synthesis in literature review

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• Write a Literature Review
• Sheridan Libraries
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• Evaluate This link opens in a new window

Get Organized

• Lit Review Prep Use this template to help you evaluate your sources, create article summaries for an annotated bibliography, and a synthesis matrix for your lit review outline.

Synthesize your Information

Synthesize: combine separate elements to form a whole.

Synthesis Matrix

A synthesis matrix helps you record the main points of each source and document how sources relate to each other.

After summarizing and evaluating your sources, arrange them in a matrix or use a citation manager to help you see how they relate to each other and apply to each of your themes or variables.  

By arranging your sources by theme or variable, you can see how your sources relate to each other, and can start thinking about how you weave them together to create a narrative.

• Step-by-Step Approach
• Example Matrix from NSCU
• Matrix Template
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• Next: Integrate >>
• Last Updated: Sep 26, 2023 10:25 AM
• URL: https://guides.library.jhu.edu/lit-review

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• Research Guides

How to Write a Literature Review

• 6. Synthesize
• Literature Reviews: A Recap
• Reading Journal Articles
• Does it Describe a Literature Review?
• 1. Identify the Question
• 2. Review Discipline Styles
• Searching Article Databases
• Finding Full-Text of an Article
• Citation Chaining
• When to Stop Searching
• 4. Manage Your References
• 5. Critically Analyze and Evaluate

Synthesis Visualization

Synthesis matrix example.

• 7. Write a Literature Review

• Synthesis Worksheet

About Synthesis

Approaches to synthesis.

You can sort the literature in various ways, for example:

How to Begin?

Read your sources carefully and find the main idea(s) of each source

Look for similarities in your sources – which sources are talking about the same main ideas? (for example, sources that discuss the historical background on your topic)

Use the worksheet (above) or synthesis matrix (below) to get organized

This work can be messy. Don't worry if you have to go through a few iterations of the worksheet or matrix as you work on your lit review!

Four Examples of Student Writing

In the four examples below, only ONE shows a good example of synthesis: the fourth column, or  Student D . For a web accessible version, click the link below the image.

Long description of "Four Examples of Student Writing" for web accessibility

• Download a copy of the "Four Examples of Student Writing" chart

Click on the example to view the pdf.

From Jennifer Lim

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• Next: 7. Write a Literature Review >>
• Last Updated: Jan 10, 2024 4:46 PM
• URL: https://researchguides.uoregon.edu/litreview

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Literature Syntheis 101

How To Synthesise The Existing Research (With Examples)

By: Derek Jansen (MBA) | Expert Reviewer: Eunice Rautenbach (DTech) | August 2023

One of the most common mistakes that students make when writing a literature review is that they err on the side of describing the existing literature rather than providing a critical synthesis of it. In this post, we’ll unpack what exactly synthesis means and show you how to craft a strong literature synthesis using practical examples.

This post is based on our popular online course, Literature Review Bootcamp . In the course, we walk you through the full process of developing a literature review, step by step. If it’s your first time writing a literature review, you definitely want to use this link to get 50% off the course (limited-time offer).

Overview: Literature Synthesis

• What exactly does “synthesis” mean?
• Aspect 1: Agreement
• Aspect 2: Disagreement
• Aspect 3: Key theories
• Aspect 4: Contexts
• Aspect 5: Methodologies
• Bringing it all together

What does “synthesis” actually mean?

As a starting point, let’s quickly define what exactly we mean when we use the term “synthesis” within the context of a literature review.

Simply put, literature synthesis means going beyond just describing what everyone has said and found. Instead, synthesis is about bringing together all the information from various sources to present a cohesive assessment of the current state of knowledge in relation to your study’s research aims and questions .

Put another way, a good synthesis tells the reader exactly where the current research is “at” in terms of the topic you’re interested in – specifically, what’s known , what’s not , and where there’s a need for more research .

So, how do you go about doing this?

Well, there’s no “one right way” when it comes to literature synthesis, but we’ve found that it’s particularly useful to ask yourself five key questions when you’re working on your literature review. Having done so,  you can then address them more articulately within your actual write up. So, let’s take a look at each of these questions.

1. Points Of Agreement

The first question that you need to ask yourself is: “Overall, what things seem to be agreed upon by the vast majority of the literature?”

For example, if your research aim is to identify which factors contribute toward job satisfaction, you’ll need to identify which factors are broadly agreed upon and “settled” within the literature. Naturally, there may at times be some lone contrarian that has a radical viewpoint , but, provided that the vast majority of researchers are in agreement, you can put these random outliers to the side. That is, of course, unless your research aims to explore a contrarian viewpoint and there’s a clear justification for doing so. 

Identifying what’s broadly agreed upon is an essential starting point for synthesising the literature, because you generally don’t want (or need) to reinvent the wheel or run down a road investigating something that is already well established . So, addressing this question first lays a foundation of “settled” knowledge.

Need a helping hand?

2. Points Of Disagreement

Related to the previous point, but on the other end of the spectrum, is the equally important question: “Where do the disagreements lie?” .

In other words, which things are not well agreed upon by current researchers? It’s important to clarify here that by disagreement, we don’t mean that researchers are (necessarily) fighting over it – just that there are relatively mixed findings within the empirical research , with no firm consensus amongst researchers.

This is a really important question to address as these “disagreements” will often set the stage for the research gap(s). In other words, they provide clues regarding potential opportunities for further research, which your study can then (hopefully) contribute toward filling. If you’re not familiar with the concept of a research gap, be sure to check out our explainer video covering exactly that .

3. Key Theories

The next question you need to ask yourself is: “Which key theories seem to be coming up repeatedly?” .

Within most research spaces, you’ll find that you keep running into a handful of key theories that are referred to over and over again. Apart from identifying these theories, you’ll also need to think about how they’re connected to each other. Specifically, you need to ask yourself:

• Are they all covering the same ground or do they have different focal points  or underlying assumptions ?
• Do some of them feed into each other and if so, is there an opportunity to integrate them into a more cohesive theory?
• Do some of them pull in different directions ? If so, why might this be?
• Do all of the theories define the key concepts and variables in the same way, or is there some disconnect? If so, what’s the impact of this ?

Simply put, you’ll need to pay careful attention to the key theories in your research area, as they will need to feature within your theoretical framework , which will form a critical component within your final literature review. This will set the foundation for your entire study, so it’s essential that you be critical in this area of your literature synthesis.

If this sounds a bit fluffy, don’t worry. We deep dive into the theoretical framework (as well as the conceptual framework) and look at practical examples in Literature Review Bootcamp . If you’d like to learn more, take advantage of our limited-time offer to get 60% off the standard price.

4. Contexts

The next question that you need to address in your literature synthesis is an important one, and that is: “Which contexts have (and have not) been covered by the existing research?” .

For example, sticking with our earlier hypothetical topic (factors that impact job satisfaction), you may find that most of the research has focused on white-collar , management-level staff within a primarily Western context, but little has been done on blue-collar workers in an Eastern context. Given the significant socio-cultural differences between these two groups, this is an important observation, as it could present a contextual research gap .

In practical terms, this means that you’ll need to carefully assess the context of each piece of literature that you’re engaging with, especially the empirical research (i.e., studies that have collected and analysed real-world data). Ideally, you should keep notes regarding the context of each study in some sort of catalogue or sheet, so that you can easily make sense of this before you start the writing phase. If you’d like, our free literature catalogue worksheet is a great tool for this task.

5. Methodological Approaches

Last but certainly not least, you need to ask yourself the question: “What types of research methodologies have (and haven’t) been used?”

For example, you might find that most studies have approached the topic using qualitative methods such as interviews and thematic analysis. Alternatively, you might find that most studies have used quantitative methods such as online surveys and statistical analysis.

But why does this matter?

Well, it can run in one of two potential directions . If you find that the vast majority of studies use a specific methodological approach, this could provide you with a firm foundation on which to base your own study’s methodology . In other words, you can use the methodologies of similar studies to inform (and justify) your own study’s research design .

On the other hand, you might argue that the lack of diverse methodological approaches presents a research gap , and therefore your study could contribute toward filling that gap by taking a different approach. For example, taking a qualitative approach to a research area that is typically approached quantitatively. Of course, if you’re going to go against the methodological grain, you’ll need to provide a strong justification for why your proposed approach makes sense. Nevertheless, it is something worth at least considering.

Regardless of which route you opt for, you need to pay careful attention to the methodologies used in the relevant studies and provide at least some discussion about this in your write-up. Again, it’s useful to keep track of this on some sort of spreadsheet or catalogue as you digest each article, so consider grabbing a copy of our free literature catalogue if you don’t have anything in place.

Bringing It All Together

Alright, so we’ve looked at five important questions that you need to ask (and answer) to help you develop a strong synthesis within your literature review.  To recap, these are:

• Which things are broadly agreed upon within the current research?
• Which things are the subject of disagreement (or at least, present mixed findings)?
• Which theories seem to be central to your research topic and how do they relate or compare to each other?
• Which contexts have (and haven’t) been covered?
• Which methodological approaches are most common?

Importantly, you’re not just asking yourself these questions for the sake of asking them – they’re not just a reflection exercise. You need to weave your answers to them into your actual literature review when you write it up. How exactly you do this will vary from project to project depending on the structure you opt for, but you’ll still need to address them within your literature review, whichever route you go.

The best approach is to spend some time actually writing out your answers to these questions, as opposed to just thinking about them in your head. Putting your thoughts onto paper really helps you flesh out your thinking . As you do this, don’t just write down the answers – instead, think about what they mean in terms of the research gap you’ll present , as well as the methodological approach you’ll take . Your literature synthesis needs to lay the groundwork for these two things, so it’s essential that you link all of it together in your mind, and of course, on paper.

Psst… there’s more!

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

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How to Synthesize Written Information from Multiple Sources

Shona McCombes

Content Manager

B.A., English Literature, University of Glasgow

Shona McCombes is the content manager at Scribbr, Netherlands.

Learn about our Editorial Process

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

On This Page:

When you write a literature review or essay, you have to go beyond just summarizing the articles you’ve read – you need to synthesize the literature to show how it all fits together (and how your own research fits in).

Synthesizing simply means combining. Instead of summarizing the main points of each source in turn, you put together the ideas and findings of multiple sources in order to make an overall point.

At the most basic level, this involves looking for similarities and differences between your sources. Your synthesis should show the reader where the sources overlap and where they diverge.

Unsynthesized Example

Franz (2008) studied undergraduate online students. He looked at 17 females and 18 males and found that none of them liked APA. According to Franz, the evidence suggested that all students are reluctant to learn citations style. Perez (2010) also studies undergraduate students. She looked at 42 females and 50 males and found that males were significantly more inclined to use citation software ( p < .05). Findings suggest that females might graduate sooner. Goldstein (2012) looked at British undergraduates. Among a sample of 50, all females, all confident in their abilities to cite and were eager to write their dissertations.

Synthesized Example

Studies of undergraduate students reveal conflicting conclusions regarding relationships between advanced scholarly study and citation efficacy. Although Franz (2008) found that no participants enjoyed learning citation style, Goldstein (2012) determined in a larger study that all participants watched felt comfortable citing sources, suggesting that variables among participant and control group populations must be examined more closely. Although Perez (2010) expanded on Franz’s original study with a larger, more diverse sample…

Step 1: Organize your sources

After collecting the relevant literature, you’ve got a lot of information to work through, and no clear idea of how it all fits together.

Before you can start writing, you need to organize your notes in a way that allows you to see the relationships between sources.

One way to begin synthesizing the literature is to put your notes into a table. Depending on your topic and the type of literature you’re dealing with, there are a couple of different ways you can organize this.

Summary table

A summary table collates the key points of each source under consistent headings. This is a good approach if your sources tend to have a similar structure – for instance, if they’re all empirical papers.

Each row in the table lists one source, and each column identifies a specific part of the source. You can decide which headings to include based on what’s most relevant to the literature you’re dealing with.

For example, you might include columns for things like aims, methods, variables, population, sample size, and conclusion.

For each study, you briefly summarize each of these aspects. You can also include columns for your own evaluation and analysis.

The summary table gives you a quick overview of the key points of each source. This allows you to group sources by relevant similarities, as well as noticing important differences or contradictions in their findings.

Synthesis matrix

A synthesis matrix is useful when your sources are more varied in their purpose and structure – for example, when you’re dealing with books and essays making various different arguments about a topic.

Each column in the table lists one source. Each row is labeled with a specific concept, topic or theme that recurs across all or most of the sources.

Then, for each source, you summarize the main points or arguments related to the theme.

The purposes of the table is to identify the common points that connect the sources, as well as identifying points where they diverge or disagree.

Step 2: Outline your structure

Now you should have a clear overview of the main connections and differences between the sources you’ve read. Next, you need to decide how you’ll group them together and the order in which you’ll discuss them.

For shorter papers, your outline can just identify the focus of each paragraph; for longer papers, you might want to divide it into sections with headings.

There are a few different approaches you can take to help you structure your synthesis.

If your sources cover a broad time period, and you found patterns in how researchers approached the topic over time, you can organize your discussion chronologically .

That doesn’t mean you just summarize each paper in chronological order; instead, you should group articles into time periods and identify what they have in common, as well as signalling important turning points or developments in the literature.

If the literature covers various different topics, you can organize it thematically .

That means that each paragraph or section focuses on a specific theme and explains how that theme is approached in the literature.

Source Used with Permission: The Chicago School

If you’re drawing on literature from various different fields or they use a wide variety of research methods, you can organize your sources methodologically .

That means grouping together studies based on the type of research they did and discussing the findings that emerged from each method.

If your topic involves a debate between different schools of thought, you can organize it theoretically .

That means comparing the different theories that have been developed and grouping together papers based on the position or perspective they take on the topic, as well as evaluating which arguments are most convincing.

Step 3: Write paragraphs with topic sentences

What sets a synthesis apart from a summary is that it combines various sources. The easiest way to think about this is that each paragraph should discuss a few different sources, and you should be able to condense the overall point of the paragraph into one sentence.

This is called a topic sentence , and it usually appears at the start of the paragraph. The topic sentence signals what the whole paragraph is about; every sentence in the paragraph should be clearly related to it.

A topic sentence can be a simple summary of the paragraph’s content:

“Early research on [x] focused heavily on [y].”

For an effective synthesis, you can use topic sentences to link back to the previous paragraph, highlighting a point of debate or critique:

“Several scholars have pointed out the flaws in this approach.” “While recent research has attempted to address the problem, many of these studies have methodological flaws that limit their validity.”

By using topic sentences, you can ensure that your paragraphs are coherent and clearly show the connections between the articles you are discussing.

As you write your paragraphs, avoid quoting directly from sources: use your own words to explain the commonalities and differences that you found in the literature.

Don’t try to cover every single point from every single source – the key to synthesizing is to extract the most important and relevant information and combine it to give your reader an overall picture of the state of knowledge on your topic.

Step 4: Revise, edit and proofread

Like any other piece of academic writing, synthesizing literature doesn’t happen all in one go – it involves redrafting, revising, editing and proofreading your work.

