how to do a literature search for research

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How to undertake a literature search: a step-by-step guide

Affiliation.

• 1 Literature Search Specialist, Library and Archive Service, Royal College of Nursing, London.
• PMID: 32279549
• DOI: 10.12968/bjon.2020.29.7.431

Undertaking a literature search can be a daunting prospect. Breaking the exercise down into smaller steps will make the process more manageable. This article suggests 10 steps that will help readers complete this task, from identifying key concepts to choosing databases for the search and saving the results and search strategy. It discusses each of the steps in a little more detail, with examples and suggestions on where to get help. This structured approach will help readers obtain a more focused set of results and, ultimately, save time and effort.

Keywords: Databases; Literature review; Literature search; Reference management software; Research questions; Search strategy.

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• Systematic Reviews
• Step 3: Conduct Literature Searches

Systematic Reviews: Step 3: Conduct Literature Searches

Created by health science librarians.

• Step 1: Complete Pre-Review Tasks
• Step 2: Develop a Protocol

About Step 3: Conduct Literature Searches

Partner with a librarian, systematic searching process, choose a few databases, search with controlled vocabulary and keywords, acknowledge outdated or offensive terminology, helpful tip - building your search, use nesting, boolean operators, and field tags, build your search, translate to other databases and other searching methods, document the search, updating your review.

• Searching FAQs
• Step 4: Manage Citations
• Step 5: Screen Citations
• Step 6: Assess Quality of Included Studies
• Step 7: Extract Data from Included Studies
• Step 8: Write the Review

  Check our FAQ's

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   Call (919) 962-0800

   Make an appointment with a librarian

  Request a systematic or scoping review consultation

Search the FAQs

In Step 3, you will design a search strategy to find all of the articles related to your research question. You will:

• Define the main concepts of your topic
• Choose which databases you want to search
• List terms to describe each concept
• Add terms from controlled vocabulary like MeSH
• Use field tags to tell the database where to search for terms
• Combine terms and concepts with Boolean operators AND and OR
• Translate your search strategy to match the format standards for each database
• Save a copy of your search strategy and details about your search

There are many factors to think about when building a strong search strategy for systematic reviews. Librarians are available to provide support with this step of the process.

Click an item below to see how it applies to Step 3: Conduct Literature Searches.

Reporting your review with PRISMA

For PRISMA, there are specific items you will want to report from your search.  For this step, review the PRISMA-S checklist.

• PRISMA-S for Searching
• Specify all databases, registers, websites, organizations, reference lists, and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted. Present the full search strategies for all databases, registers and websites, including any filters and limits used.
• For information on how to document database searches and other search methods on your PRISMA flow diagram, visit our FAQs "How do I document database searches on my PRISMA flow diagram?" and "How do I document a grey literature search for my PRISMA flow diagram?"

Managing your review with Covidence

For this step of the review, in Covidence you can:

• Document searches in Covidence review settings so all team members can view
• Add keywords from your search to be highlighted in green or red while your team screens articles in your review settings

How a librarian can help with Step 3

When designing and conducting literature searches, a librarian can advise you on :

• How to create a search strategy with Boolean operators, database-specific syntax, subject headings, and appropriate keywords 
• How to apply previously published systematic review search strategies to your current search
• How to test your search strategy's performance 
• How to translate a search strategy from one database's preferred structure to another

The goal of a systematic retrieve is to find all results that are relevant to your topic. Because systematic review searches can be quite extensive and retrieve large numbers of results, an important aspect of systematic searching is limiting the number of irrelevant results that need to be screened. Librarians are experts trained in literature searching and systematic review methodology. Ask us a question or partner with a librarian to save time and improve the quality of your review. Our comparison chart detailing two tiers of partnership provides more information on how librarians can collaborate with and contribute to systematic review teams.

Search Process

• Use controlled vocabulary, if applicable
• Include synonyms/keyword terms
• Choose databases, websites, and/or registries to search
• Translate to other databases
• Search using other methods (e.g. hand searching)
• Validate and peer review the search

Databases can be multidisciplinary or subject specific. Choose the best databases for your research question. Databases index various journals, so in order to be comprehensive, it is important to search multiple databases when conducting a systematic review. Consider searching databases with more diverse or global coverage (i.e., Global Index Medicus) when appropriate. A list of frequently used databases is provided below. You can access UNC Libraries' full listing of databases on the HSL website (arranged alphabetically or by subject ).

Generally speaking, when literature searching, you are not searching the full-text article. Instead, you are searching certain citation data fields, like title, abstract, keyword, controlled vocabulary terms, and more. When developing a literature search, a good place to start is to identify searchable concepts of the research question, and then expand by adding other terms to describe those concepts. Read below for more information and examples on how to develop a literature search, as well as find tips and tricks for developing more comprehensive searches.

Identify search concepts and terms for each

Start by identifying the main concepts of your research question. If unsure, try using a question framework to help identify the main searchable concepts. PICO is one example of a question framework and is used specifically for clinical questions. If your research question doesn't fit into the PICO model well, view other examples of question frameworks and try another!

View our example in PICO format

Question: for patients 65 years and older, does an influenza vaccine reduce the future risk of pneumonia.

Controlled Vocabulary

Controlled vocabulary is a set of terminology assigned to citations to describe the content of each reference. Searching with controlled vocabulary can improve the relevancy of search results. Many databases assign controlled vocabulary terms to citations, but their naming schema is often specific to each database. For example, the controlled vocabulary system searchable via PubMed is MeSH, or Medical Subject Headings. More information on searching MeSH can be found on the HSL PubMed Ten Tips Legacy Guide .

Note: Controlled vocabulary may be outdated, and some databases allow users to submit requests to update terminology.

View Controlled Vocabulary for our example PICO

As mentioned above, databases with controlled vocabulary often use their own unique system. A listing of controlled vocabulary systems by database is shown below.

Keyword Terms

Not all citations are indexed with controlled vocabulary terms, however, so it is important to combine controlled vocabulary searches with keyword, or text word, searches. 

Authors often write about the same topic in varied ways and it is important to add these terms to your search in order to capture most of the literature. For example, consider these elements when developing a list of keyword terms for each concept:

• American versus British spelling
• hyphenated terms
• quality of life
• satisfaction
• vaccination
• influenza vaccination

There are several resources to consider when searching for synonyms. Scan the results of preliminary searches to identify additional terms. Look for synonyms, word variations, and other possibilities in Wikipedia, other encyclopedias or dictionaries, and databases. For example, PubChem lists additional drug names and chemical compounds.

Display Controlled Vocabulary and Keywords for our example PICO

Combining controlled vocabulary and text words in PubMed would look like this:

"Influenza Vaccines"[Mesh] OR "influenza vaccine" OR "influenza vaccines" OR "flu vaccine" OR "flu vaccines" OR "flu shot" OR "flu shots" OR "influenza virus vaccine" OR "influenza virus vaccines"

Social and cultural norms have been rapidly changing around the world. This has led to changes in the vocabulary used, such as when describing people or populations. Library and research terminology changes more slowly, and therefore can be considered outdated, unacceptable, or overly clinical for use in conversation or writing.

For our example with people 65 years and older, APA Style Guidelines recommend that researchers use terms like “older adults” and “older persons” and forgo terms like “senior citizens” and “elderly” that connote stereotypes. While these are current recommendations, researchers will recognize that terms like “elderly” have previously been used in the literature. Therefore, removing these terms from the search strategy may result in missed relevant articles. 

Research teams need to discuss current and outdated terminology and decide which terms to include in the search to be as comprehensive as possible. The research team or a librarian can search for currently preferred terms in glossaries, dictionaries, published guidelines, and governmental or organizational websites. The University of Michigan Library provides suggested wording to use in the methods section when antiquated, non-standard, exclusionary, or potentially offensive terms are included in the search.

Check the methods sections or supplementary materials of published systematic reviews for search strategies to see what terminology they used. This can help inform your search strategy by using MeSH terms or keywords you may not have thought of. However, be aware that search strategies will differ in their comprehensiveness.

You can also run a preliminary search for your topic, sort the results by Relevance or Best Match, and skim through titles and abstracts to identify terminology from relevant articles that you should include in your search strategy.

Nesting is a term that describes organizing search terms inside parentheses. This is important because, just like their function in math, commands inside a set of parentheses occur first. Parentheses let the database know in which order terms should be combined. 

Always combine terms for a single concept inside a parentheses set. For example: 

( "Influenza Vaccines"[Mesh] OR "influenza vaccine" OR "influenza vaccines" OR "flu vaccine" OR "flu vaccines" OR "flu shot" OR "flu shots" OR "influenza virus vaccine" OR "influenza virus vaccines" )

Additionally, you may nest a subset of terms for a concept inside a larger parentheses set, as seen below. Pay careful attention to the number of parenthesis sets and ensure they are matched, meaning for every open parentheses you also have a closed one.

( "Influenza Vaccines"[Mesh] OR "influenza vaccine" OR "influenza vaccines" OR "flu vaccine" OR "flu vaccines" OR "flu shot" OR "flu shots" OR "influenza virus vaccine" OR "influenza virus vaccines" OR   (( flu OR influenza ) AND ( vaccine OR vaccines OR vaccination OR immunization )))

Boolean operators

Boolean operators are used to combine terms in literature searches. Searches are typically organized using the Boolean operators OR or AND. OR is used to combine search terms for the same concept (i.e., influenza vaccine). AND is used to combine different concepts (i.e., influenza vaccine AND older adults AND pneumonia). An example of how Boolean operators can affect search retrieval is shown below. Using AND to combine the three concepts will only retrieve results where all are present. Using OR to combine the concepts will retrieve results that use all separately or together. It is important to note that, generally speaking, when you are performing a literature search you are only searching the title, abstract, keywords and other citation data. You are not searching the full-text of the articles.

The last major element to consider when building systematic literature searches are field tags. Field tags tell the database exactly where to search. For example, you can use a field tag to tell a database to search for a term in just the title, the title and abstract, and more. Just like with controlled vocabulary, field tag commands are different for every database.

If you do not manually apply field tags to your search, most databases will automatically search in a set of citation data points. Databases may also overwrite your search with algorithms if you do not apply field tags. For systematic review searching, best practice is to apply field tags to each term for reproducibility.

For example:

("Influenza Vaccines"[Mesh] OR "influenza vaccine"[tw] OR "influenza vaccines"[tw] OR "flu vaccine"[tw] OR "flu vaccines"[tw] OR "flu shot"[tw] OR "flu shots"[tw] OR "influenza virus vaccine"[tw] OR "influenza virus vaccines"[tw] OR ((flu[tw] OR influenza[tw]) AND (vaccine[tw] OR vaccines[tw] OR vaccination[tw] OR immunization[tw])))

View field tags for several health databases

For more information about how to use a variety of databases, check out our guides on searching.

• Searching PubMed guide Guide to searching Medline via the PubMed database
• Searching Embase guide Guide to searching Embase via embase.com
• Searching Scopus guide Guide to searching Scopus via scopus.com
• Searching EBSCO Databases guide Guide to searching CINAHL, PsycInfo, Global Health, & other databases via EBSCO

Combining search elements together

Organizational structure of literature searches is very important. Specifically, how terms are grouped (or nested) and combined with Boolean operators will drastically impact search results. These commands tell databases exactly how to combine terms together, and if done incorrectly or inefficiently, search results returned may be too broad or irrelevant.

