how to make synthesis in review of related literature

• University of Oregon Libraries
• Research Guides

How to Write a Literature Review

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

Synthesis Visualization

Synthesis matrix example.

• 7. Write a Literature Review

• Synthesis Worksheet

About Synthesis

Approaches to synthesis.

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

How to Begin?

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

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

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

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

Four Examples of Student Writing

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

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

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

Click on the example to view the pdf.

From Jennifer Lim

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Get Organized

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

Synthesize your Information

Synthesize: combine separate elements to form a whole.

Synthesis Matrix

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

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

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

• Step-by-Step Approach
• Example Matrix from NSCU
• Matrix Template
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• Last Updated: Sep 26, 2023 10:25 AM
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Literature Syntheis 101

How To Synthesise The Existing Research (With Examples)

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

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

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

Overview: Literature Synthesis

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

What does “synthesis” actually mean?

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

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

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

So, how do you go about doing this?

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

1. Points Of Agreement

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

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

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

Need a helping hand?

2. Points Of Disagreement

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

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

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

3. Key Theories

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

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

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

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

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

4. Contexts

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

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

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

5. Methodological Approaches

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

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

But why does this matter?

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

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

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

Bringing It All Together

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

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

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

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

Psst… there’s more!

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

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How to Synthesize Written Information from Multiple Sources

Shona McCombes

Content Manager

B.A., English Literature, University of Glasgow

Shona McCombes is the content manager at Scribbr, Netherlands.

Learn about our Editorial Process

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

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

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

On This Page:

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

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

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

Unsynthesized Example

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

Synthesized Example

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

Step 1: Organize your sources

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

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

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

Summary table

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

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

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

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

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

Synthesis matrix

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

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

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

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

Step 2: Outline your structure

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

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

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

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

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

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

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

Source Used with Permission: The Chicago School

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

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

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

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

Step 3: Write paragraphs with topic sentences

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

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

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

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

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

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

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

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

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

Step 4: Revise, edit and proofread

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

Checklist for Synthesis

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

Further Information

How to Synthesise: a Step-by-Step Approach

Help…I”ve Been Asked to Synthesize!

Learn how to Synthesise (combine information from sources)

How to write a Psychology Essay

Literature Review How To

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

What is Synthesis

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

How To Synthesize Sources in a Literature Review

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

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

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

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

• 5. Synthesize your findings
• Getting started
• Types of reviews
• 1. Define your research question
• 2. Plan your search
• 3. Search the literature
• 4. Organize your results

How to synthesize

Approaches to synthesis.

• 6. Write the review
• Artificial intelligence (AI) tools
• Thompson Writing Studio This link opens in a new window
• Need to write a systematic review? This link opens in a new window

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Ask a Librarian

In the synthesis step of a literature review, researchers analyze and integrate information from selected sources to identify patterns and themes. This involves critically evaluating findings, recognizing commonalities, and constructing a cohesive narrative that contributes to the understanding of the research topic.

Here are some examples of how to approach synthesizing the literature:

💡 By themes or concepts

🕘 Historically or chronologically

📊 By methodology

These organizational approaches can also be used when writing your review. It can be beneficial to begin organizing your references by these approaches in your citation manager by using folders, groups, or collections.

Create a synthesis matrix

A synthesis matrix allows you to visually organize your literature.

Topic: ______________________________________________

Topic: Chemical exposure to workers in nail salons

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Literature Review Basics

• What is a Literature Review?
• Synthesizing Research
• Using Research & Synthesis Tables
• Additional Resources

Synthesis: What is it?

First, let's be perfectly clear about what synthesizing your research isn't :

• - It isn't  just summarizing the material you read
• - It isn't  generating a collection of annotations or comments (like an annotated bibliography)
• - It isn't  compiling a report on every single thing ever written in relation to your topic

When you  synthesize  your research, your job is to help your reader understand the current state of the conversation on your topic, relative to your research question.  That may include doing the following:

• - Selecting and using representative work on the topic
• - Identifying and discussing trends in published data or results
• - Identifying and explaining the impact of common features (study populations, interventions, etc.) that appear frequently in the literature
• - Explaining controversies, disputes, or central issues in the literature that are relevant to your research question
• - Identifying gaps in the literature, where more research is needed
• - Establishing the discussion to which your own research contributes and demonstrating the value of your contribution

Essentially, you're telling your reader where they are (and where you are) in the scholarly conversation about your project.

Synthesis: How do I do it?

Synthesis, step by step.

This is what you need to do  before  you write your review.

• Identify and clearly describe your research question (you may find the Formulating PICOT Questions table at  the Additional Resources tab helpful).
• Collect sources relevant to your research question.
• Organize and describe the sources you've found -- your job is to identify what  types  of sources you've collected (reviews, clinical trials, etc.), identify their  purpose  (what are they measuring, testing, or trying to discover?), determine the  level of evidence  they represent (see the Levels of Evidence table at the Additional Resources tab ), and briefly explain their  major findings . Use a Research Table to document this step.
• Study the information you've put in your Research Table and examine your collected sources, looking for  similarities  and  differences . Pay particular attention to  populations ,   methods  (especially relative to levels of evidence), and  findings .
• Analyze what you learn in (4) using a tool like a Synthesis Table. Your goal is to identify relevant themes, trends, gaps, and issues in the research.  Your literature review will collect the results of this analysis and explain them in relation to your research question.

Analysis tips

• - Sometimes, what you  don't  find in the literature is as important as what you do find -- look for questions that the existing research hasn't answered yet.
• - If any of the sources you've collected refer to or respond to each other, keep an eye on how they're related -- it may provide a clue as to whether or not study results have been successfully replicated.
• - Sorting your collected sources by level of evidence can provide valuable insight into how a particular topic has been covered, and it may help you to identify gaps worth addressing in your own work.
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Library Guides

Literature reviews: synthesis.

• Criticality

Synthesise Information

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

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

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

Synthesising Texts  

What is synthesis? 

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

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

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

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

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

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

How to synthesise in a literature review: 

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

Read the literature and identify these themes/issues.  

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

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

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

Present your critical analysis.  

Always provide the references. 

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

What is good synthesis?  

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

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

Selection of ideas necessary for producing the synthesis. 

Appropriateness of the interpretation.  

Elaboration of the content.  

Example of Synthesis

Original texts (fictitious): 

Synthesis: 

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

Bibliography

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

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How to Write a Literature Review - A Self-Guided Tutorial

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

You can meet with a librarian to talk about your literature review, or other library-related topics.

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

Synthesis Vizualization

Four examples of student writing.

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

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

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

Synthesis Matrix Example

From Jennifer Lim

Synthesis Templates

Synthesis grids are organizational tools used to record the main concepts of your sources and can help you make connections about how your sources relate to one another.

• Source Template Basic Literature Review Source Template from Walden University Writing Center to help record the main findings and concepts from different articles.
• Sample Literature Review Grids This spreadsheet contains multiple tabs with different grid templates. Download or create your own copy to begin recording notes.
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Chapter 7: Synthesizing Sources

Learning objectives.

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

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

7.1 Overview of synthesizing

7.1.1 putting the pieces together.

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

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

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

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

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

7.2 Creating a summary table

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

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

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

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

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

7.2.1 Creating a Summary Table

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

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

7.3 Creating a summary outline

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

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

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

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

7.4 Additional resources:

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

Literature Review: Synthesizing Multiple Sources / Indiana University

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

 Sample Literature Reviews Grid / Complied by Lindsay Roberts

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

Literature Review Table  

Test yourself.

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

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

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Writing a Literature Review: Organize, Synthesize, Evaluate

• Literature Review Process
• Literature Search
• Record your Search
• Organize, Synthesize, Evaluate
• Getting help

Table of Contents

On this page you will find:

Organizing Literature and Notes

How to scan an article.

• Reading for Comprehension
• Synthesis Matrix Information

Steps to take in organizing your literature and notes:

• Find common themes and organize the works into categories.
• Develop a subject level outline with studies you’ve found
• Expand or limit your search based on the information you found.
• How the works in each category relate to each other
• How the categories relate to each other and to your overall theme.

Available tools:

• Synthesis Matrix The "synthesis matrix" is an approach to organizing, monitoring, and documenting your search activities.
• Concept Mapping Concept Maps are graphic representations of topics, ideas, and their relationships. They allow users to group information in related modules so that the connections between and among the modules become more readily apparent than they might from an examination of a list. It can be done on paper or using specific software.
• Mind Mapping A mind map is a visual representation of hierarchical information that includes a central idea surrounded by connected branches of associated topics.
• NVIVO NVIVO is a qualitative data analysis software that can be applied for engineering literature review.

Synthesis Matrix

• Writing A Literature Review and Using a Synthesis Matrix Writing Center, Florida International University
• The Matrix Method of Literature Reviews Article from Health Promotion Practice journal.

Sample synthesis matrix

Synthesis matrix video

Skim the article to get the “big picture” for relevancy to your topic. You don’t have to understand every single idea in a text the first time you read it.

• Where was the paper published?
• What kind of journal it is? Is the journal peer-reviewed?
• Can you tell what the paper is about?
• Where are they from?
• What are the sections of the article?
• Are these clearly defined?  
• Can you figure out the purpose of the study, methodology, results and conclusion?
• Mentally review what you know about the topic
• Do you know enough to be able to understand the paper? If not, first read about the unfamiliar concepts  
• What is the overall context?
• Is the problem clearly stated?
• What does the paper bring new?
• Did it miss any previous major studies?
• Identify all the author’s assumptions.  
• Analyze the visuals for yourself and try to understand each of them. Make notes on what you understand. Write questions of what you do not understand. Make a guess about what materials/methods you expect to see. Do your own data interpretation and check them against the conclusions.  
• Do you agree with the author’s opinion?
• As you read, write down terms, techniques, unfamiliar concepts and look them up  
• Save retrieved sources to a reference manager

Read for Comprehension and Take Notes

Read for comprehension

• After first evaluation of sources, critically read the selected sources. Your goal is to determine how much of it to accept, determine its value, and decide whether you plan to include it in your literature review.
• Read the whole article, section by section but not necessarily in order and make sure you understand:

Introduction : What is known about the research and what is still unknown. Methods : What was measured? How was measured? Were the measurement appropriate? Did they offer sufficient evidence? Results : What is the main finding? Were there enough data presented? Were there problems not addressed? Discussions : Are these conclusions appropriate? Are there other factors that might have influenced? What does it need to be done to answer remaining questions?

• Find answers to your question from first step
• Formulate new questions and try to answer them
• Can you find any discrepancies? What would you have done differently?
• Re-read the whole article or just sections as many times you feel you need to
• When you believe that you have understood the article, write a summary in your own words (Make sure that there is nothing left that you cannot understand)

As you read, take (extensive) notes. Create your own system to take notes but be consistent. Remember that notes can be taken within the citation management tool.

What to write in your notes:

• identify key topic, methodology, key terms
• identify emphases, strengths, weaknesses, gaps (if any)
• determine relationships to other studies
• identify the relationship to your research topic
• new questions you have  
• suggestions for new directions, new sources to read
• everything else that seems relevant
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• How to Write a Literature Review | Guide, Examples, & Templates

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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

• Quick Run-through
• Step 1 & 2

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

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

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

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

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

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

Download Word doc Download Google doc

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

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

Make a list of keywords

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

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

Search for relevant sources

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

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

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

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

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

For each publication, ask yourself:

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

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

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

Take notes and cite your sources

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

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

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

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

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

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

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

Chronological

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

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

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

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

Methodological

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

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

Theoretical

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

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

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

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

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

As you write, you can follow these tips:

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

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

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

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

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

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

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

 Statistics

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

Research bias

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

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

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

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

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

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

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

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

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

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Writing a Literature Review

• What is a Literature Review?
• Step 1: Choosing a Topic
• Step 2: Finding Information
• Step 3: Evaluating Content
• Step 4: Taking Notes
• Step 5: Synthesizing Content
• Step 6: Writing the Review
• Step 7: Citing Your Sources
• Meet the Library Team
• Off-Campus & Mobile Access
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Tips on Synthesizing

By step 5 you are well into the literature review process. This next to last step is when you take a moment to reflect on the research you have, what you have learned, how the information fits into you topic, and what is the best way to present your findings.

Some tips on how to organize your research-

• Organize research by topic. Feel free to create subtopics as a means of connecting your research and ideas.
• Consider what points from each topic you want to address in your literature review. This is the time to start thinking about what areas you will discuss in your review and what pieces of research you will use to support your conclusions.
• After reviewing your notes, try summarizing the main points in one to two sentences.
• Draft an outline of your literature review. Start with a point, then list supporting arguments and resources. Repeat this process for each of your paper's main points.
• << Previous: Step 4: Taking Notes
• Next: Step 6: Writing the Review >>
• Last Updated: Apr 1, 2024 9:42 AM
• URL: https://libguides.llu.edu/literaturereview

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Introduction to Social Work Research

Writing a literature review.

• Background Information
• Peer Review & Evaluation
• Article Comparison
• Creating an Outline

It is important to critically think about all of the sources you've read, both background information and scholarly journal articles, and synthesize that information into new conclusions that are unique to you. A synthesis requires critical thinking about the articles, determining where themes align, what they're saying that lines up, and what they're saying that might conflict with each other. What conclusions do these conflicts cause you to draw?

This page discusses how to synthesize information from your sources.

• Literature Review: Synthesizing Multiple Sources from IUPUI's University Writing Center Walks through the process of creating a synthesis matrix.

Summarizing vs. Synthesizing

While a summary is a way of concisely relating important themes and elements from a larger work or works in a condensed form, a synthesis takes the information from a variety of works and combines them together to create something new.

Synthesis :

"Synthesis is similar to putting a puzzle together—piecing together information to create a whole. The outcome of this synthesis might be numeric, such as in an overall rating perhaps best typified in a quantitative weight and sum strategy, or through the use of meta-analysis, or the synthesis might be textual, such as in an analytic conclusion."

Synthesis. (2005). In Mathison, S. (Ed.),  Encyclopedia of evaluation . Thousand Oaks, CA: Sage Publications, Inc. doi: 10.4135/9781412950558

• Approaches to Reviewing Research in Education from Sage Knowledge

How to Synthesize

Basic steps for synthesizing information:

• Highlight the main themes/ideas of each article
• Note which themes and ideas appear across multiple articles
• Discuss how each article deals similarly or differently with each theme
• Discuss how combining the information from all three articles can better address your research question than a single article alone
• Write your deductions from combining this information in your own words using all three articles

Summary of 1 article:

By analyzing monthly cost data of 9 drugs that were approved by the FDA for Multiple Sclerosis from 1993 to 2013, Hartung, et al. determined that the cost of MS drugs is increasing far beyond inflation rates, which has a negative effect on MS patients (2015).

Summary of 2 articles:

The cost of MS drugs is increasing far beyond inflation rates, which has a negative effect on MS patients (Hartung, et al., 2015). For low income MS patients, like Shereese Hickson, this cost has proven to be more than they can pay (Hancock, 2018).

Synthesis of 2 articles:

The cost of MS drugs is increasing far beyond inflation rates, which has a negative effect on MS patients (Hartung, et al., 2015). The personal experience of Shereese Hickson shows what that negative impact looks like (Hancock, 2018). This illustrates how vulnerable populations, like low-income MS patients, can be at greater risk of experiencing the negative impacts of rising drug costs.

Hartung, D. M., Bourdette, D. N., Ahmed, S. M., & Whitham, R. H. (2015). The cost of multiple sclerosis drugs in the US and the pharmaceutical industry: Too big to fail? Neurology, 84 (21), 2185-2192. doi:10.1212/WNL.0000000000001608

Hancock, J. (2018). Chronically Ill, Traumatically Billed: $123,019 For 2 Multiple Sclerosis Treatments.  Kaiser Health News . Retrieved from  https://khn.org/news/chronically-ill-traumatically-billed-the-123k-medicine-for-ms/

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Literature Review Step by Step

• Refining Your Understanding
• Parts of a Literature Review
• Choosing a Topic
• Search Terms
• Peer Review
• Internet Sources
• Social Media Sources
• Information Landscape

About Literature Review

• From University of North Carolina A clear verbal description of the literature review process.

What is Synthesis?

"The combination of components or elements to form a connected whole" (OED)

Forming a synthesis between various ideas is the heart of your literature review, and once done, will be the core of your research paper. As a starting point try:

• finding ideas that are common or controversial • two or three important trends in the research • the most influential theories.

As you read keep these questions in mind:

• does the writer make any assumptions not supported by evidence? • what is the researcher's method? how does she gather data? • what ideas and which researchers are frequently referred to?

Some writers of Literature Review create a matrix for organizing their research articles.

This requires you to come up with a number of categories which  grow out of your reading of the literature. As you read, write down ideas, words or controversies  that occur frequently. Ask yourself why? What question are these different papers trying to answer?

This process will generate a number of categories, You can use these to create a table. The article below offers more information on this method of organizing your process.

• Creating a Matrix for Literature Review Synthesis
• << Previous: Summarize
• Next: Integrate >>
• Last Updated: Jan 22, 2024 2:05 PM
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What Synthesis Methodology Should I Use? A Review and Analysis of Approaches to Research Synthesis

Kara schick-makaroff.

1 Faculty of Nursing, University of Alberta, Edmonton, AB, Canada

Marjorie MacDonald

2 School of Nursing, University of Victoria, Victoria, BC, Canada

Marilyn Plummer

3 College of Nursing, Camosun College, Victoria, BC, Canada

Judy Burgess

4 Student Services, University Health Services, Victoria, BC, Canada

Wendy Neander

Associated data, additional file 1.

