relationship between literature review and discussion

Literature Reviews

• Starting your literature review
• Undertaking your literature review

Introduction

Analysing the literature critically, referring back from your discussion.

An important part of a literature review is being able to pull together and group what you have read in order to identify the key arguments in the previous research. This is a good foundation, but then you need to go further and analyse what others have researched.

You need to offer judgments on whether the evidence shows their arguments to be convincing or less convincing and why. This analytical groundwork means you will be able to refer back to this literature economically to provide potential reasons for your own research findings:

Do your results agree with, or disagree with, what others have found, and why might this be?

The guidance on this page offers suggestions for developing your literature review to ensure you are critically analysing what you have read.

You can ensure you are analysing critically by testing out your own views against those you are reading about: What do you think about the topic? Then as you read each new study, does the evidence presented confirm your view, or does it provide a counter-argument that causes you to question your view?

Also think about the methods used to gather the evidence - are they reliable or do they have gaps or weaknesses?

When writing up your literature review use each of your headings or themes to compare and contrast the differing views put forward in the relevant studies and explain how they relate to your investigation.

Your literature review needs to tell an interesting "story" which leads up to how and why you are doing your investigation. If you are writing a story which reads like one thing after another, this is likely to be descriptive. However, if your story is comparing, contrasting and evaluating the previous literature, you are on the right track. See the example below:

(Examples taken from original University of Queensland: Writing the literature review )

• What it means to be a critical student A brief and very useful video tutorial from the University of Leicester.
• Writing the literature review (University of Queensland) Includes practical examples of writing for literature reviews.

Your literature review has two main purposes:

1) To place your investigation in the context of previous research and justify how you have approached your investigation.

2) To provide evidence to help explain the findings of your investigation

It is this second purpose that many people forget!

When you are writing the discussion of your findings, you need to relate these back to the background literature . Do your results confirm what was found before, or challenge it? Why might this be? For example:

When writing your discussion section, you may find that you need to redraft the focus of your literature review slightly to draw out those studies that are most important to your findings. You can always remove studies that are less relevant and add others that turned out to be more significant than you initially thought.

Some academics explain the relationship between the literature review and the discussion section like an hour-glass: Your literature review starts broad, then narrows down to explain how previous research has influenced your specific investigation. The discussion starts by analysing your results, explaining what they mean for the outcome of your study, and ends by widening out to assess how these results might contribute to your field of research as a whole.

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Ten Simple Rules for Writing a Literature Review

Marco pautasso.

1 Centre for Functional and Evolutionary Ecology (CEFE), CNRS, Montpellier, France

2 Centre for Biodiversity Synthesis and Analysis (CESAB), FRB, Aix-en-Provence, France

Literature reviews are in great demand in most scientific fields. Their need stems from the ever-increasing output of scientific publications [1] . For example, compared to 1991, in 2008 three, eight, and forty times more papers were indexed in Web of Science on malaria, obesity, and biodiversity, respectively [2] . Given such mountains of papers, scientists cannot be expected to examine in detail every single new paper relevant to their interests [3] . Thus, it is both advantageous and necessary to rely on regular summaries of the recent literature. Although recognition for scientists mainly comes from primary research, timely literature reviews can lead to new synthetic insights and are often widely read [4] . For such summaries to be useful, however, they need to be compiled in a professional way [5] .

When starting from scratch, reviewing the literature can require a titanic amount of work. That is why researchers who have spent their career working on a certain research issue are in a perfect position to review that literature. Some graduate schools are now offering courses in reviewing the literature, given that most research students start their project by producing an overview of what has already been done on their research issue [6] . However, it is likely that most scientists have not thought in detail about how to approach and carry out a literature review.

Reviewing the literature requires the ability to juggle multiple tasks, from finding and evaluating relevant material to synthesising information from various sources, from critical thinking to paraphrasing, evaluating, and citation skills [7] . In this contribution, I share ten simple rules I learned working on about 25 literature reviews as a PhD and postdoctoral student. Ideas and insights also come from discussions with coauthors and colleagues, as well as feedback from reviewers and editors.

Rule 1: Define a Topic and Audience

How to choose which topic to review? There are so many issues in contemporary science that you could spend a lifetime of attending conferences and reading the literature just pondering what to review. On the one hand, if you take several years to choose, several other people may have had the same idea in the meantime. On the other hand, only a well-considered topic is likely to lead to a brilliant literature review [8] . The topic must at least be:

• interesting to you (ideally, you should have come across a series of recent papers related to your line of work that call for a critical summary),
• an important aspect of the field (so that many readers will be interested in the review and there will be enough material to write it), and
• a well-defined issue (otherwise you could potentially include thousands of publications, which would make the review unhelpful).

Ideas for potential reviews may come from papers providing lists of key research questions to be answered [9] , but also from serendipitous moments during desultory reading and discussions. In addition to choosing your topic, you should also select a target audience. In many cases, the topic (e.g., web services in computational biology) will automatically define an audience (e.g., computational biologists), but that same topic may also be of interest to neighbouring fields (e.g., computer science, biology, etc.).

Rule 2: Search and Re-search the Literature

After having chosen your topic and audience, start by checking the literature and downloading relevant papers. Five pieces of advice here:

• keep track of the search items you use (so that your search can be replicated [10] ),
• keep a list of papers whose pdfs you cannot access immediately (so as to retrieve them later with alternative strategies),
• use a paper management system (e.g., Mendeley, Papers, Qiqqa, Sente),
• define early in the process some criteria for exclusion of irrelevant papers (these criteria can then be described in the review to help define its scope), and
• do not just look for research papers in the area you wish to review, but also seek previous reviews.

The chances are high that someone will already have published a literature review ( Figure 1 ), if not exactly on the issue you are planning to tackle, at least on a related topic. If there are already a few or several reviews of the literature on your issue, my advice is not to give up, but to carry on with your own literature review,

The bottom-right situation (many literature reviews but few research papers) is not just a theoretical situation; it applies, for example, to the study of the impacts of climate change on plant diseases, where there appear to be more literature reviews than research studies [33] .

• discussing in your review the approaches, limitations, and conclusions of past reviews,
• trying to find a new angle that has not been covered adequately in the previous reviews, and
• incorporating new material that has inevitably accumulated since their appearance.

When searching the literature for pertinent papers and reviews, the usual rules apply:

• be thorough,
• use different keywords and database sources (e.g., DBLP, Google Scholar, ISI Proceedings, JSTOR Search, Medline, Scopus, Web of Science), and
• look at who has cited past relevant papers and book chapters.

Rule 3: Take Notes While Reading

If you read the papers first, and only afterwards start writing the review, you will need a very good memory to remember who wrote what, and what your impressions and associations were while reading each single paper. My advice is, while reading, to start writing down interesting pieces of information, insights about how to organize the review, and thoughts on what to write. This way, by the time you have read the literature you selected, you will already have a rough draft of the review.

Of course, this draft will still need much rewriting, restructuring, and rethinking to obtain a text with a coherent argument [11] , but you will have avoided the danger posed by staring at a blank document. Be careful when taking notes to use quotation marks if you are provisionally copying verbatim from the literature. It is advisable then to reformulate such quotes with your own words in the final draft. It is important to be careful in noting the references already at this stage, so as to avoid misattributions. Using referencing software from the very beginning of your endeavour will save you time.

Rule 4: Choose the Type of Review You Wish to Write

After having taken notes while reading the literature, you will have a rough idea of the amount of material available for the review. This is probably a good time to decide whether to go for a mini- or a full review. Some journals are now favouring the publication of rather short reviews focusing on the last few years, with a limit on the number of words and citations. A mini-review is not necessarily a minor review: it may well attract more attention from busy readers, although it will inevitably simplify some issues and leave out some relevant material due to space limitations. A full review will have the advantage of more freedom to cover in detail the complexities of a particular scientific development, but may then be left in the pile of the very important papers “to be read” by readers with little time to spare for major monographs.

There is probably a continuum between mini- and full reviews. The same point applies to the dichotomy of descriptive vs. integrative reviews. While descriptive reviews focus on the methodology, findings, and interpretation of each reviewed study, integrative reviews attempt to find common ideas and concepts from the reviewed material [12] . A similar distinction exists between narrative and systematic reviews: while narrative reviews are qualitative, systematic reviews attempt to test a hypothesis based on the published evidence, which is gathered using a predefined protocol to reduce bias [13] , [14] . When systematic reviews analyse quantitative results in a quantitative way, they become meta-analyses. The choice between different review types will have to be made on a case-by-case basis, depending not just on the nature of the material found and the preferences of the target journal(s), but also on the time available to write the review and the number of coauthors [15] .

Rule 5: Keep the Review Focused, but Make It of Broad Interest

Whether your plan is to write a mini- or a full review, it is good advice to keep it focused 16 , 17 . Including material just for the sake of it can easily lead to reviews that are trying to do too many things at once. The need to keep a review focused can be problematic for interdisciplinary reviews, where the aim is to bridge the gap between fields [18] . If you are writing a review on, for example, how epidemiological approaches are used in modelling the spread of ideas, you may be inclined to include material from both parent fields, epidemiology and the study of cultural diffusion. This may be necessary to some extent, but in this case a focused review would only deal in detail with those studies at the interface between epidemiology and the spread of ideas.

While focus is an important feature of a successful review, this requirement has to be balanced with the need to make the review relevant to a broad audience. This square may be circled by discussing the wider implications of the reviewed topic for other disciplines.

Rule 6: Be Critical and Consistent

Reviewing the literature is not stamp collecting. A good review does not just summarize the literature, but discusses it critically, identifies methodological problems, and points out research gaps [19] . After having read a review of the literature, a reader should have a rough idea of:

• the major achievements in the reviewed field,
• the main areas of debate, and
• the outstanding research questions.

It is challenging to achieve a successful review on all these fronts. A solution can be to involve a set of complementary coauthors: some people are excellent at mapping what has been achieved, some others are very good at identifying dark clouds on the horizon, and some have instead a knack at predicting where solutions are going to come from. If your journal club has exactly this sort of team, then you should definitely write a review of the literature! In addition to critical thinking, a literature review needs consistency, for example in the choice of passive vs. active voice and present vs. past tense.

Rule 7: Find a Logical Structure

Like a well-baked cake, a good review has a number of telling features: it is worth the reader's time, timely, systematic, well written, focused, and critical. It also needs a good structure. With reviews, the usual subdivision of research papers into introduction, methods, results, and discussion does not work or is rarely used. However, a general introduction of the context and, toward the end, a recapitulation of the main points covered and take-home messages make sense also in the case of reviews. For systematic reviews, there is a trend towards including information about how the literature was searched (database, keywords, time limits) [20] .

How can you organize the flow of the main body of the review so that the reader will be drawn into and guided through it? It is generally helpful to draw a conceptual scheme of the review, e.g., with mind-mapping techniques. Such diagrams can help recognize a logical way to order and link the various sections of a review [21] . This is the case not just at the writing stage, but also for readers if the diagram is included in the review as a figure. A careful selection of diagrams and figures relevant to the reviewed topic can be very helpful to structure the text too [22] .

Rule 8: Make Use of Feedback

Reviews of the literature are normally peer-reviewed in the same way as research papers, and rightly so [23] . As a rule, incorporating feedback from reviewers greatly helps improve a review draft. Having read the review with a fresh mind, reviewers may spot inaccuracies, inconsistencies, and ambiguities that had not been noticed by the writers due to rereading the typescript too many times. It is however advisable to reread the draft one more time before submission, as a last-minute correction of typos, leaps, and muddled sentences may enable the reviewers to focus on providing advice on the content rather than the form.

Feedback is vital to writing a good review, and should be sought from a variety of colleagues, so as to obtain a diversity of views on the draft. This may lead in some cases to conflicting views on the merits of the paper, and on how to improve it, but such a situation is better than the absence of feedback. A diversity of feedback perspectives on a literature review can help identify where the consensus view stands in the landscape of the current scientific understanding of an issue [24] .

Rule 9: Include Your Own Relevant Research, but Be Objective

In many cases, reviewers of the literature will have published studies relevant to the review they are writing. This could create a conflict of interest: how can reviewers report objectively on their own work [25] ? Some scientists may be overly enthusiastic about what they have published, and thus risk giving too much importance to their own findings in the review. However, bias could also occur in the other direction: some scientists may be unduly dismissive of their own achievements, so that they will tend to downplay their contribution (if any) to a field when reviewing it.

In general, a review of the literature should neither be a public relations brochure nor an exercise in competitive self-denial. If a reviewer is up to the job of producing a well-organized and methodical review, which flows well and provides a service to the readership, then it should be possible to be objective in reviewing one's own relevant findings. In reviews written by multiple authors, this may be achieved by assigning the review of the results of a coauthor to different coauthors.

Rule 10: Be Up-to-Date, but Do Not Forget Older Studies

Given the progressive acceleration in the publication of scientific papers, today's reviews of the literature need awareness not just of the overall direction and achievements of a field of inquiry, but also of the latest studies, so as not to become out-of-date before they have been published. Ideally, a literature review should not identify as a major research gap an issue that has just been addressed in a series of papers in press (the same applies, of course, to older, overlooked studies (“sleeping beauties” [26] )). This implies that literature reviewers would do well to keep an eye on electronic lists of papers in press, given that it can take months before these appear in scientific databases. Some reviews declare that they have scanned the literature up to a certain point in time, but given that peer review can be a rather lengthy process, a full search for newly appeared literature at the revision stage may be worthwhile. Assessing the contribution of papers that have just appeared is particularly challenging, because there is little perspective with which to gauge their significance and impact on further research and society.

Inevitably, new papers on the reviewed topic (including independently written literature reviews) will appear from all quarters after the review has been published, so that there may soon be the need for an updated review. But this is the nature of science [27] – [32] . I wish everybody good luck with writing a review of the literature.

Acknowledgments

Many thanks to M. Barbosa, K. Dehnen-Schmutz, T. Döring, D. Fontaneto, M. Garbelotto, O. Holdenrieder, M. Jeger, D. Lonsdale, A. MacLeod, P. Mills, M. Moslonka-Lefebvre, G. Stancanelli, P. Weisberg, and X. Xu for insights and discussions, and to P. Bourne, T. Matoni, and D. Smith for helpful comments on a previous draft.

Funding Statement

This work was funded by the French Foundation for Research on Biodiversity (FRB) through its Centre for Synthesis and Analysis of Biodiversity data (CESAB), as part of the NETSEED research project. The funders had no role in the preparation of the manuscript.

Writing a Literature Review

• What is a Literature Review?
• Step 1: Choosing a Topic
• Step 2: Finding Information
• Step 3: Evaluating Content
• Step 4: Taking Notes
• Step 5: Synthesizing Content
• Step 6: Writing the Review
• Step 7: Citing Your Sources
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Writing the Review

You've done the research and now your ready to put your findings down on paper. When preparing to write your review, first consider how will you organize your review.

The actual review generally has 5 components:

• Introduction
• Bibliography

A good literature review shows signs of synthesis and understanding of the topic. There should be strong evidence of analytical thinking as illustrated through the connections you make between the literature being reviewed. Think of it this way- a literature review is much more than a book review. It is a document where you present your sources and their overall relationship to your thesis statement.

Conversly, a poor literature review will simply list and identify the sources . In essence, it will appear to be a glorifed annotated bibliography.

• Literature Reviews: The University of North Carolina http://writingcenter.unc.edu/handouts/literature-reviews/
• Writing a Literature Review: Wesleyan University
• Literature Review Tip Sheet: Edith Cowan University See additional information, including other tip sheets at http://intranet.ecu.edu.au/research/for-research-students/research-journey/designing-and-undertaking-your-research/reviewing-the-literature http://intranet.ecu.edu.au/student/my-studies/study-advice/academic-tip-sheets

The Abstract

An abstract is a summary of your literature review. It is made up of the following parts:

• A contextual sentence about your motivation behind your research topic
• Your thesis statement
• A descriptive statement about the types of literature used in the review
• Summarize your findings
• Conclusion(s) based upon your findings

The Introduction

Like a typical research paper introduction, provide the reader with a quick idea of the topic of the literature review:

• Define or identify the general topic, issue, or area of concern. This provides the reader with context for reviewing the literature.
• Point out overall trends in what has been published about the topic; or conflicts in theory, methodology, evidence, and conclusions; or gaps in research and scholarship; or a single problem or new perspective of immediate interest.
• Establish the your reason (point of view) for reviewing the literature; explain the criteria to be used in analyzing and comparing literature and the organization of the review (sequence); and, when necessary, state why certain literature is or is not included (scope).

The body of a literature review contains your discussion of sources and can be organized in 3 ways-

• Chronological - by publication or by trend
• Thematic - organized around a topic or issue, rather than the progression of time
• Methodical - the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the "methods" of the literture's researcher or writer that you are reviewing

You may also want to include a section on "questions for further research" and discuss what questions the review has sparked about the topic/field or offer suggestions for future studies/examinations that build on your current findings.

The Conclusion

In the conclusion, you should:

Conclude by providing some insight into the relationship between the central topic of the literature review and a larger area of study such as a discipline, a scientific endeavor, or a profession

The Bibliography

Since a literature review is composed of pieces of research, it is very important that your correctly cite the literature you are reviewing, both in the reviews body as well as in a bibliography/works cited. To learn more about different citation styles, visit the " Citing Your Sources " tab.

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

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

Importance of a Good Literature Review

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

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

Given this, the purpose of a literature review is to:

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

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

Types of Literature Reviews

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

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

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

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

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

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

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

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

NOTE: Most often the literature review will incorporate some combination of types. For example, a review that examines literature supporting or refuting an argument, assumption, or philosophical problem related to the research problem will also need to include writing supported by sources that establish the history of these arguments in the literature.

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

Structure and Writing Style

I.  Thinking About Your Literature Review

The structure of a literature review should include the following in support of understanding the research problem :

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

The critical evaluation of each work should consider :

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

II.  Development of the Literature Review

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

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

III.  Ways to Organize Your Literature Review

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

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

Here are examples of other sections, usually in the form of a single paragraph, you may need to include depending on the type of review you write:

• Current Situation : Information necessary to understand the current topic or focus of the literature review.
• Sources Used : Describes the methods and resources [e.g., databases] you used to identify the literature you reviewed.
• History : The chronological progression of the field, the research literature, or an idea that is necessary to understand the literature review, if the body of the literature review is not already a chronology.
• Selection Methods : Criteria you used to select (and perhaps exclude) sources in your literature review. For instance, you might explain that your review includes only peer-reviewed [i.e., scholarly] sources.
• Standards : Description of the way in which you present your information.
• Questions for Further Research : What questions about the field has the review sparked? How will you further your research as a result of the review?

IV.  Writing Your Literature Review

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

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

V.  Common Mistakes to Avoid

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

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

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

Writing Tip

Break Out of Your Disciplinary Box!

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

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

Another Writing Tip

Don't Just Review for Content!