Checklist for Synthesis

•   Do I introduce the paragraph with a clear, focused topic sentence?
•   Do I discuss more than one source in the paragraph?
•   Do I mention only the most relevant findings, rather than describing every part of the studies?
•   Do I discuss the similarities or differences between the sources, rather than summarizing each source in turn?
•   Do I put the findings or arguments of the sources in my own words?
•   Is the paragraph organized around a single idea?
•   Is the paragraph directly relevant to my research question or topic?
•   Is there a logical transition from this paragraph to the next one?

Further Information

How to Synthesise: a Step-by-Step Approach

Help…I”ve Been Asked to Synthesize!

Learn how to Synthesise (combine information from sources)

How to write a Psychology Essay

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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

Library Guides

Literature reviews: synthesis.

• Criticality

Synthesise Information

So, how can you create paragraphs within your literature review that demonstrates your knowledge of the scholarship that has been done in your field of study?  

You will need to present a synthesis of the texts you read.  

Doug Specht, Senior Lecturer at the Westminster School of Media and Communication, explains synthesis for us in the following video:  

Synthesising Texts  

What is synthesis? 

Synthesis is an important element of academic writing, demonstrating comprehension, analysis, evaluation and original creation.  

With synthesis you extract content from different sources to create an original text. While paraphrase and summary maintain the structure of the given source(s), with synthesis you create a new structure.  

The sources will provide different perspectives and evidence on a topic. They will be put together when agreeing, contrasted when disagreeing. The sources must be referenced.  

Perfect your synthesis by showing the flow of your reasoning, expressing critical evaluation of the sources and drawing conclusions.  

When you synthesise think of "using strategic thinking to resolve a problem requiring the integration of diverse pieces of information around a structuring theme" (Mateos and Sole 2009, p448). 

Synthesis is a complex activity, which requires a high degree of comprehension and active engagement with the subject. As you progress in higher education, so increase the expectations on your abilities to synthesise. 

How to synthesise in a literature review: 

Identify themes/issues you'd like to discuss in the literature review. Think of an outline.  

Read the literature and identify these themes/issues.  

Critically analyse the texts asking: how does the text I'm reading relate to the other texts I've read on the same topic? Is it in agreement? Does it differ in its perspective? Is it stronger or weaker? How does it differ (could be scope, methods, year of publication etc.). Draw your conclusions on the state of the literature on the topic.  

Start writing your literature review, structuring it according to the outline you planned.  

Put together sources stating the same point; contrast sources presenting counter-arguments or different points.  

Present your critical analysis.  

Always provide the references. 

The best synthesis requires a "recursive process" whereby you read the source texts, identify relevant parts, take notes, produce drafts, re-read the source texts, revise your text, re-write... (Mateos and Sole, 2009). 

What is good synthesis?  

The quality of your synthesis can be assessed considering the following (Mateos and Sole, 2009, p439):  

Integration and connection of the information from the source texts around a structuring theme. 

Selection of ideas necessary for producing the synthesis. 

Appropriateness of the interpretation.  

Elaboration of the content.  

Example of Synthesis

Original texts (fictitious): 

Synthesis: 

Animal experimentation is a subject of heated debate. Some argue that painful experiments should be banned. Indeed it has been demonstrated that such experiments make animals suffer physically and psychologically (Chowdhury 2012; Panatta and Hudson 2016). On the other hand, it has been argued that animal experimentation can save human lives and reduce harm on humans (Smith 2008). This argument is only valid for toxicological testing, not for tests that, for example, merely improve the efficacy of a cosmetic (Turner 2015). It can be suggested that animal experimentation should be regulated to only allow toxicological risk assessment, and the suffering to the animals should be minimised.   

Bibliography

Mateos, M. and Sole, I. (2009). Synthesising Information from various texts: A Study of Procedures and Products at Different Educational Levels. European Journal of Psychology of Education,  24 (4), 435-451. Available from https://doi.org/10.1007/BF03178760 [Accessed 29 June 2021].

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• Last Updated: Nov 18, 2023 10:56 PM
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Methodology

• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

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

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

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

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

Prevent plagiarism. Run a free check.

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

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

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

Download Word doc Download Google doc

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

You can also use boolean operators to help narrow down your search.

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

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

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

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

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

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

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

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

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

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

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

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

As you write, you can follow these tips:

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

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

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

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

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

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

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

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

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

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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Literature Review How To

• Things To Consider
• Synthesizing Sources
• Video Tutorials
• Books On Literature Reviews

What is Synthesis

What is Synthesis? Synthesis writing is a form of analysis related to comparison and contrast, classification and division. On a basic level, synthesis requires the writer to pull together two or more summaries, looking for themes in each text. In synthesis, you search for the links between various materials in order to make your point. Most advanced academic writing, including literature reviews, relies heavily on synthesis. (Temple University Writing Center)  

How To Synthesize Sources in a Literature Review

Literature reviews synthesize large amounts of information and present it in a coherent, organized fashion. In a literature review you will be combining material from several texts to create a new text – your literature review.

You will use common points among the sources you have gathered to help you synthesize the material. This will help ensure that your literature review is organized by subtopic, not by source. This means various authors' names can appear and reappear throughout the literature review, and each paragraph will mention several different authors. 

When you shift from writing summaries of the content of a source to synthesizing content from sources, there is a number things you must keep in mind: 

• Look for specific connections and or links between your sources and how those relate to your thesis or question.
• When writing and organizing your literature review be aware that your readers need to understand how and why the information from the different sources overlap.
• Organize your literature review by the themes you find within your sources or themes you have identified. 
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Literature Review - A Self-Guided Tutorial

• Literature Reviews: A Recap
• Reading Journal Articles
• Does it describe a Literature Review?
• 1. Identify the question
• 2. Review discipline styles
• Searching article databases - video
• Finding the article full-text
• Citation chaining
• When to stop searching
• 4. Manage your references
• 5. Critically analyze and evaluate
• 6. Synthesize
• 7. Write literature review

Who's My Librarian?

Locate your University Library's subject librarian  for personalized assistance.

Students doing research in specific areas may also request assistance at other IUPUI libraries:

• IU School of Dentistry Library
• Ruth Lilly Law Library
• Ruth Lilly Medical Library  

You can sort the literature in various ways, for example:

Synthesis Matrix Example

From Jennifer Lim

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• Next: 7. Write literature review >>
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Chapter 7: Synthesizing Sources

Learning objectives.

At the conclusion of this chapter, you will be able to:

• synthesize key sources connecting them with the research question and topic area.

7.1 Overview of synthesizing

7.1.1 putting the pieces together.

Combining separate elements into a whole is the dictionary definition of synthesis.  It is a way to make connections among and between numerous and varied source materials.  A literature review is not an annotated bibliography, organized by title, author, or date of publication.  Rather, it is grouped by topic to create a whole view of the literature relevant to your research question.

Your synthesis must demonstrate a critical analysis of the papers you collected as well as your ability to integrate the results of your analysis into your own literature review.  Each paper collected should be critically evaluated and weighed for “adequacy, appropriateness, and thoroughness” ( Garrard, 2017 ) before inclusion in your own review.  Papers that do not meet this criteria likely should not be included in your literature review.

Begin the synthesis process by creating a grid, table, or an outline where you will summarize, using common themes you have identified and the sources you have found. The summary grid or outline will help you compare and contrast the themes so you can see the relationships among them as well as areas where you may need to do more searching. Whichever method you choose, this type of organization will help you to both understand the information you find and structure the writing of your review.  Remember, although “the means of summarizing can vary, the key at this point is to make sure you understand what you’ve found and how it relates to your topic and research question” ( Bennard et al., 2014 ).

As you read through the material you gather, look for common themes as they may provide the structure for your literature review.  And, remember, research is an iterative process: it is not unusual to go back and search information sources for more material.

At one extreme, if you are claiming, ‘There are no prior publications on this topic,’ it is more likely that you have not found them yet and may need to broaden your search.  At another extreme, writing a complete literature review can be difficult with a well-trod topic.  Do not cite it all; instead cite what is most relevant.  If that still leaves too much to include, be sure to reference influential sources…as well as high-quality work that clearly connects to the points you make. ( Klingner, Scanlon, & Pressley, 2005 ).

7.2 Creating a summary table

Literature reviews can be organized sequentially or by topic, theme, method, results, theory, or argument.  It’s important to develop categories that are meaningful and relevant to your research question.  Take detailed notes on each article and use a consistent format for capturing all the information each article provides.  These notes and the summary table can be done manually, using note cards.  However, given the amount of information you will be recording, an electronic file created in a word processing or spreadsheet is more manageable. Examples of fields you may want to capture in your notes include:

• Authors’ names
• Article title
• Publication year
• Main purpose of the article
• Methodology or research design
• Participants
• Measurement
• Conclusions

  Other fields that will be useful when you begin to synthesize the sum total of your research:

• Specific details of the article or research that are especially relevant to your study
• Key terms and definitions
• Strengths or weaknesses in research design
• Relationships to other studies
• Possible gaps in the research or literature (for example, many research articles conclude with the statement “more research is needed in this area”)
• Finally, note how closely each article relates to your topic.  You may want to rank these as high, medium, or low relevance.  For papers that you decide not to include, you may want to note your reasoning for exclusion, such as ‘small sample size’, ‘local case study,’ or ‘lacks evidence to support assertion.’

This short video demonstrates how a nursing researcher might create a summary table.

7.2.1 Creating a Summary Table

  Summary tables can be organized by author or by theme, for example:

For a summary table template, see http://blogs.monm.edu/writingatmc/files/2013/04/Synthesis-Matrix-Template.pdf

7.3 Creating a summary outline

An alternate way to organize your articles for synthesis it to create an outline. After you have collected the articles you intend to use (and have put aside the ones you won’t be using), it’s time to identify the conclusions that can be drawn from the articles as a group.

  Based on your review of the collected articles, group them by categories.  You may wish to further organize them by topic and then chronologically or alphabetically by author.  For each topic or subtopic you identified during your critical analysis of the paper, determine what those papers have in common.  Likewise, determine which ones in the group differ.  If there are contradictory findings, you may be able to identify methodological or theoretical differences that could account for the contradiction (for example, differences in population demographics).  Determine what general conclusions you can report about the topic or subtopic as the entire group of studies relate to it.  For example, you may have several studies that agree on outcome, such as ‘hands on learning is best for science in elementary school’ or that ‘continuing education is the best method for updating nursing certification.’ In that case, you may want to organize by methodology used in the studies rather than by outcome.

Organize your outline in a logical order and prepare to write the first draft of your literature review.  That order might be from broad to more specific, or it may be sequential or chronological, going from foundational literature to more current.  Remember, “an effective literature review need not denote the entire historical record, but rather establish the raison d’etre for the current study and in doing so cite that literature distinctly pertinent for theoretical, methodological, or empirical reasons.” ( Milardo, 2015, p. 22 ).

As you organize the summarized documents into a logical structure, you are also appraising and synthesizing complex information from multiple sources.  Your literature review is the result of your research that synthesizes new and old information and creates new knowledge.

7.4 Additional resources:

Literature Reviews: Using a Matrix to Organize Research / Saint Mary’s University of Minnesota

Literature Review: Synthesizing Multiple Sources / Indiana University

Writing a Literature Review and Using a Synthesis Matrix / Florida International University

 Sample Literature Reviews Grid / Complied by Lindsay Roberts

Select three or four articles on a single topic of interest to you. Then enter them into an outline or table in the categories you feel are important to a research question. Try both the grid and the outline if you can to see which suits you better. The attached grid contains the fields suggested in the video .

Literature Review Table  

Test yourself.

• Select two articles from your own summary table or outline and write a paragraph explaining how and why the sources relate to each other and your review of the literature.
• In your literature review, under what topic or subtopic will you place the paragraph you just wrote?

Image attribution

Literature Reviews for Education and Nursing Graduate Students Copyright © by Linda Frederiksen is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Writing in the Health and Social Sciences: Literature Reviews and Synthesis Tools

• Journal Publishing
• Style and Writing Guides
• Readings about Writing
• Citing in APA Style This link opens in a new window
• Resources for Dissertation Authors
• Citation Management and Formatting Tools
• What are Literature Reviews?
• Conducting & Reporting Systematic Reviews
• Finding Systematic Reviews
• Tutorials & Tools for Literature Reviews

Systematic Literature Reviews: Steps & Resources

These steps for conducting a systematic literature review are listed below . 

Also see subpages for more information about:

• The different types of literature reviews, including systematic reviews and other evidence synthesis methods
• Tools & Tutorials

Literature Review & Systematic Review Steps

• Develop a Focused Question
• Scope the Literature  (Initial Search)
• Refine & Expand the Search
• Limit the Results
• Download Citations
• Abstract & Analyze
• Create Flow Diagram
• Synthesize & Report Results

1. Develop a Focused   Question 

Consider the PICO Format: Population/Problem, Intervention, Comparison, Outcome

Focus on defining the Population or Problem and Intervention (don't narrow by Comparison or Outcome just yet!)

"What are the effects of the Pilates method for patients with low back pain?"

Tools & Additional Resources:

• PICO Question Help
• Stillwell, Susan B., DNP, RN, CNE; Fineout-Overholt, Ellen, PhD, RN, FNAP, FAAN; Melnyk, Bernadette Mazurek, PhD, RN, CPNP/PMHNP, FNAP, FAAN; Williamson, Kathleen M., PhD, RN Evidence-Based Practice, Step by Step: Asking the Clinical Question, AJN The American Journal of Nursing : March 2010 - Volume 110 - Issue 3 - p 58-61 doi: 10.1097/01.NAJ.0000368959.11129.79

2. Scope the Literature

A "scoping search" investigates the breadth and/or depth of the initial question or may identify a gap in the literature. 

Eligible studies may be located by searching in:

• Background sources (books, point-of-care tools)
• Article databases
• Trial registries
• Grey literature
• Cited references
• Reference lists

When searching, if possible, translate terms to controlled vocabulary of the database. Use text word searching when necessary.

Use Boolean operators to connect search terms:

• Combine separate concepts with AND  (resulting in a narrower search)
• Connecting synonyms with OR  (resulting in an expanded search)

Search:  pilates AND ("low back pain"  OR  backache )

Video Tutorials - Translating PICO Questions into Search Queries

• Translate Your PICO Into a Search in PubMed (YouTube, Carrie Price, 5:11) 
• Translate Your PICO Into a Search in CINAHL (YouTube, Carrie Price, 4:56)

3. Refine & Expand Your Search

Expand your search strategy with synonymous search terms harvested from:

• database thesauri
• reference lists
• relevant studies

Example: 

(pilates OR exercise movement techniques) AND ("low back pain" OR backache* OR sciatica OR lumbago OR spondylosis)

As you develop a final, reproducible strategy for each database, save your strategies in a:

• a personal database account (e.g., MyNCBI for PubMed)
• Log in with your NYU credentials
• Open and "Make a Copy" to create your own tracker for your literature search strategies

4. Limit Your Results

Use database filters to limit your results based on your defined inclusion/exclusion criteria.  In addition to relying on the databases' categorical filters, you may also need to manually screen results.  

