background and literature review

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Key Differences Between the Background of a Study and Literature Review

Don’t be too hard on yourself if you didn’t realize the study background and literature review were two distinct entities. The study background and literature review are both important parts of the research paper; however, due to their striking similarities, they are frequently confused with one another 1 . In this article, we will look at the key differences between the background of a study and literature review and how to write each section effectively.  

When it comes to similarities between the study background and the literature review, both provide information about existing knowledge in a specific field by discussing various studies and developments. They almost always address gaps in the literature to contextualize the study at hand. So, how do they differ from one another? Simple answer: A literature review is an expanded version of the study background, or a study background is a condensed version of a literature review. To put it another way, “a study background is to a literature review what an abstract is to a paper.”  

Differences between the background of the study and a literature review  

Though the distinctions are subtle, understanding them is critical to avoiding confusion between these two elements. The following are the differences between the background of the study and a literature review:  

• The background of a study is discussed at the beginning of the introduction while the literature review begins once the background of a study is completed (in the introduction section).  
• The study background sets the stage for the study; the main goal of the study background is to effectively communicate the need for the study by highlighting the gaps in answering the open-ended questions. In contrast, a literature review is an in-depth examination of the relevant literature in that field in order to prepare readers for the study at hand . Furthermore, the literature review provides a broad overview of the topic to support the case for identifying gaps.  
• The study background and literature review serve slightly different purposes; the study background emphasizes the significance of THE study, whereas the review of literature emphasizes advancement in the field by conducting a critical analysis of existing literature. It should be noted that a literature review also identifies gaps in the literature by comparing and analyzing various studies, but it is the study background that summarizes the critical findings that justifies the need for the research at hand.  
• Another interesting difference is how they are structured; the study background structure follows a top-down approach, beginning with a discussion of a broader area and eventually narrowing down to a specific question—study problem—addressed in the study.   
• The length of the background of the study and the literature review also differ, with the former being more concise and crisp and the latter being more detailed and elaborate.  

Tips to effectively write the background of the study  

Writing the background of the study is sometimes a difficult undertaking for early career researchers; however, because this is an important component of the paper, it is critical that once write it clearly and accurately. The background must convey the context of the study, defining the need to conduct the current study 2 . The study background should be organized in such a way that it provides a historical perspective on the topic, while identifying the gaps that the current study aims to fill. If the topic is multidisciplinary, it should concisely address the relevant studies, laying the groundwork for the research question at hand. To put it simply, the researchers can follow the structure below:  

• What is the state of the literature on the subject?  
• Where are the gaps in the field?  
• What is the importance of filling these gaps?  
• What are the premises of your research?  

The idea is to present the relevant studies to build the context without going into detail about each one; remember to keep it concise and direct. It is recommended that the findings be organized chronologically in order to trace the developments in the field and provide a snapshot of research advancements. The best way is to create an engaging story to pique readers’ interest in the topic by presenting sequential findings that led to YOUR research question. The flow should be such that each study prepares for the next while remaining in accordance with the central theme. However, the author should avoid common blunders such as inappropriate length (too long or too short), ambiguity, an unfocused theme, and disorganization.  

Tips to write the literature review without mixing it up with the background of the study  

As previously discussed in this article, the literature review is an extended version of the background of the study. It follows the background of the study and presents a detailed analysis of existing literature to support the background.   

Authors must conduct a thorough research survey that includes various studies related to the broad topics of their research. Following an introduction to a broader topic, the literature review directs readers to relevant studies that are significant for the objectives of the present study.   

The authors are advised to present the information thematically, preferably chronologically, for a better understanding of the readers from a wide range of disciplines. This arrangement provides a more complete picture of previous research, current focus, and future directions. Finally, there are two types of literature reviews that serve different purposes in papers; they are broadly classified as experimental and theoretical literature reviews. This, however, is a topic for another article.  

We believe you can now easily distinguish between the study background and the literature review and understand how you can write them most effectively for your next study. Have fun writing!  

  References  

• Qureshi, F. 6 Differences between Study Background and Literature Review. Editage Insights, May 3, 2019. https://www.editage.com/insights/6-differences-between-a-study-background-and-a-literature-review .  
• Sachdev, R. How to Write the Background of Your Study. Editage Insights, November 27, 2018. https://www.editage.com/insights/how-to-write-the-background-of-your-study .  

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What is a Literature Review? How to Write It (with Examples)

A literature review is a critical analysis and synthesis of existing research on a particular topic. It provides an overview of the current state of knowledge, identifies gaps, and highlights key findings in the literature. 1 The purpose of a literature review is to situate your own research within the context of existing scholarship, demonstrating your understanding of the topic and showing how your work contributes to the ongoing conversation in the field. Learning how to write a literature review is a critical tool for successful research. Your ability to summarize and synthesize prior research pertaining to a certain topic demonstrates your grasp on the topic of study, and assists in the learning process. 

Table of Contents

What is the purpose of literature review , a. habitat loss and species extinction: , b. range shifts and phenological changes: , c. ocean acidification and coral reefs: , d. adaptive strategies and conservation efforts: .

• Choose a Topic and Define the Research Question: 
• Decide on the Scope of Your Review: 
• Select Databases for Searches: 
• Conduct Searches and Keep Track: 
• Review the Literature: 
• Organize and Write Your Literature Review: 
• How to write a literature review faster with Paperpal? 

Frequently asked questions 

What is a literature review .

A well-conducted literature review demonstrates the researcher’s familiarity with the existing literature, establishes the context for their own research, and contributes to scholarly conversations on the topic. One of the purposes of a literature review is also to help researchers avoid duplicating previous work and ensure that their research is informed by and builds upon the existing body of knowledge.

A literature review serves several important purposes within academic and research contexts. Here are some key objectives and functions of a literature review: 2  

1. Contextualizing the Research Problem: The literature review provides a background and context for the research problem under investigation. It helps to situate the study within the existing body of knowledge. 

2. Identifying Gaps in Knowledge: By identifying gaps, contradictions, or areas requiring further research, the researcher can shape the research question and justify the significance of the study. This is crucial for ensuring that the new research contributes something novel to the field.

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3. Understanding Theoretical and Conceptual Frameworks: Literature reviews help researchers gain an understanding of the theoretical and conceptual frameworks used in previous studies. This aids in the development of a theoretical framework for the current research. 

4. Providing Methodological Insights: Another purpose of literature reviews is that it allows researchers to learn about the methodologies employed in previous studies. This can help in choosing appropriate research methods for the current study and avoiding pitfalls that others may have encountered. 

5. Establishing Credibility: A well-conducted literature review demonstrates the researcher’s familiarity with existing scholarship, establishing their credibility and expertise in the field. It also helps in building a solid foundation for the new research. 

6. Informing Hypotheses or Research Questions: The literature review guides the formulation of hypotheses or research questions by highlighting relevant findings and areas of uncertainty in existing literature. 

Literature review example 

Let’s delve deeper with a literature review example: Let’s say your literature review is about the impact of climate change on biodiversity. You might format your literature review into sections such as the effects of climate change on habitat loss and species extinction, phenological changes, and marine biodiversity. Each section would then summarize and analyze relevant studies in those areas, highlighting key findings and identifying gaps in the research. The review would conclude by emphasizing the need for further research on specific aspects of the relationship between climate change and biodiversity. The following literature review template provides a glimpse into the recommended literature review structure and content, demonstrating how research findings are organized around specific themes within a broader topic. 

Literature Review on Climate Change Impacts on Biodiversity:  

Climate change is a global phenomenon with far-reaching consequences, including significant impacts on biodiversity. This literature review synthesizes key findings from various studies: 

Climate change-induced alterations in temperature and precipitation patterns contribute to habitat loss, affecting numerous species (Thomas et al., 2004). The review discusses how these changes increase the risk of extinction, particularly for species with specific habitat requirements. 

Observations of range shifts and changes in the timing of biological events (phenology) are documented in response to changing climatic conditions (Parmesan & Yohe, 2003). These shifts affect ecosystems and may lead to mismatches between species and their resources. 

The review explores the impact of climate change on marine biodiversity, emphasizing ocean acidification’s threat to coral reefs (Hoegh-Guldberg et al., 2007). Changes in pH levels negatively affect coral calcification, disrupting the delicate balance of marine ecosystems. 

Recognizing the urgency of the situation, the literature review discusses various adaptive strategies adopted by species and conservation efforts aimed at mitigating the impacts of climate change on biodiversity (Hannah et al., 2007). It emphasizes the importance of interdisciplinary approaches for effective conservation planning. 

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How to write a good literature review 

Writing a literature review involves summarizing and synthesizing existing research on a particular topic. A good literature review format should include the following elements. 

Introduction: The introduction sets the stage for your literature review, providing context and introducing the main focus of your review. 

• Opening Statement: Begin with a general statement about the broader topic and its significance in the field. 
• Scope and Purpose: Clearly define the scope of your literature review. Explain the specific research question or objective you aim to address. 
• Organizational Framework: Briefly outline the structure of your literature review, indicating how you will categorize and discuss the existing research. 
• Significance of the Study: Highlight why your literature review is important and how it contributes to the understanding of the chosen topic. 
• Thesis Statement: Conclude the introduction with a concise thesis statement that outlines the main argument or perspective you will develop in the body of the literature review. 

Body: The body of the literature review is where you provide a comprehensive analysis of existing literature, grouping studies based on themes, methodologies, or other relevant criteria. 

• Organize by Theme or Concept: Group studies that share common themes, concepts, or methodologies. Discuss each theme or concept in detail, summarizing key findings and identifying gaps or areas of disagreement. 
• Critical Analysis: Evaluate the strengths and weaknesses of each study. Discuss the methodologies used, the quality of evidence, and the overall contribution of each work to the understanding of the topic. 
• Synthesis of Findings: Synthesize the information from different studies to highlight trends, patterns, or areas of consensus in the literature. 
• Identification of Gaps: Discuss any gaps or limitations in the existing research and explain how your review contributes to filling these gaps. 
• Transition between Sections: Provide smooth transitions between different themes or concepts to maintain the flow of your literature review. 

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Conclusion: The conclusion of your literature review should summarize the main findings, highlight the contributions of the review, and suggest avenues for future research. 

• Summary of Key Findings: Recap the main findings from the literature and restate how they contribute to your research question or objective. 
• Contributions to the Field: Discuss the overall contribution of your literature review to the existing knowledge in the field. 
• Implications and Applications: Explore the practical implications of the findings and suggest how they might impact future research or practice. 
• Recommendations for Future Research: Identify areas that require further investigation and propose potential directions for future research in the field. 
• Final Thoughts: Conclude with a final reflection on the importance of your literature review and its relevance to the broader academic community. 

Conducting a literature review 

Conducting a literature review is an essential step in research that involves reviewing and analyzing existing literature on a specific topic. It’s important to know how to do a literature review effectively, so here are the steps to follow: 1  

Choose a Topic and Define the Research Question:  

• Select a topic that is relevant to your field of study. 
• Clearly define your research question or objective. Determine what specific aspect of the topic do you want to explore? 

Decide on the Scope of Your Review:  

• Determine the timeframe for your literature review. Are you focusing on recent developments, or do you want a historical overview? 
• Consider the geographical scope. Is your review global, or are you focusing on a specific region? 
• Define the inclusion and exclusion criteria. What types of sources will you include? Are there specific types of studies or publications you will exclude? 

Select Databases for Searches:  

• Identify relevant databases for your field. Examples include PubMed, IEEE Xplore, Scopus, Web of Science, and Google Scholar. 
• Consider searching in library catalogs, institutional repositories, and specialized databases related to your topic. 

Conduct Searches and Keep Track:  

• Develop a systematic search strategy using keywords, Boolean operators (AND, OR, NOT), and other search techniques. 
• Record and document your search strategy for transparency and replicability. 
• Keep track of the articles, including publication details, abstracts, and links. Use citation management tools like EndNote, Zotero, or Mendeley to organize your references. 

Review the Literature:  

• Evaluate the relevance and quality of each source. Consider the methodology, sample size, and results of studies. 
• Organize the literature by themes or key concepts. Identify patterns, trends, and gaps in the existing research. 
• Summarize key findings and arguments from each source. Compare and contrast different perspectives. 
• Identify areas where there is a consensus in the literature and where there are conflicting opinions. 
• Provide critical analysis and synthesis of the literature. What are the strengths and weaknesses of existing research? 

Organize and Write Your Literature Review:  

• Literature review outline should be based on themes, chronological order, or methodological approaches. 
• Write a clear and coherent narrative that synthesizes the information gathered. 
• Use proper citations for each source and ensure consistency in your citation style (APA, MLA, Chicago, etc.). 
• Conclude your literature review by summarizing key findings, identifying gaps, and suggesting areas for future research. 

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How to write a literature review faster with Paperpal?  

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The literature review sample and detailed advice on writing and conducting a review will help you produce a well-structured report. But remember that a good literature review is an ongoing process, and it may be necessary to revisit and update it as your research progresses. By combining effortless research with an easy citation process, Paperpal Research streamlines the literature review process and empowers you to write faster and with more confidence. Try Paperpal Research now and see for yourself.  

A literature review is a critical and comprehensive analysis of existing literature (published and unpublished works) on a specific topic or research question and provides a synthesis of the current state of knowledge in a particular field. A well-conducted literature review is crucial for researchers to build upon existing knowledge, avoid duplication of efforts, and contribute to the advancement of their field. It also helps researchers situate their work within a broader context and facilitates the development of a sound theoretical and conceptual framework for their studies.

Literature review is a crucial component of research writing, providing a solid background for a research paper’s investigation. The aim is to keep professionals up to date by providing an understanding of ongoing developments within a specific field, including research methods, and experimental techniques used in that field, and present that knowledge in the form of a written report. Also, the depth and breadth of the literature review emphasizes the credibility of the scholar in his or her field.  

Before writing a literature review, it’s essential to undertake several preparatory steps to ensure that your review is well-researched, organized, and focused. This includes choosing a topic of general interest to you and doing exploratory research on that topic, writing an annotated bibliography, and noting major points, especially those that relate to the position you have taken on the topic. 

Literature reviews and academic research papers are essential components of scholarly work but serve different purposes within the academic realm. 3 A literature review aims to provide a foundation for understanding the current state of research on a particular topic, identify gaps or controversies, and lay the groundwork for future research. Therefore, it draws heavily from existing academic sources, including books, journal articles, and other scholarly publications. In contrast, an academic research paper aims to present new knowledge, contribute to the academic discourse, and advance the understanding of a specific research question. Therefore, it involves a mix of existing literature (in the introduction and literature review sections) and original data or findings obtained through research methods. 

Literature reviews are essential components of academic and research papers, and various strategies can be employed to conduct them effectively. If you want to know how to write a literature review for a research paper, here are four common approaches that are often used by researchers.  Chronological Review: This strategy involves organizing the literature based on the chronological order of publication. It helps to trace the development of a topic over time, showing how ideas, theories, and research have evolved.  Thematic Review: Thematic reviews focus on identifying and analyzing themes or topics that cut across different studies. Instead of organizing the literature chronologically, it is grouped by key themes or concepts, allowing for a comprehensive exploration of various aspects of the topic.  Methodological Review: This strategy involves organizing the literature based on the research methods employed in different studies. It helps to highlight the strengths and weaknesses of various methodologies and allows the reader to evaluate the reliability and validity of the research findings.  Theoretical Review: A theoretical review examines the literature based on the theoretical frameworks used in different studies. This approach helps to identify the key theories that have been applied to the topic and assess their contributions to the understanding of the subject.  It’s important to note that these strategies are not mutually exclusive, and a literature review may combine elements of more than one approach. The choice of strategy depends on the research question, the nature of the literature available, and the goals of the review. Additionally, other strategies, such as integrative reviews or systematic reviews, may be employed depending on the specific requirements of the research.

The literature review format can vary depending on the specific publication guidelines. However, there are some common elements and structures that are often followed. Here is a general guideline for the format of a literature review:  Introduction:   Provide an overview of the topic.  Define the scope and purpose of the literature review.  State the research question or objective.  Body:   Organize the literature by themes, concepts, or chronology.  Critically analyze and evaluate each source.  Discuss the strengths and weaknesses of the studies.  Highlight any methodological limitations or biases.  Identify patterns, connections, or contradictions in the existing research.  Conclusion:   Summarize the key points discussed in the literature review.  Highlight the research gap.  Address the research question or objective stated in the introduction.  Highlight the contributions of the review and suggest directions for future research.

Both annotated bibliographies and literature reviews involve the examination of scholarly sources. While annotated bibliographies focus on individual sources with brief annotations, literature reviews provide a more in-depth, integrated, and comprehensive analysis of existing literature on a specific topic. The key differences are as follows: 

References 

• Denney, A. S., & Tewksbury, R. (2013). How to write a literature review.  Journal of criminal justice education ,  24 (2), 218-234. 
• Pan, M. L. (2016).  Preparing literature reviews: Qualitative and quantitative approaches . Taylor & Francis. 
• Cantero, C. (2019). How to write a literature review.  San José State University Writing Center . 

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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.

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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 literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

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Home » Background of The Study – Examples and Writing Guide

Background of The Study – Examples and Writing Guide

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Background of The Study

Definition:

Background of the study refers to the context, circumstances, and history that led to the research problem or topic being studied. It provides the reader with a comprehensive understanding of the subject matter and the significance of the study.

The background of the study usually includes a discussion of the relevant literature, the gap in knowledge or understanding, and the research questions or hypotheses to be addressed. It also highlights the importance of the research topic and its potential contributions to the field. A well-written background of the study sets the stage for the research and helps the reader to appreciate the need for the study and its potential significance.

How to Write Background of The Study

Here are some steps to help you write the background of the study:

Identify the Research Problem

Start by identifying the research problem you are trying to address. This problem should be significant and relevant to your field of study.

Provide Context

Once you have identified the research problem, provide some context. This could include the historical, social, or political context of the problem.

Review Literature

Conduct a thorough review of the existing literature on the topic. This will help you understand what has been studied and what gaps exist in the current research.

Identify Research Gap

Based on your literature review, identify the gap in knowledge or understanding that your research aims to address. This gap will be the focus of your research question or hypothesis.

State Objectives

Clearly state the objectives of your research . These should be specific, measurable, achievable, relevant, and time-bound (SMART).

Discuss Significance

Explain the significance of your research. This could include its potential impact on theory , practice, policy, or society.

Finally, summarize the key points of the background of the study. This will help the reader understand the research problem, its context, and its significance.

How to Write Background of The Study in Proposal

The background of the study is an essential part of any proposal as it sets the stage for the research project and provides the context and justification for why the research is needed. Here are the steps to write a compelling background of the study in your proposal:

• Identify the problem: Clearly state the research problem or gap in the current knowledge that you intend to address through your research.
• Provide context: Provide a brief overview of the research area and highlight its significance in the field.
• Review literature: Summarize the relevant literature related to the research problem and provide a critical evaluation of the current state of knowledge.
• Identify gaps : Identify the gaps or limitations in the existing literature and explain how your research will contribute to filling these gaps.
• Justify the study : Explain why your research is important and what practical or theoretical contributions it can make to the field.
• Highlight objectives: Clearly state the objectives of the study and how they relate to the research problem.
• Discuss methodology: Provide an overview of the methodology you will use to collect and analyze data, and explain why it is appropriate for the research problem.
• Conclude : Summarize the key points of the background of the study and explain how they support your research proposal.