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

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

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

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

Yet Another Writing Tip

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

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

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

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

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• Writing Tips

Your Literature Review and Discussion Sections

3-minute read

• 23rd November 2015

Many things go well together in this world, like fish and chips or the birds and the bees (figuratively speaking). However, one felicitous pairing that might not immediately jump to mind are the literature review and discussion sections of your dissertation.

This is because a dissertation is more than a set of discrete essays; rather, each part should be written in a way that contributes to your dissertation as a greater whole. Nowhere is this more important than in the discussion section, as it’s essential to refer to your literature review when interpreting your results.

Why? Let us explain via the ‘Three C-Words’ (no, not that one: we’re talking about context, comparison and contribution).

1.     Context!

The main purpose of your literature review is to contextualise your research by outlining previous studies conducted in the field. Referring back to the literature review in your discussion section therefore helps set the background against which your results should be interpreted, making it easier to explain their relevance to your hypothesis.

2.     Comparison!

Simply describing your results isn’t enough in the discussion section, as you also need to interpret and analyse data in terms of your research question. One way to do this is by comparing your results to those obtained in similar studies.

For example, you might want to discuss whether your results agree or disagree with those of other researchers. If there is a difference, you’ll also want to consider why this has happened and whether it’s significant.

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However, you should not introduce new research in the discussion section. Make sure that any studies you refer to in the discussion have been addressed in the literature review. And don’t be afraid to modify your literature review as your study progresses (every dissertation project will evolve as it goes on).

3.     Contribution!

As well as discussing the relevance of your results, your discussion section should usually include some reference to how your research contributes to knowledge in your field of study.

This, again, requires that you refer to your literature review, where you have discussed existing research in your field. Ideally, you will also have formulated your research questions to address a gap in the current research. Your discussion section is thus where you explain how your results fill this gap.

In summary, referring to your literature review will make sure that your discussion section is always on topic. And remember the three C-words: context, comparison and contribution.

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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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What Is A Literature Review?

A plain-language explainer (with examples).

By:  Derek Jansen (MBA) & Kerryn Warren (PhD) | June 2020 (Updated May 2023)

If you’re faced with writing a dissertation or thesis, chances are you’ve encountered the term “literature review” . If you’re on this page, you’re probably not 100% what the literature review is all about. The good news is that you’ve come to the right place.

Literature Review 101

• What (exactly) is a literature review
• What’s the purpose of the literature review chapter
• How to find high-quality resources
• How to structure your literature review chapter
• Example of an actual literature review

What is a literature review?

The word “literature review” can refer to two related things that are part of the broader literature review process. The first is the task of  reviewing the literature  – i.e. sourcing and reading through the existing research relating to your research topic. The second is the  actual chapter  that you write up in your dissertation, thesis or research project. Let’s look at each of them:

Reviewing the literature

The first step of any literature review is to hunt down and  read through the existing research  that’s relevant to your research topic. To do this, you’ll use a combination of tools (we’ll discuss some of these later) to find journal articles, books, ebooks, research reports, dissertations, theses and any other credible sources of information that relate to your topic. You’ll then  summarise and catalogue these  for easy reference when you write up your literature review chapter. 

The literature review chapter

The second step of the literature review is to write the actual literature review chapter (this is usually the second chapter in a typical dissertation or thesis structure ). At the simplest level, the literature review chapter is an  overview of the key literature  that’s relevant to your research topic. This chapter should provide a smooth-flowing discussion of what research has already been done, what is known, what is unknown and what is contested in relation to your research topic. So, you can think of it as an  integrated review of the state of knowledge  around your research topic. 

What’s the purpose of a literature review?

The literature review chapter has a few important functions within your dissertation, thesis or research project. Let’s take a look at these:

Purpose #1 – Demonstrate your topic knowledge

The first function of the literature review chapter is, quite simply, to show the reader (or marker) that you  know what you’re talking about . In other words, a good literature review chapter demonstrates that you’ve read the relevant existing research and understand what’s going on – who’s said what, what’s agreed upon, disagreed upon and so on. This needs to be  more than just a summary  of who said what – it needs to integrate the existing research to  show how it all fits together  and what’s missing (which leads us to purpose #2, next). 

Purpose #2 – Reveal the research gap that you’ll fill

The second function of the literature review chapter is to  show what’s currently missing  from the existing research, to lay the foundation for your own research topic. In other words, your literature review chapter needs to show that there are currently “missing pieces” in terms of the bigger puzzle, and that  your study will fill one of those research gaps . By doing this, you are showing that your research topic is original and will help contribute to the body of knowledge. In other words, the literature review helps justify your research topic.  

Purpose #3 – Lay the foundation for your conceptual framework

The third function of the literature review is to form the  basis for a conceptual framework . Not every research topic will necessarily have a conceptual framework, but if your topic does require one, it needs to be rooted in your literature review. 

For example, let’s say your research aims to identify the drivers of a certain outcome – the factors which contribute to burnout in office workers. In this case, you’d likely develop a conceptual framework which details the potential factors (e.g. long hours, excessive stress, etc), as well as the outcome (burnout). Those factors would need to emerge from the literature review chapter – they can’t just come from your gut! 

So, in this case, the literature review chapter would uncover each of the potential factors (based on previous studies about burnout), which would then be modelled into a framework. 

Purpose #4 – To inform your methodology

The fourth function of the literature review is to  inform the choice of methodology  for your own research. As we’ve  discussed on the Grad Coach blog , your choice of methodology will be heavily influenced by your research aims, objectives and questions . Given that you’ll be reviewing studies covering a topic close to yours, it makes sense that you could learn a lot from their (well-considered) methodologies.

So, when you’re reviewing the literature, you’ll need to  pay close attention to the research design , methodology and methods used in similar studies, and use these to inform your methodology. Quite often, you’ll be able to  “borrow” from previous studies . This is especially true for quantitative studies , as you can use previously tried and tested measures and scales. 

How do I find articles for my literature review?

Finding quality journal articles is essential to crafting a rock-solid literature review. As you probably already know, not all research is created equally, and so you need to make sure that your literature review is  built on credible research . 

We could write an entire post on how to find quality literature (actually, we have ), but a good starting point is Google Scholar . Google Scholar is essentially the academic equivalent of Google, using Google’s powerful search capabilities to find relevant journal articles and reports. It certainly doesn’t cover every possible resource, but it’s a very useful way to get started on your literature review journey, as it will very quickly give you a good indication of what the  most popular pieces of research  are in your field.

One downside of Google Scholar is that it’s merely a search engine – that is, it lists the articles, but oftentimes  it doesn’t host the articles . So you’ll often hit a paywall when clicking through to journal websites. 

Thankfully, your university should provide you with access to their library, so you can find the article titles using Google Scholar and then search for them by name in your university’s online library. Your university may also provide you with access to  ResearchGate , which is another great source for existing research. 

Remember, the correct search keywords will be super important to get the right information from the start. So, pay close attention to the keywords used in the journal articles you read and use those keywords to search for more articles. If you can’t find a spoon in the kitchen, you haven’t looked in the right drawer. 

Need a helping hand?

How should I structure my literature review?

Unfortunately, there’s no generic universal answer for this one. The structure of your literature review will depend largely on your topic area and your research aims and objectives.

You could potentially structure your literature review chapter according to theme, group, variables , chronologically or per concepts in your field of research. We explain the main approaches to structuring your literature review here . You can also download a copy of our free literature review template to help you establish an initial structure.

In general, it’s also a good idea to start wide (i.e. the big-picture-level) and then narrow down, ending your literature review close to your research questions . However, there’s no universal one “right way” to structure your literature review. The most important thing is not to discuss your sources one after the other like a list – as we touched on earlier, your literature review needs to synthesise the research , not summarise it .

Ultimately, you need to craft your literature review so that it conveys the most important information effectively – it needs to tell a logical story in a digestible way. It’s no use starting off with highly technical terms and then only explaining what these terms mean later. Always assume your reader is not a subject matter expert and hold their hand through a journe y of the literature while keeping the functions of the literature review chapter (which we discussed earlier) front of mind.

Example of a literature review

In the video below, we walk you through a high-quality literature review from a dissertation that earned full distinction. This will give you a clearer view of what a strong literature review looks like in practice and hopefully provide some inspiration for your own. 

Wrapping Up

In this post, we’ve (hopefully) answered the question, “ what is a literature review? “. We’ve also considered the purpose and functions of the literature review, as well as how to find literature and how to structure the literature review chapter. If you’re keen to learn more, check out the literature review section of the Grad Coach blog , as well as our detailed video post covering how to write a literature review . 

Psst… there’s more!

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

16 Comments

Thanks for this review. It narrates what’s not been taught as tutors are always in a early to finish their classes.

Thanks for the kind words, Becky. Good luck with your literature review 🙂

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This is review is amazing. I benefited from it a lot and hope others visiting this website will benefit too.

Timothy T. Chol [email protected]

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This was so useful. Thank you so much.

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This is an amazing talk. I paved way for myself as a researcher. Thank you GradCoach!

Well-presented overview of the literature!

This was brilliant. So clear. Thank you

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How do I Write a Literature Review?: #5 Writing the Review

• Step #1: Choosing a Topic
• Step #2: Finding Information
• Step #3: Evaluating Content
• Step #4: Synthesizing Content
• #5 Writing the Review
• Citing Your Sources

WRITING THE REVIEW 

You've done the research and now you're ready to put your findings down on paper. When preparing to write your review, first consider how will you organize your review.

The actual review generally has 5 components:

Abstract  -  An abstract is a summary of your literature review. It is made up of the following parts:

• A contextual sentence about your motivation behind your research topic
• Your thesis statement
• A descriptive statement about the types of literature used in the review
• Summarize your findings
• Conclusion(s) based upon your findings

Introduction :   Like a typical research paper introduction, provide the reader with a quick idea of the topic of the literature review:

• Define or identify the general topic, issue, or area of concern. This provides the reader with context for reviewing the literature.
• Identify related trends in what has already been published about the topic; or conflicts in theory, methodology, evidence, and conclusions; or gaps in research and scholarship; or a single problem or new perspective of immediate interest.
• Establish your reason (point of view) for reviewing the literature; explain the criteria to be used in analyzing and comparing literature and the organization of the review (sequence); and, when necessary, state why certain literature is or is not included (scope)  - 

Body :  The body of a literature review contains your discussion of sources and can be organized in 3 ways-

• Chronological -  by publication or by trend
• Thematic -  organized around a topic or issue, rather than the progression of time
• Methodical -  the focusing factor usually does not have to do with the content of the material. Instead, it focuses on the "methods" of the literature's researcher or writer that you are reviewing

You may also want to include a section on "questions for further research" and discuss what questions the review has sparked about the topic/field or offer suggestions for future studies/examinations that build on your current findings.

Conclusion :  In the conclusion, you should:

Conclude your paper by providing your reader with some perspective on the relationship between your literature review's specific topic and how it's related to it's parent discipline, scientific endeavor, or profession.

Bibliography :   Since a literature review is composed of pieces of research, it is very important that your correctly cite the literature you are reviewing, both in the reviews body as well as in a bibliography/works cited. To learn more about different citation styles, visit the " Citing Your Sources " tab.

• Writing a Literature Review: Wesleyan University
• Literature Review: Edith Cowan University
• << Previous: Step #4: Synthesizing Content
• Next: Citing Your Sources >>
• Last Updated: Aug 22, 2023 1:35 PM
• URL: https://libguides.eastern.edu/literature_reviews

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Literature Review Tips for the Introduction and Discussion Sections

A literature review is a summary of studies related to a particular area of research. It identifies and summarizes all the relevant research conducted on a particular topic. It is important that your literature review is focused . Therefore, you should choose a limited number of studies that are central to your topic rather than trying to collect a wide range of studies that might not be closely connected.

Literature reviews help you accomplish the following:

• Evaluate past research  Collecting relevant resources will help you see what research has already been done. This will also help avoid duplication.
• Identify experts It is important to identify credible researchers who have knowledge in a given field, in order to seek their help if you get stuck with certain aspects of your research.
• Identify key questions  Your ultimate aim is to bring something new to the conversation. Collecting resources will help you determine the important questions that need to be addressed.
• Determine methodologies used in past studies Knowing how others have approached a particular topic will give you the opportunity to identify problems and find new ways to research and study a topic. If the reported methodology was successful, you can use it and save time that you would otherwise be spending on optimization.

Presenting Literature Review in the Introduction and Discussion Sections

There are many benefits to presenting literature reviews in the introduction and discussion sections of your manuscripts . However, there are differences in how you can present literature reviews in each section.

What Should be Included in the Literature Review of the Introduction Section?

The literature reviewed in the introduction should:

• Introduce the topic
• Establish the significance of the study
• Provide an overview of the relevant literature
• Establish a context for the study using the literature
• Identify knowledge gaps
• Illustrate how the study will advance knowledge on the topic

As you can see, literature review plays a significant role in the introduction section. However, there are some things that you should avoid doing in this section. These include:

• Elaborating on the studies mentioned in the literature review
• Using studies from the literature review to aggressively support your research
• Directly quoting studies from the literature review

It is important to know how to integrate the literature review into the introduction in an effective way. Although you can mention other studies, they should not be the focus. Instead, focus on using the literature review to aid in setting a foundation for the manuscript.

What Goes in the Literature Review of the Discussion Section?

Literature reviews play an important role in the discussion section of a manuscript . In this section, your findings should be the focus, rather than those of other researchers. Therefore, you should only use the studies mentioned in the literature review as support and evidence for your study.

There are three ways in which you can use literature reviews in the discussion section:

• To Provide Context for Your Study Using studies from the literature review helps to set the foundation for how you will reveal your findings and develop your ideas.
• Compare your Findings to Other Studies You can use previous literature as a backdrop to compare your new findings. This helps describe and also advance your ideas.
• State the Contribution of Your Study In addition to developing your ideas, you can use literature reviews to explain how your study contributes to the field of study.

However, there are three common mistakes that researchers make when including literature reviews in the discussion section. First, they mention all sorts of studies, some of which are not even relevant to the topic under investigation. Second, instead of citing the original article, they cite a related article that mentions the original article. Lastly, some authors cite previous work solely based on the abstract, without even going through the entire paper.

We hope this article helps you effectively present your literature review in both the introduction as well as the discussion section of your manuscript. You can also mention any other tips that will add to this article in the comments section below.

References:

[1]  http://www.math.montana.edu/jobo/phdprep/documents/phd6.pdf 

[2]  https://libguides.unf.edu/c.php?g=177129&p=1163732

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Frequently asked questions

What’s the difference between results and discussion.

The results chapter or section simply and objectively reports what you found, without speculating on why you found these results. The discussion interprets the meaning of the results, puts them in context, and explains why they matter.

In qualitative research , results and discussion are sometimes combined. But in quantitative research , it’s considered important to separate the objective results from your interpretation of them.

Frequently asked questions: Dissertation

Dissertation word counts vary widely across different fields, institutions, and levels of education:

• An undergraduate dissertation is typically 8,000–15,000 words
• A master’s dissertation is typically 12,000–50,000 words
• A PhD thesis is typically book-length: 70,000–100,000 words

However, none of these are strict guidelines – your word count may be lower or higher than the numbers stated here. Always check the guidelines provided by your university to determine how long your own dissertation should be.

A dissertation prospectus or proposal describes what or who you plan to research for your dissertation. It delves into why, when, where, and how you will do your research, as well as helps you choose a type of research to pursue. You should also determine whether you plan to pursue qualitative or quantitative methods and what your research design will look like.

It should outline all of the decisions you have taken about your project, from your dissertation topic to your hypotheses and research objectives , ready to be approved by your supervisor or committee.

Note that some departments require a defense component, where you present your prospectus to your committee orally.

A thesis is typically written by students finishing up a bachelor’s or Master’s degree. Some educational institutions, particularly in the liberal arts, have mandatory theses, but they are often not mandatory to graduate from bachelor’s degrees. It is more common for a thesis to be a graduation requirement from a Master’s degree.

Even if not mandatory, you may want to consider writing a thesis if you:

• Plan to attend graduate school soon
• Have a particular topic you’d like to study more in-depth
• Are considering a career in research
• Would like a capstone experience to tie up your academic experience

The conclusion of your thesis or dissertation should include the following:

• A restatement of your research question
• A summary of your key arguments and/or results
• A short discussion of the implications of your research

The conclusion of your thesis or dissertation shouldn’t take up more than 5–7% of your overall word count.

For a stronger dissertation conclusion , avoid including:

• Important evidence or analysis that wasn’t mentioned in the discussion section and results section
• Generic concluding phrases (e.g. “In conclusion …”)
• Weak statements that undermine your argument (e.g., “There are good points on both sides of this issue.”)

Your conclusion should leave the reader with a strong, decisive impression of your work.

While it may be tempting to present new arguments or evidence in your thesis or disseration conclusion , especially if you have a particularly striking argument you’d like to finish your analysis with, you shouldn’t. Theses and dissertations follow a more formal structure than this.

All your findings and arguments should be presented in the body of the text (more specifically in the discussion section and results section .) The conclusion is meant to summarize and reflect on the evidence and arguments you have already presented, not introduce new ones.

A theoretical framework can sometimes be integrated into a  literature review chapter , but it can also be included as its own chapter or section in your dissertation . As a rule of thumb, if your research involves dealing with a lot of complex theories, it’s a good idea to include a separate theoretical framework chapter.

A literature review and a theoretical framework are not the same thing and cannot be used interchangeably. While a theoretical framework describes the theoretical underpinnings of your work, a literature review critically evaluates existing research relating to your topic. You’ll likely need both in your dissertation .

While a theoretical framework describes the theoretical underpinnings of your work based on existing research, a conceptual framework allows you to draw your own conclusions, mapping out the variables you may use in your study and the interplay between them.

A thesis or dissertation outline is one of the most critical first steps in your writing process. It helps you to lay out and organize your ideas and can provide you with a roadmap for deciding what kind of research you’d like to undertake.

Generally, an outline contains information on the different sections included in your thesis or dissertation , such as:

• Your anticipated title
• Your abstract
• Your chapters (sometimes subdivided into further topics like literature review , research methods , avenues for future research, etc.)

When you mention different chapters within your text, it’s considered best to use Roman numerals for most citation styles. However, the most important thing here is to remain consistent whenever using numbers in your dissertation .

In most styles, the title page is used purely to provide information and doesn’t include any images. Ask your supervisor if you are allowed to include an image on the title page before doing so. If you do decide to include one, make sure to check whether you need permission from the creator of the image.

Include a note directly beneath the image acknowledging where it comes from, beginning with the word “ Note .” (italicized and followed by a period). Include a citation and copyright attribution . Don’t title, number, or label the image as a figure , since it doesn’t appear in your main text.

Definitional terms often fall into the category of common knowledge , meaning that they don’t necessarily have to be cited. This guidance can apply to your thesis or dissertation glossary as well.

However, if you’d prefer to cite your sources , you can follow guidance for citing dictionary entries in MLA or APA style for your glossary.