• Limit to Article type, e.g.,:  "randomized controlled trial" OR multicenter study
• Limit by publication years, age groups, language, etc.

NOTE: Many databases allow you to filter to "Full Text Only".  This filter is  not recommended . It excludes articles if their full text is not available in that particular database (CINAHL, PubMed, etc), but if the article is relevant, it is important that you are able to read its title and abstract, regardless of 'full text' status. The full text is likely to be accessible through another source (a different database, or Interlibrary Loan).  

• Filters in PubMed
• CINAHL Advanced Searching Tutorial

5. Download Citations

Selected citations and/or entire sets of search results can be downloaded from the database into a citation management tool. If you are conducting a systematic review that will require reporting according to PRISMA standards, a citation manager can help you keep track of the number of articles that came from each database, as well as the number of duplicate records.

In Zotero, you can create a Collection for the combined results set, and sub-collections for the results from each database you search.  You can then use Zotero's 'Duplicate Items" function to find and merge duplicate records.

• Citation Managers - General Guide

6. Abstract and Analyze

• Migrate citations to data collection/extraction tool
• Screen Title/Abstracts for inclusion/exclusion
• Screen and appraise full text for relevance, methods, 
• Resolve disagreements by consensus

Covidence is a web-based tool that enables you to work with a team to screen titles/abstracts and full text for inclusion in your review, as well as extract data from the included studies.

• Covidence Support
• Critical Appraisal Tools
• Data Extraction Tools

7. Create Flow Diagram

The PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) flow diagram is a visual representation of the flow of records through different phases of a systematic review.  It depicts the number of records identified, included and excluded.  It is best used in conjunction with the PRISMA checklist .

Example from: Stotz, S. A., McNealy, K., Begay, R. L., DeSanto, K., Manson, S. M., & Moore, K. R. (2021). Multi-level diabetes prevention and treatment interventions for Native people in the USA and Canada: A scoping review. Current Diabetes Reports, 2 (11), 46. https://doi.org/10.1007/s11892-021-01414-3

• PRISMA Flow Diagram Generator (ShinyApp.io, Haddaway et al. )
• PRISMA Diagram Templates  (Word and PDF)
• Make a copy of the file to fill out the template
• Image can be downloaded as PDF, PNG, JPG, or SVG
• Covidence generates a PRISMA diagram that is automatically updated as records move through the review phases

8. Synthesize & Report Results

There are a number of reporting guideline available to guide the synthesis and reporting of results in systematic literature reviews.

It is common to organize findings in a matrix, also known as a Table of Evidence (ToE).

• Reporting Guidelines for Systematic Reviews
• Download a sample template of a health sciences review matrix  (GoogleSheets)

Steps modified from: 

Cook, D. A., & West, C. P. (2012). Conducting systematic reviews in medical education: a stepwise approach.   Medical Education , 46 (10), 943–952.

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• Last Updated: Mar 19, 2024 11:31 AM
• URL: https://guides.nyu.edu/healthwriting

Synthesis and Literature Reviews

Why do we seek to understand the ways that authors or sources “converse” with one another?

So that we can synthesize various perspectives on a topic to more deeply understand it .

In academic writing, this understanding of the “conversation” may become the content of an explanatory synthesis paper – a paper in which you, the writer, point out various various themes or key points from a conversation on a particular topic.

Or, another assignment that you may complete in college is a literature review , which applies your synthesis skills. Literature reviews are often found in the beginning of scholarly journal articles. Literature reviews synthesize previous research that has been done on a particular topic, summarizing important works in the history of research on that topic.

• Literature reviews can be arranged by topic or theme , much like a traditional explanatory synthesis paper.
• Literature reviews can also be arranged chronologically , according to various time periods of research on a topic (i.e., what was published ten years ago, five years ago, and within the last year, for example).
• Finally, literature reviews can be arranged by discipline or field (i.e., what is the current research being done by biologists on this topic? What is the current research being done by psychologists on this topic? What is the current research being done by [insert academic discipline] on this topic?).

Just like in an explanatory synthesis paper, a Literature Review offers  only  a report on what others have already written about. The Literature Review does not reflect the author’s own argument or contributions to the field of research. Instead, it indicates that the author has read others’ important contributions and understands what has come before him or her.

The Literature Review provides context for the author’s own new research. It is the basis and background out of which the author’s research grows. Context = credibility in academic writing. When authors have broad Literature Review, they demonstrate their credibility as researchers.

English 102: Reading, Research, and Writing by Emilie Zickel is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Systematic reviews & evidence synthesis methods.

• Schedule a Consultation / Meet our Team
• What is Evidence Synthesis?
• Types of Evidence Synthesis
• Evidence Synthesis Across Disciplines
• Finding and Appraising Existing Systematic Reviews
• 0. Develop a Protocol
• 1. Draft your Research Question
• 2. Select Databases
• 3. Select Grey Literature Sources
• 4. Write a Search Strategy
• 5. Register a Protocol
• 6. Translate Search Strategies
• 7. Citation Management
• 8. Article Screening
• 9. Risk of Bias Assessment
• 10. Data Extraction
• 11. Synthesize, Map, or Describe the Results
• Open Access Evidence Synthesis Resources

What are Evidence Syntheses?

According to the Royal Society, 'evidence synthesis' refers to the process of bringing together information from a range of sources and disciplines to inform debates and decisions on specific issues. They generally include a methodical and comprehensive literature synthesis focused on a well-formulated research question. Their aim is to identify and synthesize all of the scholarly research on a particular topic, including both published and unpublished studies. Evidence syntheses are conducted in an unbiased, reproducible way to provide evidence for practice and policy-making, as well as to identify gaps in the research. Evidence syntheses may also include a meta-analysis, a more quantitative process of synthesizing and visualizing data retrieved from various studies.

Evidence syntheses are much more time-intensive than traditional literature reviews and require a multi-person research team. See this PredicTER tool to get a sense of a systematic review timeline (one type of evidence synthesis). Before embarking on an evidence synthesis, it's important to clearly identify your reasons for conducting one. For a list of types of evidence synthesis projects, see the Types of Evidence Synthesis tab.

How Does a Traditional Literature Review Differ From an Evidence Synthesis?

One commonly used form of evidence synthesis is a systematic review. This table compares a traditional literature review with a systematic review.

Video: Reproducibility and transparent methods (Video 3:25)

Reporting Standards

There are some reporting standards for evidence syntheses. These can serve as guidelines for protocol and manuscript preparation and journals may require that these standards are followed for the review type that is being employed (e.g. systematic review, scoping review, etc).​

• PRISMA checklist Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) is an evidence-based minimum set of items for reporting in systematic reviews and meta-analyses.
• PRISMA-P Standards An updated version of the original PRISMA standards for protocol development.
• PRISMA - ScR Reporting guidelines for scoping reviews and evidence maps
• PRISMA-IPD Standards Extension of the original PRISMA standards for systematic reviews and meta-analyses of individual participant data.
• EQUATOR Network The EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network is an international initiative that seeks to improve the reliability and value of published health research literature by promoting transparent and accurate reporting and wider use of robust reporting guidelines. They provide a list of various standards for reporting in systematic reviews.

Video: Guidelines and reporting standards

PRISMA Flow Diagram

The PRISMA flow diagram depicts the flow of information through the different phases of an evidence synthesis. It maps the search (number of records identified), screening (number of records included and excluded), and selection (reasons for exclusion). Many evidence syntheses include a PRISMA flow diagram in the published manuscript.

See below for resources to help you generate your own PRISMA flow diagram.

• PRISMA Flow Diagram Tool
• PRISMA Flow Diagram Word Template
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Writing the Literature Review

• Getting Started
• Step 1: Choose A Topic
• Step 2: Find Information
• Step 3: Evaluate
• Step 4: Take Notes
• Step 5: Synthesize
• Step 6: Stay Organized
• Write the Review

Synthesizing

What is "Synthesis"?

Synthesis?  

Synthesis refers to combining separate elements to create a whole.  When reading through your sources (peer reviewed journal articles, books, research studies, white papers etc.) you will pay attention to relationships between the studies, between groups in the studies, and look for any pattterns,  similarities or differences.  Pay attention to methodologies, unexplored themes, and things that may represent a "gap" in the literature.  These "gaps" will be things you will want to be sure to identify in your literature review.  

• Using a Synthesis Matrix to Plan a Literature Review Introduction to synthesis matrices, and explanation of the difference between synthesis and analysis. (Geared towards Health Science/ Nursing but applicable for other literature reviews) ***Includes a synthesis matrix example***
• Using a Spider Diagram Organize your thoughts with a spider diagram

Ready, Set...Synthesize

• Create an outline that puts your topics (and subtopics) into a logical order
• Look at each subtopic that you have identified and determine what the articles in that group have in common with each other
• Look at the articles in those subtopics that you have identified and look for areas where they differ.
• If you spot findings that are contradictory, what differences do you think could account for those contradictions?  
• Determine what general conclusions can be reported about that subtopic, and how it relates to the group of studies that you are discussing
• As you write, remember to follow your outline, and use transitions as you move between topics 

Galvan, J. L. (2006). Writing literature reviews (3rd ed.). Glendale, CA: Pyrczak Publishing

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• Open access
• Published: 23 March 2024

Mechanisms behind gender transformative approaches targeting adolescent pregnancy in low- and middle-income countries: a realist synthesis protocol

• Shruti Shukla   ORCID: orcid.org/0000-0002-4669-2597 1 ,
• Ibukun-Oluwa Omolade Abejirinde   ORCID: orcid.org/0000-0003-0139-0541 2 ,
• Sarah R. Meyer 3 ,
• Yulia Shenderovich   ORCID: orcid.org/0000-0002-0254-3397 4 &
• Janina Isabel Steinert   ORCID: orcid.org/0000-0001-7120-0075 1 , 5  

Systematic Reviews volume  13 , Article number:  95 ( 2024 ) Cite this article

Metrics details

Introduction

Adolescent pregnancy is defined as pregnancy at the age of 19 or below. Pregnancy and childbirth complications are the most significant cause of death among 15–19-year-old girls. Several studies have indicated that inequitable gender norms can increase the vulnerability of adolescent girls, including violence exposure, early marriage, and adolescent pregnancy. To address these disparities, gender transformative approaches aim to challenge and transform restrictive gender norms, roles, and relations through targeted interventions, promoting progressive changes. This realist review aims to synthesise existing evidence from a broad range of data sources to understand how, why, for whom, and in what contexts gender transformative approaches succeed in reducing adolescent pregnancy in low- and middle-income countries.

Method and analysis

We employ a five-step realist synthesis approach: (1) clarify the scope of review and assessment of published literature, (2) development of initial programme theories, (3) systematic search for evidence, (4) development of refined programme theories, and (5) expert feedback and dissemination of results. This protocol presents the results of the first three steps and provides details of the next steps.

We extracted data from 18 studies and outlined eight initial programme theories on how gender transformative approaches targeting adolescent pregnancy work in the first three steps. These steps were guided by experts in the field of sexual and reproductive health, implementation science, and realist methodology. As a next step, we will systematically search evidence from electronic databases and grey literature to identify additional studies eligible to refine the initial programme theories. Finally, we will propose refined programme theories that explain how gender transformative approaches work, why, for whom, and under which circumstances.

Ethics and dissemination

Ethics approval is not required because the included studies are published articles and other policy and intervention reports. Key results will be shared with the broader audience via academic papers in open-access journals, conferences, and policy recommendations. The protocol for this realist review is registered in PROSPERO (CRD42023398293).

Peer Review reports

Adolescent health has become a priority on the health policy agenda in recent years. Guidelines ranging from the United Nations high-level meeting on youth in 2010 to the Global Strategy for Women’s, Children’s, and Adolescents’ Health 2016–2030 to the most recent 1.8 Billion Young People for Change Campaign in 2023 have highlighted the growing attention to adolescents [ 1 , 2 ]. Adolescence is a critical period of transition from childhood to adulthood characterised by changes in cognitive, physical, social, and sexual capabilities [ 3 ]. These changes are often accompanied by heightened gender inequality and restrictive social norms, which primarily impact adolescent girls and are associated with heightened risk for violence exposure, sexually transmitted infections, early marriage, and adolescent pregnancy [ 1 , 4 ].

Adolescent pregnancy is defined as pregnancy at the age of 19 or below [ 5 ]. While the global levels of adolescent birth rate have declined from 64.5 births per 1000 women in 2000 to 42.5 births per 1000 women in 2021, it is still an important health indicator of the Sustainable Development Goals (SDGs) [ 6 ]. As of 2019, about 21 million adolescent girls aged 15–19 became pregnant in low- and middle-income countries (LMICs), 12 million of whom gave birth [ 7 ]. A recent study found that sub-Saharan Africa, followed by Latin America and the Caribbean, and South and Southeast Asia had the highest prevalence of adolescent pregnancies [ 8 ]. A significant consequence of adolescent pregnancy is the high risk of adverse health outcomes for both adolescent mothers and their children, mainly because of complications during pregnancy and childbirth, limited access to prenatal care, and a higher likelihood of living in poverty for adolescent mothers [ 9 , 10 ]. Adolescent mothers may suffer from eclampsia, puerperal endometritis, and systemic infections, and their children might be at risk of low birthweight, preterm birth, severe neonatal conditions, and newborn mortality [ 5 , 11 , 12 ]. Early marriage, lack of sex education and health services, poor socioeconomic background, and sexual risk behaviours are vital predictors of the high prevalence of adolescent pregnancies in LMICs [ 13 ]. In recent years, the COVID-19 pandemic has caused additional disruption to access to family planning services and education and also led to a surge in gender-based violence [ 14 , 15 , 16 , 17 , 18 ], which are known correlates for adolescent pregnancy. For instance, World Vision estimated that school closures alone could lead to a 65% increase in adolescent pregnancies and may block one million girls in sub-Saharan Africa from returning to school [ 14 ]. Another study from this region highlights that inequitable gender norms are associated with adolescent pregnancy [ 19 ]. The lower value of education and prioritisation of household chores for girls, men’s control over contraceptive use, lower social status, and lack of decision-making power in the daily lives of adolescent girls are some of the vital gender norms surrounding this association [ 19 , 20 ]. Therefore, it is essential to address these restrictive norms to ensure better health outcomes for adolescents throughout their life course.

One way to address restrictive gender norms is the application of gender transformative approaches (GTAs) to programme design to explicitly examine and address power relations associated with men and women and boys and girls in programmes and interventions [ 21 ]. This approach differs from the gender blind (ignores the power dynamics) and gender accommodating (acknowledges differences without addressing root causes) approaches by challenging the root causes of gender inequality and reshaping unequal power relations [ 22 ]. Levy et al. (2020) systematically reviewed the characteristics of successful programmes targeting gender inequality and restrictive gender norms. The review found that these programmes can improve knowledge, attitudes, and behaviours around health among children, adolescents, and young adults. While these are essential impacts, there are significant gaps in evidence on outcomes beyond knowledge and attitudes. For instance, only 5 out of 61 evaluation studies included in the review measured changes in the incidence of unwanted or unintended pregnancies [ 20 ]. Furthermore, most of the included studies were quantitative and often implemented interventions only with girls, thus limiting our understanding of the specific mechanisms of change and how they may differ for girls and boys. Specific to adolescent pregnancy, a few existing systematic reviews suggest that knowledge-based or skill-based interventions, contraceptive-promoting interventions, conditional cash transfers, and programmes lowering barriers to education could potentially reduce adolescent pregnancies [ 23 , 24 , 25 ]. However, evidence on these programmes is outdated, given the rise of adolescent pregnancy amidst the COVID-19 pandemic. Furthermore, authors often did not discuss potential mechanisms of change leading to a reduction in adolescent pregnancy. Lastly, these reviews and included studies do not measure gender or social norms change or shifts in norms and how that impacts adolescent pregnancy. These gaps in research point to the importance of exploring the underlying contexts and mechanisms that contribute to the potential success of GTAs targeting adolescent pregnancy.

