help researchers analyse the existing body of knowledge to determine the answers to a range of questions concerning a particular subject.

Disadvantages of literature review

Time consuming

As a literature review involves collecting and evaluating research and summarizing the findings, it requires a significant amount of time. To conduct a comprehensive review, researchers need to read many different articles and analyse a lot of data. This means that their review will take a long time to complete.

Lack of quality sources  

Researchers are expected to use a wide variety of sources of information to present a comprehensive review. However, it may sometimes be challenging for them to identify the quality sources because of the availability of huge numbers in their chosen field. It may also happen because of the lack of past empirical work, particularly if the selected topic is an unpopular one.

Descriptive writing

One of the major disadvantages of literature review is that instead of critical appreciation, some researchers end up developing reviews that are mostly descriptive. Their reviews are often more like summaries of the work of other writers and lack in criticality. It is worth noting that they must go beyond describing the literature.

Key features of literature review

Clear organisation

A literature review is typically a very critical and thorough process. Universities usually recommend students a particular structure to develop their reviews. Like all other academic writings, a review starts with an introduction and ends with a conclusion. Between the beginning and the end, researchers present the main body of the review containing the critical discussion of sources.

No obvious bias

A key feature of a literature review is that it should be very unbiased and objective. However, it should be mentioned that researchers may sometimes be influenced by their own opinions of the world.

Proper citation

One of the key features of literature review is that it must be properly cited. Researchers should include all the sources that they have used for information. They must do citations and provide a reference list by the end in line with a recognized referencing system such as Harvard.

To conclude this article, it can be said that a literature review is a type of research that seeks to examine and summarise existing research on a particular topic. It is an essential part of a dissertation/thesis. However, it is not an easy thing to handle by an inexperienced person. It also requires a lot of time and patience.

Hope you like this ‘Advantages and disadvantages of literature review’. Please share this with others to support our research work.

Other useful articles:

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Advantages and disadvantages of primary and secondary research

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Last update: 08 May 2022

References:

Jones, I., & Gratton, C. (2009) Research Methods for Sports Shttps://www.howandwhat.net/new/evaluate-website-content/tudies, 2 nd edition, London: Routledge

University of Illinois (2022) Literature review, available at: https://www.uis.edu/learning-hub/writing-resources/handouts/learning-hub/literature-review (accessed 08 May 2022)

University of Reading (2022) Literature reviews, available at: https://libguides.reading.ac.uk/literaturereview/starting (accessed 07 May 2022)

Author: M Rahman

M Rahman writes extensively online and offline with an emphasis on business management, marketing, and tourism. He is a lecturer in Management and Marketing. He holds an MSc in Tourism & Hospitality from the University of Sunderland. Also, graduated from Leeds Metropolitan University with a BA in Business & Management Studies and completed a DTLLS (Diploma in Teaching in the Life-Long Learning Sector) from London South Bank University.

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What is the Process of Traditional or Narrative Literature Review?

The process of traditional or narrative literature review is an important part of research. It helps us gather and understand all the existing knowledge about a specific topic. This approach is helpful in understanding the advantages of a narrative literature review. A narrative or traditional review gives a broader view and helps to see big ideas and also a clear overview of specific research findings. Additionally, this allows for the incorporation of diverse perspectives and theoretical frameworks, offering a comprehensive synthesis of the existing literature. It often highlights historical and contextual nuances, providing a richer understanding of the subject matter which is helpful for creating a better structure of traditional literature review. 

Structure of narrative literature review

– Introduction: The introduction establishes the context and introduces the topic.

– Inclusion Criteria: Defines what types of sources are included.

– Storytelling Approach: Weaves together diverse sources to create a narrative.

– Conceptual Frameworks: Emphasizes broader ideas and theories.

– Critique and Evaluation: Assesses the quality and relevance of sources.

– Synthesis of Findings: Connects information to draw meaningful conclusions.

– Discussion of Themes: Analyzes common threads and patterns.

– Conclusion: Summarizes key points and proposes avenues for future research.

– Citations: Provides proper references for all sources used in the review.