For example, in PubMed:

(influenza OR flu) AND vaccine is a properly combined search and it produces around 50,000 results.

influenza OR flu AND vaccine is not properly combined.  Databases may read it as everything about influenza OR everything about (flu AND vaccine), which would produce more results than needed.

We recommend one or more of the following:

• put all your synonyms together inside a set of parentheses, then put AND between the closing parenthesis of one set and the opening parenthesis of the next set
• use a separate search box for each set of synonyms
• run each set of synonyms as a separate search, and then combine all your searches
• ask a librarian if your search produces too many or too few results

View the proper way to combine MeSH terms and Keywords for our example PICO

Question: for patients 65 years and older, does an influenza vaccine reduce the future risk of pneumonia .

Translating search strategies to other databases

Databases often use their own set of terminology and syntax. When searching multiple databases, you need to adjust the search slightly to retrieve comparable results. Our sections on Controlled Vocabulary and Field Tags have information on how to build searches in different databases.  Resources to help with this process are listed below.

• Polyglot search A tool to translate a PubMed or Ovid search to other databases
• Search Translation Resources (Cornell) A listing of resources for search translation from Cornell University
• Advanced Searching Techniques (King's College London) A collection of advanced searching techniques from King's College London

Other searching methods

Hand searching.

Literature searches can be supplemented by hand searching. One of the most popular ways this is done with systematic reviews is by searching the reference list and citing articles of studies included in the review. Another method is manually browsing key journals in your field to make sure no relevant articles were missed. Other sources that may be considered for hand searching include: clinical trial registries, white papers and other reports, pharmaceutical or other corporate reports, conference proceedings, theses and dissertations, or professional association guidelines.

Searching grey literature

Grey literature typically refers to literature not published in a traditional manner and often not retrievable through large databases and other popular resources. Grey literature should be searched for inclusion in systematic reviews in order to reduce bias and increase thoroughness. There are several databases specific to grey literature that can be searched.

• Open Grey Grey literature for Europe
• OAIster A union catalog of millions of records representing open access resources from collections worldwide
• Grey Matters: a practical tool for searching health-related grey literature (CADTH) From CADTH, the Canadian Agency for Drugs and Technologies in Health, Grey Matters is a practical tool for searching health-related grey literature. The MS Word document covers a grey literature checklist, including national and international health technology assessment (HTA) web sites, drug and device regulatory agencies, clinical trial registries, health economics resources, Canadian health prevalence or incidence databases, and drug formulary web sites.
• Duke Medical Center Library: Searching for Grey Literature A good online compilation of resources by the Duke Medical Center Library.

Systematic review quality is highly dependent on the literature search(es) used to identify studies. To follow best practices for reporting search strategies, as well as increase reproducibility and transparency, document various elements of the literature search for your review. To make this process more clear, a statement and checklist for reporting literature searches has been developed and and can be found below.

• PRISMA-S: Reporting Literature Searches in Systematic Reviews
• Section 4.5 Cochrane Handbook - Documenting and reporting the search process

At a minimum, document and report certain elements, such as databases searched, including name (i.e., Scopus) and platform (i.e. Elsevier), websites, registries, and grey literature searched. In addition, this also may include citation searching and reaching out to experts in the field. Search strategies used in each database or source should be documented, along with any filters or limits, and dates searched. If a search has been updated or was built upon previous work, that should be noted as well. It is also helpful to document which search terms have been tested and decisions made for term inclusion or exclusion by the team. Last, any peer review process should be stated as well as the total number of records identified from each source and how deduplication was handled. 

If you have a librarian on your team who is creating and running the searches, they will handle the search documentation.

You can document search strategies in word processing software you are familiar with like Microsoft Word or Excel, or Google Docs or Sheets. A template, and separate example file, is provided below for convenience. 

• Search Strategy Documentation Template
• Search Strategy Documentation Example

*Some databases like PubMed are being continually updated with new technology and algorithms. This means that searches may retrieve different results than when originally run, even with the same filters, date limits, etc.

When you decide to update a systematic review search, there are two ways of identifying new articles:  

1. rerun the original search strategy without any changes. .

Rerun the original search strategy without making any changes.  Import the results into your citation manager, and remove all articles duplicated from the original set of search results.

2. Rerun the original search strategy and add an entry date filter.

Rerun the original search strategy and add a date filter for when the article was added to the database ( not the publication date).  An entry date filter will find any articles added to the results since you last ran the search, unlike a publication date filter, which would only find more recent articles.

Some examples of entry date filters for articles entered since December 31, 2021 are:

• PubMed:   AND ("2021/12/31"[EDAT] : "3000"[EDAT])
• Embase: AND [31-12-2021]/sd
• CINAHL:   AND EM 20211231-20231231
• PsycInfo: AND RD 20211231-20231231
• Scopus:   AND LOAD-DATE AFT 20211231  

Your PRISMA flow diagram

For more information about updating the PRISMA flow diagram for your systematic review, see the information on filling out a PRISMA flow diagram for review updates on the Step 8: Write the Review page of the guide.

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• Last Updated: Jul 15, 2024 4:55 PM
• URL: https://guides.lib.unc.edu/systematic-reviews

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Methodology

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

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

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

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

There are five key steps to writing a literature review:

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

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

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Table of contents

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

• Quick Run-through
• Step 1 & 2

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

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

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

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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.

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

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

 Statistics

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

Research bias

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

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

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

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

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

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

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

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

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

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Literature Review

How to search effectively.

• Find examples of literature reviews
• How to write a literature review
• Grey literature

The  Literature searching interactive tutorial  includes self-paced, guided activities to assist you in developing  effective search skills..

1. Identify search words

Analyse your research topic or question.

• What are the main ideas?
• What concepts or theories have you already covered?
• Write down your main ideas, synonyms, related words and phrases.
• If you're looking for specific types of research, use these suggested terms: qualitative, quantitative, methodology, review, survey, test, trend (and more).
• Be aware of UK and US spelling variations. E.g. organisation OR organization, ageing OR aging.
• Interactive Keyword Builder
• Identifying effective keywords

2. Connect your search words

Find results with one or more search words.

Use OR between words that mean the same thing.

E.g.  adolescent  OR  teenager

This search will find results with either (or both) of the search words.

Find results with two search words

Use AND between words which represent the main ideas in the question.

E.g. adolescent AND “physical activity”

This will find results with both of the search words.

Exclude search words

Use NOT to exclude words that you don’t want in your search results.

E.g. (adolescent OR teenager) NOT “young adult”

3. Use search tricks

Search for different word endings.

Truncation *

The asterisk symbol * will help you search for different word endings.

E.g. teen* will find results with the words: teen, teens, teenager, teenagers

Specific truncation symbols will vary. Check the 'Help' section of the database you are searching.

Search for common phrases

Phrase searching “...........”

Double quotation marks help you search for common phrases and make your results more relevant.

E.g. “physical activity” will find results with the words physical activity together as a phrase.

Search for spelling variations within related terms

Wildcards ?

Wildcard symbols allow you to search for spelling variations within the same or related terms.

E.g. wom?n will find results with women OR woman

Specific wild card symbols will vary. Check the 'Help' section of the database you are searching.

Search terms within specific ranges of each other

Proximity  w/#

Proximity searching allows you to specify where your search terms will appear in relation to each other.

E.g.  pain w/10 morphine will search for pain within ten words of morphine

Specific proximity symbols will vary. Check the 'Help' section of the database you are searching.

4. Improve your search results

All library databases are different and you can't always search and refine in the same way. Try to be consistent when transferring your search in the library databases you have chosen.

Narrow and refine your search results by:

• year of publication or date range (for recent or historical research)
• document or source type (e.g. article, review or book)
• subject or keyword (for relevance). Try repeating your search using the 'subject' headings or 'keywords' field to focus your search
• searching in particular fields, i.e. citation and abstract. Explore the available dropdown menus to change the fields to be searched.

When searching, remember to:

Adapt your search and keep trying.

Searching for information is a process and you won't always get it right the first time. Improve your results by changing your search and trying again until you're happy with what you have found.

Keep track of your searches

Keeping track of searches saves time as you can rerun them, store references, and set up regular alerts for new research relevant to your topic.

Most library databases allow you to register with a personal account. Look for a 'log in', 'sign in' or 'register' button to get started.

• Literature review search tracker (Excel spreadsheet)

Manage your references

There are free and subscription reference management programs available on the web or to download on your computer.

• EndNote - The University has a license for EndNote. It is available for all students and staff, although is recommended for postgraduates and academic staff.
• Zotero - Free software recommended for undergraduate students.
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• URL: https://uow.libguides.com/literaturereview

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Literature Searching

Introduction

Why do a literature search.

Literature searching is a critical component for any research project.  It is the part of the project where you perform a thoroughly thought-out and well-organized search in the available research literature, usually conducted in a bibliographic database, to identify the depth and breadth of good quality articles and other publications on a specific topic.  Literature searching is an iterative process, where you would repeat the process a number of times to ensure that you have found, to the best of your ability, as many relevant references on your topic as possible.

The reasons for conducting a literature search are numerous and include, but are not limited to:

• short fact-finding forays, to acquire background information on a topic,
• getting insight into the scope and breath of the literature on a particular topic,
• determining whether or not; or to what extent, research on a topic has already been done - --
• to the immensely comprehensive and lengthy evidence synthesis (https://evidencesynthesis.org/what-is-evidence-synthesis/), such as systematic reviews.

The ultimate goal of a literature search is to gain knowledge. 

In addition, a literature search helps:

• to clarify or refine the research problem or question under consideration,
• checks to see if similar research has already been done on the topic,
• verifies that this is an important problem or question which needs answering or more research,
• highlights or fills in gaps of existing knowledge or research,
• helps to find measurement instruments, research methods or techniques,
• reveals/uncovers/discloses terminology related to the field/topic and,
• identifies researchers with similar interests.

References/Additional Resources

Brettle A., Gambling, T. (2003). Needle in a haystack? Effective literature searching for research . Radiography, 9(3), 229–236.

vom Brocke, J., Simons, A., Riemer, K., Niehaves, B., Plattfaut, R. and Cleven, A. (2015) Standing on the Shoulders of Giants: Challenges and Recommendations of Literature Search in Information Systems Research . Communications of the Association for Information Systems,  37, Article 9.

Grewal, A., Kataria, H., & Dhawan, I. (2016). Literature search for research planning and identification of research problem . Indian journal of anaesthesia, 60(9), 635–639.

Watson M. (2020). How to undertake a literature search: a step-by-step guide.  British journal of nursing (Mark Allen Publishing), 29(7), 431–435.

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Researcher skills, literature searching explained.

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1. What is a literature search?

2. Decide the topic of your search

3. Identify the main concepts in your question

4. Choose a database

What is a literature search?

A literature search is a considered and organised search to find key literature on a topic. To complete a thorough literature search you should:

• define what you are searching for
• decide where to search
• develop a search strategy
• refine your search strategy
• save your search for future use.

For background reading or an introduction to a subject, you can do a shorter and more basic  Library search .

Use this guide to work your way through the all the stages of the literature searching process.

