importance of reviewing the literature in research

Why is it important to do a literature review in research?

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 “A substantive, thorough, sophisticated literature review is a precondition for doing substantive, thorough, sophisticated research”. Boote and Baile 2005

Authors of manuscripts treat writing a literature review as a routine work or a mere formality. But a seasoned one knows the purpose and importance of a well-written literature review.  Since it is one of the basic needs for researches at any level, they have to be done vigilantly. Only then the reader will know that the basics of research have not been neglected.

The aim of any literature review is to summarize and synthesize the arguments and ideas of existing knowledge in a particular field without adding any new contributions.   Being built on existing knowledge they help the researcher to even turn the wheels of the topic of research.  It is possible only with profound knowledge of what is wrong in the existing findings in detail to overpower them.  For other researches, the literature review gives the direction to be headed for its success. 

The common perception of literature review and reality:

As per the common belief, literature reviews are only a summary of the sources related to the research. And many authors of scientific manuscripts believe that they are only surveys of what are the researches are done on the chosen topic.  But on the contrary, it uses published information from pertinent and relevant sources like

• Scholarly books
• Scientific papers
• Latest studies in the field
• Established school of thoughts
• Relevant articles from renowned scientific journals

and many more for a field of study or theory or a particular problem to do the following:

• Summarize into a brief account of all information
• Synthesize the information by restructuring and reorganizing
• Critical evaluation of a concept or a school of thought or ideas
• Familiarize the authors to the extent of knowledge in the particular field
• Encapsulate
• Compare & contrast

By doing the above on the relevant information, it provides the reader of the scientific manuscript with the following for a better understanding of it:

• It establishes the authors’  in-depth understanding and knowledge of their field subject
• It gives the background of the research
• Portrays the scientific manuscript plan of examining the research result
• Illuminates on how the knowledge has changed within the field
• Highlights what has already been done in a particular field
• Information of the generally accepted facts, emerging and current state of the topic of research
• Identifies the research gap that is still unexplored or under-researched fields
• Demonstrates how the research fits within a larger field of study
• Provides an overview of the sources explored during the research of a particular topic

Importance of literature review in research:

The importance of literature review in scientific manuscripts can be condensed into an analytical feature to enable the multifold reach of its significance.  It adds value to the legitimacy of the research in many ways:

• Provides the interpretation of existing literature in light of updated developments in the field to help in establishing the consistency in knowledge and relevancy of existing materials
• It helps in calculating the impact of the latest information in the field by mapping their progress of knowledge.
• It brings out the dialects of contradictions between various thoughts within the field to establish facts
• The research gaps scrutinized initially are further explored to establish the latest facts of theories to add value to the field
• Indicates the current research place in the schema of a particular field
• Provides information for relevancy and coherency to check the research
• Apart from elucidating the continuance of knowledge, it also points out areas that require further investigation and thus aid as a starting point of any future research
• Justifies the research and sets up the research question
• Sets up a theoretical framework comprising the concepts and theories of the research upon which its success can be judged
• Helps to adopt a more appropriate methodology for the research by examining the strengths and weaknesses of existing research in the same field
• Increases the significance of the results by comparing it with the existing literature
• Provides a point of reference by writing the findings in the scientific manuscript
• Helps to get the due credit from the audience for having done the fact-finding and fact-checking mission in the scientific manuscripts
• The more the reference of relevant sources of it could increase more of its trustworthiness with the readers
• Helps to prevent plagiarism by tailoring and uniquely tweaking the scientific manuscript not to repeat other’s original idea
• By preventing plagiarism , it saves the scientific manuscript from rejection and thus also saves a lot of time and money
• Helps to evaluate, condense and synthesize gist in the author’s own words to sharpen the research focus
• Helps to compare and contrast to  show the originality and uniqueness of the research than that of the existing other researches
• Rationalizes the need for conducting the particular research in a specified field
• Helps to collect data accurately for allowing any new methodology of research than the existing ones
• Enables the readers of the manuscript to answer the following questions of its readers for its better chances for publication
• What do the researchers know?
• What do they not know?
• Is the scientific manuscript reliable and trustworthy?
• What are the knowledge gaps of the researcher?

22. It helps the readers to identify the following for further reading of the scientific manuscript:

• What has been already established, discredited and accepted in the particular field of research
• Areas of controversy and conflicts among different schools of thought
• Unsolved problems and issues in the connected field of research
• The emerging trends and approaches
• How the research extends, builds upon and leaves behind from the previous research

A profound literature review with many relevant sources of reference will enhance the chances of the scientific manuscript publication in renowned and reputed scientific journals .