How to Write Background of The Study In Thesis

The background of the study is a critical component of a thesis as it provides context for the research problem, rationale for conducting the study, and the significance of the research. Here are some steps to help you write a strong background of the study:

• Identify the research problem : Start by identifying the research problem that your thesis is addressing. What is the issue that you are trying to solve or explore? Be specific and concise in your problem statement.
• Review the literature: Conduct a thorough review of the relevant literature on the topic. This should include scholarly articles, books, and other sources that are directly related to your research question.
• I dentify gaps in the literature: After reviewing the literature, identify any gaps in the existing research. What questions remain unanswered? What areas have not been explored? This will help you to establish the need for your research.
• Establish the significance of the research: Clearly state the significance of your research. Why is it important to address this research problem? What are the potential implications of your research? How will it contribute to the field?
• Provide an overview of the research design: Provide an overview of the research design and methodology that you will be using in your study. This should include a brief explanation of the research approach, data collection methods, and data analysis techniques.
• State the research objectives and research questions: Clearly state the research objectives and research questions that your study aims to answer. These should be specific, measurable, achievable, relevant, and time-bound.
• Summarize the chapter: Summarize the chapter by highlighting the key points and linking them back to the research problem, significance of the study, and research questions.

How to Write Background of The Study in Research Paper

Here are the steps to write the background of the study in a research paper:

• Identify the research problem: Start by identifying the research problem that your study aims to address. This can be a particular issue, a gap in the literature, or a need for further investigation.
• Conduct a literature review: Conduct a thorough literature review to gather information on the topic, identify existing studies, and understand the current state of research. This will help you identify the gap in the literature that your study aims to fill.
• Explain the significance of the study: Explain why your study is important and why it is necessary. This can include the potential impact on the field, the importance to society, or the need to address a particular issue.
• Provide context: Provide context for the research problem by discussing the broader social, economic, or political context that the study is situated in. This can help the reader understand the relevance of the study and its potential implications.
• State the research questions and objectives: State the research questions and objectives that your study aims to address. This will help the reader understand the scope of the study and its purpose.
• Summarize the methodology : Briefly summarize the methodology you used to conduct the study, including the data collection and analysis methods. This can help the reader understand how the study was conducted and its reliability.

Examples of Background of The Study

Here are some examples of the background of the study:

Problem : The prevalence of obesity among children in the United States has reached alarming levels, with nearly one in five children classified as obese.

Significance : Obesity in childhood is associated with numerous negative health outcomes, including increased risk of type 2 diabetes, cardiovascular disease, and certain cancers.

Gap in knowledge : Despite efforts to address the obesity epidemic, rates continue to rise. There is a need for effective interventions that target the unique needs of children and their families.

Problem : The use of antibiotics in agriculture has contributed to the development of antibiotic-resistant bacteria, which poses a significant threat to human health.

Significance : Antibiotic-resistant infections are responsible for thousands of deaths each year and are a major public health concern.

Gap in knowledge: While there is a growing body of research on the use of antibiotics in agriculture, there is still much to be learned about the mechanisms of resistance and the most effective strategies for reducing antibiotic use.

Edxample 3:

Problem : Many low-income communities lack access to healthy food options, leading to high rates of food insecurity and diet-related diseases.

Significance : Poor nutrition is a major contributor to chronic diseases such as obesity, type 2 diabetes, and cardiovascular disease.

Gap in knowledge : While there have been efforts to address food insecurity, there is a need for more research on the barriers to accessing healthy food in low-income communities and effective strategies for increasing access.

Examples of Background of The Study In Research

Here are some real-life examples of how the background of the study can be written in different fields of study:

Example 1 : “There has been a significant increase in the incidence of diabetes in recent years. This has led to an increased demand for effective diabetes management strategies. The purpose of this study is to evaluate the effectiveness of a new diabetes management program in improving patient outcomes.”

Example 2 : “The use of social media has become increasingly prevalent in modern society. Despite its popularity, little is known about the effects of social media use on mental health. This study aims to investigate the relationship between social media use and mental health in young adults.”

Example 3: “Despite significant advancements in cancer treatment, the survival rate for patients with pancreatic cancer remains low. The purpose of this study is to identify potential biomarkers that can be used to improve early detection and treatment of pancreatic cancer.”

Examples of Background of The Study in Proposal

Here are some real-time examples of the background of the study in a proposal:

Example 1 : The prevalence of mental health issues among university students has been increasing over the past decade. This study aims to investigate the causes and impacts of mental health issues on academic performance and wellbeing.

Example 2 : Climate change is a global issue that has significant implications for agriculture in developing countries. This study aims to examine the adaptive capacity of smallholder farmers to climate change and identify effective strategies to enhance their resilience.

Example 3 : The use of social media in political campaigns has become increasingly common in recent years. This study aims to analyze the effectiveness of social media campaigns in mobilizing young voters and influencing their voting behavior.

Example 4 : Employee turnover is a major challenge for organizations, especially in the service sector. This study aims to identify the key factors that influence employee turnover in the hospitality industry and explore effective strategies for reducing turnover rates.

Examples of Background of The Study in Thesis

Here are some real-time examples of the background of the study in the thesis:

Example 1 : “Women’s participation in the workforce has increased significantly over the past few decades. However, women continue to be underrepresented in leadership positions, particularly in male-dominated industries such as technology. This study aims to examine the factors that contribute to the underrepresentation of women in leadership roles in the technology industry, with a focus on organizational culture and gender bias.”

Example 2 : “Mental health is a critical component of overall health and well-being. Despite increased awareness of the importance of mental health, there are still significant gaps in access to mental health services, particularly in low-income and rural communities. This study aims to evaluate the effectiveness of a community-based mental health intervention in improving mental health outcomes in underserved populations.”

Example 3: “The use of technology in education has become increasingly widespread, with many schools adopting online learning platforms and digital resources. However, there is limited research on the impact of technology on student learning outcomes and engagement. This study aims to explore the relationship between technology use and academic achievement among middle school students, as well as the factors that mediate this relationship.”

Examples of Background of The Study in Research Paper

Here are some examples of how the background of the study can be written in various fields:

Example 1: The prevalence of obesity has been on the rise globally, with the World Health Organization reporting that approximately 650 million adults were obese in 2016. Obesity is a major risk factor for several chronic diseases such as diabetes, cardiovascular diseases, and cancer. In recent years, several interventions have been proposed to address this issue, including lifestyle changes, pharmacotherapy, and bariatric surgery. However, there is a lack of consensus on the most effective intervention for obesity management. This study aims to investigate the efficacy of different interventions for obesity management and identify the most effective one.

Example 2: Antibiotic resistance has become a major public health threat worldwide. Infections caused by antibiotic-resistant bacteria are associated with longer hospital stays, higher healthcare costs, and increased mortality. The inappropriate use of antibiotics is one of the main factors contributing to the development of antibiotic resistance. Despite numerous efforts to promote the rational use of antibiotics, studies have shown that many healthcare providers continue to prescribe antibiotics inappropriately. This study aims to explore the factors influencing healthcare providers’ prescribing behavior and identify strategies to improve antibiotic prescribing practices.

Example 3: Social media has become an integral part of modern communication, with millions of people worldwide using platforms such as Facebook, Twitter, and Instagram. Social media has several advantages, including facilitating communication, connecting people, and disseminating information. However, social media use has also been associated with several negative outcomes, including cyberbullying, addiction, and mental health problems. This study aims to investigate the impact of social media use on mental health and identify the factors that mediate this relationship.

Purpose of Background of The Study

The primary purpose of the background of the study is to help the reader understand the rationale for the research by presenting the historical, theoretical, and empirical background of the problem.

More specifically, the background of the study aims to:

• Provide a clear understanding of the research problem and its context.
• Identify the gap in knowledge that the study intends to fill.
• Establish the significance of the research problem and its potential contribution to the field.
• Highlight the key concepts, theories, and research findings related to the problem.
• Provide a rationale for the research questions or hypotheses and the research design.
• Identify the limitations and scope of the study.

When to Write Background of The Study

The background of the study should be written early on in the research process, ideally before the research design is finalized and data collection begins. This allows the researcher to clearly articulate the rationale for the study and establish a strong foundation for the research.

The background of the study typically comes after the introduction but before the literature review section. It should provide an overview of the research problem and its context, and also introduce the key concepts, theories, and research findings related to the problem.

Writing the background of the study early on in the research process also helps to identify potential gaps in knowledge and areas for further investigation, which can guide the development of the research questions or hypotheses and the research design. By establishing the significance of the research problem and its potential contribution to the field, the background of the study can also help to justify the research and secure funding or support from stakeholders.

Advantage of Background of The Study

The background of the study has several advantages, including:

• Provides context: The background of the study provides context for the research problem by highlighting the historical, theoretical, and empirical background of the problem. This allows the reader to understand the research problem in its broader context and appreciate its significance.
• Identifies gaps in knowledge: By reviewing the existing literature related to the research problem, the background of the study can identify gaps in knowledge that the study intends to fill. This helps to establish the novelty and originality of the research and its potential contribution to the field.
• Justifies the research : The background of the study helps to justify the research by demonstrating its significance and potential impact. This can be useful in securing funding or support for the research.
• Guides the research design: The background of the study can guide the development of the research questions or hypotheses and the research design by identifying key concepts, theories, and research findings related to the problem. This ensures that the research is grounded in existing knowledge and is designed to address the research problem effectively.
• Establishes credibility: By demonstrating the researcher’s knowledge of the field and the research problem, the background of the study can establish the researcher’s credibility and expertise, which can enhance the trustworthiness and validity of the research.

Disadvantages of Background of The Study

Some Disadvantages of Background of The Study are as follows:

• Time-consuming : Writing a comprehensive background of the study can be time-consuming, especially if the research problem is complex and multifaceted. This can delay the research process and impact the timeline for completing the study.
• Repetitive: The background of the study can sometimes be repetitive, as it often involves summarizing existing research and theories related to the research problem. This can be tedious for the reader and may make the section less engaging.
• Limitations of existing research: The background of the study can reveal the limitations of existing research related to the problem. This can create challenges for the researcher in developing research questions or hypotheses that address the gaps in knowledge identified in the background of the study.
• Bias : The researcher’s biases and perspectives can influence the content and tone of the background of the study. This can impact the reader’s perception of the research problem and may influence the validity of the research.
• Accessibility: Accessing and reviewing the literature related to the research problem can be challenging, especially if the researcher does not have access to a comprehensive database or if the literature is not available in the researcher’s language. This can limit the depth and scope of the background of the study.

About the author

Muhammad Hassan

Researcher, Academic Writer, Web developer

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Research Methods: A Student's Comprehensive Guide: Literature Reviews

• Research Approaches
• Types of Sources
• Accessing Resources
• Evaluating Sources
• Question Crafting
• Search Strategies
• Annotated Bibliography
• Literature Reviews
• Citations This link opens in a new window

Literature Review

What is a Literature Review?  A literature review is a critical analysis of existing research related to a specific topic or research question. Rather than simply summarizing the sources, a literature review evaluates, compares, and synthesizes the literature to highlight trends, gaps, and insights that inform your research.

Purpose and Importance:  Literature reviews serve multiple key functions:

• Contextualization:  They provide background on your research topic, helping to situate your work within the broader field.
• Identification of Gaps:  A thorough review highlights areas where further research is needed, guiding your own contributions.
• Critical Evaluation:  By comparing and contrasting sources, you develop a deeper understanding of the subject and establish the credibility of your research.
• Foundation for Research:  A literature review demonstrates your knowledge of the field, forming a strong basis for your methodology and research approach.

Difference Between a Literature Review and an Annotated Bibliography:  While both a literature review and an annotated bibliography involve analyzing sources, they serve different purposes. An annotated bibliography focuses on summarizing and evaluating individual sources in isolation. In contrast, a literature review synthesizes multiple sources to form a cohesive narrative, identifying patterns, themes, and debates within the literature. The literature review also typically organizes the information thematically or methodologically rather than listing sources one by one.

Q: What is the main difference between a literature review and a systematic review? A: A literature review provides a broad overview of existing research on a topic, while a systematic review follows a structured methodology to identify, evaluate, and synthesize all relevant studies on a specific question.

Q: How do I choose the best type of literature review for my research? A: Consider your research question and objectives. A narrative review is suitable for broad overviews, while a systematic review is best for comprehensive analyses. A scoping review helps map out the existing literature, and a meta-analysis combines quantitative results from multiple studies.

Q: How many sources should I include in my literature review? A: The number of sources depends on your topic and the scope of your review. Generally, aim to include a comprehensive selection that represents the current state of research. Ensure sources are relevant and contribute to answering your research question.

Q: Can I include unpublished sources in my literature review? A:  Yes, including unpublished sources such as dissertations, theses, or reports can provide valuable insights and fill gaps in the published literature. Ensure these sources are credible and relevant.

Q: How do I ensure my literature review is critical and not just descriptive? A: Focus on evaluating and synthesizing the sources rather than just summarizing them. Analyze the strengths, weaknesses, and contributions of each study. Highlight trends, debates, and gaps in the literature.

Scribbr: How to Write a Literature Review

Gain valuable insights on how to write an impactful literature review with this comprehensive guide!

Scribbr: Tips for Writing a Literature Review

Explore practical tips and strategies for structuring a literature review in this detailed tutorial.

• Common Mistakes

Types of Literature Reviews

• Overview:  Provides a comprehensive summary of the research on a specific topic. It offers a broad overview of the field, summarizing the key findings and trends without a strict methodological approach.
• Purpose:  Useful for providing a general understanding of a topic, identifying major themes, and outlining the historical development of research.
• Overview:  Follows a structured and transparent methodology to identify, evaluate, and synthesize all relevant studies on a specific research question. It aims to minimize bias and provide a comprehensive overview of the evidence.
• Purpose:  Ideal for answering specific research questions by systematically collecting and analyzing data from multiple studies. It often includes a meta-analysis component to quantitatively summarize the results.
• Overview:  Maps the existing literature on a broad topic, identifying key concepts, gaps, and areas for further research. It is less focused on synthesizing results and more on exploring the extent and nature of the research.
• Purpose:  Useful for understanding the breadth of research on a topic, especially when the area is complex or emerging. It helps to clarify the scope of existing evidence and inform future research directions.
• Overview:  Uses statistical techniques to combine and analyze the results of multiple studies, providing a quantitative summary of the evidence. It aims to identify patterns and determine the overall effect size.
• Purpose:  Ideal for drawing general conclusions from a body of research, especially when individual studies have varying results. It provides a higher level of statistical power and precision.

Crafting a Literature Review

• Clarify Your Research Question:  Start by articulating the specific research question or objective that your literature review will address. This will help guide your search and ensure that the review remains focused.
• Set Boundaries:  Determine the scope of your review by defining parameters such as time frame, geographical area, or specific subtopics. This helps in managing the breadth of your review and maintaining relevance.
• Utilize Academic Databases:  Access scholarly articles, books, and other research materials using databases like JSTOR, PubMed, or Google Scholar.
• Expand Your Search:  Explore references in key studies, look for gray literature, and consult library catalogs to ensure a comprehensive search.
• Categorize Sources:  Group your sources by themes, methodologies, or chronological order. This organization helps in synthesizing information and presenting a coherent review.
• Use Reference Management Tools:  Tools such as Zotero or EndNote can assist in managing and sorting your sources effectively.
• Identify Patterns and Themes:  Look for recurring themes, trends, and debates within the literature. Analyze how different studies relate to one another.
• Compare and Contrast:  Evaluate the methodologies, findings, and perspectives of different sources. Highlight agreements and disagreements to provide a balanced view.
• Choose an Organizational Method:  Decide on a structure that best fits your review’s purpose:
• Chronological:  Organize by the timeline of research developments.
• Thematic:  Group by themes or topics.
• Methodological:  Arrange based on research methods used.
• Create an Outline:  Develop a clear outline based on your chosen structure to guide your writing and ensure logical flow.
• Analyze, Don’t Just Summarize:  Go beyond summarizing each source. Critically analyze how each piece of literature contributes to your understanding of the topic.
• Provide Context:  Explain how the literature connects to your research question or hypothesis. Show how your work builds on or challenges existing knowledge.
• Seek Feedback:  Share your draft with peers or mentors to obtain constructive feedback.
• Edit for Clarity:  Review your work for clarity, coherence, and completeness. Ensure that your review is logically organized and free of errors.

Example of a Literature Review

To illustrate how a literature review is structured and written, here's a simplified example based on a hypothetical research topic:  The Impact of Social Media on Adolescent Mental Health.

Introduction: The introduction provides an overview of the research topic and its significance.

Social media has become an integral part of adolescents' lives, raising concerns about its impact on mental health. This literature review examines existing research on how social media use affects adolescent well-being, focusing on both positive and negative outcomes.

Body: The body of the review is organized thematically or methodologically.

Positive Impacts of Social Media:

• Social Connectivity:  Studies highlight that social media platforms enable adolescents to maintain and strengthen social connections, providing emotional support and reducing feelings of isolation (Smith, 2021; Lee & Johnson, 2022).
• Educational Benefits:  Research indicates that social media can facilitate educational opportunities and learning through online communities and resources (Adams, 2020).

Negative Impacts of Social Media:

• Mental Health Issues:  Several studies link excessive social media use with increased levels of anxiety, depression, and low self-esteem among adolescents (Brown et al., 2019; Thompson & Miller, 2021).
• Cyberbullying:  Evidence shows that social media platforms can be a breeding ground for cyberbullying, leading to significant psychological distress (Green & Taylor, 2022).

Mixed Findings:

• Variability in Effects:  Some research finds that the impact of social media on mental health varies depending on individual factors such as frequency of use, type of content consumed, and pre-existing mental health conditions (Davis, 2021; Wilson, 2022).

Discussion:   The discussion synthesizes the findings, identifies trends, and highlights gaps:

The reviewed literature reveals a complex relationship between social media and adolescent mental health. While social media can offer support and educational benefits, its negative impacts—particularly related to mental health issues and cyberbullying—are significant. Further research is needed to understand how different variables affect these outcomes and to develop strategies for mitigating negative effects.

Conclusion: The conclusion summarizes the key findings and suggests areas for future research:

In summary, social media has both positive and negative effects on adolescent mental health. Addressing these impacts requires a nuanced understanding of the various factors involved and targeted interventions to support healthy social media use. Future research should focus on longitudinal studies to better assess the long-term effects of social media on mental health.

• References:  Ensure to include a list of all sources cited in the example. In a real review, this would be formatted according to the appropriate citation style (e.g., APA, MLA).
• Formatting:  Use headings and subheadings to clearly organize each section of the review.

This example provides a framework for how a literature review should be structured and the type of content that should be included. It demonstrates the synthesis of various sources to present a cohesive narrative on the research topic.