This review employs a realist approach to fill the above-mentioned research gaps. It will investigate how, why, for whom, and in what contexts gender transformative approaches succeed in reducing adolescent pregnancy. We aim to synthesise existing evidence from a broad range of data sources to develop programme theories to explain how contextual factors, intervention strategies, and programme mechanisms of GTAs may influence adolescent pregnancy.

Methodology

Realist synthesis is a theory-driven approach to evidence synthesis based on the philosophical principles of realism. Realism is defined as a broad logic of inquiry that sits between positivism and constructivism and agrees that social reality cannot be measured directly [ 26 ]. However, it can be understood by examining the relationship between context and outcome, underlined by causal forces (mechanisms) in which events occur and the outcomes produced [ 26 ]. A realist review is concerned with answering how an intervention works, whom it works for, and in what circumstances it works [ 27 ]. It differs from the traditional systematic review in that it emphasises the importance of contextual factors in shaping the effectiveness of interventions and their associated mechanisms. A realist review involves an iterative process of theory building and testing — which includes building an initial programme theory based on preliminary data and then refining this theory based on additional qualitative and quantitative data.

Gender transformative approaches are both ontologically and epistemologically complex [ 28 ]. GTAs work by changing participants’ decision-making process and altering the resources and opportunities available to them within a specific context by eliciting certain mechanism(s). Therefore, it is essential to unpack ‘what works’ to explain these interactions. This review aims to achieve this by actively seeking out the contextual (C) factors that are hypothesised to have triggered the relevant mechanism (M) to generate the outcome (O) of interest [ 26 ]. In a realist review, secondary data is used to develop these CMO configurations (CMOCs), categorise them into theory-driven initial programme theories (IPTs), and then test (confirm, refute, or refine) them with additional data to produce the refined programme theories [ 29 ].

A programme theory is an idea about how the programme works, i.e. if we do X, then Y will happen because of Z [ 27 ]. Through this ideation process, we observe patterns in published literature and develop plausible theories that inform the programme design and implementation in different settings [ 30 ]. In this realist review, we operationalise mechanisms as resources and reasoning. Resources refer to strategies or components introduced by the interventions in a specific context to elicit change. Reasoning refers to the behavioural response of participants triggered by these resources [ 31 ]. Such an operationalisation helps differentiate if data contributes contextually or mechanistically. We will utilise CMO configurations organised as if…then…because statements to answer the following research question: What are the underlying contexts and mechanisms that lead to the success of gender transformative approaches in reducing adolescent pregnancy in low- and middle-income countries? We will follow the iterative process described by Pawson et al. (2005) to conduct our realist synthesis review [ 28 ]. While we follow the five key steps outlined in the article, we also adapt the sub-steps to fit our purpose (Fig. 1 ). The protocol for this realist review is registered in PROSPERO (CRD42023398293), and we will follow the RAMESES publication standards for this realist synthesis [ 32 ].

Steps of realist review

Stages 1a and 1b — Clarify the scope of the review and development of initial programme theories

The research question for this review was developed as a part of the first author’s (S. S.) doctoral study proposal. As a next step, to refine the purpose of the review, we conducted a rapid assessment of seven systematic reviews on gender transformative approaches targeting adolescent health [ 20 , 22 , 24 , 33 , 34 , 35 , 36 ]. This search helped build the first list of interventions for developing the IPTs. We identified 18 studies from the seven systematic reviews and used them for IPTs formation. A codebook based on the CMO components was developed to guide data extraction to identify relevant factors contributing to the IPTs [ 37 ]. One author (S. S.) designed the codebook, and two other authors revised it in an online discussion (S. M., I. O. A.). The codebook is provided in Additional Table 1 . A list of experts in the field of sexual and reproductive health (SRH), programme design, realist evaluation, and adolescent health was prepared based on identified literature. We approached 12 experts via mail for their involvement in the feedback round, 7 of whom agreed.

Using the codebook, we extracted data on the study context, intervention details, strategies, implementation techniques, outcomes, and possible mechanisms that explained how different intervention modalities from the studies retrieved in stage 1 may be linked to reducing adolescent pregnancy. We then mapped the extracted information onto an initial intervention framework, outlying the aggregated information with the outcome of interest (see Fig. 2 ). The context was divided into five categories based on the ecological framework [ 38 ], and the intervention was separated into two parts, intervention strategies, and implementation components (hereon called mechanism resources). The implementation components were organised using the TIDieR checklist [ 39 ]. The mechanisms and outcomes represent a composite of data presented in the intervention documents. The framework is only a representation of the granular overview of the components and will aid the development of IPTs [ 37 , 40 ]. Based on the extracted CMO data and the framework, eight IPTs were proposed (Fig. 3 ). These IPTs were further revised by the review team and experts in two online meetings (questions for the experts can be found in the Additional file ).

Initial intervention framework

Initial programme theories

We observed that different resources were often used in combination with each other and elicited different mechanisms to impact adolescent pregnancy. For example, financial and life skill training in disadvantaged communities often used hands-on techniques in a safe space with peer interactions to elicit different mechanisms. While learning new life skills like negotiation or management increased the participant’s capability and motivated them to apply these newly acquired skills in daily life, learning financial skills triggered the accumulation of human capital and decreased dependence on men. These mechanisms may increase participants’ aspiration to look for alternatives to marriage and transactional sex and thereby decrease the risk of adolescent pregnancy. Another example is the economic strengthening applied in schools and communities in resource poor settings with high levels of poverty. These interventions integrated resources like interactive games and provided cash transfers to the family. For participants from socioeconomically low-income families with low literacy, cash transfers increased available funds, increasing their family’s flexibility to invest in education. Prolonged education triggered the increase in decision-making capacity and agency. Both these mechanisms can lead to a feeling of self-reliance and an increase in bargaining power and thereby lead to changes in risky sexual behaviour, delay marriage, and subsequently lower the risk of pregnancy. Figure 3 illustrates several pathways in which interventions may influence our outcome of interest. However, these are only the preliminary findings and will undergo further changes as the review progresses.

Stages 2 and 3 — Search for evidence and appraisal of evidence

In the second stage, we developed a search strategy based on the critical components of the research question: adolescent population, adolescent pregnancy, gender transformative programmes, and LMICs (Additional Table 2 ). In this review, the primary outcome of interest — adolescent pregnancy — was defined per the threshold set by the World Health Organization as ‘pregnancy in a female adolescent under the age of 20’ [ 41 ]. This includes intended, unintended, and unwanted pregnancies. Further, we define gender transformative approaches as ‘programmes and interventions that foster critical examination of gender norms, create opportunities for individuals to actively challenge gender norms, promote gender equality, and address power inequities between persons of different genders’ [ 42 ]. All studies included in this review will be assessed based on this definition to be qualified as ‘gender transformative’ (see Fig. 1 of Additional file ).

We will examine GTAs targeting the adolescent population (10–19 years) at any individual, group, or community level. In cases where the target population includes older participants, documents will be selected if results are disaggregated by age or if the majority of the sample comprises adolescents. All types of studies and documents describing interventions (i.e. non-experimental, experimental, quantitative, qualitative, mixed methods, implementation reports, project reports, policy briefs, blog posts) except systematic reviews, which examine a gender transformative intervention with adolescent pregnancy as one of the outcomes and that was conducted in an LMIC context, will be included. Interventions targeting both adolescent girls and boys as study participants will be considered. Only documents that provide a link between an intervention and the outcome of interest will be included. Documents published in English only will be included. The authors note that while translation software may support screening of non-English languages, data extraction in a non-English language is best conducted by a fluent speaker of that language, and the benefit of including them may be outweighed by the significant resources required [ 43 ].

The main aim of the systematic search is to identify additional evidence that will be eligible to refine, refute, or confirm the initial programme theories. The databases in our scope include (but are not limited to) the following: Embase, MEDLINE, ERIC, PsycINFO, CINAHL, Gender Studies Database, Reproductive Health Library, Studies in Family Planning, Reproductive Health Matters, International Family Planning Perspectives, and Population and Development Review. Additionally, grey literature will be included by locating resources on websites including OpenGrey, Advocates for Youth, Family Health International, Guttmacher Institute, Interagency Youth Working Group, International Center for Research on Women, Pathfinder International, Population Council, United Nations Population Fund, United Nations Children’s Fund, World Health Organization, and USAID. Based on realist methodology, the literature search process will be iterative and will embrace forward and backward citation tracking and contacting authors in cases where we need more information.

Using the above search strategy, we will pilot a standardised title and abstract screening form and full-text screening form to conduct a pilot exercise on a sample of 10 abstracts and 5 full-text articles to calibrate and test the review forms. Conflict will be mediated by another review author not involved in the screening process. We will use Rayyan, a free web tool designed to help researchers working on knowledge synthesis projects for deleting duplicates and conducting title and abstract screening [ 44 ]. Data on CMO configurations will be extracted using the codebook mentioned in stage 1, piloted by three authors using five articles to ensure codebook consistency. We will compare the results of the three authors and modify the codebook accordingly.

For the appraisal process, each article will be assessed based on relevance (whether it fits the inclusion criteria), richness (whether it can contribute to IPT building), and rigour (whether the information produced is credible and uses trustworthy methods) [ 32 ]. No article will be excluded or included based on just one criterion but on the overall value added to the research question (Fig. 4 ). The documents rated as ‘high’ according to our appraisal will be extracted first followed by those rated medium and low [ 45 ]. The authors will meet regularly to discuss their findings and modify the IPT.

Appraisal tool — relevance, richness, rigour [ 46 ]

Stages 4 and 5 — Synthesise evidence to develop refined programme theory and disseminate recommendations

In the fourth stage, the extracted data on context, mechanism and outcome underlying the interventions of each document will be analysed. We will delineate CMOCs as ‘if…then…because’ statements. Similar CMOCs will be combined to construct richer CMOC statements, differentiating various contexts and mechanisms [ 47 ]. Finally, we will iteratively refine the earlier proposed IPTs into programme theories (PTs) by testing them against the comprehensive CMOCs. Each step of this process will be discussed by members of the review team. The PTs will be sent to the experts for their feedback, following which another cycle of refinement may be required. In the final stage, the refined programme theories will be shared with the broader audience via academic papers in open-access journals, conference and institutional presentations, and policy recommendations.

Gender transformative approaches seek to change the power dynamics that perpetuate gender inequality. They promote equitable gender roles and relationships and challenge harmful social norms reinforcing gender-based discrimination. They engage men and women to be agents of change instead of putting the onus on women alone. This realist review aims to demystify how these approaches work, for whom, and under which circumstances and implementation strategies to elicit positive health impact for adolescent girls. In the following steps, we will conduct a systematic search to collect evidence on our initial programme theories and further refine them. Refined programme theories based on the context-mechanism-outcome configuration will be the final product of this review.

Published literature on interventions to address adolescent pregnancy in LMICs does not adequately engage with the mechanisms behind the successful intervention. We still need to examine how gender transformative interventions measure changes in gender norms and if they have different results when targeting younger adolescents (10–14 years) vs older adolescents (15–19 years). As a result, the evidence is inconclusive and does not provide substantial guidance about how interventions for reducing adolescent pregnancy can be improved. Other gaps in the literature include a dearth of qualitative evidence and a lack of focus on interventions with boys [ 48 ]. In response to this, we will actively seek qualitative evidence, including implementation reports, process evaluations, monitoring reports, policy briefs, and other grey literature, along with studies that include boys in the intervention. We will also report if an intervention measured norm change and how that impacted the incidence of adolescent pregnancy. By doing so, we wish to understand what adolescents think and how they react to intervention procedures, thus informing programme design further. Overall, this research will be helpful for policymakers and programme designers to understand the importance of considering the context, intervention resources, and related mechanisms when designing programmes to address adolescent pregnancy.

Availability of data and materials

Not applicable.

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Shukla, S., Abejirinde, IO.O., Meyer, S.R. et al. Mechanisms behind gender transformative approaches targeting adolescent pregnancy in low- and middle-income countries: a realist synthesis protocol. Syst Rev 13 , 95 (2024). https://doi.org/10.1186/s13643-024-02513-4

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Exploring the use of social network interventions for adults with mental health difficulties: a systematic review and narrative synthesis

• Helen Brooks   ORCID: orcid.org/0000-0002-2157-0200 1 ,
• Angela Devereux-Fitzgerald 1 ,
• Laura Richmond 1 , 2 ,
• Neil Caton 3 ,
• Mary Gemma Cherry 4 , 5 ,
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• James Downs 7   na1 ,
• Bethan Mair Edwards 8   na1 ,
• Ivaylo Vassilev 9 ,
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• Anne Rogers 9  

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People with mental health difficulties often experience social isolation. The importance of interventions to enhance social networks and reduce this isolation is increasingly being recognised. However, the literature has not yet been systematically reviewed with regards to how these are best used. This narrative synthesis aimed to investigate the role of social network interventions for people with mental health difficulties and identify barriers and facilitators to effective delivery. This was undertaken with a view to understanding how social network interventions might work best in the mental health field.

Systematic searches using combinations of synonyms for mental health difficulties and social network interventions were undertaken across 7 databases (MEDLINE, Embase, PsycINFO, CINAHL, Cochrane Library, Web of Science) and 2 grey literature databases (EThoS and OpenGrey) from their inception to October 2021. We included studies reporting primary qualitative and quantitative data from all study types relating to the use of social network interventions for people with mental health difficulties. The quality of included studies was assessed using the Mixed Methods Appraisal Tool. Data were extracted and synthesised narratively.

The review included 54 studies, reporting data from 6,249 participants. Social network interventions were generally beneficial for people with mental health difficulties but heterogeneity in intervention type, implementation and evaluation made it difficult to draw definitive conclusions. Interventions worked best when they (1) were personalised to individual needs, interests and health, (2) were delivered outside formal health services and (3) provided the opportunity to engage in authentic valued activities. Several barriers to access were identified which, without careful consideration could exacerbate existing health inequalities. Further research is required to fully understand condition-specific barriers which may limit access to, and efficacy of, interventions.

Conclusions

Strategies for improving social networks for people with mental health difficulties should focus on supporting engagement with personalised and supported social activities outside of formal mental health services. To optimise access and uptake, accessibility barriers should be carefully considered within implementation contexts and equality, diversity and inclusion should be prioritised in intervention design, delivery and evaluation and in future research.