When we began this process, we were doctoral students and a faculty member in a research methods course. As students, we were facing a review of the literature for our dissertations. We encountered several different ways of conducting a review but were unable to locate any resources that synthesized all of the various synthesis methodologies. Our purpose is to present a comprehensive overview and assessment of the main approaches to research synthesis. We use ‘research synthesis’ as a broad overarching term to describe various approaches to combining, integrating, and synthesizing research findings.

We conducted an integrative review of the literature to explore the historical, contextual, and evolving nature of research synthesis. We searched five databases, reviewed websites of key organizations, hand-searched several journals, and examined relevant texts from the reference lists of the documents we had already obtained.

We identified four broad categories of research synthesis methodology including conventional, quantitative, qualitative, and emerging syntheses. Each of the broad categories was compared to the others on the following: key characteristics, purpose, method, product, context, underlying assumptions, unit of analysis, strengths and limitations, and when to use each approach.

Conclusions

The current state of research synthesis reflects significant advancements in emerging synthesis studies that integrate diverse data types and sources. New approaches to research synthesis provide a much broader range of review alternatives available to health and social science students and researchers.

1. Introduction

Since the turn of the century, public health emergencies have been identified worldwide, particularly related to infectious diseases. For example, the Severe Acute Respiratory Syndrome (SARS) epidemic in Canada in 2002-2003, the recent Ebola epidemic in Africa, and the ongoing HIV/AIDs pandemic are global health concerns. There have also been dramatic increases in the prevalence of chronic diseases around the world [1] – [3] . These epidemiological challenges have raised concerns about the ability of health systems worldwide to address these crises. As a result, public health systems reform has been initiated in a number of countries. In Canada, as in other countries, the role of evidence to support public health reform and improve population health has been given high priority. Yet, there continues to be a significant gap between the production of evidence through research and its application in practice [4] – [5] . One strategy to address this gap has been the development of new research synthesis methodologies to deal with the time-sensitive and wide ranging evidence needs of policy makers and practitioners in all areas of health care, including public health.

As doctoral nursing students facing a review of the literature for our dissertations, and as a faculty member teaching a research methods course, we encountered several ways of conducting a research synthesis but found no comprehensive resources that discussed, compared, and contrasted various synthesis methodologies on their purposes, processes, strengths and limitations. To complicate matters, writers use terms interchangeably or use different terms to mean the same thing, and the literature is often contradictory about various approaches. Some texts [6] , [7] – [9] did provide a preliminary understanding about how research synthesis had been taken up in nursing, but these did not meet our requirements. Thus, in this article we address the need for a comprehensive overview of research synthesis methodologies to guide public health, health care, and social science researchers and practitioners.

Research synthesis is relatively new in public health but has a long history in other fields dating back to the late 1800s. Research synthesis, a research process in its own right [10] , has become more prominent in the wake of the evidence-based movement of the 1990s. Research syntheses have found their advocates and detractors in all disciplines, with challenges to the processes of systematic review and meta-analysis, in particular, being raised by critics of evidence-based healthcare [11] – [13] .

Our purpose was to conduct an integrative review of the literature to explore the historical, contextual, and evolving nature of research synthesis [14] – [15] . We synthesize and critique the main approaches to research synthesis that are relevant for public health, health care, and social scientists. Research synthesis is the overarching term we use to describe approaches to combining, aggregating, integrating, and synthesizing primary research findings. Each synthesis methodology draws on different types of findings depending on the purpose and product of the chosen synthesis (see Additional File 1 ).

3. Method of Review

Based on our current knowledge of the literature, we identified these approaches to include in our review: systematic review, meta-analysis, qualitative meta-synthesis, meta-narrative synthesis, scoping review, rapid review, realist synthesis, concept analysis, literature review, and integrative review. Our first step was to divide the synthesis types among the research team. Each member did a preliminary search to identify key texts. The team then met to develop search terms and a framework to guide the review.

Over the period of 2008 to 2012 we extensively searched the literature, updating our search at several time points, not restricting our search by date. The dates of texts reviewed range from 1967 to 2015. We used the terms above combined with the term “method* (e.g., “realist synthesis” and “method*) in the database Health Source: Academic Edition (includes Medline and CINAHL). This search yielded very few texts on some methodologies and many on others. We realized that many documents on research synthesis had not been picked up in the search. Therefore, we also searched Google Scholar, PubMed, ERIC, and Social Science Index, as well as the websites of key organizations such as the Joanna Briggs Institute, the University of York Centre for Evidence-Based Nursing, and the Cochrane Collaboration database. We hand searched several nursing, social science, public health and health policy journals. Finally, we traced relevant documents from the references in obtained texts.

We included works that met the following inclusion criteria: (1) published in English; (2) discussed the history of research synthesis; (3) explicitly described the approach and specific methods; or (4) identified issues, challenges, strengths and limitations of the particular methodology. We excluded research reports that resulted from the use of particular synthesis methodologies unless they also included criteria 2, 3, or 4 above.

Based on our search, we identified additional types of research synthesis (e.g., meta-interpretation, best evidence synthesis, critical interpretive synthesis, meta-summary, grounded formal theory). Still, we missed some important developments in meta-analysis, for example, identified by the journal's reviewers that have now been discussed briefly in the paper. The final set of 197 texts included in our review comprised theoretical, empirical, and conceptual papers, books, editorials and commentaries, and policy documents.

In our preliminary review of key texts, the team inductively developed a framework of the important elements of each method for comparison. In the next phase, each text was read carefully, and data for these elements were extracted into a table for comparison on the points of: key characteristics, purpose, methods, and product; see Additional File 1 ). Once the data were grouped and extracted, we synthesized across categories based on the following additional points of comparison: complexity of the process, degree of systematization, consideration of context, underlying assumptions, unit of analysis, and when to use each approach. In our results, we discuss our comparison of the various synthesis approaches on the elements above. Drawing only on documents for the review, ethics approval was not required.

We identified four broad categories of research synthesis methodology: Conventional, quantitative, qualitative, and emerging syntheses. From our dataset of 197 texts, we had 14 texts on conventional synthesis, 64 on quantitative synthesis, 78 on qualitative synthesis, and 41 on emerging syntheses. Table 1 provides an overview of the four types of research synthesis, definitions, types of data used, products, and examples of the methodology.

Although we group these types of synthesis into four broad categories on the basis of similarities, each type within a category has unique characteristics, which may differ from the overall group similarities. Each could be explored in greater depth to tease out their unique characteristics, but detailed comparison is beyond the scope of this article.

Additional File 1 presents one or more selected types of synthesis that represent the broad category but is not an exhaustive presentation of all types within each category. It provides more depth for specific examples from each category of synthesis on the characteristics, purpose, methods, and products than is found in Table 1 .

4.1. Key Characteristics

4.1.1. what is it.

Here we draw on two types of categorization. First, we utilize Dixon Woods et al.'s [49] classification of research syntheses as being either integrative or interpretive . (Please note that integrative syntheses are not the same as an integrative review as defined in Additional File 1 .) Second, we use Popay's [80] enhancement and epistemological models .

The defining characteristics of integrative syntheses are that they involve summarizing the data achieved by pooling data [49] . Integrative syntheses include systematic reviews, meta-analyses, as well as scoping and rapid reviews because each of these focus on summarizing data. They also define concepts from the outset (although this may not always be true in scoping or rapid reviews) and deal with a well-specified phenomenon of interest.

Interpretive syntheses are primarily concerned with the development of concepts and theories that integrate concepts [49] . The analysis in interpretive synthesis is conceptual both in process and outcome, and “the product is not aggregations of data, but theory” [49] , [p.12]. Interpretive syntheses involve induction and interpretation, and are primarily conceptual in process and outcome. Examples include integrative reviews, some systematic reviews, all of the qualitative syntheses, meta-narrative, realist and critical interpretive syntheses. Of note, both quantitative and qualitative studies can be either integrative or interpretive

The second categorization, enhancement versus epistemological , applies to those approaches that use multiple data types and sources [80] . Popay's [80] classification reflects the ways that qualitative data are valued in relation to quantitative data.

In the enhancement model , qualitative data adds something to quantitative analysis. The enhancement model is reflected in systematic reviews and meta-analyses that use some qualitative data to enhance interpretation and explanation. It may also be reflected in some rapid reviews that draw on quantitative data but use some qualitative data.

The epistemological model assumes that quantitative and qualitative data are equal and each has something unique to contribute. All of the other review approaches, except pure quantitative or qualitative syntheses, reflect the epistemological model because they value all data types equally but see them as contributing different understandings.

4.1.2. Data type

By and large, the quantitative approaches (quantitative systematic review and meta-analysis) have typically used purely quantitative data (i.e., expressed in numeric form). More recently, both Cochrane [81] and Campbell [82] collaborations are grappling with the need to, and the process of, integrating qualitative research into a systematic review. The qualitative approaches use qualitative data (i.e., expressed in words). All of the emerging synthesis types, as well as the conventional integrative review, incorporate qualitative and quantitative study designs and data.

4.1.3. Research question

Four types of research questions direct inquiry across the different types of syntheses. The first is a well-developed research question that gives direction to the synthesis (e.g., meta-analysis, systematic review, meta-study, concept analysis, rapid review, realist synthesis). The second begins as a broad general question that evolves and becomes more refined over the course of the synthesis (e.g., meta-ethnography, scoping review, meta-narrative, critical interpretive synthesis). In the third type, the synthesis begins with a phenomenon of interest and the question emerges in the analytic process (e.g., grounded formal theory). Lastly, there is no clear question, but rather a general review purpose (e.g., integrative review). Thus, the requirement for a well-defined question cuts across at least three of the synthesis types (e.g., quantitative, qualitative, and emerging).

4.1.4. Quality appraisal

This is a contested issue within and between the four synthesis categories. There are strong proponents of quality appraisal in the quantitative traditions of systematic review and meta-analysis based on the need for strong studies that will not jeopardize validity of the overall findings. Nonetheless, there is no consensus on pre-defined criteria; many scales exist that vary dramatically in composition. This has methodological implications for the credibility of findings [83] .

Specific methodologies from the conventional, qualitative, and emerging categories support quality appraisal but do so with caveats. In conventional integrative reviews appraisal is recommended, but depends on the sampling frame used in the study [18] . In meta-study, appraisal criteria are explicit but quality criteria are used in different ways depending on the specific requirements of the inquiry [54] . Among the emerging syntheses, meta-narrative review developers support appraisal of a study based on criteria from the research tradition of the primary study [67] , [84] – [85] . Realist synthesis similarly supports the use of high quality evidence, but appraisal checklists are viewed with scepticism and evidence is judged based on relevance to the research question and whether a credible inference may be drawn [69] . Like realist, critical interpretive syntheses do not judge quality using standardized appraisal instruments. They will exclude fatally flawed studies, but there is no consensus on what ‘fatally flawed’ means [49] , [71] . Appraisal is based on relevance to the inquiry, not rigor of the study.

There is no agreement on quality appraisal among qualitative meta-ethnographers with some supporting and others refuting the need for appraisal. [60] , [62] . Opponents of quality appraisal are found among authors of qualitative (grounded formal theory and concept analysis) and emerging syntheses (scoping and rapid reviews) because quality is not deemed relevant to the intention of the synthesis; the studies being reviewed are not effectiveness studies where quality is extremely important. These qualitative synthesis are often reviews of theoretical developments where the concept itself is what is important, or reviews that provide quotations from the raw data so readers can make their own judgements about the relevance and utility of the data. For example, in formal grounded theory, the purpose of theory generation and authenticity of data used to generate the theory is not as important as the conceptual category. Inaccuracies may be corrected in other ways, such as using the constant comparative method, which facilitates development of theoretical concepts that are repeatedly found in the data [86] – [87] . For pragmatic reasons, evidence is not assessed in rapid and scoping reviews, in part to produce a timely product. The issue of quality appraisal is unresolved across the terrain of research synthesis and we consider this further in our discussion.

4.2. Purpose

All research syntheses share a common purpose -- to summarize, synthesize, or integrate research findings from diverse studies. This helps readers stay abreast of the burgeoning literature in a field. Our discussion here is at the level of the four categories of synthesis. Beginning with conventional literature syntheses, the overall purpose is to attend to mature topics for the purpose of re-conceptualization or to new topics requiring preliminary conceptualization [14] . Such syntheses may be helpful to consider contradictory evidence, map shifting trends in the study of a phenomenon, and describe the emergence of research in diverse fields [14] . The purpose here is to set the stage for a study by identifying what has been done, gaps in the literature, important research questions, or to develop a conceptual framework to guide data collection and analysis.

The purpose of quantitative systematic reviews is to combine, aggregate, or integrate empirical research to be able to generalize from a group of studies and determine the limits of generalization [27] . The focus of quantitative systematic reviews has been primarily on aggregating the results of studies evaluating the effectiveness of interventions using experimental, quasi-experimental, and more recently, observational designs. Systematic reviews can be done with or without quantitative meta-analysis but a meta-analysis always takes place within the context of a systematic review. Researchers must consider the review's purpose and the nature of their data in undertaking a quantitative synthesis; this will assist in determining the approach.

The purpose of qualitative syntheses is broadly to synthesize complex health experiences, practices, or concepts arising in healthcare environments. There may be various purposes depending on the qualitative methodology. For example, in hermeneutic studies the aim may be holistic explanation or understanding of a phenomenon [42] , which is deepened by integrating the findings from multiple studies. In grounded formal theory, the aim is to produce a conceptual framework or theory expected to be applicable beyond the original study. Although not able to generalize from qualitative research in the statistical sense [88] , qualitative researchers usually do want to say something about the applicability of their synthesis to other settings or phenomena. This notion of ‘theoretical generalization’ has been referred to as ‘transferability’ [89] – [90] and is an important criterion of rigour in qualitative research. It applies equally to the products of a qualitative synthesis in which the synthesis of multiple studies on the same phenomenon strengthens the ability to draw transferable conclusions.

The overarching purpose of emerging syntheses is challenging the more traditional types of syntheses, in part by using data from both quantitative and qualitative studies with diverse designs for analysis. Beyond this, however, each emerging synthesis methodology has a unique purpose. In meta-narrative review, the purpose is to identify different research traditions in the area, synthesize a complex and diverse body of research. Critical interpretive synthesis shares this characteristic. Although a distinctive approach, critical interpretive synthesis utilizes a modification of the analytic strategies of meta-ethnography [61] (e.g., reciprocal translational analysis, refutational synthesis, and lines of argument synthesis) but goes beyond the use of these to bring a critical perspective to bear in challenging the normative or epistemological assumptions in the primary literature [72] – [73] . The unique purpose of a realist synthesis is to amalgamate complex empirical evidence and theoretical understandings within a diverse body of literature to uncover the operative mechanisms and contexts that affect the outcomes of social interventions. In a scoping review, the intention is to find key concepts, examine the range of research in an area, and identify gaps in the literature. The purpose of a rapid review is comparable to that of a scoping review, but done quickly to meet the time-sensitive information needs of policy makers.

4.3. Method

4.3.1. degree of systematization.

There are varying degrees of systematization across the categories of research synthesis. The most systematized are quantitative systematic reviews and meta-analyses. There are clear processes in each with judgments to be made at each step, although there are no agreed upon guidelines for this. The process is inherently subjective despite attempts to develop objective and systematic processes [91] – [92] . Mullen and Ramirez [27] suggest that there is often a false sense of rigour implied by the terms ‘systematic review’ and ‘meta-analysis’ because of their clearly defined procedures.

In comparison with some types of qualitative synthesis, concept analysis is quite procedural. Qualitative meta-synthesis also has defined procedures and is systematic, yet perhaps less so than concept analysis. Qualitative meta-synthesis starts in an unsystematic way but becomes more systematic as it unfolds. Procedures and frameworks exist for some of the emerging types of synthesis [e.g., [50] , [63] , [71] , [93] ] but are not linear, have considerable flexibility, and are often messy with emergent processes [85] . Conventional literature reviews tend not to be as systematic as the other three types. In fact, the lack of systematization in conventional literature synthesis was the reason for the development of more systematic quantitative [17] , [20] and qualitative [45] – [46] , [61] approaches. Some authors in the field [18] have clarified processes for integrative reviews making them more systematic and rigorous, but most conventional syntheses remain relatively unsystematic in comparison with other types.

4.3.2. Complexity of the process

Some synthesis processes are considerably more complex than others. Methodologies with clearly defined steps are arguably less complex than the more flexible and emergent ones. We know that any study encounters challenges and it is rare that a pre-determined research protocol can be followed exactly as intended. Not even the rigorous methods associated with Cochrane [81] systematic reviews and meta-analyses are always implemented exactly as intended. Even when dealing with numbers rather than words, interpretation is always part of the process. Our collective experience suggests that new methodologies (e.g., meta-narrative synthesis and realist synthesis) that integrate different data types and methods are more complex than conventional reviews or the rapid and scoping reviews.

4.4. Product

The products of research syntheses usually take three distinct formats (see Table 1 and Additional File 1 for further details). The first representation is in tables, charts, graphical displays, diagrams and maps as seen in integrative, scoping and rapid reviews, meta-analyses, and critical interpretive syntheses. The second type of synthesis product is the use of mathematical scores. Summary statements of effectiveness are mathematically displayed in meta-analyses (as an effect size), systematic reviews, and rapid reviews (statistical significance).

The third synthesis product may be a theory or theoretical framework. A mid-range theory can be produced from formal grounded theory, meta-study, meta-ethnography, and realist synthesis. Theoretical/conceptual frameworks or conceptual maps may be created in meta-narrative and critical interpretive syntheses, and integrative reviews. Concepts for use within theories are produced in concept analysis. While these three product types span the categories of research synthesis, narrative description and summary is used to present the products resulting from all methodologies.