You should form a search question before you begin. Reframing your research project into a defined and searchable question will make your literature search more specific and your results more relevant.

Decide the topic of your search

You should start by deciding the topic of your search. This means identifying the broad topic, refining it to establish which particular aspect of the topic interests you, and reframing that topic as a question.

For example:

Broad topic:  active learning and engagement in higher education

Main focus topic:  international students and online learning

Topic stated as a question:  "What is the role of active learning in improving the engagement of international students during online learning?"

Identify the main concepts in your question

Once you have a searchable question, highlight the major concepts. For example: "What is the role of  active learning  in improving the  engagement  of  international students  during  online learning ?"

You should then find keywords and phrases to express the different concepts. For example, the concept “active learning” covers a wide range of key terms, including student-based learning, problem solving and paired discussion.

It may be useful to create a concept map. First identify the major concepts within your question and then organise your appropriate key terms.

If you are researching a medicine or health related topic then you might want to use a PICO search model. PICO helps you identify the Patient, Intervention, Comparison and Outcome concepts within your research question.

P atient: Who is the treatment being delivered to? What is happening to the patient?

I ntervention: What treatment is being delivered? What is happening to the patient?

Comparison: How much better is the procedure than another? What are the alternatives?

Outcome: How is the effect measured? What can be achieved?

List synonyms for each concept. You may wish to include variant spellings or endings (plural, singular terms). Exclude parts of the PICO that do not relate to your search question. For example, you may not be drawing any comparisons in your research.

Choose a database

Subject-specific databases are the most effective way to search for journal articles on a topic. However, you can also search the Library for common information sources, such as government documents, grey literature, patents and statistics.

Find the most appropriate databases for your subject

Databases help you to find a broad range of evidence, including peer-reviewed academic articles from all over the world, from many different publishers, and over a long time period.

Databases such as Scopus and Web of Science hold expansive records of research literature, including conference proceedings, letters and grey literature.

Many databases have links to full-text articles where the Library has a subscription.

Other information sources

Go to your  subject-specific page  to see the most appropriate information sources listed for your subject area. You may need to explore more than one subject page if your topic is multi-disciplinary.

You may find it useful to make a list of which information sources you want to search to find information for your research;  a search activity template (DOCX)  can help you do this.

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Searching the Literature: The Basics

• Getting Started
• Ask a Question
• Select a Search Resource
• Develop Search Terms
• Execute the Search
• Access/Save Results
• Evaluate & Improve Your Search
• Database Fundamentals This link opens in a new window
• Ovid Medline This link opens in a new window
• CINAHL This link opens in a new window
• Cochrane Library This link opens in a new window
• PubMed This link opens in a new window
• Web of Science This link opens in a new window
• Google Scholar This link opens in a new window
• Additional Resources

What is a Literature Search?

A literature search is the act of gathering existing knowledge or data around a topic or research question.  

Regardless of the purpose of your literature search, all searches follow the same basic process:

• Ask a question
• Select a search resource
• Develop search terms
• Execute the search
• Access results
• Evaluate & improve your search

Each page in this guide explores a different step of the process and lays the groundwork for the following steps.

Why Search the Literature?

E.g. "I want to learn more about treatment options available for quitting smoking."

E.g. "I need some statistics for how smoking rates have changed over the last 20 years."    

E.g. "I'm designing a research study on the effectiveness of hypnosis for smoking cessation.  What's been done before?  What areas need further investigation?"    

E.g. "I want to gather and synthesize all the existing studies that help answer the following research question: Are support groups more effective than nicotine-replacement products for helping teenagers quit smoking?"

E.g. "What treatment should I recommend to my teenage patient interested in quitting smoking?"

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• Steps in Conducting a Literature Review

What is a literature review?

A literature review is an integrated analysis -- not just a summary-- of scholarly writings and other relevant evidence related directly to your research question.  That is, it represents a synthesis of the evidence that provides background information on your topic and shows a association between the evidence and your research question.

A literature review may be a stand alone work or the introduction to a larger research paper, depending on the assignment.  Rely heavily on the guidelines your instructor has given you.

Why is it important?

A literature review is important because it:

• Explains the background of research on a topic.
• Demonstrates why a topic is significant to a subject area.
• Discovers relationships between research studies/ideas.
• Identifies major themes, concepts, and researchers on a topic.
• Identifies critical gaps and points of disagreement.
• Discusses further research questions that logically come out of the previous studies.

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

Your literature review should be guided by your central research question.  The literature represents background and research developments related to a specific research question, interpreted and analyzed by you in a synthesized way.

• Make sure your research question is not too broad or too narrow.  Is it manageable?
• Begin writing down terms that are related to your question. These will be useful for searches later.
• If you have the opportunity, discuss your topic with your professor and your class mates.

2. Decide on the scope of your review

How many studies do you need to look at? How comprehensive should it be? How many years should it cover? 

• This may depend on your assignment.  How many sources does the assignment require?

3. Select the databases you will use to conduct your searches.

Make a list of the databases you will search. 

Where to find databases:

• use the tabs on this guide
• Find other databases in the Nursing Information Resources web page
• More on the Medical Library web page
• ... and more on the Yale University Library web page

4. Conduct your searches to find the evidence. Keep track of your searches.

• Use the key words in your question, as well as synonyms for those words, as terms in your search. Use the database tutorials for help.
• Save the searches in the databases. This saves time when you want to redo, or modify, the searches. It is also helpful to use as a guide is the searches are not finding any useful results.
• Review the abstracts of research studies carefully. This will save you time.
• Use the bibliographies and references of research studies you find to locate others.
• Check with your professor, or a subject expert in the field, if you are missing any key works in the field.
• Ask your librarian for help at any time.
• Use a citation manager, such as EndNote as the repository for your citations. See the EndNote tutorials for help.

Review the literature

Some questions to help you analyze the research:

• What was the research question of the study you are reviewing? What were the authors trying to discover?
• Was the research funded by a source that could influence the findings?
• What were the research methodologies? Analyze its literature review, the samples and variables used, the results, and the conclusions.
• Does the research seem to be complete? Could it have been conducted more soundly? What further questions does it raise?
• If there are conflicting studies, why do you think that is?
• How are the authors viewed in the field? Has this study been cited? If so, how has it been analyzed?

Tips: 

• Review the abstracts carefully.  
• Keep careful notes so that you may track your thought processes during the research process.
• Create a matrix of the studies for easy analysis, and synthesis, across all of the studies.
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Conducting a winning literature search

Erika d. ecker.

1 Spectrum Research, Inc., Tacoma, Washington, USA

Andrea C. Skelly

So what is a “winning literature search”? Simply put, it is one that provides you with the information you need to find the types of articles that will help you with clinical practice or research. Literature searching is a combination of an art and a science. Understanding the basic anatomy and physiology of searching can get you started on finding the information you need.

I. Anatomy of a Literature Search—The Skeleton

A. constructing an appropriate question.

• Asking the right question is the primary key to creating a winning search. Your questions must be answerable. If your question is too broad, your search will yield more information than you can possibly look through.

Similarly, if your study was prognostic rather than therapeutic, a PPO table would be used instead of the PICO table in order to help formulate your question. Thus, the categories would change to Patients, Prognostic factors, and Outcome.

⇛ Using treatment studies as an example, the PICO concept can really help you create an answerable question since, as you will see below, it will help you create a search strategy.

B. Using the appropriate database(s)

Now that you have honed your question, it is time to focus on efficient article retrieval. What type of information is needed and what type of articles do you need? What will you do with the information you gather? This will determine the type of information you need and types of articles that may provide that information. It also may influence the type of database you search for that information.

• Bibliographic databases contain references to published literature, such as journals and newspaper articles, conference proceedings and papers, reports, government and legal publications, patents, and books.
• Peer-reviewed literature is scholarly work that generally represents the latest original research in a field. These articles undergo expert screening before publication to ensure meaningfulness within the context of other research in the discipline and, at least in theory, sound methodology.
• “Gray” literature refers to material that is not formally published by commercial publishers or peer-reviewed journals, including reports, fact sheets, white papers, conference proceedings, and other documents from various organizations and government agencies.

The table below provides brief descriptions of common databases and sources to search both peer-reviewed and gray literature.

For example, continuing with our question regarding complications after ADR versus fusion, which type of database listed in the table makes the most sense to search? Indexed peer-reviewed articles will give us the best available and most current data and MEDLINE, which includes millions of citations for biomedical articles and can be accessed using PubMed for free, seems like a great starting place. Generally speaking, PubMed will be the best place to begin your search and there are various ways, as you will see below, to refine and limit your search in order to find exactly what you need.

II. The Physiology of Literature Searching—How It Works

Now that you have an answerable question and an idea of what type of database you need to search (at least to start), let's talk about the nuts and bolts of searching. For the purposes of this paper, we will use PubMed as the search engine.

A. Getting specific—the basics of “how to”

1. Quickstart:

• Type a word or phrase into the query box, including subject, author, and/or journal
• Click on the search button or press the “enter” key

• To retrieve more information about the search results, use the display settings menu (upper left corner) to view the abstract or MEDLINE formats, change the number of items that appear per page, and sort by recently added, publication date, first author, last author, journal, or title.
• PubMed also contains links to full-text articles (appears in upper right corner of page) at participation publishers' web sites as well as links to other third party sites such as libraries and sequencing centers.

⇛ Anything which appears in blue and is underlined is a link that reveals more information. Clicking on the title would bring up the abstract (Abstract format). Clicking on “Related articles” would provide a link to other similar articles that might be of interest.

2. Advanced searching in PubMed—MeSH terms and the MeSH database:

a. Medical subject headings (MeSH)

It is important to understand that PubMed uses a controlled vocabulary to index journal articles called MeSH and uses “automatic term mapping” to find MeSH terms when you search. MeSH terms are organized in a hierarchy called a tree, with more specific (narrower) terms arranged beneath broader terms. By default, PubMed includes in the search all narrower terms; this is called “exploding” the MeSH term. Inclusion of MeSH terms enhances and optimizes the search strategy. For example, if you looked up the term “Spine” in the MeSH database you would see ​ see :

Therefore, PubMed would retrieve every article containing any of the terms located under Spine in the hierarchy.

b. MeSH database features

MeSH vocabulary contains over 25,000 descriptors and is updated weekly and reviewed annually. You can only search citations that have been indexed for MEDLINE (92% of the PubMed database) using MeSH terms. Features include:

• Allows you to identify and select appropriate MeSH terms for a search and to see their definitions
• Builds a PubMed search strategy
• Displays MeSH terms in the hierarchy (MeSH tree) allowing you to broaden/narrow a search
• Limits MeSH terms to a major concept/topic heading for a search
• Allows you to broaden your search by choosing not to explode a term
• The list of subheadings includes terms paired at least once with a given heading in MEDLINE.
• Focuses searches using other types of MeSH terms including publication types [pt], substance names [nm] or registry numbers [rn], and pharmaceutical actions [pa]
• MeSH Brower for access to annotations: http://www.nlm.nih.gov/mesh/

To access MeSH from PubMed, click on MeSH Database on the PubMed homepage or click MeSH under “more resources” in “advanced search.”