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Mental health difficulties are increasingly globally and are one of the primary drivers of disability worldwide [ 1 , 2 ]. In the UK alone, 3.3 million adults in the United Kingdom (UK) were referred to mental health services between 2020 and 2021 [ 3 ]. More disability-adjusted life years are lost to mental health difficulties than to any other health condition in the UK, including cancer and heart disease, with considerable economic, societal and individual cost [ 4 ]. Adults with severe and/or enduring mental health difficulties, such as schizophrenia and bipolar disorder, face additional challenges; they are at greater risk of multiple physical health comorbidities, and have a 15-20-year shorter life expectancy than the general population [ 5 , 6 ]. Optimising the effectiveness and reach of mental health support for these people is essential to ensure high-quality care whilst minimising pressures on already-stretched NHS resources.

Community engagement and social connections can support people living with mental health difficulties in the community, sometimes preventing the need for the involvement of formal health service provision and providing support for recovery post-discharge [ 7 ]. Community engagement is often used as a proxy measure of community integration which is considered a fundamental aspect of recovery from mental health difficulties [ 8 ]. Evidence suggests that both close and distal social network support are associated with community integration [ 9 ]. However, recent research suggests both individual and wider barriers to community engagement [ 10 ]. This highlights the potential value of interventions designed specifically to mitigate both the individual level barriers such as physical and psychological capabilities and social barriers which reduce access to suitable community resources [ 10 ].

Social networks Footnote 1 , social connectivity and engagement in valued activities have multiple benefits for people with severe and/or enduring mental health difficulties and associated benefits for the services and people that support them. They enhance recovery and self-management, promote engagement with community-based support and extend the availability of heterogenous support for the secondary prevention of mental health difficulties, with potential to reduce direct healthcare costs [ 7 , 12 , 13 , 14 , 15 , 16 ]. It is theorised that formal and informal social support, interpersonal contact, and mobilisation of resources enhance individual coping strategies and functional support [ 17 , 18 ], thereby providing protection from stress and improving daily self-management of mental health difficulties [ 19 , 20 , 21 ]. In turn, social activity can increase the size and quality of an individual’s social network [ 22 ], further sustaining and enhancing social connectivity and well-being promotion [ 14 ].

The usefulness of social networks is contingent on the availability of requisite knowledge, understanding and willingness to provide help within networks. These are not always present, available or acceptable to individuals [ 23 ]. People with mental health difficulties tend to have smaller, less diverse networks of poorer quality and configuration, and tend to rely heavily on support from family members or health professionals [ 24 , 25 ]. Social network availability and configuration varies depending on the severity of mental health difficulties and availability of resource [ 26 ].

Interventions designed to improve people’s social networks by connecting them with meaningful and valued activities, people, and places, can extend access to support, thus aiding and sustaining recovery [ 25 ]. These interventions can be effective in optimising social connections for people with mental health difficulties [ 12 ]. It is important to note that social network interventions include those that strive to modify the composition or size of social networks by adding new members and those that seek to bring together existing network members to modify existing links to enhance the functional quality of a network. The former includes linking individuals to new activities or social situations where new network connections can be made [ 27 ] whilst the latter often take the form of network meetings which dependent on an individual’s personal situation bring together relevant network members (family, friends and other supporters) in order to optimise the consistency and connectedness of network support [ 28 ]. However, specific attention needs to be paid to implementation of these types of interventions because previous research in other fields suggest variability in uptake of network interventions, fluctuating capacity of organisations to deliver such interventions and organisational cultures which do not allow for sustainable implementation [ 29 , 30 ].

To fully translate social network interventions into mainstream mental health services and optimise their use, we must first ascertain how effective, acceptable and feasible existing interventions are, and understand their mechanisms of effect [ 12 ]. A recent systematic review examining the effectiveness, acceptability, feasibility and cost-effectiveness of existing interventions concluded that extant literature is in its infancy, but suggested that social network interventions which connect and support people to engage in social activities may be acceptable, economically viable and effective [ 12 ]. The aim of this review is to build on these findings by providing a critical overview of how social network interventions might work best for adults with mental health difficulties. We used systematic review methods to critically answer the following questions: for people with mental health difficulties, (i) what social network interventions work best and for whom; and (ii) what are the optimal conditions for implementing social network interventions?

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidance [ 31 ] informed the methods and reporting of this systematic review and narrative synthesis, and the protocol is available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020206490 .

Eligibility

Published journal articles or dissertations reporting primary data on the use of interventions designed specifically to improve and/or measure social network quantity or quality for people with mental health difficulties were included in this review. Review articles were excluded but reference lists of identified reviews were checked for potentially relevant articles. Only studies with a sample mean age ≥ 18 years and a minimum of 75% of participants with primary diagnosis of mental health difficulties (self-report or physician defined) were included.

No restrictions were imposed in relation to language or date of publication. Non-English language articles were screened for eligibility by native speakers affiliated with the research team. Papers where the sample held a primary diagnosis of substance misuse, autism spectrum disorders, dementia, attention deficit hyperactivity disorder (ADHD), or cognitive impairment were excluded. Also excluded were dyadic interventions or individual-level interventions such as purely social skills/cognition programmes. Table  1 displays full inclusion and exclusion criteria.

Search strategy

The following seven databases were searched in August 2020 with searches updated in October 2021: Medline, Embase, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Published reviews and literature on social network interventions informed the search strategy which was agreed with the wider authorship team and was subject to a Peer Review of Electronic Search Strategies (PRESS) review by an expert librarian [ 32 ]. Search terms were organised using the first two components of the Population, Intervention, Comparator, Outcome (PICO) framework (Population: People with a diagnosis of mental health difficulties or self-reported emotional distress and Intervention: Social network) and were intentionally broad to maximise search returns (see Additional File 1 for an example search syntax).

To reduce publication bias, grey literature sites such as EThoS and OpenGrey were also searched. We also contacted authors of possibly eligible conference abstracts for full manuscripts where these were not readily available and examined identified review articles and book chapters for relevant literature.

Data extraction

The data management software Covidence ( http://www.covidence.org ) was used to aid the data selection and extraction process. After duplicates were removed, titles and abstracts of identified studies were screened independently by two reviewers, and conflicts were resolved by a third reviewer in line with the inclusion/exclusion criteria (See Table  1 ). Full text reviews of potential papers were undertaken by the team, with two reviewers independently screening each paper and conflicts resolved by consensus.

Standardised data extraction forms were created in Excel and used to extract data from all eligible papers by seven team members (HB, ADF, LR, NC, JD and BME), including both academic and patient and public involvement (PPI) researchers. Extracted data included social network measures (where applicable), factors of context, mechanisms and outcomes, acceptability and standard demographics. Interventions were categorised into broad groups for the purposes of analysis by one member of the research team (HB) and checked for accuracy by another (MGC). For qualitative data, both raw data quotations and author interpretations were extracted where applicable and identified as such. A second reviewer from those outlined above (HB and ADF) cross-checked 30% of extracted data from each member of the review team for accuracy.

Quality appraisal

The Mixed Methods Appraisal Tool (MMAT) [ 33 ] was used to assess the quality of the included papers, applicable to the broad range of research arising in this review [ 34 ]. Each full-text paper was quality assessed by one reviewer in parallel with data extraction with 10% of quality appraisals cross-checked for accuracy. Disagreements were resolved through consensus.

Data synthesis

Meta-analysis of the quantitative data was not possible due to the heterogeneity of included studies. Consequently, a narrative synthesis was undertaken following the stages outlined in the Guidance on the Conduct of Narrative Synthesis in Systematic Reviews [ 35 ]. Data were collated and textual summaries of study characteristics were produced via data extraction spreadsheets (including intervention content, study design, participants, recruitment and delivery). Qualitative data from qualitative and mixed methods studies were explored inductively using aspects of thematic synthesis: a thematic framework was developed consisting of themes which were refined, merged, split or created, as necessary, with analysis of each study [ 36 ]. Constant comparison was used to translate concepts between studies [ 37 , 38 ]. Verification of findings were provided by a second researcher and verified by the wider team. The thematic framework was also applied to the quantitative data from quantitative studies and mixed-methods studies, which aided with the visual grouping of patterns across the whole data set. Quality appraisals were used to assess the robustness of the thematic analysis by removing papers of the lowest quality from each theme to consider their impact on overall presentation. No themes needed to be revised following this process so references were added back into the synthesis [ 35 ]. Data from all included studies were also grouped on aspects of context such as delivery setting and approach, diagnosis and significance of results [ 35 ]. Analytical themes were inferred from the material inherent in the descriptive findings and, together with the patterns apparent across the whole data set formed the narrative synthesis. This synthesis allowed interpretation of the concepts arising in this review beyond the primary findings of individual papers.

As shown in Fig.  1 , searches identified 22,367 potentially relevant studies, resulting in 19,575 unique citations after de-duplication. The full texts of 841 studies were reviewed for relevance, resulting in the inclusion of 54 unique papers. Of these, 17 were randomised controlled trials (RCTs), 12 were quantitative studies of other designs (‘other quantitative studies’), 13 studies were qualitative, and 12 used mixed methods. Studies were conducted in the following countries: UK (n = 25), United States of America (n = 8), Australia (n = 5), China, India, Ireland, Italy, Netherlands, Sweden and Canada (all n = 2), Denmark and Hungary (n = 1). For more information on included studies, see Additional File 2 and Additional File 3 for a completed PRISMA checklist.

PRISMA 2020 flow diagram

There was a total of 6,249 participants recruited across the included studies with an average age of 47.42 years and broadly equivalent numbers of males and females. Most (21/54) studies recruited participants with mixed forms of mental health difficulties and emotional distress. The remaining studies included only participants with the following diagnoses or self-reported difficulties Footnote 2 :

Psychosis and/or schizophrenia (n = 12).

Serious and/or long-term mental health difficulties (n = 10).

Depression (n = 4).

Mild to moderate mental health difficulties (n = 2).

DSM AXIS 1 disorders (e.g. anxiety disorders, such as panic disorder, social anxiety disorder, and post-traumatic stress disorder) (n = 2).

Psychotic and affective disorders (n = 1).

Eating disorder (n = 1).

PTSD and depression (n = 1).

For more information on participants in included studies, see Additional File 2 .

The 54 included studies reported on 51 unique interventions which were broadly categorised into five types. The most commonly reported interventions were those that supported community or social activities (25/51). These included 13 interventions that supported access to existing community resources and activities, 3 football interventions, 5 horticulture or nature-based interventions, 3 arts-based intervention and one which involved closed group social activities. The second most included type of intervention (13/51) was intensive or enhanced community treatment. These were mostly assertive community treatment (n = 3), case management approaches (n = 3) and specialised community treatment teams (n = 2). There was also one reported example of each of the following: day centre, community club, social recreation team, occupational therapy and rehabilitation specialised services. There were 7 peer support group interventions within included studies and 3 one-to-one interventions (behavioural activation, cognitive behavioural therapy and peer-led recovery). Three interventions were classified as other and these included 2 action research approaches and an enhanced sheltered accommodation project. Please see Table S1 in the additional files for additional detail on included interventions.

23/54 intervention activities were additional to statutory provision and delivered externally to statutory services, 9 were additional but were delivered within health services, 1 was a combination of both internally and externally delivered activities and 21 were designed to enhance existing provision.

There was minimal description of formal patient and public involvement (PPI) in the included studies, with notable few exceptions (n = 10; [ 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ]). PPI activities included participatory approaches such as Photovoice [ 39 ], co-production activities [ 47 ], peer researchers/facilitators [ 40 , 41 , 42 , 44 ] and inclusion of advisory groups or public advisors [ 43 , 45 , 46 , 48 ].

Quality assessment

Details of the quality assessment of included studies is found in Additional File 2 which includes assessments for each type of study. Quality assessments and main methodological weaknesses for each type of study are summarised in Table  2 .

Review question 1: what type of social network interventions work best and for whom?

Of the 17 RCTs, 12 other quantitative and 12 mixed-methods studies included, 9 RCTs [ 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 ], 3 other quantitative studies [ 58 , 59 , 60 ] and 1 mixed-methods study [ 61 ] used included a formal quantitative measure of social network size or quality. Of these, 7 provided evidence of statistically significant improvements to social networks post intervention [ 49 , 51 , 53 , 55 , 56 , 58 , 59 ] and others demonstrated improvements which favoured the intervention group but did not reach statistical significance [ 52 , 54 , 62 ]. Just over half (5/9) of the RCTs examined the effectiveness of interventions using aspects of supported socialisation [ 53 , 54 , 56 , 59 , 62 ], highlighting the potential value of these types of interventions for people with mental health difficulties. The follow up periods for RCTs ranged from 3 months to 24 months and effect sizes were generally small to moderate when compared to usual care – ranging from 0.39 to 0.65 [ 12 ].

A range of statistically significant improvements in other outcomes following intervention were reported across the included studies. These included mental health symptomatology [ 44 , 51 , 55 , 63 , 64 , 65 , 66 , 67 ], general health [ 68 ], social anxiety [ 69 ], social support, social capital and satisfaction with aspects social relationships [ 43 , 49 , 50 , 70 ], distress [ 50 ], general and social functioning/engagement [ 43 , 44 , 54 , 63 , 64 , 65 , 71 , 72 , 73 , 74 ], occupational functioning [ 75 ], structured activity levels [ 76 ], loneliness [ 43 , 54 , 64 , 69 ], relatedness and social inclusion [ 42 , 44 ], sense of belonging [ 69 ], self-esteem [ 43 ], quality of life [ 43 , 72 ], wellbeing [ 42 , 64 , 77 ], treatment adherence [ 72 ], service use [ 44 , 52 ] and satisfaction with care [ 52 , 72 ]. Of these 24 studies, 20 provided information on follow-up periods which were on average 9 months ranging from 2 to 18 months. See Additional File 2 .

It was not possible from included studies to draw definitive conclusions about the groups of people for whom these interventions work best due to the heterogeneity of participants in included studies. However, 8 of the 28 studies that demonstrated significant improvements in outcomes evaluated the effectiveness of interventions for people with schizophrenia and/or psychosis. Significant improvements at follow-up across studies were also associated with:

Being female [ 57 , 58 , 63 ].

Being married [ 43 , 58 ].

Living with a spouse or partner [ 43 ].

Completing A-levels [ 57 ].

Fewer negative symptoms [ 57 ].

Larger network at baseline [ 57 ].

Better baseline functioning [ 63 ].

Greater distress from positive symptoms [ 51 ].

Longer duration of illness [ 51 ].

People who demonstrated improvement in other outcomes [ 56 ].

Undertaking more social activities [ 51 , 65 ].

Having a better clinical prognosis [ 56 ].

What are the optimal conditions for the implementation of social network interventions?

Synthesis of data from qualitative and mixed-methods studies identified a range of barriers and facilitators to implementing social network interventions which are presented in Table  3 (Individual level barriers and facilitators) and Table  4 (Provider/agender level barriers and facilitators). Overarching themes identified during the narrative synthesis relating to optimal conditions for implementation and how interventions are thought to bring about changes in outcomes are presented below with supporting quotes presented in Table  5 .