A glossary is a collection of words pertaining to a specific topic. In your thesis or dissertation, it’s a list of all terms you used that may not immediately be obvious to your reader. In contrast, an index is a list of the contents of your work organized by page number.

The title page of your thesis or dissertation goes first, before all other content or lists that you may choose to include.

The title page of your thesis or dissertation should include your name, department, institution, degree program, and submission date.

Glossaries are not mandatory, but if you use a lot of technical or field-specific terms, it may improve readability to add one to your thesis or dissertation. Your educational institution may also require them, so be sure to check their specific guidelines.

A glossary or “glossary of terms” is a collection of words pertaining to a specific topic. In your thesis or dissertation, it’s a list of all terms you used that may not immediately be obvious to your reader. Your glossary only needs to include terms that your reader may not be familiar with, and is intended to enhance their understanding of your work.

A glossary is a collection of words pertaining to a specific topic. In your thesis or dissertation, it’s a list of all terms you used that may not immediately be obvious to your reader. In contrast, dictionaries are more general collections of words.

An abbreviation is a shortened version of an existing word, such as Dr. for Doctor. In contrast, an acronym uses the first letter of each word to create a wholly new word, such as UNESCO (an acronym for the United Nations Educational, Scientific and Cultural Organization).

As a rule of thumb, write the explanation in full the first time you use an acronym or abbreviation. You can then proceed with the shortened version. However, if the abbreviation is very common (like PC, USA, or DNA), then you can use the abbreviated version from the get-go.

Be sure to add each abbreviation in your list of abbreviations !

If you only used a few abbreviations in your thesis or dissertation , you don’t necessarily need to include a list of abbreviations .

If your abbreviations are numerous, or if you think they won’t be known to your audience, it’s never a bad idea to add one. They can also improve readability, minimizing confusion about abbreviations unfamiliar to your reader.

A list of abbreviations is a list of all the abbreviations that you used in your thesis or dissertation. It should appear at the beginning of your document, with items in alphabetical order, just after your table of contents .

Your list of tables and figures should go directly after your table of contents in your thesis or dissertation.

Lists of figures and tables are often not required, and aren’t particularly common. They specifically aren’t required for APA-Style, though you should be careful to follow their other guidelines for figures and tables .

If you have many figures and tables in your thesis or dissertation, include one may help you stay organized. Your educational institution may require them, so be sure to check their guidelines.

A list of figures and tables compiles all of the figures and tables that you used in your thesis or dissertation and displays them with the page number where they can be found.

The table of contents in a thesis or dissertation always goes between your abstract and your introduction .

You may acknowledge God in your dissertation acknowledgements , but be sure to follow academic convention by also thanking the members of academia, as well as family, colleagues, and friends who helped you.

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 .  

In a thesis or dissertation, the discussion is an in-depth exploration of the results, going into detail about the meaning of your findings and citing relevant sources to put them in context.

The conclusion is more shorter and more general: it concisely answers your main research question and makes recommendations based on your overall findings.

In the discussion , you explore the meaning and relevance of your research results , explaining how they fit with existing research and theory. Discuss:

• Your  interpretations : what do the results tell us?
• The  implications : why do the results matter?
• The  limitation s : what can’t the results tell us?

Results are usually written in the past tense , because they are describing the outcome of completed actions.

The results chapter of a thesis or dissertation presents your research results concisely and objectively.

In quantitative research , for each question or hypothesis , state:

• The type of analysis used
• Relevant results in the form of descriptive and inferential statistics
• Whether or not the alternative hypothesis was supported

In qualitative research , for each question or theme, describe:

• Recurring patterns
• Significant or representative individual responses
• Relevant quotations from the data

Don’t interpret or speculate in the results chapter.

To automatically insert a table of contents in Microsoft Word, follow these steps:

• Apply heading styles throughout the document.
• In the references section in the ribbon, locate the Table of Contents group.
• Click the arrow next to the Table of Contents icon and select Custom Table of Contents.
• Select which levels of headings you would like to include in the table of contents.

Make sure to update your table of contents if you move text or change headings. To update, simply right click and select Update Field.

All level 1 and 2 headings should be included in your table of contents . That means the titles of your chapters and the main sections within them.

The contents should also include all appendices and the lists of tables and figures, if applicable, as well as your reference list .

Do not include the acknowledgements or abstract in the table of contents.

The abstract appears on its own page in the thesis or dissertation , after the title page and acknowledgements but before the table of contents .

An abstract for a thesis or dissertation is usually around 200–300 words. There’s often a strict word limit, so make sure to check your university’s requirements.

In a thesis or dissertation, the acknowledgements should usually be no longer than one page. There is no minimum length.

The acknowledgements are generally included at the very beginning of your thesis , directly after the title page and before the abstract .

Yes, it’s important to thank your supervisor(s) in the acknowledgements section of your thesis or dissertation .

Even if you feel your supervisor did not contribute greatly to the final product, you must acknowledge them, if only for a very brief thank you. If you do not include your supervisor, it may be seen as a snub.

In the acknowledgements of your thesis or dissertation, you should first thank those who helped you academically or professionally, such as your supervisor, funders, and other academics.

Then you can include personal thanks to friends, family members, or anyone else who supported you during the process.

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• Open access
• Published: 31 July 2024

Clinical implications of the family history in patients with lung cancer: a systematic review of the literature and a new cross-sectional/prospective study design (FAHIC: lung)

• Fabrizio Citarella 1 , 2 ,
• Kazuki Takada 3 ,
• Priscilla Cascetta 4 ,
• Pierfilippo Crucitti 2 , 5 ,
• Roberta Petti 5 , 6 ,
• Bruno Vincenzi 1 , 2 ,
• Giuseppe Tonini 1 , 2 ,
• Francesco M. Venanzi 7 , 8 ,
• Alessandra Bulotta 7 , 8 ,
• Sara Oresti 7 , 8 ,
• Carlo Greco 2 , 9 ,
• Sara Ramella 2 , 9 ,
• Lucio Crinò 10 ,
• Angelo Delmonte 10 ,
• Roberto Ferrara 7 , 8 ,
• Massimo Di Maio 11 ,
• Fiorella Gurrieri 2 , 6 &
• Alessio Cortellini   ORCID: orcid.org/0000-0002-1209-5735 1 , 2 , 12  

Journal of Translational Medicine volume  22 , Article number:  714 ( 2024 ) Cite this article

21 Accesses

1 Altmetric

Metrics details

Compared to other malignancies, few studies have investigated the role of family history of cancer (FHC) in patients with lung cancer, yielding largely heterogeneous results. We performed a systematic literature review in accordance with PRISMA guidelines, searching the PubMed and Scopus databases from their inception to November 25, 2023, to identify studies reporting on the role of FHC in patients with lung cancer. A total of 53 articles were included, most with a retrospective design and encompassing a variety of geographical areas and ethnicities.

Thirty studies (56.6%) assessed patients with non-small cell lung cancer (NSCLC), while 17 studies (32.1%) assessed patients with mixed histologies. Overall, the rates of FHC ranged from 8.3 to 68.9%, and the rates of family history of lung cancer ranged from 2 to 46.8%. Twenty-seven studies investigated FHC as a potential risk factor for lung cancer, with more than half reporting an increased risk for subjects with FHC. Five studies reported on the potential role of FHC in determining clinical outcomes, and twelve studies examined the relationship between FHC and germline mutations. Notably, only one study reported a significantly increased rate of germline mutations, including ATM , BRCA2 , and TP53 , for patients with a family history of lung cancer compared to those without, but both groups had a low prevalence of mutations (< 1%).

The FAHIC—Lung (NCT06196424) is the first cross-sectional/prospective study specifically developed to identify FHC patterns and within-family clusters of other risk factors, including smoking, to guide patients with NSCLC to systematic genetic counseling. Acknowledging the largely heterogeneous results of our systematic review and considering the clinical implications of detecting pathogenic germline variants (PGVs), the FAHIC-lung study aims to identify patients potentially enriched with PGVs/likely PGVs to direct them to germline screening outside of the research setting.

Introduction

Familial aggregation and inherited predisposition have been increasingly investigated in multiple cancer types. In breast, ovarian, prostate, and colorectal malignancies, international guidelines recommend genetic counselling in patients showing risk criteria for syndromes of inherited susceptibility to cancer, as aggregations with other malignancies have been widely described within families of these patient populations [ 1 , 2 , 3 ].

With a predicted number of death of about 160 000 cases in 2023 in Europe and 127 070 in US [ 4 , 5 ], Non-Small Cell Lung Cancer (NSCLC) still remains a leading cause of cancer death worldwide. A positive smoking history represents the main risk factor [ 6 ], while environmental factors such as exposure to radon, asbestosis and air pollution have been linked to lung cancer among never smokers [ 7 , 8 , 9 ].

Few studies have investigated the impact of a positive family history of cancer (FHC) in patients with NSCLC, describing the malignancies that can occur among relatives of patients with NSCLC, while only few and rare genetic syndromes associated with inherited germline genetic mutations, such as the Li-Fraumeni, have been directly linked to lung cancer risk [ 10 ]. Most of the studies did not provide information on the potential within-family clusters of other risk factors, including exposure to tobacco smoking, environmental carcinogens, and other geographical/epidemiological factors. Additionally, retrospective approaches to this topic are heavily impacted by recall bias and misclassification [ 11 , 12 ].

To underline the importance and potential clinical implications of investigating family history of cancer (FHC) in patients with non-small cell lung cancer (NSCLC), a recent retrospective study conducted in a cohort of 7.788 patients with NSCLC, who underwent commercially available germline genetic testing and reported an FHC of 71%, found that pathogenic germline variants (PGVs) or likely PGVs were present in 14.9% of the cases. Additionally, 2.9% of the cases carried a single PGV in a gene associated with autosomal recessive inheritance. Among positive patients, 61.3% carried a PGV/likely PGV in DNA damage and response (DDR) genes, and 95.1% of them harbored a PGV in genes with potential clinical implications, including BRCA2 (2.8%), CHEK2 (2.1%), ATM (1.9%), TP53 (1.3%), BRCA1 (1.2%), and EGFR (1.0%) [ 13 ].

In this manuscript, we present the results of a systematic review of the available evidence on the role of FHC in patients with lung cancer, and the design of the FAHIC-lung study (NCT06196424), a cross-sectional study that aims to prospectively describe the FHC and the potential within-family distribution of smoking and other risk factors, to identify patients more likely to be carriers of PGVs or likely PGVs.

Systematic review—methods

Literature search strategy and study selection criteria.

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the PubMed and Scopus databases from their inception date to November 25, 2023, to identify potentially relevant articles. The search terms were “non-small cell lung cancer or NSCLC,” “family history,” “lung cancer,” and “risk.”

The inclusion criteria for the study selection were as follows: (1) patients diagnosed with NSCLC of any stage; (2) available information on the family history of cancer for the included population (e.g., prevalence and type of family history). The exclusion criteria were as follows: (1) lack of information on the family history of cancer; (2) studies not published in English; and (3) case reports.

As this study was a systematic review, ethical approval and informed consent were not required. The study protocol was registered in PROSPERO, an international prospective register of systematic reviews funded by the National Institute for Health Research (NIHR), with the registration code CRD4202450742 (available at: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024507422 ).

Data extraction and data synthesis

Two authors (F.C. and K.T.) performed the literature search and evaluated the eligibility of studies using the PICO (patients, interventions, comparison, and outcome) framework following the PRISMA criteria. Assuming a certain heterogeneity in the results, we adopted a textual narrative synthesis approach to summarize the included publications [ 14 ]. In view of that, we did not establish specific criteria for data synthesis (e.g., the minimum number of studies or level of consistency required for synthesis).

F.C. and T.K. independently reviewed and extracted data from the published papers, including first author, journal name, and year of publication. The prevalence (as a rate) of family history of cancer was summarized in a master table, along with the type of family history collected (e.g., lung-cancer specific vs. family history of any malignancy), study design, study population characteristics, smoking status of study participants and screened relatives (if available), primary tumor type (e.g., NSCLC, small cell lung cancer [SCLC], or others), number of patients included, and disease stage (e.g., early stage vs. advanced stage, if available). Study characteristics, context, and findings were summarized, and similarities/differences across studies were described in detail. Disagreements between the two authors (F.C. and K.T.) were discussed and resolved with a third independent author (A.C.).

Systematic review—results

We identified a total of 198 potentially relevant articles from the PubMed and Scopus online databases through an initial search strategy. After excluding 41 duplicate articles, we screened and reviewed the titles and abstracts of 157 articles, resulting in 54 being assessed for eligibility. Finally, a total of 53 articles were included in this systematic review. The flow diagram of the study selection process is shown in Fig.  1 while the whole search strategy with publications assessed at each step (identification, screening, eligibility and inclusion) is available as supplementary material (search strategy).

Flow diagram of the studies selection process according to the PRISMA guidelines

Overall, the vast majority of the studies had a retrospective design, with most of them being case–control or observational retrospective studies, with only one cross-sectional study [ 15 ] and one prospective study [ 16 ]. Study populations encompassed a variety of geographical areas/ethnicities, with 23 studies (43.4%) enrolling Asian patients, 13 studies (24.5%) enrolling patients with multiple ethnicities (all with a majority of white patients), 11 studies (20.7%) including non-specified ethnicities, and six studies (11.3%) including other populations. Even the included histology types showed heterogeneity, with 30 studies (56.6%) assessing patients with NSCLC, 17 studies (32.1%) assessing patients with a mixed type of lung cancer including small cell lung cancer (SCLC), four studies (7.5%) assessing other/unspecified types of lung cancer, one study (1.9%) assessing patients with adenocarcinoma, and one study (1.9%) assessing patients with EGFR -positive adenocarcinoma only.

FHC was collected through questionnaires in only three studies [ 17 , 18 , 19 ], while none of them used ad-hoc questionnaires specifically developed to collect FHC and the within-family distribution of other risk factors, including smoking. Twenty-five studies (47.2%) assessed family history (FH) by collecting all malignancies reported among relatives, 21 studies (39.6%) assessed FH of lung cancer, three studies (5.7%) assessed FHC and FH of lung cancer separately, three studies (5.7%) assessed FH of smoking-related and smoking-unrelated cancers, and two studies (3.8%) assessed FH of pre-specified types of cancer. The degree of relatedness ranged from first to second degree, although it was not reported for the majority of the included studies. One study reported on the smoking status among the relatives of study participants [ 20 ] and one study included the assessment of environmental factors (coal exposure) among the risk factors for lung cancer [ 21 ].

Overall, the rate of FHC in patients with lung cancer ranged from 8.3 [ 22 ] to 68.9% [ 20 ], while the rates of FH of lung cancer from 2 [ 23 ] to 46.8% [ 21 ]. Some studies enrolled cohorts of patients potentially enriched for FHC, such as 11 studies which assessed female patients only reporting FHC ranging from 7.7 [ 24 ] to 59.4% [ 25 ] and FH of lung cancer ranging from 6.2 [ 26 ] to 28% [ 27 ], four studies which specifically assessed never/light smoker patients only, reporting FHC ranging from 29.1 [ 28 ] to 68.9 [ 20 ], two studies assessing patients with small aggressive NSCLC, one study assessing male patients only, one study assessing smokers specifically, and one study assessing patients aged ≤ 45 years. A synoptic table with organization of results is available as supplementary file 1.

Studies investigating FHC as a risk factor for lung cancer

Overall, 27 studies investigated FHC as a potential risk factor for lung cancer (Table  1 ) [ 16 , 17 , 20 , 23 , 24 , 25 , 26 , 27 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ]. Six out of 11 studies (54.5%) that investigated the role of FHC as a whole or in pre-specified type of cancers reported an increased risk of developing lung cancer for patients with FHC, while 11 out of 16 studies (68.7%) that investigated the role of FH of lung cancer reported a significant association.

One study reported a more pronounced increased risk for women aged ≤ 45 years and a synergistic effect of smoking and FHC in increasing the risk of lung cancer [ 29 ], while another study reported that FH of lung cancer was specifically associated with an increased risk of early on set lung cancer (< 55 years old) [ 17 ]. One study that failed to demonstrate an association between FHC and lung cancer diagnosis, reported a significant effect for patients in whom at least one relative with cancer was diagnosed < 50 years of age [ 20 ], while one study that failed to demonstrate an association between FH of lung cancer and lung cancer risk, reported a significant effect for female patients only [ 42 ].

One study confirmed that FH of lung cancer was associated with risk of lung cancer in both the whole study population and among smokers [ 37 ], while another study reported that FH of lung cancer was more strongly associated with lung cancer risk in case of first/second degree of relatedness compared to collateral relatives [ 40 ].

Studies investigating the potential impact of FHC on clinical outcomes.

Five studies reported on the potential role of FHC in determining clinical outcomes (Table  2 ) [ 19 , 28 , 48 , 49 , 50 , 51 , 52 ]. One study reported no association between FH of lung cancer and outcomes [ 48 ], two studies reported a differential effect for FHC and FH of lung cancer [ 28 , 49 ] and one study reported a decreased risk of death for patients with FHC [ 50 ]. Similarly, one study reported improving outcomes from PD-1 immunotherapy with increasing burden of FHC [ 52 ].

Studies investigating associations between FHC and germline mutations.

Overall, 12 studies reported on the potential relationship between FHC and germline mutations (Table  3 ) [ 33 , 36 , 37 , 39 , 44 , 46 , 51 , 53 , 54 , 55 , 56 , 57 ]. Two studies did not show an enrichment of the germline mutations/polymorphisms of interest in patients with FHC [ 53 , 55 ], while three studies suggested a potential enrichment [ 46 , 54 , 57 ], with only one of them specifically reporting an increased rate of germline mutations including ATM, BRCA2 and TP53 for patients with family history of lung cancer compared to those with no FH [ 46 ]. Two studies reported a significant effect of the germline status in increasing the risk of lung cancer among patients with no FHC [ 33 , 36 ], while in three other studies the effect was independent of FHC [ 39 , 44 , 46 ]. One study showed a synergistic effect in increasing the risk of lung cancer of XRCC3/XRCC4 variants and FHC [ 37 ]. Two studies investigated the potential impact of germline polymorphisms on clinical outcomes, one showing an association between hOGG1 single nucleotide polymorphisms and worse survival specifically in patients without FHC [ 51 ], the other showing multifaceted effects of germline NOTCH4 polymorphisms depending on the FHC status [ 56 ].

Studies investigating associations between FHC and lung cancer somatic features.

Seven studies reported on the potential association between FHC and lung cancer somatic features (Table  4 ) [ 15 , 52 , 58 , 59 , 60 , 61 , 62 ]. Three studies did not confirm significant associations between FHC and somatic microsatellite instability status [ 58 ], somatic DDR genes status [ 52 ], or KRAS mutational status [ 59 ], while 2 studies reported a significant association between FHC and EGFR mutation [ 60 , 61 ]. In addition, another study reported an association between FHC and the occurrence of multiple somatic mutations in patients tested for multiple genes [ 62 ].