Once in the MeSH database, if you entered cancer into the search bar and clicked Go (or hit Enter) you would see ​ see :

Clicking on “neoplasms” will bring up the page where you have the option of selecting any of the features listed above to help you refine your search.

Also, clicking “links” adjacent to the MeSH term desired, will give you a drop-down menu which offers several options:

• PubMed: search PubMed with the term
• PubMed—Major topic: search PubMed with the MeSH term, retrieving only citations where the term is a major focus
• Clinical queries: put the MeSH term into the Clinical Queries box where the search may be further refined
• NLM MeSH browser: show the MeSH browser descriptor data for this term including scope note, allowable qualifiers, and the MeSH tree

⇛ The Mesh database homepage includes three brief tutorials on how to search with the MeSH database, combine MeSH terms, and apply subheadings and other features of the MeSH database.

B. Too much information! Refining your search

• Replace general search terms with more specific terms (the MeSH database would be a great resource for this)
• AND between terms returns only records that contain all of the search terms
• OR between terms returns all records that contain any of the search terms
• NOT between search terms returns only records that contain the first term and not the second
• Example: mimic* will find all terms that begin with the letters m-i-m-i-c-; eg, mimic, mimics, mimicking
• Example: behavio?r will find behaviour or behavior
• Use the “limit” option in PubMed to limit citations by age group, language, publication type, date, human studies, etc.
• Use the “advanced search” option to look up a term as it is indexed in PubMed
• Use the MeSH database features

Let's say we are interested in what the best surgical treatment is for osteoporotic spine fractures. Using some of the tips above, the chart below shows how a typical search might go: ​ go:

By combining terms (using Boolean logic), truncating a term, and using the limits option we were able to narrow our search down from 16,023 articles to a more manageable and relevant 54 articles. The “details” tab in the PubMed search window shows the complete search expression (ie, query translation) employed by PubMed, similar to what is represented in the table above. ​ above.

One of the best resources that PubMed provides for users new to the database is the online tutorials. They are brief but informative and because they are interactive you are guided step-by-step through each process. Perhaps consulting the online tutorials and the fact sheets on PubMed would be a next step for you. Give it a try! In fact, here is the link to the PubMed Tutorial homepage created by the National Library of Medicine: http://www.nlm.nih.gov/bsd/disted/pubmedtutorial/ . Also, check-out the PubMed help page which contains a plethora of information regarding all aspects of PubMed: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=helppubmed&part=pubmedhelp

III. Closing Thoughts

Remember, literature searching is a combination of an art and a science. It requires practice, intuition, and some trial and error. While there is a basic structure, a set of guidelines and many tools for assisting one with basic searches, there are a variety of nuances and advanced techniques that may be required for more specialized searches. For systematic reviews as an example, extensive searches are required and may take numerous hours, involving many databases (including those for gray literature), and a combination of advanced search strategies in order to be methodologically sound. Use of personnel with specialized expertise in conducting such searches may provide the best results and be the most resource effective.

How to do a Literature Search: Introduction

• Introduction
• Choosing a database
• Choosing keywords
• Using keywords
• Author searching
• Managing your search/results

What is a literature review?

You may be asked to write a literature review as part of an undergraduate project or postgraduate dissertation.  A well-conducted literature review will showcase your ability to:

• Survey the literature and select the most important contributions on your topic
• Critically evaluate the literature to identify key developments, trends, issues, gaps in knowledge
• Present your findings in a clear and coherent manner

The structure of a literature review may vary according to your specific subject but it will normally include these three areas:

• Introduction : an overview of your topic explaining why it is important, putting it in the wider context and perhaps highlighting recent progress and future potential.  It may also explain the scope and the organisation of your review.
• Main body : a discussion of how research in the topic has progressed to date, critically evaluating the key studies and explaining their significance.  
• Conclusion : a summary of current knowledge, highlighting any gaps in current knowledge or practice and suggesting how these may be overcome in future research.

Having identified the topic of your review, the first step will be to undertake a literature search .  

What is a literature search?

Define your research question(s).

Before you login to a database to begin your search it's crucial that you analyse your topic, breaking it down into a number of research questions.

Take, for example, this topic:   Are biofuels the answer to falling oil reserves?

You  could  type this sentence into a database search box, but that is usually not helpful, as the sentence may not contain the most appropriate keywords.  Also this single sentence is unlikely to encompass everything that you want to find out.  You need to break down the topic into a number of separate questions and then look for the answers. For this example here are some of the questions you could ask:

• What is a biofuel?  
• How are they made?
• How much of our fuel is already from biofuel (market share)?
• Could we make enough to replace oil and/or gas?
• What are the advantages and disadvantages of using biofuels compared with oil and gas?
• Could we use biofuels for transport?
• What is UK government policy relating to biofuels?

You  may  find the answers to all of these questions using a single search engine such as Google Scholar, or a single Library database, but you are more likely to succeed if you match each question to a relevant source .

Introduction to literature searching

Library video (10 minutes)

• Next: Choosing a database >>
• Last Updated: Nov 22, 2022 9:56 AM
• URL: https://library.bath.ac.uk/literaturesearch

• Submission Guidelines

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Learning Objectives

(1) Explain steps in conducting a literature search

(2) Identify resources to utilize in a literature search

(3) Perform an online literature search using U of U Health resources

Valentina is a third year pediatric resident who notices that many of the teenagers she sees in clinic use their phones to play games and connect with friends and family members. She wonders if there could be an app for teenagers to manage their chronic diseases, specifically type 1 diabetes. But where does she begin? 

What is a literature search?

iterature search is a comprehensive exploration of published literature with the purpose of finding scholarly articles on a specific topic . Managing and organizing selected scholarly works can also be useful.

Why do a literature search?

Literature search is a critical component for any evidence-based project. It helps you to understand the complexity of a clinical issue, gives you insight into the scope of a problem, and provides you with best treatment approaches and the best available evidence on the topic. Without this step, your evidence-based practice project cannot move forward.

Five steps for literature search success

There are several steps involved in conducting a literature search. You may discover more along the way, but these steps will provide a good foundation. 

Plan using PICO(T) to develop your clinical question and formulate a search strategy.

Identify a database to search.

Conduct your search in one or more databases.

Select relevant articles .

Organize your results . Remember that searching the literature is a process.

#1: Plan using PICO(T)

The PICO(T) question framework is a formula for developing answerable, researchable questions. Using PICO(T) guides you in your search for evidence and may even help you be more efficient in the process ( Click here to learn all about PICO(T) ). 

Once you have your PICO(T) question you can formulate a search strategy by identifying key words, synonyms and subject headings. These can help you determine which databases to use. 

#2: Identify a database

For your search, you will need to consult a variety of resources to find information on your topic. While some of these resources will overlap, each also contains unique information that you won’t find in other databases.  

The "Big 3" databases: Embase, PubMed, and Scopus are always important to search because they contain large numbers of citations and have a fairly broad scope. ( Click here to access these databases and others in the library's A to Z database.) 

In addition to searching these expansive databases, try one that is more topic specific.

We are here to help.

If you are conducting a literature search and are not certain of the details, don't panic! U of U Health has a wealth of resources, including experienced librarians, to help you through the process. Learn more here. 

Utah’s Epic-embedded librarian support

Did you know you can request evidence-based information from the library directly through Epic?  Contact us through Epic’s Message Basket.

Eccles Health Sciences medical librarians are able to provide expertise in articulating the clinical question, identifying appropriate data sources, and locating the best evidence in the shortest amount of time. You can also send a message to ASK EHSL .

#3: Conduct your search

Now that you have identified pertinent databases, it is time to begin the search!

Use the key words that you’ve identified from your PICO(T) question to start searching. You might start your search broadly, with just a few key words, and then add more once you see the scope of the literature. If the initial search doesn't produce many results, you can play with removing some key words and adding more granular detail.

In our intro case study, Valentina’s population is teenagers with type 1 diabetes and her intervention is a mobile app. Watch the video below to see how Valentina uses the powerful Embase PICO search feature to identify synonyms for type 1 diabetes, mobile apps, and teenagers.

Example of   Embase using PICO Why use Embase? This search casts a wider net than most databases for more results.

Common Search Terms and Symbols

AND Includes both keywords Narrows search OR Either keyword/concept Combine synonyms and similar concepts Expands search "Double quotes"  Specific phrase Wildcard* Any word ending variants (singular, plural, etc.) Example: nurs* = nurse, nurses, nursing, etc.

Controlled Vocabulary

Want to help make your search more accurate? Try using the controlled vocabulary, or main words or phrases that describe the main themes in an article, within databases. Controlled vocabulary is a standardized hierarchical system. For example, PubMed uses Medical Subject Headings or MeSH terms to “map” keywords to the controlled vocabulary. Not all databases use a controlled vocabulary, but many do. Embase’s controlled vocabulary is called Emtree, and CINAHL’s  controlled vocabulary is called CINAHL Headings. Consider focusing the controlled vocabulary as the major topic when using MeSH, Emtree, or CINAHL Headings. 

For Valentina’s question, there are MeSH terms for Adolescent, Diabetes Mellitus, Type 1, and Mobile Applications.

Example of  PubMed using MeSH MeSH helps focus your PubMed search

Talk with your librarians for more help with searching with controlled vocabularies. 

Every database uses filters to help you narrow your search. There are different filters in each database, but they tend to work in similar ways. Use filters to help you refine your search, rather than adding those keywords to the search. Filters include article/publication type, age, language, publication years, and species.

Using filters can help return the most accurate results for your search.

Article/publication types, such as randomized controlled trial, systematic reviews, can be used as filters.

Use an Age Filter, rather than adding “pediatric” or “geriatric” to your search.

Valentina uses the age filter for her question rather than as a keyword in the video below.

Example of a PubMed keyword search using filters PubMed is the most common search because it is the most widely available.

#4: Select relevant articles

Once you have completed your search, you’ll select articles that are relevant to your question. Some databases also include a “similar articles” feature which recommends other articles similar to the article you’re reviewing—this can also be a helpful tool.

When you’ve identified an article that appears relevant to your topic, use the “Snowballing” technique to find additional articles. Snowballing involves reviewing the reference lists of articles from your search. 

In other words, look at your key articles and review their reference list for additional key or seminal articles to aid in your search.

#5: Organize your results

As you begin to collect articles during your literature search, it is important to store them in an organized fashion. Most research databases include personalized accounts for storing selected references and search strategies. 

Reference managers are a great way to not only keep articles organized, but they also generate in-text citations and bibliographies when writing manuscripts, and provide a platform for sharing references with others working on your project.

A number of reference managers—such as Zotero , EndNote , RefWorks, Mendeley , and Papers are available. EndNote Basic (web-based) is freely available to U of U faculty, staff and students. If you need help with this process, contact a librarian to help you select the reference manager  that will best suit your needs.

Using these steps, you’re ready to start your literature search. It is important to remember that there is not a right or wrong way to do the search. Literature searches are an iterative process—it will take some time and negotiation to find what you are looking for. You can always change your approach, or the information resource you are using. The important thing is to just keep trying. And before you get frustrated or give up, contact a librarian . They are here to help!

This article originally appeared May 12, 2020. It was updated to reflect current practice on March 14, 2021.

Tallie Casucci

Barbara wilson.