– Clarity and Flow: Ensures the narrative is easy to follow for readers.

process of traditional or narrative literature review

Now, let us know the process of traditional or narrative literature review step-by-step which can help us to overcome all the problems of literature review.

Step 1: Define Your Topic  

Before starting, decide what you want to learn about. This is your topic. It’s like choosing a subject in school. For example, if you’re interested in dogs, your topic could be “Different Breeds of Dogs.”

Step 2: Search for Sources  

– Now, find books, articles, or websites that talk about your topic. Imagine you’re collecting information like you collect toys. 

– Look for reliable sources, like books from the library or articles from trusted websites.

Step 3: Select Relevant Material

Choose the sources that directly talk about your topic. If you’re learning about different dog breeds, you’d pick books or articles that focus on breeds, not something about cats.

Step 4: Organize Your Sources  

– Sort your sources like you would arrange your toys. Put similar ones together. 

– This makes it easier to understand and write about them later.

Step 5: Summarize Each Source  

Write short explanations of what each source says. Pretend you’re telling a friend about a cool toy you found. Keep it simple and clear.

Step 6: Analyze and Compare

Now, look at your sources closely. See if they talk about similar things or if they have different ideas. It’s like comparing different types of candies.

Step 7: Create an Outline  

– Plan how you’ll talk about each source. 

– Start with an introduction, then talk about each source one by one, and finish with a conclusion. It’s like making a plan for a story.

Step 8: Write Your Review 

– Using your outline, start writing. 

– Explain what each source says and how they relate to your topic. Use simple words and sentences, like when you’re telling a story to a friend.

Step 9: Revise and Edit 

Check your writing for any mistakes. Make sure it’s easy to understand. Fix any parts that might be confusing. It’s like polishing a favorite toy to make it look nice.

Step 10: Add Citations

This means giving credit to the people who wrote the books or articles you used. It’s a way of saying “thank you” for sharing their wisdom. Use a special format to do this, like a special way of saying “thank you.”

Final Thoughts

Understanding the process of traditional or narrative literature review is like having a special tool to explore and learn about different topics. We learned about the structure of traditional literature review, which has helped us to understand the advantages of traditional literature. Furthermore, delving into the process of a narrative literature review opens up the advantages of a narrative literature review. It allows researchers to uncover overarching themes, trends, and theoretical frameworks that might not be immediately apparent in individual studies. The structure of narrative literature review encourages a more holistic comprehension of the subject matter, fostering a deeper appreciation for the broader context within which research findings emerge. 

DissertationCanada.com offers a literature review writing service that requires an in-depth study of the references, which will form the basis for your current research work. When you approach them for literature review writing service, it can be as a part of the entire dissertation assistance package, or as an individual dissertation chapter service. As the first step, they start with assessing your topic and then go out in search of books and journals that will be the most suitable for the topic. The main goal of the literature review chapter is to create a strong research gap after analysing past studies that can be used in your research. They have a team that has been working on doctoral research for over a decade and are familiar with the type of references that are used for various subjects. They follow various citation styles like APA, Turabian, MLA, ACS, and Chicago for referencing purposes while writing the literature review. They can follow alphabetical order, chronological order or group the references according to the relation that they have with your work. They can also include a table for a listing of the references at the end of the chapter. When they prepare the literature review, they also provide a list of the references which have been included in the chapter to enable cross checking and preparation of the bibliography. In fact, they work in collaboration with their clients and take inputs for references.

FAQ Questions

How do you write a traditional or narrative literature review.

To write a traditional or narrative literature review, you gather and summarize existing research on a topic in a structured way.

What are the characteristics of a narrative literature review?

A narrative literature review tells a story by weaving together diverse sources, emphasizing broader concepts and ideas.

What is the difference between a systematic literature review and a narrative literature review?

A systematic literature review follows a structured process with specific criteria for including studies, while a narrative review focuses on storytelling and doesn’t have strict inclusion criteria.

Importance of narrative literature review?

The importance of a narrative literature review lies in its ability to provide a broader perspective, highlight conceptual frameworks, and offer a cohesive narrative for understanding a topic.