4.5. Consideration of context

There are diverse ways that context is considered in the four broad categories of synthesis. Context may be considered to the extent that it features within primary studies for the purpose of the review. Context may also be understood as an integral aspect of both the phenomenon under study and the synthesis methodology (e.g., realist synthesis). Quantitative systematic reviews and meta-analyses have typically been conducted on studies using experimental and quasi-experimental designs and more recently observational studies, which control for contextual features to allow for understanding of the ‘true’ effect of the intervention [94] .

More recently, systematic reviews have included covariates or mediating variables (i.e., contextual factors) to help explain variability in the results across studies [27] . Context, however, is usually handled in the narrative discussion of findings rather than in the synthesis itself. This lack of attention to context has been one criticism leveled against systematic reviews and meta-analyses, which restrict the types of research designs that are considered [e.g., [95] ].

When conventional literature reviews incorporate studies that deal with context, there is a place for considering contextual influences on the intervention or phenomenon. Reviews of quantitative experimental studies tend to be devoid of contextual considerations since the original studies are similarly devoid, but context might figure prominently in a literature review that incorporates both quantitative and qualitative studies.

Qualitative syntheses have been conducted on the contextual features of a particular phenomenon [33] . Paterson et al. [54] advise researchers to attend to how context may have influenced the findings of particular primary studies. In qualitative analysis, contextual features may form categories by which the data can be compared and contrasted to facilitate interpretation. Because qualitative research is often conducted to understand a phenomenon as a whole, context may be a focus, although this varies with the qualitative methodology. At the same time, the findings in a qualitative synthesis are abstracted from the original reports and taken to a higher level of conceptualization, thus removing them from the original context.

Meta-narrative synthesis [67] , [84] , because it draws on diverse research traditions and methodologies, may incorporate context into the analysis and findings. There is not, however, an explicit step in the process that directs the analyst to consider context. Generally, the research question guiding the synthesis is an important factor in whether context will be a focus.

More recent iterations of concept analysis [47] , [96] – [97] explicitly consider context reflecting the assumption that a concept's meaning is determined by its context. Morse [47] points out, however, that Wilson's [98] approach to concept analysis, and those based on Wilson [e.g., [45] ], identify attributes that are devoid of context, while Rodgers' [96] , [99] evolutionary method considers context (e.g., antecedents, consequences, and relationships to other concepts) in concept development.

Realist synthesis [69] considers context as integral to the study. It draws on a critical realist logic of inquiry grounded in the work of Bhaskar [100] , who argues that empirical co-occurrence of events is insufficient for inferring causation. One must identify generative mechanisms whose properties are causal and, depending on the situation, may nor may not be activated [94] . Context interacts with program/intervention elements and thus cannot be differentiated from the phenomenon [69] . This approach synthesizes evidence on generative mechanisms and analyzes contextual features that activate them; the result feeds back into the context. The focus is on what works, for whom, under what conditions, why and how [68] .

4.6. Underlying Philosophical and Theoretical Assumptions

When we began our review, we ‘assumed’ that the assumptions underlying synthesis methodologies would be a distinguishing characteristic of synthesis types, and that we could compare the various types on their assumptions, explicit or implicit. We found, however, that many authors did not explicate the underlying assumptions of their methodologies, and it was difficult to infer them. Kirkevold [101] has argued that integrative reviews need to be carried out from an explicit philosophical or theoretical perspective. We argue this should be true for all types of synthesis.

Authors of some emerging synthesis approaches have been very explicit about their assumptions and philosophical underpinnings. An implicit assumption of most emerging synthesis methodologies is that quantitative systematic reviews and meta-analyses have limited utility in some fields [e.g., in public health – [13] , [102] ] and for some kinds of review questions like those about feasibility and appropriateness versus effectiveness [103] – [104] . They also assume that ontologically and epistemologically, both kinds of data can be combined. This is a significant debate in the literature because it is about the commensurability of overarching paradigms [105] but this is beyond the scope of this review.

Realist synthesis is philosophically grounded in critical realism or, as noted above, a realist logic of inquiry [93] , [99] , [106] – [107] . Key assumptions regarding the nature of interventions that inform critical realism have been described above in the section on context. See Pawson et al. [106] for more information on critical realism, the philosophical basis of realist synthesis.

Meta-narrative synthesis is explicitly rooted in a constructivist philosophy of science [108] in which knowledge is socially constructed rather than discovered, and what we take to be ‘truth’ is a matter of perspective. Reality has a pluralistic and plastic character, and there is no pre-existing ‘real world’ independent of human construction and language [109] . See Greenhalgh et al. [67] , [85] and Greenhalgh & Wong [97] for more discussion of the constructivist basis of meta-narrative synthesis.

In the case of purely quantitative or qualitative syntheses, it may be an easier matter to uncover unstated assumptions because they are likely to be shared with those of the primary studies in the genre. For example, grounded formal theory shares the philosophical and theoretical underpinnings of grounded theory, rooted in the theoretical perspective of symbolic interactionism [110] – [111] and the philosophy of pragmatism [87] , [112] – [114] .

As with meta-narrative synthesis, meta-study developers identify constructivism as their interpretive philosophical foundation [54] , [88] . Epistemologically, constructivism focuses on how people construct and re-construct knowledge about a specific phenomenon, and has three main assumptions: (1) reality is seen as multiple, at times even incompatible with the phenomenon under consideration; (2) just as primary researchers construct interpretations from participants' data, meta-study researchers also construct understandings about the primary researchers' original findings. Thus, meta-synthesis is a construction of a construction, or a meta-construction; and (3) all constructions are shaped by the historical, social and ideological context in which they originated [54] . The key message here is that reports of any synthesis would benefit from an explicit identification of the underlying philosophical perspectives to facilitate a better understanding of the results, how they were derived, and how they are being interpreted.

4.7. Unit of Analysis

The unit of analysis for each category of review is generally distinct. For the emerging synthesis approaches, the unit of analysis is specific to the intention. In meta-narrative synthesis it is the storyline in diverse research traditions; in rapid review or scoping review, it depends on the focus but could be a concept; and in realist synthesis, it is the theories rather than programs that are the units of analysis. The elements of theory that are important in the analysis are mechanisms of action, the context, and the outcome [107] .

For qualitative synthesis, the units of analysis are generally themes, concepts or theories, although in meta-study, the units of analysis can be research findings (“meta-data-analysis”), research methods (“meta-method”) or philosophical/theoretical perspectives (“meta-theory”) [54] . In quantitative synthesis, the units of analysis range from specific statistics for systematic reviews to effect size of the intervention for meta-analysis. More recently, some systematic reviews focus on theories [115] – [116] , therefore it depends on the research question. Similarly, within conventional literature synthesis the units of analysis also depend on the research purpose, focus and question as well as on the type of research methods incorporated into the review. What is important in all research syntheses, however, is that the unit of analysis needs to be made explicit. Unfortunately, this is not always the case.

4.8. Strengths and Limitations

In this section, we discuss the overarching strengths and limitations of synthesis methodologies as a whole and then highlight strengths and weaknesses across each of our four categories of synthesis.

4.8.1. Strengths of Research Syntheses in General

With the vast proliferation of research reports and the increased ease of retrieval, research synthesis has become more accessible providing a way of looking broadly at the current state of research. The availability of syntheses helps researchers, practitioners, and policy makers keep up with the burgeoning literature in their fields without which evidence-informed policy or practice would be difficult. Syntheses explain variation and difference in the data helping us identify the relevance for our own situations; they identify gaps in the literature leading to new research questions and study designs. They help us to know when to replicate a study and when to avoid excessively duplicating research. Syntheses can inform policy and practice in a way that well-designed single studies cannot; they provide building blocks for theory that helps us to understand and explain our phenomena of interest.

4.8.2. Limitations of Research Syntheses in General

The process of selecting, combining, integrating, and synthesizing across diverse study designs and data types can be complex and potentially rife with bias, even with those methodologies that have clearly defined steps. Just because a rigorous and standardized approach has been used does not mean that implicit judgements will not influence the interpretations and choices made at different stages.

In all types of synthesis, the quantity of data can be considerable, requiring difficult decisions about scope, which may affect relevance. The quantity of available data also has implications for the size of the research team. Few reviews these days can be done independently, in particular because decisions about inclusion and exclusion may require the involvement of more than one person to ensure reliability.

For all types of synthesis, it is likely that in areas with large, amorphous, and diverse bodies of literature, even the most sophisticated search strategies will not turn up all the relevant and important texts. This may be more important in some synthesis methodologies than in others, but the omission of key documents can influence the results of all syntheses. This issue can be addressed, at least in part, by including a library scientist on the research team as required by some funding agencies. Even then, it is possible to miss key texts. In this review, for example, because none of us are trained in or conduct meta-analyses, we were not even aware that we had missed some new developments in this field such as meta-regression [117] – [118] , network meta-analysis [119] – [121] , and the use of individual patient data in meta-analyses [122] – [123] .

One limitation of systematic reviews and meta-analyses is that they rapidly go out of date. We thought this might be true for all types of synthesis, although we wondered if those that produce theory might not be somewhat more enduring. We have not answered this question but it is open for debate. For all types of synthesis, the analytic skills and the time required are considerable so it is clear that training is important before embarking on a review, and some types of review may not be appropriate for students or busy practitioners.

Finally, the quality of reporting in primary studies of all genres is variable so it is sometimes difficult to identify aspects of the study essential for the synthesis, or to determine whether the study meets quality criteria. There may be flaws in the original study, or journal page limitations may necessitate omitting important details. Reporting standards have been developed for some types of reviews (e.g., systematic review, meta-analysis, meta-narrative synthesis, realist synthesis); but there are no agreed upon standards for qualitative reviews. This is an important area for development in advancing the science of research synthesis.

4.8.3. Strengths and Limitations of the Four Synthesis Types

The conventional literature review and now the increasingly common integrative review remain important and accessible approaches for students, practitioners, and experienced researchers who want to summarize literature in an area but do not have the expertise to use one of the more complex methodologies. Carefully executed, such reviews are very useful for synthesizing literature in preparation for research grants and practice projects. They can determine the state of knowledge in an area and identify important gaps in the literature to provide a clear rationale or theoretical framework for a study [14] , [18] . There is a demand, however, for more rigour, with more attention to developing comprehensive search strategies and more systematic approaches to combining, integrating, and synthesizing the findings.

Generally, conventional reviews include diverse study designs and data types that facilitate comprehensiveness, which may be a strength on the one hand, but can also present challenges on the other. The complexity inherent in combining results from studies with diverse methodologies can result in bias and inaccuracies. The absence of clear guidelines about how to synthesize across diverse study types and data [18] has been a challenge for novice reviewers.

Quantitative systematic reviews and meta-analyses have been important in launching the field of evidence-based healthcare. They provide a systematic, orderly and auditable process for conducting a review and drawing conclusions [25] . They are arguably the most powerful approaches to understanding the effectiveness of healthcare interventions, especially when intervention studies on the same topic show very different results. When areas of research are dogged by controversy [25] or when study results go against strongly held beliefs, such approaches can reduce the uncertainty and bring strong evidence to bear on the controversy.

Despite their strengths, they also have limitations. Systematic reviews and meta-analyses do not provide a way of including complex literature comprising various types of evidence including qualitative studies, theoretical work, and epidemiological studies. Only certain types of design are considered and qualitative data are used in a limited way. This exclusion limits what can be learned in a topic area.

Meta-analyses are often not possible because of wide variability in study design, population, and interventions so they may have a narrow range of utility. New developments in meta-analysis, however, can be used to address some of these limitations. Network meta-analysis is used to explore relative efficacy of multiple interventions, even those that have never been compared in more conventional pairwise meta-analyses [121] , allowing for improved clinical decision making [120] . The limitation is that network meta-analysis has only been used in medical/clinical applications [119] and not in public health. It has not yet been widely accepted and many methodological challenges remain [120] – [121] . Meta-regression is another development that combines meta-analytic and linear regression principles to address the fact that heterogeneity of results may compromise a meta-analysis [117] – [118] . The disadvantage is that many clinicians are unfamiliar with it and may incorrectly interpret results [117] .

Some have accused meta-analysis of combining apples and oranges [124] raising questions in the field about their meaningfulness [25] , [28] . More recently, the use of individual rather than aggregate data has been useful in facilitating greater comparability among studies [122] . In fact, Tomas et al. [123] argue that meta-analysis using individual data is now the gold standard although access to the raw data from other studies may be a challenge to obtain.

The usefulness of systematic reviews in synthesizing complex health and social interventions has also been challenged [102] . It is often difficult to synthesize their findings because such studies are “epistemologically diverse and methodologically complex” [ [69] , p.21]. Rigid inclusion/exclusion criteria may allow only experimental or quasi-experimental designs into consideration resulting in lost information that may well be useful to policy makers for tailoring an intervention to the context or understanding its acceptance by recipients.

Qualitative syntheses may be the type of review most fraught with controversy and challenge, while also bringing distinct strengths to the enterprise. Although these methodologies provide a comprehensive and systematic review approach, they do not generally provide definitive statements about intervention effectiveness. They do, however, address important questions about the development of theoretical concepts, patient experiences, acceptability of interventions, and an understanding about why interventions might work.

Most qualitative syntheses aim to produce a theoretically generalizable mid-range theory that explains variation across studies. This makes them more useful than single primary studies, which may not be applicable beyond the immediate setting or population. All provide a contextual richness that enhances relevance and understanding. Another benefit of some types of qualitative synthesis (e.g., grounded formal theory) is that the concept of saturation provides a sound rationale for limiting the number of texts to be included thus making reviews potentially more manageable. This contrasts with the requirements of systematic reviews and meta-analyses that require an exhaustive search.

Qualitative researchers debate about whether the findings of ontologically and epistemological diverse qualitative studies can actually be combined or synthesized [125] because methodological diversity raises many challenges for synthesizing findings. The products of different types of qualitative syntheses range from theory and conceptual frameworks, to themes and rich descriptive narratives. Can one combine the findings from a phenomenological study with the theory produced in a grounded theory study? Many argue yes, but many also argue no.

Emerging synthesis methodologies were developed to address some limitations inherent in other types of synthesis but also have their own issues. Because each type is so unique, it is difficult to identify overarching strengths of the entire category. An important strength, however, is that these newer forms of synthesis provide a systematic and rigorous approach to synthesizing a diverse literature base in a topic area that includes a range of data types such as: both quantitative and qualitative studies, theoretical work, case studies, evaluations, epidemiological studies, trials, and policy documents. More than conventional literature reviews and systematic reviews, these approaches provide explicit guidance on analytic methods for integrating different types of data. The assumption is that all forms of data have something to contribute to knowledge and theory in a topic area. All have a defined but flexible process in recognition that the methods may need to shift as knowledge develops through the process.

Many emerging synthesis types are helpful to policy makers and practitioners because they are usually involved as team members in the process to define the research questions, and interpret and disseminate the findings. In fact, engagement of stakeholders is built into the procedures of the methods. This is true for rapid reviews, meta-narrative syntheses, and realist syntheses. It is less likely to be the case for critical interpretive syntheses.

Another strength of some approaches (realist and meta-narrative syntheses) is that quality and publication standards have been developed to guide researchers, reviewers, and funders in judging the quality of the products [108] , [126] – [127] . Training materials and online communities of practice have also been developed to guide users of realist and meta-narrative review methods [107] , [128] . A unique strength of critical interpretive synthesis is that it takes a critical perspective on the process that may help reconceptualize the data in a way not considered by the primary researchers [72] .

There are also challenges of these new approaches. The methods are new and there may be few published applications by researchers other than the developers of the methods, so new users often struggle with the application. The newness of the approaches means that there may not be mentors available to guide those unfamiliar with the methods. This is changing, however, and the number of applications in the literature is growing with publications by new users helping to develop the science of synthesis [e.g., [129] ]. However, the evolving nature of the approaches and their developmental stage present challenges for novice researchers.

4.9. When to Use Each Approach

Choosing an appropriate approach to synthesis will depend on the question you are asking, the purpose of the review, and the outcome or product you want to achieve. In Additional File 1 , we discuss each of these to provide guidance to readers on making a choice about review type. If researchers want to know whether a particular type of intervention is effective in achieving its intended outcomes, then they might choose a quantitative systemic review with or without meta-analysis, possibly buttressed with qualitative studies to provide depth and explanation of the results. Alternately, if the concern is about whether an intervention is effective with different populations under diverse conditions in varying contexts, then a realist synthesis might be the most appropriate.

If researchers' concern is to develop theory, they might consider qualitative syntheses or some of the emerging syntheses that produce theory (e.g., critical interpretive synthesis, realist review, grounded formal theory, qualitative meta-synthesis). If the aim is to track the development and evolution of concepts, theories or ideas, or to determine how an issue or question is addressed across diverse research traditions, then meta-narrative synthesis would be most appropriate.

When the purpose is to review the literature in advance of undertaking a new project, particularly by graduate students, then perhaps an integrative review would be appropriate. Such efforts contribute towards the expansion of theory, identify gaps in the research, establish the rationale for studying particular phenomena, and provide a framework for interpreting results in ways that might be useful for influencing policy and practice.

For researchers keen to bring new insights, interpretations, and critical re-conceptualizations to a body of research, then qualitative or critical interpretive syntheses will provide an inductive product that may offer new understandings or challenges to the status quo. These can inform future theory development, or provide guidance for policy and practice.

