systematic literature review in social work

+ Social Work: Systematic Review

• Getting Started
• Tests & Measurements
• Citing Sources--APA
• Systematic Review
• Dissertations, Theses, and Research Papers
• Professional Development

Methods for Synthesizing Qualitative Reviews

Ruth Garside, PhD, Senior Lecturer in Evidence Synthesis at the Medical School, University of Exeter

Check out PRISMA to guide your review: especially the checklist for your review and the flow diagram to develop your protocol.

The PRISMA Statement:

Anybody writing a systematic literature review should be familiar with the  PRISMA statement . The PRISMA Statement is a document that consists of a 27-item  checklist  and a  flow diagram  and aims to guide authors on how to develop a systematic review protocol and what to include when writing the review.

A protocol ideally includes the following:

Databases to be searched and additional sources (particularly for grey literature)

Keywords to be used in the search strategy

Limits applied to the search.

Screening process

Data to be extracted

Summary of data to be reported

From Majumbder, K. (2015). A young researcher's guide to a systematic review. Editage Insights. Retrieved from   https://www.editage.com/insights/a-young-researchers-guide-to-a-systematic-review#

Systematic Literature Review

Here are a couple of articles found in Sage Research Methods Online which give good definitions of what a Systematic Literature Review is and how to do one:

Dempster, M. (2003). Systematic review . In Robert L. Miller, & John D. Brewer

      (Eds.), The A-Z of Social Research. (pp. 312-317). London, England: SAGE

      Publications, Ltd. doi: http://dx.doi.org/10.4135/9780857020024.n110

​Crisp, B.R. (2015). Systematic reviews: a social work perspective . Australian

      Social Work, 68 (3): 284-295. http://dx.doi.org/10.1080/0312407X.2015.102426

Schick-Makaroff, K., MacDonald, M. Plummer, M., Burgess, J., & Neander, W. (2016).

      What Synthesis Methodology Should I Use? A Review and Analysis of Approaches to

       Research Synthesis .  AIMS Public Health, 3 (1). 172-215.

      doi: 10.3934/publichealth.2016.1.172

       http://dspace.library.uvic.ca:8080/handle/1828/7464

Inclusion/Exclusion Criteria

• Veale, T.Search concept tools. Retrieved from //medhealth.leeds.ac.uk/info/639/information_specialists/1500/search_concept_tools Describes various structures for developing criteria: PICO, PICOS, SPIDER, SPICE, etc.

Support for Systematic Reviews

• Systematic Review Search Strategies Worksheet Organize your review by topic, database, search string, and criteria
• Evaluation of Sources Questions to ask of primary source articles (both qualitative and quantitative) when evaluating their quality
• Software for Organizing Systematic Reviews From Columbia University Medical Center's Library
• Evidence-Based Practice
• Meta-Ethnography
• Qualitative Evidence Synthesis

Examples of Systematic Reviews

Prospero: International Prospective Register of Systematic Reviews

This web site collects systematic reviews in process.  By reviewing them, you can see what is included in a systematic review.

Campbell Systematic Reviews

This Monograph series is an open access collection of peer-reviewed systematic reviews.  "Campbell systematic reviews follow structured guidelines and standards for summarizing the international research evidence on the effects of interventions in crime and justice, education, international development, and social welfare." Registration and protocols are available from the Campbell Collaboration Library of Systematic Reviews .

• << Previous: Citing Sources--APA
• Next: Dissertations, Theses, and Research Papers >>
• Last Updated: Apr 17, 2024 2:48 PM
• URL: https://libguides.stthomas.edu/socialwork

© 2023 University of St. Thomas, Minnesota

Purdue Online Writing Lab Purdue OWL® College of Liberal Arts

Social Work Literature Review Guidelines

Welcome to the Purdue OWL

This page is brought to you by the OWL at Purdue University. When printing this page, you must include the entire legal notice.

Copyright ©1995-2018 by The Writing Lab & The OWL at Purdue and Purdue University. All rights reserved. This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission. Use of this site constitutes acceptance of our terms and conditions of fair use.

Literature reviews are designed to do two things: 1) give your readers an overview of sources you have explored while researching a particular topic or idea and 2) demonstrate how your research fits into the larger field of study, in this case, social work.

Unlike annotated bibliographies which are lists of references arranged alphabetically that include the bibliographic citation and a paragraph summary and critique for each source, literature reviews can be incorporated into a research paper or manuscript. You may quote or paraphrase from the sources, and all references to sources should include in-text parenthetical citations with a reference list at the end of the document. Sometimes, however, an instructor may require a separate literature review document and will have specific instructions for completing the assignment.

Below you will find general guidelines to consider when developing a literature review in the field of social work. Because social work is a social science field, you will most likely be required to use APA style. Please see our APA materials for information on creating parenthetical citations and reference lists.

1. Choose a variety of articles that relate to your subject, even if they do not directly answer your research question. You may find articles that loosely relate to the topic, rather than articles that you find using an exact keyword search. At first, you may need to cast a wide net when searching for sources.

For example: If your research question focuses on how people with chronic illnesses are treated in the workplace, you may be able to find some articles that address this specific question. You may also find literature regarding public perception of people with chronic illnesses or analyses of current laws affecting workplace discrimination.

2. Select the most relevant information from the articles as it pertains to your subject and your purpose. Remember, the purpose of the literature review is to demonstrate how your research question fits into a larger field of study.

3. Critically examine the articles. Look at methodology, statistics, results, theoretical framework, the author's purpose, etc. Include controversies when they appear in the articles.

For example: You should look for the strengths and weaknesses of how the author conducted the study. You can also decide whether or not the study is generalizable to other settings or whether the findings relate only to the specific setting of the study. Ask yourself why the author conducted the study and what he/she hoped to gain from the study. Look for inconsistencies in the results, as well.

4. Organize your information in the way that makes most sense. Some literature reviews may begin with a definition or general overview of the topic. Others may focus on another aspect of your topic. Look for themes in the literature or organize by types of study.

For example: Group case studies together, especially if all the case studies have related findings, research questions, or other similarities.

5. Make sure the information relates to your research question/thesis. You may need to explicitly show how the literature relates to the research question; don't assume that the connection is obvious.

6. Check to see that you have done more than simply summarize your sources. Your literature review should include a critical assessment of those sources. For more information, read the Experimental Psychology - Writing a Literature Review handout for questions to think about when reading sources.

7. Be sure to develop questions for further research. Again, you are not simply regurgitating information, but you are assessing and leading your reader to questions of your own, questions and ideas that haven't been explored yet or haven't been addressed in detail by the literature in the field.

Social Work Research: Literature Reviews

• Getting Started
• Finding Scholarly Articles
• Citation Searching
• Evaluating Sources This link opens in a new window
• Literature Reviews
• Evidence-Based This link opens in a new window
• Finding Instruments This link opens in a new window
• Writing & Citing

Using A Literature Review

A literature review is a very practical part of the research process.  It's how you build on other research in the field - identify best practices and tools and learn what doesn't work.  The resources on the page are here to help you structure you literature review so it's as useful as possible.  

Also take a look at any literature reviews you find as you search for articles - in addition to content and further references they'll also provide helpful structural hints. 

• Social Work Literature Review Guidelines Literature reviews are designed to do two things: 1) give your readers an overview of sources you have explored while researching a particular topic or idea and 2) demonstrate how your research fits into the larger field of study, in this case, social work.
• Considerations in Writing a Literature Review This article will briefly outline key points for you to keep in mind when writing literature reviews for social work.
• Undertaking a literature review: a step-by-step approach The purpose of this article is to present a step-by-step guide to facilitate understanding by presenting the critical elements of the literature review process. While reference is made to different types of literature reviews, the focus is on the traditional or narrative review that is undertaken, usually either as an academic assignment or part of the research process.

Conducting a Literature Review & Other Research Methods

What is a Literature Review?

"Literature reviews are systematic syntheses of previous work around a particular topic. Nearly all scholars have written literature reviews at some point; such reviews are common requirements for class projects or as part of theses, are often the first section of empirical papers, and are sometimes written to summarize a field of study. Given the increasing amount of literature in many fields, reviews are critical in synthesizing scientific knowledge." - Encyclopedia of Research Design

• APA Style Sample Papers (seventh edition) by the APA
• Sample APA Paper (lit. review begins page 3)
• Dissertations and Theses Full-Text Global Search here for examples of literature reviews from masters and doctoral theses.

Thinking About A Literature Review

Literature Reviews: An Overview

Additional How-To Guides

• CSU, Chico Office of Graduate Studies - Thesis Assistance Instructions, policies, and guidelines for graduate studies theses/projects.
• CSU, Chico Writing Center Make a one-on-one appointment with a writing tutor to help with your writing assignments.
• Learn How to Write a Review of the Literature University of Wisconsin-Madison
• Literature Review: An Overview for Graduate Students Video overview by North Carolina State University Libraries
• Literature Review: The What, Why and How-to Guide University of Connecticut University Libraries
• << Previous: Evaluating Sources
• Next: Evidence-Based >>
• Last Updated: Apr 2, 2024 9:49 AM
• URL: https://simmons.libguides.com/SSWResearch

• USC Libraries
• Research Guides
• SOWK 544: Clinical Social Work Practice with Individuals, Families, & Groups
• The Literature Review

SOWK 544: Clinical Social Work Practice with Individuals, Families, & Groups: The Literature Review

• Phases of Treatment
• Treatment Planners
• Resources for Clinical Skills
• Evidence-based Practice Resources
• Finding Scholarly Articles
• Evaluating Information Resources
• Tests & Measurements
• APA 7th Edition

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

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . Fourth edition. Thousand Oaks, CA: SAGE, 2014.

Importance of a Good Literature Review

A literature review may consist of simply a summary of key sources, but in the social sciences, a literature review usually has an organizational pattern and combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

• Give a new interpretation of old material or combine new with old interpretations,
• Trace the intellectual progression of the field, including major debates,
• Depending on the situation, evaluate the sources and advise the reader on the most pertinent or relevant research, or
• Usually in the conclusion of a literature review, identify where gaps exist in how a problem has been researched to date.

The purpose of a literature review is to:

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

Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper. 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . Los Angeles, CA: SAGE, 2011; Knopf, Jeffrey W. "Doing a Literature Review." PS: Political Science and Politics 39 (January 2006): 127-132; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012.

Types of Literature Reviews

It is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the primary studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally that become part of the lore of field.

In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews. Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are a number of approaches you could adopt depending upon the type of analysis underpinning your study.

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

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

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

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

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

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

Baumeister, Roy F. and Mark R. Leary. "Writing Narrative Literature Reviews."  Review of General Psychology 1 (September 1997): 311-320; Mark R. Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Kennedy, Mary M. "Defining a Literature." Educational Researcher 36 (April 2007): 139-147; Petticrew, Mark and Helen Roberts. Systematic Reviews in the Social Sciences: A Practical Guide . Malden, MA: Blackwell Publishers, 2006; Torracro, Richard. "Writing Integrative Literature Reviews: Guidelines and Examples." Human Resource Development Review 4 (September 2005): 356-367; Rocco, Tonette S. and Maria S. Plakhotnik. "Literature Reviews, Conceptual Frameworks, and Theoretical Frameworks: Terms, Functions, and Distinctions." Human Ressource Development Review 8 (March 2008): 120-130; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following :

• An overview of the subject, issue, or theory under consideration, along with the objectives of the literature review,
• Division of works under review into themes or categories [e.g. works that support a particular position, those against, and those offering alternative approaches entirely],
• An explanation of how each work is similar to and how it varies from the others,
• Conclusions as to which pieces are best considered in their argument, are most convincing of their opinions, and make the greatest contribution to the understanding and development of their area of research.

The critical evaluation of each work should consider :

• Provenance -- what are the author's credentials? Are the author's arguments supported by evidence [e.g. primary historical material, case studies, narratives, statistics, recent scientific findings]?
• Methodology -- were the techniques used to identify, gather, and analyze the data appropriate to addressing the research problem? Was the sample size appropriate? Were the results effectively interpreted and reported?
• Objectivity -- is the author's perspective even-handed or prejudicial? Is contrary data considered or is certain pertinent information ignored to prove the author's point?
• Persuasiveness -- which of the author's theses are most convincing or least convincing?
• Value -- are the author's arguments and conclusions convincing? Does the work ultimately contribute in any significant way to an understanding of the subject?

II.  Development of the Literature Review

Four Stages 1.  Problem formulation -- which topic or field is being examined and what are its component issues? 2.  Literature search -- finding materials relevant to the subject being explored. 3.  Data evaluation -- determining which literature makes a significant contribution to the understanding of the topic. 4.  Analysis and interpretation -- discussing the findings and conclusions of pertinent literature.

Consider the following issues before writing the literature review: Clarify If your assignment is not very specific about what form your literature review should take, seek clarification from your professor by asking these questions: 1.  Roughly how many sources should I include? 2.  What types of sources should I review (books, journal articles, websites; scholarly versus popular sources)? 3.  Should I summarize, synthesize, or critique sources by discussing a common theme or issue? 4.  Should I evaluate the sources? 5.  Should I provide subheadings and other background information, such as definitions and/or a history? Find Models Use the exercise of reviewing the literature to examine how authors in your discipline or area of interest have composed their literature review sections. Read them to get a sense of the types of themes you might want to look for in your own research or to identify ways to organize your final review. The bibliography or reference section of sources you've already read are also excellent entry points into your own research. Narrow the Topic The narrower your topic, the easier it will be to limit the number of sources you need to read in order to obtain a good survey of relevant resources. Your professor will probably not expect you to read everything that's available about the topic, but you'll make your job easier if you first limit scope of the research problem. A good strategy is to begin by searching the USC Libraries Catalog for books about the topic and review the table of contents for chapters that focuses on specific issues. You can also review the indexes of books to find references to specific issues that can serve as the focus of your research. For example, a book surveying the history of the Israeli-Palestinian conflict may include a chapter on the role Egypt has played in mediating the conflict, or look in the index for the pages where Egypt is mentioned in the text. Consider Whether Your Sources are Current Some disciplines require that you use information that is as current as possible. This is particularly true in disciplines in medicine and the sciences where research conducted becomes obsolete very quickly as new discoveries are made. However, when writing a review in the social sciences, a survey of the history of the literature may be required. In other words, a complete understanding the research problem requires you to deliberately examine how knowledge and perspectives have changed over time. Sort through other current bibliographies or literature reviews in the field to get a sense of what your discipline expects. You can also use this method to explore what is considered by scholars to be a "hot topic" and what is not.

III.  Ways to Organize Your Literature Review

Chronology of Events If your review follows the chronological method, you could write about the materials according to when they were published. This approach should only be followed if a clear path of research building on previous research can be identified and that these trends follow a clear chronological order of development. For example, a literature review that focuses on continuing research about the emergence of German economic power after the fall of the Soviet Union. By Publication Order your sources by publication chronology, then, only if the order demonstrates a more important trend. For instance, you could order a review of literature on environmental studies of brown fields if the progression revealed, for example, a change in the soil collection practices of the researchers who wrote and/or conducted the studies. Thematic [“conceptual categories”] Thematic reviews of literature are organized around a topic or issue, rather than the progression of time. However, progression of time may still be an important factor in a thematic review. For example, a review of the Internet’s impact on American presidential politics could focus on the development of online political satire. While the study focuses on one topic, the Internet’s impact on American presidential politics, it will still be organized chronologically reflecting technological developments in media. The only difference here between a "chronological" and a "thematic" approach is what is emphasized the most: the role of the Internet in presidential politics. Note however that more authentic thematic reviews tend to break away from chronological order. A review organized in this manner would shift between time periods within each section according to the point made. Methodological A methodological approach focuses on the methods utilized by the researcher. For the Internet in American presidential politics project, one methodological approach would be to look at cultural differences between the portrayal of American presidents on American, British, and French websites. Or the review might focus on the fundraising impact of the Internet on a particular political party. A methodological scope will influence either the types of documents in the review or the way in which these documents are discussed.

Other Sections of Your Literature Review Once you've decided on the organizational method for your literature review, the sections you need to include in the paper should be easy to figure out because they arise from your organizational strategy. In other words, a chronological review would have subsections for each vital time period; a thematic review would have subtopics based upon factors that relate to the theme or issue. However, sometimes you may need to add additional sections that are necessary for your study, but do not fit in the organizational strategy of the body. What other sections you include in the body is up to you but include only what is necessary for the reader to locate your study within the larger scholarship framework.

Here are examples of other sections you may need to include depending on the type of review you write:

• Current Situation : information necessary to understand the topic or focus of the literature review.
• History : the chronological progression of the field, the literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : the criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed articles and journals.
• Standards : the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

Once you've settled on how to organize your literature review, you're ready to write each section. When writing your review, keep in mind these issues.

Use Evidence A literature review section is, in this sense, just like any other academic research paper. Your interpretation of the available sources must be backed up with evidence [citations] that demonstrates that what you are saying is valid. Be Selective Select only the most important points in each source to highlight in the review. The type of information you choose to mention should relate directly to the research problem, whether it is thematic, methodological, or chronological. Related items that provide additional information but that are not key to understanding the research problem can be included in a list of further readings . Use Quotes Sparingly Some short quotes are okay if you want to emphasize a point, or if what an author stated cannot be easily paraphrased. Sometimes you may need to quote certain terminology that was coined by the author, not common knowledge, or taken directly from the study. Do not use extensive quotes as a substitute for your own summary and interpretation of the literature. Summarize and Synthesize Remember to summarize and synthesize your sources within each thematic paragraph as well as throughout the review. Recapitulate important features of a research study, but then synthesize it by rephrasing the study's significance and relating it to your own work. Keep Your Own Voice While the literature review presents others' ideas, your voice [the writer's] should remain front and center. For example, weave references to other sources into what you are writing but maintain your own voice by starting and ending the paragraph with your own ideas and wording. Use Caution When Paraphrasing When paraphrasing a source that is not your own, be sure to represent the author's information or opinions accurately and in your own words. Even when paraphrasing an author’s work, you still must provide a citation to that work.

V.  Common Mistakes to Avoid

These are the most common mistakes made in reviewing social science research literature.

• Sources in your literature review do not clearly relate to the research problem;
• You do not take sufficient time to define and identify the most relevent sources to use in the literature review related to the research problem;
• Relies exclusively on secondary analytical sources rather than including relevant primary research studies or data;
• Uncritically accepts another researcher's findings and interpretations as valid, rather than examining critically all aspects of the research design and analysis;
• Does not describe the search procedures that were used in identifying the literature to review;
• Reports isolated statistical results rather than synthesizing them in chi-squared or meta-analytic methods; and,
• Only includes research that validates assumptions and does not consider contrary findings and alternative interpretations found in the literature.

Cook, Kathleen E. and Elise Murowchick. “Do Literature Review Skills Transfer from One Course to Another?” Psychology Learning and Teaching 13 (March 2014): 3-11; Fink, Arlene. Conducting Research Literature Reviews: From the Internet to Paper . 2nd ed. Thousand Oaks, CA: Sage, 2005; Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1998; Jesson, Jill. Doing Your Literature Review: Traditional and Systematic Techniques . London: SAGE, 2011; Literature Review Handout . Online Writing Center. Liberty University; Literature Reviews . The Writing Center. University of North Carolina; Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: SAGE, 2016; Ridley, Diana. The Literature Review: A Step-by-Step Guide for Students . 2nd ed. Los Angeles, CA: SAGE, 2012; Randolph, Justus J. “A Guide to Writing the Dissertation Literature Review." Practical Assessment, Research, and Evaluation . vol. 14, June 2009; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016; Taylor, Dena. The Literature Review: A Few Tips On Conducting It . University College Writing Centre. University of Toronto; Writing a Literature Review . Academic Skills Centre. University of Canberra.

Writing Tip

Break Out of Your Disciplinary Box!

Thinking interdisciplinarily about a research problem can be a rewarding exercise in applying new ideas, theories, or concepts to an old problem. For example, what might cultural anthropologists say about the continuing conflict in the Middle East? In what ways might geographers view the need for better distribution of social service agencies in large cities than how social workers might study the issue? You don’t want to substitute a thorough review of core research literature in your discipline for studies conducted in other fields of study. However, particularly in the social sciences, thinking about research problems from multiple vectors is a key strategy for finding new solutions to a problem or gaining a new perspective. Consult with a librarian about identifying research databases in other disciplines; almost every field of study has at least one comprehensive database devoted to indexing its research literature.

Frodeman, Robert. The Oxford Handbook of Interdisciplinarity . New York: Oxford University Press, 2010.

Another Writing Tip

Don't Just Review for Content!

While conducting a review of the literature, maximize the time you devote to writing this part of your paper by thinking broadly about what you should be looking for and evaluating. Review not just what scholars are saying, but how are they saying it. Some questions to ask:

• How are they organizing their ideas?
• What methods have they used to study the problem?
• What theories have been used to explain, predict, or understand their research problem?
• What sources have they cited to support their conclusions?
• How have they used non-textual elements [e.g., charts, graphs, figures, etc.] to illustrate key points?

When you begin to write your literature review section, you'll be glad you dug deeper into how the research was designed and constructed because it establishes a means for developing more substantial analysis and interpretation of the research problem.

Hart, Chris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage Publications, 1 998.

Yet Another Writing Tip

When Do I Know I Can Stop Looking and Move On?

Here are several strategies you can utilize to assess whether you've thoroughly reviewed the literature:

• Look for repeating patterns in the research findings . If the same thing is being said, just by different people, then this likely demonstrates that the research problem has hit a conceptual dead end. At this point consider: Does your study extend current research?  Does it forge a new path? Or, does is merely add more of the same thing being said?
• Look at sources the authors cite to in their work . If you begin to see the same researchers cited again and again, then this is often an indication that no new ideas have been generated to address the research problem.
• Search the Web of Science [a.k.a., Web of Knowledge] Citation database and Google Scholar to identify who has subsequently cited leading scholars already identified in your literature review. This is called citation tracking and there are a number of sources that can help you identify who has cited whom, particularly scholars from outside of your discipline. Here again, if the same authors are being cited again and again, this may indicate no new literature has been written on the topic.

Onwuegbuzie, Anthony J. and Rebecca Frels. Seven Steps to a Comprehensive Literature Review: A Multimodal and Cultural Approach . Los Angeles, CA: Sage, 2016; Sutton, Anthea. Systematic Approaches to a Successful Literature Review . Los Angeles, CA: Sage Publications, 2016.

• << Previous: Evidence-based Practice Resources
• Next: Finding Scholarly Articles >>
• Last Updated: Jan 22, 2024 10:44 AM
• URL: https://libguides.usc.edu/SOWK544

• University Libraries
• Research Guides
• Subject Guides

Systematic Reviews in the Social Sciences

What is a systematic review in the social sciences?

Guides to conducting systematic reviews

Registering a systematic review, useful books.

• Searching Article Databases
• Covidence, Zotero, etc.

Social Sciences Librarian

Types of reviews

The form of a review generally depends on its purpose and area of interest and might focus on effectiveness of interventions, key conceptual debates, or something else. Reviews generally fall along a continuum from aggragative to interpretive.

• Traditional/narrative review - flexible methods and means of analysis, aims to identify gaps in knowledge
• Systematic review -  very structured, aims to be comprehensive and rigorous, promotes knowledge; focus on outcomes/evidence
• Rapid review - may use some of a systematic review's procedures, but more streamlined and quicker
• Scoping review - quickly draws main parameters of a topic & maps key publications, doesn't usually aim to appraise quality of publications ( See Covidence's guide to conducting scoping reviews )
• Systematic maps- more extensive than scoping reviews, maps out./categorizes literature on a specific topic
• Meta-analysis - analyzes review findings using standard statistical analysis
• Meta-synthesis - non-statistical; evaluates and analyzes findings from qualitative studies and aims to build on previous conceptualizations and interpretations

For more information see Shaw & Holland (2014). Reviewing research. In Doing Qualitative Research in Social Work . Sage.

Temple University Health Sciences Library also offers a good overview of review types related to a HEALTH SCIENCES PERSPECTIVE -- remember, this is not aimed at social scientists, but could still be a useful guide. 

Below is a summary of a good overview published by  Viktor, L. (2008). Systematic Reviewing.Social Research Update, 54. University of Surrey .  For more information, also see the "Useful Books" box at the bottom of this page.

What is a systematic review?

"Systematic reviews are a method of identifying and synthesising all the available research evidence of sufficient quality concerning a specific subject. The aim is to review and synthesise evidence in a transparent and rigorous way to enhance the validity and reliability of the findings."

Systematic reviews came to prominence in clinical medicine focused on interventions and outcomes and prioritized studies that were randomized controlled trials. They are usually conducted in a staged process and are focused on answering a particular question or set of questions.

How is it different from a traditional literature review?

In a systematic review, the focus on the comprehensiveness of the search, the quality of the evidence, and the fact that it is conducted very systematically using transparent and rigorous processes contributes to the reliability and validity of its findings as compared to a traditional literature review. Systematic reviews, focused on answering a specific question, are "less a discussion of the literature, and more a scientific tool...to summarize, appraise, and communicate the results and implications of otherwise unmanageable quantities of research."  (Petticrew & Roberts, 2006, p. 10).

In the social sciences, systematic reviews generally come out of the social policy area. Traditionally, they followed the methodology and approach taken in clinical medicine, using a highly prescribed staged methodology, statistical meta-analysis, etc. This approach has been adapted and extended in the social sciences allowing for more flexibility, less focus on comprehensiveness, the inclusion of a wider range of research and other methods of analysis (e.g. narrative), and using the method as a means to build theory.   

These organizations are focused on systematic reviews and provide resources to support conducting them.

• PRISMA PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) provides guidance on the reporting and conducting of systematic reviews and meta-analyses. Authors conducting systematic reviews can use PRISMA requirements for best practices, registration of reviews, protocols, checklists, and work flowcharts. See the PRISMA STATEMENT, EXTENSIONS and PROTOCOLS tabs for guidance.
• Cochrane Handbook for Systematic Reviews of Interventions Cochrane Systematic Reviews are conducted to draw conclusions about the quality of healthcare interventions and Cochrane has created a manual that describes the process of preparing and maintaining their systematic reviews on the effects of healthcare interventions.
• Campbell Collaboration A sister organization to Cochrane (see description above) focused on sytematic reviews of social interventions. See their TRAINING INFORMATION for excellent videos.
• EPPI-Centre Organization focused on systematic reviews and research synthesis in many areas of social policy. See their TOOLS page for helpful resources.
• What Works Clearinghouse Established by the US Dept of Education's Institute of Education Sciences to review the quality of education research and compile systematic reviews to guide practice. See their Handbooks and Other Resources tab for useful guidance.

The above resources include detailed guidelines and procedures for conducting systematic reviews. Some first steps to consider include:

1) Reviews should start with a meaningful and useful question, do you have a defined question? Is a systematic review the best way to approach this question?

2) Have you searched for other systematic reviews that have already been done on this question/topic? 

3) Develop your detailed protocol.

4) Develop an effective search strategy.

Often a systematic review is registered before it is undertaken. This article details why and where one might do this (e.g. in addtion to registries at Cochrane and Campbell, which are restricted to systematic reviews conducted within their organizations, other registries are more open, such as PROSPERO, Research Registry, INPLASY, OSF Registries, and protocols.io ). See this article for more info:

Pieper, D. & Rombey, T. (2022). Where to prospectively register a systematic review. Systematic Reviews, 11(8).  https://doi.org/10.1186/s13643-021-01877-1 

Software to Manage Systematic Reviews: Covidence

UNM has a subscription to COVIDENCE software. Visit the Library's research guide on using Covidence software for conducting systematic reviews -- learn why and how to use it.

• Covidence: Systematic Review Tool guide by Todd Quinn Last Updated Jan 23, 2024 919 views this year

Examples of social sciences systematic reviews

• One good source for examples of systematic reviews in the social sciences is the Campbell Collaboration's journal, Campbell Systematic Review s .
• Try searching in a disciplinary database using a search limiter for "systematic reviews."  For example, in PsycInfo the METHODOLOGY field has a defined limiter for systematic reviews.  If there is no defined limiter, add the phrase "systematic reviews" to your search.  

Learn about Research Methods

Learn about research methods including systematic reviews....