Studies investigating associations between FHC and other lung cancer features.

Nine studies included in this subgroup reported on associations between FHC and other lung cancer features (Table  5 ) [ 18 , 19 , 21 , 22 , 63 , 64 , 65 , 66 , 67 ]. One study reported a link between younger age at diagnosis female gender and FHC [ 63 ], one study reported an increased prevalence of FH of breast cancer among female patients with lung cancer [ 64 ], while another study reported a 10-years increasing trend over time for the prevalence of FHC [ 22 ]. Importantly, one study reported a significant association between FHC and smoking [ 19 ], while another study reported that FH of lung cancer was more frequent among young women, with synergistic effect with smoking and coil exposure in determining the younger age at diagnosis [ 21 ].

FAHIC lung—methods/design

Study design and objectives.

The FAHIC—Lung study (observational, prospective, multicenter study to investigate the family history of cancer in patients with non-small cell lung cancer) is a cross-sectional/prospective, observational, multicenter study. Consecutive patients with histologically diagnosed NSCLC will be enrolled, regardless of their age, TNM stage, smoking status, and other clinicopathologic characteristics. ClinicalTrials.gov identifier: NCT06196424.

The primary objective of the study is the identification of FHC patterns and within-family clusters of other risk factors to address patients with NSCLC for systematic genetic counseling for germline next-generation sequencing (NGS) testing to identify PGVs and likely PGVs. Secondary objectives include the description of clinicopathological and oncological characteristics of patients with NSCLC according to FHC patterns.

Patients’ family history will be carefully collected by investigators through a dedicated self-reported study questionnaire, which has been developed for the purpose of this study and validated by the genetic expert of the steering committee (F.G.) (Supplementary file 2). Study questionnaire will focus on: (1) family history of cancer; (2) type of tumors/primary tumor sites among relatives with history of cancer; (3) age at diagnosis among relatives with history of cancer; (4) biological sex of relatives with history of cancer; (5) exposure to tobacco smoking and smoking habits among relatives with history of cancer; (6) geographical origin of participants and relatives with history of cancer; (7) personal history of multiple malignancies; (8) potential professional and environmental exposure to carcinogens of participants and relatives with history of cancer; (9) ethnicity of both participants and relatives with history of cancer.

To minimize risks of recalling bias, patients will be followed up for four weeks through two study visits: the first study visit at enrolment and the follow-up study visit. During the first study visit all patient’s clinic-pathologic will be collected and study participants will be given the ad-hoc questionnaire, which will be returned to the study personnel at the follow-up study visit (Fig.  2 ).

FAHIC-lung study design diagram

The following clinic-pathologic characteristics will be collected: (1) smoking status (active/passive, package/year, total years of smoking); (2) Eastern Cooperative Oncology Group Performance Status (ECOG-PS); (3) age at diagnosis; (4) tumor histology; (5) tumor stage at diagnosis according to the 8th edition of TNM staging system; (6) ethnicity; (7) professional and environmental exposure to carcinogens; (8) programmed death ligand-1 tumor proportion score (PD—L1 TPS); (9) any available oncogenic drivers including EGFR, KRAS, BRAF, c-MET , mutations and ALK, ROS-1, RET, NTRK translocation/gene fusions; (10) personal history of other synchronous/metachronous primary malignancies.

The study plan includes an observational phase and an analytical phase:

Observational phase : after collecting participants’ questionnaires, we will first reconstruct patients’ family trees with additional information on how other potential risk factors, such as smoking history and exposure to professional/environmental carcinogens, segregate within the families with a history of cancer.

Analytical phase : once we have identified family clusters of malignancies and risk factors potentially associated with the highest risk of being carriers of germline PGVs or likely PGVs, we will proceed with the collection of blood samples for germline testing in a subgroup of patients. This will enable us to assess and compare the prevalence of PGVs/likely PGVs between patients more likely to be carriers and the control cohort. This approach aims to achieve a robust comparison, minimize systematic referrals to genetic counseling for all NSCLC patients, and optimize NGS testing requests outside the research setting. Considering the validity and comprehensiveness of high-throughput techniques in identifying PGVs/likely PGVs [ 68 ], we will assess the germline status of the groups of interest through whole exome sequencing (WES) after DNA extraction from blood samples in a two step analysis.

In the first step, the raw sequencing data (FASTQ files) will undergo bioinformatic processing. Mapping will be performed using a high-throughput aligner to ensure accurate alignment of the sequenced reads to the human genome. Variant calling will then be conducted to identify deviations from the reference genome. Filtering and annotation of these variants will focus on a pre-specified list of pre-specified genes known to be associated potentially associated with cancer (Supplementary file 3). This curated gene list will be used to prioritize PGVs/likely PGVs variants. Online tools will be utilized for variant prioritization, organizing the genes based on their correlation with lung cancer, thus enabling us to pinpoint the most relevant variants for further investigation.

In the second step, we aim to discover novel variants that may contribute to lung cancer predisposition. This phase involves a more exploratory analysis of the FASTQ data, looking beyond the known pathogenic variants. We will leverage the extensive genealogical data we have collected on the patients’ family histories to identify potential new genetic markers. The stored FASTQ files will be re-analyzed to detect previously unreported variants, incorporating bioinformatics tools and techniques for variant discovery. These include advanced algorithms for variant detection and annotation, as well as integrative approaches to assess the potential pathogenicity of novel variants. The integration of genealogical data will enhance our ability to correlate these novel variants with familial patterns of lung cancer, potentially uncovering new genetic predispositions. This comprehensive approach ensures that we maximize the utility of the sequencing data, providing a robust platform for both targeted and discovery-driven genetic analysis.

Participants selection

Inclusion Criteria include: (1) histopathological diagnosis of NSCLC (all stages); (2) age ≥ 18 years old; (3) signed written informed consent; (4) availability of familiar and/or personal anamnestic data of cancer. Exclusion Criteria include: (1) unavailability of familiar and/or personal anamnestic data of cancer; (2) patient’s refusal.

Statistical plan and sample size

The sample size of patients enrolled has been determined only for the observational phase of the study. This determination focuses on identifying patients who are more likely to be carriers of pathogenic germline variants (PGVs) or likely PGVs. This approach acknowledges the lack of information on the prevalence of germline PGVs/likely PGVs in patients with NSCLC who are not selected based on family history of cancer (FHC), as well as the limited knowledge regarding the potential characteristics that will define our group of interest. We hypothesized a prevalence of 10% of participants with an especially enriched family history of cancer to be directed to systematic germline testing; assuming a confidence level of 95% with a total width for the confidence interval of 0.1 (precision of ± 5%), the minimum number of subjects needed to properly describe the group of interest, following a binomial “exact” calculation of the sample size, is 175. To account for potential dropouts, we will enroll a minimum of 180 patients.

Descriptive statistics will be used as appropriate to report FHC data, the distribution of within-family other risk factors, and baseline clinicopathologic characteristics. Analyses will be performed using R-Studio software (R Core Team, 2021), and MedCalc® Statistical Software version 20 (MedCalc Software Ltd, Ostend, Belgium; https://www.medcalc.org ; 2021).

To the best of our knowledge, this is the first systematic review summarizing the available evidence on the role of FHC in patients with lung cancer, and the FAHIC-lung study (NCT06196424) is the first cross-sectional/prospective study specifically designed to identify patients with NSCLC more likely to be carrier of PGVs/likely PGVs, that should be systematically referred to genetic counselling and germline testing.

Our review shows that few studies have focused on the family history of cancer (FHC) in patients with lung cancer, resulting in overall heterogeneous results, beginning with the extremely wide range of FHC and family history of lung cancer rates. The category with the highest number of reports included studies assessing FHC as a potential risk factor for developing lung cancer. However, even in this category, the results were largely discordant, with a variety of different approaches and categorizations. Most of the included studies followed a retrospective approach, which is inherently associated with recall bias in collecting family history information, and none used questionnaires specifically designed to collect FHC. To mitigate this bias, we developed our ad-hoc study questionnaire, while the cross-sectional/prospective approach with the 4-week interval will allow study participants to gather and report FHC information as carefully as possible.

Something that set lung cancer apart from other malignancies, where the FHC has an established role in defining the probability of being a carrier of PGVs/likely PGVs, such as ovarian, breast, prostate, and colorectal cancer, is the role of smoking. As mentioned, smoking history represents the main risk factor for lung cancer [ 6 ], several evidence shows that passive smoking from family members can be a detrimental factor and that even the smoking habit can be “inherited”, with a sort of intergenerational transmission [ 69 , 70 ]. The FAHIC-lung questionnaire will allow us to mitigate this potential bias as well, collecting smoking habit information and environmental exposure to carcinogens among patients’ relatives with cancer.

More than a half of the studies that assessed FHC and FH of lung cancer as a potential risk factor for lung cancer concluded that FHC plays a detrimental role, with a potential synergistic effect with smoking, that seems even more pronounced among young/female patients. Our systematic review also suggests that younger patients, female, Asian, and never/light smokers may be especially enriched in FHC, although with no clear/conclusive results, while no somatic genomic feature seems to be significantly associated with FHC, except for EGFR mutations.

Recently, increasing attention has been focused on the study of germline mutations as risk factor for lung cancer, highlighting how DDR genes alterations can be found among patients with lung adenocarcinoma, even in the context of wider within-family primary tumors spectrums, including breast/pancreatic cancers or hematological malignancies [ 10 ]. Even in the context of TP53-associated genetic susceptibility, FHC is gaining a clearer role, to the point of recommending genetic counselling for patients with lung adenocarcinoma younger than 46 years old and with an especially enriched FHC or personal history of multiple primary tumors [ 71 ].

Importantly, in our systematic review only one of the studies that investigated the multifaceted role of germline mutations reported a significant enrichment among patients with FHC [ 46 ]. Rifkin and colleagues first reported a systematic review on the evidence linking germline mutations with lung cancer risk, then validated through a large case–control study of patients undergoing germline whole exome sequencing (WES) the significant association between lung cancer risk and ATM , BRCA2 and TP 53 pathogenetic/likely pathogenetic germline mutations [ 46 ]. However, despite the overall enrichment among controls, variant-based and gene-based analyses showed a low prevalence of germline PGV/likely PGV in both cases and controls [ 46 ]. In addition, they reported a higher rate of carriers among study participants with FH of lung cancer compared to those without, but with a very low overall prevalence (0.8% vs 0.7% for the combination of ATM/BRCA2/TP53 ) [ 46 ], suggesting that a simplified collection of FHC information is not enough to identify patients with the highest probability of being carriers and to properly optimize germ-line NGC access.

Among gene-specific susceptibility for lung cancer, EGFR -associated one needs a special mention. Genetic counselling is already recommended for patients with somatic EGFR positive NSCLC younger than 50 years, regardless of their family history [ 10 ], however, a proper syndromic EGFR -associated lung cancer should be suspected in the case of the novo EGFR T790M mutations, especially with a somatic variant allele frequency (VAF) ≥ 35% [ 10 , 72 ], with even more rare EGFR variants, such as V834L and V843I being increasingly recognized [ 73 , 74 ]. Lastly, we will have to consider the complexity related to the multifaceted role of multiple primary tumors. Beyond the consisting evidence linking DDR genes mutations to a personal history of multiple malignancies, recent studies reported on the potential role of pleiotropic loci in determining the risk of multiple malignancies [ 75 ].

Our study plan has, however, some limitations. First, we will have to rely on patients' ability and willingness to reconstruct their family history, therefore the recall bias will exert a certain effect despite the cross/sectional prospective approach. In addition, we have no strictly predefined definition of potential family clusters to be analyzed. However, we can anticipate that the identified group of interest will likely include young female patients with adenocarcinoma histology, never or light smokers, patients with EGFR mutations, patients with a history of multiple primary tumors, and patients with a high burden of family history. This high burden of family history is particularly expected to be enriched in non-smoking associated cancers, including lung cancer, and in the DDR-genes associated cancer spectrum, such as breast, ovarian, prostate, melanoma, and pancreatic cancers.To ensure a comprehensive analysis, we also plan to incorporate other factors collected through our detailed questionnaire. These factors include smoking habits of the patients, passive smoking exposure, working exposure to carcinogens, and smoking habits of family members. By evaluating these additional factors, we aim to identify within-family clusters of other risk factors. Specifically, we will focus on selecting patients without a history of passive smoking, identifying patients with a younger age at diagnosis among their relatives with cancer, and considering patients with low working exposure to carcinogens. Despite having these anticipations, we have deliberately chosen to adopt an unbiased approach without pre-established features to define patients for germline tests. Considering the very low prevalence of germline mutations reported so far [ 46 ], this strategy allows for a more comprehensive and inclusive analysis, ensuring that we do not overlook any potential associations or risk factors to unravel the complexity of FHC information and identify patients especially enriched in PGVs/likely PGVs. Furthermore, considering that this is an observational study, we decided to adopt a two steps approach, in order to identify patients at risk as a first step. This, to minimize the potential clinical implications for study participants and let their treating physicians refer them to genetic counseling as per their existing clinical practice. Once the group of interest will be identified, we will amend the protocol to collect blood samples and allocate fundings for germline testing. Lastly, we have to consider that the FAIHC lung study is being conducted in Italy, therefore the study population will mostly consist of white/Caucasian patients. Although this will prevent us from gathering broader information on the potential implications of different races, we will be able to focus and obtain reliable results on patients with European ancestry.

In the context of a worldwide progressive implementation of chest computed tomography based screening programs in subject with smoking history [ 76 ], and considering the initial evidence of the potential benefit of screening programs among never smokers and other subjects potentially enriched in FHC/PGVs [ 77 ], identifying patients with the highest risk of being carrier of PGVs/likely PGVs would be extremely important to develop dedicated preventing measures in non-smoker subjects. Considering the costs of commercially available germline NGS tests and the potential preventive, prognostic, and therapeutic implications of the detection of germline mutations related to familial cancers, we believe that establishing FHC patterns to identify a subgroup of patients especially enriched in PGVs to direct to germline screening outside of the research setting, would be extremely helpful in optimizing resources, spare time and eventually improve patients’ outcomes.

Data Availability

This systematic review does not involve the generation of new data. The data analyzed in this study are derived from publicly available studies and publications that are cited within the paper. All sources of data, including databases and search strategies used to identify relevant studies, are described in the Methods section. Readers interested in accessing the underlying data can refer to the referenced studies and publications for more detailed information. Due to data management regulations, individual patient-level data from the FAIHC-lung study are not available. However, inquiries from third parties can be directed to the corresponding author.

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Citarella, F., Takada, K., Cascetta, P. et al. Clinical implications of the family history in patients with lung cancer: a systematic review of the literature and a new cross-sectional/prospective study design (FAHIC: lung). J Transl Med 22 , 714 (2024). https://doi.org/10.1186/s12967-024-05538-4

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Research on the Relationship Between Higher Education, Technological Innovation, and Green Economy—Analysis Based on Chinese Data from 2011 to 2020

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• Jiahui Sun   ORCID: orcid.org/0000-0001-8702-5232 1 ,
• Hechun Wu   ORCID: orcid.org/0009-0005-1933-155X 2 &
• Song Shi   ORCID: orcid.org/0000-0003-0560-6004 3  

Higher education (HE) and technological innovation (TI) are increasingly crucial for green economic (GE) development. The provincial panel data of China from 2011 to 2020 were sorted out to explore the relationship between higher education, technological innovation, and the green economy. The coupling coordination and PVAR models were used to empirically analyze the coupling coordination and impulse response status of higher education, technological innovation, and green economy. The current research found that, firstly, the comprehensive development level of higher education, technological innovation, and green economy in Eastern China, Inner China, and Western China is on an upward trend as time passes. Secondly, in terms of time, the coupling coordination level among higher education, technological innovation, and green economy in Eastern China, Inner China, and Western China is on an upward trend as time passes. Thirdly, regarding space, the development of coupling coordination levels among higher education, technological innovation, and green economy in Eastern China, Inner China, and Western China is uneven. Among the regions, it shows the spatial distribution of “high in Eastern China, low in Inner, and Western China.” Within the regions, there is a spatial distribution pattern centering on “Beijing-Tianjin-Guangdong,” “Jiangsu-Zhejiang-Shanghai,” and “Shaanxi-Hubei-Chongqing,” and spreading to the surrounding areas. Finally, there are interactive and dynamic effects among higher education, technological innovation, and green economy in Eastern China, Inner China, and Western China. However, the interactive effects among the three have short-term effects, and the effects are minor, and most effects are not significant.

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Department of Education, Jeonju University, Jeonju, 55069, Korea

Department of English Education, Jeonbuk National University, Jeonju, 55069, Korea

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Sun, J., Wu, H. & Shi, S. Research on the Relationship Between Higher Education, Technological Innovation, and Green Economy—Analysis Based on Chinese Data from 2011 to 2020. J Knowl Econ (2024). https://doi.org/10.1007/s13132-024-02226-y

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Long-duration energy storage—a literature review on the link between variable renewable energy penetration and market creation.

1. Introduction

2. materials and methods.

• Published between 2015 and 2022;
• English language;
• LDES mentioned in the abstract;
• Wide perspective on the LDES subject;
• Main focus on the power sector of a larger system;
• Evident link between VRE penetration and initial LDES technology deployment;
• Peer-reviewed;
• Full text available online;
• Article as document type;
• Available in one or several of the targeted databases.

3. Results and Discussion

3.1. modelling tool and purpose, 3.2. model horizon and approach, 3.3. geographical market, 3.4. assumed electricity demand, 3.5. assumed variable renewable energy penetration (vre %) level, 3.6. vre mix, 3.7. weather conditions, 3.8. consideration of past installations, 3.9. applied emission requirements, 3.10. available balancing technologies (ldes type), 3.11. estimated costs and efficiencies, 3.12. ldes value and business synergies, 3.13. storage duration, 3.14. assumed interconnections, 3.15. demand side management, 3.16. curtailment possibilities, 3.17. additional findings, 3.17.1. climate change, 3.17.2. the supply chain, 3.17.3. reliability and availability constraints, 3.17.4. political and international relations, 3.17.5. safety aspects, 3.17.6. renewable phrasing, 3.18. overview, 4. conclusions, supplementary materials, author contributions, data availability statement, acknowledgments, conflicts of interest.

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Selänniemi, A.; Hellström, M.; Björklund-Sänkiaho, M. Long-Duration Energy Storage—A Literature Review on the Link between Variable Renewable Energy Penetration and Market Creation. Energies 2024 , 17 , 3779. https://doi.org/10.3390/en17153779

Selänniemi A, Hellström M, Björklund-Sänkiaho M. Long-Duration Energy Storage—A Literature Review on the Link between Variable Renewable Energy Penetration and Market Creation. Energies . 2024; 17(15):3779. https://doi.org/10.3390/en17153779

Selänniemi, Andreij, Magnus Hellström, and Margareta Björklund-Sänkiaho. 2024. "Long-Duration Energy Storage—A Literature Review on the Link between Variable Renewable Energy Penetration and Market Creation" Energies 17, no. 15: 3779. https://doi.org/10.3390/en17153779

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• How to Write a Discussion Section | Tips & Examples

How to Write a Discussion Section | Tips & Examples

Published on 21 August 2022 by Shona McCombes . Revised on 25 October 2022.