5. Discussion

What is the current state of science regarding research synthesis? Public health, health care, and social science researchers or clinicians have previously used all four categories of research synthesis, and all offer a suitable array of approaches for inquiries. New developments in systematic reviews and meta-analysis are providing ways of addressing methodological challenges [117] – [123] . There has also been significant advancement in emerging synthesis methodologies and they are quickly gaining popularity. Qualitative meta-synthesis is still evolving, particularly given how new it is within the terrain of research synthesis. In the midst of this evolution, outstanding issues persist such as grappling with: the quantity of data, quality appraisal, and integration with knowledge translation. These topics have not been thoroughly addressed and need further debate.

5.1. Quantity of Data

We raise the question of whether it is possible or desirable to find all available studies for a synthesis that has this requirement (e.g., meta-analysis, systematic review, scoping, meta-narrative synthesis [25] , [27] , [63] , [67] , [84] – [85] ). Is the synthesis of all available studies a realistic goal in light of the burgeoning literature? And how can this be sustained in the future, particularly as the emerging methodologies continue to develop and as the internet facilitates endless access? There has been surprisingly little discussion on this topic and the answers will have far-reaching implications for searching, sampling, and team formation.

Researchers and graduate students can no longer rely on their own independent literature search. They will likely need to ask librarians for assistance as they navigate multiple sources of literature and learn new search strategies. Although teams now collaborate with library scientists, syntheses are limited in that researchers must make decisions on the boundaries of the review, in turn influencing the study's significance. The size of a team may also be pragmatically determined to manage the search, extraction, and synthesis of the burgeoning data. There is no single answer to our question about the possibility or necessity of finding all available articles for a review. Multiple strategies that are situation specific are likely to be needed.

5.2. Quality Appraisal

While the issue of quality appraisal has received much attention in the synthesis literature, scholars are far from resolution. There may be no agreement about appraisal criteria in a given tradition. For example, the debate rages over the appropriateness of quality appraisal in qualitative synthesis where there are over 100 different sets of criteria and many do not overlap [49] . These differences may reflect disciplinary and methodological orientations, but diverse quality appraisal criteria may privilege particular types of research [49] . The decision to appraise is often grounded in ontological and epistemological assumptions. Nonetheless, diversity within and between categories of synthesis is likely to continue unless debate on the topic of quality appraisal continues and evolves toward consensus.

5.3. Integration with Knowledge Translation

If research syntheses are to make a difference to practice and ultimately to improve health outcomes, then we need to do a better job of knowledge translation. In the Canadian Institutes of Health Research (CIHR) definition of knowledge translation (KT), research or knowledge synthesis is an integral component [130] . Yet, with few exceptions [131] – [132] , very little of the research synthesis literature even mentions the relationship of synthesis to KT nor does it discuss strategies to facilitate the integration of synthesis findings into policy and practice. The exception is in the emerging synthesis methodologies, some of which (e.g., realist and meta-narrative syntheses, scoping reviews) explicitly involve stakeholders or knowledge users. The argument is that engaging them in this way increases the likelihood that the knowledge generated will be translated into policy and practice. We suggest that a more explicit engagement with knowledge users in all types of synthesis would benefit the uptake of the research findings.

Research synthesis neither makes research more applicable to practice nor ensures implementation. Focus must now turn seriously towards translation of synthesis findings into knowledge products that are useful for health care practitioners in multiple areas of practice and develop appropriate strategies to facilitate their use. The burgeoning field of knowledge translation has, to some extent, taken up this challenge; however, the research-practice gap continues to plague us [133] – [134] . It is a particular problem for qualitative syntheses [131] . Although such syntheses have an important place in evidence-informed practice, little effort has gone into the challenge of translating the findings into useful products to guide practice [131] .

5.4. Limitations

Our study took longer than would normally be expected for an integrative review. Each of us were primarily involved in our own dissertations or teaching/research positions, and so this study was conducted ‘off the sides of our desks.’ A limitation was that we searched the literature over the course of 4 years (from 2008–2012), necessitating multiple search updates. Further, we did not do a comprehensive search of the literature after 2012, thus the more recent synthesis literature was not systematically explored. We did, however, perform limited database searches from 2012–2015 to keep abreast of the latest methodological developments. Although we missed some new approaches to meta-analysis in our search, we did not find any new features of the synthesis methodologies covered in our review that would change the analysis or findings of this article. Lastly, we struggled with the labels used for the broad categories of research synthesis methodology because of our hesitancy to reinforce the divide between quantitative and qualitative approaches. However, it was very difficult to find alternative language that represented the types of data used in these methodologies. Despite our hesitancy in creating such an obvious divide, we were left with the challenge of trying to find a way of characterizing these broad types of syntheses.

6. Conclusion

Our findings offer methodological clarity for those wishing to learn about the broad terrain of research synthesis. We believe that our review makes transparent the issues and considerations in choosing from among the four broad categories of research synthesis. In summary, research synthesis has taken its place as a form of research in its own right. The methodological terrain has deep historical roots reaching back over the past 200 years, yet research synthesis remains relatively new to public health, health care, and social sciences in general. This is rapidly changing. New developments in systematic reviews and meta-analysis, and the emergence of new synthesis methodologies provide a vast array of options to review the literature for diverse purposes. New approaches to research synthesis and new analytic methods within existing approaches provide a much broader range of review alternatives for public health, health care, and social science students and researchers.

Acknowledgments

KSM is an assistant professor in the Faculty of Nursing at the University of Alberta. Her work on this article was largely conducted as a Postdoctoral Fellow, funded by KRESCENT (Kidney Research Scientist Core Education and National Training Program, reference #KRES110011R1) and the Faculty of Nursing at the University of Alberta.

MM's work on this study over the period of 2008-2014 was supported by a Canadian Institutes of Health Research Applied Public Health Research Chair Award (grant #92365).

We thank Rachel Spanier who provided support with reference formatting.

List of Abbreviations (in Additional File 1 )

Conflict of interest: The authors declare that they have no conflicts of interest in this article.

Authors' contributions: KSM co-designed the study, collected data, analyzed the data, drafted/revised the manuscript, and managed the project.

MP contributed to searching the literature, developing the analytic framework, and extracting data for the Additional File.

JB contributed to searching the literature, developing the analytic framework, and extracting data for the Additional File.

WN contributed to searching the literature, developing the analytic framework, and extracting data for the Additional File.

All authors read and approved the final manuscript.

Additional Files: Additional File 1 – Selected Types of Research Synthesis

This Additional File is our dataset created to organize, analyze and critique the literature that we synthesized in our integrative review. Our results were created based on analysis of this Additional File.

Literature Reviews

• Introduction
• Tutorials and resources
• Step 1: Literature search
• Step 2: Analysis, synthesis, critique
• Step 3: Writing the review

If you need any assistance, please contact the library staff at the Georgia Tech Library Help website . 

Analysis, synthesis, critique

Literature reviews build a story. You are telling the story about what you are researching. Therefore, a literature review is a handy way to show that you know what you are talking about. To do this, here are a few important skills you will need.

Skill #1: Analysis

Analysis means that you have carefully read a wide range of the literature on your topic and have understood the main themes, and identified how the literature relates to your own topic. Carefully read and analyze the articles you find in your search, and take notes. Notice the main point of the article, the methodologies used, what conclusions are reached, and what the main themes are. Most bibliographic management tools have capability to keep notes on each article you find, tag them with keywords, and organize into groups.

Skill #2: Synthesis

After you’ve read the literature, you will start to see some themes and categories emerge, some research trends to emerge, to see where scholars agree or disagree, and how works in your chosen field or discipline are related. One way to keep track of this is by using a Synthesis Matrix .

Skill #3: Critique

As you are writing your literature review, you will want to apply a critical eye to the literature you have evaluated and synthesized. Consider the strong arguments you will make contrasted with the potential gaps in previous research. The words that you choose to report your critiques of the literature will be non-neutral. For instance, using a word like “attempted” suggests that a researcher tried something but was not successful. For example: 

There were some attempts by Smith (2012) and Jones (2013) to integrate a new methodology in this process.

On the other hand, using a word like “proved” or a phrase like “produced results” evokes a more positive argument. For example:

The new methodologies employed by Blake (2014) produced results that provided further evidence of X.

In your critique, you can point out where you believe there is room for more coverage in a topic, or further exploration in in a sub-topic.

Need more help?

If you are looking for more detailed guidance about writing your dissertation, please contact the folks in the Georgia Tech Communication Center .

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Writing a Literature Review

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

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

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

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

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

What are the parts of a lit review?

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

Introduction:

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

Conclusion:

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

How should I organize my lit review?

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

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

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

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

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

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

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

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

University of Tasmania, Australia

Literature reviews.

• What is a literature review?
• How to develop a researchable question
• How to find the literature
• Taking notes
• How to bring it all together: examples, templates, links, guides

Preview the text to check for relevance. 

• the abstract
• introduction
• look at any charts, tables, graphs, diagrams

Check the number of times the article has been cited by others. The more times cited, the more important it might be. 

Read more deeply and let this guide the development of your question.

You may find that the more you read, your question changes or you discover a bigger topic or subtopics. 

Do not waste your time using a highlighter. Annotate the page and take notes. 

There are no shortcuts in this part of the process. 

For more information on managing your reading, go to the Study Toolkit in MyLO and check out the Academic Reading  and Writing module. 

Taking Notes

Use a synthesis matrix for note taking. This table c an be as simple or as complicated as you need

Advantages of using a synthesis matrix:

• allows you to  sort the ideas and thoughts while analysing and synthesising the research.
• helps make planning the structure and paragraph order easier 
• allows for paraphrasing and summarising before actually writing
• provides a clearer view of the relationship between different sources
• aids in identifying themes and patterns in the findings and conclusions.
• gives a glance view of each area under scrutiny

  The organisation/headings will change depending on the focus of your review. 

Using a spreadsheet will also help organise your reading and matrix. 

You will find some examples of a synthesis matrix to download at the bottom of this page. 

Example 1. 

C. Hartigan University of Tasmania

Example 2: Organised by themes.

from:  The Thesis Whisperer:Using a matrix to organise your notes

Example 3: Literature Review preparation.

Watch this short clip for some more ideas.  ( N.B. Ignore the APA referencing in this clip)

• Synthesis matrix
• Literature Review Prep: Synthesis matrix: Johns Hopkins University
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• Open access
• Published: 21 March 2022

Facilitators and barriers for lifestyle change in people with prediabetes: a meta-synthesis of qualitative studies

• Gyri Skoglund 1 ,
• Birgitta Blakstad Nilsson 1 , 2 ,
• Cecilie Fromholt Olsen 1 ,
• Astrid Bergland 1 &
• Gunvor Hilde 1  

BMC Public Health volume  22 , Article number:  553 ( 2022 ) Cite this article

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The increasing prevalence of type 2 diabetes worldwide is a major global public health concern. Prediabetes is a reversible condition and is seen as the critical phase for the prevention of type 2 diabetes. The aim of this study is to identify and synthesize current evidence on the perceived barriers and facilitators of lifestyle change among people with prediabetes in terms of both initial change and lifestyle change maintenance.

A systematic literature search in six bibliographic databases was conducted in April 2021. Potential studies were assessed for eligibility based on pre-set criteria. Quality appraisal was done on the included studies, and the thematic synthesis approach was applied to synthesize and analyse the data from the included studies.

Twenty primary studies were included, containing the experiences of 552 individuals. Thirteen studies reported participants perceived facilitators and barriers of lifestyle change when taking part in community-based lifestyle intervention programs, while seven studies reported on perceived facilitators and barriers of lifestyle change through consultations with health care professionals (no intervention involved).

Three analytical themes illuminating perceived barriers and facilitators for lifestyle change were identified: 1) the individual’s evaluation of the importance of initiating lifestyle change , 2) the second theme was strategies and coping mechanisms for maintaining lifestyle changes and 3) the last theme was the significance of supportive relations and environments in initiating and maintaining lifestyle change .

Awareness of prediabetes and the perception of its related risks affects the motivation for lifestyle change in people at risk of type 2 diabetes; but this does not necessarily lead to lifestyle changes. Facilitators and barriers of lifestyle change are found to be in a complex interplay within multiple ecological levels, including the interpersonal, intrapersonal, environmental and policy level. An integrated understanding and analysis of the perceived barriers and facilitators of lifestyle change might inform people with prediabetes, healthcare professionals, and policy makers in terms of the need for psychological, social, and environmental support for this population.

Peer Review reports

Type 2 diabetes represents a significant global health burden, with great impact on individuals, families, and societies. The prevalence of type 2 diabetes is increasing worldwide. Reports estimate that 578 million people will have diabetes in 2030, and the number will increase by 51% (700 million) in 2045 without urgent and sufficient action [ 1 ]. Considering the growing epidemic of diabetes and its complications, the increasing prevalence of prediabetes is a major global public health concern [ 2 ]. The term prediabetes is used to identify those individuals who are at risk of future diabetes and it is also associated with an increased cardiometabolic risk [ 2 ]. Prediabetes is a condition characterized by elevated blood glucose levels, below the threshold limit for type 2 diabetes but above normal levels, and it is estimated that 70% of individuals with prediabetes will eventually develop diabetes [ 2 , 3 ]. Prediabetes is seen as the critical phase for prevention, as the patients’ condition at this stage is reversible and could therefore serve as a window of opportunity to combat type 2 diabetes [ 3 ].

The risk of developing prediabetes increases with being overweight, living a sedentary lifestyle, age, and having a family history of diabetes [ 4 ]. Lifestyle changes aiming for healthy behaviour in terms of healthy diet, regular physical activity, and maintaining a healthy body weight are the cornerstones of prevention or the delayed onset of type 2 diabetes [ 4 , 5 ]. Weight reduction is shown to be the single-most important factor in reducing diabetes incidence: for every kilogram of weight loss, diabetes incidence has been reduced by 16 percent [ 6 ]. Several studies have shown the efficacy of lifestyle intervention with regards to diabetes prevention, with a relative risk reduction of 36–54% in those with prediabetes [ 7 ]. The positive outcomes of lifestyle changes have been observed in diverse populations [ 7 , 8 ], and diabetes prevention has therefore become a key priority for many nations, forming the basis of many national and international practice guidelines [ 9 , 10 , 11 ]. Although research has shown that lifestyle intervention programs are effective [ 7 , 8 , 12 , 13 ], improvements over the long term have been shown to deteriorate, highlighting challenges with long-term adherence and the maintenance of lifestyle changes [ 5 ]. A systematic review of obesity-related lifestyle change interventions, has shown that health behaviours that are initiated and regulated via autonomous motivation are more likely to be maintained over time through autonomous motivation, self-efficacy, and self-regulation skills [ 14 ].

Theoretical framework

In addition to previous research, the theoretical understanding of lifestyle and behavior change is important. A systematic review by Kwasnicka et al. [ 15 ] identified and synthesized 100 current theoretical explanations for behavioral change and maintenance. The review stated that there are distinct patterns of theoretical explanation for initial change and change maintenance and they highlighted the differential nature and role of five overarching, interconnected themes: maintenance motives, self-regulation, resources (psychological and physical), habits, and environmental and social influences. The individual’s motivation is crucial for behaviour change and maintenance, and motives that initiate change may differ from those maintaining change [ 15 ]. Approaches to initiate behaviour change can include motivation in the form of external pressure or control or the positive use of incentives or rewards, but these approaches are often insufficient in order to enhance maintenance of lifestyle change [ 16 ].

The ecological model

In addition to the theoretical explanations of Kwasnicka et al. [ 15 ] the ecological model can be a helpful framework in understanding the facilitators and barriers of lifestyle change in people with prediabetes in a larger context, and within a comprehensive understanding of the multiple determinants of health behaviours [ 17 ]. Health behaviours are dynamic, varying over individual’s lifespans, across settings, and over time [ 18 ], and the complex interplay of facilitators and barriers for healthy behaviours make lifestyle changes challenging to perform [ 19 , 20 ]. According to ecological models of health there are multiple levels that influence on health behaviour and these are the intrapersonal, interpersonal, environmental, and societal level [ 21 ] and the barriers and facilitators for healthy behaviours constantly interact across all these levels [ 17 ]. In addition to the individual motivation and skills for lifestyle change, the ecological perspective further addresses the environmental aspect in understanding the facilitators and barriers in play, and how they impact on lifestyle change and maintenance [ 21 ].

In a review of qualitative studies by Kelly et al. [ 22 ] on the facilitators and barriers for healthy behaviours in midlife (40–64 years), they found that examples of consistent barriers included entrenched attitudes and behaviours, a lack of knowledge, a lack of time, lack of access to transport to facilities and resources, restrictions in the physical environment, and financial costs. The facilitators of healthy behaviour included enjoyment, health benefits, social support, and clear messages. Among the included qualitative studies, however, there were none specifically addressing those with prediabetes.

Former research has found that people who were aware of their prediabetes status were more likely to report a perceived threat of developing diabetes, but they did not report increased engagement in health behaviours [ 23 , 24 , 25 ]. This indicates the need to better understand what characterizes the facilitators and barriers for lifestyle change and maintenance in people with prediabetes, and by identifying this, research on lifestyle change and the implementation of health interventions can be optimally tailored and effective.

Aim of the meta-synthesis

To our knowledge, no previous meta-syntheses examining perceived barriers and facilitators of lifestyle change among people at risk of developing type 2 diabetes have been performed. Hence, the current study aimed to identify and synthesize current qualitative evidence on facilitators and barriers of initial lifestyle change and maintenance based on the experiences of people with prediabetes.