You have a good idea about what you want to study, compare, understand or change. But where do you go from there? First, you need to be clear about exactly what it is you want to find out. In other words, what question are you attempting to answer? Librarian Tallie Casucci and nursing leaders Gigi Austria and Barb Wilson help us understand how to formulate searchable, answerable questions using the PICO(T) framework.

EBP, or evidence-based practice, is a term we encounter frequently in today’s health care environment. But what does it really mean for the health care provider? College of Nursing interim dean Barbara Wilson and Nurse manager Gigi Austria explain how to integrate EBP into all aspects of patient care.

Frequent and deliberate practice is critical to attaining procedural competency. Cheryl Yang, pediatric emergency medicine fellow, shares a framework for providing trainees with opportunities to learn, practice, and maintain procedural skills, while ensuring high standards for patient safety.

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Literature Searching

In this guide.

• Introduction
• Steps for searching the literature in PubMed
• Step 1 - Formulate a search question
• Step 2- Identify primary concepts and gather synonyms
• Step 3 - Locate subject headings (MeSH)
• Step 4 - Combine concepts using Boolean operators
• Step 5 - Refine search terms and search in PubMed
• Step 6 - Apply limits

Formulating a Well-Defined, Answerable Research Question

It is important to develop a well-defined, answerable research question because it

• Defines the focus of your literature search
• Identifies the appropriate study design and methods
• Makes searching for evidence simpler and more effective
• Helps you identify relevant results and separate relevant results from irrelevant ones

Tips for developing a clinical research question:

• The question is directly relevant to the most important health issue for the patient
• The question is focused and when answered, will help the patient the most
• The question is phrased to facilitate a targeted literature search for precise answers

Adopted from CEBM:  what makes a good clinical question

Example of a vague question:

"Is mobile technology good at managing diabetes?"

• Mobile technology is very broad. Mobile apps, mobile phones, voice/text? 
• What does “good” mean? How will you determine if the technology is effective?
• What kind of diabetes? Type 1? Type 2? Both?
• Who are the “patients”? Adults? Adolescents? Women? Patients with specific diagnoses?
• Any time frame?

Example of a well-defined question:

"Are mobile health technology interventions more effective in managing patients with Type 1 or Type 2 diabetes than in-person care?"

PICO Framework

PICO or PICO(T) (patient/problem/population, intervention, comparison, outcome, time) is a well-known approach for framing a research question. It divides the research question into key components making it easy and searchable.

Example:  "Are mobile health technology interventions more effective in managing patients with Type 1 or Type 2 diabetes than in-person care?"

Other question formulation frameworks:

PIE  (Population, Intervention, Effect / Outcome)

SPIDER  (Sample, Phenomena of Interest, Design, Evaluation, Research type)

SPICE  (Setting, Perspective, Intervention, Comparison, Evaluation)

ECLIPSE (Expectation, Client group, Location, Impact, Professionals, Service)

• << Previous: Steps for searching the literature in PubMed
• Next: Step 2- Identify primary concepts and gather synonyms >>
• Last Updated: Jul 10, 2024 2:17 PM
• URL: https://laneguides.stanford.edu/LitSearch

• University of Michigan Library
• Research Guides

The Library Research Process, Step-by-Step

• Finding Articles
• Finding & Exploring a Topic
• Finding Books
• Evaluating Sources
• Reading Scholarly Articles
• Understanding & Using a Citation Style

Peer Reviewed and Scholarly Articles

What are they? Peer-reviewed articles, also known as scholarly or refereed articles are papers that describe a research study. 

Why are peer-reviewed articles useful? They report on original research that have been reviewed by other experts before they are accepted for publication, so you can reasonably be assured that they contain valid information. 

How do you find them?  Many of the library's databases contain scholarly articles! You'll find more about searching databases below.

Watch: Peer Review in 3 Minutes

Why watch this video?

We are often told that scholarly and peer-reviewed sources are the most credible, but, it's sometimes hard to understand why they are credible and why we should trust these sources more than others. This video takes an in depth approach at explaining the peer review process. 

Hot Tip: Check out the Reading Scholarly Articles page for guidance on how to read and understand a scholarly article.

Using Library Databases

What Are Library Databases? 

Databases are similar to search engines but primarily search scholarly journals, magazines, newspapers and other sources. Some databases are subject specific while others are multi-disciplinary (searching across multiple fields and content types). 

You can view our most popularly used databases on the Library's Home Page , or view a list of all of our databases organized by subject or alphabetically at  U-M Library Databases .

Popular Multidisciplinary Databases

Many students use ProQuest , JSTOR , and Google Scholar for their initial search needs. These are multi-disciplinary and not subject-specific, and they can supply a very large number of  search results.

Subject-Specific Databases

Some popular subject-specific databases include PsycINFO for psychology and psychiatry related topics and  PubMed for health sciences topics. 

Why Should You Use Library Databases?

Unlike a Google search, the Library Databases will grant you access to high quality credible sources. 

The sources you'll find in library databases include:

• Scholarly journal articles
• Newspaper articles
• Theses & dissertations
• Empirical evidence

Database Filters & Limits Most databases have Filters/Limits. You can use these to narrow down your search to the specific dates, article type, or population that you are researching.

Here is an example of limits in a database, all databases look slightly different but most have these options:

Keywords and Starting a Search

What are Keywords?

• Natural language words that describe your topic 
• Allows for a more flexible search - looks for anywhere the words appear in the record
• Can lead to a broader search, but may yield irrelevant results

Keyword searching  is how we normally start a search. Pull out important words or phrases from your topic to find your keywords.

Tips for Searching with Keywords:

• Example: "climate change"
• Example:  "climate change" AND policy
• Example: comput* will return all words starting with four letters; computing, computer, compute, etc.  
• Example: wom?n will find both woman and women.

What are Subject Headings?

• Pre-defined "controlled vocabulary" that describe what an item is  about 
• Makes for a less flexible search - only the subject fields will be searched
• Targeted search; results are usually more relevant to the topic, but may miss some variations

Subject Terms and/or Headings are pre-defined terms that are used to describe the content of an item. These terms are a controlled vocabulary and function similarly to hashtags on social media. Look carefully at the results from your search. If you find an article that is relevant to the topic you want to write about, take a look at the subject headings. 

Hot Tip: Make a copy of this Google Doc to help you find and develop your topic's keywords.

More Database Recommendations

Need articles for your library research project, but not sure where to start? We recommend these top ten article databases for kicking off your research. If you can't find what you need searching in one of these top ten databases, browse the list of all library databases by subject (academic discipline) or title .

• U-M Library Articles Search This link opens in a new window Use Articles Search to locate scholarly and popular articles, as well as reference works and materials from open access archives.
• ABI/INFORM Global This link opens in a new window Indexes 3,000+ business-related periodicals (with full text for 2,000+), including Wall Street Journal.
• Academic OneFile This link opens in a new window Provides indexing for over 8,000 scholarly journals, industry periodicals, general interest magazines and newspapers.
• Access World News [NewsBank] This link opens in a new window Full text of 600+ U.S. newspapers and 260+ English-language newspapers from other countries worldwide.
• CQ Researcher This link opens in a new window Noted for its in-depth, unbiased coverage of health, social trends, criminal justice, international affairs, education, the environment, technology, and the economy.
• Gale Health and Wellness This link opens in a new window
• Humanities Abstracts (with Full Text) This link opens in a new window Covers 700 periodicals in art, film, journalism, linguistics, music, performing arts, philosophy, religion, history, literature, etc.
• JSTOR This link opens in a new window Full-text access to the archives of 2,600+ journals and 35,000+ books in the arts, humanities, social sciences and sciences.
• ProQuest Research Library This link opens in a new window Indexes over 5,000 journals and magazines, academic and popular, with full text included for over 3,600.
• PsycInfo (APA) This link opens in a new window Premier resource for surveying the literature of psychology and adjunct fields. Covers 1887-present. Produced by the APA.

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How to Start a Research Paper: A Comprehensive Guide

Starting a research paper can feel overwhelming, especially if you're new to the process. This guide will walk you through each step, from picking a topic to polishing your final draft. By breaking down the process into manageable parts, you'll find it easier to stay organized and focused. Let's dive in and make your research paper a success!

Key Takeaways

• Choose a topic that interests you and has enough resources available.
• Formulate a clear research question to guide your study.
• Conduct a thorough literature review to understand existing research.
• Develop a detailed research plan, including methodology and timeline.
• Ensure proper citation to maintain academic integrity.

Choosing a Research Topic

Choosing a research topic is a crucial first step in writing a research paper. It sets the foundation for your entire project . Here are some key steps to help you choose the right topic.

Formulating a Research Question

Understanding the Importance of a Research Question

A well-defined research question is the cornerstone of any successful research paper. It acts as a compass, guiding your study and ensuring that you stay on track. Without a clear research question, your paper may lack focus and coherence. This question helps you narrow down your topic and provides a clear direction for your research.

Techniques for Crafting a Strong Research Question

To craft a strong research question, start by identifying a specific issue or problem within your topic. Use the following steps:

• Identify a gap in the existing literature or a problem that needs solving.
• Make sure your question is clear and concise, avoiding vague terms.
• Ensure that your question is researchable within the scope of your resources and time.
• Align your question with your research objectives to maintain focus.

Aligning the Research Question with Objectives

Your research question should align closely with your research objectives. This alignment ensures that every part of your study is interconnected and supports your overall goals. A well-aligned research question not only clarifies your study's purpose but also helps in structuring your paper effectively.

Conducting a Literature Review

Gathering relevant sources.

Start by collecting sources that are related to your research topic. Use libraries, online databases, and academic journals to find books, articles, and papers. Skimming sources instead of reading each one fully can save you time. If a source seems useful, set it aside for a more in-depth read later.

Analyzing Existing Research

Once you have gathered your sources, read through them and take notes on key points. Pay attention to different viewpoints and how they relate to your research question. This will help you understand the current state of research in your field. To elevate your essay , start with a comprehensive literature review to ground your work in relevant scholarship.

Identifying Research Gaps

Look for areas that haven't been explored or questions that haven't been answered in the existing research. These gaps can provide a direction for your own research and make your thesis more valuable. Defining your research question and following a methodical process to synthesize findings is crucial. This step is essential in the steps in the literature review process .

Developing a Research Plan

Creating a solid research plan is crucial for the success of your thesis. It helps you stay organized and ensures that you cover all necessary aspects of your research.

Writing the Thesis Introduction

Starting your thesis introduction can be daunting, but it's crucial for setting the stage for your research. Establishing the context for your study helps readers understand the background and significance of your work. This section should provide a clear overview of what your thesis will cover, making it easier for readers to follow your arguments.

Establishing Context

Begin by providing some background information on your topic. This helps to set the stage and gives your readers a sense of what to expect. Make sure to include relevant literature and previous studies to show how your research fits into the existing body of work. This is essential for demonstrating the importance of your research .

Crafting a Thesis Statement

Your thesis statement is the heart of your introduction. Typically, it is placed at the end of the introductory paragraph. This statement should succinctly present the main argument or focus of your thesis, guiding the reader on what to expect. A clear and concise thesis statement is crucial for a strong introduction.