References:

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A Guide to Literature Reviews

Importance of a good literature review.

• Conducting the Literature Review
• Structure and Writing Style
• Types of Literature Reviews
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• Acknowledgements

A literature review is not only a summary of key sources, but  has an organizational pattern which combines both summary and synthesis, often within specific conceptual categories . A summary is a recap of the important information of the source, but a synthesis is a re-organization, or a reshuffling, of that information in a way that informs how you are planning to investigate a research problem. The analytical features of a literature review might:

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

The purpose of a literature review is to:

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Literature Reviews

• What is a literature review?
• Steps in the Literature Review Process
• Define your research question
• Determine inclusion and exclusion criteria
• Choose databases and search
• Review Results
• Synthesize Results
• Analyze Results
• Librarian Support

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.

Meryl Brodsky : Communication and Information Studies

Hannah Chapman Tripp : Biology, Neuroscience

Carolyn Cunningham : Human Development & Family Sciences, Psychology, Sociology

Larayne Dallas : Engineering

Janelle Hedstrom : Special Education, Curriculum & Instruction, Ed Leadership & Policy ​

Susan Macicak : Linguistics

Imelda Vetter : Dell Medical School

For help in other subject areas, please see the guide to library specialists by subject .

Periodically, UT Libraries runs a workshop covering the basics and library support for literature reviews. While we try to offer these once per academic year, we find providing the recording to be helpful to community members who have missed the session. Following is the most recent recording of the workshop, Conducting a Literature Review. To view the recording, a UT login is required.

• October 26, 2022 recording
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Literature reviews, what is a literature review, learning more about how to do a literature review.

• Planning the Review
• The Research Question
• Choosing Where to Search
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• Writing the Review

A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

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Conducting a literature review: why do a literature review, why do a literature review.

• How To Find "The Literature"
• Found it -- Now What?

Besides the obvious reason for students -- because it is assigned! -- a literature review helps you explore the research that has come before you, to see how your research question has (or has not) already been addressed.

You identify:

• core research in the field
• experts in the subject area
• methodology you may want to use (or avoid)
• gaps in knowledge -- or where your research would fit in

It Also Helps You:

• Publish and share your findings
• Justify requests for grants and other funding
• Identify best practices to inform practice
• Set wider context for a program evaluation
• Compile information to support community organizing

Great brief overview, from NCSU

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• Steps in Conducting a Literature Review

What is a literature review?

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

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

Why is it important?

A literature review is important because it:

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

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

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

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

2. Decide on the scope of your review

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

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

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

Make a list of the databases you will search. 

Where to find databases:

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

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

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

Review the literature

Some questions to help you analyze the research:

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

Tips: 

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

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Literature Review

• What is a Literature Review?
• What is NOT a Literature Review?
• Purposes of a Literature Review
• Types of Literature Reviews
• Literature Reviews vs. Systematic Reviews
• Systematic vs. Meta-Analysis

Literature Review  is a comprehensive survey of the works published in a particular field of study or line of research, usually over a specific period of time, in the form of an in-depth, critical bibliographic essay or annotated list in which attention is drawn to the most significant works.

Also, we can define a literature review as the collected body of scholarly works related to a topic:

• Summarizes and analyzes previous research relevant to a topic
• Includes scholarly books and articles published in academic journals
• Can be an specific scholarly paper or a section in a research paper

The objective of a Literature Review is to find previous published scholarly works relevant to an specific topic

• Help gather ideas or information
• Keep up to date in current trends and findings
• Help develop new questions

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.
• Helps focus your own research questions or problems
• Discovers relationships between research studies/ideas.
• Suggests unexplored ideas or populations
• Identifies major themes, concepts, and researchers on a topic.
• Tests assumptions; may help counter preconceived ideas and remove unconscious bias.
• Identifies critical gaps, points of disagreement, or potentially flawed methodology or theoretical approaches.
• Indicates potential directions for future research.

All content in this section is from Literature Review Research from Old Dominion University 

Keep in mind the following, a literature review is NOT:

Not an essay 

Not an annotated bibliography  in which you summarize each article that you have reviewed.  A literature review goes beyond basic summarizing to focus on the critical analysis of the reviewed works and their relationship to your research question.