Evidence Review of the Adverse Effects of COVID-19 Vaccination and Intramuscular Vaccine Administration

Vaccines are a public health success story, as they have prevented or lessened the effects of many infectious diseases. To address concerns around potential vaccine injuries, the Health Resources and Services Administration (HRSA) administers the Vaccine Injury Compensation Program (VICP) and the Countermeasures Injury Compensation Program (CICP), which provide compensation to those who assert that they were injured by routine vaccines or medical countermeasures, respectively. The National Academies of Sciences, Engineering, and Medicine have contributed to the scientific basis for VICP compensation decisions for decades.

HRSA asked the National Academies to convene an expert committee to review the epidemiological, clinical, and biological evidence about the relationship between COVID-19 vaccines and specific adverse events, as well as intramuscular administration of vaccines and shoulder injuries. This report outlines the committee findings and conclusions.

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Original research article, application of mixed reality navigation technology in primary brainstem hemorrhage puncture and drainage surgery: a case series and literature review.

• 1 Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
• 2 Pre-hospital Emergency Department, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, China
• 3 Qinying Technology Co., Ltd., Chongqing, China

Objective: The mortality rate of primary brainstem hemorrhage (PBH) is high, and the optimal treatment of PBH is controversial. We used mixed reality navigation technology (MRNT) to perform brainstem hematoma puncture and drainage surgery in seven patients with PBH. We shared practical experience to verify the feasibility and safety of the technology.

Method: We introduced the surgical procedure of brainstem hematoma puncture and drainage surgery with MRNT. From January 2021 to October 2022, we applied the technology to seven patients. We collected their clinical and radiographic indicators, including demographic indicators, preoperative and postoperative hematoma volume, hematoma evacuation rate, operation time, blood loss, deviation of the drainage tube target, depth of implantable drainage tube, postoperative complications, preoperative and 1-month postoperative GCS, etc.

Result: Among seven patients, with an average age of 56.71 ± 12.63 years, all had underlying diseases of hypertension and exhibited disturbances of consciousness. The average evacuation rate of hematoma was 50.39% ± 7.71%. The average operation time was 82.14 ± 15.74 min, the average deviation of the drainage tube target was 4.58 ± 0.72 mm, and the average depth of the implantable drainage tube was 62.73 ± 0.94 mm. Among all seven patients, four patients underwent external ventricular drainage first. There were no intraoperative deaths, and there was no complication after surgery in seven patients. The 1-month postoperative GCS was improved compared to the preoperative GCS.

Conclusion: It was feasible and safe to perform brainstem hematoma puncture and drainage surgery by MRNT. The technology could evacuate about half of the hematoma and prevent hematoma injury. The advantages included high precision in dual-plane navigation technology, low cost, an immersive operation experience, etc. Furthermore, improving the matching registration method and performing high-quality prospective clinical research was necessary.

Introduction

Primary brainstem hemorrhage (PBH) is spontaneous brainstem bleeding associated with hypertension unrelated to cavernous hemangioma, arteriovenous malformation, and other diseases. Hypertension is the leading risk factor for PBH, and other elements include anticoagulant therapy, cerebral amyloid angiopathy, et al. PBH is the deadliest subtype of intracerebral hemorrhage (ICH), accounting for 6%–10% of all ICH with an annual incidence of approximately 2–4/100,000 people [ 1 – 3 ]. The clinical characteristics of PBH are acute onset, rapid deterioration, poor prognosis, and high mortality (30%–90%) [ 1 , 4 , 5 ].

The inclusion criteria of previous ICH research all excluded PBH, such as STICH and MISTIE trials. There is no clear evidence for the optimal treatment of PBH, and the view of surgical treatment has noticeable regional differences. European and North American countries generally believe that severe disability or survival in a vegetative state is a high mental and economic burden for PBH patients and their families. These countries do not favor surgical treatment. However, many PBH surgical treatments have been carried out in China, Japan, and South Korea. Surgical treatment methods, surgical effects, monitoring methods, and complications have been investigated, and much experience has been accumulated.