Bridging the gap – the fundamental role of facilitation

Facilitators played a central role in the successful implementation of social network interventions for all types of mental health difficulties. A facilitator could support the initiation of social activity through personalised discussions about activity options and going along to activities with an individual until they had developed sufficient skills, knowledge and confidence to undertake activities on their own [ 39 , 40 , 42 , 46 , 48 , 62 , 67 , 78 , 79 , 80 , 81 , 82 ]. To do this well, facilitators needed to have sufficient local knowledge, empathy and engagement skills [ 83 , 84 ]. The development of interpersonal trust and provision of suitable options for an individual to consider were considered key to successful facilitation [ 41 , 84 ]. Other requirements included being non-judgemental, approachable, friendly, and having a basic understanding of mental health difficulties [ 41 , 42 , 48 , 62 , 66 , 67 , 74 , 82 , 85 ]. A mutual understanding and respect of roles and boundaries was also crucial to successful facilitation [ 79 ].

Participants described how facilitators needed to maintain a delicate balance between providing support to engage with new social activities and promoting independence to ensure future sustainability [ 39 , 46 , 83 ]. Facilitators could support the uptake of social activities by providing structured programmes with sufficient flexibility to overcome individual barriers to accessing local activities [ 40 ]. Studies also highlighted the need for adequate training and supervision for facilitators in advance of programmes starting and for consideration to be given to the end of interventions when contact with the facilitator ended. Sufficient facilitator relationships coming to an end and for consideration of how benefits would be sustained once the programme ended [ 67 , 79 , 81 ].

Whilst there wasequivalence in the quantitative effectiveness data in relation to peer versus non-peer facilitators [ 12 ], qualitative data identified particular strengths of peer facilitators in relation to having shared experiences and having opportunities to model behaviours. Peer facilitators were seen to provide hope for the future as an example of someone who had recovered from a mental health difficulty, and also to reduce the imbalance of power between facilitator and service user, which improved their relationship [ 41 , 79 ].

Social network interventions could benefit facilitators and host organisations by increasing knowledge about, and access to community infrastructure which provided s ongoing support to service users. Additionally, professionals were able to develop more in-depth understanding of individual service users during such interventions, which could improve understanding about individual triggers of distress and relapse [ 67 , 79 ].

My voice, my choice, my pace – the need for flexibility and valuing individual differences

Social network interventions worked best when service users felt they could choose activities within interventions which mirrored their own interests [ 46 , 48 , 67 ]. This improved uptake and engagement with social activities particularly when users felt that their voices were being heard and their choices considered [ 39 , 40 , 83 , 84 ].

Acknowledgement of individual differences and allowing people to be who they are whilst providing gentle encouragement appeared to increase engagement with valued activities [ 46 , 62 , 79 , 86 ]. Participants, particularly those with serious and/or enduring mental health difficulties, experienced increased motivation for, and enjoyment of, self-selected activities [ 79 , 82 , 86 ]. Participants described such activities as evoking a sense of fun and spontaneity which helped them to be playful and self-expressive [ 77 , 79 , 87 ] as well as to laugh and be adventurous [ 41 ]. Engagement with valued activities was seen as empowering and participants expressed an increased desire for future engagement, feeling as though they were seen as a person rather than an ‘illness’ [ 42 , 62 , 88 ]. Participation was optimised if space was provided to allow people to try different activities and ascertain what was most enjoyable for them. This allowed people to become familiar with, and embedded into, intervention locations [ 48 , 66 , 74 ].

Participants described the impact that their mental health and other external circumstances could have on their ability or readiness to engage with social network interventions. Studies recommended flexibility in implementation to mitigate against this [ 67 , 77 , 78 , 80 , 82 ]. Interventions worked best when participants felt that they could be honest in relation to their own boundaries/capabilities [ 80 ] and when they could be left alone when they needed to be [ 46 ]. This flexibility and acceptance of individual situations meant people felt their own needs, choices and health were being adequately considered, which allowed them to push themselves further than they might have thought possible [ 46 , 80 ]. It also appeared to contribute to a sense of agency and control over their own participation which was deemed important for successful engagement with social network interventions [ 46 , 82 ]. Not having individual needs met through a lack of flexibility could result in withdrawal from intervention activities [ 81 ].

Another key feature of successful social network interventions was allowing participants to progress at their own pace, one that was manageable given their individual circumstances [ 62 , 79 , 82 , 85 , 89 ]. Any pressure to move faster than this or at another’s pace was viewed as a potential barrier to these types of interventions. One study with people with serious mental health difficulties found that those who engaged with social activities independently were more consistent and committed in their engagement, and this was attributed to the ability to go at their own pace [ 78 ].

Similarly, social network interventions should not be seen as a quick fix or panacea for people with mental health difficulties. What is experienced as valuable and beneficial for one person is likely to be different for another and individual preferences may change over time. These types of interventions need to be personalised to individuals to ensure they meet people’s needs and that expectations for engagement are realistic for the individual [ 46 , 67 , 79 ]. It was recognised, within included studies, that not everyone would be able to engage with social network interventions, and this should be factored in from the outset and a flexible approach undertaken [ 79 , 80 ]. Flexibility in delivery also incorporated the ability to include the wider family, friends and other supporters in intervention activities where appropriate and desired [ 46 ].

Social building blocks – rebuilding or acquiring social resources and skills and making connections with others

Social network interventions were considered to work best when they enabled individuals to build on existing or develop new skills whilst also being supported to make connections with others [ 45 , 83 , 86 ]. This applied at an individual level (self-esteem, self-efficacy, resilience, social skills, self-management) and social network level (quantity and quality of new and existing social networks) [ 39 , 41 , 42 , 45 , 46 , 48 , 77 , 78 , 81 , 82 , 83 , 87 , 88 , 89 ]. Individual-level improvements were considered necessary in order to realise benefits from social network interventions [ 84 ]. Such benefits could be conferred formally through didactic sessions or naturally through group interactions [ 46 , 48 ].

Benefits could impact on other wider aspects of everyday life including health and employment [ 40 , 41 , 62 , 84 , 87 ] as well as having ripple effects on friends and family through the sharing of knowledge about social and cultural activities in local areas [ 78 ].

A range of potential mechanisms through which interventions were thought to bring about benefits were identified. Social network interventions provided the opportunities for distraction, allowing attendees to clear their minds which promoted self-reflection and the ability to process negative thoughts through engagement with valued activities [ 42 , 62 , 82 , 86 ]. This led to calmer states which enabled cognitive and social skills to develop or be re-established [ 62 , 86 ].

Social acceptance through connectedness with the local community helped individuals to see themselves in a more positive light, reminding them of their own strengths whilst challenging previously-held beliefs about what they could and could not do [ 48 , 77 , 80 , 82 ]. One study found that that the use of humour around previously shame-inducing situations could support people to disidentify with negative identities and increase their sense of belonging [ 80 ]. This, combined with undertaking new or re-engaging with lost skills and pursuits, could engender a sense of pride and hope for the future [ 41 , 45 , 46 , 77 , 79 , 89 ]. Studies also highlighted how connections made during intervention activities were considered to reduce the intensity of interactions within existing networks thereby improving social interactions more generally [ 45 ].

Participants described a virtuous cycle whereby participating in social network interventions developed skills and capabilities to support social connectedness, which in turn stimulated a sense of purpose, renewed interest in the world and desire for further social engagement and participation [ 39 , 41 , 46 , 62 , 77 , 78 , 81 , 83 , 86 ].

However, such benefits were not seen in all those who accessed social network interventions [ 40 ]. Involvement in interventions which were considered too challenging or encouraged downward social comparison had little impact on individual or social network outcomes [ 40 ].

The importance of a positive and safe space to support community integration

Participants expressed a strong desire to reduce social isolation and valued interventions that promoted community integration [ 42 , 77 , 87 ]. A key factor in the success of social network interventions was the context in which the intervention was delivered. Social network interventions were considered more likely to be successful if delivered in community venues external to formal health services. Those delivered in group settings were experienced as less intimidating as there was less pressure to make one-to-one connections [ 80 ].

Successful participation in real world activities was highly valued and indeed necessary for participants to benefit from social network interventions [ 39 , 83 ]. Participants felt that interventions should be integrated into local communities and provide an access point to resources rather than further segregating people with mental health difficulties [ 80 , 86 ]. However, such interactions could be challenging due to concerns about stigmatisation and previous negative experiences; facilitation or support to mitigate this was identified as imperative across studies [ 39 , 48 , 77 , 78 , 80 ]. This was particularly important at the early stages of involvement before trust and belonging had developed [ 80 ]. Engagement in shared activities that were not overburdensome (e.g. sport, games, shopping) helped to develop community relationships and overcome initial doubts and concerns [ 39 ].

Community engagement in non-judgemental settings had a range of benefits including increased community integration and improved connection to society more generally. These appeared particularly salient for those with serious mental health difficulties [ 78 , 86 , 89 ]. They also fostered the development of transferable skills that were easily integrated into everyday life and provided connections to wider society beyond the health care system [ 66 , 78 , 79 , 82 , 83 , 84 ]. It was considered important to foster connections with people in the community who understood but did not necessarily have direct experience of mental health difficulties so that the focus of interactions was on shared interests or hobbies rather than ‘illnesses’ [ 40 , 42 , 48 , 62 , 84 ]. Self-selected, reciprocal and naturally occurring social connections were highly valued and considered more likely to occur outside of formal mental health settings [ 41 , 42 , 46 , 81 , 85 , 86 ]. Participants also valued opportunities to help others and give back to the community [ 40 ].

Participants’ feeling safe, relaxed and accepted during intervention activities was considered instrumental to successful implementation of social network interventions. This was supported, where necessary, by home visits, particularly prior to community engagement [ 39 , 40 , 41 , 46 , 48 , 79 , 80 ]. These were more easily arranged for interventions in non-statutory settings, and particularly for nature or arts-based activities [ 42 , 48 , 62 , 74 , 77 , 78 ]. Outdoor interventions were generally considered to be naturally restorative, calm, peaceful and safe which facilitated social interactions [ 48 , 74 , 86 ].

The need for available, accessible and sustainable activities

The availability of appropriate community resources for supported socialisation interventions and those interventions led by the third sector was raised as a challenge to the implementation of social network interventions in included studies [ 39 , 83 ]. Funding for third sector activities was often precarious which meant that activities stopped with little notice. This was hard for intervention facilitators to keep abreast of and could be demotivating for participants [ 39 ]. Adequate staff training in relation to awareness of such activities locally and optimal ways to connect people to them was raised as a key facilitator to success.

Lack of accessibility to intervention activities was also highlighted as a barrier to intervention success. Issues included lack of funding for transport and access [ 39 , 46 , 67 , 84 ], gender inaccessibility within activities [ 40 , 41 , 77 ], inflexibility which reduced accessibility for those with work or caring responsibilities [ 67 , 78 , 79 , 89 ], stigma [ 41 ], lack of support for social anxiety and amotivation [ 42 , 66 , 67 , 77 , 79 , 80 , 82 ], social barriers, such as social norms and stereotypes [ 41 ], language barriers and low literacy [ 67 , 77 ], rurality [ 67 ], and safety concerns created by location or timing of activities (e.g. at night) [ 78 ]. These barriers were particularly pertinent for participants who lacked family support to attend groups [ 41 ].

Insufficient consideration of accessibility issues could exacerbate health inequalities and meant that participants felt unable to realise their own potential for social connectedness [ 39 , 84 ]. An example of particularly accessible environments was public allotments, which were considered widely available, inexpensive and inclusive settings, and as a result involvement was easier to maintain post intervention [ 86 ]. The provision of stipends was found to be a useful way to mitigate financial barriers [ 78 ].

Concerns were raised about the sustainability of certain activities and the potential impact of this on intervention participants [ 83 ]. Several studies highlighted harms caused by ending interventions without adequate consideration of how activities would be sustained [ 79 , 87 ]. Most documented sustainability was attributed to participants’ planning for maintenance both within and outside their own networks [ 42 , 78 , 82 ]. This was considered particularly useful when facilitated as part of the intervention itself [ 46 , 79 ], or where ongoing post-intervention engagement with activities or individuals was supported [ 62 , 82 , 87 ].

This systematic review and narrative synthesis aimed to identify and synthesise current evidence pertaining to the use of social network interventions for people with mental health difficulties, with a view to understanding their effectiveness, and the conditions in which these interventions might work best. Collectively, data from the 54 included studies demonstrated the utility of these types of interventions for people with mental health difficulties in terms of improving social networks and other health and social outcomes. Studies included a breadth of data and range of implementation and evaluation methods that lacked an explicit focus on context and outcome relationships. This made it difficult to draw definitive conclusion about what types of interventions work best for whom. However, we were able to identify conditions in which interventions can be optimally implemented.

In line with previous research, data supported the potential utility of interventions which focussed on supporting socialisation for people with mental health difficulties [ 12 , 90 , 91 ]. Most (21/54) studies included people with a range of mental health diagnoses. The remainder included participants with diagnoses of schizophrenia and/or psychosis (n = 12) or serious and/or enduring mental health difficulties (n = 10) with lesser attention given to other diagnoses. As a result, it was not possible to ascertain whom social network interventions worked best for. Encouragingly, participants demonstrated a strong desire for interventions which reduced social isolation and promoted community integration, suggesting high levels of acceptability across mental health conditions. Despite this, it is unlikely that social network interventions are a panacea, with the qualitative studies demonstrating the need to consider individual readiness for intervention participation and to ensure that interventions are sufficiently personalised to individual needs, preferences, heath, and access requirements [ 39 , 83 ].

Factors that affected the implementation of social network interventions mirrored and extended those identified in the physical health field [ 23 , 92 ]. In the current review, greater salience was given to the value of freedom, choice and personalisation within intervention activities, the need for individuals to be heard and progress at their own pace, and safe and non-judgemental spaces for intervention activities. Participants were more likely to raise concerns about stigma relating to mental health or past negative experiences with community organisations, which may relate to differences in the experience of mental health difficulties when compared to physical health difficulties [ 93 ]. Specific requirements relating to mental health and appropriate facilitation in this regard suggests a need for mental health specific training for intervention facilitators. Factors affecting the implementation of social network interventions appeared broadly applicable across mental health conditions and nuances in identified barriers and facilitators for people with specific diagnoses or severity were not discernible. Future research is required to ascertain whether there are condition-specific challenges to accessing social network interventions so that strategies to mitigate these can be developed.

This manuscript adds to existing literature by demonstrating the complexity of implementing social network interventions in the mental health field and identifying a range of access- related barriers which can hinder engagement. Failure to adequately consider the context in which an intervention will be delivered can exacerbate existing health inequalities by reducing access to potentially effective interventions [ 6 ]. This was evidenced across included studies; participants who were female, white, educated, married and had stronger baseline social networks and functioning were the most likely to access and benefit from these types of interventions [ 43 , 57 , 63 ]. This highlights the need for pre-implementation preparation to fully understand local delivery contexts and the needs of all those who might benefit from such interventions [ 94 ]. It is notable that only 2/54 included studies involved transgender participants and no included studies recorded the sexual orientation of study participants or considered neurodiversity. There were also limited numbers of identified facilitators in the included studies which related to issues of diversity and inclusion (Tables  3 and 4 ). This supports wider calls for prioritisation of equality, diversity and inclusion in the design, delivery and evaluation of social network interventions in future research in order to maximise intervention benefits [ 95 ]. This could be facilitated through co-production activities with those from diverse backgrounds and who represent or have insight into these communities.