Not a research paper   where you select resources to support one side of an issue versus another.  A lit review should explain and consider all sides of an argument in order to avoid bias, and areas of agreement and disagreement should be highlighted.

A literature review serves several purposes. For example, it

• provides thorough knowledge of previous studies; introduces seminal works.
• helps focus one’s own research topic.
• identifies a conceptual framework for one’s own research questions or problems; indicates potential directions for future research.
• suggests previously unused or underused methodologies, designs, quantitative and qualitative strategies.
• identifies gaps in previous studies; identifies flawed methodologies and/or theoretical approaches; avoids replication of mistakes.
• helps the researcher avoid repetition of earlier research.
• suggests unexplored populations.
• determines whether past studies agree or disagree; identifies controversy in the literature.
• tests assumptions; may help counter preconceived ideas and remove unconscious bias.

As Kennedy (2007) notes*, it is important to think of knowledge in a given field as consisting of three layers. First, there are the primary studies that researchers conduct and publish. Second are the reviews of those studies that summarize and offer new interpretations built from and often extending beyond the original studies. Third, there are the perceptions, conclusions, opinion, and interpretations that are shared informally that become part of the lore of field. In composing a literature review, it is important to note that it is often this third layer of knowledge that is cited as "true" even though it often has only a loose relationship to the primary studies and secondary literature reviews.

Given this, while literature reviews are designed to provide an overview and synthesis of pertinent sources you have explored, there are several approaches to how they can be done, depending upon the type of analysis underpinning your study. Listed below are definitions of types of literature reviews:

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

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

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

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

Systematic Review      This form consists of an overview of existing evidence pertinent to a clearly formulated research question, which uses pre-specified and standardized methods to identify and critically appraise relevant research, and to collect, report, and analyse data from the studies that are included in the review. Typically it focuses on a very specific empirical question, often posed in a cause-and-effect form, such as "To what extent does A contribute to B?"

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

* Kennedy, Mary M. "Defining a Literature."  Educational Researcher  36 (April 2007): 139-147.

All content in this section is from The Literature Review created by Dr. Robert Larabee USC

Robinson, P. and Lowe, J. (2015),  Literature reviews vs systematic reviews.  Australian and New Zealand Journal of Public Health, 39: 103-103. doi: 10.1111/1753-6405.12393

What's in the name? The difference between a Systematic Review and a Literature Review, and why it matters . By Lynn Kysh from University of Southern California

Systematic review or meta-analysis?

A  systematic review  answers a defined research question by collecting and summarizing all empirical evidence that fits pre-specified eligibility criteria.

A  meta-analysis  is the use of statistical methods to summarize the results of these studies.

Systematic reviews, just like other research articles, can be of varying quality. They are a significant piece of work (the Centre for Reviews and Dissemination at York estimates that a team will take 9-24 months), and to be useful to other researchers and practitioners they should have:

• clearly stated objectives with pre-defined eligibility criteria for studies
• explicit, reproducible methodology
• a systematic search that attempts to identify all studies
• assessment of the validity of the findings of the included studies (e.g. risk of bias)
• systematic presentation, and synthesis, of the characteristics and findings of the included studies

Not all systematic reviews contain meta-analysis. 

Meta-analysis is the use of statistical methods to summarize the results of independent studies. By combining information from all relevant studies, meta-analysis can provide more precise estimates of the effects of health care than those derived from the individual studies included within a review.  More information on meta-analyses can be found in  Cochrane Handbook, Chapter 9 .

A meta-analysis goes beyond critique and integration and conducts secondary statistical analysis on the outcomes of similar studies.  It is a systematic review that uses quantitative methods to synthesize and summarize the results.

An advantage of a meta-analysis is the ability to be completely objective in evaluating research findings.  Not all topics, however, have sufficient research evidence to allow a meta-analysis to be conducted.  In that case, an integrative review is an appropriate strategy. 

Some of the content in this section is from Systematic reviews and meta-analyses: step by step guide created by Kate McAllister.

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What is the Purpose of a Literature Review?

4-minute read

• 23rd October 2023

If you’re writing a research paper or dissertation , then you’ll most likely need to include a comprehensive literature review . In this post, we’ll review the purpose of literature reviews, why they are so significant, and the specific elements to include in one. Literature reviews can:

1. Provide a foundation for current research.

2. Define key concepts and theories.

3. Demonstrate critical evaluation.

4. Show how research and methodologies have evolved.

5. Identify gaps in existing research.

6. Support your argument.

Keep reading to enter the exciting world of literature reviews!