In 1998, Korean scholars performed the first craniotomy to evacuate the brainstem hematoma [ 6 ]. However, in 1989, the Japanese scholar Takahama performed stereotactic brainstem hematoma aspiration surgery [ 7 ]. In our opinion, microsurgery craniotomy requires high electrophysiological monitoring and surgical skills, and these limitations are not conductive to popularization. Minimally invasive surgery has the characteristics of a simple operation, minimally invasive, and short operation time, and it is believed to reduce the damage to critical brainstem structures and protect brainstem function as much as possible. More and more minimally invasive treatments have been adopted to improve the precision of PBH puncture, including stereotactic frameworks, robotic-assisted navigation systems, 3D printing techniques, and even laser combined with CT navigation techniques.

Mixed reality navigation technology (MRNT) is based on virtual and augmented reality development. The technology uses CT images to construct a 3D head model and design an individual hematoma puncture trajectory. The actual environmental position is captured by a camera during surgery and was fused with 3D head model synchronously. MRNT not only display the model image combined with actual environment but also navigate the puncture trajectory in real time, allowing the surgeon to precisely control puncture angle and depth to achieve a perfect procedure. This technology makes the head utterly transparent during the surgery and brings an immersive experience to the surgeon.

MRNT has broad application prospects. However, it is still in its infancy, and its application in neurosurgery has rarely been reported. Furthermore, there is no report on application of MRNT in the surgical treatment of PBH. In this study, we used MRNT to perform brainstem hematoma puncture and drainage surgery in seven patients with PBH to share practical experience to verify the feasibility and safety of the technology.

Materials and methods

General information.

With the approval of the Ethics Committee of the Chongqing Emergency Medical Center, we included seven patients diagnosed with PBH from January 2021 to October 2022. All underwent brainstem hematoma puncture and drainage surgery with MRNT under general anesthesia. Indications for surgery were patients who 1) were 18–80 years of age; 2) had hematoma volume greater than 5 mL and less than 15 mL; 3) had a diameter of the hematoma greater than 2 cm; 4) had hematoma deviating toward one side or the dorsal side; 5) had GCS less than 8; and 6) had surgery within 6–24 h after onset. Family members were informed and signed the consent form [ 8 ]. Exclusion criteria were patients who had 1) brainstem hemorrhage caused by cavernous hemangioma, arteriovenous malformation, and other diseases; 2) GCS >12; 3) bilateral pupil dilation; 4) unstable vital signs; 5) severe underlying disease; or 6) coagulation dysfunction.

Mixed reality navigation technology (MRNT)

All patients preparing for surgery were required to wear sticky analysis markers in the parieto-occipital region and undergo a CT scan before surgery. CT image scanning was performed with a 64-slice CT scanner (Lightspeed VCT 6, General Electric Company, United States of America). The image parameters included in the exposure were 3 mAS, the thickness was 5mm, and the image size was 512 × 512. The DICOM data were analyzed to construct the 3D model of the hematoma and head, and the volume of brainstem preoperative hematoma was calculated using software (Medical Modeling and Design System). In addition, the hematoma puncture trajectory was designed according to the constructed head model.

After general anesthesia, the sticky analysis markers were replaced with bone nail markers, keeping the same position [ 9 ]. Based on the principle of near-infrared optical navigation, the camera captured the actual space position in real-time, fused it with the markers of the 3D head model (HSCM3D DICOM), and transmitted the information to the wearable device (HoloLens). During surgery, the camera continuously tracked the position of the puncture needle to achieve navigation function. In short, the image processing software matched and fused information from camera systems and wearable device through multiple markers. When controlling the movement of surgical tools, the software also processed the dynamic tool position data and fused it with the virtual model through wireless transmission.

Surgical procedures

Hydrocephalus patients were first treated with external ventricular drainage (EVD), and the frontal Kocher point was selected as the cranial entry point. The procedures were cutting the skin, drilling the skull, cutting the dura mater, puncturing in the direction of the plane of binaural connection, fixing the drainage tube, and suturing it layer by layer.