Common Mistakes to Avoid

• Tip:  Ensure every source and discussion point directly relates to your research question or objective. Maintain a clear focus throughout the review.
• Tip:  Prioritize primary sources and original studies to provide a robust foundation. Use secondary sources sparingly for context or background.
• Tip:  Critically assess each study’s methodology, findings, and impact on the field. Highlight strengths and weaknesses for a balanced view.
• Tip:  Use clear headings and subheadings. Choose a logical structure (e.g., thematic, chronological) and ensure smooth transitions between sections.
• Tip:  Discuss gaps in the literature to strengthen your review and position your research within the broader field.
• Tip:  Follow the appropriate citation style meticulously. Ensure all sources are cited correctly and consistently.
• Tip:  Base conclusions on a comprehensive review of the literature. Avoid generalizations unless supported by substantial evidence from multiple sources.
• Tip:  Stay updated with recent publications and incorporate the most current research to ensure relevance and accuracy.

Literature Review Matrix

A  Literature Review Matrix  is a powerful tool that helps you organize and evaluate the sources you've gathered for your literature review. Think of it as a structured table that allows you to visually track key details from each source, helping you compare and contrast research findings, methods, and relevance to your work.

The primary goal of a Literature Review Matrix is to provide a clear and organized way to view your sources side-by-side. This makes it easier to spot patterns, identify gaps in the literature, and see how different studies connect or diverge. By using this matrix, you can:

• Summarize key information from each source.
• See the progression of research on a topic.
• Track how each source contributes to your own research goals.

When crafting your literature review, the matrix becomes a valuable reference. It offers a concise summary of each source, facilitating the synthesis of information and revealing connections between works. This organized approach helps ensure you cover all important themes and insights.

Key Components

A typical Literature Review Matrix includes:

• Author(s) & Date:  For tracking contributions and publication dates.
• Theoretical/Conceptual Framework:  Outlines the theories or concepts guiding the study.
• Research Question(s)/Hypotheses:  Identifies the focus and aims of the research.
• Methodology:  Describes the study design and methods used.
• Analysis & Results:  Summarizes the data analysis and key findings.
• Conclusions:  Highlights the main conclusions drawn from the research.
• Implications for Future Research:  Suggests areas for further investigation.
• Implications for Practice:  Discusses practical applications of the findings.

A Literature Review Matrix establishes a solid foundation for a well-organized literature review, ensuring you capture all critical insights and connections between sources. 

How to Use the Matrix

To make the most of your Literature Review Matrix, follow these steps to complete each category:

Author(s) & Date : Record the author(s) of the study and the publication date. This helps track contributions and the relevance of the research over time.

Theoretical/Conceptual Framework : Note the theories or concepts guiding the study. This provides insight into the foundation of the research and its theoretical background.

Research Question(s)/Hypotheses : Summarize the main research questions or hypotheses the study addresses. This clarifies the focus and objectives of the research.

Methodology : Describe the research design and methods used. This includes the type of study, data collection methods, and analysis techniques.

Analysis & Results : Outline the main findings and how the data was analyzed. This section highlights the key discoveries of the research.

Conclusions : Record the study’s conclusions and implications. This provides a summary of the research outcomes and their significance.

Implications for Future Research : Identify suggestions for further research proposed by the study. This helps in understanding how the research contributes to ongoing scholarly conversation.

Implications for Practice : Note any practical applications or recommendations made. This connects the research findings to real-world applications.

Accurately filling in each category of the Literature Review Matrix ensures a comprehensive and organized overview of your sources, making it easier to synthesize and integrate information into your literature review.

Why Use a Literature Review Matrix?

A Literature Review Matrix is not just a tool but a strategic aid in organizing and synthesizing your research. Here’s why it’s invaluable:

Enhanced Clarity : By laying out your sources in a matrix format, you gain a clear, visual representation of the key components of each study. This clarity helps in quickly identifying patterns, contradictions, and gaps in the literature.

Streamlined Synthesis : The matrix allows you to compare and contrast findings across multiple sources efficiently. This makes synthesizing information from different studies simpler, leading to a more cohesive and comprehensive literature review.

Efficient Writing : With all essential information organized in one place, writing your literature review becomes more straightforward. The matrix provides a structured reference that helps in drafting sections and ensuring that all relevant points are addressed.

Identification of Trends and Gaps : The matrix helps in spotting trends in research and identifying areas where further investigation is needed. This insight is crucial for framing your research questions and shaping your own study.

Improved Organization : It facilitates a systematic approach to managing your sources, reducing the risk of overlooking important details and ensuring that your review is well-organized and thorough.

Using a Literature Review Matrix enhances the efficiency and quality of your literature review process. It’s a powerful tool that supports clarity, synthesis, and effective writing, ultimately contributing to a more insightful and organized review.

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The difference between literature review and background sections of a dissertation

I was assuming these two were the same. What is the difference between them? How does one relate to another? The context here is an MA (Master of Arts) level social science dissertation in UK education system.

Should background talk about relevant research done? If so why does literature review exist? Or should the background chose only a few literature and discuss them throughly?

• literature-review
• social-science

• 1 What did your supervisor say? –  410 gone Commented Jul 29, 2015 at 15:48
• I have not received reply yet. I wonder diverse opinions. –  co co Commented Jul 29, 2015 at 16:01
• I initially thought them to be similar, if not the same. But then I had a feeling literature review is "what everyone has done on this (or similar topic)", while background is "how we pave the way to this work". This means that a dissimilar method doing the same might not appear in the background review. But it should appear in the related work / literature review. However, my feeling is that one should always do a literature review in a scientific paper / dissertation. It just might be called differently, due to different customs of various fields. –  Oleg Lobachev Commented Jul 7, 2018 at 16:52

4 Answers 4

I am working in a technical field where very often "solutions" to certain important / interesting "problems" are investigated. Roughly, the background explains what the reader needs to understand the problem, and the related work explains (and critiques) what others have done to (partially) solve or discuss this problem or related problems.

• This was how it went for me. Background: "Here's the setup for this problem". Lit Review: "Here's pretty much everything anyone has tried to address it." –  Fomite Commented Sep 23, 2015 at 19:39

Context: I'm in a US PhD program and thus my answer may not be fully appropriate for Masters in UK.

In the US, a Masters thesis is required rather than dissertation, which is required only in PhD programs. In Social Sciences, a Masters thesis shows that you understand the relevant research in some depth and that you can also apply this research to some specific problems or questions. In contrast, a PhD dissertation needs to contribute to research in some important way (even if the contribution is narrow or small).

There are no widely accepted rules for what is appropriate for Background or Literature Review chapters, or whether your thesis should include either or both.

What follows are my views, based on reading various theses and dissertations.

A Background chapter is best used to present contextual or prerequisite information that is important or essential to understand the main body of your thesis. Perhaps there were some historical developments that set the stage for your research questions or thesis. Perhaps there was some debate over key terms or scope of your subfield. Perhaps you are bringing together several disciplines, and you need to explain which aspects of each discipline you are including and not including.

A Literature Review chapter builds a conceptual structure that ties together all the key ideas from all the relevant literature. By "conceptual structure" I mean an organized way of linking individual ideas together so that their relative importance and interrelations are clear and obvious to the reader. What are the main ideas? What ideas support these main ideas? What are the contradictory ideas? On what basis to people decide what ideas or positions to support or oppose?

Viewed this way, what becomes clear is that a Literature Review chapter is less about "literature" and instead is mostly about "review".

For what it's worth, in my dissertation I will not have either chapter. Instead, I've decided to have a chapter called "Foundations" to cover both of these needs.

• "a Masters thesis is required rather than dissertation" - in your understanding, does that mean any difference in meaning, or are "thesis" and "dissertation" synonymous, with the single difference that it is a convention to call a doctoral thesis "dissertation"? –  O. R. Mapper Commented Jul 30, 2015 at 7:19
• @O.R.Mapper While I have heard them used interchangeably, I think there is a distinction between the Masters requirement and the PhD requirement, along the lines I described above. Again, this may be different outside the US. –  MrMeritology Commented Jul 30, 2015 at 16:30
• In the UK, common practice seems to be the opposite: One writes an undergraduate dissertation and a PhD thesis . But otherwise I imagine they're pretty similar to the equivalent level in the US. –  georgewatson Commented Apr 12, 2017 at 13:12

I agree that there is no absolute way to write the research background and literature review chapter. however, there is a general rule of research background which is "write from general to specific". Meaning that, write your research topic general then go specific to your topic.

I take one example of finance research topic which is education loan, and it is a quantitative study (has dependent variable (DV) and independent variables(IV)). Let say I would like to study about default payment (DV) and attitude towards loan repayment (IV).

In the background of study, paragraph 1-3 i will discuss in general about education loan including the countries that offers the edu loan, the design of loan scheme etc. in the first three of the paragraphs, i didn't touch on my specific topic which is default and its predictors.

in para 4, i will discuss briefly what is wrong with the edu loan nowadays - default (refers to when someone refuses to pay loan). and briefly discussed among the major factors that may contribute to the default.

in the next 4 paragraphs, i will focus on the major factor of default which is is attitude. i explain in detail the research trend about attitude (e.g. attitudes correlated with ignorance, dissatisfaction and misconception about the consequences of not pay loan), why attitude important. why attitude towards loan repayment becomes my major focus of the study. i will cite a few recent research who said that study between attitude and intention to pay loan still limited.

the last four para, i will discuss about the evidence about default rate in my context of research (e.g. the country that you gonna do the research, e.g. UK), put some statistic, or statement from prime minister or anything else as the evidence that default is really a problem in the UK.

While, in the literature review, I will be more specific about the relationship between attitude and intention to pay loan. read as much as you can and better to put in a literature review and synthesis matrix to summarize the past research.

I see this as relevant question which many junior researches ponder.

Literature review is usually longer and it can be a whole work/article or a part of a thesis. Background section is usually short and the first part of research article.

For literature review you should thoroughly go through all available studies, assess the important findings in them, discuss them and find some relevance for them. Poor reviews usually list the available studies and their findings. You can hypothesize with some findings especially if controversy exists. For example do the methodological differences explain the possible controversy in the findings. You should not make lengthy or intense speculations since you must stick strictly to the literature available. In the end of literature review you can give some open questions and warrant further research if your review have given examples of controversies or examples of lack of information in the literature.

The background section of a journal article should briefly describe what is reported in the literature so far. Usually you should be able to present some kind absence or need of certain information or a controversy which you will address in your research. You could also describe shortly why this lack of information or controversy should be solved. You should not hypothesize in any way or make assumptions in the background section. All that should come in the discussion section. Finally, you should only scratch the surface of the literature and not try establish reasons for different or controversial findings seen in the previous studies.

• Agreed. Your background section can tell us why you are taking up the specific topic you chose -- it will be the bridge between the literature review and the beginning of your actual study. –  aparente001 Commented Jul 29, 2015 at 22:15

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What Is Background in a Research Paper?

So you have carefully written your research paper  and probably ran it through your colleagues ten to fifteen times. While there are many elements to a good research article, one of the most important elements for your readers is the background of your study.

What is Background of the Study in Research

The background of your study will provide context to the information discussed throughout the research paper . Background information may include both important and relevant studies. This is particularly important if a study either supports or refutes your thesis.

Why is Background of the Study Necessary in Research?

The background of the study discusses your problem statement, rationale, and research questions. It links  introduction to your research topic  and ensures a logical flow of ideas.  Thus, it helps readers understand your reasons for conducting the study.

Providing Background Information

The reader should be able to understand your topic and its importance. The length and detail of your background also depend on the degree to which you need to demonstrate your understanding of the topic. Paying close attention to the following questions will help you in writing background information:

• Are there any theories, concepts, terms, and ideas that may be unfamiliar to the target audience and will require you to provide any additional explanation?
• Any historical data that need to be shared in order to provide context on why the current issue emerged?
• Are there any concepts that may have been borrowed from other disciplines that may be unfamiliar to the reader and need an explanation?

Related: Ready with the background and searching for more information on journal ranking? Check this infographic on the SCImago Journal Rank today!

Is the research study unique for which additional explanation is needed? For instance, you may have used a completely new method

How to Write a Background of the Study

The structure of a background study in a research paper generally follows a logical sequence to provide context, justification, and an understanding of the research problem. It includes an introduction, general background, literature review , rationale , objectives, scope and limitations , significance of the study and the research hypothesis . Following the structure can provide a comprehensive and well-organized background for your research.

Here are the steps to effectively write a background of the study.

1. Identify Your Audience:

Determine the level of expertise of your target audience. Tailor the depth and complexity of your background information accordingly.

2. Understand the Research Problem:

Define the research problem or question your study aims to address. Identify the significance of the problem within the broader context of the field.

3. Review Existing Literature:

Conduct a thorough literature review to understand what is already known in the area. Summarize key findings, theories, and concepts relevant to your research.

4. Include Historical Data:

Integrate historical data if relevant to the research, as current issues often trace back to historical events.

5. Identify Controversies and Gaps:

Note any controversies or debates within the existing literature. Identify gaps , limitations, or unanswered questions that your research can address.

6. Select Key Components:

Choose the most critical elements to include in the background based on their relevance to your research problem. Prioritize information that helps build a strong foundation for your study.

7. Craft a Logical Flow:

Organize the background information in a logical sequence. Start with general context, move to specific theories and concepts, and then focus on the specific problem.

8. Highlight the Novelty of Your Research:

Clearly explain the unique aspects or contributions of your study. Emphasize why your research is different from or builds upon existing work.

Here are some extra tips to increase the quality of your research background:

Example of a Research Background

Here is an example of a research background to help you understand better.

The above hypothetical example provides a research background, addresses the gap and highlights the potential outcome of the study; thereby aiding a better understanding of the proposed research.

What Makes the Introduction Different from the Background?

Your introduction is different from your background in a number of ways.

• The introduction contains preliminary data about your topic that  the reader will most likely read , whereas the background clarifies the importance of the paper.
• The background of your study discusses in depth about the topic, whereas the introduction only gives an overview.
• The introduction should end with your research questions, aims, and objectives, whereas your background should not (except in some cases where your background is integrated into your introduction). For instance, the C.A.R.S. ( Creating a Research Space ) model, created by John Swales is based on his analysis of journal articles. This model attempts to explain and describe the organizational pattern of writing the introduction in social sciences.

Points to Note

Your background should begin with defining a topic and audience. It is important that you identify which topic you need to review and what your audience already knows about the topic. You should proceed by searching and researching the relevant literature. In this case, it is advisable to keep track of the search terms you used and the articles that you downloaded. It is helpful to use one of the research paper management systems such as Papers, Mendeley, Evernote, or Sente. Next, it is helpful to take notes while reading. Be careful when copying quotes verbatim and make sure to put them in quotation marks and cite the sources. In addition, you should keep your background focused but balanced enough so that it is relevant to a broader audience. Aside from these, your background should be critical, consistent, and logically structured.

Writing the background of your study should not be an overly daunting task. Many guides that can help you organize your thoughts as you write the background. The background of the study is the key to introduce your audience to your research topic and should be done with strong knowledge and thoughtful writing.

The background of a research paper typically ranges from one to two paragraphs, summarizing the relevant literature and context of the study. It should be concise, providing enough information to contextualize the research problem and justify the need for the study. Journal instructions about any word count limits should be kept in mind while deciding on the length of the final content.

The background of a research paper provides the context and relevant literature to understand the research problem, while the introduction also introduces the specific research topic, states the research objectives, and outlines the scope of the study. The background focuses on the broader context, whereas the introduction focuses on the specific research project and its objectives.

When writing the background for a study, start by providing a brief overview of the research topic and its significance in the field. Then, highlight the gaps in existing knowledge or unresolved issues that the study aims to address. Finally, summarize the key findings from relevant literature to establish the context and rationale for conducting the research, emphasizing the need and importance of the study within the broader academic landscape.

The background in a research paper is crucial as it sets the stage for the study by providing essential context and rationale. It helps readers understand the significance of the research problem and its relevance in the broader field. By presenting relevant literature and highlighting gaps, the background justifies the need for the study, building a strong foundation for the research and enhancing its credibility.

The presentation very informative

It is really educative. I love the workshop. It really motivated me into writing my first paper for publication.

an interesting clue here, thanks.

thanks for the answers.

Good and interesting explanation. Thanks

Thank you for good presentation.

Hi Adam, we are glad to know that you found our article beneficial

The background of the study is the key to introduce your audience to YOUR research topic.

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Hi Maryam, we are glad to know that you found our resource useful.

my understanding of ‘Background of study’ has been elevated.

Hi Peter, we are glad to know that our article has helped you get a better understanding of the background in a research paper.

thanks to give advanced information

Hi Shimelis, we are glad to know that you found the information in our article beneficial.

When i was studying it is very much hard for me to conduct a research study and know the background because my teacher in practical research is having a research so i make it now so that i will done my research

Very informative……….Thank you.

The confusion i had before, regarding an introduction and background to a research work is now a thing of the past. Thank you so much.

Thanks for your help…

Thanks for your kind information about the background of a research paper.

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Very informative. I liked even more when the difference between background and introduction was given. I am looking forward to learning more from this site. I am in Botswana

Hello, I am Benoît from Central African Republic. Right now I am writing down my research paper in order to get my master degree in British Literature. Thank you very much for posting all this information about the background of the study. I really appreciate. Thanks!

The write up is quite good, detailed and informative. Thanks a lot. The article has certainly enhanced my understanding of the topic.

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How to write a literature review introduction (+ examples)

The introduction to a literature review serves as your reader’s guide through your academic work and thought process. Explore the significance of literature review introductions in review papers, academic papers, essays, theses, and dissertations. We delve into the purpose and necessity of these introductions, explore the essential components of literature review introductions, and provide step-by-step guidance on how to craft your own, along with examples.

Why you need an introduction for a literature review

In academic writing , the introduction for a literature review is an indispensable component. Effective academic writing requires proper paragraph structuring to guide your reader through your argumentation. This includes providing an introduction to your literature review.

It is imperative to remember that you should never start sharing your findings abruptly. Even if there isn’t a dedicated introduction section .

When you need an introduction for a literature review

There are three main scenarios in which you need an introduction for a literature review:

What to include in a literature review introduction

It is crucial to customize the content and depth of your literature review introduction according to the specific format of your academic work.

Academic literature review paper

The introduction of an academic literature review paper, which does not rely on empirical data, often necessitates a more extensive introduction than the brief literature review introductions typically found in empirical papers. It should encompass:

Regular literature review section in an academic article or essay

In a standard 8000-word journal article, the literature review section typically spans between 750 and 1250 words. The first few sentences or the first paragraph within this section often serve as an introduction. It should encompass:

Introduction to a literature review chapter in thesis or dissertation

Some students choose to incorporate a brief introductory section at the beginning of each chapter, including the literature review chapter. Alternatively, others opt to seamlessly integrate the introduction into the initial sentences of the literature review itself. Both approaches are acceptable, provided that you incorporate the following elements:

Examples of literature review introductions

Example 1: an effective introduction for an academic literature review paper.

To begin, let’s delve into the introduction of an academic literature review paper. We will examine the paper “How does culture influence innovation? A systematic literature review”, which was published in 2018 in the journal Management Decision.

Example 2: An effective introduction to a literature review section in an academic paper

The second example represents a typical academic paper, encompassing not only a literature review section but also empirical data, a case study, and other elements. We will closely examine the introduction to the literature review section in the paper “The environmentalism of the subalterns: a case study of environmental activism in Eastern Kurdistan/Rojhelat”, which was published in 2021 in the journal Local Environment.