What is a Literature Review?

A literature review is a critical summary and evaluation of the existing research (e.g., academic journal articles and books) on a specific topic. It is typically included as a separate section or chapter of a research paper or dissertation, serving as a contextual framework for a study. Literature reviews can vary in length depending on the subject and nature of the study, with most being about equal length to other sections or chapters included in the paper. Essentially, the literature review highlights previous studies in the context of your research and summarizes your insights in a structured, organized format. Next, let’s look at the overall purpose of a literature review.

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Literature reviews are considered an integral part of research across most academic subjects and fields. The primary purpose of a literature review in your study is to:

Provide a Foundation for Current Research

Since the literature review provides a comprehensive evaluation of the existing research, it serves as a solid foundation for your current study. It’s a way to contextualize your work and show how your research fits into the broader landscape of your specific area of study.  

Define Key Concepts and Theories

The literature review highlights the central theories and concepts that have arisen from previous research on your chosen topic. It gives your readers a more thorough understanding of the background of your study and why your research is particularly significant .

Demonstrate Critical Evaluation 

A comprehensive literature review shows your ability to critically analyze and evaluate a broad range of source material. And since you’re considering and acknowledging the contribution of key scholars alongside your own, it establishes your own credibility and knowledge.

Show How Research and Methodologies Have Evolved

Another purpose of literature reviews is to provide a historical perspective and demonstrate how research and methodologies have changed over time, especially as data collection methods and technology have advanced. And studying past methodologies allows you, as the researcher, to understand what did and did not work and apply that knowledge to your own research.  

Identify Gaps in Existing Research

Besides discussing current research and methodologies, the literature review should also address areas that are lacking in the existing literature. This helps further demonstrate the relevance of your own research by explaining why your study is necessary to fill the gaps.

Support Your Argument

A good literature review should provide evidence that supports your research questions and hypothesis. For example, your study may show that your research supports existing theories or builds on them in some way. Referencing previous related studies shows your work is grounded in established research and will ultimately be a contribution to the field.  

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Conducting a Literature Review

Benefits of conducting a literature review.

• Steps in Conducting a Literature Review
• Summary of the Process
• Additional Resources
• Literature Review Tutorial by American University Library
• The Literature Review: A Few Tips On Conducting It by University of Toronto
• Write a Literature Review by UC Santa Cruz University Library

While there might be many reasons for conducting a literature review, following are four key outcomes of doing the review.

Assessment of the current state of research on a topic . This is probably the most obvious value of the literature review. Once a researcher has determined an area to work with for a research project, a search of relevant information sources will help determine what is already known about the topic and how extensively the topic has already been researched.

Identification of the experts on a particular topic . One of the additional benefits derived from doing the literature review is that it will quickly reveal which researchers have written the most on a particular topic and are, therefore, probably the experts on the topic. Someone who has written twenty articles on a topic or on related topics is more than likely more knowledgeable than someone who has written a single article. This same writer will likely turn up as a reference in most of the other articles written on the same topic. From the number of articles written by the author and the number of times the writer has been cited by other authors, a researcher will be able to assume that the particular author is an expert in the area and, thus, a key resource for consultation in the current research to be undertaken.

Identification of key questions about a topic that need further research . In many cases a researcher may discover new angles that need further exploration by reviewing what has already been written on a topic. For example, research may suggest that listening to music while studying might lead to better retention of ideas, but the research might not have assessed whether a particular style of music is more beneficial than another. A researcher who is interested in pursuing this topic would then do well to follow up existing studies with a new study, based on previous research, that tries to identify which styles of music are most beneficial to retention.

Determination of methodologies used in past studies of the same or similar topics.  It is often useful to review the types of studies that previous researchers have launched as a means of determining what approaches might be of most benefit in further developing a topic. By the same token, a review of previously conducted studies might lend itself to researchers determining a new angle for approaching research.

Upon completion of the literature review, a researcher should have a solid foundation of knowledge in the area and a good feel for the direction any new research should take. Should any additional questions arise during the course of the research, the researcher will know which experts to consult in order to quickly clear up those questions.