Providing an Overview of the Study

Finally, outline the structure of your thesis. This roadmap will help readers navigate through your work, knowing what each section will address. By clearly presenting the layout, you reduce thesis anxiety and make your research more accessible.

Choosing a Research Methodology

Choosing the right research methodology is crucial for the success of your study. It determines how you will collect and analyze data, and ultimately, how you will answer your research question. Here are some key points to consider when selecting a methodology.

Qualitative vs. Quantitative Methods

First, decide whether your research will be qualitative, quantitative, or a mix of both. Qualitative research focuses on understanding concepts, thoughts, or experiences. It often involves interviews, focus groups, or content analysis. On the other hand, quantitative research aims to quantify the problem by way of generating numerical data or data that can be transformed into usable statistics. This often involves surveys, experiments, or secondary data analysis.

Selecting Data Collection Tools

Once you've chosen between qualitative and quantitative methods, the next step is to select the appropriate data collection tools. For qualitative research, you might use interviews, focus groups, or observational methods. For quantitative research, consider surveys, experiments, or existing datasets. The choice of tools should align with your research objectives and the type of data you need to collect.

Justifying Methodological Choices

Finally, it's essential to justify your methodological choices. Explain why the selected methods are suitable for your research and how they will help you achieve your objectives. This step is crucial for gaining approval from stakeholders and ensuring the success of your project. Make sure to address any potential limitations and how you plan to mitigate them.

Organizing Research Materials

Creating a categorization system.

To start, you need a system to categorize your research materials. This can be as simple as using folders on your computer or as advanced as specialized software. Organizing your notes into categories helps you find information quickly. You can use sticky notes or a mind map to group related ideas. This step is crucial for keeping your research structured and accessible.

Using Reference Management Software

Using reference management software like Zotero or Mendeley can save you a lot of time. These tools help you keep track of your sources and format citations correctly. They also allow you to create a library of references that you can easily search through. This is especially useful when you need to cite sources in your paper.

Synthesizing Information

Synthesizing information means combining ideas from different sources to create a comprehensive understanding of your topic. Look for common themes, debates, and gaps in the literature. This will help you formulate a strong research question and provide a solid foundation for your thesis. Summarizing and integrating findings from various sources will make your research more robust and credible.

Drafting the Research Paper

Writing the First Draft

Once your outline is ready, it's time to start writing your first draft. This is the longest step, but if you've prepared well, it should go smoothly. Begin with your thesis statement and then fill out the introduction with secondary information. The body of your paper will contain the bulk of your research, divided into sections with headers for easy navigation. Don't worry about perfection at this stage ; focus on getting your ideas down .

Incorporating Feedback

After completing your first draft, seek feedback from your supervisor and peers . Their insights can help you see your work from different perspectives and identify areas for improvement. Revising is a continuous process of re-seeing your writing, considering larger issues like focus, organization, and audience.

Polishing the Final Draft

Finally, polish your final draft. Pay attention to grammar, punctuation, and formatting. Ensure that your thesis is clear, concise, and free of errors. This step is crucial for making a strong impression and effectively communicating your research findings.

Maintaining Academic Integrity

Proper citation practices.

Proper citation is essential to uphold academic integrity. Always give credit to the original authors of the sources you use. This not only helps you avoid plagiarism but also strengthens your arguments by backing them up with credible sources. Citing your sources correctly is a fundamental aspect of academic writing.

Avoiding Plagiarism

Plagiarism is a serious offense in the academic world. It involves using someone else's work without giving them credit. To avoid plagiarism, make sure to paraphrase correctly and use quotation marks when directly quoting someone. Utilize plagiarism detection tools to ensure your work is original.

Ensuring Credibility of Sources

Using credible sources is crucial for the integrity of your research. Evaluate the reliability of your sources by checking the author's credentials and the publication's reputation. Credible sources add weight to your arguments and help you build a strong foundation for your research.

Effective Data Collection and Analysis

Choosing data collection methods.

Selecting the right data collection methods is crucial for the success of your research. Consider methods such as surveys, interviews, or experiments based on your research needs. Aligning data collection techniques with research needs ensures relevant and robust findings.

Analyzing Collected Data

Once you have gathered your data, the next step is to analyze it accurately . Use statistical tools and software to help you interpret the data. Create tables and graphs to illustrate your findings clearly. This will help you present your results in a structured and understandable way.

Interpreting Results

Interpreting your results is an essential part of your thesis. Discuss how your findings relate to your research questions and the existing literature. Highlight the significance of your analyses and the reliability of your findings. This will help you draw meaningful conclusions and provide valuable insights into your research topic.

Revising and Editing the Research Paper

Reviewing for clarity and coherence.

When revising your research paper, focus on ensuring that your ideas are clear and logically organized. Each section should flow smoothly into the next, and your arguments should be well-structured. Reading your paper out loud can help you catch issues that you might miss when reading silently. Additionally, consider having someone else review your paper to provide a fresh perspective.

Addressing Feedback

Incorporating feedback is a crucial part of the revision process. Share your draft with peers, mentors, or advisors and be open to their suggestions. Addressing feedback can help you identify areas for improvement and strengthen your arguments. Remember, revising is a continuous process of refining your work.

Final Proofreading

The final step in the editing process is proofreading. This involves checking for grammar, spelling, and punctuation errors. Use tools like spellcheckers or digital writing assistants to help with this task. Ensure that your paper follows the required formatting guidelines and that all citations are correctly formatted. A well-proofread paper enhances the credibility of your research.

Revising and editing your research paper can be a daunting task, but it doesn't have to be. Our step-by-step guides make the process simple and stress-free. Whether you're stuck on where to start or need help polishing your final draft, we've got you covered. Visit our website to discover how our resources can help you achieve academic success.

Starting a research paper might seem overwhelming, but breaking it down into manageable steps can make the process much easier. From selecting a topic that interests you to organizing your research and drafting your paper, each step is crucial for success. Remember to stay focused on your research question, use reliable sources, and keep your writing clear and concise. By following these guidelines, you'll be well on your way to crafting a compelling and informative research paper. Good luck, and don't hesitate to seek help if you need it!

Frequently Asked Questions

How do i choose a research topic.

Start by thinking about what interests you. Pick a topic that you find fun and fulfilling. This will keep you motivated throughout your research. Make a list of subjects you enjoy and see how they can relate to your field of study.

Why is a research question important?

A research question guides your study and keeps you focused. It helps you set specific goals and determine the direction of your research.

What is a literature review?

A literature review involves gathering and analyzing existing research on your topic. It helps you understand what has already been studied and identify gaps that your research can fill.

How do I create a research plan?

Start by outlining your methodology, creating a timeline, and allocating resources effectively. A solid plan helps you stay organized and ensures you cover all necessary aspects of your research.

What should be included in a thesis introduction?

Your introduction should establish the context for your study, present your thesis statement, and provide an overview of what your thesis will cover.

How do I choose the right research methodology?

Decide whether to use qualitative or quantitative methods, select appropriate data collection tools, and justify your choices based on your research goals.

What are proper citation practices?

Always give credit to the original authors of the sources you use. Use a consistent citation style and ensure all sources are properly cited to avoid plagiarism.

How do I revise and edit my research paper?

Review for clarity and coherence, address feedback from peers or advisors, and do a final proofreading to catch any errors.

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Letters (Correspondence)

A letter from Alix of Vergy (1225, April)

Alix of Vergy, duchess of Burgundy

This is a letter from "Epistolae: Medieval Women's Letters". Epistolae is a collection of medieval Latin letters to and from women. The letters collected date from the 4th to the 13th centuries, and they are presented in their original Latin as well as in English translation. Dr. Joan Ferrante, Professor Emerita of English and Comparative Literature of Columbia University, has, with her colleagues, collected and translated these letters mainly from printed sources. She worked with the Columbia Center for New Media Teaching and Learning to develop this unique open online collection for teaching and research purposes.

• Latin letters
• Women authors
• Latin language--Translating into English
• Manuscripts, Latin (Medieval and modern)

More About This Work

Related items.

• DOI Copy DOI to clipboard

• Open access
• Published: 26 August 2024

Regional differences in pediatric pneumococcal vaccine schedules for Indigenous children in Canada: an environmental scan

• Sarah Mahon 1 ,
• Laura Reifferscheid 1 ,
• Lisa Kenzie 1 &
• Shannon E. MacDonald   ORCID: orcid.org/0000-0003-4675-4433 1 , 2  

BMC Health Services Research volume  24 , Article number:  990 ( 2024 ) Cite this article

40 Accesses

Metrics details

Streptococcus pneumoniae bacteria causes substantial morbidity and mortality worldwide, especially in children under 5 years of age. Prevention of these outcomes by pneumococcal conjugate vaccines (PCV) is an important public health initiative, supported by publicly funded vaccination programs in Canada. While the National Advisory Committee on Immunization (NACI) provides national recommendations for vaccination schedules, decisions on vaccination program delivery are made regionally, creating potential for variability across the country. In addition, defining the groups that are most at risk has become a complex endeavor for provinces and territories in Canada, specifically considering Indigenous children.

In this environmental scan, we reviewed policy documents, provincial/territorial and international PCV schedules, and scientific literature, and consulted with vaccination program stakeholders and experts from across the country, in order to understand the evolution of PCV vaccination guidelines and policies in Canada and identify whether and how the needs of Indigenous children are addressed.

As of March 2023, most regions do not specify particular vaccination requirements for Indigenous children; however, three provinces identify Indigenous children as “high risk” and use varying language to recommend a four dose, rather than the routine three dose, schedule. Our results also draw attention to evidence gaps supporting a differing practice for Indigenous populations.

Conclusions

Future PCV program innovation requires inclusive and clear policies as well as definitive evidence-based policies and practices in order to improve equitable population health.

Peer Review reports

Introduction

Streptococcus pneumoniae bacteria can cause a range of illnesses, from mild (e.g. sinusitis, otitis media) to more serious invasive diseases such as meningitis, bacteremia, and pneumonia, resulting in substantial morbidity and mortality worldwide [ 1 , 2 ]. Young children are particularly at high risk for invasive pneumococcal disease (IPD); the World Health Organization estimates that almost 500,000 children under 5 years of age die each year worldwide as a result of pneumococcal disease [ 2 ]. Among the 92 recognized serotypes of S. pneumoniae , 24 serotypes that cause IPD can be prevented by vaccination, and 15 of these are known to cause the majority of disease [ 1 ]. Antimicrobial resistance to some serotypes makes prevention through the use of vaccination even more vital [ 1 ].

Higher rates of IPD have historically been reported among some Indigenous populations in developed countries around the world [ 1 , 3 ]. Lower immunization coverage and increased delays in the timeliness of vaccine receipt have also been recognized for Indigenous children in both the United States [ 4 ] and Australia [ 5 ], though studies from Canada indicate mixed results [ 6 , 7 ]. Indigenous Peoples are defined internationally as descendants of those who originally inhabited a land, and retain their diverse cultural and political characteristics, despite consistent violations of their rights and identities by colonizing societies [ 8 ]. In Canada, there are distinct groups of Indigenous Peoples (including First Nations, Inuit and Métis Peoples) who share a historical and ongoing experience of colonization alongside stigmatizing experiences within the healthcare system [ 9 ]. These stigmatizing experiences act to reduce the accessibility and quality of health care, contributing to distrust of healthcare institutions and ultimately avoidance or delay of health care, and has been shown to lead to vaccine hesitancy [ 9 , 10 , 11 ].