• UNM Library Research Guide on Qualitative Research Methods & Tools Visit our guide to learn more about qualitative research methods and tools at UNM and beyond.
• Next: Searching Article Databases >>
• Last Updated: Nov 8, 2023 7:26 PM
• URL: https://libguides.unm.edu/socscisr

• Search Menu
• Advance articles
• Editor's Choice
• Author Guidelines
• Submission Site
• Open Access
• About The British Journal of Social Work
• About the British Association of Social Workers
• Editorial Board
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Dispatch Dates
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Introduction, systematic literature searching, methodology, thematic synthesis, declaration of conflicting interest.

• < Previous

Social Workers’ Experiences of Bureaucracy: A Systematic Synthesis of Qualitative Studies

• Article contents
• Figures & tables
• Supplementary Data

Katheryn Margaret Pascoe, Bethany Waterhouse-Bradley, Tony McGinn, Social Workers’ Experiences of Bureaucracy: A Systematic Synthesis of Qualitative Studies, The British Journal of Social Work , Volume 53, Issue 1, January 2023, Pages 513–533, https://doi.org/10.1093/bjsw/bcac106

• Permissions Icon Permissions

Since the 1990s managerialism has spread across the public sector, implementing private sector practices targeting greater efficiency in public services. Consequently, reforms focusing on risk management, standardisation, fragmentation and accountability have increased demands for paperwork and procedure compliance from street-level bureaucrats (SLBs). Focusing specifically on the impact on social work, this paper presents the findings of a systematic literature review synthesising social workers experience of bureaucracy across thirty-nine published qualitative studies. Despite warnings being voiced about the risks associated with enforcing highly bureaucratic and managerial cultures in social work, evidence reinforces the consequences predicted over two decades prior. Major themes from the systematic synthesis include negative effects on social workers and service users, social workers’ resistance to bureaucratic structures and the coping strategies they employed. Although the review found some positive perspectives, this was sporadic and only reported in a minority of studies. As SLBs, social workers face an important question: What should be prioritised in the delivery of social services? Managing procedures, administration and documentation or pursuing sustainable change through meaningful engagement with service users?

When Max Weber wrote about bureaucracy at the turn of the twentieth century, the mechanics of bureaucratic governance we described through: specialisation, hierarchical structures of authority, rules and regulation, formal processes of employment and an impersonal, uniform application of procedures ( Coulshed and Mulleder, 2006 ; Hughes and Wearing, 2013 ). As a sociologist and historian, Weber argued bureaucracy offered the potential to establish equitable governance ( Weber, 1988 ). Yet, the potential benefits of bureaucratic governance were linked to a pure bureaucracy, free from the complexities of the real world and the flexibility it demands.

A century later, amidst significant technological and scientific advancement, we see a resurgence of the bureaucratic method. An environment of regulation and control has expanded across social services in western and westernised countries through the rise of managerialism ( Parton, 2006 ; Burton and van den Broek, 2009 ). Driven by New Public Management reforms which sought to transform the public sector through implementing private sector performance criteria and practices in the pursuit of efficiency and economy ( Lapsley, 2009 ), managerialism focuses on risk management, control, fragmentation of services and accountability, consequently increasing demands for paperwork and procedure compliance from street-level bureaucrats (SLBs). The nature of this resurgence warrants attention to question the impact on service delivery and public servants. The current systematic review shines a light upon its effect on social work practice by synthesising social workers experience of bureaucracy as presented in published qualitative studies.

Following the steps proposed by McGinn et al. (2016) to appraise database precision and search functions, nine bibliographic databases were selected for the study (Applied Social Science Index and Abstracts (ASSIA), Child and Adolescent Development, International Bibliography of the Social Sciences, PsycINFO, Social Care Online, Sociology database, Sociological Abstracts, Social Science Citation Index, Social Science Abstracts). Because databases differ in their schedules for indexing literature ( Shek, 2008 ) the 30th April 2020 was set two weeks prior to the first database search to reduce access bias.

Table 1 presents the inclusion and exclusion criteria applied to each citation retrieved. No studies were excluded based on quality, but it was noted that only two of the thirty-nine articles reported researcher positionality and reflexivity, a key method for navigating potential bias (for further detail, see Pascoe et al. , 2021 ; Pascoe, 2022 ).

Summary of inclusion and exclusion criteria.

Characteristics of included studies ( n  = 39).

Search strategy

(‘Social work’ OR ‘social service’ OR ‘case management’ OR ‘care management’ OR ‘casework’ OR ‘human services’) AND (Experience OR perspective OR belie* OR response OR reaction OR perception OR opinion) AND (bureaucra* OR managerialism OR ‘new public management’ OR ‘performance management’ OR ‘paperwork’ OR ‘form-talk’)

Additionally, a thesaurus function was employed with PsycINFO to map terms onto subject headings. In total, 1,137 citations were retrieved. After removing duplicates, 509 titles and abstracts were assessed by the first author. In instances of ambiguity, articles were discussed with the research team to determine inclusion/exclusion. Thirty-nine articles meet the inclusion criteria. An overview of this process is detailed in Figure 1 ; however, for comprehensive detail of the search method, see Pascoe et al. (2021) .

Systematic literature search overview.

Overview of themes and subthemes.

Primary study report findings were synthesised using a thematic synthesis methodology ( Thomas and Harden, 2008 ; Barnett-Page and Thomas, 2009 ). Harnessing Nvivo (version 12), initial open codes were constructed inductively through line-by-line coding of findings reported in each article, identified as text labelled ‘results’ or ‘findings’ ( Thomas and Harden, 2008 ). Each code was clearly defined, and extracts were linked to multiple codes where appropriate. The open codes and relevant extracts were reviewed after analysing half of the articles and again upon completion to ensure consistency. In total, sixty-three open codes were created. These were then organised into second-level codes known as descriptive themes, grouping similarities and identifying differences. The final step was a process of deeper analysis, interrogating the relationships between codes to develop the analytical themes presented here ( Thomas and Harden, 2008 ; Barnett-Page and Thomas, 2009 ).

As seen in Table 2 , more than two-thirds of the articles were published between January 2011 and April 2020, indicating a growing interest in the effects of bureaucracy and managerialism on social workers and their practice. The articles were published across twenty-four different journals. Although the British Journal of Social Work represented the largest proportion of publications (eleven out of thirty-nine) reflecting the dominance of the UK research context, the diverse journal coverage reveals the interdisciplinary nature of social work. Journals not typically considered social work specific were evident including Time & Society, Public Administration and Organisation, emphasising the importance of including a broad range of sources to increase the sensitivity of systematic literature reviews.

The fields of practice varied significantly, including child protection, social work in schools, palliative care, social welfare, rural social work, mental health, criminal justice and disability. No individual field dominated the literature, and many studies drew on participants from multiple organisations and a mixture of sectors.

The thematic synthesis identified a range of negative impacts of bureaucracy and managerialism, both on social workers and service users. A narrative of resistance to bureaucracy dominated, and several coping strategies to work within a paperwork-dominated culture were explored. However, a minority of participants expressed positive perspectives regarding the impact of bureaucracy on social work practice. The themes and subthemes are displayed in Figure 2 .

Theme 1: Negative effects of bureaucracy on the social worker and profession

Overwhelmingly, the most common theme evident in the systematic synthesis was the negative effects of bureaucracy on social work and social workers. Participants discussed how the introduction of standardised assessments, output measures, fragmented practice, increased recording procedures and rigid protocols have contributed to a shift in service delivery and organisational priorities, reinforcing a compliance and paperwork-oriented culture. The subthemes illustrate the role of technology in exacerbating the dominance of bureaucracy, deskilling of the workforce and increased job insecurity, ultimately contributing to significant threats to the personal well-being of social workers and increased frustration.

Subtheme: Bureaucratic demands increased through technology

We spend 80% of our time inputting data into the various IT interfaces we have to utilise to maintain records, to undertake formal risk assessments and to record key performance indicators in order that our funding can be justified/secured. ( Fenton and Kelly, 2017 , p. 468) [Criminal Justice, Scotland] 1 … computer programs had been introduced to assist in the formulation of care packages. Some care managers felt that technology had contributed to their de-professionalization in that they were now ‘basically glorified data-inputters’. ( Dustin, 2006 , p. 301) [Statutory Social Service Departments, England]

Subtheme: Deskilling the work force

… Supervision is [now] more about checking you have completed your paperwork correctly, and on time. ( Carey, 2009 , p. 513) [Elder care and Disability, England] … there was a consensus that supervision was irregular, often cancelled or interrupted, overly focussed on caseload management and monitoring, superficial rather than analytical, and inattentive to professional development. ( McNeill, 2001 , p. 681) [Probation, Scotland]

We get more training on how to accurately fill out forms than on treatment needs. Human service is an after-thought. ( Abramovitz and Zelnick, 2015 , p. 281) [United States of America]

Subtheme: Job insecurity constraining practice

I’m quite careful about who I approach. I know who not to approach, who not to annoy…. That is something you’re very conscious of, the fact you’re not permanent, and if something comes up against you, a complaint is made, and it could potentially impact another contract coming down the line. ( Harmon and Garrett, 2015 , p. 45) [Housing, Ireland]

Subtheme: Impact on personal well-being and heightened frustration

I often experience anxiety over the amount of paperwork and getting written up if it is not done. Yet I am also expected to do a million other things that take me away from the paperwork. I feel I am on my way to burning out. ( Abramovitz and Zelnick, 2015 , p. 290) [United States of America] As much as social workers may want to do justice to their clients … it is not possible because they don’t have such powers. I sometimes feel like an ant in this department. Social workers also almost have the same problems that are faced by their clients; justice is not done to them. Even their human rights are violated. To say it clearly … social workers are as oppressed as their clients are by those above them. ( Dlamini and Sewpaul, 2015 , p. 472) [Department of Social Development, South Africa]

This paperwork is too much, it’s ridiculous.… You don’t stop. This is crazy, this is ridiculous. Look at all these forms, look at the length of all these forms, they’re repetitive. Some of this care plan is irrelevant to what we provide now, eligibility criteria, for example. For me it doesn’t really change things for the better as far as I can see. ( Yuill and Gordon, 2018 , p. 283) [Britain] Every system has another system and every piece of paper has three forms to achieve a task and you’re accountable for everything and there are reports required and everything’s audited. What could be simple becomes incredibly complex at times and I often struggle with that. ( Beddoe and Fouche, 2014 , p. 202) [Children and Adult Services, International]

Theme 2: Risks to service users

In addition to the widely experienced negative effects of bureaucracy on practice and social workers well-being, so too has bureaucracy increased risks for service users.

Subtheme: Losing sight of the client and their needs

… one of the more telling remarks about the dominance of paperwork and bureaucracy, and how it shaped their working lives, was Frances’s reply when asked about the clients or service users in her daily work as she had not mentioned them that much in the interview, referring in the main to paperwork and tight budgets: “They got lost”, she replied. ( Yuill and Gordon, 2018 , p. 284) [Britain] If the majority of your time is being spent collecting information, something is missing; something is being lost and it is that relationship … We should be thinking to minimise the bureaucratic burden as much as possible. ( Sarwar and Harris, 2019 , p. 678) [Child Protection, England and Wales]

(…) by restricting intervention to tightly defined criteria and ignoring the importance of preventative work, social workers noted the potential that rejecting those seeking support can escalate challenges, with one study highlighting how continuously denying supports could see an increase in permeant placements of children in care institutions. ( Hultman et al. , 2018 , p. 924) [Child disability, Sweden] Families have to tell their story over and over again, and the only answer they get is a referral to another social worker. Of course, they start to distrust social work. ( Roets et al. , 2016 , p. 316) [Children and Family Services, Belgium]

… it was not unusual for the initial stages of assessment on some of the teams included in our study to be carried out wholly or partially without the participation, or even the knowledge, of the person being ‘assessed’. ( Ellis et al. , 1999 , p. 273) [Disability, England] I went out on a case where somebody had done an assessment and all, everything was filled in right and what I had to do was let the mother speak for about five minutes and you knew that she was actually quite unwell in terms of her mental health …. I actually figured if you did sort of question answer, question answer, she might hold it together. ( Horwath, 2011 , p. 1080) [Child Protection, England and Wales]

Subtheme: Shifting ethos from effectiveness to efficiency

When I first came into social work, we were encouraged to look at the whole person….. more recent years have seen a major emphasis on risk instead and we are all about achieving targets. ( Fenton and Kelly, 2017 , p. 11) [Criminal Justice, Scotland] They [Social workers] reported a mission drift from providing personalised care to cost-cutting and efficiency. ( Groves et al. , 2016 ) [Hong Kong]

Subtheme: Service users unable to navigate systems

… lower SES patients may have great difficulty accessing the benefits. They do not always know what their entitlements are; they may not be able to read or understand instructions and fill in the forms to file for their entitlements; and they may have difficulty presenting themselves convincingly before the committees that vet and authorise the benefits. ( Baum et al. , 2016 , p. 609) [Healthcare, Israel]

Theme 3: Resistance to bureaucracy

Despite the increased monitoring and control over practice, standardised procedures, impact on well-being and increased risks to service users, social workers reported a narrative of resistance and acts of discretion that push back against bureaucratic structures. Resistance was present in thirty articles.

Subtheme: Narratives of resistance

… they felt that procedures should not be so detailed as to negate the role of professional judgement: where they identified problems with the rules, the authority should listen to their concerns. ( Evans, 2013 , p. 749) [Adult social work, England] The following social worker, like many other practitioners we surveyed, independently used the term ‘cookie cutter’ to describe their agency’s overly standardized and lack of comprehensive service provision. ‘We’re here to help people with various issues, whether it’s housing, health, mental health or domestic violence. They’re people, and you can’t “cookie-cutter” them.’ ( Abramovitz and Zelnick, 2015 , p. 288) [United States of America] Put me in front a computer screen and suddenly everything needs to be divided into pieces, but we are working with human beings. Their story is one story and all pieces are interconnected with each other. ( De Corte et al. , 2019 , p. 1326) [Child Welfare and Protection, Belgium]

Subtheme: Specific acts of resistance

Lisa reported that she engaged in activity that could be viewed ‘deviant’ in that she chose not to let the community welfare officer know that family members, were staying in an apartment funded by social welfare even though they were not legally entitled to under the HRC: ‘I turned a blind eye to the younger generations being in that family household, even though they weren’t supposed to be.’ ( Harmon and Garrett, 2015 , p 45) [Housing, Republic of Ireland] Very often, mothers ask me how to deal with their mass of paperwork. In that case, I just do it off the cuff. I refuse to refer them to other social workers. I think they’d better think about making their practice accessible rather than blaming mothers for not doing their paperwork. ( Roets et al. , 2016 , p. 317) [Child Welfare and Protection, Belgium]

Resistance was also reportedly dependant on the relationship with managers ( Carey, 2009 ), and linked to individual confidence to question decisions, systems and managers ( Gregory, 2011 ; Juujarvi et al. , 2020 ).

Theme 4: Coping and accommodation strategies

Although most studies reported on the negative effects of bureaucracy and managerialism, it was evident that not all social workers were actively resistant or working to provoke change. Instead, several coping strategies were identified for managing work within their restrictive settings. This included contextualising the impact of bureaucracy by identifying more pressing concerns to practice and service users, such as a lack of resources ( Parry-Jones et al. , 1998 ; Mayer, 2001 ; Postle, 2002 ; Gregory, 2010 ; Yalli and Albrithen, 2011 ; Dlamini and Sewpaul, 2015 ; Yuill and Gordon, 2018 ; Lavee and Strier, 2019 ; Marti-Garcia et al. , 2019 ). Although only present in five articles, formal and informal peer support was highly valued by participants, offering solidarity and a safe space to express concerns and insecurities about their work ( Mayer, 2001 ; Gregory, 2011 ; Yalli and Albrithen, 2011 ; Dlamini and Sewpaul, 2015 ; Groves et al. , 2016 ).

Social workers also reported a range of practical strategies to manage competing demands such as using personal computers to work from home out of hours ( Disney et al. , 2019 ; Sarwar and Harris, 2019 ), reducing their advocacy role and remaining quiet to persevere when no achievable solution could be seen ( Dlamini and Sewpaul, 2015 ; Weinberg, 2016 ), and creative practices to manage deadlines for initial assessments such as ‘starting the clock once they had made contact with the family’ ( Horwath, 2011 , p. 1078).

Theme 5: Positive perceptions of bureaucracy

Not all social workers perceived bureaucracy and managerialism as a barrier to effective practice. Rather than being viewed as a form of control, a minority of social workers found conformity with technical procedures a source of job satisfaction by directing their attention and increasing the rate of case processing to prevent a backlog in the system ( Ellis et al. , 1999 ; Dixon, 2013 ; Sarwar and Harris, 2019 ). The added layers of accountability through hierarchical structures and strict reporting procedures were also regarded as a positive by reducing individual liability and offering legitimacy in decision making by referring to policy documents ( Beddoe and Fouche, 2014 ; Fenton and Kelly, 2017 ; Hultman et al. , 2018 ; Sarwar and Harris, 2019 ; Juujarvi et al. , 2020 ).

Rules are actually there for a very good reason and it's to promote equality. Never, ever, ever bend the rules. Because if you do you start slipping in terms of your own professionalism. ( Evans, 2013 , p. 748) [Adult Social Work, England]

Lastly, the use of clear forms and guides was perceived to streamline processes for conducting assessments and offered reassurance that the correct questions were asked, and necessary information was recorded ( Horwath, 2011 ; Fenton and Kelly, 2017 ; Hultman et al. , 2018 ; Sarwar and Harris, 2019 ). No study exclusively reported positive perspectives and there was no association with a specific field of practice or journal.

There are opposing views on the use of discretion and whether it is used by SLBs to make their job easier and manageable, or whether discretion is based on their relationships with individuals and their professional judgement of need (see Maynard-Moody and Musheno, 2000 ). In response to serious case reviews which seek to improve practice by reducing uncertainty, the increase of bureaucracy through proceduralism and recording has reduced the role of discretion through prescription. Such developments have obscured the centrality of relationships and attention has been focused on doing things right, not doing the right thing ( Parton, 2006 ; Munro, 2011 ).

Frustration with control over practice, constrained discretion and on-going monitoring is not a new phenomenon. In their critical commentary about managerialism, Tsui and Cheung (2004) emphasised how shifting power from front line social workers to service managers would result in de-professionalising social work, reducing autonomy and denying social workers’ expertise. In discussing the features of managerialism, Tsui and Cheung (2004 , p. 439) warned that professional practitioners could feel like ‘alienated bureaucrats’ when employed in a managerial organisational context. In the same year, Munro (2004) critiqued existing systems of auditing, arguing that a focus on outputs and paperwork does not account for the intricate interpersonal skills necessary for effective social work practice. It was cautioned that rigid frameworks would significantly reduce discretion, eliminating the ability to provide a personalised service and respond to individual circumstances. Despite such warnings, this literature review and thematic synthesis demonstrates a continued dominance of bureaucratic structures and managerialist policies, confirming the predicted sense of alienation and frustration in social work practice. Once a ‘bedrock of successful support and treatment’ ( Howe, 1996 , p. 93), the synthesis demonstrates how managerialism and bureaucracy devalues relationships by reducing time spent with service users, prioritising outputs, increasing paperwork and diminishing the sense of trust in the profession.

Implications

The implications for social work are far reaching. The experiences of ethical stress and workload pressures demonstrate how current bureaucratic and managerial organisational systems have placed staff well-being on a precipice. Staff retention, recruitment and burnout have been a constant concern in the profession ( Jones, 2001 ; Kim and Stoner, 2008 ; McFadden et al. , 2015 ). Yet, to reduce workplace stress and increase staff satisfaction, the synthesis reinforces the need to address organisational structures and managerial cultures, rather than focusing on individual resilience ( Arches, 1991 ; Harlow, 2010 ).

Bureaucracy and the effects of managerialism have also placed service users at risk. With increased control over practice and rigid systems reducing discretion, the ability for social workers to tailor interventions to meet diverse needs and respond to broader systematic influences is eroded. Furthermore, research participants expressed concern over the (in)ability for service users to navigate systems, understand expectations and meet compliance requirements in an increasingly bureaucratic industry. Concerns, ultimately, highlight the risk of bureaucracy inhibiting access to services that individuals and families are entitled to.

Both narratives and acts of resistance indicate that social workers remain critical of the role and influence of bureaucracy and managerialism on social services. The ethical stress described and felt by social workers shows an awareness of how the values and principles of human services are fundamentally different from the market values that have driven managerial and bureaucratic change ( Tsui and Cheung, 2004 ; Baines, 2006 ). Whilst it has been forewarned that SLBs are at risk of becoming preoccupied with procedures and standardisation over delivering quality service ( Lapsley, 2009 ), this literature review suggests social workers are yet to adopt a strict compliance mentality.

Furthermore, the synthesis shows resistant acts are not large scale, radical interventions but occur at an individual level, whereby social workers are taking steps to enable positive outcomes for service users. Acts such as overruling automatic referrals and aiding families in completing documentation evidence that there remains space for discretion ( Evans and Harris, 2004 ), but not to the same extent first theorised by Lipsky’s (1980) work on SLBs. Whilst organisational management, funders and monitoring bodies continue to implement bureaucratic systems and managerial principles, the space to adapt services to meet needs and opportunities to use professional discretion is threatened. The synthesis has shown that creative thinking is necessary to work in an enabling way within a disabling system ( Baines, 2006 ), yet a system overhaul is required for social work to hold true to the professional values of human rights, social justice, empowerment and respect for diversity. It is not solely the responsibility of the individual social worker to deliver effective, person-centred services, however, as work conditions must be conducive to outcome focused, relationship-based practice. Team leaders, service managers, directors, governance boards and funders must partner with social workers to critically review the existing systems to reduce the administrative burdens and enable greater time for meaningful engagement with service users.

Although risks have been identified since the 1990s (see Arches, 1991 ; Jones, 2001 ; Postle, 2001 ), literature shows social workers continue to experience negative effects of bureaucracy and managerialism, with little movement in organisational structures. With twenty-seven of the thirty-nine articles published since 2015, this review suggests bureaucracy not only persists but has expanded across the sector.

Although a minority of studies found bureaucracy offered something akin to peace of mind to a small number of practitioners, there remains little doubt that bureaucracy is inhibiting the delivery of person-centred relationship-based services that social workers are trained to deliver. The small acts of transgression against bureaucracy reported here underline how significantly service delivery models and organisational priorities have shifted. The ongoing fragmentation and ‘tick box’ approach is deconstructing social work, dividing practice into segmented tasks. Considering this evidence, the social work profession faces a juncture. Should this approach continue to dominate practice, how true to social work do these roles remain? Whilst this systematic literature review only included peer-reviewed academic journals, given that the literature is clear on these negative impacts, collective action and consideration of alternative platforms to harness research in the campaign for change is necessary.

This work was supported by the University of Ulster and the Doctoral Training Alliance as a recipient of the Marie Sklodowska-Curie PhD Fellowship Programme. This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 801604.

The author declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Conflict of interest statement. None declared.

The field of practice and research context is declared with each quote if details were reported in the literature.

Abramovitz M. , Zelnick J. ( 2015 ) ‘ Privatization in the human services: Implications for direct practice ’, Clinical Social Work Journal , 43 ( 3 ), pp. 283 – 93 .

Google Scholar

Arches J. ( 1991 ) ‘ Social structure, burnout and job satisfaction ’, Social Work , 36 ( 3 ), pp. 202 – 6 .

Baines D. ( 2006 ) ‘“ If you could change one thing.” Social service workers and restructuring ’, Australian Social Work , 59 ( 1 ), pp. 20 – 34 .

Barnett-Page E. , Thomas J. ( 2009 ) ‘ Methods for the synthesis of qualitative research: A critical review ’, BMC Medical Research Methodology , 9 , 591 – 11 .

Baum N. , Shalit H. , Kum Y. , Tal M. ( 2016 ) ‘ Social workers’ role in tempering inequality in healthcare in hospitals and clinics: A study in Israel ’, Health & Social Care in the Community , 24 ( 5 ), pp. 605 – 13 .

Beddoe L. , Fouche C. ( 2014 ) ‘ “Kiwis on the move”: New Zealand social workers’ experiences of practising abroad ’, British Journal of Social Work , 44(Suppl 1) , pp. i193 – 208 .

Bertotti T. ( 2010 ) ‘ Decision-making and ethical dilemmas of child and family social workers ’, Social Work & Society , 8 ( 1 ), pp. 148 – 50 .

Burton J. , van den Broek D. ( 2009 ) ‘ Accountability and countable: Information management systems and the bureaucratization of social work ’, British Journal of Social Work , 39 ( 7 ), pp. 1326 – 42 .

Carey M. ( 2009 ) ' “ It’s a bit like being a robot or working in a factory”: Does Braverman help explain the experiences of State Social Workers in Britain since 1971? ’, Organization , 16 ( 4 ), pp. 505 – 27 .

Coulshed V. , Mulleder A. ( 2006 ) Management in Social Work , 3rd edn, London , Palgrave McMillian .

Google Preview

De Corte J. , Devlieghere J. , Roets G. , Roose R. ( 2019 ) ‘ Top-down policy implementation and social workers as institutional entrepreneurs: The case of an electronic information system in Belgium ’, The British Journal of Social Work , 49 ( 5 ), pp. 1317 – 32 .

Disney T. , Warwick L. , Ferguson H. , Leigh J. , Cooner T. , Beddoe L. , Jones P. , Osborne T. ( 2019 ) ‘ “Isn’t it funny the children that are further away we don’t think about as much?”: Using GPS to explore mobilities and geographies of social work and child protection practice ’, Children and Youth Services Review , 100 , 39 – 49 .

Dixon J. ( 2013 ) ‘ Effective strategies for communication? Student views of a communication skills course eleven years on ’, British Journal of Social Work , 43 ( 6 ), pp. 1190 – 205 .

Dlamini T. , Sewpaul V. ( 2015 ) ‘ Rhetoric verses reality in social work practice: Political, neoliberal and new managerial influences ’, Social Work/Maatskaplike Werk , 50 ( 4 ), pp. 467 – 81 .

Dustin D. ( 2006 ) ‘ Skills and knowledge needed to practise as a care manager: Continuity and change ’, Journal of Social Work , 6 ( 3 ), pp. 293 – 313 .

Ellis K. , Davis A. , Rummery K. ( 1999 ) ‘ Needs assessment, street-level bureaucracy and the new community care ’, Social Policy & Administration , 33 ( 3 ), pp. 262 – 80 .

Evans T. ( 2011 ) ‘ Professionals, managers and discretion: Critiquing street-level bureaucracy ’, British Journal of Social Work , 41 ( 2 ), pp. 368 – 86 .

Evans T. ( 2013 ) ‘ Organisational rules and discretion in adult social work ’, British Journal of Social Work , 43 ( 4 ), pp. 739 – 58 .

Evans T. , Harris J. ( 2004 ) ‘ Street-level bureaucracy, social work and the (exaggerated) death of discretion ’, British Journal of Social Work , 34 ( 6 ), pp. 871 – 95 .

Fenton J. , Kelly T. ( 2017 ) ' “ Risk is King and needs to take a backseat!” Can social workers’ experiences of moral injury strengthen practice? ’, Journal of Social Work Practice , 31 ( 4 ), pp. 461 – 75 .

Gregory M. ( 2010 ) ‘ Reflection and resistance: Probation practice and the ethic of care ’, British Journal of Social Work , 40 ( 7 ), pp. 2274 – 90 .

Gregory M. ( 2011 ) ‘ Practical wisdom and the ethic of care in probation practice ’, European Journal of Probation , 3 ( 3 ), pp. 60 – 77 .

Groves J. , Ho W. , Siu K. ( 2016 ) ‘ Exploring the sacred-secular dialect in everyday social work practice: An analysis of religious responses to managerialism among outreach social workers in Hong Kong ’, British Journal of Social Work , 46 ( 5 ), pp. 1411 – 28 .

Harmon A. , Garrett P. ( 2015 ) ‘ It’s like Weber’s “iron cage”’: Irish social workers’ experience of the Habitual Residence Condition (HRC) ’, Critical and Radical Social Work , 3 ( 1 ), pp. 35 – 52 .