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

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

Importance of a Good Literature Review

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

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

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

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

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

Types of Literature Reviews

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

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

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

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

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

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

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

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

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

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

Structure and Writing Style

I.  Thinking About Your Literature Review

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

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

The critical evaluation of each work should consider :

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

II.  Development of the Literature Review

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

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

III.  Ways to Organize Your Literature Review

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

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

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

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

IV.  Writing Your Literature Review

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

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

V.  Common Mistakes to Avoid

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

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

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

Writing Tip

Break Out of Your Disciplinary Box!

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

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

Another Writing Tip

Don't Just Review for Content!

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

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

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

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

Yet Another Writing Tip

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

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

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

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

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• Volume 19, Issue 1
• Reviewing the literature
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• Joanna Smith 1 ,
• Helen Noble 2
• 1 School of Healthcare, University of Leeds , Leeds , UK
• 2 School of Nursing and Midwifery, Queens's University Belfast , Belfast , UK
• Correspondence to Dr Joanna Smith , School of Healthcare, University of Leeds, Leeds LS2 9JT, UK; j.e.smith1{at}leeds.ac.uk

https://doi.org/10.1136/eb-2015-102252

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Implementing evidence into practice requires nurses to identify, critically appraise and synthesise research. This may require a comprehensive literature review: this article aims to outline the approaches and stages required and provides a working example of a published review.

Are there different approaches to undertaking a literature review?

What stages are required to undertake a literature review.

The rationale for the review should be established; consider why the review is important and relevant to patient care/safety or service delivery. For example, Noble et al 's 4 review sought to understand and make recommendations for practice and research in relation to dialysis refusal and withdrawal in patients with end-stage renal disease, an area of care previously poorly described. If appropriate, highlight relevant policies and theoretical perspectives that might guide the review. Once the key issues related to the topic, including the challenges encountered in clinical practice, have been identified formulate a clear question, and/or develop an aim and specific objectives. The type of review undertaken is influenced by the purpose of the review and resources available. However, the stages or methods used to undertake a review are similar across approaches and include:

Formulating clear inclusion and exclusion criteria, for example, patient groups, ages, conditions/treatments, sources of evidence/research designs;

Justifying data bases and years searched, and whether strategies including hand searching of journals, conference proceedings and research not indexed in data bases (grey literature) will be undertaken;

Developing search terms, the PICU (P: patient, problem or population; I: intervention; C: comparison; O: outcome) framework is a useful guide when developing search terms;

Developing search skills (eg, understanding Boolean Operators, in particular the use of AND/OR) and knowledge of how data bases index topics (eg, MeSH headings). Working with a librarian experienced in undertaking health searches is invaluable when developing a search.

Once studies are selected, the quality of the research/evidence requires evaluation. Using a quality appraisal tool, such as the Critical Appraisal Skills Programme (CASP) tools, 5 results in a structured approach to assessing the rigour of studies being reviewed. 3 Approaches to data synthesis for quantitative studies may include a meta-analysis (statistical analysis of data from multiple studies of similar designs that have addressed the same question), or findings can be reported descriptively. 6 Methods applicable for synthesising qualitative studies include meta-ethnography (themes and concepts from different studies are explored and brought together using approaches similar to qualitative data analysis methods), narrative summary, thematic analysis and content analysis. 7 Table 1 outlines the stages undertaken for a published review that summarised research about parents’ experiences of living with a child with a long-term condition. 8

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An example of rapid evidence assessment review

In summary, the type of literature review depends on the review purpose. For the novice reviewer undertaking a review can be a daunting and complex process; by following the stages outlined and being systematic a robust review is achievable. The importance of literature reviews should not be underestimated—they help summarise and make sense of an increasingly vast body of research promoting best evidence-based practice.

• ↵ Centre for Reviews and Dissemination . Guidance for undertaking reviews in health care . 3rd edn . York : CRD, York University , 2009 .
• ↵ Canadian Best Practices Portal. http://cbpp-pcpe.phac-aspc.gc.ca/interventions/selected-systematic-review-sites / ( accessed 7.8.2015 ).
• Bridges J , et al
• ↵ Critical Appraisal Skills Programme (CASP). http://www.casp-uk.net / ( accessed 7.8.2015 ).
• Dixon-Woods M ,
• Shaw R , et al
• Agarwal S ,
• Jones D , et al
• Cheater F ,

Twitter Follow Joanna Smith at @josmith175

Competing interests None declared.