Thus, the author successfully introduces the literature review, from which point onward it dives into the main concept (‘subalternity’) of the research, and reviews the literature on socio-economic justice and environmental degradation.

Examples 3-5: Effective introductions to literature review chapters

Numerous universities offer online repositories where you can access theses and dissertations from previous years, serving as valuable sources of reference. Many of these repositories, however, may require you to log in through your university account. Nevertheless, a few open-access repositories are accessible to anyone, such as the one by the University of Manchester . It’s important to note though that copyright restrictions apply to these resources, just as they would with published papers.

Master’s thesis literature review introduction

Phd thesis literature review chapter introduction.

The second example is Deep Learning on Semi-Structured Data and its Applications to Video-Game AI, Woof, W. (Author). 31 Dec 2020, a PhD thesis completed at the University of Manchester . In Chapter 2, the author offers a comprehensive introduction to the topic in four paragraphs, with the final paragraph serving as an overview of the chapter’s structure:

PhD thesis literature review introduction

The last example is the doctoral thesis Metacognitive strategies and beliefs: Child correlates and early experiences Chan, K. Y. M. (Author). 31 Dec 2020 . The author clearly conducted a systematic literature review, commencing the review section with a discussion of the methodology and approach employed in locating and analyzing the selected records.

Steps to write your own literature review introduction

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Writing Research Background

Research background is a brief outline of the most important studies that have been conducted so far presented in a chronological order. Research background part in introduction chapter can be also headed ‘Background of the Study.” Research background should also include a brief discussion of major theories and models related to the research problem.

Specifically, when writing research background you can discuss major theories and models related to your research problem in a chronological order to outline historical developments in the research area.  When writing research background, you also need to demonstrate how your research relates to what has been done so far in the research area.

Research background is written after the literature review. Therefore, literature review has to be the first and the longest stage in the research process, even before the formulation of research aims and objectives, right after the selection of the research area. Once the research area is selected, the literature review is commenced in order to identify gaps in the research area.

Research aims and objectives need to be closely associated with the elimination of this gap in the literature. The main difference between background of the study and literature review is that the former only provides general information about what has been done so far in the research area, whereas the latter elaborates and critically reviews previous works.

John Dudovskiy

Frequently asked questions

What is the difference between a literature review and a theoretical framework.

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 .

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.

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?

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.

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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Bibliometrics & citations, view options, 1 introduction, 2 background and related work, 2.2 related work.

3.1 Data Collection

TITLE-ABSTR-KEY (distributed ledger technology OR DLT OR blockchain) AND TITLE-ABSTR-KEY (health* OR medical) AND TITLE-ABSTR-KEY (application OR scenario OR use case)

3.2 Data Analysis

4.1 Patient-Centric Health Data Management

4.1.1 use case description..

4.1.2 Access Management.

4.1.3 secure record-keeping., 4.1.4 data sharing incentivization., 4.2 management of electronic healthcare records (ehrs), 4.2.1 use case description..

4.2.2 Access Management.

4.2.3 secure record-keeping., 4.3.1 use case description..

4.3.2 Access Management.

4.3.3 secure record-keeping., 4.3.4 process automation., 4.4 biomedical research, 4.4.1 use case description..

4.4.2 Access Management.

4.4.3 secure record-keeping., 4.4.4 data sharing incentivization., 4.4.5 process automation., 4.5 supply chain management (scm) for pharmaceutical drugs or medical devices, 4.5.1 use case description..

4.5.2 Secure Record-Keeping.

4.5.3 process automation., 4.6 contact tracing and warning for pandemics, 4.6.1 use case description..

4.6.2 Secure Record-Keeping.

4.6.3 process automation., 5 discussion, 5.1 principal findings, 5.2 implications.

5.3 Limitations and Future Research

6 conclusion, a.1. dlt characteristics.

A.2. Rationale for Characteristics

Index Terms

Applied computing

Life and medical sciences

Health care information systems

Software and its engineering

Software creation and management

Designing software

Recommendations

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William and Mary, USA

Association for Computing Machinery

New York, NY, United States

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• Distributed ledger technology
• DLT-based applications
• DLT characteristics
• Research-article

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What Helps Children and Young People to Disclose their Experience of Sexual Abuse and What Gets in the Way? A Systematic Scoping Review

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• Published: 18 September 2024

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• Lynne McPherson   ORCID: orcid.org/0000-0002-3356-2216 1 ,
• Kathomi Gatwiri   ORCID: orcid.org/0000-0002-7794-6481 1 ,
• Anne Graham   ORCID: orcid.org/0000-0002-9308-8536 1 ,
• Darlene Rotumah   ORCID: orcid.org/0000-0002-2346-7856 2 ,
• Kelly Hand   ORCID: orcid.org/0009-0008-1269-8983 1 ,
• Corina Modderman   ORCID: orcid.org/0000-0002-7375-5047 3 ,
• Jaime Chubb 4 &
• Samara James 1  

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Global research has found that prevalence rates of child sexual abuse suggest that this is a significant ongoing public health concern. A recent Australian study, for example, revealed that more than three girls and almost one in five boys reported experiencing sexual abuse before the age of 18. Self-reported rates of abuse, however, far exceed official figures, suggesting that large numbers of children who experience sexual abuse do not come to the attention of relevant authorities. Whether and how those children have tried to tell their stories remains unclear.

The goal of the review was to explore scholarly literature to determine what was known about what enables or constrains children to disclose their experience of sexual abuse.

A systematic scoping review was undertaken to better understand the current state of knowledge in the scholarly literature on child sexual abuse disclosure. Thirty-two scholarly publications were included for analysis following a rigorous process of sourcing articles from five databases and systematically screening them based on transparent inclusion and exclusion criteria. Ecological systems and trauma-informed theoretical paradigms underpinned an inductive thematic analysis of the included manuscripts.

Three multi-dimensional themes were identified from the thirty-two publications. These themes were: factors enabling disclosure are multifaceted; barriers to disclosure include a complex interplay of individual, familial, contextual and cultural issues; and Indigenous victims and survivors, male survivors, and survivors with a minoritised cultural background may face additional barriers to disclosing their experiences of abuse.

Conclusions

The literature suggests that a greater understanding of the barriers to disclosures exists. Further research that supports a deeper understanding of the complex interplay of enablers and the barriers to disclosure across diverse populations is needed. In particular, future research should privilege the voices of victims and survivors of child sexual abuse, mobilising their lived experiences to co-create improved practice and policy.

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Introduction

The prevalence of child sexual abuse is a matter of critical interest for researchers, policymakers and practitioners working with children, young people and their families. Worldwide estimates of child sexual abuse (CSA) prevalence are alarming, with an average of 18–20% of females and 8–10% of males reporting experiences of abuse (Pereda et al., 2009 ). A recent study in the USA, drawing from a sample of 2639 respondents aged 18–28, concluded that the overall prevalence rate of child sexual abuse was 21.7%. For females, this rate was found to be 31.6% and for males, 10.8% (Finkelhor et al., 2024 ). In Australia, the recently published Australian Child Maltreatment Study collected nationally representative data on rates of abuse and neglect and found that 37.3% of girls and 18.8% of boys had experienced child sexual abuse (Matthews et al., 2023 ).

Self-reported rates of abuse far exceed official figures, suggesting that large numbers of children who experience sexual abuse do not come to the attention of relevant authorities. As an example of the discrepancy between official statistics versus reports by survivors, offender conviction rates appear to be far lower than reported abuse. One study, for example, found that police did not lay charges in more than half of 659 cases where child sexual abuse was reported to them (Christensen et al., 2016 ). The two reasons provided were, first, insufficient evidence, and second, aspects of the child’s disclosure, particularly timing and detail, were inadequate for successful prosecution. In another example, a study based on an analysis of administrative data over a fourteen-year timeframe found that only one in five reported child sexual abuse matters proceeded further than the initial investigation phase. In this study, only 12% of reported offences resulted in a conviction, with the authors claiming that their findings were consistent with other studies (Cashmore et al., 2020 ). Further research to enable a better understanding of “how these (prosecution) decisions are made, over and above the characteristics of the complainant, suspect and type of offence” was recommended (Cashmore et al., 2020 , p. 93).

In another example, a meta-analysis that combined estimates of prevalence rates of child sexual abuse across 217 studies, then comparing these rates with official data from sources such as the police and child protection, found that analyses based on self-reports of victims and survivors revealed prevalence rates of up to 30 times greater than official reports (Stoltenborgh et al., 2015 ), indicating a sizeable gap between self-reported experiences of child sexual abuse by survivors and rates recorded by official authorities. Such a sizable gap suggests that further investigation into research that examines the process of disclosure is much needed, with a focus on what factors enable and constrain children and young people from talking about the abuse that they have experienced.

Child sexual abuse disclosure is theorised as a multifaceted, iterative and contextualised phenomenon that interacts directly or indirectly across a range of ecological variables. Both ecological (Bronfenbrenner., 1979 ) and trauma theories (Alaggia et al., 2019 ) consider a child victim within their context by considering the micro, meso and macro implications issues faced by children who have experienced the trauma of child sexual abuse.

In summary, the rationale for this review emerges from the child sexual abuse research literature, which reports very high prevalence rates of abuse, particularly where research participants are offered anonymity as young adults to recall their experiences (Finkelhor et al., 2024 ; Matthews et al., 2023 ). Evidence of these high rates of abuse, drawn from research, are not matched by official administrative data published in government reports, with research outcomes reporting on child sexual abuse prevalence up to 30 times greater than official statistics from relevant authorities (Stoltenborgh et al., 2015 ).

These issues raise serious and urgent questions about how children and young people who have experienced child sexual abuse are listened to, heard and responded to. Children and young people may raise their concerns in attempts to tell, only to meet with barriers that prevent them from feeling supported and safe.

This scoping review aimed to address that gap by examining the literature reporting on disclosures of child sexual abuse by examining the literature reporting on disclosures of child sexual abuse by considering the question: What do we know about what influences or enables children and young people to disclose their experience of child sexual abuse, and what are the barriers to disclosure?

A Systematic Scoping Review

Using the framework developed by Arksey and O’Malley ( 2005 ), a systematic scoping review methodology was used to identify the available research literature on the disclosure of child sexual abuse. To clarify the use of the term ‘systematic’ in the context of a scoping review, we adopted a methodologically sound process for searching the literature to scope the current state of knowledge concerning child sexual abuse disclosure (Allagia et al., 2019 ). The purpose of this review was to map the literature on child sexual abuse disclosure, identify key concepts that hinder or enable disclosure, and highlight gaps in the research. Scoping studies are particularly well-suited for complex topics, as they provide valuable insights for policymakers, practitioners, and future research (McPherson et al., 2019 ). Mapping the literature involved a five-stage sequential process as follows: developing a research question, systematically identifying potentially relevant studies, screening and selecting relevant studies based on identified inclusion and exclusion criteria, charting the data and collating, summarising and reporting the results (Arksey & O’Malley, 2005 , p. 8). This five-stage approach emphasises the importance of building a credible critique when investigating a largely unexplored topic (Munn et al., 2018 ).

Theoretical Frame

This review took a multi-theoretical approach. Drawing on ecological systems and trauma-informed theoretical paradigms provided a robust framework for understanding the complex barriers to disclosing childhood sexual abuse. By integrating these two theories, we gained an understanding of how, at the individual level, trauma symptoms like shame, guilt, and fear can inhibit disclosure and, additionally, how relational dynamics (microsystems) and broader systemic and societal factors at the exo-system and macrosystem levels, can either support or hinder disclosure. CSA disclosure is often not a one-off event but rather a dynamic process reflecting the trauma of the abuse that may take place over time and can include incidents of retraction where survivors recant their stories (Alaggia et al., 2019 ). This phenomenon was first theorised by Roland Summit in 1983 and was revisited some decades later as child victims of abuse were reported to ‘accommodate’ abuse to the extent that disclosure was often delayed, conflicted and ultimately retracted (McPherson et al., 2017 ).

An ecological framework (Bronfenbrenner, 1979 ) considers a child contextually by taking into account the “ontogenic, micro-system, exo-system and macro-system” layers that inform childhood experiences (Alaggia, 2010 . p. 36). At the micro level, family dynamics can obstruct disclosure due to concerns about not being believed or feelings of loyalty to the abuser. In a different study, Alaggia ( 2004 ) points out that although children disclose in many different ways, the closer the familial relationship between the child and the perpetrator, the more difficult disclosure gets. CSA disclosure within a mesosystem encompasses the interactions among different components of the microsystem, such as churches, schools, and neighbourhoods, which can impede the disclosure process. In such interacting systems, the child who discloses can be placed in a liminal place, on the boundaries of the systems that the family is situated in, leading to demands for “compromise” for the “purposes of damage limitation” (Gardner, 2012 , p. 102). The exosystem, encompassing broader social systems like social services, can introduce complexities in the disclosure process due to inadequate reporting structures and limited interagency collaboration and resources for investigating child sexual abuse claims and frameworks of support to children who disclose. Gardner ( 2012 , p. 105) refers to these as “anxiety-provoking institutional dilemmas” wherein institutions respond with procedures that contain anxiety rather than through a trauma-informed practice of prioritising safety to reduce the risk of re-traumatisation. The macro-system envelopes the societal norms, laws, and policies, which influence the stigma and cultural taboos around child sexual abuse, potentially affecting how authorities or the adults in a child’s life respond to disclosures of child sexual abuse. Child sexual abuse disclosure is, therefore, a multifaceted, iterative and contextualised phenomenon that interacts directly or indirectly across all these ecological variables (Alaggia et al., 2019 ).

Five-Phased Approach

Phase one: developing the research question.

The following research question framed the systematic scoping review:

What do we know about what influences or enables children and young people to disclose their experience of child sexual abuse, and what are the barriers to disclosure?

Phase Two: The Framework for Systematically Identifying Relevant Studies

A search strategy that aimed to identify peer-reviewed literature was developed. With the support of a research librarian, five electronic databases (InfoRMIT; Psychology and Behavioural Sciences Collection; APA PsycInfo; Academic Search Premier; ProQuest) were searched using a combination of carefully selected keywords: Child*ren, youth, AND Sexual Abuse OR Sexual Assault AND Disclosure OR Telling OR Sharing AND Barrier s OR Hindrance OR Facilitators OR Enablers . Searches were run from 2013 to (July) 2023.

Inclusion criteria The search was restricted to peer-reviewed academic journal articles published in English between 2013 and 2023. Articles focusing on what helped or hindered disclosure that helped to better understand children’s experience of disclosing were included. The inclusion criteria included both articles about children and young people (aged under 18) and articles about adults with lived experience of child sexual abuse who were recalling their experiences of disclosure.

Exclusion criteria Articles were excluded if published before 2013, were not published in a peer-reviewed scholarly journal or did not address the research question. Therefore, articles reporting rates and prevalence, prevention literature (unless it addressed responses to disclosure), diagnostic tools, practice frameworks, and legislative requirements were excluded. Non-English articles were also excluded due to the resources required for translation.

Grey literature was excluded due to quality, reliability, and publication bias concerns. Additionally, challenges in standardising and accessing globally available grey literature made it difficult to ensure evidence-based verification and reproducibility in the review (Mahood, 2014 ). Only peer-reviewed scholarly articles were included to maintain a systematic and transparent methodology.

Phase Three: Selection of Relevant Studies and Charting of the Data

Two researchers applied the inclusion and exclusion criteria to all the citations that the search strategy identified, continually reflecting on search strategies and methodological choices at each stage of sifting, charting and sorting (Arksey & O’Malley, 2005 ). Initial searches from the databases with the date, source and language criteria applied provided a list of 1625 publications. Titles were screened to ensure broad relevance to the research question and duplicates, with 1532 articles excluded. A review of abstracts was then undertaken for the remaining 93 articles, which led to a further 24 articles being removed.

Full-text articles (n = 69) were retrieved for those articles that had been included. Authors 1 and 4 examined these articles independently to decide if the articles confirmed the inclusion criteria. Author 2 resolved disagreement, resulting in 32 articles being included in the scoping review for inclusion in a thematic analysis. See Fig.  1 for the PRISMA that charts the screening process.

Prisma flow chart. Moher et al. ( 2009 )

Phases 4 and 5: Collating and Analysing the Results

Two researchers (Researchers 1 and 2) reviewed the selected thirty-two articles using Braun and Clarke’s ( 2021 ) ‘reflexive thematic analysis’ framework to code and identify emerging themes in the data. The six-phase process includes 1) data familiarisation and writing familiarisation notes; 2) systematic data coding; 3) generating initial themes from coded and collated data; 4) developing and reviewing themes; 5) refining, defining and naming themes; and 6) writing the report (Braun & Clarke, 2021 ).

As part of phase one, two researchers familiarised themselves with the data using a ‘descriptive-analytical’ method to consistently describe and categorise the key findings relevant to the research question, which formed the basis of the analysis (Arksey & O'Malley, 2005 ). Through this process, the researchers mapped the types, locations and key findings of included studies. The final set of 32 publications was collated and presented as a first-level analysis in Table  1 . There was no attempt to ‘weigh’ or assess the quality of each study as it is not the purpose of a scoping review, which seeks to present an overview of the material reviewed and, consequently, enable the identification of gaps in existing literature (Arksey & O'Malley, 2005 , p. 17).

In phases 2 and 3, the two researchers began reviewing and generating initial codes to “identify and make sense of patterns of meaning across a dataset” (Braun & Clarke, 2021 , p. 331) before organising the data thematically using the database program Excel. In phases 4 and 5, the researchers continued to refine and develop themes, encompassing the reflexive qualitative skills of the researchers as analytic resources. The themes were reviewed carefully together and independently by the broader research team to evolve the analysis, an “analytic process involving immersion in the data, reading, reflecting, questioning, imagining, wondering, writing, retreating, returning.” (Braun & Clarke, 2021 , p. 332).

Results and Thematic Discussion

The researchers undertook reflexive consultation together and independently to enhance the overall research process. This critical process involved two researchers screening, charting, and collating data. By incorporating this reflexive consultative approach, the researchers ensured they continually reflected on search strategies and methodological choices. This method is not linear but iterative and requires the researchers to engage with each stage of the scoping review reflexively (Arksey & O’Malley, 2005 ).

The researchers “made sense of” the data by summarising and interpreting key themes, patterns, and gaps using various frameworks, including a ‘descriptive-analysis’ (Arksey & O’Malley, 2005 ) and ‘reflexive thematic analysis’ (Braun & Clarke, 2021 ). Preliminary themes and findings were then developed, reported and refined with the broader research team of eight academic researchers and practitioners as subject matter experts to gather their insights, perspectives, and feedback on the preliminary findings. Using a ‘reflexive thematic analysis’ to gather insights, perspectives, and feedback, the researchers enhanced and evolved understandings of child sexual abuse disclosure (Braun & Clarke, 2021 ). This ‘consultation exercise’ is supported by other researchers who have recognised the value of consultation in enriching and confirming research outcomes (Oliver, 2001 ).