Harlow E. ( 2010 ) ‘ Why don't women want to be social workers anymore? New managerialism, post-feminism and the shortage of social workers in social services departments in England and Wales ’, European Journal of Social Work , 7 ( 2 ), pp. 167 – 179 .

Horwath J. ( 2011 ) ‘ See the practitioner, see the child: The Framework for the Assessment of Children in Need and their Families ten years on ’, British Journal of Social Work , 41 ( 6 ), pp. 1070 – 87 .

Howe D. ( 1996 ) ‘Surface and depth in social work practice’, in Parton N. (eds), Social Theory, Social Change and Social Work , London , Routledge .

Hughes M. , Wearing M. ( 2013 ) Organisations and Management in Social Work , 2nd edn, London , Sage Publications .

Hultman L. , Forinder U. , Fugl-Meyer K. , Pergert P. ( 2018 ) ‘ Maintaining professional integrity: Experiences of case wrokers performing the assessments that determine children’s access to personal assistance ’, Disability & Society , 33 ( 6 ), pp. 909 – 31 .

Ingram R. , Smith M. ( 2018 ) Relationship-Based Practice: Emergent Themes in Social Work Literature (Insight 41; pp. 1 – 15 ), Bradenton, FL, Iriss .

Jones C. ( 2001 ) ‘ Voices from the frontline: State social workers and New Labour ’, British Journal of Social Work , 31 ( 4 ), pp. 547 – 62 .

Juujarvi S. , Kallunki E. , Luostari H. ( 2020 ) ‘ Ethical decision-making of social welfare workers in the transition of services: The ethics of care and justice perspectives ’, Ethics and Social Welfare , 14 ( 1 ), pp. 1 – 83 .

Kim H. , Stoner M. ( 2008 ) ‘ Burnout and turnover intention among social workers: Effects of role stress, job autonomy and social support ’, Administration in Social Work , 32 ( 3 ), pp. 5 – 25 .

Kjorstad M. ( 2005 ) ‘ Between professional ethics and bureaucratic rationality: The challenging ethical position of social workers who are faced with implementing a workfare policy ’, European Journal of Social Work , 8 ( 4 ), pp. 381 – 98 .

Laird S. , Morris K. , Archard P. , Clawson R. ( 2018 ) ‘ Changing practice: The possibilities and limits for reshaping social work practice ’, Qualitative Social Work , 17 ( 4 ), pp. 577 – 93 .

Lapsley I. ( 2009 ) ‘ New public management: The cruellest invention of the human spirit ’, Abacus , 45 ( 1 ), pp. 1 – 21 .

Lavee E. , Strier R. ( 2019 ) ‘ Transferring emotional capital as coerced discretion: Street-level bureaucrats reconciling structural deficiencies ’, Public Administration , 97 ( 4 ), pp. 910 – 25 .

Lee J. ( 2012 ) ‘ Social work in Australia ’, Australian Social Work , 65 ( 4 ), pp. 552 – 70 .

Leung T. ( 2006 ) ‘ Accountability to welfare service users: Challenges and responses of service providers ’, British Journal of Social Work , 38 ( 3 ), pp. 531 – 45 .

Lipsky M. ( 1980 ) Street Level Bureaucracy: Dilemmas of the Individual in Public Services , New York, NY , Russell Sage Foundation .

Marti-Garcia S. , Fernandez-Borrero M. , Vazquez-Aguado O. ( 2019 ) ‘ Professional perceptions of intervention with families in a crisis context ’, Journal of Social Service Research , 45 ( 5 ), pp. 648 – 58 .

Mayer A. ( 2001 ) ‘ Rural social work: The perceptions and experiences of five remote practitioners ’, Australian Social Work , 54 ( 1 ), pp. 91 – 102 .

Maynard-Moody S. , Musheno M. ( 2000 ) ‘ State agent or citizen agent: Two narratives of discretion ’, Journal of Public Administration Research and Theory , 10 ( 2 ), pp. 329 – 58 .

McFadden P. , Campbell A. , Taylor B. ( 2015 ) ‘ Resilience and burnout in child protection social work: Individual and organisational themes from a systematic literature review ’, British Journal of Social Work , 45 ( 5 ), pp. 1546 – 63 .

McGinn T. , Taylor B. , McColgan M. , McQuilkan J. ( 2016 ) ‘ Social work literature searching: Current issues with databases and online search engines ’, Research on Social Work Practice , 26 ( 3 ), pp. 266 – 77 .

McNeill N. ( 2001 ) ‘ Developing effectiveness: Frontline perspectives ’, Social Work Education , 20 ( 6 ), pp. 671 – 87 .

Munro E. ( 2004 ) ‘ The impact of audit on social work practice ’, British Journal of Social Work , 34 ( 8 ), pp. 1075 – 95 .

Munro E. ( 2011 ) The Munro Review of Child Protection: Final Report , London, Department of Education .

Parry-Jones B. , Grant G. , McGrath M. , Caldock K. , Ramcharan P. , Robinson C. ( 1998 ) ‘ Stress and job satisfaction among social workers, community nurses and community psychiatric nurses: Implications for the care management model ’, Health & Social Care in the Community , 6 ( 4 ), pp. 271 – 85 .

Parton N. ( 2006 ) ‘ Changes in the form of knowledge in Social Work: From the social to the informational ’, British Journal of Social Work , 38 ( 2 ), pp. 253 – 69 .

Pascoe K. M. ( 2022 ) ‘ Reflections on a systematic literature review: Questioning the (in)visibility of researcher positionality ’, Social Work Research , 46 ( 2 ), pp. 176 – 80 . https://doi.org/10.1093/swr/svac006

Pascoe K. M. , Waterhouse-Bradley B. , McGinn T. ( 2021 ) ‘ Systematic literature searching in social work: A practical guide with database appraisal ’, Research on Social Work Practice , 31 ( 5 ), pp. 541 – 51 .

Postle K. ( 2001 ) ‘ The social work side is disappearing. I guess it started with us being called care managers ’, Practice , 13 ( 1 ), pp. 13 – 26 .

Postle K. ( 2002 ) ‘ Working ‘Between the idea and the reality’: Ambiguities and tensions in care managers’ work ’, British Journal of Social Work , 32 ( 3 ), pp. 335 – 51 .

Roets G. , Roose R. , Schiettecat T. , Vandenbroeck M. ( 2016 ) ‘ Reconstructing the foundations of joined-up working: From organisational reform towards a joint engagement of child and family services ’, British Journal of Social Work , 46 ( 2 ), pp. 306 – 22 .

Roysum A. ( 2013 ) ‘ The reform of the welfare services in Norway: One office—One way of thinking ’, European Journal of Social Work , 16 ( 5 ), pp. 708 – 23 .

Ruch G. ( 2005 ) ‘ Relationship-based practice and reflective practice: Holistic approaches to contemporary childcare social work ’, Child Family Social Work , 10 ( 2 ), pp. 111 – 23 .

Ruch G. ( 2013 ) ‘Understanding contemporary social work: We need to talk about relationships’, in Parker J. , Doel M. (eds), Professional Social Work , London , Sage Publications .

Sarwar A. , Harris M. ( 2019 ) ‘ Children’s services in the age of information technology: What matters most to frontline professionals ’, Journal of Social Work , 19 ( 6 ), pp. 699 – 718 .

Shek D. ( 2008 ) ‘ Comprehensiveness of Social Work Abstracts as a database for researchers and practitioners ’, Research on Social Work Practice , 18 ( 5 ), pp. 500 – 5006 .

Thomas J. , Harden A. ( 2008 ) ‘ Methods for the thematic synthesis of qualitative research in systematic reviews ’, BMC Medical Research Methodology , 8 ( 45 ), pp. 45 – 10 .

Trevithick P. ( 2003 ) ‘ Effective relationship-based practice: A theoretical exploration ’, Journal of Social Work Practice , 17 ( 2 ), pp. 163 – 76 .

Tsui M. , Cheung F. ( 2004 ) ‘ Gone with the wind: The impact of managerialism on human services ’, British Journal of Social Work , 34 ( 3 ), pp. 437 – 42 .

Weber M. ( 1988 ) Max Weber a Biography , 2nd edn, London , Routledge .

Weinberg M. ( 2016 ) ‘ Critical approaches to ethics in social work: Kaleidoscope not bleach ’, Social Alternatives , 35 ( 4 ), pp. 85 – 9 .

Yalli N. , Albrithen A. ( 2011 ) ‘ The perceptions of the personal and professional factors influencing social workers in Saudi hospitals: A qualitative analysis ’, Social Work in Health Care , 50 ( 10 ), pp. 845 – 62 .

Yuill C. , Gordon R. ( 2018 ) ‘ Social workers and alienation: The compassionate self and the disappointed juggler ’, Critical and Radical Social Work , 6 ( 3 ), pp. 275 – 89 .

Yuill C. , Mueller-Hirth N. ( 2019 ) ‘ Paperwork, compassion and temporal conflicts in British social work ’, Time & Society , 28 ( 4 ), pp. 1532 – 51 .

Email alerts

Citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1468-263X
• Print ISSN 0045-3102
• Copyright © 2024 British Association of Social Workers
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Boston University Libraries

Literature Reviews in Social Work

About this guide.

• What is a Literature Review
• Types of Literature Reviews
• Guidelines for Writing a Literature Review
• Searching for Books, Articles, and Other Resources
• Associations and Research Institutes
• Statistical Sources
• Government Resources
• Citing Your Sources

The purpose of this guide is to provide background and guidelines related to literature reviews in social work. Included are BU databases useful for social work research, search tips, and a listing of some associations and research institutes that produce research reports or provide links to research literature that might be useful in a review. The correct citation of sources is particularly important in a literature review and this guide includes a listing of the various style manuals, including APA and the Chicago Manual of Style. (Original author, Meredith Kirkpatrick, 2021)

Related Guides

• Social Work
• Social Work Policy Resources
• Systematic Reviews in the Social Sciences
• Next: What is a Literature Review >>
• Last Updated: Dec 11, 2023 11:17 AM
• URL: https://library.bu.edu/literaturereviews

Subject guides

Social work: systematic reviews.

• Help with Searching
• Reading lists

Systematic Reviews

• Grey literature

Creative Commons Image (CCO)

What is a systematic review and do you really need to do one?

A systematic review is a very specific approach to searching for literature which seeks to find all studies which have been published and which meet the review's eligibility criteria.  A true systematic review should include clear objectives with eligibility criteria for inclusion; a methodology, which it should be possible to replicate; critical appraisal of the findings of included studies; and a systematic presentation and synthesis of the findings of the selected studies (Higgins & Green, 2011). If you are not sure whether you need to do a systematic review or just a literature review, here is a useful guide which will help you decide, produced by Lynn Kysh at the University of Southern California.

In the words of the Cochrane Handbook,

"A systematic review attempts to collate all empirical evidence that fits pre-specified eligibility criteria in order to answer a specific research question.  It uses explicit, systematic methods that are selected with a view to minimizing bias, thus providing more reliable findings from which conclusions can be drawn and decisions made"

Here is a useful video from  Rachael McCoo l at York Health Economics Consortium outlining the differences between the types of review:

Cochrane have created a free online course available for those who want to learn more about conducting systematic reviews, entitled Conducting an Intervention Review. Developed by world-leading experts, this course provides over 10 hours of self-directed learning on the complete systematic review process for both new and experienced review authors.  It is available here .

There are more useful definitions of different types of systematic review linked to on the  Glasgow Caledonian University website . 

Antman,  1992,  Oxman ,  1993 (cited in  Higgins & Green, 2011, section 1.2.2).

Higgins, J.P.T. & Thomas, J. (Eds.).  Cochrane Handbook for Systematic Reviews of Interventions  Version 6 (updated October 2019). The Cochrane Collaboration, 2019. Retrieved from:  https://training.cochrane.org/handbook/current

Running and recording your searches

At this stage in the process, good record keeping is vital.  You will need to keep an up to date and accurate list of searches run against keywords and how many results each line of your search strategy produced.  Because new articles are always being added to databases, always keep a record of the dates you ran your searches.  Because accuracy is so important, it is a good idea to write up your searches as you run them.

Some databases enable you to register your own account so that you can save searches to retrieve them later and also set up alerts to be informed of new articles which are added to the database which match your search criteria.  

If the database you're using has a Search History function like CINAHL, this will enable you to easily combine different lines of your search strategy. For more information on this functionality, see the CINAHL help pages .

Critical appraisal and synthesis of your results

Once you have decided which studies are to be included in your systematic review report, you will need to critically appraise their quality.  There are a number of tools available which will help you to do this, including:

• SIGN Critical Appraisal Notes and Checklists

You will also need to pull your findings together, or "synthesise" them.  You may choose to do this using narrative synthesis, if you are dealing with qualitative research or statistical synthesis, if you are dealing with quantitative research.  There are two chapters in York University's Centre for Reviews and Dissemination guidance for systematic reviews which will be of great help with this process:

• CRD Guidance: 1.3.5.1: Narrative Synthesis
• CRD Guidance: 1.3.5.2: Quantitative synthesis of comparative studies

Centre for Reviews and Dissemination. (2009).  Systematic Reviews: CRD’s guidance for undertaking reviews in health care . York: CRD, University of York.

Writing and reporting your review

When writing up your research, there are a number of models you can use to guide your reporting process

• PRISMA : PRISMA is used primarily for reporting on systematic reviews and meta-analyses. It's useful for lots of different types of research, but was designed primarily with randomised trials in mind.
• MOOSE : Meta-analysis of observational studies in epidemiology (MOOSE). Please note, more information on MOOSE is available here , but is not part of library subscriptions

Your search strategy

Before you start searching you will need to develop a detailed search protocol.  Your search will need to aim for high sensitivity, in other words, it needs to be a very broad, comprehensive search which covers all possible terminology.  This will mean a corresponding low level of precision, or relevance.

Scoping the review in detail is crucial, for example what population is of interest and within that population what age group?  How far back in time do you need to go?  You will also need to identify all the databases and other sources of literature which are relevant to search, including grey literature.  At the scoping stage it is important to run preliminary searches to identify some key papers which are relevant to the review.

You will need to turn your question into a search strategy which uses both free text and thesaurus terms, having first ensured that you have read and understood any proposals or protocols which have been agreed for the review. You may find it helpful to use a tool to structure your search strategy such as PICO or SPIDER. 

It is a good idea for more than one person to be involved with drafting the search strategy and it should always be checked to ensure that it retrieves key papers which have already been identified at the scoping stage. The strategy can then be revised before the full search is run.  Once you have identified a strategy which works for one database, you can adapt it for other databases.

For help with search strategies, here are some useful links:

• A list of alternative search concept tools to PICO
• General search strategy help
• Key databases which we subscribe to at Huddersfield
• Resources for searching grey literature
• Grindley. D. J. C. & Karantana, A. (2018). Putting the 'systematic' into searching: tips and resources for search strategies in systematic reviews. Journal of Hand Surgery. https://doi.org/10.1177%2F1753193418778978 - this article includes lots of useful tips on developing a comprehensive list of search terms, as well as general guidance.

Managing your search results

To manage your results effectively, we recommend that you use a reliable reference manager such as RefWorks. As well as providing a good place to store your references and organise them thematically, RefWorks has a deduplication tool which will be invaluable to you as you will be using multiple databases to run your systematic review, so some duplication of results is inevitable.

You can set yourself up with a subscription to RefWorks  - we recommend the Use login from my institution option.

More information and help on using RefWorks is available from our reference management guide .

Further help

Bryony Ramsden a nd Kate McGuinn are available to advise on search strategies for systematic reviews but, due to time constraints, are not currently able to take part in the systematic review process. If you need further help, the following links and information may be of assistance

Guides available online

• The University of Oxford Bodleian Library has a subject guide about all aspects of systematic reviews
• The University of York has published a free guide on systematic reviews that is available here .
• Glasgow Caledonian has a website filled with useful information on carrying out a systematic review

Books in the library

• Glasziou, P. (2001). Systematic reviews in health care: a practical guide. Cambridge: Cambridge University Press.
• Gough, D., Oliver, S., & Thomas, J. (2017). An introduction to systematic reviews (2nd Ed.). London: SAGE.
• Webb, C., & Roe, B. H. (2007). Reviewing research evidence for nursing practice: systematic reviews. Oxford: Blackwell.

Organisation websites

• Cochrane - Cochrane's website has a wealth of information about systematic reviews and details of online and face to face training
• Cochrane Training - Cochrane's training arm has a YouTube channel filled with useful information and guidance
• Campbell Collaboration - Information and support for reviewers in the areas of Crime and Justice, Disability, Education, International Development, Knowledge Translation and Implementation, Nutrition and Social Welfare
• Joanna Briggs Institute - an international not-for-profit, research and development centre at the University of Adelaide, South Australia
• << Previous: Reading lists
• Next: TV & Media >>
• Last Updated: Mar 14, 2024 1:32 PM
• URL: https://hud.libguides.com/socialwork
• Library Services
• email: [email protected]
• tel: 01484 473888
• University of Huddersfield
• Brightspace
• I.T. Support

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Study Protocol

Exploring the inequalities experienced by health and care workforce and their bases – A scoping review protocol

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Current address: University of Essex, Colchester, United Kingdom

Affiliation School of Health & Social Care, University of Essex, Colchester, United Kingdom

Roles Conceptualization, Supervision, Writing – review & editing

• Roomi Aziz, 
• Anuj Kapilashrami, 
• Reza Majdzadeh

• Published: April 16, 2024
• https://doi.org/10.1371/journal.pone.0302175
• Reader Comments

Planning for investment in human resources for health (HRH) is critical to achieve Universal Health Coverage (UHC) and establish a sustainable health system. Informed planning warrants a better understanding of the health labour market (HLM) to tackle a variety of health and care workforce challenges: from addressing critical supply shortage, to ensuring optimal skills mix and distribution, and addressing motivation and performance challenges. Scant evidence around the overall role of socioeconomic and cultural factors like gender, race, marital status, citizenship (migrant) status, workplace hierarchy etc. in determining workforce composition, deployment, distribution, retention, un- and underemployment, sub-optimal work environments and other factors in the ‘HRH crisis’ warrants further exploration. This scoping review protocol aims to map and present the available evidence on inequalities experienced by health and care workforce, the socio-economic, cultural and other bases of these inequalities, and their outcomes/ consequences. PubMed, Web of Science, CINAHL and SCOPUS will be used to identify relevant literature. All types of published study designs in English language will be included if they discuss any inequality experienced by any category of health and care workers. Elaborate keyword categories for health and care workers and inequalities context have been developed, tested and reduced to the near-final search string. Eligible articles will be charted using the Joanna Briggs Institute checklist. The sample data extraction chart in JBI manual will be used as a basic skeleton with fields added to it to serve the needs of the scoping review. Descriptive analysis will be performed, depicting basic frequencies. While no further analysis has been advised in the JBI and PRISMA protocol, thematic analysis will be undertaken; following the Braun and Clarke’s method with some modification and open coding as suggested by Maquire and Delahunt.

Citation: Aziz R, Kapilashrami A, Majdzadeh R (2024) Exploring the inequalities experienced by health and care workforce and their bases – A scoping review protocol. PLoS ONE 19(4): e0302175. https://doi.org/10.1371/journal.pone.0302175

Editor: Steve Zimmerman, Public Library of Science, UNITED KINGDOM

Received: September 28, 2023; Accepted: March 25, 2024; Published: April 16, 2024

Copyright: © 2024 Aziz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: No datasets were generated or analysed during the current study. All relevant data from this study will be made available upon study completion.

Funding: As a Commonwealth scholar, I am undertaking a funded PhD at the University of Essex, with my tuition and living supported by the Commonwealth. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors did not receive a salary from any of my funders.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Human Resources for Health (HRH) is one of the six building blocks of health systems [ 1 ], and referred to as the backbone of health systems [ 2 , 3 ]. Adequate numbers, quality and diversity of HRH are critical for achieving Sustainable Development Goals (SDG) generally and target 3.8C Universal Health Coverage (UHC), indicator 3.C.1 ‘health worker density and distribution’ specifically. HRH ascertains the effectiveness of all other inputs in a country’s health system which in turn ensures the health and viability of national and global economies [ 4 ].

Although documented earlier, global HRH crisis was prominently first highlighted in WHO’s 2006 world health report [ 5 ], where the report identified crisis level shortages in 57 countries and estimated a global deficit of 2.4 million doctors, nurses and midwives then.

HRH crisis is most often expressed as shortage of health and care workers, demand or need, using measures like HRH density per 1000 population [ 6 , 7 ]. However, this measure limits the understanding of HRH to just a supply problem [ 8 , 9 ], and while useful for understanding the overall deficits in HRH availability, is not adequate for country level-planning for sustainable workforce [ 10 ].

Due to this evidence gap and emphasis on workers’ density, globally HRH planning at the policy and programmatic levels typically stays limited to supply strategies like scaling up of training capacities and building more medical/ nursing schools [ 11 ]. This is partly because most of the available evidence on HRH crisis focuses on workforce distribution and related challenges [ 12 – 19 ]. This traditional policy approach fails to see other systemic and structural factors and dimensions of the health labour market (HLM) [ 20 – 25 ].

In order to start changing that outlook, and drive evidence-informed policy design, it is important to first map the evidence available, before advocating for integration of this evidence in developing policies or programs.

In conclusion, effective HRH planning requires a deeper understanding of the structural and systematic inequalities that health and care workers experience. To accordingly inform the discourse on HRH, this scoping review aims to systematically map literature that attempts to understand the inequalities experienced by health and care workers, their bases, their subsequent outcomes and the resulting impact on HLM and health system. This mapping will present the key concepts, research methods, theories and sources of evidence in HRH research using an inequality lens [ 26 ].

Materials and methods

Existing directories of Prospero, Figshare and Open Science Framework (OSF) were reviewed to identify if any existing protocol for a similar study existed. In the absence of any relevant registration, a priori protocol for this scoping review was developed following the Joanna Briggs Institute (JBI) approach for scoping review steps [ 27 ], as also recommended by Cochrane [ 28 , 29 ]. These instructions expand upon Arksey and O’Malley’s work [ 30 ] and the protocol is guided by the Population-Concept-Context framework. This protocol is also in alignment with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and the latest PRISMA Scoping Review Extension Checklist (PRISMA-ScR) [ 31 – 33 ], which will guide the organisation and structure of the review ( S1 File ). Since the scoping review will only be based on published data with no data being collected from human participants, ethical approval is not required.

The following processes will be applied and are described in detail below:

Stage 1: Identifying the research question

Stage 2: identifying relevant studies, stage 3: study selection, stage 4: charting the data.

• Stage 5: Collating, summarising, and reporting the results.

The scoping review protocol was also pre-registered with the Open Science Framework [registration URL osf.io/ktrvm]

The WHO’s 2021 HLM analytical framework has for the first time described the HRH stock and HLM mismatches not just by a) numbers (shortage or surplus); or b) skills (over or under-qualified) but also c) discrimination due to the cultural and social context of the market [ 11 ]. Following this report, the new health and care workforce guides on utilising health and care workforce data are specifically highlighting how to capture discriminatory experiences of health and care workers. However, this is still a new understanding. Preliminary searches revealed limited works, and no existing systematic or scoping review looking at the range or intersectionality of inequalities experienced by health and care workers. Withing this context, PRISMA scoping review checklist guidance was followed to formulate the review questions as follows:

• What are the kinds of inequalities experienced by health and care workers?
• What are the bases of these inequalities and what are their outcomes?

Population–concept- context (PCC) framework was used to identify the main elements and conceptualize the review question. The framework was also used to identify the relevant keywords and inform the search strategy [ Table 1 ].

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0302175.t001

Existing scoping and systematic reviews on either of the components (population or concept) from the PCC framework were searched in PubMed and SCOPUS to identify keywords and phrases found in the titles and abstracts of papers that were likely to be included in the scoping review. Possible synonyms and combinations of the identified search terms were collected. Additional conditions like limiting to types of studies or geography were also considered and tested but eventually not included in the final protocol. The final keywords were also shared with three subject experts for their comments, to ensure that any essential HRH or inequality-related keywords are not missed.

Two sets of keywords were developed: For the population (health and care workforce) and for the concept (inequalities within health and care workforce). For health and care workforce, WHO’s definition and elaborations were used to search for possible cadres and job categories [ 34 , 35 ]. These definitions and categorizations encompass a wide range of health and care workers, including physicians, nurses, midwives, community health workers, and other health professionals. Understanding that literature around health and care workforce could be generic (human resources for health or health professionals or healthcare providers) or specific (nurses or dentists or surgeons) and this was incorporated in the search strategy. Categories of health and care workers unique to different national contexts were also included e.g. auxiliaries, health aides, Accredited Social Health Activists (ASHA) workers, Community Health Extension Workers (CHEWs), Lady Health Workers (LHWs) etc. Different iterations were run to reduce keywords and customize for the final database choices.

For the concept keywords set (inequalities experienced), a range of keywords was originally included, ranging from inequalities, bias and discrimination, to bullying, victimisation, micro aggressions, racism, violence and assault. However, it was decided that the search be kept open for the expected outcomes and experiences and not locked with the key words. Therefore the final words included were around inequalities, inequities and discrimination.

On the basis of the initial literature review, a list of relevant databases has been put together, including 20+ databases accessible through University of Essex’s registration with EBSCO. Based on the subsequent discussions and finalization of scoping review objectives, a review of literature will be performed in PubMED, CINAHL Ultimate, Web of Science and SCOPUS. In addition to this, a list of five-ten extremely relevant articles will be developed and entered into Research Rabbit App and Connected Papers App to identify closest network of relevant papers and expert authors, which will also be scoped and considered for inclusion.

Initial drafts of the search strategy have been reviewed by the Library Team at the University of Essex. Prior to finalization of the search string, multiple iterations were run with different keyword and search strategy combinations i.e. searching the concept keywords in title or abstract fields, before finalization of the root search string. The final search components (both population and concept) will be applied in the article TITLE to reduce the number of irrelevant articles.

Database-specific search string variants with the final key words and relevant index terms, Boolean operators, truncation and wildcard symbols will be developed for each of these databases.

Initially it was intended that only research after the year 2005 will be included, following the WHO’s 2006 World Health Report which was an exhaustive assessment of health and care workforce situation globally [ 36 ]. However, in the final search string no date restrictions have been placed, considering the fact that the World Health Report did not specifically frame any challenges experienced unequally by the health and care workers due to their positionality.

All published research articles in English language will be included. Papers will be excluded if they do not fit into the conceptual framework of the study, for example studying inequitable health and care workforce distribution without focusing on inequalities being experienced by health and care workers, papers focusing on health workers but not their experiences, papers focusing on inequalities being perpetuated by health and care workers or being addressed by them [ Table 2 ].

https://doi.org/10.1371/journal.pone.0302175.t002

The proposed search string will be run and based on outputs of the first 100 articles, the search strategy will be adjusted for sensitivity and specificity.

Data extraction: Data outputs from the four databases will be imported into Rayyan software, duplicates will be removed using software’s automated and AI detection, and a consolidated excel file will be exported for screening and data charting. For articles that the authors are unable to retrieve with the institutional access, support will be sought from the university library team.

Title and Abstract screening: First titles and then abstracts will be screened by two reviewers to exclude studies that qualify the exclusion criteria [ Table 2 ]. In addition to the first author, who has prior experience of HRH-related situational profiling, strategy development and research, an external relevant expert with experience of scoping reviews will be invited as a second reviewer to support with screening of articles. A small sample of scoped studies will be selected to pilot the application of eligibility criteria, and presented to the second and third authors to smooth out any disagreements and seek consensus before moving ahead with the final screening.

Text reading: Full text of included studies will be assessed for eligibility, and reasons for exclusion will be provided for studies that will be rejected. Data for the included studies will be charted.

Discrepancy assessment: Results of the two reviewers will be assessed, discrepancies will be discussed and if required, a third reviewed will be invited to make a final decision. The entire flow will be documented and presented in the PRISMA flow chart.

No critical quality appraisal will be undertaken for this scoping review, since this is not required in a scoping review and is completely optional as per JBI and PRISMA Guidelines for scoping reviews [ 33 ].