Read the full text or download the PDF:

• Open access
• Published: 03 June 2024

Patients’ expectations surrounding revision total hip arthroplasty: a literature review

• Omar Mohammad   ORCID: orcid.org/0000-0002-3054-2578 1 ,
• Shahril Shaarani 2 ,
• Adnan Mohammad 3 &
• Sujith Konan 2  

Arthroplasty volume  6 , Article number:  28 ( 2024 ) Cite this article

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Revision total hip arthroplasties (RTHA) are associated with a higher complication rate than primary total hip arthroplasties (THA), and therefore it is important for patients to have realistic expectations regarding outcomes. The aim of this literature review was to gather and summarize the available evidence on patients’ expectations following RTHA.

A literature search was conducted in PubMed, PsycINFO, Cochrane, Google Scholar, Web of Science and Embase from inception to November 2023. Articles assessing patient expectations for RTHA were included. Methodological quality was assessed by two independent reviewers using the National Heart, Lung and Blood Institute (NIH) study quality assessment tool for observational cohort and cross-sectional studies. A qualitative analysis was performed involving the summarization of study characteristics and outcomes.

The search strategy generated 7,450 references, of which 5 articles met the inclusion criteria. Methodological quality scores ranged from 7–10. Patients had high expectations concerning future walking ability, pain and implant longevity relative to actual postoperative outcomes. A significant positive correlation was found between fulfilled expectations of pain and walking ability and patient satisfaction ( r  = 0.46–0.47). Only two studies assessed the fulfillment of patient expectations. Great variability was seen in the measurement of expectations.

Patients undergoing RTHA appeared to have high expectations for pain and functionality compared to postoperative outcomes. However, there was a paucity of high-quality data in this area, limiting the accuracy of the conclusion. Further research is needed, that emphasizes developing a sound theoretical framework for expectations, allowing for the consistent implementation of valid measurement tools for patient expectations.

Introduction

Total hip arthroplasty (THA) is a cost-effective procedure for improving a patient’s quality of life (QOL), pain, and function when conservative therapies have failed [ 1 , 2 , 3 ]. Despite the widely recognized success of THA, there is a certain level of risk that may necessitate a revision procedure. The incidence of revisions is on the rise and is projected to increase by 31% by 2030 in England & Wales, UK [ 4 ].

When compared to primary THA, revision THA (RTHA) is associated with higher rates of short- and long-term complications, elevated mortality rates, lower satisfaction, and smaller improvements in functional outcomes [ 5 , 6 , 7 , 8 , 9 , 10 , 11 ]. Whether patients undergo either primary or RTHA, they largely expect a reduction in pain and an improvement in both function and quality of life [ 12 , 13 , 14 , 15 ]. In the preoperative period, it is important to assess these expectations, to ensure that patients have a realistic perspective of the outcomes of the operation and are not dissatisfied. Aside from technical factors and the quality of existing bone, patient factors may also partially explain the less favourable outcomes of RTHA relative to primary THA [ 8 ].

There is a growing body of literature across a variety of medical specialties linking clinical outcomes with patients’ expectations and satisfaction. Patient satisfaction has been shown to lead to higher compliance and attendance for monitoring and follow-up care [ 16 ], which are integral factors in optimizing prosthesis longevity. Furthermore, patients’ expectations are strongly correlated with satisfaction, with satisfied patients having their expectations fulfilled [ 17 ] and unrealistic expectations being correlated with dissatisfaction [ 18 ]. This has led to increasing emphasis on measures of quality of life and patients’ feelings of satisfaction [ 19 , 20 ]. Therefore, as a reflection of this shift in emphasis, it has become essential to gain a better understanding of patients’ expectations.

Although patient expectations have been widely discussed in current primary THA research [ 17 , 18 , 21 ], there is an apparent sparsity in the RTHA literature. This literature review therefore aimed to comprehensively assess all relevant studies evaluating the expectations of patients undergoing RTHA, and how this in turn relates to post-operative outcomes where possible.

Materials and methods

Search strategy.

A comprehensive electronic literature search was performed in the following databases: PubMed, The Cochrane Library, Google Scholar, PsychINFO, Web of Science and Embase to identify eligible studies published until the 7th November 2023. Search terms were derived from MeSh terms in PubMed and free text terms relating to (1) hip arthroplasty, (2) revision and (3) expectations/expectancies (Table  1 ). Although Haanstra et al. offered distinct definitions for expectations and expectancies as being “cognitions regarding probable future events” and “the act or state of expecting” [ 22 ], the current literature uses the two terms interchangeably to show that an individual is “expecting something to occur in the future”. Therefore, whilst they are different concepts, no distinction was acknowledged between the two.