Following the research team's engagement with the ‘reflexive thematic analysis’ process in the analysis phase, the researchers continued to workshop emergent themes concerning the research question and theoretical framework. Three core themes were identified in the analyses of the 32 articles: (i) Factors enabling disclosure are multifaceted; (ii) Barriers to disclosure include a complex interplay of individual, familial, contextual and cultural issues; (iii) Indigenous victims and survivors, male survivors and survivors with a minoritised cultural background may face additional barriers to disclosing their experiences of abuse.

A summary of the multifaceted barriers and enablers impacting the disclosure of child sexual abuse across various domains is presented below in Table  2 .

Within each theme, these factors are discussed below using a social-ecological and reflexive critical theoretical lens.

Factors Enabling Disclosure are Multifaceted

While most research in this review identified barriers to disclosure, some enabling influences were also identified. Disclosure is conceptualised as a process rather than a one-time event (Tat & Ozturk, 2019 ) that can be affected by personal (individual), interpersonal (mutual or related) and societal (socio-political) factors (Easton et al., 2014 ; Ullman, 2023 ). For example, strong personal factors that influence disclosure may be the desire to protect oneself and prevent further abuse, seek support, clarification, and validation, unburden themselves, seek justice, and document the abuse. (Easton et al., 2014 ; Kasstan, 2022 ; Lusky-Weisrose et al., 2022 ; Ullman, 2023 ). Often, the likelihood of disclosing increases with age (Wallis & Woodworth, 2020 ).

A trusted and supportive individual, such as a parent, friend, teacher, or counsellor, is a significant interpersonal factor that encourages disclosure. The perception of protectiveness and safety from ‘trusted adults’ is crucial, particularly from mothers, who are often recipients of disclosure (Russell & Higgins, 2023 ). According to Rakovec-Felser and Vidovič ( 2016 ), this is especially important for female child victims of sexual abuse. These researchers found that those with safe and supportive mothers needed about nine months to disclose the abuse, whereas those without such support took approximately 6.9 years to disclose.

Having safe or ‘trusted adults’ also appeared in other research as an enabler of what helps children to ‘tell’ or disclose instances of abuse or CSA-related concerns (Russell & Higgins, 2023 ). However, an important finding was that disclosures to ‘trusted adults’ primarily occurred when the perpetrator was also an adult. In instances when the perpetrators of CSA were peers, children and young people were less likely to ‘tell’ adults, professionals, or organisations and more likely to ‘tell’ a friend (Russell & Higgins, 2023 ).

Societal or environmental factors that enable disclosure were linked to ‘memorable life events’ by Allnock ( 2017 ). These events are significant moments that can change one's life, which Allnock ( 2017 ) calls ‘turning points’, critical moments where survivors feel motivated to disclose their experiences. Turning points could occur accidentally following discussions, conversations, or watching television programs where sexual abuse appeared as a theme, enabling awareness of abusive behaviours and acting as a catalyst to tell (Allnock, 2017 ). Turning points could also represent the escalation of the offender’s behaviour, survivors becoming aware of other victims, or interventions by police investigations or child protection that may mutually ‘help others’ (Ullman, 2023 ).

Barriers to Disclosure include a Complex Interplay of Individual, Interpersonal, and Contextual Issues

Reflecting previous research, barriers to disclosure were found to outweigh facilitators of disclosure and tend to be multifaceted (Collin-Vézina et al., 2015 ; Easton et al., 2014 ). Barriers involve a complex interplay of individual, familial, contextual, and cultural issues, with age and gender predictive of delayed disclosure for younger children and adolescents (Sivagurunathan et al., 2019 ).

Multiple studies identified barriers across three broad domains, including personal (internal) barriers, which may include not identifying the experience as sexual abuse, and internal emotions such as shame, self-blame, fear and hopelessness (Collin-Vézina et al., 2015 ; Devgun et al., 2021 ; Easton, 2013 ) or the ‘the normality/ambiguity of the situation’ (Wager, 2015 ). Young children, particularly preschoolers, often have specific fears and barriers to telling or disclosing even when asked by professionals, as they might not understand the purpose of the interview, the crime they have been victim to, or the consequences of disclosing (Magnusson et al., 2017 ). Interpersonal barriers, including dynamics with the perpetrator, the relationship between the perpetrator and family, and the fear of consequences or negative self-representation, were found to impact disclosure significantly (Allnock, 2017 ; Collin-Vézina et al., 2015 ; Devgun et al., 2021 ; Easton, 2013 ; Gemara & Katz, 2023 ; Gruenfeld et al., 2017 ; Halvorsen et al., 2020 ; Wager, 2015 ).

Social or environmental barriers including limited social networks, a lack of opportunities or access to safe adults to disclose to can also lead to disclosures being downplayed or ignored by those who received them, often reinforcing internalised victim-blaming (Collin-Vézina et al., 2015 ). These barriers may include social and cultural norms related to sex, misconceptions and stereotypes about child sexual abuse survivors and perpetrators, and a lack of viable services to respond to disclosures (Collin-Vézina et al., 2015 ; Devgun et al., 2021 ; Easton, 2013 ; Mooney, 2021 ). In fact, according to Easton ( 2013 ) and Marmor ( 2023 ), many survivors who disclosed their experiences of CSA were unable to receive help despite their disclosures. In some cases, the mishandling of disclosures by law enforcement officers, child protection specialists, medical staff, and mental health professionals also created further barriers to disclosing from a sense of hopelessness (Pacheco et al., 2023 ; Wager, 2015 ). Furthermore, a range of context-specific issues were identified in the literature as barriers to disclosure. These included the impact of colonisation, cultural issues, and gender, which are discussed below.

Indigenous Victims and Survivors, Male Survivors and Survivors with a Minoritised Cultural Background May Face Additional Barriers to Disclosing their Experiences of Abuse

Some authors highlighted the ongoing legacy of colonial violence as a personal and structural barrier to the disclosure of child sexual abuse (Braithwaite, 2018 ; Tolliday, 2016 ). For Australian First Nations Peoples who were victims and survivors, “child sexual abuse in Aboriginal and Torres Strait Islander communities is a complex issue that cannot be understood in isolation from the ongoing impacts of colonial invasion, genocide, assimilation, institutionalised racism, and severe socio-economic deprivation. Service responses to child sexual abuse are often experienced as racist, culturally, financially, and/or geographically inaccessible” (Funston, 2013 , p. 381). Consistent with these findings, Tolliday ( 2016 ) examines historical efforts to address sexual safety for Aboriginal and Torres Strait Islander women and children, concluding that these problems cannot be resolved unless the underlying trauma experienced by First Nations Peoples is attended to. An additional barrier for Australian First Nations Peoples may be a level of mistrust in authorities such as police and child protection services, who were found to be involved in the forced removal of Aboriginal and Torres Strait Islander children from their families (Human Rights & Equal Opportunity Commission, 1997 ).

In investigating delayed disclosure, Braithwaite ( 2018 ) found that for rural Alaskan Native survivors, the impact of colonisation may be a significant barrier to survivors disclosing abuse. The inability to trust authorities directly results from colonisation and systemic, intergenerational poverty, where disclosing abuse may negatively impact already impoverished families.

Cultural and Racial Issues

In reporting on these issues, it is important not to present child sexual abuse as an inherent racial, religious, or cultural concern. As Taylor and Norma ( 2013 ) argue, describing interpersonal barriers for women of culturally or racially diverse backgrounds in Australia to disclose childhood sexual abuse has often been described as “cultural”, but it is more a “familial culture” rather than an aspect of ethnic culture, wherein barriers to reporting sexual abuse are from wanting to protect their family and community from shame, stigma, or loss of dignity in a society where a community as a whole can be racially and culturally vilified for the actions of a few offenders.

In other contexts, researchers found that “familial culture” barriers were experienced by many survivors in other highly racialized contexts. For example, researchers found that in South Africa, the desire for families to preserve the dignity of the family and avoid shame in the community may have inhibited children from wanting to disclose sexual abuse, consequently prioritising the reputation of the family over disclosure (Ramphabana et al., 2019 ). Likewise, in East Asian communities in Canada, the concern that such a negative incident can ruin the family and the victim’s reputation and damage relationships with other community members can also dissuade disclosure from children and reporting from their families (Roberts et al., 2016 ). When living within cultural norms that promote self-scrutiny, children feel responsible for their actions and may blame themselves for the abuse or for the impacts of disclosing (Roberts et al., 2016 ).

Fear of family disruption or breaking up the family, including placement in foster care or the criminal justice system (Allnock, 2017 ), were also mentioned as barriers to disclosure. This was found particularly in contexts where perpetrators contribute financially to the family or are the breadwinners upon whom the children rely for survival. These fears may be compounded within cultures enshrined within strong patriarchal values, where male dominance over women and children is normalised or socially accepted. This has been witnessed in East Asian communities in Canada, which are greatly influenced by Confucian philosophy and patriarchal lineage and where societal and familial harmony is expected to outweigh personal needs. Taken together, this could contribute significantly to the low reporting rate of Asian child sexual abuse, which is disproportionate to that of Caucasian children in Canada (Roberts et al., 2016 ). Other factors for low disclosure are linked to fears of condemnation or desire to protect parents, family, and community from reprisal, including, in extreme circumstances, fear of ostracization, death threats, honour killings (Marmor, 2023 ), physical violence, the risk of being disowned by family or expelled from school, discrimination, isolation from social networks, and emotional abuse within the community (Obong'o et al., 2020 ). For already vulnerable, minoritised communities, this creates a double layer of vulnerability in broader society.

How a community views sex can also make it difficult for children, families, and communities to identify and disclose child sexual abuse, particularly in sexually conservative, religious-cultural contexts where sex may be taboo, stigmatising, or disrespectful to discuss with children (Ramphabana et al., 2019 ). In a study from Zimbabwe, stigma and discrimination from being labelled as having sexually transmitted diseases or for losing their virginity were expressed as a fear of disclosure (Obong'o et al., 2020 ). There are also religious prohibitions against reporting sexual abuse or violence to secular authorities (Marmor, 2023 ), as this would tarnish the religious image in secular contexts. This suggests that the emphasis on purity culture, silencing of discussions on sexuality, diminished reporting due to fear of the influence of secular values, and reliance on disclosing to religious authority figures rather than professionals act as religious and cultural barriers to reporting child sexual abuse (Lusky-Weisrose et al., 2022 ). When combined, it reduces survivors’ ability to identify and disclose child sexual abuse alongside institutional barriers and adds layers of possible isolation in cultural contexts that also serve as social protection for minoritised groups.

Gender Issues

The role of gender in child sexual abuse disclosure was identified as a noteworthy barrier. Researchers highlight the difference in disclosure patterns of male child sexual abuse survivors, which tend to be delayed for years or even decades compared to female survivors, and some male survivors were found to have lower rates of ever disclosing the abuse (Easton, 2013 ; Easton et al., 2014 ). Like many survivors of child sexual abuse, male survivors feared not being believed, justifiably, as historically there was a lack of awareness of the existence of male child sexual abuse, despite researchers finding that approximately 15% of adult men report being sexually abused during childhood (Easton et al., 2014 ). The mass media coverage of institutional abuse scandals, such as those at the Catholic Church, Boy Scouts of America, and Penn State University, have now raised public awareness of the sexual abuse of boys and how the impacts of child sexual abuse, such as deep-seated rage, shame, spiritual distress, and stigma (Easton, 2013 ) have influenced delayed or non-disclosure.

Gendered societal norms also strongly influence individual, group, and societal ideas and behaviours towards male sexual abuse (Sivagurunathan et al., 2019 ). These include, notably, ideas of male gender identity, masculinity, and masculine norms such as winning, emotional control, homophobia, and self-reliance, including negative attitudes towards victimhood and help-seeking. Additionally, as boys are often sexually abused by other males, many survivors fear the stigma of being labelled homosexual (Easton, 2013 ; Easton et al., 2014 ). Some survivors who self-identified as gay or bisexual also feared that others would use their abuse to explain their sexual orientation, saying it “made me gay” (Easton, 2013 ; Easton et al., 2014 ). Other survivors also questioned their sexual orientation due to their abuse experiences, blamed themselves, or feared being seen by others as having unconsciously invited the abuse (Sivagurunathan et al., 2019 ).

External barriers to disclosure were also identified regarding child protection workers, law enforcement, and clinicians (Easton, 2013 ), as well as religious institutions, such as churches and mosques, who were also found to have obstructed the identification and treatment of child sexual abuse in males due to societal attitudes about sex and the stigma of child sexual abuse. Additionally, there is a double standard when it comes to how sexual abuse among men is framed in mainstream media in a society that tends to glorify the sexual abuse of male children as a sexual initiation or sexual prowess if the perpetrator is an older woman. These double standards may, in turn, result in the further reluctance of male child sexual abuse survivors to disclose such experiences (Sivagurunathan et al., 2019 ), which is part of the reason why the helpfulness of responses to child sexual abuse disclosure across a male survivor’s lifespan is mixed (Easton, 2013 ). Combined, they all link to larger societal issues around gendered social expectations and how they impact child sexual abuse disclosure. If hegemonic masculinity and the conforming of traditional gendered roles lead to delayed disclosure or not disclosing at all for male survivors, a question arises concerning the child sexual abuse experiences of transgender and gender-diverse people, who are disproportionately affected by prejudice-motivated discrimination and violence.

Implications for Policy, Practice and Further Research

Thirty-two manuscripts were reviewed to respond to the question: What is known about what influences or enables children and young people to disclose their experience of child sexual abuse, and what are the barriers to disclosure?

This review found that a significant enabler for disclosure is the presence of a safe relationship. This finding is consistent with emerging knowledge about the impact of trauma, which suggests that children may first choose to disclose to a friend or person they trust. Another clear finding in the literature is that disclosure should not be conceptualised as a single event at a point in time. Disclosure is seen as multifaceted, contextual and likely to be iterative, taking place over time. This raises critical questions about the extent to which legislative, policy and practice frameworks are sensitised to this finding.

These findings should contribute to the design of policies that support practices enabling children to experience safe spaces and relationships within which they may feel able to disclose, in their own time, the abuse that they have experienced. Services designed to engage and support all children and young people, including schools, sports and recreation facilities, should give attention to various strategies to promote a sense of safety for their child participants. These services should be accompanied by clearly articulated policies to support children and young people through the process of disclosure. In addition, services designed to respond to child victims, such as statutory child protection and police, must be designed with children in mind. In practice, adult-centric forensic models of interviews conducted by police and child protection may be premised on a single contact with the child. This approach may not match the child’s need to reveal details of their experience over time in what we know to be an often iterative process. All children’s services should become familiar with the behavioural indicators that some children, particularly younger children, may demonstrate rather than using words to disclose.

The notable research gaps are of importance for future research. For example, critical questions are raised concerning the lack of studies on diverse cohorts, including LGBTQIA + survivors, Indigenous survivors or survivors living with a disability. Whilst the prevailing research does address the facilitators of disclosure to an extent, the volume of literature reporting on the barriers to disclosure is greater. A more in-depth understanding by policymakers, practitioners and researchers of some of the obstacles, including broader social and sociocultural barriers, is needed.

Further research to hear from a diverse cohort of survivors to explore their experiences of disclosing child sexual abuse is urgently needed. Overall, this review highlights the need to advance the understanding of the processes of child sexual abuse across diverse cohorts and contexts to improve service systems’ capacity to listen, hear, and respond appropriately to children and young people.

Overall, this review highlights the need to advance the understanding of the processes of child sexual abuse across diverse cohorts and contexts to improve service systems’ capacity to listen, hear, and respond appropriately to children and young people.

Limitations of the Study

Several methodological limitations apply to this analysis. This review has not identified all relevant literature due to the scope of databases searched and the likelihood that not all contemporary search terms were utilised, which might limit the comprehensiveness of the review. The research question sought information about disclosures of child sexual abuse; however, many practice responses to disclosure are likely unpublished in scholarly journals. As grey literature was excluded, potentially valuable insights from reports, theses, conference papers, and other non-peer-reviewed sources were not considered. This limitation is compounded by the inherent difficulty in drawing generalisable conclusions from scoping reviews, which encompass a variety of methodologies, populations, and contexts.

Another limitation is that only articles published in English were included, potentially resulting in the exclusion of crucial studies published in other languages. Additionally, the reliance on peer-reviewed journals may introduce publication bias, as studies with significant or positive results from the UK or North America are more likely to be published. There is also the possibility of subjective bias, as the identification and interpretation of themes depend on the researchers' perspectives.

Furthermore, as it is not within the remit of a scoping review to assess the quality of included studies, findings from lower-quality studies are considered alongside those from higher-quality studies without differentiation. However, the choice to include and conduct scholarly literature that undergoes independent double-blind peer review was made to reduce quality and publication bias risks.

Rather than simply being a one-off event, the disclosure of child sexual abuse is often a complex and ongoing process (Alaggia et al., 2019 ). More is known about barriers than enablers to disclosure, with barriers dominating the published literature sourced in this review. It is evident that, for children and young people, talking about the abuse that they have endured can be overwhelmingly challenging for them across personal, interpersonal and broader levels.

When children and young people begin to disclose, this review raised critical questions about how service systems respond to initial disclosure, particularly the extent to which policies and systems are designed to reflect children’s best interests.

Adults noticing when children and young people are distressed helps victims and survivors to disclose, as does creating trusting relationships to provide opportunities to tell their stories (Russell et al., 2023 ). To whom children elect to disclose is an important question, with recent research suggesting that when children and young people feel unsafe, they are more likely to tell a friend than an adult (Russell et al., 2023 ). Research is urgently required to develop a more robust understanding of the enablers of disclosure across diverse populations. This research needs to privilege the voices of victims and survivors with lived and living experiences of child sexual abuse.

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McPherson, L., Gatwiri, K., Graham, A. et al. What Helps Children and Young People to Disclose their Experience of Sexual Abuse and What Gets in the Way? A Systematic Scoping Review. Child Youth Care Forum (2024). https://doi.org/10.1007/s10566-024-09825-5

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Roungeris, L.; Devadze, G.; Talliou, C.; Griva, P. Prediction of Postoperative Complications after Major Lung Resection: A Literature Review. Anesth. Res. 2024 , 1 , 146-156. https://doi.org/10.3390/anesthres1020014

Roungeris L, Devadze G, Talliou C, Griva P. Prediction of Postoperative Complications after Major Lung Resection: A Literature Review. Anesthesia Research . 2024; 1(2):146-156. https://doi.org/10.3390/anesthres1020014

Roungeris, Loizos, Guram Devadze, Christina Talliou, and Panagiota Griva. 2024. "Prediction of Postoperative Complications after Major Lung Resection: A Literature Review" Anesthesia Research 1, no. 2: 146-156. https://doi.org/10.3390/anesthres1020014

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• PMC11390361

In-Hospital Mortality in Patients With Acute Myocardial Infarction: A Literature Overview

Khalid a alnemer.