The discussion section is where you delve into the meaning, importance, and relevance of your results .

It should focus on explaining and evaluating what you found, showing how it relates to your literature review , and making an argument in support of your overall conclusion . It should not be a second results section .

There are different ways to write this section, but you can focus your writing around these key elements:

• Summary: A brief recap of your key results
• Interpretations: What do your results mean?
• Implications: Why do your results matter?
• Limitations: What can’t your results tell us?
• Recommendations: Avenues for further studies or analyses

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Table of contents

What not to include in your discussion section, step 1: summarise your key findings, step 2: give your interpretations, step 3: discuss the implications, step 4: acknowledge the limitations, step 5: share your recommendations, discussion section example.

There are a few common mistakes to avoid when writing the discussion section of your paper.

• Don’t introduce new results: You should only discuss the data that you have already reported in your results section .
• Don’t make inflated claims: Avoid overinterpretation and speculation that isn’t directly supported by your data.
• Don’t undermine your research: The discussion of limitations should aim to strengthen your credibility, not emphasise weaknesses or failures.

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Start this section by reiterating your research problem  and concisely summarising your major findings. Don’t just repeat all the data you have already reported – aim for a clear statement of the overall result that directly answers your main  research question . This should be no more than one paragraph.

Many students struggle with the differences between a discussion section and a results section . The crux of the matter is that your results sections should present your results, and your discussion section should subjectively evaluate them. Try not to blend elements of these two sections, in order to keep your paper sharp.

• The results indicate that …
• The study demonstrates a correlation between …
• This analysis supports the theory that …
• The data suggest  that …

The meaning of your results may seem obvious to you, but it’s important to spell out their significance for your reader, showing exactly how they answer your research question.

The form of your interpretations will depend on the type of research, but some typical approaches to interpreting the data include:

• Identifying correlations , patterns, and relationships among the data
• Discussing whether the results met your expectations or supported your hypotheses
• Contextualising your findings within previous research and theory
• Explaining unexpected results and evaluating their significance
• Considering possible alternative explanations and making an argument for your position

You can organise your discussion around key themes, hypotheses, or research questions, following the same structure as your results section. Alternatively, you can also begin by highlighting the most significant or unexpected results.

• In line with the hypothesis …
• Contrary to the hypothesised association …
• The results contradict the claims of Smith (2007) that …
• The results might suggest that x . However, based on the findings of similar studies, a more plausible explanation is x .

As well as giving your own interpretations, make sure to relate your results back to the scholarly work that you surveyed in the literature review . The discussion should show how your findings fit with existing knowledge, what new insights they contribute, and what consequences they have for theory or practice.

Ask yourself these questions:

• Do your results support or challenge existing theories? If they support existing theories, what new information do they contribute? If they challenge existing theories, why do you think that is?
• Are there any practical implications?

Your overall aim is to show the reader exactly what your research has contributed, and why they should care.

• These results build on existing evidence of …
• The results do not fit with the theory that …
• The experiment provides a new insight into the relationship between …
• These results should be taken into account when considering how to …
• The data contribute a clearer understanding of …
• While previous research has focused on  x , these results demonstrate that y .

Even the best research has its limitations. Acknowledging these is important to demonstrate your credibility. Limitations aren’t about listing your errors, but about providing an accurate picture of what can and cannot be concluded from your study.

Limitations might be due to your overall research design, specific methodological choices , or unanticipated obstacles that emerged during your research process.

Here are a few common possibilities:

• If your sample size was small or limited to a specific group of people, explain how generalisability is limited.
• If you encountered problems when gathering or analysing data, explain how these influenced the results.
• If there are potential confounding variables that you were unable to control, acknowledge the effect these may have had.

After noting the limitations, you can reiterate why the results are nonetheless valid for the purpose of answering your research question.

• The generalisability of the results is limited by …
• The reliability of these data is impacted by …
• Due to the lack of data on x , the results cannot confirm …
• The methodological choices were constrained by …
• It is beyond the scope of this study to …

Based on the discussion of your results, you can make recommendations for practical implementation or further research. Sometimes, the recommendations are saved for the conclusion .

Suggestions for further research can lead directly from the limitations. Don’t just state that more studies should be done – give concrete ideas for how future work can build on areas that your own research was unable to address.

• Further research is needed to establish …
• Future studies should take into account …
• Avenues for future research include …

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• Open access
• Published: 01 August 2024

A multicenter cross-sectional study in China revealing the intrinsic relationship between medical students’ grade and their perceptions of the learning environment

• Runzhi Huang 1 , 2   na1 ,
• Weijin Qian 3   na1 ,
• Sujie Xie 1 , 2   na1 ,
• Mei Cheng 4   na1 ,
• Meiqiong Gong 5 ,
• Shuyuan Xian 1 , 2 ,
• Minghao Jin 3 ,
• Mengyi Zhang 3 ,
• Jieling Tang 3 ,
• Bingnan Lu 3 ,
• Yiting Yang 3 ,
• Zhenglin Liu 3 ,
• Mingyu Qu 3 ,
• Haonan Ma 3 ,
• Xinru Wu 3 ,
• Huabin Yin 6 ,
• Xiaonan Wang 7 ,
• Xin Liu 8 ,
• Yue Wang 9 ,
• Wenfang Chen 10 ,
• Min Lin 11 ,
• Chongyou Zhang 12 ,
• Erbin Du 13 ,
• Qing Lin 14 ,
• Zongqiang Huang 15 ,
• Jie Zhang 16 ,
• Guoyang Zhang 17 ,
• Yifan Liu 3 ,
• Yu Chen 18 ,
• Jun Liu 19 &
• Shizhao Ji 1 , 2  

BMC Medical Education volume  24 , Article number:  832 ( 2024 ) Cite this article

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Metrics details

Medical school learning environment (MSLE) has a holistic impact on students’ psychosomatic health, academic achievements, and personal development. Students in different grades perceive MSLE in different ways. Thus, it is essential to investigate the specific role of student’s grade in the perception of MSLE.

Using the Johns Hopkins Learning Environment Scale (JHLES) as a quantification instrument for the perception level of MSLE, 10,901 medical students in 12 universities in China were categorized into low or high JHLES group according to their questionnaires. We investigated the relationship between student’s grade and JHLES category by univariate analysis employing Pearson Chi-square test and Welch’s ANOVA. Then multivariable logistic regression analysis confirmed the predictive efficacy of student’s grade. A nomogram concerning the prediction of low JHLES score probability in medical students was also constructed.

A significant difference between two JHLES categories among students in different grades was observed ( p  < 0.001), with the proportion of the high JHLES group dominating in grade 1, 5, and the graduate subgroups ( p  < 0.001). The mean JHLES score declined especially in the third and fourth graders compared to freshmen ( p  < 0.001), while the mean score among the fifth graders had a remarkable rebound from the third graders ( p  < 0.001). Most imperatively, identified by multivariable logistic regression analysis, students in grade 3 (OR = 1.470, 95% CI = 1.265–1.709, p  < 0.001) and 4 (OR = 1.578, 95% CI = 1.326–1.878, p  < 0.001) perceived more negatively than freshmen. The constructed nomogram provided a promising prediction model for student’s low JHLES score probability, with accuracy, accordance, and discrimination (area under the curve (AUC) = 0.627).

The student’s grade was a significant influencing factor in medical students’ perception of MSLE. The perceptions among the third and fourth graders got worse, probably due to the worrying changes in various aspects of MSLE during that period. The relevant and appropriate interventions to improve medical students’ perceptions are urgently needed.

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Introduction

Learning environment (LE) is ordinarily defined as a psychosomatic and social learning climate provided by an academic institution where students experience the curriculum, the facilities, and the interactions with faculty and peers [ 1 ]. As one of the imperative elements in medical universities, medical school learning environment (MSLE) has been associated with students’ academic achievements, overall health, and contentment [ 2 , 3 ]. A satisfying perception of a supportive MSLE can not only improve a student’s academic record, confidence, sense of wellbeing and personal development, but also diminish distress and self-doubt [ 3 , 4 , 5 , 6 , 7 , 8 ]. On the contrary, an unfavorable and stressful MSLE may give rise to burnout and apprehension [ 6 , 9 ]. Seeking intrinsic or extrinsic influencing factors for MSLE and then promptly rectifying of undesirable factors are critical as well as indispensable for the formation of an advantageous MSLE, which can promote the students’ learning and the evolution of their professional identities [ 5 ].

The quality of a MSLE can be evaluated by medical students’ perceptions of it, and the latter can be quantitively measured by the Johns Hopkins Learning Environment Scale (JHLES) introduced by Shochet, R. B. et al. [ 5 ]. With 7 subscales and a total of 28 items, a higher JHLES score represents a more positive perception of MSLE. Conceivably, with the increment of a medical student’s grade, multifaceted variations take place simultaneously, which may result in changes of MSLE in diverse directions. For instance, from the matriculating students to the fourth graders, the curriculum and workload become increasingly burdensome, and most medical students will undergo a period of transition from a basic to a clinical learning style [ 10 , 11 , 12 , 13 ]. Previous studies have reported that medical students in different grades perceived MSLE differently, which has been confirmed in medical schools in a variety of countries, such as Sudan, Tunisia, Vietnam, and India [ 14 , 15 , 16 , 17 ]. For instance, a study has demonstrated an increase in the depression rate in senior medical students compared with freshmen, which might be related to the delicate changes in MSLE in part [ 18 ]. In addition, our precedent cross-sectional study involving medical students from 11 universities in China has elaborated that the student’s grade was one of the influencing factors for MSLE perception [ 19 ]. Despite previous efforts on the relationship between a student’s grade and MSLE, the concrete and exact impact of this potential influencing factor on student’s perception of MSLE has not been revealed. Therefore, it is essential to investigate the specific role of student’s grade in the perception of MSLE, so as to guide educators in developing appropriate and feasible interventions.

In this study, we mainly focused on elucidating the relationship between student’s grade and their MSLE perceptions. More precisely, we hoped to explore the discrepancy in MSLE perceptions among students in different grades along with the possible reasons, which might provide reliable evidence for specialists in the field of medical education to carry out corresponding interventions. The optimized MSLE will foster the shaping of students’ professional qualities as well as the development of the medical education, which is of great consequence.

Materials and methods

Sample selection and data extraction.

This study (CHEC2023-284) was approved by the Ethics Committee of the First Affiliated Hospital of Naval Medical University. A multicenter, large-scale sample study was conducted in 12 universities in China, which included 6 university categories: the 985 Project Universities (Peking University and Tongji University), the 211 Project Universities (Zhengzhou University), the Non-985/211 Project Universities (Jinggangshan University), the First Batches of Medical Universities (Capital Medical University, Chongqing Medical University, Fujian Medical University, Harbin Medical University, and Southwest Medical University), the Second Batches of Medical Universities (Mudanjiang Medical University), and the military universities (Naval Medical University and Air Force Medical University). The medical students from different grades in these universities were selected to complete a questionnaire in which the subscales and items reflected their perceptions of MSLE.

Primarily, we performed a pilot study with 20 students in Naval Medical University selected by stratified random sampling according to their grade. Students from grade 1 to 5 and graduate students were coded on the basis of their student number and then integrated into the random number table for the corresponding grade. Subsequently, 3 undergraduate students in each grade and 5 graduate students were randomly selected to fill in the questionnaire. As the questionnaire was translated into Chinese according to the original template (see in 2.2), several items should be modified according to students feedbacks to improve its readability and rationality. We changed all questions into positive declarative sentences to better apply Likert scale (see later). We also changed some words for easier comprehension in Chinese, such as, “student” into “classmate”, “school” into “medical school”, “clinical” into “clinical field”, etc. A few possible predisposed terms were deleted or changed into neutral words. Ultimately, the accuracy as well as fluency of the questionnaire have been greatly improved. It was then integrated into a trustworthy and professional online platform called Wenjuanxing ( https://www.wjx.cn/ ) for questionnaire inquiry.

Followingly, the link to the normative questionnaire was delivered to relevant responsible officers in medical schools of aforementioned 12 universities. Students were categorized by grade (from grade 1 to grade 5), and all registered students in 1 or 2 classes of each grade were randomly selected by stratified cluster sampling, who were included and then were invited to fill out the questionnaire. Graduate medical students from Tongji University, Capital Medical University, Chongqing Medical University, Fujian Medical University, Harbin Medical University, Mudanjiang Medical University, and Naval Medical University also participated in this study. Return students were excluded. Before distributing the questionnaire, all participated students were informed of the study’s purpose and the anonymity of their collaboration. 12,600 questionnaires were distributed to 12 universities and 11,265 of them were obtained from the respondents. Eventually, the unqualified questionnaires with inaccurate variables or unknown information were excluded, and a total of 10,901 valid questionnaires were downloaded for further analyses. The demographic information as well as other results were extracted and showed in a table integrally.

JHLES instrument for the assessment of students’ perceptions of MSLE

The Johns Hopkins Learning Environment Scale (JHLES) was applied to evaluate the students’ perceptions of MSLE in this study. With great reliability, utility, and validity, JHLES comprises 7 subscales, including the community of peers with 6 items, the faculty relationships with 6 items, the academic climate with 5 items, the meaningful engagement with 4 items, the mentoring with 2 items, the inclusion and safety with 3 items, and the physical space with 2 items [ 5 ]. The detailed scale information was listed in Supplementary Table 1. The Likert scale method of five points ranging from strongly disagreed (1 point) to strongly agreed (5 points) was utilized to score each item, and the final score of 28 items altogether was calculated. A high JHLES score indicated a positive perception of MSLE, whereas a low score meant the opposite [ 5 , 20 ].

Statistical analysis

For the sake of exploring the probable influencing factors for perceptions of MSLE, the participants were classified into low or high JHLES score group by the median JHLES score (104) collected from this study. Pearson Chi-Square tests were performed to investigate the potential factors affecting the JHLES score, and the significant variables were displayed in a heatmap. Then, the student’s grade variable was extracted to excavate its relationship with the JHLES score, and a further Welch’s ANOVA analysis was conducted. Moreover, the proportion of two JHLES score groups and the mean JHLES score in different subgroups of the student’s grade were computed as well. The results were exhibited in bar, scatter, and violin plots.

In this study, we aimed to discover whether student’s grade was a possible predictor for JHLES score. We also incorporated significant factors in the nomogram to develop a multivariable prediction model in order to support decision making for the improvement of MSLE in the field of education. To substantiate that student’s grade was a potential predictor of students’ perceptions of MSLE, grade and 6 other demographic variables such as age, gender, ethnicity, major, native place, and grade point average (GPA) were integrated into the multivariable logistic regression analysis. The odds ratio (OR), 95% confidence interval (CI), and p value for each variable were demonstrated in a table. Additionally, a nomogram on the basis of the above 7 significant variables was constructed for better visualization and prediction of the low JHLES score probability for each participant. Tables displayed the score of each variable subclassification as well as the linear predictor in the nomogram. Furthermore, the efficaciousness and predictive accordance of the nomogram model was evaluated by C-index using bootstrap method, with 1000 iterations. The net benefits of the medical students were assessed by the decision curve analysis (DCA), while the calibration performance was evaluated by calibration curve, simultaneously. Afterwards, participants were randomized into a train set (70%) and a test set (30%) for internal validation with the application of “CreateDataPartition” function of the R package (version 4.1.3, www.r-project.org ). The nomogram was established in the train set and validated in the test set, with receiver operation characteristic (ROC) curve validating the discrimination of nomograms in train, test and total sets. The outcomes were visualized respectively. Furthermore, the relationship between 28 items of JHLES and student’s grade was explored by Pearson Chi-Square test. Finally, a graphic abstract was created using Biorender website ( https://biorender.com/ ).

In this study, the analyzing processes were performed in R (Institute for Statistics and Mathematics, version 4.1.3; www.r-project.org ; Vienna, Austria) and SPSS20.0 (SPSS Inc., Chicago, IL, USA). For descriptive statistics, the continuous variables with normal distribution were described by mean ± standard deviation (SD), while the median with interquartile range was used for continuous variables with abnormal distribution. Number and percentage were utilized for categorical variables. Only a two-sided p value smaller than 0.05 was considered statistically significant.

General information

The flowchart of this study was displayed in Fig.  1 . 12,600 questionnaires were distributed to the included medical students from 12 universities in China. Among them, 11,265 questionnaires in total were obtained, while only 10,901 valid questionnaires were selected for subsequent analyses. The respond and analysis proportion were 89.40% and 86.52%, respectively. The general information and characteristics of participants were showed in Table  1 . The students’ ages ranged from 16 to 40 years, but the majority (98.09%) were between the ages of 16 and 25. Nearly 60% of all were female. Most students came from Fujian Medical University (23.24%), and a majority of students majored in clinical medicine (79.52%). In the aspect of student’s grade, almost 70% of students had a 5-year educational system, and there were more students in grade 1 comparatively with a percentage of 34.86, followed by grade 2 (18.74%), grade 4 (17.15%), grade 3 (15.28%), grade 5 (11.91%), and graduate students (2.06%). A large proportion of students’ parents had a low education level. Over 70% of students regarded their learning environment in schools and doctor-patient relationship in hospitals as good or excellent, and only a fraction of students was uninterested in medicine (2.11%). According to the JHLES category, 54.46 percent of students thought their MSLE was good.

The flowchart for data extraction and subsequent analyses. JHLES, Johns Hopkins Learning Environment Scale

Identify influencing factors with statistical significance of JHLES score

Ten thousand nine hundred one students were divided into high or low JHLES category according to the median score (104), where a high or low score was consistent with positive or negative perceptions towards MSLE. Preliminarily, the Pearson Chi-Square test was implemented to identify the striking influencing factors for JHLES score, and 10 significant variables (age, gender, university, university category, major, only child, native place, educational system, GPA, and grade) as well as a demographic variable, ethnicity, were holistically demonstrated in Fig.  2 . The “***” and “**” at the upper right corner of each variable represented its p value < 0.001 or 0.01, respectively. Whereafter, student’s grade variable with great significance was chosen to study its impact on the JHLES score.

Pearson Chi-Square tests identify the influencing factors with significant differences between the high and low JHLES categories. GPA, grade point average; JHLES, Johns Hopkins Learning Environment Scale

Figure  3 A revealed the notable difference between two JHLES categories among students in different grades ( p  < 0.001). Furthermore, there was a significant difference in the composition of the high and low JHLES categories in grade 1, grade 5, and graduate students with p values less than 0.001, with the high JHLES category clearly dominating. It suggested that the medical students’ perceptions of MSLE were more positive and energetic among freshmen, grade 5 and the graduate stage. Despite the fact that the proportion of students in low JHLES category elevated stepwise from grade 2 to grade 4, eventually surpassing the high group (49%) in grade 4, there were no significance of JHLES score in these 3 grades ( p  > 0.05).