Since 2002, the National Advisory Committee on Immunization (NACI) in Canada has recommended that infants less than two years of age be vaccinated with pneumococcal conjugate vaccines (PCV) [ 2 ]. Four pneumococcal conjugate vaccines (initially PCV-7, followed by PCV-10, PCV-13, and most recently PCV-15) have been licensed for use in infants, with vaccine availability varying based on changing recommendations. Since the introduction of the PCV into routine schedules for Canadian pediatric populations, there have been many changes in NACI recommendations due to vaccine developments and changes in dosing schedules, including which populations are considered at high risk for IPD and may require different PCV dosing.

While NACI provides ongoing and timely public health guidance to inform immunization schedules, Canada’s thirteen provinces and territories are individually responsible for the implementation of vaccination programs within their jurisdiction [ 12 ]. In First Nations reserve communities, delivery of health services is a patchwork of federal, provincial/territorial, and Indigenous government jurisdictions. Funding for these health services is provided through various sources, including provincial health authorities and Indigenous Services Canada (including coverage for non-insured health benefits) [ 13 ], varying according to where the services are accessed. Health program funding on reserve communities is provided by Indigenous Services Canada under the purview of the First Nations and Inuit Health Branch (FNIHB), with health care services being provided by either FNIHB or the communities themselves [ 14 ]. Indigenous Peoples living outside of reserve communities can access health care services provided by provincial/territorial programs. These overlapping systems have the potential to result in significant variation in immunization practices for Indigenous populations between and within the provinces and territories. Thus, clear, transparent, and evidence-informed policies that support, rather than stigmatize, the needs of Indigenous children are required to achieve equitable population health.

Given these complexities, an evaluation of infant PCV vaccination policies specific to Indigenous children in Canada is warranted. This information is required to better understand the context of pediatric pneumococcal disease and PCV coverage, facilitating program evaluation and improvement. These findings may provide insights relevant to other colonized countries with significant Indigenous populations, and assist with international comparisons. Thus, the purpose of this study was to investigate changes in Canadian pediatric PCV recommendations over time, and compare current schedules used in different jurisdictions across the country and internationally, with particular consideration for whether and how the needs of Indigenous children are addressed. In addition, we sought to identify evidence supporting a high risk routine PCV schedule for Indigenous children. Throughout this paper we respectfully use the term “Indigenous”, unless using language cited directly from the literature. Although “Aboriginal” is another general term that collectively refers to First Nations, Métis and Inuit Peoples, it is historically linked to Canadian government policies and is no longer the preferred terminology [ 15 ].

Between January and April 2023, we conducted an environmental scan of published literature, publicly available vaccination policy documents, and expert consultation. Environmental scans are recognized as a useful approach to examining a health issue in order to direct decision making, and involve acquiring relevant and credible information from various sources [ 16 ]. The environmental scan was informed by Wilburn et al. [ 17 ] and included the stages of: determining the information to be collected, identifying and engaging stakeholders, and analyzing and synthesizing results from the scan into a concise summary. This environmental scan was exempt from ethics review, given that it involved collection and analysis of publicly available documents.

The initial search strategy for peer-reviewed literature was created in consultation with a librarian at the University of Alberta (Additional file 1 ). Identified literature was limited to North American studies, and those available as full text. We also searched references of relevant documents for additional literature. Current and historical NACI documents pertaining to pediatric PCV vaccination recommendations were retrieved via the Public Health Agency of Canada website, and all provincial and territorial government health websites were reviewed for current policies, immunization manuals, or publicly available PCV schedule guidelines. These websites were further searched using the terms “First Nation”, “Indigenous”, or “Aboriginal” to identify any differences in PCV guidelines for this group and any evidence supporting PCV vaccine practices. For international comparison, PCV guidelines were also retrieved from other high-income countries with similar histories of colonization of Indigenous populations (United States, Australia, and New Zealand).

Next, we identified immunization program stakeholders in each province and territory, including regional immunization coordinators from FNIHB (who cover multiple jurisdictions) and/or provincial/territorial health ministries. Stakeholders were emailed a questionnaire asking them to identify differences in PCV immunization delivery in Indigenous communities and for Indigenous Peoples (Additional file 2 ). All stakeholders were asked to forward the questionnaire to those in their organization with knowledge of vaccination programs in Indigenous communities. Specifically, we asked if Indigenous communities within their jurisdiction followed provincial/territorial immunization schedules, and if there was potentially variation in schedules between Indigenous communities in their jurisdiction. Respondents were also asked to clarify how immunization programs in Indigenous communities were funded in their jurisdiction.

Evolution of national recommendations

The timeline of Canadian national PCV recommendations is summarized in Fig.  1 and detailed in Additional file 3 . The first national recommendation regarding PCV vaccination for children under 2 years of age was released by NACI in 2002 [ 18 ]. This statement recommended four doses of PCV-7 for all children, with additional doses of 23-valent pneumococcal polysaccharide vaccine (PPV-23) for those at high risk of pneumococcal disease. The statement also identified Indigenous populations as medically high-risk (along with children with chronic medical conditions and those who attend group day care), based on higher reported IPD incidence rates among some American Indian populations and Alaska Native populations, and among Indigenous populations in northern regions of Canada, compared to non-Indigenous populations. The statement qualified the risk for Indigenous children as moderate, with low strength of evidence (grade C, insufficient evidence or include or exclude).

Timeline of childhood pneumococcal conjugate vaccine (PCV) recommendations and schedules in Canada [ 1 , 2 , 18 , 19 , 20 , 21 , 22 ]

In their 2006 statement, NACI recommended that routine PCV-7 vaccination for healthy children be decreased from four to three doses. However, they noted that “as studies evaluating the three-dose schedule were not conducted among children at high-risk of invasive pneumococcal disease, NACI emphasizes that such children should continue to receive 4 doses” [ 19 , p.3]. Indigenous children remained included in the medically high-risk group.

In June 2010, NACI released a statement outlining recommendations for the newly approved ten-valent pneumococcal conjugate vaccine (PCV-10) [ 20 ]. In this statement, Indigenous children were still identified as medically high-risk and thus eligible for a four-dose series, referencing previous statements and surveillance data from northern Quebec, Nunavut, and Northern Labrador reporting a decrease in IPD post- introduction of PCV programs [ 21 ]. Then, in November 2010, NACI released a statement introducing the thirteen-valent pneumococcal conjugate vaccine (PCV-13); Indigenous children were no longer included in the medically high-risk group [ 22 ]. However, the statement recommended that healthy children of Indigenous origin or children who attend group childcare receive an extra dose of PCV-13 at 36–59 months of age if the child had appropriate pneumococcal vaccination but had not previously received PCV-13 [ 22 ]. The Canadian Immunization Guideline continues to reflect this recommendation [ 1 ].

Most recently, NACI released an interim statement in March 2023 regarding the introduction of the fifteen-valent pneumococcal conjugate vaccine (PCV-15) to the pediatric population [ 23 ]. In this statement, NACI recommended that PCV-15 vaccine may be used interchangeably with PCV-13 in children less than 18 years of age, with no changes to the dosing schedule for either healthy (three-dose series) or medically high-risk children (four-dose series) [ 23 ]. Indigenous children are not discussed within this interim guideline.

Differences in immunization guidelines across Canada

Canadian provinces and territories have taken varying approaches to how they identify Indigenous children in their PCV guidelines (Table  1 and Additional file 2 ).

As per current publicly available provincial/territorial guidelines in Canada, most jurisdictions (British Columbia, New Brunswick, Nova Scotia, Ontario, Prince Edward Island, Quebec, Saskatchewan, and Yukon) recommend a three-dose vaccine series for healthy children, and do not specify any special vaccination requirements for Indigenous populations. Conversely, there are three provinces that specify Indigenous children require a fourth dose of PCV at 6 months of age (Alberta, Manitoba, and Newfoundland and Labrador). In Alberta, the language used is that “Indigenous children (defined as having at least one parent who is indigenous; includes First Nations, Inuit, and Métis) beginning immunization at younger than seven months should receive four doses of vaccine” [ 24 , p.5]. Manitoba’s provincial guideline states that children living in First Nations communities are eligible to receive four doses [ 26 ]. Both of these provinces differentiate Indigenous populations from those who are medically at-risk. Lastly, Newfoundland and Labrador guidelines include Indigenous children who live in remote and rural communities within their medically high-risk group and state that they provide an extra dose of PCV-13 to this population [ 28 ].

The routine PCV vaccination guidelines for the Northwest Territories and Nunavut both specify four doses of PCV-13 for all populations of infants. While all other jurisdictions offer the three-dose series at 2, 4, and 12 months of age, with an extra dose at 6 months for specified at-risk groups, the Northwest Territories offers a four-dose series at 2, 4, 6, and 18 months of age and Nunavut offers their four-dose series at 2, 4, 6, and 15 months of age. There is no specific mention of Indigenous populations within the Northwest Territories’ publicly available information. Nunavut guidelines affirm that Indigenous children living in northern Canada have a three times higher incidence rate of IPD than non-Indigenous children, though Indigenous populations are not listed in their medically high-risk group [ 31 ].

Immunization delivery in Indigenous communities

Information regarding PCV delivery in Indigenous communities was gathered through a targeted survey of regional immunization coordinators from each Canadian province and territory. A total of twelve responses were obtained from immunization program experts (namely, immunization coordinators or immunization practice consultants) in all jurisdictions except Nunavut. In most jurisdictions, respondents indicated that immunization programs are delivered in partnership with Indigenous governments and funded by federal programs. However, there are some exceptions. Notably, reserve communities do not exist to the same degree in the Northwest Territories, Yukon, or Nunavut due to differing agreements for Inuit and, therefore, health service delivery in these jurisdictions is the sole responsibility of the territorial government. British Columbia uniquely operates under a tripartite agreement with the federal, provincial, and First Nations governments, where the responsibility for planning, management, service delivery, and funding of health programs falls under the British Columbia First Nations Health Authority (FNHA) [ 37 ]. All respondents indicated that Indigenous communities follow guidelines for the jurisdiction in which they reside.

Guidelines from other high-income countries

In the United States, the Advisory Committee on Immunization Practices (ACIP) recommends a four-dose series for the general population at 2, 4, 6, and between 12 and15 months [ 38 ]. They currently recommend PCV-13 or PCV-15 vaccine for all populations, and do not identify any increased disease risk for Indigenous children within their publicly available information [ 38 ]. New Zealand and Australia both recommend a three-dose series of PCV-13 for their general population. The Australian Technical Advisory Group on Immunisation (ATAGI) recommends a fourth dose at 6 months of age for their Indigenous population, stating that Aboriginal and Torres Strait Islander children are at increased risk of pneumococcal infection and should receive four doses at 2, 4, 6, and 12 months of age (compared to three doses at 2, 4, and 12 months for non-Indigenous populations) [ 39 ]. However, they do not consider these Indigenous populations within their medically high-risk group. The New Zealand Immunisation Advisory Centre specifies a 3-dose PCV schedule at 6 weeks, 5 and 12 months for all children [ 40 ].