A preliminary data charting form has been developed to determine variables to extract. The sample data extraction chart in JBI manual was used as a basic skeleton with fields added to it to serve the needs of the scoping review. The initial review iterations and subsequent discussions with the supervisory team have aided in identifying the study features, types of inequalities, experiences, workforce outcomes, methodologies etc. to be extracted [ S2 Table ].

Data abstraction will be conducted using the Excel output file that will be developed a priori and pilot-tested on a sample set of papers. Revisions, amendments, and additions will be made to the chart along the process to capture rich information, while simultaneously correcting the extraction of previously extracted studies. During the review process, inconsistencies in the charting will be resolved and fields may be reduced/ added to make data more meaningful. For example, multiple studies use race, culture and ethnicity interchangeably. These fields will be charted separately but at the time of descriptive analysis of the studies included, based on thematic overlaps categories may be folded/ collapsed. The data entry fields in Excel file have been designed to ensure pivoting and cross-tabulation for descriptive analysis later.

Both quantitative and qualitative data will be abstracted on study objectives, country of setting, existing frameworks or theories used to generate knowledge, types of knowledge synthesis approaches, key results, types of factors being studied (e.g. gender, race, parenthood etc.), types of experiences as a result (discrimination, prejudice, bullying, harassment etc.), the resulting impact on health and care workers’ career (barriers to career progress, leadership, penalties) or their well-being (psychosocial burnout, physical fatigue etc.), behaviours adopted by health and care workers embodying these experiences (choosing to ignoring, increasing effort, leaving work etc.). Fields like year of publication, country of publication, DOI and published keywords will be automatically extracted at the time of search and imported into the software.

Stage 5: Collating, summarising, and reporting the results

Basic descriptive analysis will be undertaken by the first author to map the origins/ country settings of the selected papers, types of papers, inequalities and bases, health and care workforce outcomes etc. This data will be presented in tables and graphs. MS Excel and Power Bi will be used to develop charts. Snapshot summaries of the final included studies will be presented.

Although scoping review guidelines do not call for analysis beyond basic descriptive analysis, such as frequency counts of concepts, populations etc. mapped in tables or graphs [ 37 , 38 ], a thematic analysis will also be undertaken [ 39 ] to capture the breadth and depth of information beyond the frequency of appearing of concepts in the scoped literature, following the Braun and Clarke’s method with some modification [ 40 , 41 ]. No software will be used for this thematic analysis. Based on the pilot studies reviewed earlier, on average any included study in this review is expected to unpack one-three bases of inequalities and discuss on average at least two possible outcomes. Keeping this in context, the articles will not be assigned individual codes. Instead multiple codes will be assigned to each article and Maguire and Delahunt‘s approach of theoretical thematic analysis will be used to capture information that is relevant to, or of interest vis-à-vis the scoping review objective [ 40 ]. Pre-set codes will not be assigned, and instead open coding will be done, developing and modifying the codes as more articles are scoped. The initial codes [ 42 ] will be captured in the Excel output form.

Once the coding is completed, the codes will be re-examined and if found similar/related, will be grouped under a theme. For example, articles studying mental health impact on health and care workers, distress, burn-out, exhaustion may be grouped as ‘burning out’, under ‘embodiment of discriminatory experiences by health and care workers and impact on their personal well-being’. The themes will be predominantly descriptive. Overlapping themes will be re-grouped. Finally, a thematic map will be drawn to conceptualize the evidence covered and respond to the original objective of the scoping review. In addition, codes derived by these themes will also be re-assigned to the included articles to develop an evidence heat map.

The sections of analysis, discussion and conclusion of the scoping review will be co-developed by the three authors, reflecting the rich experience and subject expertise of the authors: that of inequalities in health systems, social inequalities and intersectionality, and health systems strengthening and restructuring.

To the authors’ best knowledge, this review protocol is the most recent and comprehensive to report on the breadth of literature mapping the inequalities experienced by health and care workers. Its main aim is to understand the kinds of inequalities, their bases and health and care workforce outcomes covered in literature. The scoping review will reveal the different points within the HLM covered in the literature on health and care workers’ experiences, identifying gaps in knowledge for informing policies and planning, and it is hoped that its results will be relevant to policy makers as well as HRH workers.

Dissemination plans

The results of this review will be disseminated through publications in peer-reviewed journals, conference presentations, op-eds and social media discussion threads in researcher networks working on HRH and health systems strengthening.

Study design limitations

To authors’ knowledge and based on the literature search undertaken for this, this is the first scoping review to explore impact of multiple inequalities experienced by health and care workers on their professional and personal lives. Since a date restriction has not been set, as a consequence a broad extent of literature is expected to provide the basis for this scoping review. Furthermore, articles of interest published in other languages will be missing in this review, especially those from countries in East Asia and Europe.

Supporting information

S1 table. keywords developed for population and concept..

https://doi.org/10.1371/journal.pone.0302175.s001

S2 Table. Preliminary data extraction chart.

https://doi.org/10.1371/journal.pone.0302175.s002

S1 File. PRISMA scoping review checklist.

https://doi.org/10.1371/journal.pone.0302175.s003

• 1. WHO, "Monitoring the building blocks of health systems: A handbook of indicators and their measurement strategies," WHO, Geneva, 2010.
• View Article
• PubMed/NCBI
• Google Scholar
• 4. W. H. O. WHO, "Health employment and economic growth: an evidence base," (in en), Publications 2017 2017, https://apps.who.int/iris/handle/10665/326411 .
• 5. WHO, "The World Health Report 2006 ‐ Working together for health," World Health Organization, Geneva, 2006.
• 10. C. H. Herbst, J. X. Lie, and F. A. Akala, "Health workforce in low and middle income countries," in Making health systems work in low and middle income countries, S. Siddiqi, A. Mataria, K. D. Rouleau, and M. Iqbal, Eds., 2022.
• 11. WHO, "Health labour market analysis guidebook," WHO, Geneva, 2021.
• 18. WHO, "Exploring health workforce inequalities: Case studies from three countries," WHO, Human Resources for Health Observer Issue 4 2010.
• 20. WHO, "Strengthening the collection, analysis and use of health workforce data and information ‐ A handbook," WHO, 2023.
• 28. A. C. Tricco, "Doing Scoping Reviews," in Cochrane Learning Live Webinar, ed: Cochrane Training, 2017.
• 33. A. c. Tricco et al., "PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation," Annals of Internal Medicine, vol. 169, no. 7, pp. 467–473, 2018.
• 34. WHO, "Global strategy on human resources for health: workforce 2030," WHO, Geneva, Strategy Document 2016.
• 35. WHO, "Classifying health workers: mapping occupations to the international standard classification," WHO, Geneva, 2019.
• 36. "The World Health Report 2006 ‐ Working together for health," World Health Organization, Geneva, 2006.

• Open access
• Published: 15 April 2024

Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis

• Christopher J. Byrne 1 , 2 ,
• Fabio Sani 3 ,
• Donna Thain 2 ,
• Emma H. Fletcher 2 &
• Amy Malaguti 3 , 4  

Harm Reduction Journal volume  21 , Article number:  81 ( 2024 ) Cite this article

207 Accesses

Metrics details

Background and aims

Psychological and social status, and environmental context, may mediate the likelihood of experiencing overdose subsequent to illicit drug use. The aim of this systematic review was to identify and synthesise psychosocial factors associated with overdose among people who use drugs.

This review was registered on Prospero (CRD42021242495). Systematic record searches were undertaken in databases of peer-reviewed literature (Medline, Embase, PsycINFO, and Cinahl) and grey literature sources (Google Scholar) for work published up to and including 14 February 2023. Reference lists of selected full-text papers were searched for additional records. Studies were eligible if they included people who use drugs with a focus on relationships between psychosocial factors and overdose subsequent to illicit drug use. Results were tabulated and narratively synthesised.

Twenty-six studies were included in the review, with 150,625 participants: of those 3,383–4072 (3%) experienced overdose. Twenty-one (81%) studies were conducted in North America and 23 (89%) reported polydrug use. Psychosocial factors associated with risk of overdose ( n  = 103) were identified and thematically organised into ten groups. These were: income; housing instability; incarceration; traumatic experiences; overdose risk perception and past experience; healthcare experiences; perception of own drug use and injecting skills; injecting setting; conditions with physical environment; and social network traits.

Conclusions

Global rates of overdose continue to increase, and many guidelines recommend psychosocial interventions for dependent drug use. The factors identified here provide useful targets for practitioners to focus on at the individual level, but many identified will require wider policy changes to affect positive change. Future research should seek to develop and trial interventions targeting factors identified, whilst advocacy for key policy reforms to reduce harm must continue.

Introduction

People Who Use Drugs (PWUD) experience myriad harms which drive substantial morbidity and mortality [ 1 , 2 , 3 , 4 , 5 , 6 ]. In 2019, approximately 6% of the world’s population used illicit drugs at least once – including using illicitly obtained prescription medications in the context of polydrug use – and this is predicted to rise to 11% by 2030 [ 7 , 8 ]. Approximately 21% of PWUD are estimated to have experienced recent non-fatal overdose – known to precipitate future fatal overdose – equating to an estimated 3.2 million people, while approximately 42% have ever experienced overdose [ 2 ]. Internationally, approximately 500,000-600,000 fatalities are attributable to drug use annually, with close to 80% of these related to opioids and 25–30% directly induced by opioid overdose [ 7 , 9 ]. This can include illicit drugs, such as heroin, as well as use of illicitly obtained pharmaceutical opioids, such as morphine, fentanyl, and oxycodone [ 2 , 3 ]. The escalation in drug-related harms and mortality in recent decades has been attributed to a triple-wave epidemic, mediated by supply and demand side drivers, characterised by widespread opioid use; beginning with prescription opioid pills, transitioning through heroin use, and culminating in synthetic opioids – of variable quality and potency – including fentanyl variants, and nitazenes, often combined with or substituted for heroin [ 10 , 11 ].

In North America alone, nearly 600,000 people have died from an opioid-induced overdose in the last two decades with 1.2 million predicted to meet the same fate by 2029 if current trends persist. Elsewhere in the Americas substantial mortality rates have also been recorded [ 12 , 13 ]. In the UK and Western Europe, overdose and mortality rates associated with polydrug use are increasing year-on-year in some nations, with opioids involved in most fatalities [ 14 , 15 , 16 , 17 ]. In Australasia, an estimated 51% of PWUD are reported to have experienced non-fatal overdose, while this is estimated at approximately 34%, 45%, and 50%, in East & Southeast Asia, South Asia, and Central Asia, respectively [ 2 ]. Indeed, Asia, relative to North America, Europe, and Australia, has the highest crude mortality rates among PWUD, with many attributable to fatal overdose [ 3 ]. Although data from African settings is sparse, the available evidence suggests that overdose consequent to illicit drug use, fatal or non-fatal, is increasingly common worldwide, and constitutes a significant threat to public health. Beyond opioids, other central nervous system depressants – benzodiazepines, alcohol – play a critical role contributing to risk, usually in the context of polydrug use [ 17 ]. Similarly, stimulants like cocaine in different forms, and amphetamines, are commonly used together with opioids and elevate risk by artificially masking respiratory depression [ 17 , 18 ].

Responding to these alarming trends, many have endeavoured to improve surveillance and trial interventions to protect people who use drugs from harm. Some existing medicalised interventions include naloxone provision [ 19 , 20 , 21 , 22 ], opioid agonist therapy (OAT) [ 23 ], opioid antagonist therapy [ 24 ], supervised consumption sites [ 25 , 26 , 27 ], related healthcare engagement [ 28 ], detoxification [ 29 ], and integrated prevention activities [ 30 ]. Naloxone provision has gained particular salience due to its efficacy in rapidly reversing opioid-induced overdose symptoms [ 31 ]. Conventionally carried in medical and pre-hospital settings, evidence has shown high willingness among overdose bystanders to administer it [ 20 , 32 , 33 ]. Subsequently, several countries spanning Europe, Australia, and North America, have adopted legislative changes to enable provision without prescription, and protect bystanders who administer it from prosecution [ 34 , 35 , 36 ]. Beyond medicalised interventions, recovery-based approaches which prioritise empowerment, self-determination, and holistic wellbeing, have been widely adopted to underpin recovery journeys with senses of identity, belonging, purpose, and social connection [ 37 ]. Peer outreach and in-reach programmes for overdose reduction, as well as mutual help programmes, have also demonstrated efficacious impacts on recovery [ 38 , 39 , 40 , 41 ]. Such approaches acknowledge that recovery is an ongoing process that requires support, compassion, and dedication, which often extends beyond drug use alone to shifts in identity [ 42 , 43 , 44 ].

It is in the context of the varied approaches to overdose intervention, and the acknowledgement that experiences of drug effects are influenced by psychological characteristics and social processes, that we sought to evaluate the available evidence quantifying the risk of overdose among PWUD associated with psychosocial factors [ 45 , 46 ]. That is, features that pertain to the influence of social factors on an individual’s mind or behaviour, and to the interrelation of behavioural and social factors upon outcomes [ 47 ]. These may relate, for example, to social resources, like healthcare access or income source; psychological resources, such as risk perception; and psychological morbidity. Several guidelines on illicit drug use and dependence recommend psychosocial interventions, often targeting behaviour change through mindfulness, motivational interviewing, cognitive behavioural therapy (CBT) based interventions, and acceptance and commitment therapy [ 48 , 49 , 50 , 51 , 52 ]. These interventions are frequently positioned as adjuncts to overall treatment packages, as they are of uncertain benefit relative to medicalised therapies [ 53 , 54 , 55 ].

Over the years, many risk factors for overdose have been identified, for example: polydrug use; psychiatric comorbidity; unstable housing; witnessing overdose; substance use disorder; prescription of opioids; increasing pharmacy use; increasing opioid prescribers; vulnerability to socio-economic marginalisation; hepatitis C/HIV infection; male gender; rural residence; certain employment types/industries; incarceration; familial distress; disability; detoxification programme experience; the built environment; and suicidality as key factors [ 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 ]. However, despite this expansive evidence base, prior to this review, we were unable to identify any unified work that identified which psychosocial factors are associated with overdose, and therefore best to target with interventions found in prevailing guidelines.

Generating this information is critically important in the current era of increasingly limited public health resource and multiple competing public health priorities. Given their prevalence in clinical guidelines, and the uncertainty around their benefits, we sought to understand which psychosocial factors might impact on risk of overdose, to inform future intervention development and clinical practice. Accordingly, we undertook a systematic review with a narrative synthesis, which aimed to identify which, if any, psychosocial factors are associated with risk of overdose, whether fatal or non-fatal.

This review complied with the updated PRISMA statement checklist for reporting of systematic reviews and meta-analyses [ 68 ] and reporting guidelines for synthesis without meta-analysis in systematic reviews [ 69 ]. The review protocol with methods and inclusion criteria was registered in advance on PROSPERO (CRD42021242495).

Eligibility criteria

Only studies written in English were considered. The search (up to 14 February 2023) was completed with no limitations on publication dates and no geographic restrictions.

Participants

Studies were required to include PWUD as participants.

The exposure in this study was psychosocial factors which are associated with fatal and non-fatal overdose. Psychosocial was defined as pertaining to the influence of social factors on an individual’s mind or behaviour, and to the interrelation of behavioural and social factors on the outcome [ 47 ].

In studies where comparison was undertaken, PWUD who experienced overdose were compared to PWUD who did not.

The primary outcome was overdose (fatal or non-fatal) consequent to use of illicit, or illicitly obtained controlled, drugs. Intentional overdose was excluded where possible, as suicidality constitutes different behavioural characteristics to unintentional overdose. Where it was unclear whether intention was assessed or not, the study was included.

The review included observational studies (cross-sectional, cohort, case-control, and qualitative studies). Case series, case reports, and reviews, were excluded.

Information sources

The following databases were searched via OVID: Medline, Embase and PsycINFO. Cinhal was searched via EBSCOhost. Grey literature was explored by searching with Google Scholar. Reference lists of selected full-text studies were manually screened for further identification of relevant studies.

Search strategy

The search strategy was identical across databases, adjusting for database-specific search requirements. An example of the search strategy is provided in the Supplementary File. Reference lists for manuscripts eligible for full text review were searched manually for relevant titles; whilst Google Scholar was searched with ‘Psychosocial factors AND drug overdose’, and results screened manually. Screening stopped once 100 sequential results did not match search terms, given the results were ordered according to accuracy and relevance. Database searches were saved in an EBSCOhost or OVID account folder. Duplicates were removed.

Study selection and data extraction

Search results were exported from relevant databases into Microsoft Excel 365 spreadsheets for screening, with tables on study characteristics and psychosocial factors created using Microsoft Word 365. One reviewer (AM) screened titles for inclusion. Two reviewers (AM and CJB) screened all abstracts and full texts independently and a third reviewer (FS) arbitrated. Inter-rater agreement, calculated using Cohen’s kappa in Stata 17 BE, indicated high levels of agreement for both abstract (κ = 0.672 [0.565-0.780], p  < .001) and full-text (κ = 0.835 [0.697-0.974], p  < .001) screening. Data were extracted by two reviewers (AM and CJB), and separated into tables. First, data were extracted for study and sample characteristics: author, study design, location and location type, sample size, gender, age, ethnicity, population type, drugs (and other substances) reported, overdose definition, and number who experienced overdose. Second, psychosocial factors associated with overdose identified in each study along with comparators and the estimated effects/description of the association were extracted and tabulated.

Risk of bias assessment

Two reviewers independently assessed risk of bias for all included studies, discussing any discrepancies and mutually agreeing on final assessment; where required, arbitration was conducted by a third person to arrive at a final decision. The National Institutes of Health Study Quality Assessment Tools for quantitative studies, and the Critical Appraisal Skills Programme Qualitative studies checklist for qualitative studies, were used [ 70 , 71 ]. In brief, these prompt quality appraisal by considering clarity of research aims; definition of, and homogeneity of, study populations; participation rates; appropriateness of analytic approaches; clarity of outcomes measured; and ethical conduct.

Effect measures

Effect measures extracted from the studies were tabulated. Given the heterogeneous nature of the studies selected for the review, and the attendant factors examined, results were narratively synthesised; effects were not meta-analysed.

Synthesis procedure

Data were extracted manually and tabulated according to study characteristics and study findings (identified factor, author, effect size, and direction of effect). The tables were used to familiarise the reviewers with the data initially. Once data extraction was complete, the findings were reviewed, and relationships within the data and overlapping themes were annotated throughout the process of narratively synthesising individual data. The themes were discussed among three members of the research team (AM, CJB, FS) and a peer worker with lived experienced of drug use to ensure they were as accurate a reflection of the lived reality of drug use as could feasibly be achieved for a review. Themes were considered against the review question and full dataset to ensure they were focused and addressed the research question. Extracted data within each theme were then inspected to explore differences in effect direction and potential bias introduced by the different study designs included in the review. Where divergences existed, these were considered in light of study design and risk of bias. Following these steps, the manuscript was drafted, which continued the analytical, procedural, and conceptual thinking for the synthesis to be completed.

Study selection

The screening results are illustrated in Fig.  1 . During the search, 2,802 titles were screened: 2,408 were excluded, and 394 were selected for abstract review. After exclusion of duplicates, 187 remained. After further review, 61 were selected for full text assessment. Thirty-five studies were excluded with reason, whilst 26 were selected for quality appraisal and analysis.

Prisma flow chart summarising the screening process

Study characteristics

All studies focussed on overdose, fatal and non-fatal, consequent to illicit drug use as the primary outcome. This was often combined with use of legal substances (e.g. alcohol), and/or illicitly obtained controlled drugs, meaning the cohorts examined were often in the context of polydrug use. One study defined the outcome as death by unintentional overdose, according to post-mortem medical examination records [ 72 ], while one examined people hospitalised with ICD-9 codes for opioid-induced non-fatal overdose [ 73 ]. All other studies relied on self-reported non-fatal overdose disclosure, though outcome timeframes varied. In nine studies, participants self-reported ever experiencing overdose [ 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 ]. For nine other studies, the primary outcome was self-reported overdose in the last six months [ 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 ]. The primary outcome for three studies was experience of overdose in the past 12 months [ 92 , 93 , 94 ]. Riggs et al. defined the primary outcome as self-reported overdose in the last three years, while Argento et al. defined it as self-reported overdose during the study observation period (participants were sampled over nine years and follow-up varied) [ 95 , 96 ]. Lastly, for one study the primary outcome was self-reported overdose in the past five years [ 97 ]. Descriptive characteristics of each study are in Table  1 .

The total sample comprised 150,625 people. Of those, the number of participants who experienced overdose, according to the definitions reported, ranged from 3,383 to 4,072 (3%). A range is provided as one study did not report the number with sufficient clarity [ 87 ].

Most studies were conducted in North America ( n  = 21), three were in Asia, one was in Europe, and one in Australia. Participant ages ranged from 21 to 56 years. Six studies focussed on female and/or gender minority participants [ 75 , 77 , 84 , 88 , 90 , 96 ], and the remainder had a preponderance of male participants (Table  1 ). Twenty-three studies reported polydrug use and, of those, eight specified this was a mixture of prescription and illicit drugs. Three studies did not disclose the specific drugs used [ 73 , 74 , 88 ].

Methodological quality

No methodological concerns were identified which warranted removal of any of the included studies (Supplementary file 1 ).

Psychosocial factors

Factors associated with overdose ( n  = 103) were extracted from each study and structured into ten thematically similar groupings (Table  2 ; Fig.  2 ).

Thematic groups of factors found to impact on experience of overdose in reviewed studies ( n  = 103)

Note : N in each circle is the number of factors within that thematic group. Groups with smaller N are smaller circles, while groups with the same N are the same colour. Groups are randomly scattered as there is no inherent hierarchy or linearity to their impact

Eighteen studies reported odds ratios (OR) as the measure of the association between factors and exposure to overdose [ 73 , 75 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 90 , 91 , 93 , 94 , 95 ]. Two studies reported incidence rate ratios (IRR) [ 74 , 76 ], two reported relative risk (RR) [ 89 , 92 ], and two reported hazard ratios (HR) [ 72 , 96 ]. Two studies were qualitative, so no quantitative estimates were reported [ 77 , 97 ]. Given the heterogeneity of measures and study designs, summary statistics were not calculated, and meta-analysis was not performed [ 98 ]. Despite this heterogeneity, estimates of effects were considered and informed the narrative synthesis.

Eight studies explored the relationship between income source and/or unemployment and odds, or risk, of overdose [ 73 , 75 , 81 , 85 , 87 , 89 , 90 , 94 ]. Winter et al. demonstrated sustained unemployment prior to imprisonment was associated with four-to-five times higher risk of overdose following liberation. Mitra et al. also showed a four-fold increase in odds associated with unemployment. Similarly, Pabayo et al. found 40% and 70% higher odds of overdose among men and women respectively, in receipt of social welfare. Harris et al. showed recent engagement in sex work was associated with 60% higher odds of overdose, while Fairbairn et al. reported ever engaging in sex work was associated with twice the odds. El-Bassel et al. examined compounding effects of sex work and violence, with over ten years sex work experience also associated with twice the odds of overdose, and combined exposure to this with recent violence, including from intimate partners, increasing the odds four-fold. Analysis from Latkin et al. (2019) implied selling drugs in the past 30 days was associated with two-to-three times higher odds of overdose. Finally, work by Silva et al. found identifying as a lower socio-economic status growing up increased odds of overdose by 80%.

Homeless/housing instability

Eight studies explored this theme [ 73 , 81 , 87 , 88 , 89 , 90 , 91 , 95 ]. Unstable housing and lack of accommodation was consistently found to increase the odds and risk of overdose. Mitra et al. observed the largest effect, with housing insecurity increasing the odds of overdose seven-to-eight-fold. Thumath et al. found recent homelessness was associated with 60% higher odds, current homelessness increased odds by 30% according to Riggs et al., while being unhoused in the past six months was associated with 50–70% increased odds in a study by Harris et al. in an all-female sample, and 30% higher odds in Pabayo et al. in a restricted male-only analysis. The highest estimate among examinations of recent homelessness was by Silva et al, who showed past 90-day homelessness increased odds of overdose by close to three-fold, while Tomko et al. estimated a two-fold increase. Ever experiencing homelessness and ever living in a foster home were associated with five-fold and 60% increases in odds of overdose in work by Thumath et al. and Silva et al. respectively. Finally, Winter et al. found experience of unstable accommodation one month prior to incarceration increased risk of overdose three-fold among recently liberated prisoners.

Incarceration

Eight studies explored incarceration-related factors [ 72 , 75 , 77 , 79 , 81 , 86 , 89 ]. Winter et al. estimated any previous incarceration as an adult resulted in five-times higher risk of overdose, while Milloy et al. and El-Bassel et al. estimated a roughly four-fold increase in odds of overdose for participants with similar histories, and Silva et al. estimated a doubling of odds. Harris et al. and Lake et al. found incarceration in the past six months was also associated with twice the odds of overdose, with the effect enduring when adjusted for physical or emotional neglect in the work by Lake et al. El-Bassel et al. estimated a more pronounced effect among those with history of incarceration and intimate partner violence, who experienced five-times higher odds of overdose, with those who experienced non-partner violence having close to four-times higher odds. Recent liberation from prison, coupled with mental ill health, conferred a 50% higher hazard of overdose in work by Pizzicato et al. and Lamonica et al., in their qualitative study, also found that recent liberation from carceral settings increased risk of overdose in a suburban all-female cohort.

Traumatic experiences

Nine studies assessed traumatic experiences [ 75 , 77 , 84 , 86 , 88 , 89 , 90 , 91 , 96 ]. Lamonica et al. found emotional trauma, such as negative life events and consequent depressive states, increased risk of overdose. Various other traumatic experiences were examined, but multiple iterations of physical trauma pre-dominated. Thumath et al. found experience of intimate partner violence doubled the odds of overdose among marginalised women in Canada, Lake et al. found physical abuse and neglect increased odds of overdose by 40% and 30% respectively. Harris et al. found recent physical violence increased overdose odds by 80% in an all-female cohort, with that increasing to close to three-fold among sex workers and adjusted for confounders. Combined physical and sexual workplace violence was associated with twice the odds of overdose among sex workers in Goldenberg et al., while sexual abuse carried a 50% increase in odds in Lake et al., and any physical/sexual violence conferred a 90% increase in hazard in Argento et al. El-Bassel et al. examined multiple type of physical violence, imparted by intimate partners and others, and found consistently elevated odds of overdose, with severe physical violence conferring 30% increased odds in adjusted analysis.

Beyond physical trauma, Tomko et al. identified a 70% increase in odds of overdose among those who experience daily psychological pain in adjusted analysis. Separately, severe emotional abuse conferred a 50% increase in odds in adjusted analysis by Lake et al. Adverse childhood events, such as removal from family as a child, or removal from parental care, were associated with a four-fold increase in odds by Winter et al. and a doubling of odds by Thumath et al., respectively. Similarly, having a child removed from one’s care held a 60% increase in odds in adjusted analysis by Thumath et al., and child custody loss was linked with higher overdose risk in qualitative work by Lamonica et al. Finally, Thumath et al. found food insecurity drove a 90% increased in odds of overdose.

Overdose risk perception and past experience

Risk perception and past experiences with overdose were evaluated in six studies [ 74 , 77 , 80 , 81 , 92 , 95 ]. There were divergent effects between perceived severity of prior overdose experience and participants’ perception of their own susceptibility to overdosing in work by Bonar et al., where higher perceived severity was linked to 40% decreased incidence and higher perceived susceptibility was linked to 50% higher incidence. Vicarious experience, i.e. witnessing an overdose, was associated with two-fold higher odds of subsequent overdose experience in Riggs et al., while ever witnessing a family member overdose conferred 60% higher odds in adjusted analysis by Silva et al. Schiavon et al. estimated that the higher the number of times a participant witnessed another person overdose, odds of subsequent overdose experience increased by 40%, with odds increasing four-fold where the other person was identified as a friend. Prior experience of overdose was also linked to 70% higher risk of subsequent overdose in Grau et al. whereas, in qualitative work by Lamonica et al., being a ‘novice’ to drug use, which may include erroneous polydrug use, was linked to higher risk.