The Pearson Chi-Square test and Welch’s ANOVA explore the differences in the JHLES score among students from different grades. A Pearson Chi-Square test showed significant differences in the JHLES score in terms of the student’s grade by bar plots ( p  < 0.001). B Significant differences in the mean JHLES score of students from different grades were suggested by Welch’s ANOVA and visualized in scatter plots and violin plots ( p  < 0.001). JHLES, Johns Hopkins Learning Environment Scale

Subsequently, Welch’s ANOVA indicated the significant differences ( p  < 0.001) in the mean JHLES score of students from different grades (Fig.  3 B). From grade 1 to grade 4, the mean JHLES score gradually declined from 106.71 to 103.22, especially in the third and fourth graders compared to freshmen ( p  < 0.001), which denoted the students’ perceptions of MSLE getting worse in grade 3 and 4. The mean score of the fourth graders was also significantly below that of the sophomores ( p  < 0.05). However, the mean JHLES score among the fifth graders (106.62) was strikingly higher compared to the third ( p  < 0.001), and the graduates’ mean score was even higher (108.26). Conceivably, the results were in accordance with those of the Pearson Chi-Square tests above. More positive perceptions of MSLE were observed in freshmen, sophomores, fifth graders, and graduates rather than in third and fourth graders. Moreover, the individual difference was also an important issue as the JHLES score ranged from the minimum 28 to the maximum 140 within a single grade. As the external environment was similar in the same grade, the own characteristics and personal factors of students may contribute to the discrepancy of their perceptions towards MSLE.

Multivariable logistic regression analysis for validating student’s grade as a potential predictor

To ulteriorly explore whether the student’s grade was a potential predictor for the medical students’ perceptions of MSLE, the grade together with 6 other demographic variables (age, gender, ethnicity, major, native place, and GPA) were incorporated into the multivariable logistic regression analysis. The statistics data like OR, 95% CI and p value were depicted in Table  2 . It was discovered that the age of 26–40 and male were both positively related to high JHLES score probability and further, the better perception of MSLE (OR = 0.426, 95% CI = 0.283–0.642, p  < 0.001; OR = 0.733, 95% CI = 0.675–0.795, p  < 0.001). Next, students who majored in nursing or phylaxiology were more likely associated with worse perceptions (OR = 1.494, 95% CI = 1.248–1.788, p  < 0.001; OR = 1.272, 95% CI = 1.085–1.491, p  = 0.003), yet the native places of students such as the prefecture city and provincial capital were considered to have a converse effect on students’ perceptions (OR = 0.790, 95% CI = 0.701–0.891, p  < 0.001; OR = 0.762, 95% CI = 0.659–0.881, p  < 0.001). Conspicuously, GPA in all subgroup levels was significant with a p value < 0.001. Higher GPA levels of students were associated with more satisfying and positive perceptions of MSLE.

Finally, employing the grade 1 subgroup as a reference, the grade 2 (OR = 1.242, 95% CI = 1.109–1.391, p  < 0.001), grade 3 (OR = 1.470, 95% CI = 1.265–1.709, p  < 0.001), and grade 4 (OR = 1.578, 95% CI = 1.326–1.878, p  < 0.001) were significant risk factors for low JHLES probability, which indicated that students in these 3 grades perceived worse of MSLE than the freshmen group. Nevertheless, the fifth graders and the graduates born no significance from students in grade 1. In conclusion, after the integration of demographic data in multivariable logistic regression analysis the student’s grade still remained a potential predictor for medical students’ perceptions of MSLE.

A nomogram for prediction of low JHLES score probability and further validation

A nomogram containing the aforementioned 7 variables was constructed for JHLES score prediction as well as visualization (Fig.  4 A). The subgroups of each variable were assigned corresponding points in the nomogram based on the multivariable logistic regression analysis, listed in Table  3 . It was worth noting that a student with higher total points in the nomogram model would be more likely to possess a lower JHLES score, representing his or her poorer perception of MSLE. In the nomogram, the score for age 16–20 (67) was higher than 21–25 (61) and 26–40 (0). Females as well as ethnic Han were inclined to have a low JHLES score. In terms of major, nursing students might have the worst perceptions with 49 points, followed by students of phylaxiology (36), preclinical medicine (21), clinical medicine (17), and stomatology (0). Moreover, students from the provincial capital (0) and prefecture city (3) tended to gain a favorable perception of MSLE in contrast with students from the municipality (25), country (21), village (18), and town (14). For GPA, a higher GPA was always correlated with better perception. Most imperatively, there was not a one-way trend of increasing or decreasing points across different students’ grades, which was of great interest. The third and fourth graders scored higher (45 and 50, respectively), while freshmen (15), sophomores (32), the fifth graders (20), and the graduates (0) held lower points, which strongly indicated that students in grade 3 and 4 perceived MSLE as being more inferior, discouraging and unfavorable in comparison with students in grade 1, 2, 5, and the graduates. The prediction of the nomogram’s total points for low JHLES probability was particularized in Table  4 .

Construction and validation of the nomogram. A A nomogram for predicting the low JHLES score probability of medical students. B The DCA of the nomogram. The X axis represented the range of threshold probability based on the nomogram, at which an intervention might be applied. The Y axis typically represented the net benefit, which was calculated by weighing both the benefits (true positives) and harms (false positives) associated with intervention across different threshold probability. The curve’s shape and position relative to reference lines (treating everyone or treating no one) help assess the clinical usefulness of the nomogram. When the low JHLES probability of the nonadherence prediction nomogram reached 0.26, giving proper interventions to students could obtain higher net benefits compared to treating every student. C The ROC curves of the nomogram for the train, test, and total sets (AUC = 0.627), indicating excellent predictive accordance and discrimination. D The calibration curve for the nomogram. The X axis represents the nomogram-predicted probability, and Y axis represents the actual probability of a low JHLES score. The fitted curve (blue line, R = 1) of the black dots indicates great performance of the nomogram. JHLES, Johns Hopkins Learning Environment Scale; DCA, decision curve analysis; ROC, receiver operating characteristic; AUC, area under the curve

The DCA curve unearthed that when the low JHLES probability of the nonadherence prediction nomogram reached 0.26, giving proper interventions to students could obtain higher net benefits compared with treating every student (Fig.  4 B). If the probability predicted by the nomogram was lower than the threshold value, it was better not to intervene in order to avoid overcorrection. Besides, the efficacy of the nomogram was also evaluated by the ROC curve, of which all three area under the curves (AUCs) in the train, test, and total sets were 0.627 (Fig.  4 C), suggesting a modest predictive accordance, accuracy, and discrimination. The calibration curve in Fig.  4 D displayed the nomogram’s great performance and consistency with the physical truth.

Further study on the relationship between student’s grade and subscales of JHLES

A descriptive heatmap clustered by student’s grade was generated in order to intuitively exhibit the distribution of 28 items’ score of JHLES for each student (Figure S1). Subsequently, Pearson Chi-Square test was performed for students in grade 3 and 4 as well as other graders, showing that all 28 items scores were significantly different between the two grade categories ( p  < 0.001, Figure S2), which indicated MSLE changes in various aspects between grade 3/4 and other grades.

After meticulously discussing the reasons for the negative perception of MSLE among students in grade 3 and 4, together with the corresponding interventions, a graphic abstract was generated, showed in Fig.  5 .

The summary graph of the relationship between students’ grades and their perceptions of MSLE. MSLE, medical school learning environment

In this study, 10,901 responses of the JHLES questionnaire from students in 12 medical universities in China were collected. After employing Pearson Chi-Square tests and Welch’s ANOVA, students’ grade was ascertained as a significant influencing factor, and a lower mean JHLES score was observed in grade 3 and 4 subgroups compared to grade 1 (or grade 2). Whereafter, student’s grade was validated as a potential predictor of MSLE perceptions in multivariable logistic regression analysis. Interestingly, the third and fourth graders were more likely to perceive MSLE negatively than matriculating students, while there was no significance for the fifth graders or the graduates. Subsequently, a nomogram was generated to better predict the probability of low JHLES score, that is, the probability of poor MSLE perception, showing modest predictive performance.

This study has concluded that, in terms of medical student’s perception of MSLE, the student’s grade was a potential predictor. During the first four years of study, their perceptions became more negative annually. The matriculating students’ perceptions were strikingly better than those of students in grade 3 and 4, while the fifth graders and the graduates perceived MSLE similarly to freshmen. However, the diagnostic tools for the nomogram exhibited contradictory results. The calibration curve showed excellent accordance with actual situation of the nomogram, while the AUC value of ROC curve only reached 0.627, indicating a not that good predictive accuracy. As stated in a previous article, the ROC performance may be fluctuated according to different clinical situations, like participant populations [ 21 ]. In our study, 10,901 students were included to construct the predictive nomogram. The large sample size might affect the ROC performance. Although the AUC value was low, it at least represented the association between student’s grade and JHLES score, which was supported by a large number of literatures. Anterior studies have reached a semblable conclusion, suggesting our results were of great reliability and uniformity. For instance, students majoring in occupational therapy have scented out a reduction of teaching quality from grade 1 to 3, which was a component of MSLE [ 22 ]. Using the Dundee Ready Educational Environment Measure (DREEM) questionnaire, it was discovered that the preclinical students (grade 1 and 2) perceived a more favorable LE than the clinical students (grade 3 and 4) in both India and Vietnam medical schools [ 16 , 23 , 24 ]. Meanwhile, the fifth- and sixth-year medical students in Thailand possessed better academic and social perceptions than the fourth graders, and the graduates or residents perceived the education environment optimistically [ 25 , 26 , 27 ]. Conservatively speaking, ROC curve was a necessary procedure for the diagnosis of model efficiency, and it implied a modest predictive performance of our nomogram. Therefore, the interpretation as well as application of the nomogram should be cautious. Additionally, the practical situation ought to be taken into account. Further studies with higher level of evidence such as prospective study, intervention study, or randomized controlled trial (RCT) are recommended in order to improve the study’s accuracy and clinical transformation efficacy.

The evident deterioration of MSLE perceptions of students in grade 3 and 4 might be correlated with the changes in multiple facets of MSLE along with the accompanying stress. Firstly, due to the curriculum provision system for medical students in China, the third and fourth graders were exposed to clinical courses and were requested to enter the hospital for probation. The quantified MSLE perception score was found to substantially decrease at the stage of preclinical-clinical transition [ 10 , 11 ]. In this lengthy transition from the classroom-based LE to the clinical-based LE, students were required to face a completely novel teaching method, which was quite tough. Besides, some students would be apprehensive about their insufficient knowledge during the probationary period, with a sense of incompetence and unpreparedness [ 28 ]. Also, they were worried about making mistakes and the lack of an inclusive atmosphere in the clinical LE [ 29 , 30 ]. Meanwhile, in addition to the perceptual changes, physical space was also changed at preclinical-clinical transition period. Before grade 3, students were often arranged to study in medical universities with comprehensive and well-equipped facilities, such as library, canteen, and gymnasium, which could meet students’ daily needs. After they entered the clinical stage, students may be admitted to the dormitory provided by hospitals with less sense of university. Besides, negative factors like conflicts between patients and doctors would worsen the clinical learning environment, leading to a more passive perception of MSLE by third and fourth graders [ 31 ].

Secondly, the third and fourth graders on probation had fewer opportunities to interact with their classmates, compared to their junior freshmen and sophomores who learned altogether in a single classroom by class [ 10 ]. An earlier study has illustrated that freshmen and sophomores involved in the learning community (LC) were apt to get more help from their companions, which led to a positive perception of MSLE [ 32 ]. As for students in grade 3 and 4, they may gradually realize the responsibility and duty of becoming medical workers, and would spend more time on their heavy schoolwork instead of attending social activities and interacting with peers. Thus, the supportive community of peers and the mutual assistance obtained from each other were attenuated among students in grade 3 and 4, resulting in their much more anxious perceptions of MSLE [ 15 ].

Thirdly, unlike other majors, medicine is a subject that a person needs to devote himself to continuously studying throughout his life. A wide range of courses, including basic courses like immunology, genetics, and cell biology, together with clinical courses such as internal medicine and surgery, were allocated in the first four years’ schedule for medical students. With the increase in a student’s grade, the relative curriculum became more onerous. The gradual increase in academic and examination pressure reached a peak in the fourth year of study, which was discouraging for the fourth graders. Some students at this period may suffer from the tight curriculum schedule and frequent test arrangement, which contributed to a not so good academic climate. It could partially explain their poor perceptions of MSLE [ 13 , 15 ].

Fourthly, some universities in China have advocated the introduction of scientific research into MSLE of undergraduates since the third year of study. Despite the fact that this integration fostered students’ subsequent academic achievements and cultivated their research skills as well as critical thinking, it has brought the third and fourth graders a certain amount of pressure [ 33 , 34 ]. For instance, students may find it challenging to match a suitable mentor in their interested specialty. Certain fields of research and clinical practice may face a scarcity of mentors with sufficient expertise, while in popular or highly competitive field, students would need to compete with other interested peers to acquire the favor of their dreamed mentors. Also, mentors sometimes were too busy to pay close attention to students due to heavy workload and numerous research projects, leading to disappointment and unmet expectations. Although being mentored is deemed to have a positive influence on career development of students, the above difficulties hindered students’ improvement [ 35 ].

Last but not least, medical students in grade 3 and 4, especially grade 4, were additionally confronted with the pressure of applying for a higher degree through the postgraduate entrance exam or the exemption of the admission exam. Because of the cultivating pattern of Chinese medical students, a majority of graduates with a bachelor’s degree desired to enter a higher learning institution for the purpose of learning more professional knowledge. Therefore, they were supposed to accumulate more stress in this process to a certain extent. In conclusion, based on the five reasons listed above that increase anxiety, the perceptions of MSLE among students in grade 3 and 4 were indeed worse than those among freshmen and sophomores.

As for the fifth graders, there was a partial recovery of the perception score of MSLE. During their internships, the previous pressure from schoolwork, examinations, and the application for a higher degree suddenly disappeared. Students often felt untrammeled to strive for the knowledge they yearned for [ 36 ]. They also gained abundant experience through the teaching and practice of physicians and their interactions with patients in the clinical LE [ 36 ]. Furthermore, they could exchange information and related resources with peers to help each other navigate the stressful preclinical-clinical transition period [ 37 ], creating a supportive climate that might be beneficial to promote the development of their MSLE perceptions in a positive direction. For the graduates, they paid more attention to their professional responsibilities after accessing a new stage of study, which might change their primary perceptions of MSLE [ 38 ].

A small number of studies have drawn opposite conclusions from our study. In two medical schools in Pakistan and Turkey, medical students in grade 3 and 4 seemed to perceived better than freshmen, according to the DREEM questionnaire [ 39 , 40 ]. The existing discrepancy was presumably due to different students’ adaptations to clinical tasks, different teaching method or medical curricula in different countries. In addition, students’ perception of MSLE might be influenced by surrounded social relationships with fellow students, faculty and other members in the university, which could be discrepant across various culture settings. It’s of great importance to conduct further research on these influencing factors to gain a more complete understanding of the MSLE perceptions by medical students in different grades.

Apart from the discrepancy of student’s perception of MSLE among 6 grades, there were also difference within each grade, which could be partly attributed to individual factors of students. As displayed in Pearson Chi-Square test, GPA and whether being an only child were significant factors for JHLES score. Previous studies have concluded that a good perception of MSLE contributed to better academic performance [ 41 , 42 ], while better academic performance, measured by GPA in most of medical universities in China, would provide students with sense of achievement together with more learning engagement for a higher goal, which could indeed promote their positive perception of MSLE. Moreover, being an only child was usually related to more concern and solicitude shone from parents as well as a more supportive atmosphere around, which may alleviate student’s daily pressure and improve their positive perception. Besides, the variance of MSLE perception may also due to distinct personality traits of students, such as extroverted, cooperated, or introverted character, which would affect their perception and engagement model in MSLE. Nonetheless, studies in terms of the influence of student’s personal factors on MSLE perception were still a scarcity, and further research is in an urgent need.

To promote academic performance, psychosomatic health, and the development of students at all grades, it is necessary for the professionals in the education field to take related interventions into effect to improve MSLE for medical students in grade 3 and 4 [ 29 ]. A peer teaching program has exhibited its remarkable efficacy in promoting communication between students in higher and lower grades or within peers [ 32 , 34 , 43 ], which proved to ease the fretfulness of the preclinical-clinical transition for junior graders and also elevate the teaching skills and the comprehension of medical knowledge for senior graders. What’s more, students-paired clinical placements have exerted a favorable effect on their MSLE and health [ 44 ]. As another intervention, adjusting the course structure, such as through the application of the integrated curriculum, could enhance students’ academic performance along with their perceptions of MSLE [ 45 , 46 ]. Besides, a supportive educational environment was recommended, encompassing an encouraging teacher-student relationship, timely feedback and close attention from teachers, which profoundly contributed to students’ satisfaction with MSLE, as well as alleviated the stress of the transition period [ 47 , 48 , 49 ]. Additionally, the simulation-based training for students on probation was another intervention to benefit their transition to clinical placements [ 50 ]. More feasible interventions are expected to be formulated in the near future to advance MSLE and students’ developmental potential. The graphic abstract of this study was presented in Fig.  5 .

Limitations still exist in this cross-sectional study. First, as it was defined as a cross-sectional study, only correlation can be provided rather than causal inference. It was unable to determine whether student’s grade or some other underlying factors caused the variation in the perception of MSLE. Second, even though the five-point Likert scale from strongly disagree to strongly agree was expounded in the questionnaire, some participants may respond to the items subjectively, which might influence the veracity and credibility of the collected data (reporting bias). Third, although a structural stratified random sampling method was utilized for participants selection, there still existed some systematic error. Moreover, as 6 grades were designed for pairwise comparisons, a total of 15 times comparisons increased the probability of a significant result, which was called the alpha error. Cross validation is recommended to verify whether the associations observed on our data are maintained on the new data. Fourth, despite the 7 subscale scores of JHLES were collected along with the total score, we just displayed and discussed the result instead of exploring thoroughly which aspect of MSLE could be deeply influenced by grade. Last but not least, the stressors and appropriate interventions for students with negative perceptions of MSLE pointed out in this article should be investigated in future studies, which was of great significance for medical educators and decision makers. Nevertheless, our study is still the first to concentrate on the intrinsic relationship between a student’s grade and a student’s perception of MSLE in China, in which the multi-center design and a huge sample size guarantee representative and typical results. Further research with higher level of evidence such as case–control study, cohort study and so on is urgently needed, in order to investigate the causal relationships between a medical student’s perception of MSLE and grade or other factors such as the GPA, major, and university category.