1 Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU

Acute myocardial infarction (AMI) continues to be a predominant cause of global morbidity and mortality, with in-hospital mortality (IHM) serving as a pivotal metric for patient outcomes. This review explores the influence of several clinical variables on IHM in individuals with AMI. Factors such as age, gender, body mass index (BMI), smoking habits, existing comorbidities, prior coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), and biomarkers, including high-sensitivity cardiac troponin T (hs-cTnT) and creatine kinase MB (CK-MB), significantly affect the prognosis of the patient. Advanced age and comorbid conditions such as diabetes and hypertension exacerbate myocardial damage and systemic impacts, thus increasing IHM. Gender and BMI are also critical, and women and patients with obesity face different risks. Smoking increases both the risk of AMI and IHM, underscoring the importance of cessation interventions. ST-elevation myocardial infarction is associated with elevated IHM and requires immediate reperfusion therapy, while non-ST-elevation myocardial infarction requires customized management for risk assessment. Previous CABG and PCI add complexity to AMI treatment and elevate IHM due to pre-existing coronary pathology and the intricacies of the procedures involved. The application of biomarker-centered techniques facilitates the swift identification of individuals at elevated risk, improves therapeutic planning, and reduces IHM for patients with AMI. Understanding and incorporating these clinical determinants are essential to optimize the management of AMI, minimize IHM, and improve patient outcomes. This all-encompassing strategy requires ongoing research, quality improvement efforts, and personalized care approaches.

Introduction and background

Acute coronary syndrome (ACS) represents a common clinical manifestation of cardiovascular disease (CVD), which annually results in a large number of hospital admissions and emergency department consultations around the world [ 1 ]. Despite advances in reperfusion strategies and improvements in supportive pharmacological treatments, people with acute myocardial infarction (AMI) continue to experience a significant likelihood of subsequent cardiovascular events and mortality rates (8.9 million deaths worldwide in 2019) that are noteworthy [ 1 - 3 ]. Consequently, many risk determinants and prognostic indices have been established to forecast short- and long-term detrimental consequences [ 4 ].

The prevalence of AMI or ACS in the elderly has decreased significantly due to improvements in both primary and secondary CVD prevention methods. However, a similar decline is not evident among younger demographics, as defined by Ando et al. [ 5 ]. Despite the advances in pharmacological treatment and cardiac catheterization techniques, the rate of in-hospital mortality (IHM) for those with AMI remains an area fraught with clinical complexities. It is imperative to discern the clinical determinants related to IHM within this group. This knowledge is vital for practical risk assessment, prognosis determination, and design of interventions designed to improve patient survival rates; these points were critically analyzed [ 6 ].

As innovative approaches to managing AMI (such as fibrinolytic and invasive therapies) emerge, frameworks to assess mortality risk also advance. In recent times, numerous models have been established to measure mortality risk among patients with myocardial infarction (MI), which includes impairment in diastolic and systolic function, atherosclerotic disease, and coronary artery anomalies [ 7 ]. These models consider immediate (during hospitalization) and extended (across various intervals after discharge from medical facilities) outcomes. Among these are clinical scoring instruments specifically designed for application in hospital settings, offering cardiologists practical tools for day-to-day use in clinical settings [ 8 ].

Primary percutaneous coronary intervention (PCI) is recognized as the superior method of reperfusion treatment for AMI, particularly in cases where patients have ST-segment elevation myocardial infarction (STEMI). However, research focusing on younger demographics needs to be more varied due to their relatively low rates of AMI manifestation [ 5 ]. The European Society of Cardiology (ESC) endorses clinical scales that assess mortality risks among MI sufferers within its most recent directives on MI management. Currently, the GRACE score is valued for its exceptional discriminatory capacity. Thus, it is the fundamental index for evaluating individuals with NSTEMI (non-ST-elevation myocardial infarction) [ 9 ]. Observational studies from the United States and Canada have documented a substantial decrease in IHM rates among patients with AMI who received PCI intervention compared to those who did not [ 10 ]. For clinicians, risk evaluation metrics play an integral role by enhancing clinical judgment processes, informing about appropriate pharmacological treatments, helping to determine the necessary lengths of hospital stays, and helping to craft follow-up care after discharge strategies [ 8 ].

When examining contemporary methodologies to assess mortality risk in patients with AMI, it becomes evident that they predominantly use a consistent array of factors. These include initial clinical challenges, vital statistics observed upon hospital admission, laboratory test results, and presentation of MI as seen on electrocardiograms (ECG), all gauged during the initial patient encounter. By analyzing these variables, healthcare professionals can determine the preliminary mortality risk for those hospitalized with confirmed MI. At the heart of the management of AMI lies a comprehensive grasp and synthesis of various clinical indicators that shape patient outcomes, delineate risk categories, and influence IHM rates.

Our current review of the literature investigates the principal clinical determinants linked to IHM among individuals diagnosed with AMI. The probability of survival after an AMI diagnosis differs markedly between the demographics of the patients due to a multitude of factors, such as gender variance, ethnic background, chronological age, specific types of AMI, pre-existing health conditions, and chosen medical interventions [ 10 ]. Our goal is to integrate existing clinical research findings and authoritative protocols to provide an exhaustive analysis of prognostic indicators of IHM and their implications for evaluating risk and guiding treatment choices. By elucidating these elements, we intend to deepen our understanding of the intricate mechanisms that influence mortality associated with AMI and contribute insights conducive to refining patient care delivery while striving toward decreasing death rates.

Clinical factors associated with IHM in patients with AMI

Effective handling of AMI requires a thorough understanding and synthesis of multiple clinical elements such as age, gender, co-morbidities (like hypertension (HTN) and diabetes), body mass index (BMI), biological markers, etc. These collective elements dictate the patient's prognosis, risk assessment, and treatment results, underscoring the need for a multidisciplinary method and personalized care tactics to improve results and minimize hospital mortality in patients with AMI.

The crucial role of age in AMI-induced IHM cannot be understated, given its extensive influence on the patient's physiological state, the severity of comorbid conditions, and their response to treatment. It is well established that advanced age is a substantial standalone forecaster of negative results in patients with AMI.

With age, the cardiovascular system undergoes physiological transformations such as increased arterial rigidity, abnormal myocardial contractility and relaxation, and impaired coronary circulation [ 11 ]. Approximately 30-40% of all hospitalized patients with ACS are adults 75 years and older, and a significant proportion of ACS-related deaths are observed in this demographic within the United States [ 12 , 13 ]. Age is a significant risk factor for diffuse coronary disease and a worsening prognosis in hospitalized patients with unstable angina (UA) or NSTEMI [ 14 ]. The TIMI III registry revealed that patients 75 years and older with UA/NSTEMI exhibited more extensive and severe coronary disease, experiencing poorer outcomes both during hospitalization and within the first six weeks after discharge compared to those under 75 years of age [ 14 ].

Elderly individuals frequently exhibit an increased prevalence of concurrent medical conditions, including HTN, diabetes mellitus (DM), chronic renal disease, and peripheral vascular disease, which are recognized risk factors for cardiovascular events and IHM in patients with AMI [ 15 ]. In the same article, the coexistence of multiple comorbidities was reported to complicate the clinical management of AMI and increase the risk of IHM. Death rates have been documented to be higher in 55 and older patients compared to those under 55 years of age (OR: 4.07; 95% CI: 2.16-7.64) [ 15 ].

Elderly individuals may show unusual or vague signs of AMI, such as exhaustion, breathlessness, or disorientation, which could delay recognition and diagnosis of the critical incident [ 16 ]. The average duration from the appearance of symptoms to the initial medical interaction was recorded at 12.7 hours, with a range of 10 minutes to 96 hours. Increased the incidence of IHM [ 7 ]. Additionally, Khan et al. concluded that the non-standard manifestations of MI are extensive; patients may suffer from chest pain lacking the typical characteristics of angina pectoris or may not experience chest pain at all. Most of the patients were elderly and generally had pain and discomfort in the abdominal, cranial, and cervical areas [ 7 ]. Multiple research studies have established a strong link between advanced age and elevated IHM rates among patients with AMI with diabetes (OR: 2.33; 95%CI: 1.42-3.81; p= 0.001 [ 15 ], with heart failure of AMI at 25.9% [ 17 ]. Elderly subjects (about 6.3% above age 80 yrs) show higher short-term and long-term mortality rates after AMI compared to their younger counterparts, where IHM was associated with hypoxia at admission (OR: 1.70; 05%CI: 1.30-2.22) [ 18 ]. There was a notable association between age-adolescence and increased mortality rates among patients with AMI (P = 0.001) [ 15 ]. Older adults often suffer from chronic low-grade inflammation, which is associated with frailty and CVD [ 13 ]. A person who is frail is characterized by a physiological decline across multiple organ systems which increases vulnerability to stressors, increasing the likelihood of functional decline, hospitalization, and death [ 19 ]. In patients with frailty, less aggressive approaches may yield better outcomes due to increased risk for adverse outcomes. Clinical practitioners are advised to manage competing noncardiac risks in frail patients with MI by paying more attention [ 19 ].

In the realm of AMI and IHM, gender is a significant clinical variable that influences patient presentation, treatment approaches, and eventual outcomes. Historically, men have been perceived to be more susceptible to AMI than women, especially in their younger years [ 20 ]. On the contrary, women tend to experience AMI later in life (57± 7 years), often accompanied by nontraditional symptoms, which could result in missed diagnoses and treatment delays [ 20 , 21 ]. A 2022 study by Rohani et al. revealed that 18.8% (n = 105) passed away before discharge of all MI patients admitted to the hospital [ 15 ]. About 28.4% of these fatalities were women, while men accounted for 13.6%. When analyzing these groups, it was found that 88.7% (n = 93) of those who did not survive belonged to the age group 55 years or older.

The risk factors for AMI are differentially distributed between genders, leading to distinct patterns in its manifestation and prognosis. Women are more likely to suffer from comorbid conditions such as HTN, diabetes, and obesity. In contrast, men show a higher propensity toward habits such as smoking and excessive alcohol use [ 22 , 23 ]. It is hypothesized that estrogen confers cardio-protection, resulting in a lower incidence of AMI in premenopausal women compared to men of the same age [ 24 ]. However, this cardioprotective effect decreases after menopause, increasing the risk of AMI in older women. Asgari et al. found in their investigation that the majority (66.3%) of MI patients were male [ 25 ]. Rohini et al. observed that most of the hospitalized women (85%) were 55 years or older, while only 62% of the men belonged to this age group [ 15 ]. The literature reveals gender-based discrepancies in AMI management, with women receiving recommended treatments such as aspirin, beta-blockers, and reperfusion therapy less frequently. These disparities could potentially lead to poorer outcomes and higher mortality rates among women [ 23 ]. Numerous studies indicate elevated mortality rates in the hospital and 30 days after MI in women compared to men [ 26 ]. This trend is particularly evident among younger women (under 55), with the gender disparity decreasing with age [ 26 ]. For example, research by Nazzal and Alonso revealed a high IHM rate in women under 45 years of age (OR: 2.3; 95%CI: 1.5-3.3) [ 27 ]. The increase in early mortality in females is believed to be due to differences in the presentation of symptoms [ 28 , 29 ].

Elgendy et al. identified that, compared to their male counterparts, women who experienced AMI accompanied by cardiogenic shock received guideline-based treatment less frequently within the initial 24 hours and at the time of discharge [ 30 ]. This gender-based discrepancy has previously been observed in patients with AMI, regardless of the presence of cardiogenic shock [ 31 ]. Previous studies have confirmed that women are less likely to undergo cardiac catheterization and receive mechanical circulatory support devices [ 32 ]. On a positive note, the research did not reveal differences in the frequency of primary PCI among STEMI patients [ 32 ]. However, women were less likely to achieve a door-to-device time of less than 90 minutes [ 30 ]. The root of this delay remains unclear, whether it is attributable to patient-specific or system-wide delays in the recognition of STEMI (for example, due to gender-related variances in the presentation of symptoms or the ability of healthcare professionals to identify and appreciate symptoms) or whether it stems from post-STEMI recognition care is undetermined in the analysis by Elgendy et al. [ 28 ].

Smoking is acknowledged as a contributing determinant of IHM in AMI scenarios, essentially accelerating the onset of STEMI in subjects supposedly healthier [ 33 ]. Although smoking plays a crucial role in the onset of atherosclerosis, numerous studies have indicated that smokers who receive fibrinolytic treatment for AMI exhibit better outcomes compared to non-smokers, as it causes thrombosis, arterial inflammation, and dilatation and dysfunction [ 34 ]. This phenomenon is called the "smoker paradox." For example, GUSTO I, the most extensive trial evaluating the impact of smoking on clinical outcomes, included 11,975 non-smokers, 11,117 former smokers, and 17,507 current smokers. Non-smokers showed significantly higher IHM (9.9% versus 3.7%) and 30-day mortality rates (10.3% versus 4.0%) [ 35 ]. The superior results observed in smokers after fibrinolysis can be attributable to several factors: first, smokers often have elevated levels of hematocrit and baseline fibrinogen, indicating a hypercoagulable state. These more active thrombogenic processes can lead to a more significant thrombus burden, which is more amenable to fibrinolytic therapy, resulting in higher patency rates and a higher probability of achieving TIMI-3 flow in the infarct-related artery after fibrinolysis [ 36 ]. Second, smokers exhibit a more favorable risk profile compared to non-smokers; they are generally younger (average age is 11 years younger in GUSTO I) and show a lower prevalence of diabetes, HTN, previous MI, and severe coronary artery disease [ 37 ].

A study by Song et al. found a decrease in IHM between current smokers and nonsmokers (OR: 0.78, 95% CI: 0.69 to 0.88, p=0.001) [ 38 ]. However, the same study did not observe significant differences in IHM between former smokers and non-smokers (OR: 0.89, 95% CI: 0.77 to 1.04, p=0.1443). Another investigation indicated that smoking was associated with reduced all-cause IHM, with only 6.5% of smokers dying during hospitalization compared to 13.2% of non-smokers (OR: 0.46; 95% CI: 0.34-0.63) [ 39 ].

The risk of AMI is directly related to the duration and severity of smoking habits, with even indirect exposure to tobacco smoke increasing cardiovascular risk [ 40 , 41 ]. A study by Venkatason et al. found a positive link between smoking and improved outcomes in patients with STEMI and NSTEMI [ 42 ]. In the NSTEMI cohort, smokers exhibited a higher incidence of coronary revascularization in the hospital (21.6% for smokers versus 16.7% for non-smokers, P < 0.001). On the contrary, in the STEMI cohort, the rates were comparable between smokers and non-smokers.

 A meta-analysis of PCI trials found that smoking is associated with a higher risk of mortality from all causes and heart failure [ 43 , 44 ]. Furthermore, Gao et al. found an increased risk of recurrent MI associated with smoking [ 45 ]. In conclusion, smoking plays a vital role in AMI, affecting its pathogenesis, presentation, treatment, and patient outcomes. Recognizing the harmful impact of tobacco on cardiovascular health emphasizes the need for interventions to stop smoking to reduce morbidity and mortality from CVD and increase its outcome.

Body Mass Index

Obesity, characterized by an elevated BMI, is correlated with an increased probability of cardiovascular diseases such as HTN, dyslipidemia, and DM [ 46 ]. Specific research has identified a counterintuitive U-shaped correlation between BMI and long-term cardiovascular health outcomes. This occurrence, known as the "obesity paradox," indicates that individuals with higher BMI could exhibit similar or even reduced mortality rates compared to those with normal BMI. At the same time, those with very low BMI experience poorer outcomes [ 47 ]. The obesity paradox likely results from the intricate interplay of various potential mechanisms, including energy reserves, nutritional status, earlier detection of cardiovascular symptoms, faster medical response, and chronic oxidative stress and inflammation [ 47 ]. Following are few examples that discuss the importance of BMI as a clinical factor in AMI.

The research carried out by Elbaz-Greener et al. found that hospitalizations for NSTEMI and STEMI were 75.6% and 24.4%, respectively [ 48 ]. The same study identified a BMI below 19 kg/m 2 as an independent predictor of poorer outcomes and IHM through a multivariate analysis (odds ratio (OR): 1.47, 95% confidence interval (CI): 1.29-1.67).

Angerås et al. observed a peak in survival rates among overweight or moderately obese patients (BMI <35), while those who were underweight or had average weight exhibited the highest mortality risk during follow-up periods [ 49 ].

In contrast, some studies contradicted the obesity paradox, showing increased mortality rates in patients with a BMI greater than 40 kg/m 2 [ 50 , 51 ].

Significantly, the underweight group was consistently associated with a significantly elevated risk of IHM in all cardiovascular diseases compared to the standard BMI group (OR: 1.52, 95% CI: 1.45-1.60) [ 52 ].

Some studies reported a J-shaped relationship between BMI and mortality in patients hospitalized for AMI in recent years. These results confirm that the "obesity paradox" remains relevant in the contemporary management of AMI [ 48 , 53 ].

The TRACE study indicates that among patients experiencing AMI, overall obesity is inversely correlated with mortality rates. Specifically, patients with an underweight AMI exhibited a higher mortality risk (OR: 1.73; 95% CI 1.23-2.44) [ 54 ]. On the contrary, within the same study, overweight women demonstrated a reduced mortality risk (OR: 0.78; 95% CI: 0.68-0.90).

The CRUSADE initiative similarly found that only underweight patients faced an elevated mortality risk (OR: 1.2; 95% CI: 1.0-1.4) [ 55 ].

Ellis et al. observed that patients with a BMI of less than 25 kg/m 2 or more than 35 kg/m 2 had higher mortality rates after PCI [ 56 ].

Powell et al. also identified this bimodal distribution, noting increased mortality risks at both extremes of BMI [ 57 ]. Both studies reported a consistent reduction in adverse outcomes for BMI values below 40 kg/m 2 .

Furthermore, the protective nature of obesity has been proposed to be attributable to larger vessel sizes in general [ 58 ].

Co-morbidities (Diabetes and HTN)

DM and HTN are critical clinical determinants in the realm of AMI and IHM [ 59 , 60 ]. Over the last four decades, significant advances in outcomes have been documented for the general population with AMI, regardless of the status of the DM. However, consistent observation has shown a two-fold increase in IHM rates among DM patients [ 60 ]. In the general population, the incidence of HTN increases progressively with increasing age in both genders; however, it is consistently higher in all age groups in black individuals, posing a more substantial risk factor for coronary artery disease compared to whites. Approximately 54% of Americans aged 65 to 74 years have HTN, whereas the prevalence among black individuals is 72% [ 61 ].

The frequency of mortality in hospital settings was markedly higher among hypertensive patients, registering at 5.9% compared to 4.0% (P <0.001) [ 62 ]. Research indicated that people with HTN and STEMI are more prone to type 2 diabetes and exhibit elevated blood glucose levels upon admission if they do not have a prior diagnosis of diabetes, which adversely impacts their prognosis [ 63 ]. A detailed examination of the Acute Myocardial Infarction Registry (KAMIR), which included data from 8568 Korean patients with STEMI, corroborated that type 2 diabetes is prevalent among patients with hypertensive STEMI. These patients demonstrated poorer clinical and angiographic results, a higher probability of heart failure, and a higher risk of major adverse cardiovascular events (MACE) during long-term follow-up [ 64 ]. Sheifer et al. investigated 102,399 patients with AMI and found that diabetes independently predicted delays in treatment initiation (OR: 1.11, 95% CI: 1.07-1.14) [ 65 ]. Numerous investigations have indicated that patients with AMI who also have diabetes frequently exhibit non-classical symptoms, such as the absence of persistent chest pain, sweating, and referred pain. A history of diabetes has been identified as an independent predictor of such atypical presentations. These results are consistent with previous studies [ 66 , 67 ].