Healthcare experiences

Most healthcare experiences, across eight studies, focused on medicalised addictions treatment [ 76 , 80 , 81 , 84 , 86 , 89 , 91 , 94 ]. Ever experiencing addictions treatment was associated with a 60% increased incidence of overdose in Havens et al., while Latkin et al. estimated a 50% increase in odds. However, when examined by Silva et al., the increase in odds was two-fold, and ever receiving opioid substitution therapy conferred a three-fold increase in relative risk in Winter et al. Schiavon et al. estimated that with increasing number of treatment episodes, the odds of experiencing overdose increased by 60% in adjusted analysis. Conversely, Lake et al. found that being denied access to addictions treatment was associated with close to three-fold odds of overdose. Other studies examined healthcare need, with Goldenberg et al. identifying unmet healthcare need was associated with 70% higher odds of overdose, and Tomko et al. linking unmet mental health care need to a 40% increase in adjusted analysis.

Perception of own drug use and injecting skills

Three studies examined participants’ perceptions of their own drug use, two of which were qualitative [ 77 , 95 , 97 ]. In the quantitative work, Riggs et al. estimated that participants who perceived they had a drug ‘problem’ had five-fold higher odds of subsequent overdose in adjusted analysis. Lamonica et al. found participants who disclosed a lack of knowledge about drug use, a lack of control over the quality of the drugs they were using, or lack of knowledge of their tolerance of those drugs, had higher risk of experiencing overdose. Chang et al. termed similar types of knowledge as ‘opioid expertise’ – this also included perceived self-control over opioid use and one’s bodily response – and identified that participants who felt they possessed a high degree of opioid expertise had increased risk of overdose. Related to the sense of expertise and experience, low injecting skill was examined in two studies [ 86 , 87 ]. Both linked requiring assistance with injecting with increased odds of overdose. Lake et al. found requiring help to inject increased odds by 90%, with adjusted models for physical and sexual abuse yielding 70% higher odds, and adjusted models for physical and emotional neglect yielding 70% and 50% higher odds respectively. Likewise, Pabayo et al., found that, among men, requiring help injecting increased odds of overdose by 74%.

Injecting setting

Injecting setting was assessed in four studies [ 83 , 84 , 85 , 86 ]. Injecting in public spaces in the past six months was consistently linked with higher odds of overdose. Lake et al. found a close to three-fold increase in odds of overdose in a Canadian cohort, which attenuated to 90% when adjusted for experience of emotional abuse, and to 70% when adjusted for experience of emotional neglect. Fairbairn et al. estimated a more pronounced effect, with a close to five-fold increase in odds associated with injecting in public settings. Both cohorts were sampled in Vancouver, Canada. Conversely, these studies found diverging effects for injecting alone in the last six months. Lake et al. estimated an 80% increase in odds, while Fairbairn et al. found the odds of overdose decreased by 60%. Fear of police intervention while injecting in public spaces was associated with a two-fold increase in odds by Bazazi et al., including in adjusted analysis. While ‘rushed’ outdoor drug use in the last six months conferred a 30% increase in odds in work by Goldenberg et al.

Conditions within physical environment

In related analyses, specific conditions within the wider physical environment were found to mediate overdose likelihood in six studies that examined this [ 83 , 84 , 90 , 93 , 94 , 96 ]. Proximity to harm reduction provision was examined in three studies, with somewhat diverging outcomes. First, Bazazi et al., found that among those who reported that a needle and syringe provision (NSP) site was the main source of their injecting equipment acquisition, this was linked to a 60% reduction in odds of overdose. However, Latkin et al. (2019) found that among those who replaced syringes through such a service, there was a three-to-four-fold increase in odds. Vallance et al. also reported a similar finding, where participants that resided in areas of high harm reduction coverage had twice the odds of overdose in adjusted analysis. In further conflicting results, Goldenberg et al. identified police-related barriers to harm reduction access doubled odds of overdose in adjusted analysis.

Similarly, Argento et al., found the same parameter conferred a close to three-fold increase in hazard of overdose in adjusted analysis, while Harris et al. observed that, among women, being stopped, searched, detained, or assaulted by police conferred a 50% increase in odds. This increased to a doubling of odds when stratified for sex workers only. Meanwhile, living in an area characterised by criminalisation, marginalisation, and prevalence of drug use, was associated with 40% higher odds of overdose in the same paper. Somewhat similar to wider drug use prevalence in the area, residing in a neighbourhood with an increasing number of known settings in which to use drugs was associated with 30% increase in odds overdose in adjusted analysis by Latkin et al.

Social network traits

Finally, density of social networks and supports were examined in six studies [ 76 , 77 , 78 , 82 , 84 , 87 ]. Pabayo et al. found three or more social supports was associated with a 50% reduction in odds of overdose among women in adjusted analysis. While, in their study, Tobin et al. found density of social network at baseline, and increases in density reported during follow-up, were associated with 90% and 80% reductions in odds in adjusted analyses. However, among those who reported recent injection drug use, Tobin et al. found increasing density in social network conferred a 20% increase in overdose odds in adjusted analysis, while Latkin et al. (2004) identified that reporting increasing numbers of people who inject heroin in one’s social network was associated with 20% higher odds of past overdose, and 30% higher odds of recent overdose. Conversely, in the same study, increasing numbers of contacts who snort heroin, rather than inject, was associated with a 20% reduction in odds of overdose.

Conflicting somewhat with these findings, Tobin et al. also found that, among those who reported recent injection drug use, an increasing number of people who inject drugs in participants’ social networks was associated with 80% reduced odds of overdose in adjusted analysis. Similarly, Havens et al. found increasing numbers of support members in one’s social network was linked to a 20% increased in incidence of overdose in adjusted analysis. Latkin et al. found increasing levels of conflict within a participant’s social network conferred a 30% increase in odds, whilst other studies examined intimate partnerships. In their qualitative study, Lamonica et al., found being friends, or in an intimate partnership, with someone who uses drugs increased participants’ risk of overdose. Similarly, Goldenberg et al., reported that providing drugs for an intimate partner (who was male) was associated with a 40% increase in odds of overdose.

This review is the first to our knowledge which specifically evaluated psychosocial factors associated with unintentional overdose consequent to illicit drug use, with many reviewed studies documenting polydrug use. Prior research suggests the majority of serious overdoses are unintentional, implying our findings are pertinent to the experiences of many people who use drugs [ 99 ]. While existing review evidence has elucidated many important factors, as noted in the Introduction, none highlighted the important connections between sex work, violence, or social networks, and overdose risk that we identified [ 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 ]. Twenty-six studies from seven countries were reviewed, only two of which were qualitative, with the vast majority conducted in North America. Most participants were male, though several studies examined female-only cohorts. The overall proportion estimated to have experienced overdose was 3%, contrasting sharply with global estimates of 21% (15-26%) of PWUD reported to have recently experienced overdose [ 2 ]. Sample sizes varied widely, with two registry studies reporting disproportionately large samples relative to other reviewed studies, and low relative overdose prevalence [ 72 , 73 ]. Excluding these from the estimate would bring the overall prevalence closer to 16%. Thus we believe most studies reviewed are representative of the at-risk population.

Identified factors were structured into ten overarching groups, with some thematically similar correlates yielding conflicting results. Factors varied from the individual (e.g. risk perception) to the structural (e.g. housing) in a manner which illustrates the synergies between biological factors, psychological traits, and social processes, both at micro and macro levels, which influence an individual’s likelihood of experiencing overdose [ 45 , 46 , 100 , 101 ].

For example, income played an important role in mediating risk, with experience of sex work, unemployment, drug selling, social welfare receipt, and lower socio-economic status, all associated with increased reports of overdose. The relationship between income and health may be explained by subjective psychosocial experiences mediated by work environments and exposure to unemployment [ 102 , 103 ]. However, the correlates reported are characterised by socioeconomic marginalisation, which speaks to the economic and political frameworks which worsen health outcomes for people who use drugs within the model of interdiction which predominates globally. For instance, at the micro level, while the individual acts involved in drug use may have shaped sex worker/client interactions and were important in moderating overdose risk, the ultimate harm induced by that behaviour was enabled by the fact sex workers were reticent to report overdose due to criminalisation and structural stigmatisation, both of their drug use but also their method of income generation [ 104 ]. The risk environment for sex workers was elucidated further by El-Bassel et al. who demonstrated the compounding impact of violence and sex work on overdose risk [ 75 ]. The context may then be at least partially characterised by risky drug use and frequent violence at the micro level – a common experience among sex workers operating in a social environment of gendered norms and unequal power dynamics – which is enabled by public policy at the macro level which marginalises sex workers and leaves them vulnerable to harms related to drug use [ 105 , 106 ]. These findings speak to the urgent need to cease using criminal law to enforce morals upon income generation and strengthen the previously elucidated case for this as the best strategy to reduce harms experienced by sex workers [ 107 ].

At the individual level, there is little evidence to support the use of psychosocial interventions to improve health and well-being among sex workers, perhaps due to the structural factors at play [ 108 ]. Separate to this, unemployment was generally associated with higher risk than sex work and other income factors such as social welfare receipt, participation in the illicit drug trade, and lower socio-economic status, and it is important to note that the relationship between these factors and overdose may be mediated by social capital and isolation [ 59 , 62 , 109 ]. These, in turn, drive worse psychosocial outcomes, which are enabled by prevailing policies of state-imposed methods of control (social welfare) of non-conforming behaviour (non-participation in ‘normative’ modes of economic activity), and intentional criminalisation of drug use which erodes drug supply quality and increases overdose risk [ 10 ].

In a similar vein, housing instability was consistently linked with increased odds of overdose, similar to prior research which observed this [ 110 ]. Among vulnerable adults experiencing homelessness, psychological and social issues at the micro level, such as self-esteem, social support, coping mechanisms, and emotional distress, have been associated with increased substance use [ 111 ]. Further, people facing homelessness experience frequent stigmatisation which negatively impacts mental health and well-being, and wider social interactions. Whilst drug use in this context of unstable housing will be influenced by immediate social norms of the situation, there is an overarching synergy between housing and drug use which has driven opioid-overdose to be a leading cause of death among people experiencing it [ 112 , 113 , 114 ]. Research suggests this synergy confers 38% higher odds of overdose [ 115 ]. These issues are likely manifestations of both immediate social interactions in the context of insecure housing, and macro housing policy which inhibits the social environments which vulnerable individuals are enabled to access. Recent work has reported positive effects for psychosocial interventions in reducing psychological morbidity among people experiencing homelessness [ 116 ], but these will not negate the risks which require wider policy reform around housing programmes [ 112 ]. For example, many housing programmes restrict PWUD accessing their services as a matter of policy, despite housing being linked with harm reduction impacts and improved psychosocial measures which may facilitate recovery-based approaches [ 117 , 118 , 119 ]. The results illustrate a need for supportive and stable housing – a fundamental requirement to establish a sense of safety and stability – to be viewed as a critical intervention which policy makers and public health practitioners should seek to deliver to moderate prevalence of overdose.

The likelihood of becoming homeless may be mediated by history of incarceration [ 120 ]. Incarceration was consistently linked to higher risk of overdose in reviewed studies, and other work not reviewed here [ 115 ]. The circumstances surrounding the first two weeks post liberation have been demonstrated to induce an up to eight-fold increase in risk of fatal overdose relative to subsequent weeks and, furthermore, all-cause mortality is up to 12.7 times higher than that of the general population among those recently liberated, with most attributable to fatal overdose [ 121 , 122 ]. While mental health difficulties, victimisation, and feeling unsafe during incarceration, have been linked to poorer psychosocial adjustment upon liberation (which psychosocial interventions may help address), these findings emphasise the inadequacy of efforts by health and welfare services, and carceral establishments, to assist people in the vulnerable period following liberation with transitional social and medical supports [ 123 , 124 , 125 ].

Research has shown relapse to drug use in this window occurs in the context of poor social support, situational stressors (violence, poverty, isolation, availability), and decreased tolerance [ 125 ]. Conversely, exposure to factors which address these, such as housing, social supports (including avoiding old social networks), mutual help programmes, and spiritual services, have been cited as protective [ 125 ]. Overdose risk caused by liberation to environments that trigger drug use may be somewhat ameliorated by provision of take-home naloxone, but research has shown people in prison may not be receptive to training and carriage of naloxone, and motivation to carry it is complicated by desires to remain abstinent [ 126 , 127 ]. Beyond individual factors, useful conceptual frameworks have been posited to frame the multilevel nature of the determinants involved in overdose risk upon liberation, which suggest researchers shift the lens through which this issue framed from the individual to the socio-structural [ 128 , 129 ]. Our findings highlight the harms conferred by structural control mechanisms which reinforce criminalisation of drug use and compound inequalities experienced by people who use drugs in health outcomes.

There were additive effects for incarceration with physical neglect and recent experience of violence. Intimate partner violence (IPV) was among the traumatic experiences linked to higher risk, alongside multiple types of intimate partner and non-partner violence, including sexual abuse and neglect. It was unclear from the results whether IPV, abuse, and neglect experienced were reciprocal/bidirectional, however all but one study examining these experiences were in female cohorts. So the relationship between overdose risk and these factors may be understood as the confluence of the drug effects, the norms and boundaries concerning gender-based violence within the immediate social context, and wider cultural and systemic factors which perpetuate gender-based violence. At the individual level, psychosocial interventions, with advocacy and psychological components, can reduce depressive symptomology and post-traumatic stress among IPV survivors, which may ameliorate overdose risk [ 130 ]. However, they do not mitigate against re-experience and therefore policy changes which address the physical, social, and economic circumstances that manifest in the macro environment, and perpetuate gender-based violence, are critical to reducing risk, alongside individual interventions. One relevant example is the ongoing pilot of discreet payments to women availing of aid services in Scotland to abscond from circumstances of abuse [ 131 ].

In studies which examined experiences of healthcare, unmet needs and denied care were important in elevating overdose risk. PWUD are less likely to be able to avail of preventive healthcare to screen and manage conditions due to frequent experiences of stigma, distrust, and frustration in health environments; with those same people often blamed for the stigma they experience [ 132 , 133 , 134 , 135 , 136 ]. Unmet health needs have been linked to increased depression, with 29% (21-37%) of PWUD meeting the threshold for clinical depression diagnosis, and consequent self-harm and post-traumatic stress common [ 1 , 137 ]. There were also associations between experience of addictions treatment and overdose which were unexpected, given OAT is known to be protective against drug-related mortality [ 138 ]. This association may be explained by severity of dependence (and related suboptimal dosage); changes in tolerance whilst engaging with treatment; those who engaged with treatment having a higher likelihood of follow-up for overdose; those with past overdose experience being more likely to be referred for treatment; OAT discontinuity and re-entry; and transferring between OAT providers [ 139 , 140 ]. It should further be acknowledged that, though it is an established harm reduction tool, OAT can (and has) been interpreted as a mechanism of control through which moral discipline is inculcated in people who participate in drug use [ 141 , 142 ]. Through this lens, OAT engagement is necessitated only by ongoing interdiction and the intersecting inequalities and harms this produces. Safer supply and decriminalisation of drug use present reasonable (structural) approaches relative to individual interventions such as OAT, which may aid in mitigating overdose risk at the population level, whilst simultaneously mitigating against negative effects of interventions premised on ill-conceived moral frameworks [ 143 , 144 ].

Some environmental factors linked to overdose included experience of police-related interventions such as blocking access to harm reduction, stopping, arresting, and detaining people. All of which are more likely to occur in areas characterised by socio-economic marginalisation and prevalent drug use. Policing of drug use is characterised by violence which drives increased psychological distress among PWUD [ 145 , 146 ]. Similarly, rushed and public injecting, often accompanied by punitive policing, drove increased risk, as demonstrated in previous work [ 115 ]. Social-ecological frameworks have been proposed to articulate a means of addressing such factors, as it is unlikely individual-level interventions will modify these risks [ 147 , 148 ]. It is likely public health approaches which account for the societal, communal, and interpersonal factors, which drive these risks will be required to mitigate against the high likelihood of overdose they confer. These approaches require policy change – particularly regarding criminalisation of drug use and associated policing – while educational campaigns and clear service pathways to harm reduction are also critical.

At a more individual level, perception and social issues noted highlight the interconnectedness between drug use, individual psychology, and social processes. Social support systems impact psychological and physical wellbeing, and the interplay of social networks with environmental and individual factors can differentially impact upon psychological stressors [ 149 ]. This was apparent in the results, with contrasting effects observed. Higher density of social networks of varying degrees were protective against overdose in one study [ 82 ], while others which examined social networks characterised by conflict, ongoing injecting, and exposure to recent overdose among peers, signalled harmful impacts. Individually, peer social support may reduce psychological distress which in turn reduces overdose risk [ 150 , 151 ], and interventions which target social connectedness may be beneficial in this context [ 152 ]. More broadly, these results may be viewed through the Social Identity Model of Recovery, which proposes that recovery from drug use relies on a shift in identity wherein individuals reshape their social network to one wherein drug use is uncommon [ 43 , 44 , 153 ]. Reviewed studies which signalled harmful impacts studied social networks characterised by ongoing risks, whilst one might infer that those which examined network density where actually examining surrogates of networks wherein use of drugs was less prevalent. Where recovery from drug use is sought, peer support can be critical. One form which this takes is in mutual aid groups, which have been shown to catalyse changes in social networks, increase recovery capital, and enhance commitment to sobriety, through community reinforcement [ 154 , 155 ]. Additionally, alternative unstructured peer support strategies, such as recovery cafes, can also be enabling, whilst strategies like ‘spotting’ can help to enhance overdose response in the context of ongoing drug use [ 156 , 157 ].

Furthering the consideration of social context, witnessing overdose is deleterious to psychological wellbeing, causes post-traumatic stress, and can drive people to engage in risky drug use behaviours to manage feelings of bereavement and trauma [ 158 , 159 ]. Psychological distress has itself been independently associated with close to ten-times higher odds of overdose in young people [ 110 ]. Therefore trauma-informed psychosocial interventions for post-traumatic stress – which have been demonstrated as effective, particularly CBT-based therapies – may be important to integrate into existing harm reduction services [ 160 , 161 ]. Particularly when prefaced by safety and stabilisation work within a phased interventional model, to establish safety and create coping mechanisms before trauma reprocessing occurs [ 162 ]. However, an increase in psychological wellbeing may not mitigate against social factors such as requiring injecting assistance – shown previously to increase risk by approximately 58% – and risk conferred by one’s perception of their drug use [ 115 ]. Factors which implied low injecting skill were associated with increased risk – psychosocial interventions may improve injecting skills among PWUD [ 163 ] – alongside identifying as an expert in drug use. This contrasts with research among people who use new psychoactive substances, where expertise has been linked to higher risk perception and greater control in exposure to risk [ 164 ]. Individual-level interventions which assess and affect changes to psychological mechanisms that relate risk perception to overdose risk may therefore also be appropriate to explore.

Limitations

There are several limitations to this review. First, we did not undertake a meta-analysis due to the heterogeneity in effect estimates and study designs, instead opting for narrative review of the effects. Although appropriate for the heterogeneous study types and factors examined, this provides limited information for decision making relative to meta-analysis and risks emphasising the results of some studies erroneously and potentially misrepresenting the evidence [ 165 ]. Second, reviewed studies were concentrated in high-income countries, mostly in North America, significantly limiting the generalisability of the work. No work from African settings was identified, which is a critical limitation given the ongoing epidemic of extra-medical use of opioids (tramadol) and expansion of cocaine markets in recent years into African and Near and Middle Eastern settings, beyond conventional markets in Europe and North America [ 166 ]. This likely means PWUD in these settings will be disproportionately impacted by associated harms in coming years, with little representation in research. Third, our search strategy included terms for ‘psychosocial’, ‘psychological’, ‘social’, or ‘behavioural’, which was intended to be comprehensive. Nonetheless, some relevant research may have been omitted unintentionally due to the search design and/or interpretation of the results by the reviewers, given the broad scope and interpretability of the term ‘psychosocial’; we mitigated against this by referencing a recognised definition when interpreting and extracting results, and citing works thought to be relevant in the Discussion [ 47 ]. Finally, only two studies reviewed were qualitative in nature. This suggests the findings may omit relevant work documenting subjective experience, not captured in the quantitative studies. We suggest two reasons for this: our search strategy did not include terms for methodology like ‘quantitative’ or ‘qualitative’ which may have resulted in more results returned for relevant qualitative work; and much qualitative work proximal to overdose which we reviewed for inclusion concurrently examined factors which made them ineligible on the basis of our criteria (e.g. suicidal ideation; relationships).

Globally, rates of fatal and non-fatal overdose continue to increase, alongside many cognate harms, consequent to illicit drug use [ 1 , 2 , 167 ]. This review identified many psychosocial correlates of overdose which spoke to the interdependencies between drug use, psychological traits, and social processes, alongside the overlapping structural, societal, and environmental inequities which govern harms related to drug use, and therefore frame the risks related to overdose. Existing harm reduction interventions are insufficient to resolve the crisis of overdose and avoidable fatalities consequent to the opioid epidemic [ 168 ]. To date, many national drug policies are premised more on ideology than evidence, and our findings support the view that punitive approaches are not just ineffective in reducing prevalence of overdose, but actually contribute to the risk environment which increases it [ 144 ]. Where we believe this review adds value for the harm reduction movement is in elucidating several themes not previously identified in existing review evidence, which may be helpful in policy work concerning drug use, and clarifying the factors which practitioners may seek to engage at the individual level when exploring psychosocial interventions in harm reduction services, to facilitate therapeutic response. For example: mechanisms underlying risk perception, social connectedness, coping mechanisms, and screening and management of IPV [ 50 , 51 , 52 , 55 ].

Data availability

As this was a systematic review, no original data was generated in completing the work. All cited works are listed in the References for consultation.

Colledge S, Larney S, Peacock A, Leung J, Hickman M, Grebely J, et al. Depression, post-traumatic stress disorder, suicidality and self-harm among people who inject drugs: a systematic review and meta-analysis. Drug Alcohol Depend. 2020;207:107793.

Article   PubMed   Google Scholar  

Colledge S, Peacock A, Leung J, Larney S, Grebely J, Hickman M, et al. The prevalence of non-fatal overdose among people who inject drugs: a multi-stage systematic review and meta-analysis. Int J Drug Policy. 2019;73:172–84.

Degenhardt L, Bucello C, Mathers B, Briegleb C, Ali H, Hickman M, et al. Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. Addiction. 2011;106(1):32–51.

Degenhardt L, Charlson F, Stanaway J, Larney S, Alexander LT, Hickman M, et al. Estimating the burden of disease attributable to injecting drug use as a risk factor for HIV, Hepatitis C, and hepatitis B: findings from the global burden of Disease Study 2013. Lancet Infect Dis. 2016;16(12):1385–98.

Larney S, Peacock A, Mathers BM, Hickman M, Degenhardt L. A systematic review of injecting-related injury and disease among people who inject drugs. Drug Alcohol Depend. 2017;171:39–49.

Larney S, Tran LT, Leung J, Santo T Jr., Santomauro D, Hickman M, et al. All-cause and cause-Specific Mortality among people using Extramedical opioids: a systematic review and Meta-analysis. JAMA Psychiatry. 2020;77(5):493–502.

United Nations Office on Drugs and Crime. World Drug Report 2021. United Nations Office on Drugs and Crime; 2021. 24/06/2021.

Conway KP, Vullo GC, Nichter B, Wang J, Compton WM, Iannotti RJ, et al. Prevalence and patterns of polysubstance use in a nationally representative sample of 10th graders in the United States. J Adolesc Health. 2013;52(6):716–23.

Article   PubMed   PubMed Central   Google Scholar  

World Health Organization. Opioid overdose 2023 [updated 29/08/2023. www.who.int/news-room/fact-sheets/detail/opioid-overdose .

Ciccarone D. The triple wave epidemic: supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy. 2019;71:183–8.

Alcohol and Drug Foundation. Nitazenes 2023 [updated 22/11/2023. https://adf.org.au/drug-facts/nitazenes/ .

United Nations Office on Drugs and Crime. Drug-related deaths and mortality rates in Americas 2018 [updated 21/06/2018. https://dataunodc.un.org/drugs/mortality/americas .

The Lancet Public Health. Opioid overdose crisis: time for a radical rethink. Lancet Public Health. 2022;7(3):e195.

Article   CAS   PubMed   Google Scholar  

ONS. Deaths related to drug poisoning in England and Wales. 2020 registrations: Office of National Statistics; 2021 [ https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2020/pdf .

EMCDDA. European Drug Report. Trends and developments: European Monitoring Centre for Drugs and Drug Addiction; 2021 [updated 09/06/2021. https://www.emcdda.europa.eu/system/files/publications/13838/TDAT21001ENN.pdf .

McAuley A, Matheson C, Robertson JR. From the clinic to the street: the changing role of benzodiazepines in the Scottish overdose epidemic. Int J Drug Policy. 2022;100:103512.

European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Polydrug use: health and social responses. 2021.

Degenhardt L, Grebely J, Stone J, Hickman M, Vickerman P, Marshall BDL, et al. Global patterns of opioid use and dependence: harms to populations, interventions, and future action. Lancet. 2019;394(10208):1560–79.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Bird SM, McAuley A, Perry S, Hunter C. Effectiveness of Scotland’s National Naloxone Programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison. Addiction. 2016;111(5):883–91.

Clark AK, Wilder CM, Winstanley EL. A Systematic Review of Community Opioid Overdose Prevention and Naloxone Distribution Programs. J Addict Med. 2014;8(3):153–63.

McDonald R, Strang J. Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria. Addiction. 2016;111(7):1177–87.

Bird SM, McAuley A. Scotland’s National Naloxone Programme. Lancet. 2019;393(10169):316–8.

NICE. Methadone and buprenorphine for the management of opioid dependence (TA114). London: National Institute for Health and Care Excellence; 2007. 24/01/2007.

Google Scholar  

NICE. Naltrexone for the management of opioid dependence (TA115). London: National Insitute for Health and Care Excellence; 2007. 24/01/2007.

EMCDDA. Drug consumption rooms: an overview of provision and evidence. Lisbon; 2016 07/06/2018.

Kerr T, Mitra S, Kennedy MC, McNeil R. Supervised injection facilities in Canada: past, present, and future. Harm Reduct J. 2017;14.

Shorter GW, Harris M, McAuley A, Trayner KM, Stevens A. The United Kingdom?s first unsanctioned overdose prevention site; a proof-of-concept evaluation. Int J Drug Policy. 2022;104.

Caven M, Robinson EM, Eriksen AJ, Fletcher EH, Dillon JF. Hepatitis C diagnosis and treatment, impact on engagement and behaviour of people who inject drugs, a service evaluation, the hooked C project. J Viral Hepat. 2020;27(6):576–84.

NICE. Drug misuse in over 16s: opioid detoxification (CG52). London: National Institute for Health and Care Excellence; 2007. 25/07/2007.

NICE. Drug misuse prevention: targeted interventions (NG64). London: National Institute for Health and Care Excellence; 2017. 22/02/2017.

Wermeling DP. Review of naloxone safety for opioid overdose: practical considerations for new technology and expanded public access. Ther Adv Drug Saf. 2015;6(1):20–31.

McDonald R, Breidahl S, Abel-Ollo K, Akhtar S, Clausen T, Day E, et al. Take-Home Naloxone kits: attitudes and Likelihood-Of-Use outcomes from a European survey of potential overdose witnesses. Eur Addict Res. 2022;28(3):220–5.

World Health Organization and United Nations Office on Drugs and Crime. UNODC-WHO stop-overdose-safely (S-O-S) project implementation in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine: summary report. Geneva: World Health Organization; 2021.

Government of Canada. About the Good Samaritan Drug Overdose Act 2021 [updated 23/11/2021. https://www.canada.ca/en/health-canada/services/opioids/about-good-samaritan-drug-overdose-act.html .

The Network for Public Health Law. Legal Interventions to Reduce Overdose Mortality: Overdose Good Samaritan Laws. 2023 17/07/2023.

EMCDDA, Take-. home Naloxone 2019 [updated 30/08/2019. https://www.emcdda.europa.eu/publications/topic-overviews/take-home-naloxone_en .

National Association for Alcoholism and Drug Abuse Counselors (NAADAC). Using recovery-oriented principles in addiction counselling practice. 2014 23/07/2014.