The medical student’s grade was validated as a potential predictor for the medical student’s perception of MSLE, and the nomogram was also constructed as a reliable tool for the prediction of the student’s negative MSLE perception. The third and fourth graders held a higher probability of perceiving MSLE negatively probably due to the preclinical-clinical transition in MSLE, less support from peers, heavier workload, emerging research pressure, and the stress of applying for a higher degree. Consequently, appropriate interventions are urgently needed to improve the quality of MSLE among students in grade 3 and 4.

Availability of data and materials

The datasets generated and/or analyzed during the current study are available in the supplementary material.

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Acknowledgements

Not applicable.

This study was supported in part by the National Natural Science Foundation of China (81930057, 81772076, 81971836), CAMS Innovation Fund for Medical Sciences (2019-I2M-5–076), Deep Blue Talent Project of Naval Medical University, 234 Academic Climbing Programme of Changhai hospital and Achievements Supportive Fund (2018-CGPZ-B03); Shanghai Rising-Star Program (Sailing Special Program) (No. 23YF1458400). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author information

Runzhi Huang, Weijin Qian, Sujie Xie and Mei Cheng contributed equally to this work, and all should be considered first author.

Authors and Affiliations

Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University, No. 168 Changhai Road, Yangpu District, Shanghai, 200433, People’s Republic of China

Runzhi Huang, Sujie Xie, Shuyuan Xian & Shizhao Ji

Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences, 200433, Shanghai, People’s Republic of China

Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China

Weijin Qian, Minghao Jin, Mengyi Zhang, Jieling Tang, Bingnan Lu, Yiting Yang, Zhenglin Liu, Mingyu Qu, Haonan Ma, Xinru Wu & Yifan Liu

Department of Nephrology, the First Affiliated Hospital of Naval Medical University, 200433, Shanghai, People’s Republic of China

Office of Educational Administration, Shanghai University, Shanghai, 200444, China

Meiqiong Gong

Department of Orthopedics, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, 100 Haining Road, Shanghai, China

Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, 10 Xitoutiao, Beijing, 100069, China

Xiaonan Wang

Department of Rheumatology and Immunology, Second Affiliated Hospital of Naval Medical University, Shanghai, China

Department of Health Statistics, School of Public Health, Air Force Medical University, No.169,Changle West Road, Xi’an, 710032, China

Faculty of Medicine, Jinggangshan University, 28 Xueyuan Road, Ji’An, 343009, China

Wenfang Chen

Mental Health Education and Consultation Center,Chongqing Medical University, 61 Daxuecheng Middle Road, Chongqing, 401331, China

Basic Medical College, Harbin Medical University, 157 Baojian Road, Harbin, 150081, Heilongjiang, China

Chongyou Zhang

Frist Clinical Medical College, Mudanjiang Medical University, 66 Tongxiang Street, Mudanjiang, 157011, China

Department of Human Anatomy, Laboratory of Clinical Applied Anatomy, School of Basic Medical Sciences, Fujian Medical University, 1 Xuefu North Road, Fuzhou, 350122, China

Department of Orthopedics, The First Affiliated Hospital of Zhengzhou University, 1 Jianshe East Road, Zhengzhou, 450052, China

Zongqiang Huang

Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, 2699 Gaoke West Road, Shanghai, 201204, China

Maastricht University School of Health Professions Education, Maastricht, the Netherlands

Guoyang Zhang

Department of Gyneacology and Obstetrics, The First Affiliated Hospital of Naval Medical University, Yangpu District, No. 168 Changhai Road, Yangpu District, Shanghai, 200433, China

Department of Anesthesiology, Shanghai Pulmonary Hospital Affiliated to Tongji University, 507 Zheng Min Road, Shanghai, 200433, China

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Contributions

Conception/design: Runzhi Huang, Weijin Qian, Sujie Xie, Mei Cheng, Meiqiong Gong, Shuyuan Xian, Minghao Jin, Mengyi Zhang, Jieling Tang, Bingnan Lu, Yiting Yang, Zhenglin Liu, Mingyu Qu, Haonan Ma, Xinru Wu, Huabin Yin, Xiaonan Wang, Xin Liu, Yue Wang, Wenfang Chen, Min Lin, Chongyou Zhang, Erbin Du, Qing Lin, Zongqiang Huang, Jie Zhang, Guoyang Zhang, Yifan Liu, Yu Chen, Jun Liu, Shizhao Ji. Collection and/or assembly of data: Runzhi Huang, Weijin Qian, Sujie Xie, Mei Cheng, Meiqiong Gong, Shuyuan Xian, Minghao Jin, Mengyi Zhang, Jieling Tang, Bingnan Lu, Yiting Yang, Zhenglin Liu, Mingyu Qu, Haonan Ma, Xinru Wu, Huabin Yin, Xiaonan Wang, Xin Liu, Yue Wang, Wenfang Chen, Min Lin, Chongyou Zhang, Erbin Du, Qing Lin, Zongqiang Huang, Jie Zhang, Guoyang Zhang, Yifan Liu, Yu Chen, Jun Liu, Shizhao Ji. Data analysis and interpretation: Runzhi Huang, Weijin Qian, Sujie Xie, Mei Cheng, Meiqiong Gong, Shuyuan Xian, Minghao Jin, Mengyi Zhang, Jieling Tang, Bingnan Lu, Yiting Yang, Zhenglin Liu, Mingyu Qu, Haonan Ma, Xinru Wu, Huabin Yin, Xiaonan Wang, Xin Liu, Yue Wang, Wenfang Chen, Min Lin, Chongyou Zhang, Erbin Du, Qing Lin, Zongqiang Huang, Jie Zhang, Guoyang Zhang, Yifan Liu, Yu Chen, Jun Liu, Shizhao Ji. Manuscript writing: Runzhi Huang, Weijin Qian, Sujie Xie, Mei Cheng, Meiqiong Gong, Shuyuan Xian, Minghao Jin, Mengyi Zhang, Jieling Tang, Bingnan Lu, Yiting Yang, Zhenglin Liu, Mingyu Qu, Haonan Ma, Xinru Wu, Huabin Yin, Xiaonan Wang, Xin Liu, Yue Wang, Wenfang Chen, Min Lin, Chongyou Zhang, Erbin Du, Qing Lin, Zongqiang Huang, Jie Zhang, Guoyang Zhang, Yifan Liu, Yu Chen, Jun Liu, Shizhao Ji. Final approval of manuscript: Runzhi Huang, Weijin Qian, Sujie Xie, Mei Cheng, Meiqiong Gong, Shuyuan Xian, Minghao Jin, Mengyi Zhang, Jieling Tang, Bingnan Lu, Yiting Yang, Zhenglin Liu, Mingyu Qu, Haonan Ma, Xinru Wu, Huabin Yin, Xiaonan Wang, Xin Liu, Yue Wang, Wenfang Chen, Min Lin, Chongyou Zhang, Erbin Du, Qing Lin, Zongqiang Huang, Jie Zhang, Guoyang Zhang, Yifan Liu, Yu Chen, Jun Liu, Shizhao Ji.

Corresponding authors

Correspondence to Huabin Yin , Xiaonan Wang , Xin Liu , Yue Wang , Wenfang Chen , Min Lin , Chongyou Zhang , Erbin Du , Qing Lin , Zongqiang Huang , Jie Zhang , Guoyang Zhang , Yifan Liu , Yu Chen , Jun Liu or Shizhao Ji .

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Huang, R., Qian, W., Xie, S. et al. A multicenter cross-sectional study in China revealing the intrinsic relationship between medical students’ grade and their perceptions of the learning environment. BMC Med Educ 24 , 832 (2024). https://doi.org/10.1186/s12909-024-05538-4

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Effect of different physical activity interventions on perinatal depression: a systematic review and network meta-analysis

• Yu Shuai 1 , 4   na1 ,
• Jinlong Wu 2   na1 ,
• Chenmu Li 3 &
• Dong Li 4  

BMC Public Health volume  24 , Article number:  2076 ( 2024 ) Cite this article

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Perinatal depression can have profound impacts on both families and society. Exercise therapy is gradually becoming a widely used adjunct treatment for perinatal depression. Some studies have already focused on the relationship between physical activity and perinatal depression (PND). However, there is currently a lack of systematic and comprehensive evidence to address the crucial question of making optimal choices among different forms of physical activity. This study aims to compare and rank different physical activity intervention strategies and identify the most effective one for perinatal depression.

Four databases, namely PubMed, Cochrane Library, Embase, and Web of Science, were searched for randomized controlled trials assessing the impact of physical activity interventions on perinatal depression. The search covered the period from the inception of the databases until May 2024. Two researchers independently conducted literature screening, data extraction, and quality assessment. Network meta-analysis was performed using Stata 15.1.

A total of 48 studies were included in the analysis. The results indicate that relaxation therapy has the most effective outcome in reducing perinatal depression (SUCRA = 99.4%). Following that is mind-body exercise (SUCRA = 80.6%). Traditional aerobics and aquatic sports were also effective interventions (SUCRA = 70.9% and 67.1%, respectively).

Our study suggests that integrated mental and physical (MAP) training such as relaxation therapy and mind-body exercise show better performance in reducing perinatal depression. Additionally, while exercise has proven to be effective, the challenge lies in finding ways to encourage people to maintain a consistent exercise routine.

Trial registration

This study has been registered on PROSPERO (CRD 42,023,469,537).

Peer Review reports

Introduction

Perinatal Depression (PND), defined as depression occurring during pregnancy (prenatal depression) or after childbirth (postpartum depression), is a common mental disorder with a prevalence exceeding 10% [ 1 , 2 ]. Risk factors for PND may include a history of depression, lower socioeconomic status, poor physical health, anxiety about pregnancy, and reduced social support, while better living conditions and higher levels of education are possible protective factors [ 3 , 4 ]. Research suggests that the prevalence of perinatal depression is higher among women in low and middle-income countries compared to women in high-income countries [ 5 ], and first-time mothers may have a higher risk of postpartum depression compared to multiparous women [ 6 ]. Perinatal depression may negatively affect a mother’s quality of life, intimate relationships, birth outcomes, and the likelihood of breastfeeding. Additionally, it may have long-term impacts on a child’s social, emotional, cognitive, language, motor, and adaptive behavior development [ 7 , 8 ].

Both pharmacological and non-pharmacological treatments may help alleviate symptoms of perinatal depression in women [ 9 ]. However, due to concerns about potential adverse effects of medications on the health of the fetus and infant, some women tend to prefer non-pharmacological treatments [ 10 ]. Non-pharmacological treatments primarily include psychological interventions, physical therapies, exercise therapy, music therapy, acupuncture, and more [ 11 ]. Psychological intervention may be a first-line treatment for mild to moderate perinatal depression, with their therapeutic effects possibly lasting 6–12 months [ 12 ]. Among these, Cognitive Behavioral therapy (CBT) and Interpersonal Therapy (IPT) are both potentially effective psychological interventions for treating perinatal depression [ 13 ].

It’s worth noting that exercise therapy, due to its low cost and ease of implementation, has gradually become a widely used adjunctive treatment for postpartum depression [ 14 ]. Exercise during pregnancy and postpartum may benefit the health of both the mother and the fetus. It can potentially reduce the risk of conditions such as preeclampsia, gestational hypertension, gestational diabetes, excessive weight gain during pregnancy, and complications during delivery. It may also improve the psychological health of pregnant and postpartum women, reducing the incidence and severity of perinatal depression [ 15 , 16 , 17 , 18 ]. The American College of Obstetricians and Gynecologists (ACOG) considers exercise to be generally safe for perinatal women and recommends that women engage in moderate-intensity exercise for 20–30 min most days of the week, as it may play a significant role in preventing postpartum depression [ 19 ].

Previous studies have indicated that aerobic exercise may be positively correlated with the alleviation of perinatal depression symptoms. Group exercise, participant-choice exercise, and combined interventions involving exercise have all shown potential efficacy as intervention measures [ 14 , 20 ]. Prenatal yoga has been demonstrated to possibly improve current mood and reduce symptoms of both prenatal and postpartum depression [ 21 , 22 , 23 ]. Compared to sedentary women, those who engage in moderate physical activity in an aquatic environments may have a lower risk of postpartum depression [ 24 ]. A randomized controlled trial indicated that progressive muscle relaxation exercise (PMRE) may reduce the risk of postpartum depression and increase maternal attachment [ 25 ].

Previous meta-analyses have often focused on the relationship between physical activity and perinatal depression [ 26 , 27 , 28 ]. However, there is a lack of high-quality evidence to support decisions regarding the optimal choice among various physical activity interventions. To address this gap and provide more precise and safe treatment options for women with perinatal depression, this study conducted a network meta-analysis and systematic review based on high-quality randomized controlled trials (RCTs). The aim was to compare and rank different physical activity interventions and determine the best physical activity intervention for perinatal depression. This research seeks to offer more accurate guidance for the treatment of perinatal depression in women.

Protocol and registration

We followed the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines for literature inclusion, data organization, statistical analysis, and results reporting. This study has also been registered on PROSPERO (CRD 42,023,469,537).

Data sources and search strategy

We conducted a comprehensive search for relevant literature on the association between physical activity and perinatal depression in four electronic databases: PubMed, Cochrane Library, Embase, and Web of Science. The initial search covered the period from the inception of each database up to June 20, 2023. Considering the timeliness of the research, we also conducted a secondary search covering the period from June 20, 2023, to May 19, 2024. Following the PICOS (Population, Intervention, Comparison, Outcome, Study Design) principles, the search terms included “Exercise” or “Exercises” or “Physical Activity” or “Physical Activities” or “Motor Activity” or “Sport” or “Aerobics” or “Training” or “Trainings” or “Jogging” or “Walking” or “Ambulation” or “Yoga” or “Swimming” or “Dancing” or “Cycling” or “Resistance” or “Pilates” or “Stretching” and “Postpartum Depression” or “Postnatal Depression” or “Postnatal Dysphoria” or “Postpartum Dysphoria” or “Puerperal depression” or “Antepartum depression” or “Antenatal depression” or “Perinatal depression” or “Prenatal depression” or “Depression during pregnancy” or “Postpartum psychosis.” For specific search strategies, please refer to Appendix B1 and Appendix B2 .

Study selection

After conducting the literature search using the aforementioned search strategy, two authors (YS and DL) independently conducted the literature screening process. Initial screening was performed by reviewing the titles and abstracts of the retrieved articles to identify potentially relevant studies. Subsequently, the articles with higher relevance were selected for full-text retrieval and examination. Ultimately, the literature meeting the criteria was included in the statistical analysis. In cases of disagreement, group discussions were held among team members to reach a consensus.

Inclusion and exclusion criteria

This systematic review, based on the PICOS framework, established criteria for the selection, inclusion, and exclusion of literature.

Inclusion criteria for literature were as follows:

Study subjects were perinatal women, including those during pregnancy and within one year postpartum [ 29 ].

Interventions involved various types of exercise or physical activity.

Studies reported data on depression indicators in perinatal women before and after the intervention.

Experimental study designs were limited to randomized controlled trials (RCTs).

Original data were provided.

The studies were written in English.

Exclusion criteria for literature were as follows:

Study participants were not perinatal women.

The intervention did not include physical activity.

There was no reporting on depression-related outcomes.

The study types included qualitative research, reviews, theses, conference papers.

Non-interventional study designs, including cross-sectional studies, case-control studies, and cohort studies.

Original data were not provided.

The studies were written in a language other than English.

Data extraction

The data from the included trials were independently extracted by two authors (YS and DL). Any discrepancies that arose during this process were resolved through group discussions. The following information was extracted from each study:

Descriptive information, such as author(s), year, and country.

Participant characteristics, including age range, gender, and sample size.

Intervention details, including time, frequency, and duration.

Outcome measurements, specifically related to perinatal depression.

When interventions or outcomes were unclear but presented graphically, the Engauge Digitizer software was used to extract data. For studies with multiple follow-up assessments, data were only extracted immediately after the intervention. In cases where standard deviations were not provided, they were calculated from the confidence intervals (95%) of the mean within the intervention or control group.

Quality assessment

We utilized the Cochrane Risk of Bias assessment tool (RoB2) to evaluate the quality of the studies based on five criteria: (1) Randomization process; (2) Deviation from intended interventions; (3) Missing outcome data; (4) Outcome measurement; (5) Selection of the reported result. Based on this, we assessed the overall bias of each study, categorizing them as having low risk, high risk, or some concerns.

Statistical analysis

We calculated the Standardized Mean Difference (SMD) with a 95% confidence interval (CI) for continuous outcomes. We assessed the statistical heterogeneity using the P-value from the chi-square test and the I 2 statistic. Considering that the included studies utilized various depression scales, we employed a random-effects model to ensure consistency and comparability in calculating the average difference. Following the recommendations of PRISMA NMA, we used a Bayesian framework and the Markov chain Monte Carlo simulation in Stata 15.1 software to aggregate and analyze NMA data [ 30 , 31 ]. Node-splitting analysis was used to quantify and explain the consistency between indirect and direct comparisons. If the p -value was greater than 0.05, it was considered consistent through the consistency test.

We conducted a network meta-analysis using a Bayesian model. Data preprocessing was performed using the network package, and evidence network plots were generated. In the evidence network plot, each point represents an intervention, and the size of the point corresponds to the sample size included in the respective intervention study. Lines connecting two points represent direct comparisons between two interventions, and the thickness of the line segment indicates the number of studies included in the comparison, with thicker lines indicating more included studies. To rank the effects of different types of exercise, we calculated the Surface Under the Cumulative Ranking Curve (SUCRA) and presented the probability ranking in a table. SUCRA is expressed as a percentage, where a higher proportion indicates a better effect of the intervention. To assess publication bias, we generated a funnel plot and conducted both Begg’s test and Egger’s test. Additionally, we applied the trim-and-fill method using a random-effects model for further analysis.

Trial selection

To ensure the accuracy of the literature retrieval and screening process, two researchers (YS and DL) with expertise in the fields of perinatal depression and exercise science independently screened titles, abstracts, and full-text articles after the literature search was completed. The inter-rater reliability (Cohen’s kappa) between these two screening stages was calculated, including the screening stages for titles and abstracts, as well as the full-text screening stage. The consistency levels were categorized as follows: fair consistency (0.40–0.59), good consistency (0.60–0.74), and excellent consistency (> 0.75) [ 32 ].

In our initial search, we conducted a comprehensive search of four electronic databases from their inception to June 20, 2023, identifying a total of 7,912 articles. Following the removal of duplicate studies ( n  = 1,494), 6,418 relevant articles remained. Subsequently, through title and abstract screening, 6,295 articles were excluded, leaving 102 articles eligible for full-text review. During this stage, the inter-rater reliability between the two assessors was classified as “good” (Cohen’s kappa = 0.73). After a full-text review, 57 articles were further excluded. Among these, 11 were not randomized controlled trials, 17 did not involve exercise interventions, 26 had unavailable data, and 3 lacked full-text access. Consequently, the initial search screened out 45 studies. To ensure the research was up-to-date, we also conducted a secondary search, comprehensively reviewing the literature from June 20, 2023, to May 19, 2024, in the four electronic databases, identifying 896 articles. After these two searches and careful screening, a total of 48 studies were included in the quantitative synthesis (Fig.  1 ). During this stage, the inter-rater reliability between the two assessors was classified as “excellent” (Cohen’s kappa = 0.84).