Before coronary artery bypass graft (CABG) and before percutaneous coronary intervention (PCI)

CABG surgery effectively alleviates symptoms and improves patient outcomes. However, patients who undergo CABG typically exhibit advanced stages of coronary atherosclerosis, predisposing them to an increased risk of symptom recurrence and adverse events [ 68 , 69 ]. In contrast, PCI is a non-surgical method aimed at improving coronary blood flow at the site of obstruction through techniques such as balloon inflation, stent deployment, and/or atherectomy performed via a coronary catheter [ 70 ]. The anatomical complexity and blood supply of the coronary artery in patients with a history of CABG differ significantly from those without previous bypass surgery. This complexity complicates the identification of the culprit vessels during emergency angiography, and bypass grafts often complicate the scenario [ 71 ]. In a retrospective study by Liu et al., primary PCI procedures in 78 patients with AMI and previous CABG surgery showed a lower success rate and higher IHM compared to patients without previous bypass surgery [ 71 ]. The mortality rate within the hospital was found to be 4.6 times higher compared to the study counterparts during the equivalent period of time.

In another observational analysis by Blachutzik et al., findings indicated that of 121 patients with prior CABG had 13% IHM, adverse outcomes were related to advanced age and congestive heart failure [ 72 ]. Another investigation, the CAMI registry study that spans 2013-2014, found that 8% of Chinese patients admitted for AMI, including STEMI and NSTEMI with previous CABG and PCI, had a history of previous MI [ 73 ]. A study by Xie et al. demonstrated that CABG produced better results compared to PCI IHM (OR= 1.41, 95% CI 1.22-1.63, p< 0.001) [ 74 ]. The same research reported that the cumulative meta-analysis of all-cause mortality indicated significant differences between CABG and PCI at three years of follow-up, with the disparity becoming notable at five years of cardiac-specific mortality.

Cardiac troponin and creatine kinase-MB as biomarkers

High-sensitivity cardiac troponin T (hs-cTnT) and creatine kinase MB (CK-MB) are widely recognized biomarkers for the clinical diagnosis of AMI [ 75 ]. Measuring cardiac troponin T (cTn-T) in blood is fundamental for identifying MI. As cTnI and cTnT are present exclusively in cardiomyocytes and possess a distinctive cardiac-specific amino acid sequence, they have become the primary biomarkers for the detection of MI or other myocardial injuries [ 76 ]. The guideline-recommended approach to diagnosing MI involves measuring cardiac troponin I (cTnI) or cTnT in the blood [ 77 ]. The leading cause of MI is inadequate oxygen supply and acute ischemia of cardiac tissue [ 77 ]. However, these biomarkers have some limitations, which include sampling over time, poorly predicted long-term outcomes, and unstable angina [ 78 ].

The onset of acute ischemia initiates cardiomyocyte necrosis, which causes the breakdown of cell membranes and organelles, leading to the subsequent release of cellular proteins into the bloodstream. This process results in a significant elevation in cTn levels in the blood, typically peaks within 10-20 hours in patients who undergo reperfusion of blocked coronary arteries or 24-50 hours in those without reperfusion after the onset of acute ischemia [ 79 , 80 ]. Elevated troponin levels can persist for up to 10-14 days after MI, much longer than other markers of MI, such as creatine kinase-MB or myoglobin. It is hypothesized that this extended release of cTnI and cTnT from the tissue is due to the binding of the troponin complex to other elements of thin filaments within cardiomyocytes [ 79 , 80 ].

Numerous investigations have shown that these markers can predict immediate and long-term mortality in AMI and are related to the severity of coronary lesions and the size of the infarct [ 81 - 83 ]. As the estimated glomerular filtration rate (eGFR) decreases, the probability of cardiovascular death increases progressively, with approximately half of patients with advanced chronic kidney disease (CKD). In a study involving 5022 patients, 70.5% were diagnosed with STEMI, while 29.5% had NSTEMI [ 83 ]. The same research indicated that as eGFR decreased, high-sensitivity cardiac troponin T (hs-cTnT) and IHM increased. At the same time, creatine kinase-MB (CK-MB) did not show a proportional increase, leading to an elevated cTnT/CK-MB ratio. Chronic kidney disease (CKD), a critical prognostic factor in AMI, also affects troponin T levels [ 84 ]. A recent meta-analysis highlighted the high sensitivity of hs-cTnT in predicting mortality among patients with CKD, noting that each 10 ng/L increase in hs-cTnT is associated with a 14% increase in the risk of all-cause mortality [ 85 ]. The ratio of hs-cTnT to CK-MB also shows promise as a tool for risk stratification in people with AMI and CKD [ 83 ]. In an additional study by Sivarajah et al. involving 420 patients, the primary outcome of IHM was significantly higher in the group with elevated cTn levels (14.6% vs. 6.3%; p = 0.008) [ 86 ].

CK-MB demonstrates a clinical sensitivity of 90% for the diagnosis of AMI, but its relatively low specificity counterbalances this. It is detectable within 12 hours after the onset of AMI symptoms, reaches peak serum concentrations at 24 to 36 hours, and normalizes in 48 to 72 hours. Due to these release kinetics, total CK measurement is inadequate for the early diagnosis of AMI in six hours [ 87 ]. To improve the cardiac-specific diagnosis of AMI, measuring both total CK and CK-MB is suggested, the latter being the cardiac-specific isoenzyme of CK. A CK-MB to CK ratio greater than 6% indicates myocardial injury, while a ratio less than 6% suggests skeletal muscle damage or other non-cardiac causes [ 87 ]. Elevated levels of CK-MB in STEMI patients undergoing primary angioplasty are associated with higher mortality rates; however, the relationship between these values and short-term outcomes remains undetermined [ 88 ].

Research by Rakowski et al. indicated that the level of CK-MB measured 12 hours after PCI emerged as a more accurate predictor of infarct size at six months compared to levels measured 6, 18, 24, and 48 hours after PCI. This measurement was also more reliable than the CK-MB area under the curve and the peak CK-MB values [ 89 ]. Furthermore, CK-MB levels significantly correlate with IHM rates in patients with STEMI who underwent PCI [ 90 ]. According to research by Dohi et al., analysis of peak CK-MB levels may be an effective method to estimate the infarct size and predict left ventricular dysfunction. In particular, a peak level of CK-MB that exceeds 300 U/L can be expected to result in around 80% of patients having a large STEMI (infarct size ≥ 17%) following early reperfusion therapy [ 91 ].

Conclusions

Acute management of MI is a complex task that requires understanding and amalgamating numerous clinical factors to improve patient outcomes. In individuals with AMI, clinical variables such as age, sex, smoking status, BMI, comorbid conditions, history of CABG, and PCI, along with biomarkers, affect presentation, prognosis, and therapeutic approaches. Due to physiological changes associated with aging, gender, BMI, smoking, and an increased burden of comorbidities, these clinical factors play an important role in the outcomes of AMI. Patients with HTN, DM, and CKD find it more challenging to manage AMI and have a worse prognosis because they increase myocardial damage. Customized management strategies and comprehensive risk assessments are essential for patients with AMI to optimize outcomes and lower mortality rates.

Patients with DM and HTN are at risk of AMI because they have comorbidity conditions and require personalized treatment approaches. The history of previous CABG or PCI plays a crucial clinical role in AMI, where overall outcomes are affected. A personalized treatment plan and specialized medical attention are necessary to improve results and minimize hospital mortality. Managing AMI in individuals with a history of CABG or PCI requires close collaboration between cardiologists, cardiac surgeons, and multidisciplinary teams. Management of IM relies on biomarkers to diagnose, prognostic, and assess risk. The IHM of patients with AMI is reduced by using biomarker-based methods to quickly detect high-risk individuals. AMI risk prediction and personalized care can be advanced through ongoing research and enhancement of these clinical factors.

Disclosures

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design:   Khalid A. Alnemer

Acquisition, analysis, or interpretation of data:   Khalid A. Alnemer

Drafting of the manuscript:   Khalid A. Alnemer

Critical review of the manuscript for important intellectual content:   Khalid A. Alnemer

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• Volume 11, Issue Suppl 1
• 04130 Acute porphyrias as a prime example for (unrecognized) rare but treatable disease in the emergency department: a patient survey and systematized literature review
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• Sandra Pflock ,
• Hannah Carolina Mücke ,
• Rajan Somasundaram ,
• Eva Diehl-Wiesenecker
• Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Emergency Medicine and Porphyria Clinic, Berlin, Germany

Background Rare diseases (RD) like akute porphyrias (APs) present a particular challenge for emergency physicians (EP), as their acute symptoms are usually nonspecific and resemble common clinical presentations. This is compounded by low awareness and limited training of EP regarding RD, often leading to patients with RD being discharged without an accurate diagnosis. Consequently, despite the availability and necessity of targeted diagnostic and treatment options, RD patients may experience further complications and fatal outcomes. This study aimed to characterise patients with RD, such as APs, in the ED and to raise awareness of the problem of unrecognised rare but treatable diseases in the ED.

Methods The BEAWARE study conducted from July 2023 to June 2024 surveyed patients with RD throughout the German-speaking area, focusing on acute symptoms and presentations in the ED. A select group of RD, including AHP, was chosen to meet the following criteria: (a) causing acute symptoms, (b) diagnosable in the ED for adolescents or adults and (c) availability of therapeutic options. In addition, Embase and MEDLINE were searched up to November 2023 in a systematized literature review of articles on the clinical characteristics of patients with AHP in the ED.

Results A total of 147 RD patients (15 with APs) participated in the survey. Except for one patient, all AP patients (93.3%) reported that they did present to the ED prior to diagnosis. 8/14 of AP patients presented to the ED 1–2 times, 4/15 3–5 times, 1/15 11–20 times and 1/15 more than 20 times with symptoms of their later diagnosed AP.

Of 327 identified articles, 3 could be included that described the clinical presentation of 59 AP patients in the ED. The most common symptoms were abdominal pain (53/59) and neurological symptoms (confusion, paresis, numbness of the extremities, and seizures). The main reported trigger factors included menstrual cycle (28/36) and medication (8/49). Imaging typically yielded unremarkable results. Vital signs were within normal ranges for most patients and hyponatremia was observed in 32/46 patients. The patients‘ outcomes ranged from hospital release after two days to respiratory paralysis (in 3/59 patients) followed by three months of recovery and death in one patient due to a delay in diagnosis for a month.

Discussion and Conclusion Patients with APs frequently present to the ED prior to diagnosis and remain often undiagnosed for several visits. The sometimes serious and even fatal consequences emphasize the need for immediate diagnosis and treatment of APs in the ED.

Awareness and knowledge of rare diseases such as APs should be increased in the emergency department. So far, little is known in the literature about the presentation of AP patients in the emergency department. Perhaps AI-supported algorithms can support rapid diagnosis in the future.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjgast-2024-ICPP.80

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• Paternal exposure to antiseizure medications and offspring outcomes: a systematic review
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• http://orcid.org/0000-0002-6484-5972 Eliza Honybun 1 , 2 ,
• Genevieve Rayner 1 , 2 ,
• http://orcid.org/0000-0003-0534-3718 Charles B Malpas 1 , 3 ,
• Terence J O'Brien 3 , 4 , 5 ,
• Frank J Vajda 3 , 4 , 5 ,
• Piero Perucca 2 , 4 , 5 , 6 ,
• Emilio Perucca 2 , 4
• 1 Melbourne School of Psychological Sciences , The University of Melbourne , Melbourne , Victoria , Australia
• 2 Department of Medicine, Austin Health , The University of Melbourne , Melbourne , Victoria , Australia
• 3 Department of Medicine, Royal Melbourne Hospital , The University of Melbourne , Melbourne , Victoria , Australia
• 4 Department of Neuroscience, School of Translational Medicine , Monash University , Melbourne , Victoria , Australia
• 5 Departments of Neurology , Royal Melbourne Hospital , Melbourne , Victoria , Australia
• 6 Department of Neurology , Austin Health , Melbourne , Victoria , Australia
• Correspondence to Professor Piero Perucca; piero.perucca{at}unimelb.edu.au

Background Concerns have recently been raised about risks to the fetus resulting from paternal exposure to antiseizure medications (ASMs). To address these concerns, we conducted a systematic review of the literature to assess neurodevelopmental and anatomical outcomes in offspring born to fathers taking ASMs at the time of conception.

Methods Electronic searches of MEDLINE, PsycINFO, and Embase were conducted to identify human studies published in English that reported on outcomes, comprising neurodevelopmental disorders, major congenital malformations, small-for-gestational age or low birth weight, in offspring of fathers taking ASMs at conception. Quality analysis of included studies was undertaken using the Newcastle-Ottawa Scale. A narrative synthesis was used to report study findings.

Results Of 923 studies identified by the search and screened by title and abstract, 26 underwent full-text review and 10 met eligibility criteria. There was limited evidence available, but there appeared to be no clear evidence for an adverse impact of paternal ASM use on offspring outcomes. Few isolated adverse findings were not replicated by other investigations. Several methodological limitations prevented meta-analysis, including failure by most studies to report outcomes separately for each individual ASM, heterogeneity in measurement and outcome reporting, and small numbers of monotherapy exposures.

Conclusions Although there were limited data available, this systematic review provides reassuring evidence that paternal exposure to ASMs at conception is unlikely to pose any major risk of adverse outcomes for the offspring. Further research is needed to examine the relationship between preconception ASM use in males and offspring outcomes at birth and postnatally.

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/jnnp-2024-334077

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WHAT IS ALREADY KNOWN ON THIS TOPIC

While maternal use of some antiseizure medications carries an elevated risk of adverse outcomes for the developing fetus, it is unclear whether paternal exposure to these drugs also carries risks for the offspring.

WHAT THIS STUDY ADDS

Our systematic review shows that evidence for any risk to the offspring resulting from paternal exposure to antiseizure medications is scarce and inconsistent, with most studies showing no increased risk compared with unexposed controls. Therefore, the available evidence does not justify major concerns.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

The results of our study inform the counselling of males with epilepsy and highlight the need for more research in this area, focusing in particular on risks associated with individual medications.

Introduction

The teratogenic effects of antiseizure medications (ASMs) taken by mothers are well-documented. 1 In contrast, the outcomes of offspring of fathers taking ASMs have received substantially less attention. In recent years, however, preclinical studies have clearly demonstrated that epigenetic changes in the paternal germline induced by drugs or toxins can lead to anatomical teratogenicity and adverse neurodevelopmental effects in the offspring. 2 3 These findings raised important concerns and highlighted the need to determine their potential applicability to the clinical setting. 4

Adverse effects of ASMs on male fertility have been frequently documented. 5 Of note, many ASMs, including phenytoin, carbamazepine, benzodiazepines, valproate, gabapentin, topiramate, zonisamide, levetiracetam, pregabalin, and cannabidiol have been reported to cause testicular toxicity or to affect sperm quality in experimental animals. 6–14 Transgenerational effects have also been reported, including anatomical teratogenicity in the offspring of male mice treated with pregabalin, 13 behavioural abnormalities and impaired reproductive function across multiple generations after paternal exposure to cannabidiol in zebrafish, 15 behavioural abnormalities in the offspring of male mice treated with valproate, 16 17 and transgenerational transmission of autism-like phenotypes by the offspring of mice exposed to valproate during pregnancy. 18 Clinically, alterations in sperm count, morphology or motility have been associated with valproate, 19–21 carbamazepine, 20 oxcarbazepine, 20 and levetiracetam, 22 even though for some of these ASMs findings are inconsistent. 23 Because of its common association with anatomical and behavioural teratogenicity after maternal exposure, valproate has undergone particular scrutiny with respect to potential male reproductive toxicity. A 2023 report by the Medicines and Healthcare products Regulatory Agency (MHRA) 21 in the UK, highlighted that many studies support its testicular toxicity in preclinical models and its effects on human sperm quality, as well as the risk of impaired fertility in men exposed to the drug. A potential transgenerational transmission of anatomical and neurodevelopmental disorders resulting from prenatal exposure to valproate was suggested by a French survey, 24 but the results of this report cannot be meaningfully interpreted due to a high likelihood of reporting and ascertainment bias. Greater concerns, however, were raised by a recent register-based study commissioned by the European Medicines Agency (EMA), yet to be published in full following peer review, which apparently found a 50% increased risk of neurodevelopmental disorders in children born to men taking valproate compared with those born to men on lamotrigine or levetiracetam. 25 26 Notably, the EMA acknowledged that the study was hampered by methodological limitations and could not establish whether the adverse offspring outcomes were actually attributable to paternal valproate exposure. 25

Motivated by the aforementioned experimental data and the study commissioned by the EMA, we performed a systematic review of the literature in humans to examine the neurodevelopmental and anatomical outcomes in offspring of fathers taking ASMs around the time of conception.

Standard protocol approvals, registrations, and patient consents

The protocol for this review was developed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The review protocol was registered on PROSPERO on 20 November 2023 (registration number CRD42023481600).

Eligibility

This systematic review included articles that reported on the outcomes of children paternally exposed to ASMs, either as monotherapy or polytherapy, with no restrictions placed on the indication of usage. Exposure was defined as paternal use of ASMs at the time of, or in the months before, conception. Eligible study designs included the following: observational cohort studies, population-based datasets, register-based studies, and case-control studies. No restrictions were placed on the time of publication, but eligible studies were required to report original data and be in English language. We excluded animal studies, studies that only reported on child outcomes following maternal ASM exposure, duplicate publications reporting the same data, review articles, commentaries, letters to the Editor, studies where the number of exposed offspring was <10, and studies where the full text was not available.

Literature search and screening

The electronic search terms were developed in consultation with a tertiary librarian ( online supplemental file 1 ). Electronic searches of Medline, PsycINFO, Embase were conducted in November 2023, with additional hand searching of Google Scholar (related articles) and reference lists of included studies to identify articles not captured in primary searches. Electronic searches, utilising the same strategy and screening procedure, were updated in June 2024 to identify any additional eligible studies published since the original searches, resulting in the identification of one new eligible study. Two reviewers (EH and EP) independently screened titles and abstracts for eligibility, reviewed full-text articles for inclusion, extracted data and rated the quality of included studies in Covidence, with discrepancies resolved by a third reviewer (PP).

Supplemental material

Data synthesis and reporting.

Extracted data pertaining to study information and population characteristics included: study design, country, method of participant recruitment (eg, prospective pregnancy register, national population dataset), demographic and clinical characteristics of the father (age, exposure to other teratogens, education level and health status (if known)), number of exposed offspring and their demographic information (age, sex), and recruitment of comparison group (if applicable). The primary outcome was risk of adverse outcomes, including neurodevelopmental disorders (eg, autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD), intellectual disability (ID), developmental delay, or other developmental problems), major congenital malformations (MCMs), small-for-gestational age (SGA), and low birth weight in offspring of fathers treated with ASMs. Extracted outcomes were expressed as odds, hazard, or risk ratios, with associated 95% confidence interval (95% CI).