This review identified a range of facilitators and barriers to implementing social network interventions in the mental health field potentially identifying a fundamental set of requirements as well as more bespoke requirements specific to type of need (Tables  3 and 4 ). Concomitantly, it highlighted the need to consider both downstream and upstream factors relating to implementation (i.e., individual motivation, capabilities, and opportunities and social and organisation level capacity). There was a particular tension between the sustainability of intervention activities and meaningful outcomes for participants. Consideration should therefore be given to how interventions are delivered (e.g. length of engagement time and potential enhanced role of facilitators) and the need to prioritise valued resources/activities that are sustainable [ 23 ].

In terms of implications for health services, findings illustrated the importance of targeting people with lower levels of baseline social functioning and people with smaller social networks or networks of poorer quality at baseline [ 57 , 63 ]. Given the need for a safe and accessible venue for intervention delivery and the importance of the facilitator role, provision for someone to accompany people to activities, especially during early interactions should be included in intervention design [ 80 ]. The findings also lend support to recent calls to reorient mental health service provision and reduce the focus on individual psychopathology and one-to-one interactions with health professionals [ 96 , 97 ]. An alternative focus oncare provision through outreach work and engagement with community resources, to harness the collective value of social networks would potentially be of more value [ 98 ]. This review also highlights the need to prioritise third sector funding to provide suitable resources for people to access [ 29 ].

Strengths and limitations

This review benefits from comprehensive search strategies which incorporated both published and grey literature, the inclusion of papers published in languages other than English, and the rigour of screening and extraction processes. Hand-searching of relevant journals and included papers identified a further two papers to be included. Another strength was the inclusion of seven members of the review team who had lived experience of mental health difficulties and two members who had clinical experience of delivering mental health care. This enhanced the review in several ways: ensuring that search terms were inclusive and comprehensive; clarifying understanding of social network interventions; and enhancing contextualisation of implementation barriers and facilitators. The qualitative studies provided most learning in relation to the use of social network interventions for people with mental health difficulties. There is a need to further this research by testing these factors against outcomes through powered mechanistic trials.

Several limitations should also be considered. First, incorporation of two grey literature databases is unlikely to have fully addressed potential publication bias. Second, whilst attempts were made to integrate study quality into the narrative synthesis, the overall quality of included studies may have impacted on the synthesis presented. Finally, the review only included the views of participants in social network interventions in relation to perceived barriers and facilitators to implementation, and it may be that these participants were not fully aware of all the potential factors that impacted implementation. The review also did not include those who had a primary diagnosis of substance misuse, autism spectrum disorders, dementia, attention deficit hyperactivity disorder (ADHD), or cognitive impairment. These limitations should be carefully weighed against the feasibility of managing and synthesising manuscripts from a review strategy that was more inclusive.

Strategies for improving the social networks of people with mental health difficulties should focus on ensuring access to personalised and supported social activities outside of formal mental health services. To optimise access and uptake, accessibility barriers should also be carefully considered within implementation contexts, and equality, diversity and inclusion should be prioritised in intervention design, delivery and evaluation, as well as in future research in this area.

Data availability

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Personally-meaningful communities, connections and ties which link people to relationships, resources and activities that may help to manage and optimise their mental health [ 11 ].

Terms are used that were included in the original paper.

Abbreviations

Attention deficit hyperactivity disorder

Mixed Methods Appraisal Tool

Population, intervention, comparatory, outcome

• Patient and public involvement

Peer Review of Electronic Search Strategies

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

randomised control tried

United Kingdom

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Acknowledgements

The authors would like to thank Alice Newton-Braithwaite for her helpful comments on the final version of the manuscript.

Funding for this project is through the Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0418-20011) via the National Institute for Health Research (NIHR). Views expressed within this article are those of the author(s) and not necessarily those of the Department of Health and Social Care or the NIHR.

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Mental Health Research Group, Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK

Helen Brooks, Angela Devereux-Fitzgerald, Laura Richmond, Penny Bee & Karina Lovell

Department of Clinical, Education & Health Psychology, University College London, London, UK

Laura Richmond

Patient and Public Involvement Contributor, University of Manchester, Manchester, UK

Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK

Mary Gemma Cherry

Linda McCartney Centre, Liverpool University Hospitals NHS Trust, Prescot St, Liverpool, UK

Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK

Karina Lovell

Patient and Public Involvement Contributor, Cambridge, UK

James Downs

School of Health Sciences, University of Manchester, Manchester, UK

Bethan Mair Edwards

NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, UK

Ivaylo Vassilev & Anne Rogers

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HB, MGC, PB, KL, II and AR obtaining funding for the study, formulated the review questions and designed the review. HB, PB, ADF KL, LR, NC, JD, BME, LB undertook title and abstract and full-text screening, data extraction and quality appraisal. HB, ADF and MGC undertook the narrative analysis. HB led the writing of the manuscript with input from AR and MGC. All authors provided input into draft manuscripts and approved the final version for submission.

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Brooks, H., Devereux-Fitzgerald, A., Richmond, L. et al. Exploring the use of social network interventions for adults with mental health difficulties: a systematic review and narrative synthesis. BMC Psychiatry 23 , 486 (2023). https://doi.org/10.1186/s12888-023-04881-y

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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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Psychological scars of genocide: a systematic review of post-traumatic outcomes in Kurdish Anfal survivors

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• Published: 22 March 2024

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• Harem Nareeman Mahmood   ORCID: orcid.org/0000-0002-3238-9714 1 , 2 ,
• Darya Rostam Ahmed 2 ,
• Sina Neldner 1 &
• Frank Neuner 1 , 3  

The Anfal genocide, including the infamous Halabja chemical attack, has imprinted deep scars on the Kurdish community in Iraq that lasted for decades. Despite significant historical documentation, the enduring psychological impact on survivors is less examined. This systematic review synthesizes existing research to address this gap. Adhering to the PRISMA guidelines, this review systematically searched databases for scholarly articles examining the mental health of Kurdish survivors following the 1988 Anfal genocide, with a focus on PTSD, depression, and anxiety. Of the initial 201 articles identified, seven met the inclusion criteria. These studies were subjected to a thorough data extraction and qualitative synthesis, and their quality was appraised using the Mixed Methods Appraisal Tool (MMAT). The selected studies encompassed a combined sample of 760 participants, ranging in age from 7 to 92 years. The findings revealed high prevalence rates of PTSD, particularly in children, with a prevalence rate of 87%. In adults, PTSD and depression prevalence rates in unselected samples were estimated at 86.2% and 49%, respectively. Qualitative findings from survivors reveal a complex interplay of depression, intrusive memories, and societal isolation, compounded by poverty and discrimination, with health concerns like respiratory and ocular problems further exacerbating psychological distress. However, non-representative samples and absence of control groups limit result generalization. The literature reviewed indicates substantial psychological distress among the Anfal genocide survivors, underscoring an urgent need for targeted mental health interventions. Future research needs representative samples and validated tools for precise prevalence assessment and comprehensive impact understanding.

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Introduction

Psychological trauma and the global perspective on genocides.

Throughout history, atrocities like genocides and chemical warfare have deeply harmed survivors’ mental well-being. Although some studies have documented the lasting impact of mass atrocities in survivors of the Holocaust (Horáčková et al., 2020 ; Harel et al., 1988 ), the Rwandan genocide (De Jong et al., 2001 ; Roth et al., 2014 ), and the genocide against the Yazidi people (Ibrahim et al., 2018 ; Ahmed & Heun, 2023 ), research exploring the psychological effects of mass atrocities is still limited, possibly due to the complex nature of mental health and its subtler effects compared to physical harm (Silove et al., 2008 ; Ng & Norwood, 2000 ). Acknowledging the historical magnitude of these events, it is imperative to focus on their lasting psychological ramifications. While this review incorporates necessary historical context to understand the extent of the Anfal genocide, the primary objective is to synthesize current research findings on the psychological impact this historical atrocity continues to have on Kurdish survivors.

Kurdish populations in Iraq during the Anfal campaign

The Kurdish population in Iraq suffered severe human rights violations during the Anfal genocide, also referred to as the Al-Anfal Campaign, from February to September 1988 under Saddam Hussein’s regime. This campaign unfolded in eight distinct phases, with each phase witnessing major military operations against the Kurds (Shorsh, 2007 ). Among these operations, the chemical attack on Halabja stands out as the most infamous, causing an estimated 5,000 deaths and injuring over 10,000 in just a few hours (Black et al., 1994 ). Overall, between 50,000 and 100,000 Kurdish individuals are believed to have been killed during the Anfal campaign (Hiltermann, 2007 ). This campaign led to the destruction of around 4,000 Kurdish villages and the displacement of up to a million individuals (Human Rights Watch, 1993 ). To date, some of those affected remain unaccounted for, casting persistent uncertainty over their families (Montgomery & Hennerbichler, 2020 ).

Such catastrophic events are likely to have profound and lasting psychological effects on the survivors. Experiences of severe trauma and loss and combined with the uprooting from familiar environments, contribute to a potentially complex and challenging pattern of mental health conditions (Al Shawi & Hassen, 2022 ). Furthermore, the psychological outcomes of such widespread and systemic violence and disruption are possibly exacerbated by ongoing sociopolitical difficulties, such as protracted displacement and persistent insecurity (Porter & Haslam, 2005 ). These additional stressors and adversities can compound the psychological toll of the original traumas and contribute to a range of negative mental health outcomes (Mahmood et al., 2022b ; Mahmood, 2023 ), potentially resembling complex PTSD, a condition often associated with prolonged and repeated trauma (Cloitre et al., 2009 ).

The need for a systematic review

Research on genocide survivors, including those from the Yazidi community (Denkinger et al., 2021 ; Ahmed & Heun, 2023 ), Rohingya refugees (Hossain et al., 2021 ), and Rwandan genocide (Munyandamutsa et al., 2012 ; Rieder & Elbert, 2013 ; Rugema et al., 2015 ; Schaal et al., 2009 ), consistently underscore the profound and persistent mental health challenges faced by these groups. Post-conflict studies on genocide survivors in Iraq indicate that survivors present with high rates of post-traumatic stress disorder (PTSD), depression, and anxiety disorders (Al Shawi & Hassen, 2022 ). Yet, only a few studies have specifically focused on the mental health of Kurdish Anfal survivors. A systematic review is essential to thoroughly examine the limited data available, assess its quality, pinpoint existing knowledge gaps, and lay a substantial groundwork for future scholarly inquiries, policy development, and the design of therapeutic measures. The limited research available impedes the development of specialized mental health programs and highlights the prevailing inequities in healthcare services (Miller & Rasmussen, 2010 ).

Objective, scope, and prospective impact of the current review

Using the PRISMA guidelines from Page et al. ( 2021 ), the current review aims to critically analyze and synthesize empirical studies on the psychological outcomes among Kurdish survivors of the Anfal genocide, documenting the observed prevalence of conditions such as PTSD, depression, and anxiety. It critically evaluates the methodological approaches of the included studies, highlighting the limitations due to non-representative sampling and underscoring the necessity for methodologically sound future research to determine accurate prevalence rates and establish a clearer understanding of the genocide’s psychosocial consequences. Through meticulous examination of existing literature, the review seeks to offer a comprehensive understanding of the current state of knowledge, emphasizing the unique challenges faced by these survivors. The review aims to delineate the observed mental health conditions and inform the need for methodologically robust research.

Study Design

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline (Page et al., 2021 ). The systematic review was conducted following the PRISMA guidelines, ensuring a comprehensive and reproducible approach to identifying, screening, and synthesizing the relevant literature on the psychological aftermath of the Anfal genocide among survivors. The research questions of this systematic review are designed to synthesize the existing findings on mental health conditions in survivors of the Anfal Genocide. The scope includes assessing the reported prevalence rates and outcomes of these conditions, while acknowledging the constraints posed by non-representative sampling and the methodologies of the included studies.

Search strategy

A comprehensive and exhaustive search was performed across three major electronic databases: PubMed, Scopus, and Google Scholar. Our search strategy employed a combination of specific keywords, Medical Subject Headings (MeSH) terms, and Boolean operators for the identification of pertinent articles. The terms used for search included: “Anfal”, “Genocide”, “Halabja”, “Chemical attacks”, “Kurdish”, “Kurdistan”, “Iraq”, “trauma”, “mental health”, “PTSD”, “Depression”, “Anxiety”, “Violence”, “survivors”, “victims”. The search was restricted to English language articles published from 1988 up until September 20, 2023. In addition, the reference lists of included articles were also hand-searched for additional relevant articles. To ensure a comprehensive review, the scope of our search strategy was both broad and precise. Our literature search and selection criteria were meticulously designed to capture the most contemporary and relevant research, with an emphasis on findings that directly address the post-traumatic outcomes experienced by the survivors.

Eligibility criteria

Inclusion criteria.

Studies qualified for inclusion in the systematic review if they met the following conditions: (1) were conducted on Kurdish populations who were exposed to the Anfal genocide campaign from February to September 1988; (2) evaluated mental health conditions such as PTSD, depression, anxiety, and related disorders in individuals affected by Anfal campaign; and (3) were peer-reviewed, English language studies published between 1988 and September 2023.

Exclusion criteria

Studies were excluded if they: (1) focused on non-Kurdish populations; (2) did not assess mental health outcomes linked to the Anfal genocide and the Halabja chemical attack; (3) solely investigated physical health outcomes; or (4) were not peer-reviewed and published in English.

Data extraction and synthesis

Data extraction was conducted independently by two reviewers (DRA & HNM) using a standardized form. Discrepancies between reviewers were infrequent and resolved through discussion and consensus, ensuring a reliable synthesis of the data. The extracted information included study characteristics (author, publication year), participant demographics, evaluated mental health outcomes, measurement instruments, and key findings. The included studies’ findings were qualitatively synthesized, summarizing the main themes and trends related to trauma and mental health in the Kurdish population affected by the Anfal genocide and the Halabja chemical attack.

Quality assessment

The quality of the included studies was assessed using the Mixed Methods Appraisal Tool (MMAT), designed for appraising the methodological quality of qualitative, quantitative, and mixed methods studies (Hong et al., 2019 ). Each study was evaluated based on five criteria: clear research question/objectives, adequate data collection, contextual consideration in data interpretation, appropriateness of data analysis, and minimization of bias. Each criterion was scored as either ‘Yes’ (1 point) or ‘No/Can’t tell’ (0 points), for a maximum possible MMAT score of 5 (indicating the highest quality) per study. The quality assessment was conducted independently by two researchers (HNM and DRA). In cases of initial disagreement on MMAT scores, the researchers engaged in a structured discussion to reconcile differences. Following this, the average of their reconciled scores was used to calculate the final score for each study, as presented in Table  1 . While assessing methodological quality using MMAT, studies were also evaluated for the extent to which they addressed instrument validity, especially concerning cultural sensitivity and diagnostic utility within the Kurdish population. This process ensured a consistent and accurate evaluation of the studies, reflected by the calculated interrater reliability. The interrater reliability, as measured by Cohen’s Kappa, was 0.78, indicating a substantial level of agreement between the two researchers.