The patient was placed in a prone position with the head frame fixed. The puncture point was 2 cm below the transverse sinus and 3 cm lateral to the midline of the hematoma side. After cutting the skin, the muscle was separated. The dura mater was cut through a drilled hole. Wearing HoloLens, the surgeon synchronously observed actual head structure and fused puncture trajectory from multiple angles and used dual-plane navigation technology [ 9 ] for hematoma puncture. After watching that the drainage tube was in place, the puncture needle was removed, and a 5 mL empty syringe was connected for suction. The drainage tube was fixed and sutured layer by layer. The head CT was reviewed immediately after the surgery, and the decision whether to inject urokinase according to the drainage tube’s position and the residual hematoma volume. Urokinase was injected from a drainage tube for 2-3 w units every 12 h, usually 4–6 times, and kept for 1.5 h before opening the tube. The retention time of the drainage tube was no more than 72 h after the surgery. The surgical procedure to apply MRNT is shown in Figure 1 .

Figure 1 . Surgical procedure for brainstem hematoma puncture and drainage surgery with MRNT (A) Patients were required to wear sticky analysis markers in the parieto-occipital region. (B) The camera captured the real space position of the calibration plate, puncture needle, and head. (C) Wearing HoloLens, the surgeon viewed the two planes of the image. (D) MRNT displays the model image and the actual environment synchronously, allowing the surgeon to perform precise surgery. (E) The real-time navigation of MRNT showed that the puncture needle was close to the hematoma target. (F) The surgeon was aspirating the hematoma.

Clinical and radiographic indicators

The indicators for analysis included: demographic indicators, preoperative and postoperative hematoma volume, hematoma evacuation rate, operation time, blood loss, deviation of the drainage tube target, depth of implantable drainage tube, postoperative complications, and preoperative and 1-month postoperative GCS, etc.

The deviation of the drainage tube target was defined as the distance between the tip of the drainage tube and the planned puncture hematoma target. The deviation calculation was done with the BLENDER 2.93.3 software, which used the 3D global coordinate system to visualize the distance.

The head CT examination was reviewed within 24 h after surgery, and the postoperative hematoma volume was measured by non-operators using previous software (Medical Modeling and Design System). Hematoma evacuation rate = (preoperative hematoma volume - postoperative hematoma volume)/preoperative hematoma volume.

Statistical analysis

All statistical analyses were performed with SPSS (version 21, IBM, Chicago, IL, United States). Quantitative variables are presented as means ± standard deviations. The normality of quantitative variables was assessed through the Kolmogorov-Smirnov test. If the distribution was found to be normal, paired t -test were performed. The categorical variables are presented as percentages and tested by χ2 or Fisher’s test. A p -value less than 0.05 was considered statistically significant.

From January 2021 to October 2022, seven patients were diagnosed with PBH and underwent brainstem hematoma puncture and drainage surgery with MRNT. A summary of the demographic and clinical characteristics of the patients was provided in Table 1 . Among the seven patients, five were men, with an average age of 56.71 ± 12.63 years (37–74 years). The seven cases had underlying hypertension, and four cases had diabetes. The average time from onset to admission was 4.2 ± 1.47 h. Seven patients had prominent disturbances of consciousness, four required ventilator assistance, and three had a high fever.

Table 1 . Demographic and clinical characteristics of seven patients.

According to the brainstem hematoma classification advocated by Chung [ 10 ], 2 cases belonged to small unilateral tegmental type, 4 cases belonged to basal-tegmental type, and other 1 case belonged to bilateral tegmental type. The average volume of preoperative brainstem hematoma was 8.47 ± 2.22 mL (range, 5.45–12.2 mL), the average volume of postoperative brainstem hematoma was 4.16 ± 1.17 mL (range, 3.14–5.95 mL), and the differences were significant. The average hematoma evacuation rate was 50.39% ± 7.71% (range, 41.65%–63.23%). Four of the seven patients underwent EVD first (57.1%), and one underwent EVD 2 days after hematoma puncture and drainage surgery. The average operation time was 82.14 ± 15.74 min, the average blood loss was 32.2 ± 8.14 mL, the average deviation of the drainage tube target was 4.58 ± 0.72 mm (range, 3.36–5.32 mm), and the average depth of the implantable drainage tube was 62.73 ± 0.94 mm (range, 61.42–64.23 mm). Three patients were injected with urokinase after surgery, and the average retention time of the drainage tube was 53.56 ± 7.83 h.