The quality analysis of included studies was assessed independently by two reviewers (EH and EP) using the Newcastle Ottawa Scale (NOS), a risk of bias tool recommended for evaluating non-randomised studies. 27 Studies received a maximum of 8 points across three domains: selection of study groups (3 points); comparability of study groups (2 points); and ascertainment of exposure and outcomes (3 points).

Due to the small number of eligible studies and heterogeneity of outcomes data, a meta-analysis could not be performed. Extracted data was synthesised into a narrative review reporting the risk of adverse outcomes. Findings were provided separately by ASM type, where applicable, with the strength of evidence commented on within each section.

Access to the study data will be considered on reasonable request to the corresponding author.

Search results

A total of 1298 titles were identified through electronic and manual searches. After removal of duplicates, 923 articles underwent title and abstract screening ( figure 1 ). Of these, 26 underwent full-text review for assessment of eligibility, yielding 10 studies which were included in the final review. Of the included studies, there were six population-based cohort studies, three prospective cohort studies, and one cross-sectional study. Further details on the studies included in the final review are presented in table 1 .

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PRISMA flowchart of study selection. ASM, antiseizure medication.

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Study characteristics of the included articles

Quality analysis

The quality of the included studies was variable ( table 2 ). One study did not have an unexposed cohort to which outcome data could be compared, 28 which resulted in lower quality assessment ratings. In one study, it was unclear how paternal ASM exposure status was ascertained; the cohort was labelled as ‘offspring of men with epilepsy’, and it was assumed via the outcome data that all men were ASM-treated but the study methodology lacked sufficient description. 29 Only one study controlled for ASM dose (>750 mg/d vs ≤750 mg/d valproate), 30 and only three studies reported findings separately for each ASM as opposed to a class, 31 32 although some studies controlled for relevant confounding variables in outcome analyses, including paternal or maternal age, past history of psychiatric disorders, and exposure to other teratogens. The quality analysis ratings for the outcome assessment category ratings were the most variable; population-based studies recorded outcomes through secure record linkage to databases which are subject to variable diagnostic accuracy and lack information on important variables, whereas other studies relied on self-reporting, which is subject to recall bias, or did not adequately describe how outcome data were collected.

Quality analysis of studies included in the review

Neurodevelopmental outcomes

Neurodevelopmental outcomes of offspring paternally exposed to ASMs are summarised in table 3 and online supplemental table 1.

Neurodevelopmental outcomes of offspring paternally exposed to ASMs at time of conception

Neurodevelopmental disorders as a composite outcome

A retrospective nationwide population-based study from Denmark found no significant increase in overall risk of neurodevelopmental disorders (composite outcome, comprising ID, ASD, ADHD, and disorders of psychological development) in the offspring of fathers exposed to valproate (n=1336) compared with offspring of valproate-unexposed fathers (n=1,234,017), adjusting for potential confounders. 30 Similar results were obtained when undertaking a series of additional analyses, such as restricting the analysis to offspring of fathers exposed to high-dose valproate (>750 mg/d) or lower doses of valproate, or when excluding disorders of psychological development ( table 3 ).

Autism spectrum disorder (ASD)

One prospective cohort study found a significantly increased risk of autistic traits among 18-month-old offspring of fathers who took ASMs within 6 months of conception (n=147) compared with unexposed controls (n=60 583). 33 However, there was no significant increase in proportion of offspring meeting the cut-off for ASD on another screening instrument at the same time point, and the increased risk of autistic traits was no longer identified at age 36 months in a smaller cohort (n=110). Three population-based studies found no significantly increased risk of ASD diagnosis compared with unexposed controls among offspring exposed to any ASM (n=2087), 31 benzodiazepines (n=64 570), 34 valproate (any exposure n=1336, >750 mg/d n=715, ≤750 mg/d=721, monotherapy n=1017), 30 valproate monotherapy (n=458), 31 carbamazepine monotherapy (n=582), 31 or other ASM monotherapies (n=605). 31

Attention deficit/hyperactivity disorder (ADHD)

There was no increased risk of ADHD traits among 36-month-old offspring paternally exposed to ASMs (n=110) compared with unexposed controls (n=43 571) in a prospective cohort study. 33 Population-based studies found no increased risk of ADHD diagnosis compared with unexposed controls following paternal exposures to any ASM (n=2087), 31 benzodiazepines (n=64 570), 34 valproate monotherapy (n=458), 31 carbamazepine monotherapy (n=582), 31 or other ASM monotherapies (n=605). 31

Intellectual disability (ID)

Intelligence quotient (IQ) at age 4 years was within normal limits among offspring of fathers with epilepsy treated with ASMs at the time of conception (n=396). 29 One population-based study found no increased risk of ID diagnosis compared with unexposed controls for offspring paternally exposed to any ASM (n=2087), valproate monotherapy (n=458), carbamazepine monotherapy (n=582), or other ASM monotherapies (n=605). 31

Other neurodevelopmental outcomes

In a cohort of ASM-exposed offspring that also had elevated autistic traits, these children (n=147) were significantly more likely to score outside the normal range on a measure of personal-social skills compared with unexposed controls born to fathers without epilepsy (n=60 583). 33 Gross motor skills, fine motor skills, communication skills, aggressive symptoms, and difficult temperament were all within normal limits for ASM-exposed offspring at 18 months (n=177) and at 36 months (n=110) compared with unexposed controls (n=60 583) 33 35 ( online supplemental table 1 ).

Major congenital malformations (MCMs)

A full description of findings on the risk of MCMs following paternal ASM exposure is reported in table 4 . Among cross-sectional and prospective cohort studies, there was no elevation in the rate of MCMs among offspring paternally exposed to ASMs (n=396) compared with maternal ASM exposures (n=305), or unexposed offspring (n=49 590) 29 ; no MCMs reported among 22 ASM-exposed offspring 28 ; and no significant increase in MCMs among 241 ASM-exposed offspring compared with unexposed controls (n=106 899). 33 In population-based studies, no increased risk of MCMs was found among offspring of fathers exposed to diazepam (n=1354), 36 benzodiazepine-derived anxiolytics (n=3047) or benzodiazepines as hypnotics/sedatives (n=736), 37 any ASM (n=2087, 31 valproate (monotherapy n=458 31  any exposure n=805 32 , any exposure n=1,336 30 , >750 mg/d n=715 30 , ≤750 mg/d n=621) 30 , carbamazepine (monotherapy n=582 31 , any exposure n=687) 32 , or other ASM monotherapies (n=605) 31 compared with unexposed offspring.

Anatomical outcomes in offspring paternally exposed to ASMs at time of conception

One study found a mildly increased risk of congenital anomalies in offspring exposed to any ASM, as well as lamotrigine (n=612) and oxcarbazepine (n=587). 32 However, the study did not distinguish between minor and major anomalies, and did not report the type of ASM treatment (monotherapy or polytherapy) or doses used. Moreover, based on additional comparisons, the authors concluded the difference may be attributable to the underlying indication rather than ASM exposure.

Small-for-gestational age (SGA)/birth weight

Data on SGA or birth weight in relationship to paternal ASM exposure are provided in table 4 . There was no significant increase in the number of infants born SGA in one prospective cohort study of ASM-exposed offspring (n=241) when compared with unexposed offspring (n=106 899). 33 One population-based study of diazepam-exposed infants (n=1354) found an increase in the rates of SGA compared with unexposed offspring (n=3 36 893); however, the authors noted that the finding may be confounded by maternal age and smoking status. 36

One cross-sectional study reported normal birth weight for infants paternally exposed to ASMs (n=22), 28 and a prospective cohort study found no increase in the number of ASM-exposed infants (n=241) with low birth weight compared with unexposed controls (n=106 899). 33

Other outcomes

One prospective cohort study found no increase in the rates of low APGAR scores or pre-term births among infants exposed to ASMs (n=241) compared with unexposed offspring (n=1 06 899) 33 ( online supplemental table 1 ). A population-based study of offspring paternally exposed to diazepam (n=1354) found more than a two-fold increased risk of perinatal mortality compared with unexposed offspring (n=3 36 893); however, the study failed to control for maternal age and smoking status, and maternal diazepam exposure. 36 The same study found no increased risk of spontaneous abortion, pre-term birth, Down’s syndrome, or other chromosomal abnormalities for offspring paternally exposed to diazepam, compared with unexposed offspring. 36 In a small cohort study, infants paternally exposed to ASMs (n=22) were reported to have normal birth length. 28

This systematic review is timely in view of the 2024 public release by the EMA 25 and the MHRA 38 of the main results of a meta-analysis of data from a retrospective observational study on birth outcomes in children born to men taking valproate, lamotrigine or levetiracetam at about the time of conception. The study, based on data from multiple registry databases in Denmark, Sweden, and Norway, is yet to be published after peer review and therefore could not be included in our analysis. However, an extended abstract has been made available recently on the EMA website. 26 The findings of the study indicated that paternal exposure to valproate in the 3 months before conception was associated in the offspring with a pooled adjusted HR of 1.50 (95% CI: 1.09 to 2.07) for neurodevelopmental disorders (a composite outcome comprising intellectual disabilities, ASD and ADHD) compared with exposure to lamotrigine or levetiracetam. The adjusted cumulative risk of neurodevelopmental disorders was estimated to be ‘around 5%’ in the valproate-exposed cohort compared with ‘around 3%’ in the lamotrigine- and levetiracetam-exposed cohorts. 25 No difference between exposure groups was found for congenital malformations in a pooled analysis across Denmark and Norway (crude pooled OR=0.81, 95% CI: 0.48 to 1.36). 26 Overall, the study had several major methodological limitations, largely related to inability to account for potential major confounders. In particular, the analysis could not control for the paternal condition for which the treatments were prescribed, even though epilepsy was more common in the valproate cohort (57–70%, depending on country) than in the combined levetiracetam/lamotrigine cohort (41–59%). Likewise, the study did not control for the type of epilepsy, which probably differed across exposure groups and may have influenced neurodevelopmental risks. There was also considerable heterogeneity in datasets and outcomes across countries, and across treatment groups. Importantly, duration of follow-up of exposed offspring differed across ASM groups, being longer for valproate. In Sweden and Denmark, the proportion of offspring followed up for >8 years was almost twice as large in the valproate group compared with the lamotrigine/levetiracetam group (Sweden: 41.8% vs 23.3%; Denmark: 74.3% vs 40.2%). Since the probability of identifying a neurodevelopmental disorder, including ASD, is age-dependent and is likely to be highest when children start school, this may have biased the risk estimate against the valproate-exposed group. The EMA’s public release and the study abstract do acknowledge the study limitations, including the inability to identify the type(s) of neurodevelopmental disorders at putatively increased risk, and emphasise that because of potential confounders a cause-effect relationship with paternal valproate exposure could not be established.

Our systematic review did not find clear evidence of an increased risk of adverse outcomes among offspring paternally exposed to ASMs. While there were some isolated unfavourable findings, these were not confirmed by other studies. Specifically, an increased prevalence of autistic traits reported at age 18 months in ASM-exposed offspring was not confirmed using a more robust assessment tool at the same age, or replicated by another ASD screening tool in the same cohort at age 36 months, 33 or confirmed by other population-based studies. 30 31 34 Other signals included a report of abnormal personal-social skills at age 18 months in the same cohort of ASM-exposed offspring with autistic traits, 33 an increased risk of SGA following paternal exposure to diazepam that was likely confounded by maternal factors, 36 and an increased risk of birth defects reported in a study that was hampered by combining minor and major malformations 32 and was not replicated by other investigations. 28–33 36 37 While nothing especially alarming emerges from this review, only a few studies were included and some of these had a relatively small sample size and therefore low power to detect treatment effects. Moreover, many studies combined ASM exposures together, precluding detailed analysis of outcomes associated with individual ASMs. Of note, risks associated with paternal valproate exposure were investigated by only three studies with respect to risk of congenital malformations, 30 , 31 32 and by only two studies with respect to risk of neurodevelopmental disorders. 30 31 Of note, the latest population-based study from Denmark, published after the release of the MHRA restrictions, focused specifically on neurodevelopmental disorders after paternal valproate exposure compared with unexposed controls, and found no significant increase in risk, with the upper limit of the 95% CI of the adjusted HR being below the risk estimate of the EMA-commissioned study. 30

There were several methodological weaknesses identified by our review. In addition to failure by most studies to provide data on risks associated with specific ASMs, only one study 30 assessed the influence of paternal ASM dose, which is known to affect the risk of MCMs and adverse neurodevelopmental outcomes in offspring of ASM-treated mothers. 39 40 Moreover, many studies neglected to control for confounders, such as age, educational attainment, exposure to other teratogens, relevant medical and psychiatric history, and other factors. There was heterogeneity in the length of follow-up for some studies, particularly those aimed at investigating neurodevelopmental outcomes, with some conducted during infancy 35 or early childhood 29 33 and others extending follow-up into adolescence. 31 34 Furthermore, there was heterogeneity in how neurodevelopmental disorders were measured and defined, with some studies investigating the presence of specific traits, 33 35 and others quantifying the risk of diagnosis of neurodevelopmental disorders at a population level. 30 31 34 For studies aimed at investigating the risk of MCMs, there was variability in how congenital anomalies were measured, with some applying stringent classification systems (eg, the European Surveillance of Congenital Anomalies (EUROCAT), and the International Classification of Diseases (ICD)-10) for the definition of MCMs, 30–32 41 whereas another measured the presence of any defect with no distinction made between major or minor anomalies. 32 This variability in the definition and measurement of both MCMs and neurodevelopmental outcomes hindered data synthesis and prevented meta-analysis for this review.

Evaluating second generation adverse effects of medications is methodologically challenging because these effects can only be investigated in observational studies. These studies are subject to bias from unmeasured potential confounding variables, and therefore an understanding of risks requires a clear signal across multiple investigations, which is precisely what is lacking based on the evidence reviewed. To date, the only signal of concern was raised by the EMA-commissioned study which, as discussed above, could be affected by major confounders. The European regulator acknowledged that available data are inconclusive in establishing cause-effect relationships, but recommended that doctors should inform males taking valproate about the potential risks, discuss the possibility of effective contraception, and review regularly the need for valproate therapy particularly for individuals planning fatherhood. 25 The MHRA took a more restrictive approach, apparently influenced by preclinical data on valproate reproductive toxicity and potential association with reduced fertility, and determined that, as from 31 January 2024 ‘valproate must not be started in new patients (male or female) younger than 55 years unless two specialists independently consider and document that there is no other effective or tolerated treatment, or there are compelling reasons why the reproductive risks do not apply’. 38 The wisdom of the UK regulatory changes has been questioned 42 because restricting the use of valproate could result in prescription of a less effective medication, particularly in individuals with generalised epilepsies where valproate is the most effective ASM. 43 Avoidance of valproate or its delayed introduction in individuals that require this medication for seizure control is likely to lead to an increased risk of morbidity and mortality, including an increased risk of sudden unexpected death in epilepsy (SUDEP). A significant increase in maternal SUDEP has already been shown in the UK during a period in which the stricter guidelines for prescribing valproate in females were introduced. 44 There is also a risk of generating anxiety among valproate-treated men with epilepsy, ultimately leading to poor medication adherence and breakthrough seizures. In view of the findings of this systematic review, particularly the reassuring results from the recent large population-based study from Denmark, 30 the MHRA restrictions regarding the use of valproate in men should be reappraised and potentially revised.

While the findings summarised in our systematic review are overall reassuring for males taking ASMs including valproate, it is clear that the potential reproductive implications of ASM exposure in males remain an under-investigated area of research that should be prioritised over the next decade. Future research should aim at replicating the methodology of maternal ASM studies and employ detailed clinical evaluations of offspring paternally exposed to different ASM monotherapies through implementation of large prospective investigations. Some of these studies could use the infrastructure already established for prospective pregnancy registries of women taking ASMs and begin to enrol males on ASMs to assemble a well-characterised cohort of offspring outcome data.

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Supplementary data.

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• Data supplement 1

PP and EP are joint senior authors.

Contributors EH, PP and EP conceived and designed the systematic review. EH, GR, CBM, PP, FV, TOB and EP contributed to the conception and development of the study protocol. EH drafted the protocol and registered it on PROSPERO. EH, EP, and PP contributed to the data acquisition, analysis, and interpretation. EH is the first author and guarantor, PP is the corresponding author of the review. All authors reviewed, edited, and approved the final manuscript.

Funding EH is supported by an Australian Government Research Training Program (RTP) Scholarship. PP is supported by an Emerging Leadership Investigator Grant from the Australian National Health and Medical Research Council (APP2017651), the University of Melbourne, Monash University, the Austin Medical Research Foundation, and the Norman Beischer Medical Research Foundation.

Competing interests CBM has received conference travel support and/or speaker fees from Merck, Novartis, and Biogen. He has received research support from the National Health and Medical Research Council, Multiple Sclerosis Research Australia, the University of Melbourne, the Royal Melbourne Hospital Neuroscience Foundation, and Dementia Australia. TOB has received research support from the Epilepsy Society of Australia, National Health and Medical Research Council, Royal Melbourne Hospital Neuroscience Foundation, Sanofi-Aventis, UCB Pharma, Janssen-Cilag, Novartis, and Sci-Gen. EP received speaker’s or consultancy fees from Eisai, GRIN Therapeutics, Shackelford Pharma, Sintetica, SKL Life Science, Sun Pharma, Takeda, UCB Pharma and Xenon Pharma and royalties from Wiley, Elsevier, and Wolters Kluwers. He is also on the board of EURAP-International Registry of Antiepileptic Drugs and Pregnancy, a non-profit organization which received financial support from Accord, Angelini, Bial, EcuPharma, Eisai, Glenmark, GW Pharma, GlaxoSmithKline, Sanofi, SF Group, Teva, UCB, and Zentiva. PP has received speaker honoraria or consultancy fees to his institution from Chiesi, Eisai, LivaNova, Novartis, Sun Pharma, Supernus, and UCB Pharma, outside of the submitted work. He is an Associate Editor for Epilepsia Open. He is also on the board of EURAP-International Registry of Antiepileptic Drugs and Pregnancy, a non-profit organization which received financial support from Accord, Angelini, Bial, EcuPharma, Eisai, Glenmark, GW Pharma, GlaxoSmithKline, Sanofi, SF Group, Teva, UCB, and Zentiva. GR has received speaker honoraria from Liva Nova. FV has received research support for the Australian Pregnancy Register from the Epilepsy Society of Australia, National Health and Medical Research Council, Royal Melbourne Hospital Neuroscience Foundation, Epilepsy Action Australia, Sanofi-Aventis, UCB Pharma, Janssen-Cilag, Novartis, and Sci-Gen. He is also on the board of EURAP-International Registry of Antiepileptic Drugs and Pregnancy, a non-profit organization which received financial support from Accord, Angelini, Bial, EcuPharma, Eisai, Glenmark, GW Pharma, GlaxoSmithKline, Sanofi, SF Group, Teva, UCB, and Zentiva. EH does not have any conflicts of interest to disclose.

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Linked Articles

• Editorial commentary Paternal exposure to antiseizure medications and offspring outcomes Torbjörn Tomson Journal of Neurology, Neurosurgery & Psychiatry 2024; - Published Online First: 19 Sep 2024. doi: 10.1136/jnnp-2024-334474

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