Rationale for differing schedule

The literature search identified limited evidence supporting the rationale for a differing PCV schedule for Indigenous children. The available literature refers to higher incidence rates of IPD among both Canadian and American Indigenous populations [ 3 , 21 , 41 , 42 , 43 , 44 , 45 , 46 ]. However, only two studies included data from after 2010 [ 44 , 45 ], when PCV-13 was introduced and provinces/territories began to decrease recommended dosing for healthy children from 4 doses to 3 doses. Most literature focused on circumpolar northern Indigenous populations [ 3 , 21 , 41 , 43 , 44 , 45 , 46 ].

Two studies identified potential biological risk factors for increased risk of pneumococcal disease in Indigenous children. First, an article from 1980 described eustachian tube differences between Indigenous and non-Indigenous children in the United States as a potential contributor to higher prevalence of otitis media among Indigenous children [ 47 ]. Second, a 2018 study done in the Canadian provinces of Manitoba and Saskatchewan identified a rare primary immunodeficiency occurring in certain Cree populations, which increased infant susceptibility to early-onset bacterial, viral, and fungal infections including streptococcus pneumonia [ 48 ].

In addition to potential biological risk factors, the social determinants of health and other impacts of ongoing colonization have been proposed as risk factors contributing to higher rates of IPD among Indigenous populations [ 49 , 50 ]. However, few studies have attempted to quantify these relationships, and there is no evidence that these social determinants lead to decreased vaccine effectiveness, necessitating a higher dose schedule. A total of seven studies examined the impact of living conditions on IPD risk, including household crowding [ 51 , 52 , 53 ], water quality [ 52 , 53 , 54 , 55 ], and air quality due to wood burning stoves or tobacco exposure [ 52 , 56 , 57 ]. Overall, these studies found relationships between the determinants listed and higher risk of IPD, increased risk of pneumococcal carriage, and severity in hospital outcomes.

The limited information ascertained from this literature search was validated by personal communication with practice experts representing provincial and territorial immunization programs. The immunization practice experts we consulted in Alberta, where a fourth dose of PCV is recommended for all Indigenous children, reported that the rationale for this dosing schedule was not included in training and information material accessed by frontline staff.

This study provides a comprehensive overview of PCV recommendations in Canada, thereby drawing attention to factors that could contribute to uncertainty for both healthcare providers and families about vaccine needs of Indigenous children. We identified changes in national recommendations over time, guideline differences between Canadian jurisdictions, and limited published evidence exploring the potential cause(s) of elevated pneumococcal disease risk among Indigenous children. Moreover, the apparent assumption that the additional fourth dose for Indigenous populations will improve health outcomes in pneumococcal disease was not supported by published evidence regarding the effectiveness of a fourth PCV dose among these children.

Due mainly to changes in pneumococcal vaccine products over time, numerous NACI statements related to PCV have been released since 2002. In these statements, the risk categorization of Indigenous populations has evolved. In June 2010 and previous years, Indigenous children were considered to be within NACI’s high-risk group; however, they were removed from that category in November of the same year without explicit rationale or reference to evidence [ 20 , 22 ]. Within that same November statement there is a differing recommendation for “healthy (not high risk) children who are of Aboriginal origin” to receive an additional dose of PCV-13 for the age group of 36–59 months of age that have age-appropriate PCV vaccination (PCV-7, PCV-10), but have not been vaccinated with PCV-13 [ 22 , p.9].

As of March 2023, three Canadian provinces (Alberta, Manitoba, Newfoundland and Labrador) specify different PCV dosing for Indigenous children compared to non-Indigenous children, while two territories (Northwest Territories, Nunavut) specify a four-dose schedule for all children in the region. Approximately 5% of Canada’s total population identifies as Indigenous; however, the proportion of Indigenous Peoples living in these jurisdictions is the highest in Canada, with the highest proportion in Nunavut (85.7%) followed by the Northwest Territories (49.6%) [ 58 ]. Among the provinces, Manitoba has the highest proportion of Indigenous populations (18.1%), with Newfoundland and Labrador (9.3%) and Alberta (6.8%) representing the third and fourth highest proportions [ 59 ].

The provinces with different dosing schedules for Indigenous children have taken different approaches to defining risk-related eligibility. For example, Alberta guidelines specify that Indigenous children in the province should receive four doses of PCV to ensure they are fully immunized regardless of where they live [ 24 ]. This differs from Manitoba, where children living in rural First Nations communities are eligible for four doses [ 26 ]; and for Newfoundland and Labrador, where Indigenous children are considered medically high-risk (i.e. eligible for a four-dose series) only if living in remote and rural communities [ 28 ]. However, distinctions in immunization practice for Indigenous Peoples based solely on living in an urban setting versus living on a rural reserve may not align with the potential impacts of the social determinants of health. While certain social risk-factors that contribute to elevated pneumococcal disease risk (e.g. lack of clean water) are more common in rural or remote living environments in Canada, other risk factors (e.g. overcrowding) can be present in urban, rural, or remote settings.

Healthcare professionals and parents in jurisdictions where different PCV schedules for Indigenous children are in place require clear rationale for this need. Without this information, immunization providers may feel unequipped to deal with questions from Indigenous parents regarding the need for a fourth dose, and Indigenous families may feel as if they are unfairly treated differently (i.e. stigmatized) with this immunization schedule. It has been shown that differential treatment/policies have the potential to lead to vaccine hesitancy, which can negatively impact vaccine uptake [ 10 , 11 ]. For Indigenous Peoples, negative experiences with vaccination may also reinforce the history of their interactions with westernized healthcare that has been shaped by unsafe care, lack of respectful treatment, racism, and discrimination [ 60 ]. In addition to exacerbating barriers to accessing healthcare resources, these negative experiences have also been directly linked to chronic stress and poor coping behaviors, contributing to negative mental and physical outcomes [ 9 ]. In order to fully address the Truth and Reconciliation Commission calls to action, there is a need to advocate for evidence-based immunization practice and empower Indigenous Peoples to achieve their full health potential [ 61 ].

To support the development of clear policies and informational resources, updated research supporting regional vaccination needs (i.e. surveillance data) is required. Research clarifying the impact of potential biological and/or social risk factors on disease risk and/or vaccine efficacy would help to appropriately target a four-dose schedule. By comparing the impact of differing PCV schedules on IPD prevalence across the country, it may also be possible to develop insights on the effectiveness of a fourth PCV dose in this population.

Immunization guidelines for communicable disease prevention are the responsibility of provincial and territorial governments. Therefore, given the differences in schedules across Canada, it is advisable that governments examine PCV policies and ensure they are based on evidence and reflect their unique provincial and territorial populations, allowing for greater public transparency in provincial immunization policy decisions. Further to this, a review of the language within the policy that outlines the differing schedules to ensure inclusivity and recognition of the potential stigmatizing outcomes is crucial. The responsibility falls on governing organizations to reflect on historical contexts and challenge current practice inequities, especially for groups that experience stigma and discrimination within the healthcare system.

While clarity around the PCV needs for Indigenous children is required, newer NACI recommendations acknowledge the complexity of adult Indigenous healthcare needs in Canada. The current NACI pneumococcal vaccination recommendation for adults states that “First Nations, Métis, or Inuit communities in Canada have a younger age distribution compared to the general Canadian population but have also been observed to have increased risk for severe pneumococcal disease due to a variety of intersecting factors including underlying medical conditions and potential decreased access to healthcare. Therefore, age-based recommendations may need to be modified to offer effective protection to individuals in these communities. Autonomous decisions should be made by Indigenous Peoples with the support of healthcare and public health partners in accordance with the United Nations Declaration on the Rights of Indigenous Peoples” [ 62 , p.25]. This support for personal empowerment will encourage provinces and territories to seek unique solutions in collaboration with Indigenous groups, in order to tailor vaccination needs. Additional knowledge on how vaccination providers, and the Indigenous parents/caregivers they serve, navigate differential vaccination requirements is required.

Limitations

As Indigenous healthcare delivery is complex in Canada, it was not feasible to locate and contact immunization program providers in each Indigenous community to identify their current practices, policies, and guidelines. However, by exploring both national and provincial health websites, and obtaining input from regional-level program administrators, we were able to obtain a clear picture of broad practices across Canada. Because we were unable to independently identify the individuals most appropriate to target to ask about Indigenous vaccination delivery, we depended on higher level managers to distribute the questionnaire accordingly, and thus could not capture information on response rate. However, responses represented 12 of 13 target regions.

Our ability to understand the rationale for differing regional guidelines for Indigenous children was limited to published literature and publicly available guideline documents. This search was targeted, rather than comprehensive, so it is possible that relevant publications were missed in our search. However, we confirmed our findings with experts in immunology, infectious disease, and immunization programming in order to ensure we were accurately representing the state of the literature. In addition, diversity in general immunization advice and guidance across provinces and territories is often driven by local expert knowledge of community needs. For instance, provinces and territories may internally conduct analysis of regional disease patterns to inform immunization schedules, but may not share this information with the general population. Therefore, justification for the fourth dose may not have been captured in this scan.

PCV recommendations have necessarily changed over time, and there are inconsistencies in PCV dosing guidelines for Indigenous children across the jurisdictions of Canada. Evolving guidelines and unclear rationale for changes can cause uncertainty for healthcare providers. Differing treatment that is not supported by evidence may lead to stigmatizing practices and overall mistrust and apprehension by Indigenous Peoples in accessing health services, which ultimately impacts their health and wellbeing. Developing clear and inclusive policies, with transparent rationale, that reflect necessary immunization practices should be a priority for governments in order to improve health outcomes for Indigenous children. There is a need to advocate for evidence-based practice while addressing the Truth and Reconciliation Commission calls to action by acknowledging the persistent and deep health inequalities in Canada.

Data availability

Data presented in this manuscript are publicly available.

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Acknowledgements

The authors would like to thank Julia Plain, RN for her guidance as a student capstone advisor for the project, and Alberta Health Staff for their support in reviewing early manuscript drafts. We would also like to acknowledge the assistance of Megan Kennedy, MLIS in developing the initial search strategy. LR is supported by a Canadian Institutes of Health Research doctoral research award.

No funding was received for conducting this study.

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

Sarah Mahon, Laura Reifferscheid, Lisa Kenzie & Shannon E. MacDonald

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SM, LR, SEM conceptualized and designed the study; SM completed data acquisitions; all authors contributed to interpretation of the data; SM, LR, LK drafted the manuscript; SEM supervised the study. All authors contributed to critical revision of the manuscript and approved the final version.

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Correspondence to Shannon E. MacDonald .

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Additional file 1. Appendix A: Medline and EMBASE Search Strategy

Additional file 2. appendix b: questionnaire for immunization program stakeholders, additional file 3. appendix c: summary of recommendations and immunization schedules, rights and permissions.

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Mahon, S., Reifferscheid, L., Kenzie, L. et al. Regional differences in pediatric pneumococcal vaccine schedules for Indigenous children in Canada: an environmental scan. BMC Health Serv Res 24 , 990 (2024). https://doi.org/10.1186/s12913-024-11400-6

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Received : 26 October 2023

Accepted : 05 August 2024

Published : 26 August 2024

DOI : https://doi.org/10.1186/s12913-024-11400-6

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