There were no intraoperative deaths in seven patients. Two patients had slight intraoperative fluctuations in vital signs. The most common postoperative comorbidity was pneumonia (7/7, 100%), followed by gastrointestinal bleeding (5/7, 71.43%). There were no rebleeding incidents, ischemic stroke, intracranial infection, or epilepsy within 2 weeks after surgery. The preoperative high fever symptoms were relieved after surgery. Only one patient died due to pneumonia 12 days after surgery, one patient gave up 20 days after surgery. Two patients were conscious and three patients were still in a coma 1 month after surgery.

The average preoperative GCS was 6.57 ± 1.51, and the average postoperative GCS was 10.00 ± 2.83 1 month after surgery. The improvement was statistically significant. The representative cases are shown in Figure 2 and Figure 3 .

Figure 2 . The representative case 2 (A) Preoperative CT showed PBH in the axial, sagittal, and coronal planes. (B) The 3D model constructed from CT images showed hematoma and designed the puncture trajectory from the axial, sagittal, and coronary positions. (C) Postoperative CT of the axial plane showed that the drainage tube location was precise. The yellow circle indicated the tip of the drainage tube. (D) Fusion of preoperative and postoperative 3D model showed that the preoperative hematoma volume was 5.45 mL, the postoperative hematoma volume was 3.18 mL, the hematoma evacuation rate was 41.65%, the deviation of the target drainage tube was 4.22 mm, and the depth of the implantable drainage tube was 63.42 mm.

Figure 3 . The representative case 5. (A) Preoperative CT showed PBH in the axial, sagittal, and coronal planes. (B) The 3D model constructed from CT images showed hematoma, lateral ventricular, and a designed puncture trajectory from axial, sagittal, and coronary positions. (C) Postoperative CT of the axial plane showed that the drainage tube location was precise. The yellow circle indicated the tip of the drainage tube. (D) Fusion of the preoperative and postoperative 3D model showed that the preoperative hematoma volume was 10.21 mL, the postoperative hematoma volume was 5.95 mL, the hematoma evacuation rate was 41.72%, the deviation of the drainage tube target was 3.36 mm. The depth of the implantable drainage tube was 61.84 mm.

The brainstem is small, deep in the skull, and includes the midbrain, pons, and medulla oblongata. The brainstem is the center of life, controlling respiration, heart rate, blood pressure, and body temperature. About 60%–80% of PBH occurs in the pons due to the rupture of the perforating vessels of the basilar artery [ 1 , 2 ]. Hypertension is one of the most common causes of severe cerebrovascular disease. By causing mechanical and chemical damage to essential structures in the brainstem, such as the nucleus clusters and the reticular system, the hematoma quickly induces clinical symptoms such as coma, central hyperthermia, tachycardia, abnormal pupils, and hypotension. The prognosis is extremely poor, which presents a challenge to existing treatment methods.

The conservative treatment strategy for PBH is mainly related to the hypertensive treatment strategy for ICH [ 11 ]. Since the primary damage of PBH is irreversible, surgical treatment is believed to relieve mechanical compression of the hematoma and prevent secondary injury, improving prognosis [ 1 , 12 , 13 ]. However, there have been some controversies about surgical treatment. Due to the high mortality and disability rate of PBH, it is necessary to strictly evaluate the indications for surgery. Indications for surgery proposed by Shresha included a hematoma volume greater than 5 mL, a relatively concentrated hematoma, GCS less than 8, progressive neurological dysfunction, and uneventful vital signs, particularly requiring ventilatory assistance [ 14 ]. Huang established a brainstem hemorrhage scoring system and suggested patients with a score of 2–3 might benefit from surgical treatment. A score of 4 was a contraindication to surgical treatment [ 15 ]. A review of 10 cohort studies showed that the patients in the surgical group were 45–65 years old, unconscious, with a GCS of 3–8, and the hematoma volume was approximately 8 mL. The surgical group had a better prognosis and lower mortality than the conservative treatment group. The research also suggested that older age and coma were not contraindications for brainstem hemorrhage surgery [ 16 ]. According to the Chinese guidelines for brainstem hemorrhage, we specified the following surgical indications: age 18–80 years old, hematoma volume greater than 5 mL and less than 15 mL, hematoma diameter greater than 2 cm, hematoma deviated to one side or the dorsal side, GCS less than 8, surgery performed within 6–24 h after onset, and family consent [ 8 ].