Meta-synthesis, or qualitative evidence synthesis, is the synthesis of primary research studies that relate to a specific topic in order to arrive at a new or enhanced understanding of a specific phenomenon being explored [ 26 ]. One approach to the synthesis of the findings of qualitative research is thematic synthesis as described by Thomas and Harden [ 27 ]. This method combines approaches from both meta-ethnography and grounded theory and was originally developed to guide review of intervention needs, appropriateness, and effectiveness [ 26 , 28 ]. The approach of thematic synthesis is based on the method of thematic analysis used in primary qualitative research, however thematic synthesis enables new insights, interpretations and theories to be developed that has not been seen in the primary studies [ 29 ]. This meta-synthesis was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) (ID: CRD42020180051). We followed the Enhancing Transparency of Reporting the Synthesis of Qualitative Research (ENTREQ) framework [ 30 ].

Search strategy

Systematic comprehensive literature searches were conducted in six bibliographical databases: Medline, Embase PsychInfo, CINAHL, Web of Science, and Cochrane. This choice of databases is in line with suggestions presented in the systematic review on optimal database combinations for literature searches in systematic reviews [ 31 ]. The searches were done by the first author (GS) with close assistance from a health research librarian. The search strategy aimed to cover primary studies addressing the study population of interest, phenomena of interest, and setting of interest; we limited the search to qualitative studies (see Additional file 1 ). The literature search was initially developed in Medline and afterwards translated to the other databases’ search syntax with both text words and adapted thesaurus terms. We also screened the reference lists of the included studies and related systematic reviews to identify further papers. Non-English studies were excluded to prevent cultural and linguistic bias in translations, and there was no publication year limit. The review includes data for studies identified in searches up to April 21st, 2021.

Selection criteria

The primary studies were selected according to the study population, phenomenon of interest, setting and study design. An explicit description of criteria for inclusion and exclusion is presented in Table 1 . The phenomenon of interest of this meta-synthesis was facilitators and barriers to lifestyle change and maintenance in people with prediabetes. When selecting the primary studies, we presumed that the facilitators and barriers could be identified from the data in the studies, but it did not necessarily have to be explicitly mentioned. The primary studies included according to the setting criteria, involved several studies where experiences from participation in a structured lifestyle intervention program were reported. The lifestyle interventions described in these studies mainly focused on physical activity and dietary change and weight loss.

One researcher (GS) screened all titles and abstracts retrieved from the literature search results, excluding studies that did not meet the inclusion criteria. The full texts of potentially relevant articles were then screened independently by two authors in groups of pairs (GS and AB, GS and GH, GS and BBN), and additional information was sought from the authors of the full text articles where necessary. If consensus was not reached between the two researchers, a third reviewer was consulted.

Quality appraisal

Two authors in groups of pairs (GS and AB, GS and GH, GS and BBN) conducted a quality assessment of the included studies independently according to the Critical Appraisal Skills Program (CASP) checklist for qualitative research [ 33 ]. The checklist of ten questions allowed for the systematic appraisal of the qualitative research evidence included in our review (Table 2 ). The checklist guides the reviewer when assessing the validity, result and relevance of each study. After this initial independent assessment, the results of the appraisal were discussed, and a third reviewer was consulted to resolve any disagreements. There was an agreement that no studies were to be excluded based on the quality appraisal. However, an assessment of methodological quality would provide transparency and understanding of the relative strength and weaknesses of the body of evidence included [ 29 ].

Data extraction and synthesis

The data extracted from the primary studies included all the text in the studies’ results chapters, including participant quotations. The extracted text was entered verbatim into NVivo Pro 12 (NVivo qualitative data analysis software; Melbourne, Australia: QSR International Pty Ltd., 2018). Each study was read several times to ensure that all the extracted text was related to the perspectives and experiences of people with prediabetes.

We used the thematic synthesis approach by Thomas and Harden [ 27 ], and this involved three main stages:

1) Line-by-line coding of the findings of the primary studies:

Two independent reviewers performed an inductive line-by-line coding of the extracted material. New codes were generated independently of the original codes used in the primary studies. The codes were compared, and all codes that represented similarities across the primary studies and belonged to the same concept were organized into categories.

2) Development of descriptive themes:

Descriptive subthemes were formed through the merging and grouping of categories in an iterative process, staying close to the primary data in the included studies. The primary studies were read and reviewed by GS to ensure that the descriptive themes captured and reflected the depth of the data reported in the primary studies.

3) Development of analytical themes:

The descriptive themes were discussed in the research team in relation to the research question and organized within the main analytical themes. This was an iterative and cyclic process. In the analytical stage of the synthesis, we wanted to go beyond the descriptive findings trying to generate new understanding. After the development of the analytical themes, we related this to a higher-level theoretical framework to illuminate the central themes in the synthesis.

Meta-synthesis researchers’ background and preconceptions

The research team consisted of two PhD students (GS and CFO) and three researchers with a clinical and academic background, all of whom were physiotherapists (AB, GH, and BBN). Although the authors acknowledge that there has been much debate regarding the definition of prediabetes and share some of the expressed concerns in the literature regarding the usefulness of this label [ 54 , 55 ], the present analysis did not assume a critical stance toward this diagnosis, as our main aim was to use it as a descriptive category that would allow us to identify and review the existing literature in this area and on this population. It was the first author’s preunderstanding that risk perception is crucial in the initiation of lifestyle changes and that prediabetes might be a particularly challenging state in this respect. Furthermore, the researchers shared the preunderstanding that lifestyle change is complex and cannot be completely understood within a biomedical perspective. We used reflexive discussions to become aware of these preconceptions and reduce their influence on the analysis. However, in line with the qualitative research paradigm [ 56 ], we also acknowledge that they inevitably influenced the synthesis.

Literature search results

The literature search resulted in 9058 identified studies and, after duplicates were removed, 6035 studies. Titles and abstracts were screened by the first author (GS), and, of these, 54 full-text articles were found to be considered eligible. These were screened by two independent reviewers according to pre-set criteria for inclusion and exclusion, and 20 studies were finally included; see PRISMA flow diagram (Fig.  1 ).

PRISMA Flow Diagram-identification and selection of studies [ 57 ]

Study characteristics

The 20 included studies were published between 2008 and 2021 and involved 552 participants in total. The age of the participants ranged from 21–79 years; 312 participants were women and 240 were men. All participants had been diagnosed with prediabetes within the last year (when the data was collected). Eight studies were from Europe, three from Asia, two from the South Pacific, four from the USA, two from Canada, and one from Africa. Each study was systematically assessed for its research question or statement of purpose, research method, theoretical framework, sample size, and setting. The characteristics of the 20 studies included in the thematic synthesis are presented in Table 3 .

Thirteen studies reported on the participant perceived facilitators and barriers of lifestyle change when taking part in community-based lifestyle intervention programs [ 34 , 36 , 37 , 38 , 39 , 40 , 46 , 47 , 48 , 49 , 50 , 51 , 53 ], while seven studies reported on the participants perceived facilitators and barriers of lifestyle change through consultations with health care providers (no intervention involved) [ 35 , 41 , 42 , 43 , 44 , 45 , 52 ]. Thirteen studies [ 35 , 36 , 37 , 39 , 41 , 45 , 46 , 47 , 48 , 49 , 50 , 52 , 53 ] reported on the barriers and facilitators of lifestyle change and behavioural change maintenance, addressing both exercise and diet (participants exposed to an lifestyle intervention in nine studies, whereas no intervention in four studies), four studies [ 38 , 40 , 42 , 43 ] reported on exercise only (participants exposed to an lifestyle intervention in two studies, whereas no intervention in two), and three studies [ 34 , 44 , 51 ] reported on diet only (participants exposed to an lifestyle intervention in two studies, whereas no intervention in one).

Quality assessment

Of the then criteria used to assess the methodological quality [ 33 ], all the included studies met seven or more of these criteria. Two studies [ 36 , 51 ] were graded with seven out of ten points, three studies [ 37 , 38 , 53 ] were graded with eight points, six studies [ 39 , 41 , 45 , 46 , 47 , 52 ] were graded with nine points and nine studies [ 34 , 35 , 40 , 42 , 43 , 44 , 48 , 49 , 50 ] with ten points (Table 2 ). The relationship between the researcher and participants were one domain that was assessed not to be adequately described in several of the included studies [ 37 , 38 , 39 , 41 , 45 , 47 , 51 , 52 , 53 ].

Thematic synthesis of the qualitative studies

In total 986 codes were recorded from the extracted data, from which eight descriptive themes emerged. From the synthesis and analysis of the included primary studies, three main themes illuminating the perceived barriers and facilitators of lifestyle change among people with prediabetes were identified: 1) the individual’s evaluation of the importance of initiating lifestyle change; 2) strategies and coping mechanisms for maintaining lifestyle change; and 3) the significance of supportive relations and environments in initiating and maintaining lifestyle change (Fig.  2 ).

Emergent descriptive and analytical themes

In general, the primary studies demonstrated that there are multiple barriers and facilitators in the process of lifestyle change, and they exist in a complex interplay. Table 4 presents how the different primary studies are distributed across the main themes and subthemes based on whether they included lifestyle intervention programs or not, and the area of lifestyle change, being exercise or diet, or both. The presentation of the results is supplemented with quotes from participants in the included primary studies.

Theme 1: The individual’s evaluation of the importance of initiating lifestyle change

The first theme focused on the impact of the awareness and perception of risk on the individual’s evaluation of the importance of initiating lifestyle change, specifically considering reactions to the diagnosis of prediabetes and the internal struggle during the process of lifestyle change.

The impact of the awareness and perception of risk when diagnosed with prediabetes

Our analysis revealed that a vital facilitator in healthy lifestyle changes was when people became aware of being at a high risk of developing type 2 diabetes and realized the potential threat to their health. They experienced fear regarding the consequences of disease and facing an uncertain future [ 34 , 36 , 38 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 50 , 52 , 53 ]. Several participants in the primary studies reflected on the experience of having family members diagnosed with diabetes and expressed the desire to stay healthy and alive for their children and grandchildren to not become a burden to their family [ 34 , 36 , 38 , 41 , 43 , 44 , 46 , 47 , 48 ]. For example, one individual said:

There’s a big element of worry . . . like I’m on the train and I can’t stop it. You get that worry of ‘are you going to be able to stop this from getting worse?’ . . . like ‘whoa, what’s going on here?’ . . . I don’t want to become diabetic, that would be my main concern, I don’t want what comes with that. [ 48 ]

Several participants in the reviewed studies were aware of the increased risk of the progression to type 2 diabetes if lifestyle changes were not made and they were determined to stay ahead of their disease development [ 34 , 36 , 38 , 41 , 42 , 43 , 44 , 46 , 47 , 48 , 50 , 53 ]. In one of the included studies, participants reported that, at the time of their prediabetes diagnosis, their health care consultations provided little to no information on how to comprehend and understand the impact of its risk [ 52 ]. Several participants described shock when diagnosed with prediabetes [ 34 , 36 , 38 , 49 , 50 , 52 , 53 ]. For some participants this shock motivated them for lifestyle change, others found it difficult to identify themselves as being in an ‘at risk state’, as this conflicted with their own perceptions of having a healthy lifestyle creating a distance to future risk [ 42 , 45 , 48 , 52 , 53 ]. Hence, the findings illustrated how the recognition of prediabetes as asymptomatic and not associated with a medical condition or equated with severe illness led to a downplaying of the risk by the participants in the reviewed studies [ 42 , 45 , 48 , 52 , 53 ].

The internal struggle in the process of lifestyle change

Feelings of both guilt and self-blame arose with a diagnosis of prediabetes. The findings illustrated this phenomenon by describing how participants in our included studies accepted a personal responsibility for their outcomes [ 34 , 35 , 38 , 39 , 42 , 47 , 48 , 50 , 51 , 52 , 53 ]. In one study, a participant expressed a sense of commitment and personal responsibility to society in terms of lifestyle change and preventive behaviours [ 50 ]. Internal struggles with self-criticism and self-blame, especially when it came to dietary changes, were described by several participants in the included studies as leading to lower self-esteem and a lack of confidence, which, in turn, inhibited the driving force for change [ 35 , 39 , 42 , 47 , 48 , 53 ]. An individual described this feeling in the following way:

How am I going to do this? It seems so overwhelming. I know I should ideally lose a hundred pounds to get back to…my ideal weight, but it seems like such an insurmountable mountain to climb that why even try? [ 48 ]

A recurrent theme in our findings was how the gap between behavioural intentions and actual behaviour change amplified the negative feelings of guilt and self-blame that, in turn, lead to stress [ 34 , 35 , 39 , 48 , 52 , 53 ]. One of the studies demonstrated that stress affected behaviour change in terms of different emotional and cognitive responses for the participants in the included studies, with participants describing how this challenged their self-control, decision-making, and self-regulation [ 53 ]. One participant stated:

Sometimes I get very angry at myself because I don’t have the self-control to say: ‘stop eating that and go and exercise.’ Typically, I intend to do it, but then I feel anxious and I go and eat a pastry or something like that. Then after I feel terrible and I start thinking, how is it possible that I cannot get over this stress? [ 53 ]

Several of the studies described how temptation for sweet foods challenged the participants’ sense of self-control, making it difficult for them to implement healthy changes in their diet [ 34 , 36 , 44 , 45 , 47 , 51 , 52 , 53 ]. One study described how increased awareness regarding the necessity of dietary change created new cravings and temptations [ 53 ]. For some participants, having to reduce sugar and missing the sweet taste of foods were particularly challenging [ 34 , 36 , 45 , 48 , 51 , 53 ], describing it as a feeling of sacrificing the good life [ 45 ].

In some studies, the participants described that the stress and energy involved in making lifestyle changes would compromise their quality of life, also noting that they had greater concerns than progressing to diabetes [ 34 , 39 , 40 , 42 , 47 , 48 , 52 , 53 ]. One participant expressed the following:

I think there’s always a risk, I think there’s always some sort of risk, but it’s a very . . . I put it really on the backburner. If you think of priorities, it’s falling downstairs or tripping over, and I do try and eliminate risk. This is why I’ve started off with this Pilates teacher, which is definitely making me more aware of balance. Diabetes, it doesn’t worry me particularly. [ 52 ]

The importance of internal motivation and positive health feedback

Our findings demonstrated that experienced positive health feedback among the participants facilitated lifestyle change. For example, participants from several of the studies experienced benefits from exercising, such as improved physical condition and mental well-being. This encouraged them and led to a sense of accomplishment [ 41 , 43 , 47 , 49 , 53 ]. Improved physical condition, mental well-being, the enjoyment of different activities, and taking pleasure in nature were described as drivers of the maintenance of exercise change [ 38 , 40 , 41 , 43 , 46 , 47 , 49 , 52 , 53 ]. This sense of overall well-being and enjoyment was depicted as a central autonomous motivation for exercise, and, for many participants, exercise was also connected with being outdoors and taking pleasure in nature [ 38 , 40 , 41 , 43 , 49 ]. Accordingly, one individual described the following:

So, when you go outside to exercise, you feel the sunshine, you breathe in the fresh air, your body will then be good. It is for our wellbeing. [ 43 ]

Several participants in the included studies highlighted the value of former experience with exercise and how this facilitated their self-confidence to seek new activities that gave them further positive experiences with exercise [ 40 , 42 , 43 , 46 , 49 , 52 , 53 ]. Some participants explained that exercise also became integrated into their sense of self when it became a routine and a habit. Being able to identify oneself as a person with an active lifestyle and the desire to be a good role model for one’s children were facilitators for lifestyle change [ 38 , 40 , 47 , 49 ]. Participants also reported experiencing a sense of self-control that strengthened their motivation to adhere to a regular exercise regimen [ 43 , 46 , 50 , 51 ].

As with exercise, receiving positive health feedback from dietary change was described as giving a sense of mastery and self-control that facilitated maintenance. The participants in some of the studies experienced weight loss, a decrease in blood pressure, and a reduction in medication use in terms of dosage, as well as increased energy and improved sleep [ 34 , 42 , 44 , 46 , 51 , 53 ].

Theme 2: Strategies and coping mechanisms for maintaining lifestyle change

The focus in the second theme was on the strategies and coping mechanisms involved in lifestyle change maintenance, including making plans and setting attainable goals and the importance of knowledge and skills in mastering lifestyle change maintenance.

The motivation in making plans and setting goals

Making plans and setting goals were helpful facilitators of initiating and maintaining lifestyle change. Several studies emphasized that the process of guiding one’s own thoughts, behaviours, and feelings was important in order to make more concrete plans and set realistic and specific goals [ 34 , 36 , 38 , 39 , 40 , 41 , 47 , 49 , 51 , 53 ]. One participant noted:

I established a goal. I force myself to run three laps no matter how sluggish I feel. . . If I run today, I feel that I have paid attention to my health and I feel at peace. [ 39 ]

In two of the studies, self-compassion was highlighted as a strategy for making plans and setting goals [ 48 , 49 ]. Being kind to oneself was also put forward as making it easier to set attainable goals and prioritize oneself in finding the space, energy, and time for healthy changes [ 48 , 49 , 52 , 53 ]. Making time for lifestyle change was presented as a challenge in the process of making plans and reaching goals. Obligations regarding time, such as family commitments and workload, were often mentioned as barriers to participants being more physically active [ 34 , 38 , 40 , 41 , 42 , 43 , 46 , 47 , 49 , 50 , 51 , 53 ]. In several studies, female participants described how they found it difficult to find the time for and prioritize exercise when fulfilling their various responsibilities as wives, mothers, daughters, and, in some cases, caregivers [ 42 , 43 , 46 , 47 , 51 , 53 ]. One participant described their obligations as follows:

From Monday to Friday, I’m working . . . then Saturday and weekend I need to run errands for my children, my husband, and on top of that there is the housework. I also need to spend some time to visit my parents. Time is very important to me, I have so many duties and roles to fulfil, my first priority is always my family. [ 43 ]

Male participants, however, more often cited work as their reason for having ‘no time’ [ 43 ]. For example, one explained:

I am always so busy . . . in the evenings there are always papers to look at, I have no time for exercise. . . I simply don’t have the time. [ 41 ]

Knowledge and skills in mastering lifestyle change maintenance

The included studies presented a broad range of accounts about how one strategy for coping with lifestyle changes involves attaining knowledge, competence, and skills regarding exercise and a healthy diet for managing change [ 34 , 35 , 36 , 39 , 41 , 44 , 46 , 47 , 49 , 50 , 51 , 52 , 53 ]. Some of the studies demonstrated how knowledge and understanding affected how the participants behaved, enabling them to re-evaluate former habits [ 35 , 41 , 43 , 44 , 49 , 51 , 52 ].