Waye KM, Goyer J, Dettor D, Mahoney L, Samuels EA, Yedinak JL, et al. Implementing peer recovery services for overdose prevention in Rhode Island: an examination of two outreach-based approaches. Addict Behav. 2019;89:85–91.

Scott CK, Dennis ML, Grella CE, Nicholson L, Sumpter J, Kurz R, et al. Findings from the recovery initiation and management after overdose (RIMO) pilot study experiment. J Subst Abuse Treat. 2020;108:65–74.

Welch AE, Jeffers A, Allen B, Paone D, Kunins HV. Relay: a peer-delivered Emergency Department-based response to nonfatal opioid overdose. Am J Public Health. 2019;109(10):1392–5.

Weiss RD, Griffin ML, Marcovitz DE, Hilton BT, Fitzmaurice GM, McHugh RK et al. Correlates of opioid abstinence in a 42-Month Posttreatment Naturalistic Follow-Up study of prescription opioid dependence. J Clin Psychiatry. 2019;80(2).

Laudet AB. What does recovery mean to you? Lessons from the recovery experience for research and practice. J Subst Abuse Treat. 2007;33(3):243–56.

Best D, Beckwith M, Haslam C, Alexander Haslam S, Jetten J, Mawson E, et al. Overcoming alcohol and other drug addiction as a process of social identity transition: the social identity model of recovery (SIMOR). Addict Res Theory. 2016;24(2):111–23.

Article   Google Scholar  

Dingle GA, Cruwys T, Frings D. Social identities as pathways into and out of addiction. Front Psychol. 2015;6:1795.

Moore D. Beyond Zinberg’s ‘social setting’: a processural view of illicit drug use. Drug Alcohol Rev. 1993;12(4):413–21.

Zinberg NE, Drug. Set and setting: basis for Controlled Intoxicant Use. London: Yale University Press; 1986.

Oxford English Dictionary. Psychosocial Oxford: Oxford University Press. 2022 [updated 03/2022. www.oed.com/view/Entry/153937 .

NICE. Drug misuse in over 16s: psychosocial interventions (CG51). London: National Institute for Health and Care Excellence; 2007.

Donroe JH, Tetrault JM. Narrowing the treatment gap in managing opioid use disorder. Can Med Assoc J. 2018;190(9):E236–7.

NSW Department of Health. Drug and Alcohol Psychosocial interventions Professional Practice guidelines. Gladesville NSW 2111; 2008 06/05/2008.

Fisher A, Nepal S, Harvey L, Peach N, Marel C, Kay-Lambkin F, et al. Drug and alcohol psychosocial interventions. The Sax Institute; 2020.

American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders. 2 ed. American Psychiatric Association; 2006.

Amato L, Minozzi S, Davoli M, Vecchi S. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Db Syst Rev. 2011(10).

Goldberg SB, Pace B, Griskaitis M, Willutzki R, Skoetz N, Thoenes S et al. Mindfulness-based interventions for substance use disorders. Cochrane Db Syst Rev. 2021(10).

Darker CD, Sweeney BP, Barry JM, Farrell MF, Donnelly-Swift E. Psychosocial interventions for benzodiazepine harmful use, abuse or dependence. Cochrane Db Syst Rev. 2015(5).

Lyons RM, Yule AM, Schiff D, Bagley SM, Wilens TE. Risk factors for drug overdose in Young people: a systematic review of the literature. J Child Adolesc Psychopharmacol. 2019;29(7):487–97.

van Draanen J, Tsang C, Mitra S, Phuong V, Murakami A, Karamouzian M, et al. Mental Disorder and opioid overdose: a systematic review. Soc Psychiatry Psychiatr Epidemiol. 2022;57(4):647–71.

Wang L, Hong PJ, Jiang W, Rehman Y, Hong BY, Couban RJ, et al. Predictors of fatal and nonfatal overdose after prescription of opioids for chronic pain: a systematic review and meta-analysis of observational studies. CMAJ. 2023;195(41):E1399–411.

van Draanen J, Tsang C, Mitra S, Karamouzian M, Richardson L. Socioeconomic marginalization and opioid-related overdose: a systematic review. Drug Alcohol Depend. 2020;214:108127.

Green TC, McGowan SK, Yokell MA, Pouget ER, Rich JD. HIV infection and risk of overdose: a systematic review and meta-analysis. AIDS. 2012;26(4):403–17.

King NB, Fraser V, Boikos C, Richardson R, Harper S. Determinants of increased opioid-related mortality in the United States and Canada, 1990–2013: a systematic review. Am J Public Health. 2014;104(8):e32–42.

Cano M, Oh S, Osborn P, Olowolaju SA, Sanchez A, Kim Y, et al. County-level predictors of US drug overdose mortality: a systematic review. Drug Alcohol Depend. 2023;242:109714.

Mital S, Wolff J, Carroll JJ. The relationship between incarceration history and overdose in North America: a scoping review of the evidence. Drug Alcohol Depend. 2020;213:108088.

Clingan SE, Woodruff SI, Gaines TL, Davidson PJ. Detoxification, 12-step meeting attendance, and non-fatal opioid overdoses among a suburban/exurban population with opioid use disorder. J Addict Dis. 2023;41(4):266–73.

Morgan JR, Wang J, Barocas JA, Jaeger JL, Durham NN, Babakhanlou-Chase H, et al. Opioid overdose and inpatient care for substance use disorder care in Massachusetts. J Subst Abuse Treat. 2020;112:42–8.

Bohnert AS, Roeder K, Ilgen MA. Unintentional overdose and suicide among substance users: a review of overlap and risk factors. Drug Alcohol Depend. 2010;110(3):183–92.

Martins SS, Sampson L, Cerda M, Galea S. Worldwide Prevalence and trends in Unintentional Drug Overdose: a systematic review of the literature. Am J Public Health. 2015;105(11):e29–49.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Bmj-Brit Med J. 2021;372.

Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. Bmj-Brit Med J. 2020;368.

National Institutes of Health. National Institutes of Health Study. Quality Assessment Tools 2021 [updated 15/07/2021. https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools .

Critical Appraisal Skills Programme. CASP Qualitative Studies Checklist Oxford2016 [updated 06/12/2016. https://casp-uk.net/casp-tools-checklists/ .

Pizzicato LN, Drake R, Domer-Shank R, Johnson CC, Viner KM. Beyond the walls: risk factors for overdose mortality following release from the Philadelphia Department of Prisons. Drug Alcohol Depen. 2018;189:108–15.

Mitra A, Ahsan H, Li WJ, Liu WS, Kerns RD, Tsai J et al. Risk factors Associated with Nonfatal Opioid Overdose leading to Intensive Care Unit Admission: a cross-sectional study. Jmir Med Inf. 2021;9(11).

Bonar EE, Bohnert ASB. Perceived severity of and susceptibility to overdose among injection drug users: relationships with Overdose History. Subst Use Misuse. 2016;51(10):1379–83.

El-Bassel N, Pala AN, Mukherjee TI, McCrimmon T, Mergenova G, Terlikbayeva A et al. Association of Violence against Female Sex Workers who use drugs with Nonfatal Drug Overdose in Kazakhstan. Jama Netw Open. 2020;3(10).

Havens JR, Oser CB, Knudsen HK, Lofwall M, Stoops WW, Walsh SL, et al. Individual and network factors associated with non-fatal overdose among rural Appalachian drug users. Drug Alcohol Depen. 2011;115(1–2):107–12.

Lamonica AK, Boeri M, Turner J. Circumstances of overdose among suburban women who use opioids: extending an urban analysis informed by drug, set, and setting. Int J Drug Policy. 2021;90.

Latkin CA, Hua W, Tobin K. Social network correlates of self-reported non-fatal overdose. Drug Alcohol Depen. 2004;73(1):61–7.

Milloy MJ, Fairbairn N, Hayashi K, Suwannawong P, Kaplan K, Wood E et al. Overdose experiences among injection drug users in Bangkok, Thailand. Harm Reduct J. 2010;7.

Schiavon S, Hodgin K, Sellers A, Word M, Galbraith JW, Dantzler J, et al. Medical, psychosocial, and treatment predictors of opioid overdose among high risk opioid users. Addict Behav. 2018;86:51–5.

Silva K, Schrager SM, Kecojevic A, Lankenau SE. Factors associated with history of non-fatal overdose among young nonmedical users of prescription drugs. Drug Alcohol Depen. 2013;128(1–2):104–10.

Tobin KE, Hua W, Costenbader EC, Latkin CA. The association between change in social network characteristics and non-fatal overdose: results from the SHIELD study in Baltimore, MD, USA. Drug Alcohol Depen. 2007;87(1):63–8.

Bazazi AR, Zelenev A, Fu JJ, Yee I, Kamarulzaman A, Altice FL. High prevalence of non-fatal overdose among people who inject drugs in Malaysia: correlates of overdose and implications for overdose prevention from a cross-sectional study. Int J Drug Policy. 2015;26(7):675–81.

Goldenberg S, Watt S, Braschel M, Hayashi K, Moreheart S, Shannon K. Police-related barriers to harm reduction linked to non-fatal overdose amongst sex workers who use drugs: results of a community-based cohort in Metro Vancouver, Canada. Int J Drug Policy. 2020;76.

Fairbairn N, Wood E, Stoltz JA, Li K, Montaner J, Kerr T. Crystal methamphetamine use associated with non-fatal overdose among a cohort of injection drug users in Vancouver. Public Health. 2008;122(1):70–8.

Lake S, Hayashi K, Milloy MJ, Wood E, Dong HR, Montaner J, et al. Associations between childhood trauma and non-fatal overdose among people who inject drugs. Addict Behav. 2015;43:83–8.

Pabayo R, Alcantara C, Kawachi I, Wood E, Kerr T. The role of depression and social support in non-fatal drug overdose among a cohort of injection drug users in a Canadian setting. Drug Alcohol Depen. 2013;132(3):603–9.

Thumath M, Humphreys D, Barlow J, Duff P, Braschel M, Bingham B et al. Overdose among mothers: the association between child removal and unintentional drug overdose in a longitudinal cohort of marginalised women in Canada. Int J Drug Policy. 2021;91.

Winter RJ, Stoove M, Degenhardt L, Hellard ME, Spelman T, Jenkinson R, et al. Incidence and predictors of non-fatal drug overdose after release from prison among people who inject drugs in Queensland, Australia. Drug Alcohol Depen. 2015;153:43–9.

Article   CAS   Google Scholar  

Harris MTH, Goldenberg S, Cui ZS, Fairbairn N, Milloy MJS, Hayashi K et al. Association of sex work and social-structural factors with non-fatal overdose among women who use drugs in Vancouver, Canada. Int J Drug Policy. 2023;112.

Tomko C, Schneider KE, Rouhani S, Urquhart GJ, Park JN, Morris M et al. Identifying pathways to recent non-fatal overdose among people who use opioids non-medically: how do psychological pain and unmet mental health need contribute to overdose risk? Addict Behav. 2022;127.

Grau LE, Green TC, Torban M, Blinnikova K, Krupitsky E, Ilyuk R et al. Psychosocial and contextual correlates of opioid overdose risk among drug users in St. Petersburg, Russia. Harm Reduct J. 2009;6.

Vallance K, Pauly B, Wallace B, Chow C, Perkin K, Martin G, et al. Factors associated with public injection and nonfatal overdose among people who inject drugs in street-based settings. Drug-Educ Prev Polic. 2018;25(1):38–46.

Latkin CA, Gicquelais RE, Clyde C, Dayton L, Davey-Rothwell M, German D, et al. Stigma and drug use settings as correlates of self-reported, non-fatal overdose among people who use drugs in Baltimore, Maryland. Int J Drug Policy. 2019;68:86–92.

Riggs KR, Hoge AE, DeRussy AJ, Montgomery AE, Holmes SK, Austin EL et al. Prevalence of and risk factors Associated with Nonfatal Overdose among veterans who have experienced homelessness. Jama Netw Open. 2020;3(3).

Argento E, Shannon K, Fairbairn N, Moreheart S, Braschel M, Goldenberg S. Increasing trends and incidence of nonfatal overdose among women sex workers who use drugs in British Columbia: the role of criminalization-related barriers to harm reduction. Drug Alcohol Depen. 2023;244.

Chang JS, Behar E, Coffin PO. Narratives of people who inject drugs on factors contributing to opioid overdose. Int J Drug Policy. 2019;74:26–32.

Higgins J, Thomas J, Chandler J, Cumpston M, Li T, Page M, et al. editors. Cochrane Handbook for Systematic Reviews of Interventions version 6.3 2022.

Bohnert ASB, Walton MA, Cunningham RM, Ilgen MA, Barry K, Chermack ST, et al. Overdose and adverse drug event experiences among adult patients in the emergency department. Addict Behav. 2018;86:66–72.

Maher L, Dertadian G. Qualitative research. Addiction. 2018;113(1):167–72.

Rhodes T. The ‘risk environment’: a framework for understanding and reducing drug-related harm. Int J Drug Policy. 2002;13(2):85–94.

Hounkpatin HO, Wood AM, Dunn G. Does income relate to health due to psychosocial or material factors? Consistent support for the psychosocial hypothesis requires operationalization with income rank not the Yitzhaki Index. Soc Sci Med. 2016;150:76–84.

Thomson RM, Igelstrom E, Purba AK, Shimonovich M, Thomson H, McCartney G, et al. How do income changes impact on mental health and wellbeing for working-age adults? A systematic review and meta-analysis. Lancet Public Health. 2022;7(6):e515–28.

Lavalley J, Collins AB, Mayer S, Gaudette L, Krusi A, McNeil R, et al. Negotiating sex work and client interactions in the context of a fentanyl-related overdose epidemic. Cult Health Sex. 2021;23(10):1390–405.

Buttram ME, Surratt HL, Kurtz SP. Resilience and syndemic risk factors among African-American female sex workers. Psychol Health Med. 2014;19(4):442–52.

Footer KHA, Park JN, Allen ST, Decker MR, Silberzahn BE, Huettner S, et al. Police-related correlates of client-perpetrated violence among female sex workers in Baltimore City, Maryland. Am J Public Health. 2019;109(2):289–95.

Brooks-Gordon B, Morris M, Sanders T. Harm reduction and decriminalization of sex work: introduction to the Special section. Sex Res Social Policy. 2021;18(4):809–18.

Turner K, Meyrick J, Miller D, Stopgate L. Which psychosocial interventions improve sex worker well-being? A systematic review of evidence from resource-rich countries. BMJ Sex Reprod Health. 2022;48(e1):e88–100.

Navarro-Carrillo G, Alonso-Ferres M, Moya M, Valor-Segura I. Socioeconomic status and Psychological Well-Being: revisiting the role of subjective socioeconomic status. Front Psychol. 2020;11:1303.

Calvo M, MacFarlane J, Zaccaro H, Curtis M, Caban M, Favaro J, et al. Young people who use drugs engaged in harm reduction programs in New York City: overdose and other risks. Drug Alcohol Depend. 2017;178:106–14.

Stein JA, Dixon EL, Nyamathi AM. Effects of psychosocial and situational variables on substance abuse among homeless adults. Psychol Addict Behav. 2008;22(3):410–6.

Doran KM, Fockele CE, Maguire M. Overdose and homelessness-why we need to talk about housing. Jama Netw Open. 2022;5(1):e2142685.

Fine DR, Dickins KA, Adams LD, De Las Nueces D, Weinstock K, Wright J, et al. Drug overdose mortality among people experiencing homelessness, 2003 to 2018. Jama Netw Open. 2022;5(1):e2142676.

Reilly J, Ho I, Williamson A. A systematic review of the effect of stigma on the health of people experiencing homelessness. Health Soc Care Community. 2022;30(6):2128–41.

Kerr T, Fairbairn N, Tyndall M, Marsh D, Li K, Montaner J, et al. Predictors of non-fatal overdose among a cohort of polysubstance-using injection drug users. Drug Alcohol Depend. 2007;87(1):39–45.

Hyun M, Bae SH, Noh D. Systematic review and meta-analyses of randomized control trials of the effectiveness of psychosocial interventions for homeless adults. J Adv Nurs. 2020;76(3):773–86.

Friedman MR, Kay ES, Maclin BJ, Hawk ME. Housing is harm reduction. AIDS. 2023;37(9):1477–9.

Kerman N, Polillo A, Bardwell G, Gran-Ruaz S, Savage C, Felteau C, et al. Harm reduction outcomes and practices in Housing First: a mixed-methods systematic review. Drug Alcohol Depend. 2021;228:109052.

Nixon LL, Burns VF. Exploring harm reduction in supportive housing for formerly homeless older adults. Can Geriatr J. 2022;25(3):285–94.

Moschion J, Johnson G. Homelessness and incarceration: a reciprocal relationship? J Quant Criminol. 2019;35(4):855–87.

Merrall EL, Kariminia A, Binswanger IA, Hobbs MS, Farrell M, Marsden J, et al. Meta-analysis of drug-related deaths soon after release from prison. Addiction. 2010;105(9):1545–54.

Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, et al. Release from prison–a high risk of death for former inmates. N Engl J Med. 2007;356(2):157–65.

Schappell A, Docherty M, Boxer P. Violence and victimization during incarceration: relations to Psychosocial Adjustment during Reentry to the community. Violence Vict. 2016;31(2):361–78.

Hechanova MRM, Reyes JC, Acosta AC, Tuliao AP. Psychosocial treatment for incarcerated methamphetamine users: the Philippines experience. Int J Prison Health. 2020;16(4):343–58.

Binswanger IA, Nowels C, Corsi KF, Glanz J, Long J, Booth RE, et al. Return to drug use and overdose after release from prison: a qualitative study of risk and protective factors. Addict Sci Clin Pract. 2012;7(1):3.

Sondhi AC. Addressing perceptions of opiate-using prisoners to take-home naloxone: findings from one English region. Drugs Alcohol Today. 2016;16(2):124–30.

Pearce LA, Mathany L, Rothon D, Kuo M, Buxton JA. An evaluation of take Home Naloxone program implementation in British columbian correctional facilities. Int J Prison Health. 2019;15(1):46–57.

Joudrey PJ, Khan MR, Wang EA, Scheidell JD, Edelman EJ, McInnes DK, et al. A conceptual model for understanding post-release opioid-related overdose risk. Addict Sci Clin Pract. 2019;14(1):17.

Flam-Ross JM, Lown J, Patil P, White LF, Wang J, Perry A, et al. Factors associated with opioid-involved overdose among previously incarcerated people in the U.S.: a community engaged narrative review. Int J Drug Policy. 2022;100:103534.

Micklitz HM, Glass CM, Bengel J, Sander LB. Efficacy of Psychosocial Interventions for Survivors of Intimate Partner Violence: a systematic review and Meta-analysis. Trauma Violence Abuse. 2023:15248380231169481.

Scottish Government. Support to leave an abusive relationship 2023 [updated 17/10/2023. https://www.gov.scot/news/support-to-leave-an-abusive-relationship/ .

Nambiar D, Stoove M, Dietze P. A cross-sectional study describing factors associated with utilisation of GP services by a cohort of people who inject drugs. BMC Health Serv Res. 2014;14:308.

Chan Carusone S, Guta A, Robinson S, Tan DH, Cooper C, O’Leary B, et al. Maybe if I stop the drugs, then maybe they’d care?-hospital care experiences of people who use drugs. Harm Reduct J. 2019;16(1):16.

Lloyd C. The stigmatization of problem drug users: a narrative literature review. Drugs: Educ Prev Policy. 2013;20(2):85–95.

Muncan B, Walters SM, Ezell J, Ompad DC. They look at us like junkies: influences of drug use stigma on the healthcare engagement of people who inject drugs in New York City. Harm Reduct J. 2020;17(1):53.

Treloar C, Rance J, Yates K, Mao L. Trust and people who inject drugs: the perspectives of clients and staff of needle Syringe Programs. Int J Drug Policy. 2016;27:138–45.

Eimontas J, Gegieckaite G, Zamalijeva O, Pakalniskiene V. Unmet Healthcare needs Predict Depression symptoms among older adults. Int J Environ Res Public Health. 2022;19(15).

McAuley A, Fraser R, Glancy M, Yeung A, Jones HE, Vickerman P, et al. Mortality among individuals prescribed opioid-agonist therapy in Scotland, UK, 2011-20: a national retrospective cohort study. Lancet Public Health. 2023;8(7):e484–93.

Bogdanowicz KM, Stewart R, Chang CK, Shetty H, Khondoker M, Day E, et al. Excess overdose mortality immediately following transfer of patients and their care as well as after cessation of opioid substitution therapy. Addiction. 2018;113(5):946–51.

Clausen T, Waal H, Thoresen M, Gossop M. Mortality among opiate users: opioid maintenance therapy, age and causes of death. Addiction. 2009;104(8):1356–62.

Bourgois P. Disciplining addictions: the bio-politics of methadone and heroin in the United States. Cult Med Psychiatry. 2000;24(2):165–95.

Moore D. Governing street-based injecting drug users: a critique of heroin overdose prevention in Australia. Soc Sci Med. 2004;59(7):1547–57.

Gagnon M, Rudzinski K, Guta A, Schmidt RA, Kryszajtys DT, Kolla G, et al. Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada. Harm Reduct J. 2023;20(1):81.

The Lancet. Drug decriminalisation: grounding policy in evidence. Lancet. 2023;402(10416):1941.

Cooper HL. War on drugs Policing and Police Brutality. Subst Use Misuse. 2015;50(8–9):1188–94.

Mattingly DT, Howard LC, Krueger EA, Fleischer NL, Hughes-Halbert C, Leventhal AM. Change in distress about police brutality and substance use among young people, 2017–2020. Drug Alcohol Depend. 2022;237:109530.

Jalali MS, Botticelli M, Hwang RC, Koh HK, McHugh RK. The opioid crisis: need for systems science research. Health Res Policy Syst. 2020;18(1):88.

Jalali MS, Botticelli M, Hwang RC, Koh HK, McHugh RK. The opioid crisis: a contextual, social-ecological framework. Health Res Policy Syst. 2020;18(1):87.

Ozbay F, Johnson DC, Dimoulas E, Morgan CA, Charney D, Southwick S. Social support and resilience to stress: from neurobiology to clinical practice. Psychiatry (Edgmont). 2007;4(5):35–40.

PubMed   Google Scholar  

Li F, Luo S, Mu W, Li Y, Ye L, Zheng X, et al. Effects of sources of social support and resilience on the mental health of different age groups during the COVID-19 pandemic. BMC Psychiatry. 2021;21(1):16.

Aram JW, Spencer MRT, Garnett MF, Hedegaard HB. Psychological distress and the risk of drug overdose death. J Affect Disord. 2022;318:16–21.

Malaguti A, Byrne CJ, Sani F, Power K, Eriksen A, Dillon JF. Drug network identification predicts injecting risk behavior among people who inject drugs on hepatitis C virus treatment in Tayside, Scotland. Behav Med. 2022:1–11.

Donaldson SR, Radley A, Dillon JF. Transformation of identity in substance use as a pathway to recovery and the potential of treatment for hepatitis C: a systematic review protocol. BMJ Open. 2022;12(2):e049713.

Martinelli TF, van de Mheen D, Best D, Vanderplasschen W, Nagelhout GE. Are members of mutual aid groups better equipped for addiction recovery? European cross-sectional study into recovery capital, social networks, and commitment to sobriety. Drugs: Educ Prev Policy. 2021;28(5):389–98.

Meyers RJ, Miller WR, Hill DE, Tonigan JS. Community reinforcement and family training (CRAFT): engaging unmotivated drug users in treatment. J Subst Abuse. 1998;10(3):291–308.

UK Addiction Treatment Centres. Five Reasons Why Recovery Cafes Are Becoming Popular in the UK 2018 [ https://www.ukat.co.uk/blog/society/5-reasons-recovery-cafes-becoming-popular-uk/ .

Perri M, Kaminski N, Bonn M, Kolla G, Guta A, Bayoumi AM, et al. A qualitative study on overdose response in the era of COVID-19 and beyond: how to spot someone so they never have to use alone. Harm Reduct J. 2021;18(1):85.

Schneider KE, Tomko C, Nestadt DF, Silberzahn BE, White RH, Sherman SG. Conceptualizing overdose trauma: the relationships between experiencing and witnessing overdoses with PTSD symptoms among street-recruited female sex workers in Baltimore, Maryland. Int J Drug Policy. 2021;92:102859.

Macmadu A, Frueh L, Collins AB, Newman R, Barnett NP, Rich JD, et al. Drug use behaviors, trauma, and emotional affect following the overdose of a social network member: a qualitative investigation. Int J Drug Policy. 2022;107:103792.

Gehringer R, Freytag A, Krause M, Schlattmann P, Schmidt K, Schulz S, et al. Psychological interventions for posttraumatic stress disorder involving primary care physicians: systematic review and Meta-analysis of randomized controlled trials. BMC Fam Pract. 2020;21(1):176.

Stein MB. Posttraumatic stress disorder in adults: Psychotherapy and psychosocial interventions: Wolters Kluwer; 2021 [updated 31/07/2023. www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-psychotherapy-and-psychosocial-interventions .

Herman JL. Trauma and recovery: the aftermath of violence - from domestic abuse to political terror. 2022 ed. New York: Basic Books; 2022. 469 p.

Gilchrist G, Swan D, Shaw A, Keding A, Towers S, Craine N, et al. The acceptability and feasibility of a brief psychosocial intervention to reduce blood-borne virus risk behaviours among people who inject drugs: a randomised control feasibility trial of a psychosocial intervention (the PROTECT study) versus treatment as usual. Harm Reduct J. 2017;14(1):14.

Bujalski M, Wieczorek L, Sieroslawski J. Risk perception and risk aversion among people who use new psychoactive substances. Int J Drug Policy. 2021;97:103326.

Cumpston MS, Brennan SE, Ryan R, McKenzie JE. Synthesis methods other than meta-analysis were commonly used but seldom specified: survey of systematic reviews. J Clin Epidemiol. 2023;156:42–52.

United Nations Office on Drugs and Crime. World Drug Report (Booklet 1 - executive Summary/Policy implications). Vienna: United Nations Office on Drugs and Crime; 2022. 26/06/2022.

Degenhardt L, Webb P, Colledge-Frisby S, Ireland J, Wheeler A, Ottaviano S, et al. Epidemiology of injecting drug use, prevalence of injecting-related harm, and exposure to behavioural and environmental risks among people who inject drugs: a systematic review. Lancet Glob Health. 2023;11(5):e659–72.

Greer A, Ritter A. Harm reduction and the opioid crisis: emerging policy challenges. Int J Drug Policy. 2019;71:139–41.

Download references

Acknowledgements

We wish to acknowledge and thank Teresa Flynn, Tammie Brown, Ann Eriksen, Dr Jennifer Breen, and Dr Fiona Cowden, for their contributions to this review and our wider research programme.

This study was funded by the Scottish Drug Death Taskforce (grant number: DDTFRF16). The funder was not involved in collection, analysis, and/or interpretation of data, in the writing of the report, or in the decision to submit the manuscript for publication.

Author information

Authors and affiliations.

Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK

Christopher J. Byrne

Directorate of Public Health, NHS Tayside, Kings Cross Hospital, Dundee, UK

Christopher J. Byrne, Donna Thain & Emma H. Fletcher

Division of Psychology, School of Humanities, Social Sciences and Law, University of Dundee, Scrymgeour Building, Dundee, UK

Fabio Sani & Amy Malaguti

Tayside Drug and Alcohol Recovery Psychology Service, NHS Tayside, Dundee, UK

Amy Malaguti

You can also search for this author in PubMed   Google Scholar

Contributions

Conceptualisation: AM. Methodology: AM, CJB, FS. Software: Not applicable. Validation: Not applicable. Formal analysis: AM, CJB, FS. Investigation: AM, CJB, FS. Resources: Not applicable. Data curation: AM, CJB, FS. Writing – Original Draft: CJB, AM. Writing – Review & Editing: All authors. Visualisation: AM, CJB. Supervision: AM, CJB. Project administration: AM. Funding acquisition: AM.

Corresponding author

Correspondence to Christopher J. Byrne .

Ethics declarations

Ethics approval and consent to participate.

Not applicable.

Consent for publication

Competing interests.