The surgical treatments for PBH included microscopic craniotomy to evacuate the hematoma, which removed the hematoma as much as possible, performed hemostasis, and removed the fourth ventricular hematoma to smooth the circulation of cerebrospinal fluid. However, this technology required various intraoperative monitoring methods and proficient surgical skills. The most widely chosen method was stereotactic hematoma puncture and drainage surgery. To achieve precise puncture of the brainstem hematoma, surgeons had used invasive stereotaxic frames [ 17 ], robot-assisted navigation systems [ 18 ], the 3D printing technology navigation method [ 19 ], and laser combined with CT navigation technology [ 13 ]. The above techniques had shortcomings, including invasive placement positioning framework, the risk of skull bleeding and infection, expensive costs of robot-assisted and neuronavigation systems, the lengthy procedure of 3D printing technology, etc.

We innovatively used MRNT to perform brainstem hematoma puncture and drainage surgery. Our team used this technology to successfully perform intracranial foreign body removal [ 20 ] and minimally invasive puncture surgery for deep ICH, with a deviation of the drainage tube target of 5.76 ± 0.80 mm [ 9 ]. Based on previous experience and technical improvement, we applied technology to perform brainstem hematoma puncture and drainage surgery. The average volume of preoperative brainstem hematoma was 8.47 ± 2.22 mL, postoperative brainstem hematoma was 4.16 ± 1.17 mL, and the average hematoma evacuation rate was 50.39% ± 7.71%, which prevented hematoma primary compression and secondary injury. The surgical procedure under general anesthesia took an average of 82.14 ± 15.74 min, the average target deviation was 4.58 ± 0.72 mm, and the average depth of the implantable drainage tube was 62.73 ± 0.94 mm. The depth of the drainage tube was longer than that in the application of deep ICH, which required higher precision. Moreover, we found MRNT was safe in seven patients.

A comparison of the precision of augmented reality technology, mixed reality technology, and traditional stereotactic methods have been discussed in previous literature. Van Doormaal et al. conducted a holographic navigation study using augmented reality technology. They found that the fiducial registration error was 7.2 mm in a plastic head model, and the fiducial registration error was 4.4 mm in three patients [ 21 ]. A meta-analysis was conducted to systematically review the accuracy of augmented reality neuronavigation and compare it with conventional infrared neuronavigation. In 35 studies, the average target registration error of 2.5 mm in augmented reality technology was no different from that of 2.6 mm in traditional infrared navigation [ 22 ]. Moreover, In the study of neuronavigation using mixed reality technology, the researchers received a target deviation range of 4–6 mm [ 23 – 25 ].

The augmented reality technology application scenarios mainly involve intracranial tumors and rarely involve ICH. Qi et al. used mixed reality navigation technology to perform ICH surgery. They also used markers for point registration and image fusion. The results showed that the occipital hematoma puncture deviation was 5.3 mm due to the prone and supine position, and the deviation in the basal ganglia was 4.0 mm [ 26 ]. Zhou et al. also presented a novel multi-model mixed reality navigation system for hypertensive ICH surgery. The results of the phantom experiments revealed a mean registration error of 1.03 mm. The registration error was 1.94 mm in clinical use, which showed that the system was sufficiently accurate and effective for clinical application [ 27 ]. A summary of the deviations in the application of MR or AR was provided in Table 2 .

Table 2 . Reported cases of deviations in the application of MR or AR in neurosurgery.