The importance of skills and competence was highlighted in our included studies [ 43 , 44 , 46 , 47 , 49 , 51 , 53 ], with one woman describing the following:

. . . my cooking is all standard, you add the oil, the salt, and the sauce. But if you ask me to cook healthy food, like reduce the oil, reduce the salt, don’t use the sauce, then I don’t know how to cook already. Also, I have been cooking white rice all my life, now you tell me change to brown or red rice, I don’t know how to cook, how to make it tasty like white rice. [ 44 ]

Health care providers can help people with prediabetes by supplying them with information and guidance that will equip them with the knowledge, competence, and skills they need to facilitate and manage lifestyle changes and the risk they are facing [ 34 , 36 , 37 , 41 , 42 , 46 , 47 , 49 , 50 ]. Specifically, one participant mentioned the following:

It wasn’t stop this, stop that. It was cut down on this, cut down, little steps. . .The favourite saying is ‘little steps.’ And that’s probably one of the most helpful sayings I’ve ever heard. Not trying to do it in a week or two weeks, or two months or three months. It’s over a period of time, you know? [ 34 ]

Because of the perceived complexity of information regarding lifestyle change, several participants emphasized the importance of clarity and simplicity as well as pedagogical and empowering dialogue [ 34 , 35 , 36 , 37 , 41 , 46 , 47 , 49 , 50 ]. Access to information and guidance in developing manageable strategies were also deemed vital for coping with lifestyle changes [ 34 , 35 , 36 , 37 , 41 , 46 , 47 , 49 , 50 ].

Theme 3: The significance of supportive relations and environments in initiating and maintaining lifestyle change

The third theme focuses on the role of supportive relations being support from family, health care providers and peers in initiating and maintaining lifestyle change. In this final theme, supportive environments include external monitoring and support from lifestyle intervention programs, facilitating surroundings, and the availability of health promoting options for lifestyle change.

Family as allies for change and the importance of support from health care providers and peers

In the included studies, the spouse or children of the participants were described as important allies when it came to motivation for initiating and continuing lifestyle changes. Several participants highlighted how support from family members acted as a form of supervision, with family members checking up on them and encouraging shared decisions in facilitating healthy behaviours [ 40 , 42 , 49 , 51 , 53 ]. In terms of making dietary changes, the influence of one’s spouse and children was also noted as playing an important role in whether recommendations from health care providers were met or not. This influence could take the form of informative reminders from family members in meal situations [ 34 , 36 , 44 , 47 , 51 , 53 ]. For example, one woman mentioned:

My children will say, ‘mom that’s salty, don’t eat’ or you know, they will say ‘this is too fat, don’t eat’, you know what I mean? They will remind me and keep a look-out on my diet. [ 44 ]

Acceptance of the necessity of change within the family was another important factor for participants. A mutual understanding of the process of change was described as leading to increased involvement and support from family members, which, in turn motivated and encouraged participants [ 34 , 36 , 42 , 44 , 51 , 53 ]. Some studies also pointed out that family norms regarding being active could be part of participants’ identities and family cultures. In our findings, this was demonstrated to facilitate attempts to make lifestyle changes [ 41 , 43 , 51 , 53 ]. On the other hand, family norms, traditions, and culture could sometimes be barriers to lifestyle change, especially in terms of dietary changes [ 34 , 36 , 44 , 45 , 46 , 51 , 53 ]. The studies found that the participants described social expectations and pressure around providing and being offered foods as a challenge, with family gatherings and parties presented as examples of challenging settings with fewer healthy food options [ 34 , 36 , 44 , 45 , 46 , 51 , 53 ]. In the context of everyday life, food traditions and eating norms in families could also sometimes make dietary change difficult [ 34 , 36 , 44 , 51 , 53 ]. One individual described the following:

My whole family eats white rice since young, it has become a habit, a culture in us. Now say change to brown rice, not easy, it takes time for us to adjust to the new taste of brown rice. [ 44 ]

Receiving support and encouragement and not feeling alone in making lifestyle changes were described as positive effects of joining a group with other people with prediabetes [ 34 , 36 , 37 , 39 , 41 , 48 , 50 ]. Participants specifically described the benefits of sharing their experiences, exchanging ideas and strategies, and being motivated by each other [ 34 , 36 , 37 , 39 , 41 , 48 , 49 , 50 ]. Some participants highlighted that, when participating in a lifestyle program and joining a group with peers, external support from peers led to more physical activity and exercise on their part [ 39 , 41 ]. In one study, female participants described the importance of support from other women in a female-only setting, emphasizing the mutual understanding of barriers and other experiences that are specific to women [ 37 ].

Empowering communication was highlighted by participants in all studies as a key factor facilitating the supportive function of health care providers [ 34 , 36 , 37 , 39 , 41 , 44 , 46 , 47 , 49 , 51 ]. Participants in most of the studies emphasized how health care providers could facilitate lifestyle change [ 34 , 36 , 37 , 39 , 41 , 44 , 46 , 47 , 51 ]. Feeling accountable, receiving trusted communication and care, and being addressed with respect and empathy were also identified as important characteristics of this support [ 34 , 36 , 37 , 38 , 41 , 44 , 46 , 47 ]. One woman, when explaining how her health care professional helped her, stated the following:

It was the way she encouraged me, how she uplifted me. I am so grateful . . . So, I think having the right people at the forefront there just to open you up, you know, and acknowledging where I am at. [ 34 ]

The motivation of external monitoring in maintaining lifestyle change

In several studies, the participants highlighted that a successful facilitator they strongly valued was being monitored in intervention programs during the process of lifestyle change [ 34 , 36 , 37 , 38 , 39 , 40 , 46 , 47 , 49 , 50 ]. Participating in a program imparted a sense of commitment on them, and the participants were held accountable for their attempts to make healthy changes [ 34 , 36 , 37 , 38 , 39 , 40 , 46 , 47 , 49 , 50 ]. Having to report on their progress to a supervisor or having official measurements of their weight loss or improved physical condition taken in the near future, were described as strong motivators encouraging the participants to push themselves [ 36 , 37 , 38 , 40 , 46 , 47 ]. Tailoring lifestyle interventions to individuals also seemed to facilitate the process of making healthy changes. The freedom of choice and flexibility in a tailored program was seen to allow participants to set personalized and meaningful goals [ 34 , 37 , 46 , 47 , 50 ].

Five studies highlighted the importance of technological devices in monitoring healthy lifestyle change and how such devices could provide support for those not participating in a lifestyle intervention program. The data from step-counter technology and the feedback provided from this was described as motivating and inspiring [ 37 , 41 , 49 , 53 ]. For example, a user of a Fitbit stated:

I have a Fitbit that makes it easier, because I like to challenge myself to make sure I get my steps every day. So, lots of times, I’ll get home in the evening and I’ll see them at 9000 steps, and I’ll like go out and walk up and down the driveway. [ 41 ]

The value of using digital tracking and apps to document the process of change and regulate food consumption was also described as an external motivation in terms of dietary change [ 53 ], with one participant expressing the following:

I must not just settle with reducing carbohydrates, but I must, as we say, document it. I had a friend that believed that, for everything you did, you had to keep a record of it and said, ‘It’s like sports; if you don’t keep a record, you’re only practicing. [ 53 ]

In a study that used an online-modality lifestyle intervention program, the participants highlighted the logistical benefits of the flexibility and convenience of a digital follow-up [ 37 ], showing how this could make lifestyle intervention programs more accessible regarding distance and geography or according to work schedule or family obligations.

The availability of health promoting options and facilitating surroundings

Participants described experiencing barriers and facilitators of lifestyle change in their work environments, in their neighbourhoods, in their local communities, and at the societal level [ 34 , 38 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 49 , 50 , 51 , 53 ]. For example, three of the studies described how making healthy changes to one’s diet was challenging when there were limited healthy options at the workplace or local restaurants [ 34 , 44 ]. Several participants cited financial restraints as barriers to lifestyle change [ 34 , 36 , 44 , 45 , 47 , 51 , 53 ], with the high cost of healthy food leading some to choose unhealthy food because it was the more affordable option [ 34 , 36 , 44 , 45 , 47 , 51 , 53 ]. For example, one individual stated:

Look, the barrier to those goal settings is budget, you know . . . So, when you see on TV people saying they’re eating unhealthily, what they’re doing, what we’re doing is we’re eating to a budget planned to survive for the week.... So, don’t go telling poor people ‘you’re going to get diabetes if you eat this and this and this’; so we want you to eat this food, but it’s too expensive for you to buy, you know. [ 36 ]

In several studies, we found that having access to exercise facilities and organized activities in local communities, parks, and green areas made it easier to initiate and maintain physical activity and exercise [ 35 , 38 , 40 , 41 , 43 , 46 , 47 , 49 ]. However, climate and weather conditions could affect access to those spaces and some participants experienced bad weather and climate as a barrier to exercise [ 38 , 40 , 41 , 43 , 46 ]. Having access to nature and outdoor life was also described as an important facilitator for physical activity [ 41 , 43 , 49 ]. Moreover, some participants pointed out that it was too expensive for them to use indoor training facilities. In one study, participants acknowledged a governmental health promotion strategy to lower the cost of accessing different indoor training facilities as a positive solution [ 47 ].

This meta-synthesis aimed to explore, synthesize, and interpret qualitative research on facilitators and barriers of lifestyle change and maintenance among people with prediabetes. In line with the ecological framework, our findings indicate that the relevant barriers and facilitators are found within the intrapersonal, interpersonal, environmental, and policy level. We identified three main themes within these ecological levels being the individual’s evaluation of the importance of lifestyle change, strategies and coping mechanisms for maintaining lifestyle change and the importance of supportive relations and environments in initiating and maintaining lifestyle change. These themes are not independent, they exist in a complex interplay, which our discussion will reflect. In addition to the ecological framework [ 17 , 21 ] the findings will be discussed in light of the central themes in the theoretical explanations of behavioural change maintenance presented in the review by Kwasnicka et al. [ 15 ].

The individual’s evaluation of the importance of initiating lifestyle change

At the intrapersonal level, individual motives are crucial for initiating and maintaining behaviour change and are the drivers of volitional behaviour [ 15 ]. Our findings indicate that getting the diagnosis of prediabetes, affected the participants’ perception of risk and motivation towards initiating lifestyle change, but the internal struggle experienced by many participants also affected the individual’s evaluation of the importance of initiating lifestyle change. These findings align with the review by Kwasnicka et al. [ 15 ] in highlighting the importance of intrinsic motivation and autonomy in facilitating the maintenance of initial lifestyle change.

Using the label ‘prediabetes’ on individuals at high risk of type 2 diabetes may increase the perceived threat of developing diabetes [ 55 ]. Our findings illustrate that the recognition of prediabetes as asymptomatic and not equating it with severe illness in some cases led to a downplaying of the associated risk [ 48 , 52 , 53 ]. This reveals some of the complexity of initiating lifestyle change in the face of an invisible disease; thus, this is perhaps what sets the prediabetes population apart from other high-risk populations. Our findings and previous research [ 23 , 24 ] suggest that health care providers should emphasize illness severity and provide cues to action to encourage health behaviours, whilst at the same time acknowledging the fear and insecurity that might arise when dealing with the diagnosis of prediabetes.

According to a systematic review and meta-analysis by Hennessey et al. [ 58 ], struggle in the process of lifestyle change may create stress and deplete one’s cognitive and emotional capacity, which, in turn, challenges or disrupts the self-regulatory capacity. Kwasnicka et al. [ 15 ] state that self-regulation is a limited resource, and coping with behavioural barriers, overcoming temptations, managing lapses, and avoiding relapses is a demanding process and requires sustained effort. This might explain why participants in the included studies searched for a balance between preserving their mental needs and focusing on preventive behaviours [ 34 , 39 , 40 , 42 , 47 , 48 , 52 , 53 ]. According to Kwasnicka et al. [ 15 ] individuals are more likely to initiate behaviour change at times when their psychological and physical resources are plentiful, and the opportunity costs are low. Our findings reflected that when resources are low, individuals need more guidance and support in order to cope with the initiation and maintenance of lifestyle changes, especially when it comes to setting attainable goals and maintaining a balanced effort in everyday life.

The importance of intrinsic motivation and positive health feedback

According to the review by Kwasnicka et al. [ 15 ], the motivation to avoid negative health consequences is hypothesized to be insufficient to maintain preventive behaviour requiring maintained effort. In line with our findings, individuals are intrinsically motivated when lifestyle change is perceived as personally relevant and resembling one’s values and beliefs [ 16 ]. To support individuals with prediabetes in the process of initiating and maintaining lifestyle change, as well as to enhance intrinsic and autonomous motivation, it seems important that health care providers explore the individual’s perceptions of risk, their beliefs, and their personal values. In line with the ecological model this also pertains to the individual differences in culture and their different social and environmental contexts [ 21 ].

Several participants in the included studies experienced success with exercise and dietary changes after lifestyle change interventions. This was experienced through perceived positive health feedback, such as improved physical condition, weight loss, and this enhanced self-efficacy in the participants [ 41 , 43 , 47 , 49 , 52 , 53 ]. The attainment of prior success and one’s own perception of a positive psychological state are, according to Bandura [ 59 ], suggested to increase self-efficacy and are therefore important for behavioural change maintenance. This is in line with Rothman [ 60 ], who emphasizes that the individual’s decision to maintain a behaviour change is dependent on their perceived satisfaction with the received outcomes.

Strategies and coping mechanisms for maintaining lifestyle change

The process of making plans and setting goals, knowledge and skills and the formation of habits, are important aspects in the process of identifying strategies and coping mechanisms to maintain lifestyle changes [ 16 ]. These aspects are discussed mainly at the intrapersonal level but they cannot be understood isolated from social, environmental, and societal influences.

According to Hennessy et al. [ 58 ], setting goals initiates self-regulation and acts as a key mechanism for behaviour change. Self-regulation refers to any effort to actively control unwanted behaviour by inhibiting dominant and automatic behaviours, such as urges, emotions, or desires, and replacing them with goal-directed responses [ 15 ]. A systematic review by Leman et al. [ 61 ] found that people require self-efficacy and self-regulation to motivate their consistent performance of healthy behaviour.

Several participants in the included studies experienced a gap between their behavioural intentions and actual behaviour change, which then amplified their feelings of self-blame, guilt, and shame, especially when in terms of dietary changes [ 34 , 35 , 48 , 52 , 53 ]. This can cause dissatisfaction and lead individuals to either expend greater effort toward achieving the lifestyle change goals or disengage from these goals [ 15 ]. This underlines the importance of setting attainable, personal, relevant, and intrinsically motivated goals.

In two of the included studies, self-compassion was put forward as a strategy for making plans and setting goals [ 48 , 49 ]. According to Neff [ 62 ], self-compassion entails three main overlapping and interacting components: self-kindness versus self-judgement, common humanity versus isolation, and mindfulness versus over-identification. Interestingly, in a recent meta-analysis by Liao et al. [ 63 ], a positive association was found between self-compassion and self-efficacy, indicating that self-compassion may play a role in protecting one’s self-efficacy when experiencing failures [ 63 ].

A Finnish study of adults with increased risk of type 2 diabetes found that eating competence is associated with a healthy diet and could therefore, in the long term, support the prevention of type 2 diabetes [ 64 ]. Supporting autonomy and confidence is central in facilitating competence [ 16 ] and health care providers therefore play an important role when giving information and guidance. According to Gardner et al. [ 65 ], habit formation takes place after a period of the successful self-regulation of a new behaviour, and this is considered to play a fundamental role in generating health behaviour. Once a new behaviour has become a habit, it requires less effort, and the level of required self-regulation is reduced [ 15 ]. Gardner et al. [ 65 ] stated that habits persist even when conscious motivation decreases, and, therefore, habit formation should be encouraged in interventions to promote long-term maintenance.

The importance of supportive relations and environments in initiating and maintaining lifestyle change

Within the ecological framework supportive relations and environments were identified at the interpersonal level, the environmental level and the policy level, affecting the motivation for initiating and maintaining lifestyle change for individuals with prediabetes.

At the interpersonal level of the ecological framework, supportive relations and social influence can be found in formal and informal social networks [ 21 ]. In line with the ecological perspective, Barry et al. [ 66 ] highlighted the importance of socio-cultural influences in diabetes prevention policies. When addressing barriers and facilitators for lifestyle change, we must consider the impact of social norms and cultural aspects within families and communities and consider how health behaviours are shaped within different contexts [ 67 ]. Considering this, lifestyle intervention programs and health care communication aiming to facilitate lifestyle change in people with prediabetes, should include and involve the families or other significant persons in the whole process. This could enhance the individuals’ perceived sense of relatedness in the lifestyle change process, which is important in maintaining a new behaviour [ 16 ]. In line with our findings, peer support can enhance the internalization and maintenance of lifestyle change through perceived relatedness, connection, and trust [ 16 ].