CJB has received honoraria from the International Network for Health and Hepatitis in Substance Users (INHSU), and grant funding from the Scottish Society of Physicians, unrelated to the submitted work. FS received funding from the Scottish Drug Deaths Taskforce related to the submitted work. AM has received funding from the Scottish Drug Deaths Taskforce related to the submitted work, and funding from the British Psychological Society unrelated to the submitted work. EF and DT report no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Byrne, C.J., Sani, F., Thain, D. et al. Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis. Harm Reduct J 21 , 81 (2024). https://doi.org/10.1186/s12954-024-00999-8

Download citation

Received : 18 September 2023

Accepted : 03 April 2024

Published : 15 April 2024

DOI : https://doi.org/10.1186/s12954-024-00999-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Psychosocial
• Narrative synthesis
• Systematic review
• Drug-related death

Harm Reduction Journal

ISSN: 1477-7517

• Submission enquiries: [email protected]

• Open access
• Published: 14 November 2023

Employment of patients with rheumatoid arthritis - a systematic review and meta-analysis

• Lilli Kirkeskov 1 , 2 &
• Katerina Bray 1 , 3  

BMC Rheumatology volume  7 , Article number:  41 ( 2023 ) Cite this article

1751 Accesses

1 Citations

7 Altmetric

Metrics details

Patients with rheumatoid arthritis (RA) have difficulties maintaining employment due to the impact of the disease on their work ability. This review aims to investigate the employment rates at different stages of disease and to identify predictors of employment among individuals with RA.

The study was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines focusing on studies reporting employment rate in adults with diagnosed RA. The literature review included cross-sectional and cohort studies published in the English language between January 1966 and January 2023 in the PubMed, Embase and Cochrane Library databases. Data encompassing employment rates, study demographics (age, gender, educational level), disease-related parameters (disease activity, disease duration, treatment), occupational factors, and comorbidities were extracted. Quality assessment was performed employing Newcastle–Ottawa Scale. Meta-analysis was conducted to ascertain predictors for employment with odds ratios and confidence intervals, and test for heterogeneity, using chi-square and I 2 -statistics were calculated. This review was registered with PROSPERO (CRD42020189057).

Ninety-one studies, comprising of a total of 101,831 participants, were included in the analyses. The mean age of participants was 51 years and 75.9% were women. Disease duration varied between less than one year to more than 18 years on average. Employment rates were 78.8% (weighted mean, range 45.4–100) at disease onset; 47.0% (range 18.5–100) at study entry, and 40.0% (range 4–88.2) at follow-up. Employment rates showed limited variations across continents and over time. Predictors for sustained employment included younger age, male gender, higher education, low disease activity, shorter disease duration, absence of medical treatment, and the absence of comorbidities.

Notably, only some of the studies in this review met the requirements for high quality studies. Both older and newer studies had methodological deficiencies in the study design, analysis, and results reporting.

Conclusions

The findings in this review highlight the prevalence of low employment rates among patients with RA, which increases with prolonged disease duration and higher disease activity. A comprehensive approach combining clinical and social interventions is imperative, particularly in early stages of the disease, to facilitate sustained employment among this patient cohort.

Peer Review reports

Rheumatoid arthritis (RA) is a chronic, inflammatory joint disease that can lead to joint destruction. RA particularly attacks peripheral joints and joint tissue, gradually resulting in bone erosion, destruction of cartilage, and, ultimately, loss of joint integrity. The prevalence of RA varies globally, ranging from 0.1- 2.0% of the population worldwide [ 1 , 2 ]. RA significantly reduces functional capacity, quality of life, and results in an increase in sick leave, unemployment, and early retirement [ 3 , 4 , 5 ]. The loss of productivity due to RA is substantial [ 2 , 5 , 6 , 7 ]. A 2015 American study estimated the cost of over $250 million annually from RA-related absenteeism in United States alone [ 8 ].

Research has highlighted the importance of maintaining a connection to the labour market [ 3 , 9 ], Even a short cessation from work entails a pronounced risk of enduring work exclusion [ 10 ]. In Denmark merely 55% on sick leave for 13 weeks succeeded in re-joining the workforce within one year. Among those on sick leave for 26 weeks, only 40% returned to work within the same timeframe [ 11 ]. Sustained employment is associated with an improved health-related quality of life [ 12 , 13 ]. Early and aggressive treatment of RA is crucial for importance in achieving remission and a favourable prognosis reducing the impact of the disease [ 2 , 14 , 15 , 16 ]. Therefore, initiating treatment in a timely manner and supporting patients with RA in maintaining their jobs with inclusive and flexible workplaces if needed is critical [ 3 , 17 ].

International studies have indicated, that many patients with RA are not employed [ 18 ]. In 2020, the average employment rate across Organization for Economic Co-operation and Development (OECD) countries was 69% in the general population (15 to 64 years of age), exhibiting variations among countries, ranging from 46–47% in South Africa and India to 85% in Iceland [ 19 ]. Employment rates were lower for individuals with educational levels below upper secondary level compared to those with upper secondary level or higher education [ 19 ]. For individuals suffering with chronic diseases, the employment rates tend to be lower. Prognostic determinants for employment in the context of other chronic diseases encompasses the disease’s severity, employment status prior to getting a chronic disease, and baseline educational level [ 20 , 21 , 22 ]. These somatic and social factors may similarly influence employment status of patients with RA. Several factors, including the type of job (especially physically demanding occupations), support from employers and co-workers, social safety net, and disease factors such as duration and severity, could have an impact on whether patients with RA are employed [ 17 , 23 , 24 ]. Over the years, politicians and social welfare systems have tried to improve the employment rates for patients with chronic diseases. In some countries, rehabilitation clinics have been instrumental in supporting patients to remain in paid work. Healthcare professionals who care for patients with RA occupy a pivotal role in preventing work-related disability and support the patients to remain in work. Consequently, knowledge of the factors that contribute to retention of patients with RA at work is imperative [ 17 , 25 ].

The aim of this study is therefore to conduct a systematic review, with a primary focus on examining employment rates among patients with RA at the onset of the disease, at study entry, and throughout follow-up. Additionally, this study intends to identify predictors of employment. The predefined predictors, informed by the author’s comprehensive understanding of the field and specific to RA, encompass socioeconomic factors such as age, gender, level of education, employment status prior to the disease, disease stage and duration, treatment modalities, and comorbidities, including depression, which are relevant both to RA and other chronic conditions [ 26 ].

This systematic review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for studies that included employment rate in patients with rheumatoid arthritis [ 27 ]. PROSPERO registration number: CRD42020189057.

Selection criteria and search strategies

A comprehensive literature search was conducted, covering the period from January 1966 to January 2023 across the PubMed, Embase, and Cochrane Library databases using the following search terms: (Rheumatoid arthritis OR RA) AND (employment OR return to work). Only studies featuring a minimum cohort size of thirty patients and articles in the English language were deemed eligible for inclusion.

The initial screening of articles was based on the titles and abstracts. Studies comprising a working-age population, with current or former employment status, and with no limitations to gender, demographics, or ethnicity were included in this review. Articles addressing topics of employment, work ability or disability, return to work or disability pension were encompassed within the scope of this review. Full-time and part-time employment, but not ‘working as housewives’ was included in this review’s definition of employment. Studies involving other inflammatory diseases than RA were excluded. Reference lists in the selected articles were reviewed, and more articles were included if relevant. A review of the reference lists in the initially selected articles was conducted, with additional articles incorporated if they proved relevant to the research objectives. The eligible study designs encompassed cohort studies, case–control studies, and cross-sectional studies. All other study designs, including reviews, case series/case reports, in vitro studies, qualitative studies, and studies based on health economics were systematically excluded from the review.

Data extraction, quality assessment and risk-of-bias

The data extraction from the selected articles included author names, year of publication, study design, date for data collection, employment rate, study population, age, gender, educational level, ethnicity, disease duration, and pharmacological treatment. To ensure comprehensive evaluation of study quality and potential bias, quality assessment was independently assessed by two reviewers (LK and KB) using the Newcastle–Ottawa Scale (NOS) for cross-sectional and cohort studies [ 28 ]. Any disparities in the assessment were resolved by discussion until consensus was reached. For cross-sectional studies the quality assessment included: 1) Selection (maximum 5 points): representativeness of the sample, sample size, non-respondents, ascertainment of the risk factor; 2) Comparability (maximum 2 points); study controls for the most important, and any additional factor; 3) Outcome (maximum 3 points): assessment of outcome, and statistical testing. For cohort studies the assessment included: 1) Selection (maximum 4 points): representativeness of the exposed cohort, selection of the non-exposed cohort, ascertainment of exposure, demonstration that the outcome of interest was not present at start of study; 2) Comparability (maximum 2 points): comparability of cohorts on the basis of the design or analysis; 3) Outcome (maximum 3 points): assessment of outcome, was the follow-up long enough for outcomes to occur, and adequacy of follow up of cohorts. The rating scale was based on 9–10 items dividing the studies into high (7–9/10), moderate (4–6) or low (0–3) quality. A low NOS score (range 0–3) indicated a high risk of bias, and a high NOS score (range 7–9/10) indicated a lower risk of bias.

Analytical approach

For outcomes reported in numerical values or percentages, the odds ratio along with their 95% confidence intervals (CI) were calculated, whenever feasible. Weighted means were calculated, and comparisons between these were conducted using t-test for unpaired data. Furthermore, meta-analysis concerning the pre-determined and potentially pivotal predictors for employment status, both at disease onset, study entry, and follow-up was undertaken. The predictors included age, gender, ethnicity, level of education, duration of disease, treatment, and the presence of comorbities, contingent upon the availability of the adequate data. Additionally, attempts have been made to find information regarding on job categorizations, disease activity (quantified through DAS28; disease activity score for number of swollen joints), and quality of life (SF-36 scores ranging from 0 (worst) to 100 (best)). Age was defined as (< = 50/ > 50 years), gender (male/female), educational level college education or more/no college education), race (Caucasian/not Caucasian), job type (non-manual/manual), comorbidities (not present/present), MTX ever (no/yes), biological treatment ever (no/yes), prednisolone ever (no/yes), disease duration, HAQ score (from 0–3)), joint pain (VAS from 1–10), and DAS28 score. Age, disease duration, HAQ score, VAS score, SF36 and DAS28 were in the studies reported by mean values and standard deviations (SD). Challenges were encountered during attempts to find data which could be used for analysing predictors of employment status before disease onset, and at follow-up, as well as factors related to treatments beyond MTX, prednisolone, and biological as predictors for being employed after disease onset. Test for heterogeneity was done using Chi-squared statistics and I 2 , where I 2 below 40% might not be important; 30–60% may represent moderate heterogeneity; 50–90% substantial heterogeneity; and 75–100% considerable heterogeneity. Meta-analysis for predictors for employment and odds ratio; confidence intervals; and test for heterogeneity were calculated using the software Review Manager (RevMan, version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014).

General description of included studies

The search yielded a total of 2277 references addressing RA its association with employment. Following the initial title screen, 199 studies were considered relevant for further evaluation. Of those, 91 studies ultimately met the inclusion criteria. Figure  1 shows the results of the systematic search strategy.

Flow chart illustrating the systematic search for studies examining employment outcome in patients with rheumatoid arthritis

Table 1 summarizes the general characteristics of the included studies. The publication year of the included studies ranged from 1971 to 2022. Among the studies, 60 (66%) adopted a cross-sectional research design [ 13 , 18 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 129 ] with a total of 41,857 participants analysing data at a specific point in time. Concurrently, 31 studies (34%) adopted a cohort design [ 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 , 130 ] with a total of 59,974 participants. Most of these studies exhibited a small to moderate sample size, with a median of 652 participants. Additionally, single centre studies and studies from high-income countries were predominant. Study details are shown in Table 1 .

General description of study participants

On average, patients with RA were 51 years old, with an age range spanning from 42 to 64 years. Furthermore, the female population accounted for 75.9% of the patient cohort, with a range from 41 to 92%. The duration of the disease at study entry exhibited significant variability, ranging from less than one year up to more than 18 years on average.

• Employment rate

At disease onset, the employment rate was 78.8% (weighted mean, range 45.4–100), at study entry 47.0% (range 18.5–100), and during the follow-up period 40.0% (range 4–88.2), as shown in Table 2 . Notably, a comparative analysis of the employment rates between Europe and North America indicated no substantial difference ( p  = 0.93). However, the comparison between Europe, North America and ‘other continents’ did yield significant differences (or nearly differences) with p -values of 0.003 and 0.08, respectively.

The employment rate exhibited no change, when comparing studies from the 1980s through to 2022. Specifically, the weighted mean for the years 1981–2000 was 49.2%, aligning closely with the corresponding figures for the years 2001–2010 (49.2%) and 2011–2022 43.6%. These findings were statistically non-significant, with p -values of 0.80 for comparison between year 1981–2000 and 2001–2010; 0.66 for 2001–2010 and 2011–2022, and 0.94 for 1981–2000 and 2011–2022, shown in Figure S 1 , see Additional file.

Among the studies included in the analysis, nineteen studies included data of employment at follow-up, with durations ranging from 1 to 20 years, Table 2 . For instance, Jäntti, 1999 [ 97 ] reported an employment rate 69% one year after disease onset, which gradually declined to 50% after 15 years and further to 20% after 20 years. Similarly, Mäkisara, 1982 [ 63 ] demonstrated that 60% of the patients were employed 5 years after disease onset, 50% after 10 years, and 33% after 15 years. Nikiphorou, 2012 [ 101 ] reported an employment rate of 67% at study entry, which decreased to 43% after 10 years.

In addition, seven studies included data of employment rate among patients comparing different medical treatments [ 18 , 44 , 56 , 91 , 105 , 110 , 119 ]. These studies indicated that, on average, 55.0% (weighted mean) of the patients were employed after receiving treatment with MTX, while 42.8% after undergoing treatment with a combination of MTX + Adalimumab (all patients were employed at disease onset in these specific studies).

Predictors for employment

Information of normative comparison data to use for meta-analysis of predictors for employment at study entry was available for age, gender, educational level, race, job type, comorbidities, MTX at any time, biological treatment at any time, prednisolone at any time, disease duration, HAQ score, joint pain (VAS-score), and disease activity (DAS28 score). Predictors for employment at study entry was being younger /age below 50 years, being a male, higher educational level (college or more), non-manual work, having no comorbidities, no medical treatment, short disease duration, and low HAQ score, VAS-score, or DAS28 score. Heterogeneity was small for age, gender, medical treatment, and moderate for educational level, and job type as indicted by the I 2 values, Table  3 , and shown in detail in Figures S 2 , S 3 , S 4 , S 5 , S 6 , S 7 , S 8 , S 9 , S 10 , S 11 , S 12 , S 13 , S 14 , S 15 and S 16 , see Additional file.

Assessment of quality of included studies

All studies were subject to rigorous quality assessment. These assessments resulted in categorisation of either medium quality ( n  = 64; 70%) or high-quality studies ( n  = 27; 30%), with no studies falling into the low-quality category. The quality assessment is shown in Tables  4 and 5 .

Notably, many studies were characterised by several common attributes, including cross-sectional study design, single-centre-settings, relatively small sample sizes, and the reliance on self-reported patient data. When including only the high-quality studies in the analyses, the employment rates at study entry changed from 47% (weighted mean, all studies) to 50% (weighted mean, high quality studies).

Key findings

This systematic review has identified a decline in the employment rate among patients with RA, with a notable decrease from disease onset during the study entry to follow-up, where only half of the patients were employed. These findings corroborate earlier research that indicated a substantial decline in employment rates among patients with RA over time. Notably, previous studies have reported that approximately one third of patients with RA stopped working within 2 to 3 years after disease onset, and more than half was unable to work after 10 to 15 years [ 23 , 63 , 93 , 97 , 101 ]. Only few studies have included data from the general population, comparing the employment rates with the rates for patients with RA [ 89 , 90 ]. Comparisons with the general population further underscored the challenges faced by RA patients, as their employment rates were consistently lower.

Despite changes in medical treatment, social security systems, and societal norms over the past decades, there was no significant improvement in the employment for patients with RA. This pattern aligns with data from the Global Burden of Disease studies, highlighting the persistent need for novel approaches and dedicated efforts to support patients with RA in sustaining employment [ 2 , 123 ]. Recent recommendations from EULAR (European Alliance of Associations for Rheumatology) and ACR (American College of Rheumatology) have emphasized the importance of enabling individuals with rheumatic and musculoskeletal diseases to engage in healthy and sustainable work [ 17 , 124 , 125 ].

While different countries possess different social laws and health care systems for supporting patients with chronic diseases, the variations in the weighted mean of employment rates across countries were relatively minor.

In the meta-analysis, one of the strongest predictors for maintaining employment was younger age at disease onset [ 43 , 51 , 101 , 116 ]. Verstappen, 2004 found that older patients with RA had an increased risk of becoming work disabled, potentially caused by the cumulative effects of long-standing RA, joint damage, and diminished coping mechanisms, compared to younger patients [ 23 ].

More women than men develop RA, however this study showed that a higher proportion of men managed to remain employed compared to women [ 18 , 36 , 42 , 43 , 46 , 62 , 71 , 89 , 101 , 116 ]. Previous studies have shown inconsistent results in this regard. Eberhart, 2007 found that a significantly higher number of men with RA worked even though there was no difference in any disease state between the sexes [ 93 ]. De Roos,1999 showed that work-disabled women were less likely to be well-educated and more likely to be in a nonprofessional occupation than working women. Interestingly, there was no association of these variables among men. Type of work and disease activity may influence work capacity more in women than in men [ 46 ]. Sokka, 2010 demonstrated a lower DAS28 and HAQ-score in men compared to women among the still working patients with RA, which indicated that women continued working at higher disability and disease activity levels compared with men [ 18 ].

Disease duration also played a significant role as a predictor of employment outcomes [ 33 , 36 , 45 , 71 , 77 , 86 , 102 , 111 ]. Longer disease duration correlate with decreased employment likelihood, which could be attributed to older age and increased joint damage and disability in patients with longer-standing RA.

Higher educational levels were associated with a greater possibility of employment [ 30 , 43 , 45 , 46 , 51 , 62 , 86 ]. This is probably due to enhanced job opportunities, flexibility, lower physical workload, better insurance coverage, and improved health care for well-educated individuals. This is further supported by the fact that having a manual work was a predictor for not being employed [ 30 , 39 , 43 , 44 , 45 ].

Furthermore, health-related quality of life, as measured by SF 36, lower disease activity (DAS28 scores), reduced joint pain (VAS-score), and lower disability (HAQ score) were additionally predictors for being employed [ 33 , 35 , 36 , 45 , 71 , 86 ]. This support the statement that the fewer symptoms from RA, the greater the possibility of being able to work.

The results showed that the presence of comorbidity was a predictor for not being employed, aligning with findings from previous studies that chronic diseases such as cardiovascular disease, lung disease, diabetes, cancer, and depression reduced the chances of being employed [ 126 ]. Moreover, the risk of exiting paid work increased with multimorbidity [ 127 ].

While limited data were available for assessing the impact of treatment on employment, indications suggested that patients with RA were receiving medical treatments, such as MTX or biological medicine, were more likely to be unemployed. One possible explanation for this phenomenon could be that patients with RA, who were receiving medical treatment, had a more severe and a longer duration of RA compared to those, who had never been on medical treatment. However, the scarcity of relevant studies necessitates caution when drawing definitive conclusions in this regard.

Therefore, the predictors for employment found in this review were being younger, being a male, having higher education, low disease activity, low disease duration, and being without comorbidities. This is supported by previous studies [ 93 , 116 ]

In summary, this review underscores the importance of managing disease activity, offering early support to patients upon diagnosis, and reducing physically demanding work to maintain employment among patients with RA. Achieving success in this endeavour requires close cooperation among healthcare professionals, rehabilitation institutions, companies, and employers. Furthermore, it is important that these efforts are underpinned by robust social policies that ensure favourable working conditions and provide financial support for individuals with physical disabilities, enabling them to remain active in the labour market.

Strengths and limitations

The strength of this review and meta-analysis lies in the inclusion of a large number of articles originating from various countries. Furthermore, the data showed a consistent employment rate in high quality studies compared to all studies. However, there are some limitations to this review. No librarian was used to define search terms and only three databases were searched. Furthermore, the initial search, selection of articles, data extraction, and analysis was undertaken only by one author, potentially leading to the omission of relevant literature and data. The review also extended back to 1966, with some articles from the 1970s and 1980s included. Given the significant changes in medical treatment, social security systems, and society over the past decades, the generalizability of the findings may be limited.

Moreover, the majority of studies did not include a control group from the general population, which limited the ability to compare employment rates with the general population in the respective countries. Many studies were cross-sectional in design, which limits the evidence of causality between employment rate and having RA. However, the employment rate was approximately the same in high quality studies compared to all studies, which supports an association. A substantial number of studies relied on self-reported employment rates, introducing the potential for recall bias. Additionally, many studies did not account for all relevant risk factors for unemployment failing to control for all relevant confounders.

EULAR have made recommendation for point to consider when designing, analysing, and reporting of studies with work participation as an outcome domain in patients with inflammatory arthritis. These recommendations include study design, study duration, and the choice of work participation outcome domains (e.g., job type, social security system) and measurement instruments, the power to detect meaningful effects, interdependence among different work participation outcome domains (e.g., between absenteeism and presentism), the populations included in the analysis of each work participation outcome domain and relevant characteristics should be described. In longitudinal studies work-status should be regularly assessed and changes reported, and both aggregated results and proportions of predefined meaningful categories should be considered [ 128 ]. Only some of the studies in this review met the requirements for high quality studies. In both older and newer studies methodological deficiencies persisted in study design, analysis, and reporting of results, as recommended by EULAR.

Perspectives for future studies

Future research in this area should focus on developing and evaluating new strategies to address the ongoing challenges faced by patients with RA in maintaining employment. Despite many initiatives over the years, there has been no success in increasing employment rates for patients with RA in many countries. Therefore, there is a pressing need for controlled studies that investigated the effectiveness of interventions such as education, social support, and workplace adaptations in improving employment outcomes for these individuals.

This systematic review underscores the low employment rate among patients with RA. Key predictors of sustained employment include being younger, having higher educational level, short disease duration, and lower disease activity, along with fewer comorbidities. Importantly, the review reveals that the employment rate has not changed significantly across different time periods. To support patients with RA in maintaining their employment, a comprehensive approach that combines early clinical treatment with social support is crucial. This approach can play a pivotal role in helping patients with RA stay connected to the labour market.

Availability of data and materials

The datasets used and/or analyzed during the current study are available in the supplementary file.

Abbreviations

• Rheumatoid arthritis

Methotrexate

Newcastle Ottawa Quality Assessment Scale

Standard deviation

Not analyzed

Not relevant

Disease activity

Health Assessment Questionnaire

Visual analog scale for pain

European Alliance of Associations for Rheumatology

American College of Rheumatology

Almutairi K, Nossent J, Preen D, Keen H, Inderjeeth C. The global prevalence of rheumatoid arthritis: a meta-analysis based on a systematic review. Rheumatol Int. 2021;41:863–77.

Article   PubMed   Google Scholar  

Safiri S, Kolahi AA, Hoy D, Smith E, Bettampadi D, Mansournia MA, et al. Global, regional and national burden of rheumatoid arthritis 1990–2017: a systematic analysis of the Global Burden of Disease study 2017. Ann Rheum Dis. 2019;78:1463–71.

Verstappen SMM. Rheumatoid arthritis and work: The impact of rheumatoid arthritis on absenteeism and presenteeism. Best Pract Res Clin Rheumatol. 2015;29:495–511.

Madsen CMT, Bisgaard SK, Primdahl J, Christensen JR, von Bülow C. A systematic review of job loss prevention interventions for persons with inflammatory arthritis. J Occup Rehabil. 2021;4:866–85.

Kessler RC, Maclean JR, Petukhova M, Sarawate CA, Short L, Li TT, et al. The effects of rheumatoid arthritis on labor force participation, work performance, and healthcare costs in two workplace samples. J Occup Environ Med. 2008;50:88–98.

Filipovic I, Walker D, Forster F, Curry AS. Quantifying the economic burden of productivity loss in rheumatoid arthritis. Rheumatology. 2011;50:1083–90.

Burton W, Morrison A, Maclean R, Ruderman E. Systematic review of studies of productivity loss due to rheumatoid arthritis. Occup Med. 2006;56:18–27.

Article   Google Scholar  

Gunnarsson C, Chen J, Rizzo JA, Ladapo JA, Naim A, Lofland JH. The employee absenteeism costs of reumatoid arthritis. Evidence from US National Survey Data. J Occup Environ Med. 2015;57:635–42.

van der Noordt M, Ijzelenberg H, Droomers M, Proper KI. Health effects of employment: a systematic review of prospective studies. Occup Environ Health. 2014;71:730–6.

Google Scholar  

Virtanen M, Kivimäki M, Vahtera J, Elovainio M, Sund R, Virtanen P, et al. Sickness absence as a risk factor for job termination, unemployment, and disability pension among temporary and permanent employees. Occup Environ Med. 2006;63:212–7.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Vilhelmsen J. Længerevarende sygefravær øger risikoen for udstødning [long-term sick-leave increase the risk of job termination]. 2007.  https://www.ae.dk/analyse/2007-10-laengerevarende-sygefravaer-oeger-risikoen-for-udstoedning .

Grønning K, Rødevand E, Steinsbekk A. Paid work is associated with improved health-related quality of life in patients with rheumatoid arthritis. Clin Rheumatol. 2010;29:1317–22.

Article   PubMed   PubMed Central   Google Scholar  

Chorus AMJ, Miedema HS, Boonen A, van der Linden S. Quality of life and work in patients with rheumatoid arthritis and ankylosing spondylitis of working age. Ann Rheum Dis. 2003;62:7.

Ma MHY, Kingsley GH, Scott DL. A systematic comparison of combination DMARD therapy and tumour necrosis inhibitor therapy with methotrexate in patients with early rheumatoid arthritis. Rheumatology (Oxford). 2010;49:91–8.

Article   CAS   PubMed   Google Scholar  

Vermeer M, Kuper HH, Hoekstra M, Haagsma CJ, Posthumus MD, Brus HL, et al. Implementation of a treat-to-target strategy in very early rheumatoid arthritis. Results of the Dutch arthritis monitoring remission induction cohort study. Arthritis Rheum. 2011;63:2865–72.

Vermeer M, Kuper HH, Bernelot Moens HJ, Drossaers-Bakker KW, van der Bijl AE, van Riel PL, et al. Sustained beneficial effects of a protocolized treat-to-target strategy in very early rheumatoid arthritis: three-year results of the Dutch rheumatoid arthritis monitoring remission induction cohort. Arthritis Care Res. 2013;65:1219–26.

Article   CAS   Google Scholar  

Boonen A, Webers C, Butink M, Barten B, Betteridge N, Black DC, et al. 2021 EULAR points to consider to support people with rheumatic and musculoskeletal diseases to participate in healthy and sustainable paid work. Ann Rheum Dis. 2023;82:57–64.

Sokka T, Kautianen H, Pincus T, Verstappen SMM, Aggarwai A, Alten R, et al. Work disability remains a major problem in rheumatoid arthritis in the 2000s: data from 32 countries in the QUEST-RA study. Arthritis Res Ther. 2010;1(R42):1–10.

OECD. Employment rate (indicator). 2020. https://dataoecd.org/emp/employment-rate.htm . Assessed on 11 May.

Hannerz H, Pedersen BH, Poulsen OM, Humle F, Andersen LL. A nationwide prospective cohort study on return to gainful occupation after stroke in Denmark 1996–2006. BMJ Open. 2011;1:1–5.

Tumin D, Chou H, Hayes D Jr, Tobias JD, Galantowicz M, McConnell PI. Employment after hearth transplantation among adults with congenital heart disease. Congenit Heart Dis. 2017;12:794–9.

Islam T, Dahlui M, Majid HA, Nahar AM, MohdTaib NA, Su TT, MyBCC study group. Factors associated with return to work of breast cancer survivors: a systematic review. BMC Public Health. 2014;14:1–13.

Verstappen SMM, Bijlsma JWJ, Verkleij H, Buskens E, Blaauw AAM, Borg EJ, Jacobs JWG. Overview of work disability in rheumatoid arthritis patients as observed in cross-sectional and longitudinal surveys. Arthritis Rheum. 2004;51:488–97.