In addition to precision puncture and hematoma drainage, surgical treatment of PBH also required further discussion on the timing of surgery, external ventricular drainage, and fibrinolytic drugs. Shrestha et al. found that surgical treatment within 6 h after onset was associated with a good prognosis [ 14 ]. The ultra-early operation alleviated the hematoma mass effect and reduced secondary injury. In particular, for patients with a severe condition, early hematoma aspiration could immediately eliminate harmful effects and prevent worse clinical outcomes [ 17 ] However, many primary hospitals are not equipped with PBH surgical treatment abilities. Patients have to waste a lot of time in the transfer process, which is a big challenge in clinical treatment. PBH can also cause cerebrospinal fluid circulation disorder that induces patients to become unconscious. External ventricular drainage is beneficial in improving cerebrospinal fluid circulation, managing intracranial pressure, and facilitating patient recovery [ 17 ]. In our study, external ventricular drainage was performed in five cases of seven patients. Previous research investigating the effects of rtPA on ICH and ventricular hemorrhage by MISTIE and CLAEA demonstrated that fibrinolytic drug administration did not increase the risk of hemorrhage [ 30 – 33 ]. Currently, there is no evidence and consensus to verify the effects of the thrombolytic drug used in PBH. We also found that urokinase did not increase the risk of bleeding and improve drainage efficiency, as reported in previous literature [ 13 , 18 ].

Compared with the expensive neuronavigation system, mixed reality navigation technology was an independent research and development project, the equipment of the technology was simple, and the cost was low. The effect of the technology met the clinical application of intracerebral hemorrhage surgery, and was beneficial to popularization for primary hospital.

There were also some limitations in our technology. Firstly, in order to introduce our innovative mixed reality navigation technology earlier and faster, we reported few cases, so there are not enough data to verify the advancement of the technology. At present, it was difficult to perform a cohort study because of the small number of patients enrolled. We plan to carry out clinical study with other centers in the future. Secondly, navigation technology was mainly based on point-matching technology, which enabled the fusion of the image model with the actual space through markers. Implementing invasive markers in the skull might carry potential risks of bleeding or infection. Moreover, the procedure required CT examinations before surgery, which delayed surgery time, and increased costs. Some researchers proposed the face registration plan, but the target deviation of the face registration was higher than that of the point registration, and the clinical practicability was poor [ 34 ]. Clinical practice must explore a precise, simple, fast, and noninvasive matching and fusion innovative solution.

It was feasible and safe to perform brainstem hematoma puncture and drainage by MRNT. Early minimally invasive precise surgery could prevent hematoma primary and secondary injury, and improve the prognosis of patients with PBH. The advantages included high precision in dual-plane navigation technology, low cost, an immersive operation experience, etc. Furthermore, improving the matching registration method and performing high-quality prospective clinical research was necessary.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

Ethics statement

The studies involving humans were approved by Ethics Committee of the Chongqing Emergency Medical Center. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

XT: Writing–original draft, Data curation, Software. YaW: Writing–original draft. GT: Conceptualization, Project administration, Writing–original draft. YiW: Investigation, Resources, Software, Writing–original draft. WX: Resources, Formal Analysis, Writing–original draft, Writing–review and editing. YL: Methodology, Writing–original draft. YD: Writing–review and editing. PC: Writing–review and editing, Conceptualization, Writing–original draft.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This study was financially supported by the Fundamental Research Funds for the Central Universities (2022CDJYGRH-015) and Medical Research Project of Science and Technology Bureau and Health Commission, Chongqing, China (2023MSXM076).

Conflict of interest

Author YiW was employed by Qinying Technology Co., Ltd.

The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: primary brainstem hemorrhage, mixed reality navigation technology, brainstem hematoma puncture and drainage surgery, neuronavigation, deviation

Citation: Tang X, Wang Y, Tang G, Wang Y, Xiong W, Liu Y, Deng Y and Chen P (2024) Application of mixed reality navigation technology in primary brainstem hemorrhage puncture and drainage surgery: a case series and literature review. Front. Phys. 12:1390236. doi: 10.3389/fphy.2024.1390236

Received: 23 February 2024; Accepted: 26 March 2024; Published: 17 April 2024.

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Copyright © 2024 Tang, Wang, Tang, Wang, Xiong, Liu, Deng and Chen. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Yongbing Deng, [email protected] ; Peng Chen, [email protected]

† These authors share first authorship

This article is part of the Research Topic

Multi-Sensor Imaging and Fusion: Methods, Evaluations, and Applications – Volume II