A systematic review and meta-analysis that investigated the best method to improve self-efficacy to promote lifestyle and recreational physical activity in healthy adults [ 68 ], found that interventions that included feedback on their past performance or others’ performance (comparative feedback) produced the highest levels of self-efficacy.

Lifestyle intervention programmes are not necessarily suitable for all individuals with prediabetes. This can be due to different life phases, family settings or personal preferences; or practical or logistical barriers, such as care responsibility, work, or geographical distance. In one study offering an online-modality lifestyle intervention programme, participants highlighted the logistical benefits of the flexibility and convenience of a digital follow-up [ 37 ]. There is promising evidence regarding the efficacy of diabetes prevention eHealth interventions [ 69 ], and the integration of specific behaviour change techniques and digital features may optimise digital diabetes prevention interventions achieving clinically significant weight loss in individuals with prediabetes [ 70 ]. At the same time our findings described that the use of technological devices and digital follow-up was motivating and inspiring [ 37 , 41 , 49 , 53 ] and this further supports the potential of acceptance and increased use of digital eHealth interventions in the prevention of type 2 diabetes.

In line with the ecological model and our findings, barriers and facilitators to promote healthy diet and physical activity in our external environment are to a great extent beyond the control of the individual. McLeroy [ 21 ] referred to “the ideology of individual responsibility” and how this may inhibit our understanding of the potential environmental assault on health and the opportunities for healthy behaviours. According to the review by Barry et al. [ 66 ], watchfulness should be put towards a biomedical approach where prediabetes is recognized as a reversible state of abnormal glucose metabolism that can be reversed solely by altering the individual patient’s lifestyle. This may lead to an overemphasis on the individual’s responsibility for lifestyle change, resulting in the creation of policy neglecting the complex sociocultural environment affecting health and illness. Therefore, identifying behaviour change and maintenance strategies that are tailored for individuals with prediabetes in their socio-cultural environment, is of great importance for the individual having prediabetes as well as for the society in order to reduce their risk of progression to type 2 diabetes [ 71 ].

At the public policy level, there are a range of incentives policy makers can use to influence health behaviour for the population and the individuals at risk for type 2 diabetes, including legislation, information campaigns and price signals [ 72 ]. A systematic review and meta-analysis has shown that the risk of being diagnosed with type 2 diabetes is associated with low socio-economic status [ 73 ]. Moreover, individuals of a lower level of socioeconomic status are more often exposed to negative lifestyle habits, such as smoking, physical inactivity, obesity, and low fruit and vegetable consumption [ 74 ]. Thus, a central challenge when implementing lifestyle interventions in practice is reaching people with prediabetes across social groups and socio-economic positions to avoid reinforcing health inequalities.

Strengths and limitations of the meta-synthesis

To the best of our knowledge, this is the first review to explore qualitative research on the facilitators and barriers of lifestyle changes and lifestyle change maintenance among people with prediabetes. The application of a rigorous and systematic meta-synthesis technique with a transparent analytical procedure strengthens our paper. Synthesizing qualitative research is viewed as essential in achieving the goal of evidence-based practice and mainly features the use of the best available evidence as the foundation for this practice [ 75 ]. Another strength is that the included studies represent findings from several different countries with variously structured health systems. Despite this heterogeneity, we were able to identify many common themes, thus indicating how heterogeneity can be a strength rather than a limitation in a meta-synthesis [ 76 ].

A limitation to the meta-synthesis could be that the included articles were restricted to the English language, similar potential studies reported in other languages were consequently not retrieved nor appraised. Our included studies had no publication year limit, the oldest studies were conducted in 2008. However, in qualitative research one may argue that people’s experiences and perceptions on a specific topic are affected by context and the aspect of time to varying degrees. A meta-synthesis is a new and more comprehensive interpretation of already interpreted qualitative data from the primary studies [ 76 ], hence we did not use the raw data from the primary studies.

Practical implications

The findings of these meta-synthesis might inform people with prediabetes, healthcare professionals and policy makers, in terms of the need for psychological, social, and environmental support for this population. More qualitative research is needed in this field to explore the reasons behind unhealthy behaviour and consider the complex interplay between all ecological levels influencing health behaviour. The translation of lifestyle intervention programs into practice seems to be limited since rates of type 2 diabetes are set to rise further. Considering this, it would be useful to pay more attention to the importance of the communication of risk and how people perceive risk and understand the diagnosis of prediabetes. This might provide insight into why people engage (or not) in lifestyle intervention programs for diabetes prevention. Lifestyle interventions in general seem to appeal more to those with greater resources and who can apply the appropriate information to improve health [ 77 ], therefore there is also a need for studies focusing on the effect of interventions for different groups in terms of socioeconomical status, culture, gender, and level of knowledge regarding prediabetes.

This meta-synthesis offers important insights into evidence relevant to understanding the complexity and challenges of lifestyle change among people with prediabetes. Awareness of prediabetes and the perception of its related risks affects the motivation for lifestyle change; but this does not automatically lead to lifestyle changes. Facilitators and barriers for lifestyle change in people at risk for type 2 diabetes are found to be in a complex interplay within multiple levels of an ecological framework. Our findings illustrate how internal motivation and successful self-regulation facilitate lifestyle change and maintenance at the intrapersonal level. At the interpersonal level, social influence and support from family, peers, and health professionals comprise important facilitators; however, family and social norms can also represent barriers to change. Lifestyle intervention programs are important supportive contexts for lifestyle change, enhancing autonomy, competence and relatedness. Moreover, technological devices for monitoring lifestyle change could provide support for those not participating in a lifestyle intervention programme. The environmental and policy levels set the foundations for the availability of health promoting options and plays a crucial role in shaping the conditions for successful lifestyle change. A purely individual approach is far from sufficient in combating the rising global epidemic of type 2 diabetes. A great responsibility lies on health authorities and policymakers to create health-promoting environments.

Availability of data and materials

All data generated or analysed during this study are included in this published article. The data presented in our review are retrieved from the published papers of the included studies.

Abbreviations

Impaired fasting glucose

Impaired glucose tolerance

Fasting plasma glucose

Fasting blood glucose

Oral glucose tolerance test

Body mass index

Type 2 diabetes

Diabetes prevention program

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Acknowledgements

The authors would like to thank health research librarian Malene W. Gundersen for her support and guidance regarding the literature search.

This project was made possible as a part of a research-funded PhD being undertaken by GS, through internal distribution of PhD fellowship at OsloMet-Oslo Metropolitan University, Faculty of Health Sciences. No external funding was obtained for this study.

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The first author (GS) conducted the literature search and the initial screening for relevant studies. GS, AB, GH and BBN conducted the selection of the studies and the quality appraisal. GS and AB synthesized and analysed the data from the primary studies and CFO contributed to the methodology. GS prepared the manuscript and all authors contributed to the conceptualisation, development, critical review and editing of the manuscript. All authors approved the submission of the final manuscript.

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Skoglund, G., Nilsson, B.B., Olsen, C.F. et al. Facilitators and barriers for lifestyle change in people with prediabetes: a meta-synthesis of qualitative studies. BMC Public Health 22 , 553 (2022). https://doi.org/10.1186/s12889-022-12885-8

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Delayed discharge in inpatient psychiatric care: a systematic review

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Delayed discharge is problematic. It is financially costly and can create barriers to delivering best patient care, by preventing return to usual functioning and delaying admissions of others in need. This systematic review aimed to collate existing evidence on delayed discharge in psychiatric inpatient settings and to develop understanding of factors and outcomes of delays in these services.

A search of relevant literature published between 2002 and 2022 was conducted on Pubmed, PsycInfo and Embase. Studies of any design, which published data on delayed discharge from psychiatric inpatient care in high income countries were included. Studies examining child and adolescent, general medical or forensic settings were excluded. A narrative synthesis method was utilised. Quality of research was appraised using the Mixed Methods Appraisal Tool (MMAT).

Eighteen studies from England, Canada, Australia, Ireland, and Norway met the inclusion criteria. Six main reasons for delayed discharge were identified: (1) accommodation needs, (2) challenges securing community or rehabilitation support, (3) funding difficulties, (4) family/carer factors, (5) forensic considerations and (6) person being out of area. Some demographic and clinical factors were also found to relate to delays, such as having a diagnosis of schizophrenia or other psychotic disorder, cognitive impairment, and increased service input prior to admission. Being unemployed and socially isolated were also linked to delays. Only one study commented on consequences of delays for patients, finding they experienced feelings of lack of choice and control. Four studies examined consequences on services, identifying high financial costs.

Overall, the findings suggest there are multiple interlinked factors relevant in delayed discharge that should be considered in practice and policy. Suggestions for future research are discussed, including investigating delayed discharge in other high-income countries, examining delayed discharge from child and forensic psychiatric settings, and exploring consequences of delays on patients and staff. We suggest that future research be consistent in terms used to define delayed discharge, to enhance the clarity of the evidence base.

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Date of registration.

9th December 2021.

Delayed discharge, also termed ‘bed blocking’ and ‘delayed transfer of care,’ refers to when patients remain in hospital beyond the time they are determined to be clinically fit to leave [ 1 , 2 ]. It is an international challenge, costly to individuals, health services and governments [ 3 , 4 ], impacting physical health settings, and also psychiatric inpatient services [ 5 ].

Psychiatric inpatient stays are one of the most expensive forms of treatment for mental health conditions, particularly when compared to care delivered in community settings [ 6 ]. Prolonged stays in mental health hospitals likely increase resource use and as such financial expenditure. This is particularly concerning in instances of delayed discharge when stays are determined to not be of clinical benefit. Delayed discharge also could prevent admission of new patients, contributing to bed crises, where there are not enough beds for all who require admission [ 7 ]. This can have consequences on the course of recovery for newly referred patients, either delaying admission, contributing to inappropriate placements, or leading to individuals being placed out of area [ 7 , 8 ]. Extended hospital stay could also detrimentally impact the delayed patient themselves, preventing their return to usual day-to-day functioning and make returning to the community increasingly difficult [ 9 , 10 ].

Existing reviews have examined predictors of longer stays in psychiatric inpatient settings, finding substance use and being employed are associated with shorter length of stay; while being female, having a diagnoses of mood or psychotic disorders and use of Electroconvulsive Therapy are associated with longer stay [ 11 ]. However, there is not to our knowledge a systematic review collating evidence examining delayed discharge in psychiatric settings. As delayed discharge is a unique experience, distinct from long stay driven by clinical need, it requires separate focus to further understand this specific experience.

Furthermore, a large body of evidence has examined delayed discharge in physical health settings with several systematic reviews, examining causes and outcomes. Such reviews have found that delayed discharges were linked to problems in discharge planning, transfer of care difficulties and patient age [ 12 , 13 ]. Outcomes for services included overcrowding and financial costs, whereas outcomes for patients included infections, depression, reduction in activities and mortality. There may be both overlapping and non-overlapping factors associated with delayed discharge between physical and psychiatric inpatient settings. For example, inpatient psychiatric services may differ in organisational structure, daily workings, and treatment focus from general medical services. The clinical population might also differ in psychiatric and physical health settings, for example in age, socio-economic status, and other demographic, plus clinical factors. As such, it is vital that separate attention be given to the area of psychiatric care.

This systematic review aims to fill the current research gap and synthesise existing literature on psychiatric delayed discharges. We aimed to synthesise the available international data from high-income countries, as the prevalence and underlying reasons for delayed discharge are likely to be highly sensitive to context and heterogeneous across countries. This is due to factors such as different models of healthcare funding, and the varying social role of the family in providing care, for example. Developing in-depth understanding of the causes and consequences of delays in a psychiatric inpatient context is important in informing practice and policies at a service, organisational, societal, and government level. This could help develop ways to reduce occurrence of delays and mitigate any negative impacts.

The aim of this review was to increase understanding of what is known about factors influencing delayed discharge in adult psychiatric inpatient settings. Secondary aims were to examine outcomes of delayed discharge for patients and compare findings across different psychiatric settings and age groups.

The systematic review protocol was pre-registered on PROSPERO before the review was started and the searches were run (PROSPERO: 292515). The review is reported in line with PRISMA guidelines [ 14 , 15 ]. The primary research question of this review is: What is known about factors associated with delayed discharge from inpatient psychiatric care settings?

Secondary research questions were:

What are the outcomes for those who have experienced delayed discharge from inpatient psychiatric settings, for example, in mental health outcomes, health outcomes, readmissions and quality of life?

What are the outcomes on services in terms of resources and costs from delayed psychiatric inpatient discharge?

What are the experiences of staff and patients of delayed discharge from inpatient mental health wards?

Are there differences between types of inpatient services, including acute, rehabilitation or specialist inpatient wards, in factors and costs, are there differences between working age adults and older adults, in experiences of delayed discharge, search strategy.

Initial searches were conducted on the 15th of January 2022, and updated on the 5th of August 2022. Pubmed, PsycInfo and Embase were searched.

Search terms (Appendix B in supplementary materials) were developed through examining key words of published studies on the topic, reviewing the terms used in comparative reviews based in physical health settings and thesaurus mapping. Terms included: “delayed discharge,” “bed blocking” and “long stays.” Search terms were piloted on each database prior to running the final search.

The search included studies published from 2002. A 20-year search timeframe was selected, as psychiatric inpatient care has adapted in response to changing need and updated knowledge over time. As such, studies published before 2002 are likely to be less relevant to current practice.

Following database searches, reference lists of included papers were examined, to identify any relevant studies missed in the search. A forward citation search was also conducted, to identify any relevant studies that were cited in the included papers.

Inclusion and exclusion criteria

Studies were included if they reported data related to delayed discharge or associated outcomes, in adult psychiatric inpatient wards. Specialist and rehabilitation psychiatric inpatient settings were included. Studies of any design were included, providing they were published in a peer-reviewed journal. Both quantitative and qualitative studies were included.

Studies exploring delayed discharge in child or adolescent units and/or forensic units were excluded. This was because the causes and outcomes of delays in such settings are likely unique, given the specialist context. For example, there is likely different systemic involvement from families and different governing legislation in these contexts. As such, it was determined that such settings were too disparate, and synthesising studies from these settings together with adult psychiatric settings could lead to inaccurate conclusions. Physical health settings were also excluded, given the different processes, procedures and treatment focus involved in such settings. In addition, reviews have already been conducted examining delayed discharge from such settings. Studies not conducted in high-income countries were also excluded. In this review, we included high-income countries as defined by World Bank criteria, accessed in January 2022 [ 16 ] (see Appendix C in supplementary material for the list of included countries). Globally, countries differ in the conceptualisation of mental health and provisions offered, therefore, limiting this review to only high-income countries would enable comparisons to be made.

Study selection and data extraction

Screening was conducted using Covidence Systematic Review Software [ 17 ]. All records were independently double-screened by two reviewers at both title/abstract and full-text stage. Conflicts were resolved by discussion to reach consensus, with referral to the senior author (PJ) when needed.

A standardised template was used for data extraction, with all included studies being independently double extracted by two reviewers, with consensus achieved by discussion where needed.

A narrative synthesis method was used. For data examining reasons for delayed discharge, a deductive approach was taken initially. Authors identified possible reasons for delays based on existing literature and organised data under these categories/themes. Any data that did not fit into the pre-defined categories was pooled as ‘other’. All categories were then reviewed, with particular attention placed on the ‘other’ categories, to determine if additional categories need to be added or existing categories adapted. Sub-categories were identified when appropriate through coding. Once categories were established, the number of papers which reported each reason/factor were tabulated and data was reviewed to examine relationships, exploring both links and disparities within and between studies. The final synthesis was checked by three authors (AT, TJ, and CM), to achieve final agreement.

Data relating to outcomes/consequences of delayed discharge was synthesised in a similar way, with data initially organised into three categories: (1) consequences for patients, (2) consequences for service, (3) consequences for staff. Categories were reviewed by the authors following synthesis. Financial costs were converted to US dollars by the authors to support comparison.

Quality assessment of the included studies formed part of the synthesis with the appraisal of quality considered in the interpretation of results.

Quality Assessment

Quality assessment of studies was completed during the synthesis stage. In the protocol, we initially outlined that the Quality Assessment Tool for Studies of Diverse Designs (QATSDD) would be utilised [ 18 ]. However, following a trial of this tool with the included papers, we noted disparities in interpretations between authors. Therefore, the Mixed Methods Appraisal Tool (MMAT) was established to be a more suitable appraisal of quality for the included studies. The MMAT was developed for assessing and comparing the quality of studies using quantitative, qualitative and mixed-methods design, in one tool [ 19 ]. This tool was selected as studies of different designs were included in the review and this tool allows for quality appraisal across five different study types, distinguishing between methodology.

Two initial screening questions were answered to determine appropriateness of using the MMAT to assess quality of the study (are there clear research questions and do the collected data address the research questions). If screening questions are not passed, this tool is deemed inappropriate. Providing the screening questions were passed, quality was assessed on five questions within one of five categories. The category in which questions were answered was determined by study design. The MMAT discourages from scoring and assigning qualitative labels to describe quality, instead advises a more detailed evaluation of quality [ 19 ]. This approach has therefore been taken in this paper.

To achieve reliable and accurate quality ratings, every study was quality rated by two members of the research team and conflicts were discussed to reach consensus.

Identification of studies

Figure  1 (PRISMA flowchart) shows the study selection process. After removing duplicates, a total of 4891 papers were identified for screening. 4397 papers were excluded at title and abstract stage. Full texts were then obtained for 492 papers. Two full texts could not be obtained via the library service and the authors did not respond to a request for the paper. There were four papers obtained that were erratum’s, all of which related to excluded studies that were not examining delayed discharge and as such, were not linked to the included studies. Following full text screening 18 papers were eligible for inclusion. Each paper represented a different study.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart

Study characteristics

Table  1 shows the characteristics of the 18 included studies. Twelve of these studies examined delayed discharge as a primary outcome, with three of these studies specifically examining Housing Related Delayed Discharge (HRDD). HRDD is defined as instances where delayed discharge is attributed to housing issues. The remaining studies ( n  = 6) reported delayed discharge as secondary outcomes. Fifteen studies were of quantitative observational design, two studies used mixed methodologies and one was qualitative.