A summary of the evidence searches and selection process

Trial characteristics

Table  1 presents the characteristics of the 48 included studies. All studies were published between 2003 and 2024. The United States had the highest number of publications, with a total of 11 papers. The sample size in the intervention groups ranged from 8 to 396 individuals, totaling 2,930 perinatal women. The control group sample sizes ranged from 7 to 382 individuals, totaling 2,907 perinatal women. The average age of women included in the experimental and control groups was less than 40 years.

To investigate whether different types of physical activity have varying effects on perinatal women’s depression, we classified them into seven types based on common features of physical activity and previous related research [ 27 , 33 ]. This classification was determined through team discussions and expert consultations. The seven types include aquatic sport (2 studies) [ 24 , 34 ], combination exercise (10 studies) [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 ], mind-body exercise (14 studies) [ 22 , 23 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ], relaxation therapy (3 studies) [ 25 , 57 , 58 ], strength training (2 studies) [ 59 , 60 ], traditional aerobics (12 studies) [ 20 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 ], and walking (5 studies) [ 72 , 73 , 74 , 75 , 76 ].

Non-physical activity interventions included no intervention, health education, social support, and usual care. Measurement tools commonly used for perinatal depression included the Edinburgh Postnatal Depression Scale (EPDS), Center for Epidemiological Studies Depression Scale (CES-D), Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS), Psychological General Well-Being Index (PGWBI), Depression Anxiety Stress Scales (DASS), Profile of Mood States (POMS), Hamilton Depression Rating Scale (HDRS), and Physical health questionnaire-9 (PHQ-9), among others.

Risk of bias

Of the 48 studies, 35 were considered to have a low risk of bias in the randomization process, while 13 studies did not specify their randomization process. All studies were deemed to have a low risk of bias in terms of deviations from intended interventions and missing outcome data. For outcome measurement bias, 39 studies were considered to have a low risk, while 9 studies were considered to have a high risk. Regarding selective reporting bias, 47 studies were judged to have a low risk, with only 1 study having a high risk of selective reporting bias. Based on these five criteria, we categorized the overall risk of the 48 studies: 38 studies were considered to have a low overall risk of bias, and 10 studies were considered to have a high overall risk of bias. Detailed bias assessment results of the included studies can be found in Fig.  2 and Appendix C .

Risk of bias of included studies

Certainty of evidence

Assessment was conducted according to the GRADE method, and the specific results can be found in Appendix E1 .

• Network meta-analysis

Figure  3 represents the Network Meta-Analysis diagram. It is evident that the three interventions with the largest sample sizes in the experimental group are traditional aerobics, mind-body exercise, and combination exercise. In the control group, the three interventions with the largest sample sizes are usual care, health education, and no intervention. The most frequently studied comparisons involve traditional aerobics versus usual care, combination exercise versus usual care, and mind-body exercise versus usual care.

Network diagram

As shown in Table  2 , the statistically significant results of the network meta-analysis are as follows: Relaxation therapy [MD=-3.13, 95% CI=(-6.02, -0.23)] demonstrated greater efficacy compared to mind-body exercise. When compared to traditional aerobics, relaxation therapy [MD=-3.69, 95% CI=(-6.58, -0.80)] showed superior effectiveness. Relaxation therapy [MD=-4.10, 95% CI=(-7.61, -0.58)] exhibited higher efficacy than walking. In comparison to combination exercise, relaxation therapy [MD=-4.90, 95% CI=(-7.92, -1.87)] was more effective. Both relaxation therapy [MD=-5.21, 95% CI=(-8.28, -2.14)] and mind-body exercise [MD=-2.08, 95% CI=(-3.98, -0.19)] demonstrated greater efficacy than health education. When contrasted with strength training, relaxation therapy [MD=-5.69, 95% CI=(-9.84, -1.53)] exhibited higher effectiveness.

Relaxation therapy [MD=-5.91, 95% CI=(-8.60, -3.21)], mind-body exercise [MD=-2.78, 95% CI=(-4.16, -1.40)], and traditional aerobics [MD=-2.21, 95% CI=(-3.50, -0.93)] were all more effective than usual care. When compared to no intervention, relaxation therapy [MD=-6.45, 95% CI=(-9.35, -3.55)], mind-body exercise [MD=-3.32, 95% CI=(-5.14, -1.50)], and traditional aerobics [MD=-2.76, 95% CI=(-4.68, -0.83)] showed greater effectiveness. Furthermore, relaxation therapy [MD=-7.75, 95% CI=(-12.42, -3.08)], mind-body exercise [MD=-4.62, 95% CI=(-8.40, -0.84)], and traditional aerobics [MD=-4.06, 95% CI=(-8.06, -0.06)] were found to be more effective than social support.

In terms of the probability of different interventions affecting depression as indicated by SUCRA, relaxation therapy ranked first (SUCRA = 99.4%), followed by mind-body exercise (SUCRA = 80.6%). Subsequently, traditional aerobics and aquatic sport ranked next (SUCRA = 70.9% and 67.1%, respectively). The specific results are presented in Fig.  4 .

Publication bias

As shown in Fig.  5 , we first used a funnel plot to assess publication bias. The distribution of studies in the funnel plot appeared roughly symmetrical, with no obvious signs of publication bias upon visual inspection. Subsequently, we conducted Begg’s test and Egger’s test, yielding the following results: Begg’s test indicated significant bias ( p  ≤ 0.000), while Egger’s test showed no significant bias ( p  = 0.075), as detailed in Appendix D1 and Appendix D2 . We conducted further evaluation of publication bias using trim-and-fill analysis with a random-effects model. The results indicated that after adjustment through trim-and-fill, there was a slight decrease in the estimated effect size, but the change was minimal. This suggests that there may be some publication bias present in the original data, but its impact is not substantial. Overall, the estimated effect size remained significant, indicating a certain robustness of the study findings (see Appendix D3 and Appendix D4 ). Additionally, sensitivity analysis conducted by iteratively excluding individual studies revealed no significant impact on the overall results (see Appendix D5 and Appendix D6 ).

Funnel plot on publication bias

This study aimed to compare the effects of different physical activity interventions on perinatal depression in women. The research indicates that the top four intervention measures for reducing perinatal depression, in order, are relaxation therapy, mind-body exercise, traditional aerobics, and aquatic sports. Detailed results can be found in Table  3 .

Characteristics of depression include an increased preoccupation with negative information, difficulty in disengaging from negative information, and cognitive control deficits when processing negative information [ 77 ]. A recent study has shown that both physical activity and mental engagement can help maintain brain health, slowing down disease progression, and that intellectual engagement may be the most effective remedy for individuals with cognitive issues [ 78 ]. Mental and physical (MAP) training is an innovative clinical intervention that combines mental training through meditation with physical training through aerobic exercise [ 79 ]. The relaxation therapy and mind-body exercise in this study both fall under the integrated MAP training category. The results of this study suggest that, compared to traditional aerobics, integrated MAP training may offer more effective treatment for perinatal depression. On one hand, physical training can enhance muscle strength and flexibility, alleviate physiological discomfort such as back pain and fatigue [ 80 ]. On the other hand, mental training can also promote hormone secretion in the endocrine and nervous systems, alleviate stress and negative emotions, and improve self-efficacy [ 53 ].

Some studies also provide supporting evidence: the combination of aerobic exercise and meditation can promote neurogenesis in the hippocampus and maintain the vitality of neurons, reduce rumination, improve defects in cognitive control processes, and reduce depressive symptoms [ 79 ]. Buddhist walking meditation can improve functional health and vascular reactivity, reduce depression, and appear to offer greater overall improvement compared to traditional walking exercise [ 81 ]. Combining mindfulness with physical activity seems to have a more beneficial impact on sleep quality and emotional regulation in individuals with severe depression compared to mindfulness or physical activity alone, making it a valuable treatment strategy [ 82 ].

Perinatal women typically need to consider various factors such as physiology, psychology, safety, and personal energy when selecting exercises, as these factors interact to potentially lead to different optimal forms of exercise compared to women with general depression. Specifically, physiological changes are significant during the perinatal period, including hormonal fluctuations, weight gain, and changes in body center of gravity, which may affect tolerance and effectiveness of different types of exercise. For instance, high-intensity exercise may be effective for women with general depression but may not be suitable or sustainable for pregnant women who may worry about miscarriage or harming the baby due to excessive exertion [ 83 ]. Secondly, the perinatal period is characterized by significant emotional fluctuations, with women experiencing higher levels of anxiety and emotional swings, which may affect their response to exercise. For example, gentle exercises such as yoga may be more suitable for perinatal women as they not only alleviate depression but also help reduce anxiety and stress [ 55 ]. Furthermore, perinatal women need to consider the safety and comfort of exercise. For example, low-impact, low-intensity exercises such as swimming or walking may be more suitable as they impose less stress on joints and muscles, reducing the risk of exercise-related injuries [ 84 ]. Lastly, perinatal women may have limited time and energy due to physical fatigue and the responsibility of caring for a newborn. Therefore, short, efficient, and home-based exercises may be more popular and effective.

Relaxation therapy may be the most effective intervention for perinatal depression. Previous research has demonstrated that relaxation training, such as progressive muscle relaxation, can help individuals reduce stress, enhance psychological and physiological relaxation, thereby improving overall health [ 85 ]. Progressive muscle relaxation is a deep muscle relaxation technique based on the principle that muscle tension is a physiological response to stimulating thoughts [ 86 ]. It can inhibit the activity of the sympathetic nervous system, promote relaxation of the body and mind, improve sleep quality, and reduce post-Cesarean section pain intensity [ 87 , 88 ]. Additionally, muscle relaxation training helps stimulate the secretion of endorphins, enhancing immune function and happiness, potentially reducing depression and anxiety in pregnant women [ 89 , 90 , 91 ].

Several scholars have investigated the efficacy of relaxation therapy as an intervention for depression. Li et al. (2020) conducted a meta-analysis, revealing that relaxation techniques offer an economical, safe, and low-risk approach to alleviating depression symptoms in adult patients. Their findings underscored the ease of teaching and implementation [ 92 ]. Similarly, Jorm et al. (2015) reported in their meta-analysis that relaxation techniques outperformed no or minimal treatment in reducing self-reported depression symptoms, though they were not as effective as psychotherapy [ 93 ]. Conversely, Jia et al. (2020) found no significant difference in the efficacy of relaxation therapy and psychotherapy in reducing self-reported depression symptoms, suggesting that relaxation therapy may offer comparable benefits to psychotherapy [ 94 ]. Additionally, Klainin-Yobas et al. (2015) conducted a systematic review of 15 empirical studies focusing on relaxation interventions for anxiety and depression in the elderly. Their analysis indicated that elderly individuals receiving relaxation interventions generally experienced greater reductions in depression and anxiety compared to control groups, with progressive muscle relaxation training demonstrating the most pronounced effect [ 95 ].

Relaxation therapy offers several advantages over aerobic exercise and resistance training for perinatal women. First, dual benefits for physical and mental health. Relaxation therapy promotes blood circulation and relieves muscle tension, effectively reducing common perinatal discomforts such as back pain, edema, and insomnia. It emphasizes mind-body integration; by regulating breathing, focusing attention, and relaxing muscles, it alleviates anxiety and stress, thereby improving depressive symptoms. Chen et al. (2021) found that body-mind relaxation meditation is associated with changes in thalamocortical functional connectivity in patients with major depressive disorder, which may enhance positive emotions, emotional stability, and attention [ 96 ]. Tragea et al. (2014) showed that relaxation (breathing and progressive muscle relaxation) reduces anxiety and perceived stress in pregnant women and enhances their sense of internal control [ 97 ]. Second, high safety. Perinatal women, especially in late pregnancy, often feel fatigued or physically exhausted. Aerobic exercise and resistance training may put excessive strain on the body, while relaxation techniques like deep breathing, meditation, and body relaxation are mild physical activities with low demands and lower injury risks. This makes relaxation therapy more suitable for perinatal women. Third, easy to perform and sustainable. Relaxation therapy is simple and can be performed at home or any quiet environment without specific venues or equipment, making it convenient for long-term practice. It does not require prolonged sessions and can be flexibly scheduled, fitting well with the routines and daily arrangements of perinatal women.

Mind-body exercise may be the intervention that ranks second only to relaxation therapy. It is a gentle and slow form of exercise represented by practices like Tai Chi, Qigong, and yoga, emphasizing the coordination of meditation, physical exercise, and breathing [ 98 , 99 ]. Mind-body therapies are often used in the treatment of depression to help alleviate its severity [ 100 ]. Yoga is one of the most commonly used mind-body interventions, which may alleviate physical and psychological discomfort, potentially reducing the risk of perinatal depression by increasing Brain-Derived Neurotrophic Factor (BDNF) and lowering serum cortisol levels [ 101 , 102 , 103 , 104 ]. Yoga can also improve psychological and physical health by promoting social connections and enhancing self-efficacy [ 23 ]. A Chinese Chan-based mind-body intervention has also been shown to potentially reduce the intake of antidepressant medication and improve depressive symptoms, including attention difficulties, gastrointestinal health issues, and overall sleep quality [ 105 ].

Traditional aerobics and aquatic sports may also be relatively effective physical activity interventions. Aerobic exercise may reduce depressive symptoms through biological mechanisms such as promoting the secretion of endorphins, serotonin, and norepinephrine [ 38 ]. Aquatic aerobic exercise is a low-impact activity with advantages such as a lower risk of miscarriage, reduced swelling, increased diuresis, decreased arterial pressure, and less back pain compared to weight-bearing exercise on land [ 106 ]. Water-based exercise programs can reduce fatigue and improve various aspects of emotional states, including tension, depression, anger, and mental fatigue, as well as enhance leg and abdominal muscle endurance [ 107 ].

In 2020, the WHO guidelines on physical activity and sedentary behavior recommended that all pregnant women and postpartum women without contraindications engage in at least 150 min of moderate-intensity aerobic exercise per week, along with muscle strength training and gentle stretching activities during pregnancy and postpartum, while reducing sedentary behavior [ 17 ]. A study suggested that exercise not only serves as a treatment for depression but also plays a positive role in preventing its onset. This study found a dose-response relationship between physical activity and the incidence of depression, indicating that even activity levels below the recommended guidelines can yield significant mental health benefits [ 108 ]. However, a recent study comparing the effects of antidepressant medication and running exercise on anxiety, depression, and overall health indicated that both therapies offer similar mental health benefits, but running exercise performs better in improving physical health. Although exercise therapy is a good option and might even be a better one, the challenge lies in increasing exercise adherence and motivating individuals to consistently engage in physical activity [ 109 ].

In summary, different physical activity interventions have varying degrees of impact on perinatal depression in women. The clinical significance of this study lies in providing clear intervention selection criteria for the treatment of perinatal depression. The results indicate that relaxation therapy and mind-body exercises such as yoga and tai chi significantly alleviate symptoms of perinatal depression. This provides empirical support for clinicians in formulating treatment plans, suggesting the inclusion of these forms of physical activity in the routine treatment protocols for perinatal women. Additionally, the study emphasizes the importance of encouraging and assisting perinatal women in maintaining long-term exercise habits. It highlights the need for healthcare providers to design sustainable intervention measures and support systems to enhance compliance and treatment effectiveness in perinatal women.

Strengths and limitations

This study has several strengths. Firstly, it is the first network meta-analysis on the impact of physical activity on perinatal depression, providing a scientific reference for the selection of appropriate physical activity interventions for perinatal women. Secondly, the inclusion of a substantial number of studies enhances the accuracy of the research findings. Thirdly, our study only included randomized controlled trials and excluded observational and cross-sectional studies, which increases the reliability of the results. However, there are also some limitations to our network meta-analysis. For instance, individual differences among perinatal women with depression may lead to heterogeneous effects of physical activity interventions, and different dosages of physical activity may influence the effectiveness of these interventions.

Future research could consider the following aspects. First, personalized physical activity interventions based on the individual characteristics of perinatal women with depression could be explored. For example, factors such as whether they are advanced maternal age (35 years or older), have a history of previous depression, experience depression during pregnancy or postpartum, or the severity of their depression (mild, moderate, or severe) could be taken into account when selecting targeted physical activity interventions. Tailoring interventions to the age, history of depression, timing of depression, and severity of depression among perinatal women can enhance the effectiveness of physical activity interventions. Second, investigating the optimal dosage of physical activity interventions for perinatal depression, including intervention frequency, duration, and intensity, would contribute to improving the precision of physical activity interventions.

This study explored the impact of different types of physical activities on perinatal depression. Based on the findings, we recommend women consider participating in integrated mental and physical (MAP) training, such as relaxation therapy and mind-body exercises, to potentially prevent or treat perinatal depression more effectively. Additionally, before implementing physical activity interventions, it is necessary to conduct comprehensive individual characteristic assessments of women with perinatal depression to ensure the selection of the optimal type of physical activity and intervention dosage. Furthermore, community and hospital staff can maintain regular communication with pregnant and postpartum women, supervise and encourage them to maintain consistent exercise habits, and provide support to alleviate adverse emotional experiences during the perinatal period. Future research could explore personalized physical activity interventions based on individual characteristics of women with perinatal depression. It could also investigate the optimal dosage of physical activity interventions for treating perinatal depression to enhance the effectiveness and accuracy of physical activity interventions.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

• Perinatal depression

Mental and physical training

Cognitive-behavioral therapy

Interpersonal therapy

American College of Obstetricians and Gynecologists

Randomized controlled trials

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Population, Intervention, Comparison, Outcome, Study Design principles

Standardized Mean Difference

Confidence interval

Surface Under the Cumulative Ranking Curve

Edinburgh Postnatal Depression Scale

Center for Epidemiological Studies Depression Scale

Beck Depression Inventory

Hospital Anxiety and Depression Scale

Psychological General Well-Being Index

Profile of Mood States

Hamilton Depression Rating Scale

Physical health questionnaire-9

World Health Organization

Intervention group

Control group

No intervention

High-intensity interval training

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Hanjiang Normal University, Shiyan, China

College of physical education, Southwest University, Chongqing, China

Guangzhou Sport University, Guangzhou, China

Chodang University, Muan, Republic of Korea

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All authors contributed to the study conception and design. YS and DL conceived and designed the study. YS, DL, CML and JLW collected the data. YS, JLW and DL analysed and interpreted the data. YS, DL and JLW drafted the manuscript. YS, CML and DL revised the manuscript. All authors have read and agreed to the published version of the manuscript.

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Shuai, Y., Wu, J., Li, C. et al. Effect of different physical activity interventions on perinatal depression: a systematic review and network meta-analysis. BMC Public Health 24 , 2076 (2024). https://doi.org/10.1186/s12889-024-19564-w

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