Wilkie R, Bjork M, Costa-Black KM, Parker M, Pransky G. Managing work participation for people with rheumatic and musculoskeletal diseases. Best Pract Res. 2020;34:1–16.

Varekamp I, Haafkens JA, Detaille SI, Tak PP, van Dijk FJH. Preventing work disability among employees with rheumatoid arthritis: what medical preofessionals can learn form patients’ perspective. Arthritis Rheum. 2005;53:965–72.

Kirkeskov L, Carlsen RK, Lund T, Buus NH. Emloyment of patients with kidney failure treated with dialysis or kidney transplantation - a systematic review and metaanalysis. BMC Nephrol. 2021;22–348:1–17.

Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2020;2021:372. https://doi.org/10.1136/bmj.n71 .

Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Losos M, et al. Newcastle-Ottawa Scale (NOS) for assessing the quality if nonrandomized studies in meta-analyses. 2009. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp .

Al-Jabi SW, Seleit DI, Badran A, Koni A, Zyoud SH. Impact of socio-demographic and clinical characteristics on functional disability and health-related quality of life in patients with rheumatoid arthritis: a cross-sectional study from Palestine. Health Qual Life Outcomes. 2021;19:241.

Allaire SH, Anderson JJ, Meenan RF. Reducing work disability associated with rheumatoid arthritis: Identifiction of additional risk factors and persons likely to benefit from intervention. Arthritis Care Res. 1996;9(5):9.

Allaire S, Wolfe F, Niu J, Lavalley MP. Comtemporary prevalence and incidence of work disability associated with rheumatoid arthritis in the US. Arthritis Rheum. 2008;59(4):7.

Anno S, Sugioka Y, Inui K, Tada M, Okano T, Mamoto K. Evaluation of work disability in Japanese patients with rheumatoid arthritis: from the TOMORROW study. Clin Rheumatol. 2018;37:9.

Azevedo ABC, Ferraz MB, Ciconelli RM. Indirect costs of rheumatoid arthritis in Brazil. Value Health. 2008;11:869–77.

Backman CL, Kennedy SM, Chalmers A, Singer J. Participation in paid and unpaid work by adults with rheumatoid arthritis. J Rheumatol. 2004;31:47–57.

PubMed   Google Scholar  

Berner C, Haider S, Grabovac I, Lamprecht T, Fenzl KH, Erlacher L, et al. Work ability and employment in rheumatoid arthritis: a cross-sectional study on the role of muscle strength and lower extremity function. Int J Rheumatol. 2018;2018:11.

Bertin P, Fagnani F, Duburcq A, Woronoff AS, Chauvin P, Cukierman G, et al. Impact of rheumatoid arthritis on career progression, productivity, and employability: the PRET Study. Joint Bone Spine. 2016;83:6.

Bodur H, Borman P, Alper B, Keskin D. Work status and related variables in patients with rheumatoid arthitis and ankylosing spondylitis. Turk J Rheumatol. 2011;26(2):19.

Cadena J, Vinaccia S, Perez A, Rico MI, Hinojosa R, Anaya JM. The impact of disease activity on the quality of life, mental health status, and family dysfunction in Colombian patients with rheumatoid arthritis. Clin Rheumatol. 2003;9:142–50.

Callahan LF, Bloch DA, Pincus T. Identification of work disability in rheumatoid arthritis : physical, radiographic and laboratory variables do not add explanatory power to demographic and functional variables. J Clin Epidemiol. 1992;45(2):12.

Camilleri JP, Jessop AM, Davis S, Jessop JD, Hall M. A survey of factors affecting the capacity to work in patients with rheumatoid arthritis in South Wales. Clin Rehabil. 1995;9:4.

Chen MH, Lee MH, Liao HT, Chen WS, Lai CC, Tsai CY. Health-related quality of life outcomes in patients with rehumatoid arthritis and ankylosing spondylitis after tapering biologic treatment. Clin Rheumatol. 2018;37:429–38.

Chorus AMJ, Miedema HS, Wevers CJ, van der Linden S. Labour force participation among patients with rheumtoid arthritis. Ann Rheum Dis. 2000;59:6.

Chorus AMJ, Miedema HS, Wevers CJ, van der Linden S. Work factors and behavioural coping in relation to withdrawal from the labour force in patients with rheumatoid arthritis. Ann Rheum Dis. 2001;60:8.

Chung CP, Sokka T, Arbogast PG, Pincus T. Work disability in early rheumatoid arthritis: higher rates but better clinical status in Finland compared with the US. Ann Rheum Dis. 2006;65:5.

Dadoniene J, Stropuviene S, Venalis A, Boonen A. High work disability rate among rheumatoid arthritis patients in Lithuania. Arthritis Rheum. 2004;51:433–9.

De Roos AJ, Callahan LF. Differences by sex in correlates of work status in rheumatoid arthritis patients. Arthritis Care Res. 1999;12:381–91.

Dejaco C, Mueller T, Zamani O, Kurtz U, Egger S, Resch-Passini J, et al. A prospective study to evaluate the impact of Golimumab therapy on work productivity and activity, and quality of life in patients with rheumatoid arthritis, psoriatic arthritis and axil spondylarthritis in a real life setting in AUSTRIA. The Go-ACTIVE Study. Front Med. 2022;9:1–9.

Doeglas D, Suurmeijer T, Krol B, Sanderman R, van Leeuwen M, van Rijswijk M. Work disability in early rheumatoid arthritis. Ann Rheum Dis. 1995;54:6.

Fara N, Recchia O, Sequeira G, Sanchez K. Disability due to rheumatic diseases in the city of Junín, Argentina. Rheumatol Int. 2019;39:729–33.

Fifield J, Reisine S, Sheehan TJ, McQuillan J. Gender, paid work, and symptoms of emotional distress in rheumatoid arthritis patients. Arthritis Rheum. 1996;39:427–35.

Gomes RKS, Schreiner LC, Vieira MO, Machado PH, Nobre MRC. Staying in the labor force among patients with rheumatoid arthritis and associated factors in Southern Brazil. Adv Rheumatol. 2018;58(14):1–9.

Hamdeh HA, Al-Jabi SW, Koni A, Zyoud SH. Health-related quality of life and treatment satisfaction in Palestinians with rheumatoid arthritis: a cross-sectional study. BMC Rheumatol. 2022;6(19):1–12.

Hazes JM, Taylor P, Strand V, Purcaru O, Coteur G, Mease P. Physical function improvements and relief from fatigue and pain are associated with incresed productivity at work and at home in rheumatoid arthritis patients treated with certolizumab pegol. Rheumatology. 2010;49:1900–10.

Hulander E, Lindqvist HM, Wadell AT, Gjertsson I, Winkvist A, Bärebring L. Improvements in body composition after a proposed anti-inflammatory diet are modified by employment status in weight-stable patients with rheumatoid arthritis, a randomized controlled crossover trial. Nutrients. 2022;14:1058.

Intriago M, Maldonado G, Guerrero R, Moreno M, Moreno L, Rios C. Functional disability and its determinants in Ecudorian patients with rheumatoid arthritis. Open Access Rheumatol. 2020;12:97–104.

Kavanaugh A, Smolen JS, Emery P, Purcaru O, Keystone E, Richard L, et al. Effect of certolizumab pegol with ethotrexate on home and work place productivity and social activities in patients with active rheumatoid arthritis. Arthritis Rheum. 2009;61:1592–600.

Kwon JM, Rhee J, Ku H, Lee EK. Socioeconomic and employment status of patients with rheumatoid arthritis in Korea. Epidemiol Health. 2003;34:1–7.

Lacaille D, Sheps S, Spinelli JJ, Chalmers A, Esdaile JM. Identification of modifiable work-related factors that influence the risk of work disability in rheumatoid arthritis. Arthritis Rheum. 2004;51:843–52.

Lahiri M, Cheung PPM, Dhanasekaran P, Wong SR, Yap A, Tan DSH, et al. Evaluation of a multidisciplinary care model to improve quality of life in rheumatoid arthritis: a randomised controlled trial. Qual Life Res. 2022;31:1749–59.

Lapcevic M, Vukovic M, Gvozdenovic BS, Mioljevic V, Marjanovic S. Socioeconomic and therapy factor influence on self-reported fatigue, anxiety and depression in rheumatoid arthritis patients. Rev Bras Reumatol. 2017;57(6):12.

Mattila K, Buttgereit F, Tuominen R. Impact of morning stiffness on working behaviour and performance in people with rhematoid arthritis. Rheumatol Int. 2014;34:1751–8.

McQuillan J, Andersen JA, Berdahl TA, Willett J. Associations of rheumatoid arthritis and depressive symptoms over time: Are there differences by education, race/ethnicity, and gender? Arthritis Care Res. 2022;0:1–9.

Mäkisara GL, Mäkisara P. Prognosis of funcrional capacity and work capacity in rheumatoid arthritis. Clin Rheumatol. 1982;1(2):9.

Meenan RF, Yelin EH, Nevitt M, Epstein WV. The impact of chronic disease. A sociomedical profile of rheumatoid arthritis. Arthritis Rheum. 1981;24:544–9.

Morf H, Castelar-Pinheiro GR, Vargas-Santos AB, Baerwald C, Seifert O. Impact of clinical and psychological factors associated with depression in patients with rheumatoid arthritis: comparative study between Germany and Brazil. Clin Rheumatol. 2021;40:1779–87.

Newhall-Perry K, Law NJ, Ramos B, Sterz M, Wong WK, Bulpitt KJ, et al. Direct and indirect costs associated with the onset of seropositive rheumatoid arthritis. J Rheumatol. 2000;27:1156–63.

CAS   PubMed   Google Scholar  

Osterhaus JT, Purcaru O, Richard L. Discriminant validity, responsiveness and reliability of the rheumatoid arthritis-specific Work Productivity Survey (WPS-RA). Arthritis Res Ther. 2009;11(R73):1–12.

Pieringer H, Puchner R, Pohanka E, Danninger K. Power of national economy, disease control and employment status in patients with RA - an analytical multi-site ecological study. Clin Rheumatol. 2016;35:5.

Rosa-Gocalves D, Bernardes M, Costa L. Quality of life and functional capacity in patients with rheumatoid arthritis - Cross-sectional study. Reumatol Clin. 2018;14:360–6.

Sacilotto NC, Giorgi RDN, Vargas-Santos AB, Albuquerque CP, Radominski SC, Pereira IA, et al. Real - rheumatoid arthritis in real life - study cohort: a sociodemographic profile of rheumatoid arthritis in Brazil. Adv Rheumatol. 2020;60:20.

Shanahan EM, Smith M, Roberts-Thomson L, Esterman A, Ahern M. Influence of rheumatoid arthritis on work participation in Australia. Intern Med J. 2008;38:166–73.

Smolen JS, van der Heijde DM, Keystone EC, van Vollenhoven RF, Golding MB, Guérette B, et al. Association of joint space narrowing with impairment of physical function and work ability in patients with early rheumatoid arthritis: protection beyond disease control by adalimumab plus methotrexate. Ann Rheum Dis. 2012;72:1156–62.

Syngle D, Singh A, Verma A. Impact of rheumatoid arthritis on work capacity impairment and its predictors. Clin Rheumatol. 2020;39:1101–9.

Tamborenea MN, Pisoni C, Toloza S, Mysler E, Tate G. Pereira D et al Work instability in rheumatoid arthritis patients from Argentina: prevalence and associated factors. Rheumatol Int. 2015;35:107–14.

Tanaka Y, Kameda H, Saito K, Kanedo Y, Tanaka E, Yasuda S, et al. Response to tocilizumab and work productivity in patients with rheumatoid arthritis: 2-year follow-up of FIRST ACT-SC study. Mod Rheumatol. 2021;21:42–52.

van der Zee-Neuen A, Putrik P, Ramiro S, Keszei AP, Hmamouchi I, Dougados M, Boonen A. Large country differences in work outcomes in patients with RA - an analysis in the multinational study COMORA. Arthritis Res Ther. 2017;19:216.

van Jaarsveld CHM, Jacobs JWG, Schrijvers AJP, van Albada-Kuipers GA, Hofman DM, Bijlsma JWJ. Effects of rheumatoid arthritis on employment and social participation during the first years of disease in the Netherlands. Br J Rheumatol. 1998;37:848–53.

Verstappen SMM, Boonen A, Bijlsma JWJ, Buskens E, Verkleij H, Schenk Y, et al. Working status among Dutch patients with rheumatoid arthritis: work disability and working conditions. Rheumatology. 2005;44:202–6.

Vliet Vlieland TPM, Buitenhuis NA, van Zeben D, Vandenbroucke JP, Breedveld FC, Hazes JMW. Sociodemographic factors and the outcome of rheumatoid arthritis in young women. Ann Rheum Dis. 1994;53:803–6.

Li F, Ai W, Ye J, Wang C, Yuan S, Xie Y, et al. Inflammatory markers and risk factors of RA patients with depression and application of different scales in judging depression. Clin Rheumatol. 2022;41:2309–17.

Wan SW, He HG, Mak A, Lahiri M, Luo N, Cheung PP, et al. Health-related quality of life and its predictors among patients with rheumatoid arthritis. Appl Nurs Res. 2016;30:176–83.

Xavier RM, Zerbini CAF, Pollak DF, Morales-Torres JLA, Chalem P, Restrepo JFM, et al. Burden of rheumatoid arthritis on patients’ work productivity and quality of life. Adv Rheumatol. 2019;59:47.

Yajima N, Kawaguchi T, Takahashi R, Nishiwaki H, Toyoshima Y, Oh K, et al. Adherence to methotrexate and associated factors considering social desirability in patients with rheumatoid arthritis: a multicenter cross-sectional study. BMC Rheumatol. 2022;6(75):1–8.

Yates M, Ledingham JM, Hatcher PA, Adas M, Hewitt S, Bartlett-Pestell S, et al. Disease activity and its predictors in early inflammatory arthritis: findings from a national cohort. Rheumatology. 2021;60:4811–20.

Yelin E, Henke C, Epstein W. The work dynamics of the person with rheumatoid arthritis. Arthritis Rheum. 1987;30:507–12.

Zhang W, Bansback N, Guh D, Li X, Nosyk B, Marra CA, et al. Short-term influence of adalimumab on work productivity outcomes in patients with rheumatoid arthritis. J Rheumatol. 2008;35:1729–36.

Żołnierczyk-Zreda D, Jędryka-Góral A, Bugajska J, Bedyńska S, Brzosko M, Pazdur J. The relationship between work, mental health, physical health, and fatigue in patients with rheumatoid arthritis: a cross-sectional study. J Health Psychol. 2020;25:665–73.

da Rocha Castellar Pinheiro G, Khandker RK, Sato R, Rose A, Piercy J. Impact of rheumatoid arthritis on quality of life, work productivity and resource utilisation: an observational, cross-sectional study in Brazil. Clin Exp Rheumatol. 2013;31:334–40.

Albers JMC, Kuper HH, van Riel PLCM, Prevoo MLL, Van’t Hof MA, van Gestel AM, et al. Socio-economic consequences of rheumatoid arthritis in the first year of the disease. Rheumatology. 1999;38:423–30.

Barrett EM, Scott DGI, Wiles NJ. The impact of rheumatoid arthritis on employment status in the early years of disease: a UK community-based study. Rheumatology. 2000;39:7.

Bejano V, Quinn M, Conaghan PG, Reece R, Keenan AM, Walker D, et al. Effect of the early use of the anti–tumor necrosis factor Adalimumab on the prevention of job loss in patients with early rheumatoid arthritis. Arthritis Care Res. 2008;59:1467–74.

Eberhardt K, Larsson BM, Nived K. Early rheumatoid arthritis – some social, economical, and psychological aspects. Scand J Rheum. 1993;22:119–23.

Eberhardt K, Larsson BM, Nived K, Lindqvist E. Work disability in rheumatoid arthritis- development over 15 years and evaluation of predictive factors over time. J Rheumatol. 2007;34:481–7.

Halpern MT, Cifaldi MA, Kvien TK. Impact of adalimumab on work participation in rheumatoid arthritis: comparison of an open-label extension study and a registry-based control group. Ann Rheum Dis. 2009;68:930–7.

Herenius MMJ, Hoving JI, Sluiter JK, Raterman HG, Lems WF, Dijkmans BAC, et al. Improvement of work ability, quality of life, and fatique in patients with rheumatoid arthritis treated with adalimumab. J Occup Environ Health. 2010;52:618–21.

Hoving JL, Bartelds GM, Sluiter JK, Sadiraj K, Groot I, Lems WF, et al. Perceived work ability, quality of life, and fatigue in patients with rheumatoid arthritis after a 6-month course of TNF inhibitors: prospective intervention study and partial economic evaluation. Scand J Rheumatol. 2009;38:246–50.

Jäntti J, Aho K, Kaarela K, Kautiainen H. Work disability in an inception cohort of patients with seropositive rheumatoid arthritis: a 20 year study. Rheumatology. 1999;38:4.

Kaarela K, Lehtinen K, Luukkainen R. Work capacity of patients with inflammatory joint diseases: an eight-year follow-up study. Scand J Rheumatol. 1987;16:403–6.

McWilliams DF, Varughese S, Young A, Kiely PD, Walsh DA. Work disability and state benefit claims in early rheumatoid arthritis: the ERAN cohort. Rheumatology. 2014;53:9.

Mau W, Bornmann M, Weber H, Weidemann HF, Hecker H, Raspe HH. Prediction of permanent work disability in a follow-up study of early rheumatoid arthritis: results of a tree structured analysis using RECPAM. Br J Rheumatol. 1996;35:652–9.

Nikiphorou E, Guh D, Bansback N, Zhang W, Dixey J, Williams P, et al. Work disability rates in RA. Results from an inception cohort with 24 years follow-up. Rheumatology. 2012;51:8.

Nordmark B, Blomqvist P, Andersson B, Hägerström M, Nordh-Grate K, Rönnqvist R, et al. A two-year follow-up of work capacity in early rheumatoid arthritis: a study of multidisciplinary team care with emphasis on vocational support. Scand J Rheumatol. 2006;35:7–14.

Pincus T, Callahan LF, Sale WG, Brooks AL, Payne LE, Vaughn WK. Severe functional declines, work disability, and increased mortality in seventy-five rheumatoid arthritis patients studied over mine years. Arthritis Rheum. 1984;27:864–72.

Puolakka K, Kautiainen H, Möttönen T, Hannonen P, Hakala M, Korpela M, et al. Predictors of productivity loss in early rheumatoid arthritis: a 5 year follow up study. Ann Rheum Dis. 2005;64:130–3.

Puolakka K, Kautiainen H, Möttönen T, Hannonen P, Korpela M, Julkunen H, et al. Impact of initial aggressive drug treatment with a combination of disease-modifying antirheumatic drugs on the development of work disability in early rheumatoid arthritis. Arthritis Rheum. 2004;50:55–62.

Reisine S, Fifield J, Walsh S, Feinn R. Factors associated with continued employment among patients with rheumatoid arthritis: a survival model. J Rheumatol. 2001;28:2400–8.

Reisine S, Fifield J, Walsh S, Dauser D. Work disability among two cohorts of women with recent onset rheumatoid arthritis: a survival analysis. Arthritis Rheum. 2007;57:372–80.

Robinson HS, Walters K. Return to work after treatment of rheumatoid arthritis. Can Med Assoc J. 1971;105:166–9.

CAS   PubMed   PubMed Central   Google Scholar  

Smolen JS, Han C, van der Heijde D, Emery P, Bathon JM, Keystone E, et al. Infliximab treatment maintains employability in patients with early rheumatoid arthritis. Arthritis Rheum. 2006;54:716–22.

van Vollenhoven RF, Cifaldi MA, Ray S, Chen N, Weisman MH. Improvement in work place and household productivity for patients with early rheumatoid arthritis treated with adalimumab plus methotrexate: work outcomes and their correlations with clinical and radiographic measures from a randomized controlled trial companion study. Arthritis Care Res. 2010;62:226–34.

Vazquez-Villegas ML, Gamez-Nava JI, Celis A, Sanchez-Mosco D, de la Cerda-Trujillo LF, Murillo-Vazquez JD, et al. Prognostic factors for permanent work disability in patients with rheumatoid arthritis who received combination therapy of conventional synthetic disease-modifying antirheumatic drugs. A retrospective cohort study. J Clin Rheumatol. 2017;23:376–82.

Verstappen SMM, Jacobs JWG, Kruize AA, Erlich JC, van Albada-Kuipers GA, Verkleij H, et al. Trends in economic consequences of rheumatoid arthritis over two subsequent years. Rheumatology. 2007;46:968–74.

Vlak T, Eldar R. Disability in rheumatoid arthritis after monotherapy with DMARDs. Int J Rehabil Res. 2003;26:207–12.

Yelin E, Trupin L, Katz P, Lubeck D, Rush S, Wanke L. Association between etanercept use and employment outcomes among patients with rheumatoid arthritis. Arthritis & Rheum. 2003;48:3046–54.

Young A, Dixey J, Cox N, Davies P, Devlin J, Emery P, et al. How does functional disability in early rheumatoid arthritis (RA) affect patients and their lifes? Results of 5 years of follow-up in 732 patients from the Early RA Study (ERAS). Rheumatology. 2000;39:603–11.

Young A, Dixey J, Kulinskaya E, Cox N, Davies P, Devlin J, et al. Which patients stop working because of rheumatoid arthritis? Results of five years’ follow up in 732 patients from the Early RA Study (ERAS). Ann Rheum Dis. 2002;61:335–40.

Zirkzee EJM, Sneep AC, de Buck PDM, Allaart CF, Peeters AJ, Ronday HK, et al. Sick leave and work disability in patients with early arthritis. Clin Rheumatol. 2008;27:9.

Reisine S, McQuillan J, Fifield J. Predictors of work disability in rheumatoid arthritis patients. Arthritis Rheum. 2005;38:1630–7.

Verstappen SMM, Watson KD, Lunt M, McGrother K, Symmons PM, Hyrich KL. Working status in patients with rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis: results from the British Society for Rheumatology Biogics Register. Rheumatology. 2010;49:1570–7.

Nissilä M, Isomäki H, Kaarela K, Kiviniemi P, Martio J, Sarna S. Prognosis of inflammatory joint diseases. A three-year follow-up study. Scand J Rheumatol. 1983;12:33–8.

Han C, Smolen J, Kavanaugh A, St.Clair EW, Baker D, Bala M. Comparison of employability outcomes among patients with early or long-standing rheumatoid arthritis. Arthritis Rheum. 2008;59:510–4.

Gwinnutt JM, Leggett S, Lunt M, Barton A, Hyrich KL, Walker-Bone K, et al. Predictors of presenteeism, absenteeism and job loss in patients commencing methotrexate or biologic therapy for rheumatoid arthritis. Rheumatology. 2020;59:2908–19.

Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020. https://doi.org/10.1016/S0140-6736(20)32340-0:1-12 .

Gwinnutt JM, Wieczorek M, Balanescu A, Bischoff-Ferrari HA, Boonen A, Cavalli G, et al. 2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases. Ann Rheum Dis. 2023;82:48–56.

England BR, Smith BJ, Baker NA, Barton JL, Oatis CA, Guyatt G, et al. 2022 American College of Rheumatology Guideline for exercise, rehabilitation, diet, and additional integrative interventions for rheumatoid arthritis. Arthritis Care Res. 2023;75:1603–15.

Vu M, Carvalho N, Clarke PM, Buchbinder R, Tran-Duy A. Impact of comorbid conditions on healtcare expenditure and work-related outcomes in patients with rheumatoid arthritis. J Rheumatol. 2021;48:1221–9.

Amaral GSG, Ots P, Brouwer S, van Zon SKR. Multimorbidity and exit from paid employment: the effect of specific combinations of chronic health conditions. Eur J Public Health. 2022;32:392–7.

Boonen A, Putrik P, Marques ML, Alunno A, Abasolo L, Beaton D, et al. EULAR Points to Consider (PtC) for designing, analysing and reporting of studies with work participation as an outcome domain in patients with inflammatory arthritis. Ann Rheum Dis. 2021;80:1116–23.

Lajas C, Abasolo L, Bellajdel B, Hernandez-Garcia C, Carmona L, Vargas E, et al. Costs and predictors of costs in rheumatoid arthritis: A prevalence-based study. Arthritis Care Res. 2003;49:64–70.

Reisine S, McQuillan J, Fifield J. Predictors of work disability in rheumatoid arthritis patients. Arthritis Rheum. 1995;38:1630–7.

Download references

Acknowledgements

Open access funding provided by Royal Library, Copenhagen University Library

Author information

Authors and affiliations.

Department of Social Medicine, University Hospital Bispebjerg-Frederiksberg, Copenhagen, Denmark

Lilli Kirkeskov & Katerina Bray

Department of Social Medicine, University Hospital Bispebjerg-Frederiksberg, Nordre Fasanvej 57, Vej 8, Opgang 2.2., 2000, Frederiksberg, Denmark

Lilli Kirkeskov

Department of Occupational and Social Medicine, Holbaek Hospital, Holbaek, Denmark

Katerina Bray

You can also search for this author in PubMed   Google Scholar

Contributions

LK performed the systematic research, including reading articles, performed the blinded quality assessment and the meta-analysis, and drafted and revised the article. KM performed the blinded quality assessment and the discussion afterwards of articles to be included in the research and the scores, and drafted and revised the article.

Corresponding author

Correspondence to Lilli Kirkeskov .

Ethics declarations

Ethics approval and consent to participate.

Not applicable as this is a systematic review. All the studies that are included have obtained ethical approval and consent as appreciated by the journal in which they have been published.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: figure s1..

Employment; year of investigation.

Additional file 2: Figure S2.

Forest Plot of Comparison: Predictors for employment. Outcome: Younger or older age.

Additional file 3: Figure S3.

Forest Plot of Comparison: Predictors for employment. Outcome: >50 yr or <50 yr of age.

Additional file 4: Figure S4.

Forest Plot of Comparison: Predictors for employment. Outcome: Gender: Male or Female.

Additional file 5: Figure S5.

Forest Plot of Comparison: Predictors for employment. Outcome: Educational level: no college education or college education or higher.

Additional file 6: Figure S6.

Forest Plot of Comparison: Predictors for employment. Outcome: no comorbidities present or one or more comorbidities present.

Additional file 7: Figure S7.

Forest Plot of Comparison: Predictors for employment. Outcome: Ethnicity: Caucasian or other than Caucasian.

Additional file 8: Figure S8.

Forest Plot of Comparison: Predictors for employment. Outcome: Short or long disease duration.

Additional file 9: Figure S9.

Forest Plot of Comparison: Predictors for employment. Outcome: Low or high Health Assessment Questionnaire, HAQ-score.

Additional file 10: Figure S10.

Forest Plot of Comparison: Predictors for employment. Outcome: Low or high VAS-score.

Additional file 11: Figure S11.

Forest Plot of Comparison: Predictors for employment. Outcome: Job type: blue collar workers or other job types.

Additional file 12: Figure S12.

Forest Plot of Comparison: Predictors for employment. Outcome: No MTX or MTX.

Additional file 13: Figure S13.

Forest Plot of Comparison: Predictors for employment. Outcome: No biological or biological.

Additional file 14: Figure S14.

Forest Plot of Comparison: Predictors for employment. Outcome: No prednisolone or prednisolone.

Additional file 15: Figure S15.

Forest Plot of Comparison: Predictors for employment. Outcome: Low or high DAS score.

Additional file 16: Figure S16.

Forest Plot of Comparison: Predictors for employment. Outcome: Low or high SF 36-score.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Kirkeskov, L., Bray, K. Employment of patients with rheumatoid arthritis - a systematic review and meta-analysis. BMC Rheumatol 7 , 41 (2023). https://doi.org/10.1186/s41927-023-00365-4

Download citation

Received : 07 June 2023

Accepted : 20 October 2023

Published : 14 November 2023

DOI : https://doi.org/10.1186/s41927-023-00365-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Return to work
• Unemployment

BMC Rheumatology

ISSN: 2520-1026

• Submission enquiries: [email protected]
• General enquiries: [email protected]