In the included studies, there was a range of psychiatric inpatient settings: psychiatric/general mental health units ( n  = 11), Psychiatric Intensive Care Units (PICUs) ( n  = 2), older adult psychiatric units ( n  = 3) and Mental Health Trusts ( n  = 1). One study looked across three inpatient settings: acute psychiatric, PICU and older adult. Studies were conducted in five high income countries (England = 10, Ireland = 1, Australia = 3, Canada = 3, and Norway = 1). There were no studies from any other high-income countries, identified in the search.

The MMAT quality scores are shown (Table  2 ). One included study [ 20 ] did not meet initial criteria to be assessed using this tool, as the research questions were unclear.

All studies were of fairly good quality, with all studies meeting at least three out of five of the quality assessment criteria. Quality was highest in Australian and Canadian studies, with included papers in these countries meeting all five quality assessment criteria [ 21 , 22 , 23 , 24 , 25 , 26 ]. Quality assessment ratings indicate that three quantitative descriptive studies included, did not clearly report use of a representative sample or appropriate measures. Ratings per question are shown in Table two.

Research Q1

What is known about factors associated with delayed discharge.

Thirteen studies identified reasons for delayed discharge (Table  1 ). The results showed that there are many complex reasons for delays with often overlapping contributing factors. We categorised reasons for delay into six categories: (1) accommodation needs, (2) difficulty securing rehabilitation or community support, (3) finance/funding challenges, (4) family/carer factors, (5) forensic factors, (6) patient being out of area.

The most common reason for delays was due to accommodation and placement factors. This was identified as a contributing reason for delay in twelve studies and a further two studies assessed Housing-Related Delayed Discharge (HRDD), suggesting accommodation factors contributing to delay in these cases. Accommodation/placement factors included limited availability of placements ( n  = 7), difficulty finding appropriate placements ( n  = 5), awaiting or undergoing placement assessment ( n  = 3), challenges in person returning to accommodation ( n  = 3), e.g., awaiting repairs or adaptations to their home, individuals being rejected from placement ( n  = 2), patients/family rejecting placement ( n  = 2) and awaiting transfer ( n  = 1). It should be noted that one of the studies which examined specific accommodation factors was unable to be quality assessed due to not having clear research questions and therefore did not meet the screening criteria for assessment with the MMAT [ 20 ], and two studies only met three of the five quality assessment criteria, with queries regarding the quality of measures used and analysis technique for one study [ 27 ], and some difficulties integrating and meeting the full quality criteria for the mixed methods approaches used in the second [ 28 ]. The second reason identified for delays was difficulty sourcing support for the person to enable discharge, such as community, rehabilitation, and homecare support. This contributed to delays in twelve studies. Eight of these studies met four to five of the quality assessment criteria, one was not able to be assessed [ 20 ], and three only met three of the five quality assessment criteria [ 27 , 28 , 29 ]. A third reason for delay was finance/funding challenges identified in nine studies. These included challenges obtaining funding, patients/families’ refusal to pay for placements and funding applications being rejected. Six studies identified family/carers factors in creating delays, such as family conflict, family not wanting the person to live with them and ongoing family discussion. The quality of two of the studies identifying family and finance factors should be considered, as one of these studies was unable to be quality assessed due to a lack of clear research questions [ 20 ] and a second met only three of the five quality assessment criteria [ 28 ]. The fifth reason identified in this review as contributing to delay was forensic factors, which accounted for delays in three studies, all of good methodological quality. Forensic delays incorporated delay by Ministry of Justice and awaiting forensic assessment. Person being out of area was highlighted as a reason for delay in only one study and it was not possible to quality assess this study due to no specific research questions identified [ 20 ], suggesting limited exploration or evidence for out of areas contributing to delays.

Fourteen studies included in this review examined the demographic and clinical factors relevant in delays, with eight conducting significance testing to establish associations. Significant associations with delay were having a diagnosis of schizophrenia or other psychotic disorder ( n  = 4), cognitive impairment ( n  = 3) and type/amount of service input prior to admission ( n  = 3). All studies reporting these significant results were of a good methodological quality, achieving at least four of the five MMAT quality criteria. Results were mainly consistent across those studies which examined significance, however, there was one study of good quality that did not find significant association with schizophrenia diagnosis [ 22 ]. The impact of physical health differed between Australia and England, where in one English study having fair-excellent health was more associated with delays [ 30 ], though two Australian studies found poorer physical health linked to delays [ 24 , 25 ]. Findings related to demographic characteristics, including gender, age, ethnicity, socio-economic status, were inconsistent across studies. The only consistent finding was that a smaller proportion of the delayed group were employed ( n  = 3). One of these studies found significant association between being unemployed and delayed discharge. The two other studies found only one member of the delayed group was employed, less than non-delayed groups, though this was not significance tested. There was some indication that being not being married and lacking a support network, was higher in delayed groups. One study found significant relationships to being unmarried and another finding that the delayed group were visited significantly less often by relatives. The other studies did not conduct significance testing. However, there was no significant relationship related to marriage between delayed and non-delayed groups in two studies [ 22 , 31 ]. One of these studies only clearly met three of the quality assessment criteria [ 31 ], though the other met all five quality assessment criteria. Being male was significantly associated with delays in two Canadian studies [ 21 , 22 ]. No significant association with gender was found in other studies.

The supplementary materials provide additional analysis of results for research question one, further describing each study’s findings. Additional materials also include tables showing tabulation of which study examined each variable.

Research Q2

What are the outcomes for those who have experienced delayed discharge from inpatient psychiatric settings for example, in mental health outcomes, health outcomes, readmissions and quality of life.

Only one study examined individual outcomes of delayed discharge for patients [ 26 ]. As such, there is limited data to draw conclusions to answer this research question. The study that evaluated patient outcomes was of qualitative design and good quality. The study explored Housing-Related Delayed Discharge (HRDD) in Australia for 10 patients using semi-structured interviews. They found consequences of lack of choice and control for patients, which impacted mental wellbeing, physical health and created a sense of anticipation for transition to community. Some participants highlighted a positive outcome of delayed discharge in preventing homelessness.

Research Q3

What is the outcome on services in terms of resources and costs from delayed psychiatric inpatient discharge.

Four studies assessed financial costs of delayed discharge for services, providing limited evidence in terms of financial outcomes. Each study focused on a different country. At an old age psychiatry unit in England, delayed discharges were estimated to cost over $855,820 for the year [ 20 ]. Notably, this study was not quality assessed due to the omission of research questions. In a high-quality paper from Australia, HRDD cost the health district $2,828,174 over one year [ 25 ]. While both papers present yearly costs, there is disparity in area covered, contributing to difficulty making comparisons regarding financial expenditure. Two studies calculated financial expenditure and did not present the cost per year. In a Canadian study, using the median number of delayed days ( M  = 17), it was calculated that the average cost incurred by one episode of delayed days was approximately $5,746 [ 21 ]. Furthermore, in Norway, $491,406 was allocated to delays on the acute ward included in the study, though methodological quality might be queried, due to lack of clarity on whether the sample was representative and the appropriateness of measures utilised [ 29 ]. The information necessary to calculate costs per year or costs per delayed day, to enable comparisons to be made across studies, has not included in the studies.

Aside from financial costs, no other type of outcome for services were assessed.

Research Q4

None of the included studies explored specific experiences of delayed discharge for staff. Some information on experiences for patients is detailed in question two.

Research Q5

This systematic review identified studies in acute psychiatric, older adult and Psychiatric Intensive Care Unit (PICU) settings. Only one study included Learning Disability inpatient care settings [ 28 ]. This study was of mixed-method design and met three quality assessment criteria. No studies reported data from rehabilitation units. There were few differences identified between types of setting. Prevalence of delayed discharge was highest in older adult settings (56.9%) [ 30 ] and PICU settings (51.1%) [ 32 ], compared to working age adult settings (18–32%) [ 31 , 33 ]. However, the highest proportion of delayed days was found in acute psychiatric settings in Norway acute psychiatric units (54.8%) [ 29 ]. More information on prevalence is provided in supplementary materials.

Reasons for delay did not vary much across type of setting. There is a potential service difference in the impact of physical health in delays, as having fair-excellent health was more associated with delays in an English older adult study [ 30 ], while in a working age adult sample in Australian studies [ 24 , 25 ], having poor health was more associated with delays. However, this could represent a disparity in country. There were some other differences across countries found. Forensic reasons for delay were only found in the UK ( n  = 2), as was due to patient being out of area ( n  = 1). In UK settings, there was no significant difference found in gender between those delayed and those not [ 30 , 34 ], though there was in Canada [ 21 ]. England and Australia were the only countries identifying funding issues as contributing to delay. Each country will have its own respective funding system, which could impact delays. For example, two Australian studies identified difficulties with their own National Disability Insurance Scheme [ 24 , 25 ].

Research Q6

Only five of the included studies looked specifically at older adult settings, all of which were in the UK. A further five studies, from the UK and Canada, included older adults within their sample, despite not examining a specific older adult setting.

The highest proportion of inpatients experiencing delayed discharge were from older adult settings, with one study identifying 56.9% [ 30 ] of inpatients experiencing delays. There were lower rates of delayed patients in working age adult psychiatric inpatient settings in comparison, with 3.5% [ 21 , 25 ] to 39.1% [ 29 ] of patients experiencing delay. Similarly, two studies in Canada identified that a higher proportion of older adults made up the delayed group compared to the non-delayed group, suggesting that older adult inpatients are more likely to experience delay [ 21 , 22 ]. However, two English studies found delayed discharge was not associated with age [ 31 , 35 ]. One of these studies met only three quality assessment criteria, with lack of clarity regarding the quality of sampling and representativeness of the sample [ 31 ].

In terms of reasons for delay, no clear differences were found across age groups. Although when limiting comparisons to studies conducted in the UK, family/carer factors was identified as a reason for delay more frequently in older adult samples ( n  = 3) compared to studies looking at working age adults ( n  = 1). To support this finding, one study in England found that eight older adult trusts identified patient/carer exercising choice as a reason for delay, whereas the same was true for only four working age adult trusts [ 28 ]. However, this finding cannot be generalised across all countries. There is also some indication that cognitive impairment/dementia might increase likelihood of delay in older adult samples, as two studies identified the role of dementia and greater cognitive impairment in the delayed older adult groups [ 20 , 30 ]. A further two studies examined the impact of cognitive impairment, finding association with delay [ 21 , 22 ]. However, these studies included working age samples, so it is unclear who in the sample this impacted. In addition, physical health status could cause delays differently in older adult populations. In an older adult UK sample having fair-excellent health was more associated with delays [ 30 ], whereas two Australian studies in working age adult inpatient settings found poorer physical health increased delays [ 24 , 25 ]. This difference could however be attributed to country or setting. Funding was identified as a reason for delay in all studies in older adult settings ( n  = 5), but the same was not true for the other setting types. Forensic factors were not found to be a reason for delay in any of the studies with older adult inpatients, conversely patient being out of area was only identified as a reason for delay in an older adult sample [ 20 ].

This systematic review aimed to fill a research gap and examine factors contributing to delayed discharge in adult psychiatric inpatient settings and explore associated consequences. This adds a unique contribution to the evidence base, which predominantly has focused on delayed discharge from physical health settings. Eighteen studies were included for synthesis.

The findings suggest that there are varying inter-related reasons for delay, including accommodation or placement needs, difficulties securing the required support services, funding and finance challenges, family/carer factors, forensic factors and the person being out of area. There were mixed findings regarding demographic and clinical characteristics associated with delays. However, this review showed that delays could be associated with the person having diagnosis of schizophrenia or other psychotic disorder, cognitive impairment, being unemployed and receiving increased service input prior to admission.

There were only a few studies that commented on outcomes of delays. Only one study examined outcomes for patients, identifying feelings of lack of choice and control, while four studies looked at financial outcomes for services, finding large costs associated with delays. This points to a lack of evidence examining the outcomes and experiences of psychiatric delayed discharge, and therefore requires further attention in research.

This review adds to and expands on existing findings, identifying similarities and differences between longer stay generally. For example, one review [ 11 ] found that long stay was associated with mood and psychotic disorders, use of Electroconvulsive Therapy, and being female. Being married, employed, and using substances were associated with a shorter stay [ 11 ]. Our review found that psychiatric delayed discharge was also associated with diagnosis of schizophrenia or other psychotic disorder and being unemployed. However, we found delayed discharge to be associated with cognitive impairment and increased service input prior to admission, but not gender or treatment. This could suggest some important differences in those at risk of delays or those requiring longer inpatient treatment. It is important to note however, the review by Gopalakrishina and colleagues did not distinguish between those patients with long stay clinically warranted and delayed discharge patients [ 11 ]. It would be of benefit for future research on long stay patients to better define their sample based on those who clinically needed treatment or longer stay patients in the context of delayed discharge, allowing similarities and differences to be better explored. This will support policy makers and service managers to better identify those at risk of delays that are not clinically necessary, and those who might need additional clinical input. The findings in this review provide some suggestion that there could be benefit in considering a person’s social context when they are admitted to psychiatric inpatient care, including their living situation at admission, employment status and cognitive functioning. Identifying patients at higher risk of delays earlier in admission might be useful, to ensure more time be given to organise and find appropriate accommodations, placements and service support and facilitate discharge. Wider policy and structural changes are needed, such as improving the availability of appropriate accommodation placements.

It is important to highlight that there were discrepancies across studies in language used to term delayed discharge, e.g., ‘alternate level of care,’ ‘waiting days’ and ‘prolonged stay.’ Due to such discrepancies in definitions and terminology, during the screening process it was at times difficult to determine if studies were focused on delayed discharge or longer lengths of stay clinically required. In this review, studies were excluded if the focus was unclear to prevent incorrect conclusions being drawn related to the unique experience of delayed discharge. However, this means other relevant findings might have been missed. It would therefore be useful for future research on psychiatric inpatient care to ensure clarity in the terminology and definitions used in reports. There were also discrepancies in the way financial costs related to delays were reported, i.e., whether reported as cost per day, cost per year. This made comparing the costs across countries challenging and prevented clear conclusions being drawn. Future research should therefore aim to ensure clarity when reporting financial expenditure, for example, by calculating the daily cost of delays. It is important to highlight that only eighteen studies were identified over the 20-year search period, suggesting this area has not yet been subject to much research focus. All high-income countries met inclusion, but the final sample included studies from only five countries. It might have been expected that studies in other high-income countries be identified, particularly given the expensive nature of inpatient stays and as such delayed discharge. It might be beneficial for future research to further examine delayed discharge in psychiatric settings across other countries, particularly in the USA and EU. For the purposes of this review, studies not conducted in high-income countries were excluded. This was because lower-income countries might experience different factors contributing to delays due to differences in healthcare funding and social factors. As such, separate attention should be given to these settings, to understand similarities or differences in reasons for delays across low- and mid- income countries. Studies on forensic psychiatric settings and child and adolescent settings were also excluded in this instance, so again, there might be benefit in future research examining these areas.

Furthermore, future research could look not only at factors creating delays, but those causing longer delays. Some of the studies in this review began examining this, but more research in this area could be of interest. Finally, while the quality of included studies was relatively high, the studies were primarily of quantitative audit design and infrequently conducted significance testing. As such, further exploration of associations using significance testing would strengthen the evidence base.

In conclusion, 18 studies identified reasons for delayed discharge, including accommodation and placement related factors, challenges securing appropriate support, funding difficulties, family/carer factors, forensic factors and person being out of area. Delay was associated with having a diagnosis of schizophrenia or other psychotic disorder, cognitive impairment, increased service involvement prior to admission, and being unemployed. Service, societal and policy changes might be indicated, to improve accommodation and care provisions following discharge. Future research should continue to examine prolonged inpatient psychiatric stays, ensuring to distinguish between long stays and delayed discharge and improve clarity in terminology used.

Data availability

The data on which this review is based will be made publicly available on publication. A link to data for anonymous peer-review is here: https://osf.io/j4kng/?view_only=1fbf2558d9d044bbb1778fccd5fd6f51 .

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Department of Psychology, University of Bath, Bath, BA2 7AY, UK

Ashley-Louise Teale, Ceri Morgan, Tom A. Jenkins & Pamela Jacobsen

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AT and PJ formulated the initial research questions and developed the systematic review protocol. AT ran the searches on databases. AT, CM and TJ conducted the screening, data extraction and quality assessment. PJ acted as senior reviewer to resolve any conflicts. AT synthesised the results. All authors contributed to data synthesis and interpretation. AT wrote the paper. All authors read and approved the final version of manuscript for submission.

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Correspondence to Ashley-Louise Teale .

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Teale, AL., Morgan, C., Jenkins, T.A. et al. Delayed discharge in inpatient psychiatric care: a systematic review. Int J Ment Health Syst 18 , 14 (2024). https://doi.org/10.1186/s13033-024-00635-9

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Received : 28 July 2023

Accepted : 25 March 2024

Published : 06 April 2024

DOI : https://doi.org/10.1186/s13033-024-00635-9

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• Delayed discharge
• Bed blocking
• Delayed transfer
• Psychiatric inpatient
• Inpatient treatment
• Prolonged stays
• Length of stay

International Journal of Mental Health Systems

ISSN: 1752-4458

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