Selection process

The search across the three databases yielded a total of 201 articles. After removing 47 duplicates, 154 unique articles remained for screening. During the screening process, we excluded 115 articles were excluded based on their abstracts as they did not align with our research question. This left us with 39 articles for potential inclusion. Thus, the remaining articles underwent a comprehensive full-text assessment to determine their eligibility. Out of these, we excluded 32 articles based on our predefined eligibility criteria: nine were not peer-reviewed, ten focused on physical health outcomes, and thirteen were narrative stories. Consequently, we included seven articles in the final systematic review, see Fig.  1 .

PRISMA flow diagram

Study designs

Four studies, conducted by Ahmad et al. ( 2000 ), Dworkin et al. ( 2008 ), Taha and Abdurrahman ( 2020 ), and Neldner et al. ( 2023 ), employed a cross-sectional design. Moradi et al. ( 2022 ) utilized a case-control approach. Bolton et al. ( 2013 ) adopted a qualitative methodology, specifically using a grounded theory approach, and Moradi et al. ( 2019 ) applied a qualitative design with semi-structured interviews based on the WHO’s definition of general health and quality of life (QOL) domains. Detailed studies characteristics can be found in Table  2 .

Participants

The studies encompassed a total of 760 participants, comprising 423 males and 337 females. Participant’s age ranged from 7 to 92 years. The smallest study sample had 16 participants (Moradi et al., 2019 ), while the largest included 291 participants (Dworkin et al., 2008 ). Table  2 shows more details about the participants of all included studies.

Diagnostic measurements

Different instruments were utilized across the studies to assess mental health issues. These tools included the Harvard Trauma Questionnaire (HTQ), Posttraumatic Stress Disorder Reaction Index (PTSD-RI), PTSD Symptom Checklist-Civilian (PTSS-C), Montgomery-Åsberg Depression Rating Scale-Self Report (MADRS-S), RAND Short Form 36 (SF-36), War and Adversity Exposure Checklist (WAEC), PTSD Checklist for DSM-5 (PCL-5), Derogatis Hopkins Symptom Checklist-25 (D-HSCL-25), and Social Acknowledgment Scale (SAS). Bolton et al. ( 2013 ) utilized free list interviews, while Moradi et al. ( 2019 ) implemented a semi-structured interview guide based on the WHO’s definition of general health and quality of life (QOL) domains.

Results of quantitative studies

Ahmad et al. ( 2000 ): Focused on the PTSD impact on children affected by the military operation “Anfal” in Iraqi Kurdistan. A prevalence rate of 87% was observed among children. It’s noteworthy that female children (95%) exhibited a higher prevalence rate than male children (79%). Interestingly, among the children, those aged between 7 and 12 years reported a higher prevalence (94%) compared to their older counterparts aged 13–17 years (80%). Caregivers, particularly female caregivers (96%), exhibited a higher PTSD prevalence than their male counterparts (24%), with those aged 18–41 years showing a 68% prevalence compared to 52% in the 42–91 age group.

Dworkin et al. ( 2008 ) assessed the psychosocial effects of the Halabja chemical attack, finding variations in PTS scores across demographics, with women exhibiting a mean PTS score of 1.97 and men 1.83. Age influenced PTS scores, with the 46–55 age group having the highest mean score of 2.04. Further, the study by Taha and Abdurrahman ( 2020 ) surveyed Anfal survivors, revealing a PTSD prevalence of 86.2%. Notably, females reported higher PTSD symptom scores (mean = 3.4) than males (mean = 2.9). The analysis indicated that age did not significantly predict PTSD diagnosis.

Moradi et al. ( 2022 ) explored the long-term depressive symptoms in survivors who were exposed to sulfur mustard (SM) during the Halabja chemical attack, observed an overall mean score of 22.9 within the exposed group, indicative of moderate depression. While the study did not find significant gender differences in depression scores, it did report that female survivors had a slightly higher overall mean MADRS-S score (24.3) compared to male survivors (21.4).

Using culturally validated instruments, Neldner et al. ( 2023 ) conducted a comprehensive study on survivors of the Halabja chemical attack in 1988, documenting the traumatic impact and associated mental health outcomes. On average, participants reported experiencing 5.07 types of traumatic events related to the genocide. The study found that 51.7% of the survivors met the criteria for PTSD and 49.0% for depression. For a more detailed and structured elucidation of all quantitative revelations, see Table  3 .

Results of qualitative studies

Bolton et al. ( 2013 ) examined the mental health and psychosocial issues of Kurdish survivors of torture and genocide using grounded theory. Key themes identified include ongoing trauma-related issues, current life challenges, and social perception/treatment issues. It highlighted that survivors suffer from problems such as depression, intrusive memories, isolation, and societal treatment, and these issues are compounded by current stressors like poverty and discrimination.

The study by Moradi et al. ( 2019 ) explores the major health concerns of civilians in Halabja who survived SM exposure with long-term respiratory symptoms. The qualitative study reveals a significant deterioration in physical and psychological health due to SM exposure. Predominant issues include respiratory symptoms, fatigue, sleeping disorders, ocular problems, depressive symptoms, anxiety, and limitations in daily life activities. Access to healthcare was notably poor, with a lack of financial resources to obtain treatment.

Quality assessment of included studies

The methodological quality of the included studies, assessed using MMAT, varied, with total scores ranging from 3 to 5 out of a maximum possible score of 5. The mean quality score among all studies was 4.2. This average score indicates the overall methodological robustness of the studies considered in this review, while the range illustrates the variability in quality. The MMAT scores for each study are summarized in Table  1 . Although the MMAT scores denote a level of methodological quality, they are insufficient to evaluate crucial methodological criteria, in particular instrument validity in the specific context, as well as representativeness’ of the sample. Although the studies generally reported findings from samples that were not help-seeking and seemingly unselected, none of the studies could ascertain representativeness of their sample.

The primary objective of this systematic review was to explore potential associations between the Anfal genocide and mental health outcomes among Kurdish survivors of the Anfal campaign of 1988. Seven pertinent studies were scrutinized, providing both quantitative and qualitative insights. This section delves into the findings and contrasts them with other seminal works in the field.

One of the most striking findings from this review is the prevalence of psychopathological outcomes. A dominant theme in the quantitative studies is the strikingly high prevalence of PTSD and related disorders among the populations under study. For instance, Ahmad et al. ( 2000 ) identified a PTSD prevalence of 87% among children impacted by the Anfal military operation. This prevalence is consistent with findings from other studies on war-impacted children (Derluyn et al., 2004 ; Betancourt et al., 2013 ). The disparities evident across age groups and genders are consistent with previous research that suggests certain demographics might be more predisposed to PTSD (Tolin & Foa, 2006 ). While discussing the prevalence rates, it is crucial to remember that these are derived from non-representative studies. Consequently, these rates should not be generalized to the entire population of Kurdish survivors of the Anfal Genocide. The findings highlight the need for more comprehensive, representative research to accurately determine the prevalence of mental health conditions in this population.

Regarding depression, Neldner et al. ( 2023 ) conducted a cross-sectional study and found that almost half of their study participants were diagnosed with depression. On the other hand, Moradi et al. ( 2022 ) utilized a case-control approach, highlighting the significant psychological effects on those exposed to chemical warfare. Their case-control research revealed that survivors exposed to SM had notably high levels of depression, a finding in line with other studies on the mental health impacts of chemical warfare (Ghaedi et al., 2012 ). Moradi et al. ( 2022 ) further found a connection between depression, thoughts of suicide, and sleep problems. While the case-control design provides valuable comparative data, it’s important to note that additional factors in the survivors’ current life situations may also contribute to the high depression scores reported, a nuance that is supported by the broader literature on trauma (Ribeiro et al., 2012 ).

In addition to the statistical findings, our review highlighted deeper, qualitative insights. The studies by Bolton et al. ( 2013 ) and Moradi et al. ( 2019 ) provide a closer look into the personal experiences of trauma survivors. Their stories are similar to findings from other trauma studies (Ford et al., 2015 ), where survivors describe ongoing memories, feelings of being rejected by society, and a deep sense of abandonment. These results emphasize the wide range of challenges survivors face. It shows that the effects of trauma are not just psychological but also influence how they are viewed in society and their overall quality of life.

Gender, age, and Trauma

The studies reviewed consistently showed significant gender differences in PTSD prevalence, with females frequently exhibiting greater vulnerability to trauma-related disorders, a finding supported by Ahmad et al. ( 2000 ) and Taha and Abdurrahman ( 2020 ), and consistent with broader research suggesting women may have an increased risk for such conditions (Olff et al., 2017 ; Mahmood et al., 2019 , 2022a ). The underlying causes could be multifaceted, encompassing biological, environmental, and societal factors. Age, while a determinant in trauma reactions, presented variable influences across studies. Some research suggests that younger individuals might display more resilience due to fewer life responsibilities and more adaptive coping mechanisms (Cherewick et al., 2016 ), whereas other studies indicate that the vulnerability could increase with age due to cumulative stress and decreased physiological resilience ( Ogle et al., 2014 ). Surprisingly, Taha and Abdurrahman ( 2020 ) reported instances where the severity of the traumatic experience had a more pronounced impact than the typically expected age-related resilience, indicating that the contextual intensity of trauma can sometimes override age-related coping capacities. This observation aligns with Ditlevsen and Elklit ( 2010 ), who noted significant disparities in the lifespan distribution of PTSD symptoms, suggesting that both gender and age, alongside the nature and context of the traumatic event, are crucial determinants of PTSD occurrence.

Cumulative and enduring impact of Trauma

Taha and Abdurrahman ( 2020 ) and Neldner et al. ( 2023 ) highlighted the compounded psychological impact of enduring multiple traumatic events over time. Given the continued instability in the region, it is likely that Anfal survivors have encountered additional traumas following the genocide, which could exacerbate their psychological distress. This is consistent with patterns observed in survivors from various conflict zones (Neuner et al., 2004 ), where the accumulation of traumatic experiences significantly worsens psychological outcomes. Similarly, Dworkin et al. ( 2008 ) underscored that the detrimental effects of trauma are enduring and do not simply diminish over time. Long-term studies corroborate this, illustrating that the consequences of trauma can persist for many years post-event (Cooper et al., 2019 ; Blackmore et al., 2020 ; Mahmood et al., 2022b ).

In light of these persistent effects, and the shared societal and healthcare ramifications, the following considerations are imperative. These findings not only highlight the enduring impact of the Anfal genocide but also point to a broader societal responsibility. The synthesis of the current literature underscores a pressing need for culturally informed mental health interventions that are sensitive to the unique experiences of Kurdish Anfal survivors. This review serves as a call to action for policymakers and healthcare providers to allocate resources and develop programs tailored to this population.

Quality of included studies

The methodological quality of the studies included in this review varied, as indicated by their MMAT scores. While many studies had clear objectives and reliable data collection methods, some encountered design issues, which were reflected in lower MMAT scores. Overall, most studies were of moderate to high quality, supporting the credibility of the review’s findings. However, it is essential to contextualize the methodological robustness with the understanding that MMAT scores do not necessarily reflect the validation of assessment instruments. The lack of direct evidence on cultural sensitivity and diagnostic reliability of these instruments within the Kurdish population suggests a need for further investigation, which is crucial for substantiating the reported prevalence rates of mental health conditions among genocide survivors.

Limitations and future directions

This systematic review has unveiled crucial insights into the mental health implications of the Anfal genocide on Kurdish communities, revealing a need for more extensive research. The existing studies—limited in number and with small cohorts—highlight a gap in high-quality research, particularly in the prevalence of conditions such as anxiety alongside PTSD and depression. Both lack of control groups from unaffected population with similar socio-historical backgrounds and the non-representativeness of the samples undermines our ability to extrapolate these findings to the broader population. Future studies should prioritize methodological rigor, using validated tools and larger, more diverse samples. Such research is essential not only for a comprehensive understanding of the genocide’s impact but also for developing robust mental health interventions that can foster resilience and well-being in the face of past and ongoing adversities.

The scarcity of research on the Anfal genocide is a significant limitation, especially given the importance of quality research in top-tier journals. This gap affects our complete understanding of the genocide’s impact on Kurdish mental health and questions the existing research’s applicability. Future studies must address this, emphasizing methodological rigor, larger samples, and thorough peer reviews. Such commitment will strengthen the evidence base and help design appropriate mental health interventions.

Such research is essential not only for a comprehensive understanding of the genocide’s impact but also for developing robust mental health interventions that can foster resilience and well-being in the face of past and ongoing adversities. Recognizing these gaps, this review serves as a clarion call for further research, more informed policy formulation, and enhanced guidance for mental health professionals. Highlighting significant mental health challenges within the Kurdish community, it aims to lay the groundwork for future scholarly efforts, policy development, and therapeutic strategies that are culturally sensitive and responsive to the needs of the survivors and their families.

The Kurdish Anfal genocide has inflicted lasting psychological trauma on survivors, an issue that this study has highlighted with great concern. It underscores the vital need for mental health strategies that are both culturally responsive and trauma-informed, aiming to enhance the resilience and psychological well-being of those affected. Despite shedding new light on these issues, our research is limited by the narrow range of existing studies and their inherent methodological constraints. Therefore, there is an imperative for future research to comprehensively explore the psychological impact of these events to develop effective interventions for survivors and their families. Additionally, the healing process is closely linked to the acknowledgement and memorialization of their ordeals, reinforcing the role of historical recognition in psychological recovery. In light of our findings, we advocate for a significant increase in international research collaboration and the establishment of mental health programs. These initiatives must prioritize ongoing, empathetic support, which is crucial for the long-term healing of Anfal genocide survivors.

Data availability

This article is a systematic review and synthesizes findings from previously published literature. Information on the data analyzed during the current study is available from the corresponding author on reasonable request.

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Contributions

Harem Nareeman Mahmood (H.N.M.) and Darya Rostam Ahmed (D.R.A.) conceived the study. Both H.N.M. and D.R.A. were involved in the development of the methodology, data collection, syntax, and analysis, as well as in conducting the quality assessment of the included studies. H.N.M. wrote the final draft of the manuscript. Sina Neldner (S.N.) and D.R.A. assisted in reviewing and editing the drafting and critical revision of all sections of the manuscript. Frank Neuner (F.N.) provided critical feedback and revised the manuscript for important intellectual content. All authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

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Correspondence to Harem Nareeman Mahmood .

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Mahmood, H.N., Ahmed, D.R., Neldner, S. et al. Psychological scars of genocide: a systematic review of post-traumatic outcomes in Kurdish Anfal survivors. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-05863-3

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Accepted : 09 March 2024

Published : 22 March 2024

DOI : https://doi.org/10.1007/s12144-024-05863-3

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