Inclusion criteria

The individual search results from each database were combined barring duplicates, and the remaining titles and abstracts were then screened against the inclusion criteria found below.

The studies had to meet the following inclusion criteria to be eligible:

The study included revision THA patients;

Patients’ expectations were assessed;

The study had to be written in English;

The patients were adults > 18 years of age.

If an article assessed both primary and RTHA groups but failed to report the data separately for each group, the study was excluded, as we would not be able to extract the relevant data.

Two reviewers (OM and SRS) independently assessed the full text articles, based on the title and abstract, against the inclusion criteria. If there was any uncertainty regarding the eligibility of a study the full text was examined. The results of the search are shown in Table  2 .

Data extraction and methodological quality assessment

The same two reviewers extracted relevant data from the included studies using a standardized data extraction form (Table  3 ). The form included information on study design, study population, follow-up period, measurement of expectations and outcome measurements. Moreover, data on the strength of the relationship between expectations and outcomes was extracted where possible (e.g., P -values and correlation coefficients).

Furthermore, the methodological quality of the selected studies was assessed using the National Heart, Lung and Blood Institute (NIH) study quality assessment tool for observational cohort and cross-sectional studies [ 26 ]. Each study was judged on key concepts for internal validity, such as sample size, exposure/outcome measurement and compatibility of the groups. There were fourteen questions in total, for which studies could score a maximum of 14 points in sum. If there was any disagreement between the two reviewers, it was agreed that a discussion would be held to reach a point of consensus. This did not occur.

Data analysis

Due to the heterogeneity of the measurement of patients’ expectations in the studies identified, it was not possible to statistically pool the data in a meta-analysis. Instead, a qualitative analysis was performed involving the summarization of study characteristics and outcomes, as well as a methodological assessment using the NIH quality assessment tool. Studies were noted as poor quality if they scored 0–4, fair if they scored 5–10 and good if they scored 11–14 out of 14 questions [ 27 ].

Study selection process

The literature search retrieved a total of 7,450 records. After removal of duplicates ( n  = 162), records not in English ( n  = 382), non-human studies ( n  = 251) and studies not on adults aged > 18 ( n  = 1,876), a total of 4,779 papers remained. After screening of the titles and abstracts, 4,742 studies were excluded, as they either did not assess patient expectations, did not include revision THA or were review articles. This left a total of 37 studies for further investigation. After full-text assessment, a further 32 articles were excluded, leaving 5 articles that met all the inclusion criteria [ 12 , 14 , 23 , 24 , 25 ] and were subsequently included in this review (Fig.  1 ).

Flowchart of literature search and selection process

Study characteristics

Five cohort studies were included in this review. The sample size ranged from 60 to 320 participants. Four studies only included RTHA [ 12 , 14 , 23 , 25 ] and one included both primary and RTHA [ 24 ]. In the assessment of expectations, two studies utilized a single item measurement which utilized either a three-point Likert-scale [ 23 ] or a six-point Likert-scale [ 25 ], two studies implemented a two-item instrument utilizing either a 4-point Likert scale [ 12 ] or a close-ended multiple-choice format [ 24 ]. One study modified the pre-existing Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC scale—a validated instrument) to assess patients’ expectations of pain, stiffness and physical function in 6 months after the revision operation [ 14 ]. Overall, no validated instruments were used in the assessment of patients’ expectations in revision THA across all studies.

Methodological quality

The average quality score was 9 out of 14 (range 7–9) (Table  2 ). As expected, the lowest scoring items were:

“Were the outcome assessors blinded to the exposure status of the participants?” —due to all studies having utilized a self-reported questionnaire;

“For exposures that can vary in amount or level, did the study examine different levels of the exposure as related to the outcome”;

“Was the exposure(s) assessed more than once over time?”—as the exposure was a single revision THA.

Other notable methodological shortcomings were the common lack of sample size justification and often absent statistical analyses of confounding variables.

Expectations

The measurement of patient expectations varied across the studies included in this review. Two studies focused on revision longevity expectations [ 23 , 24 ]. Barrack et al. implemented a single postoperative question concerning implant longevity and scaled responses using a 3-point Likert scale. Hellman et al. also measured implant longevity expectations using a single retrospective question and graded responses with close-ended multiple-choice questions.

One study prospectively measured the expectations of future pain and walking ability utilizing two questions scaled via a 4-point Likert scale [ 12 ]. One study assessed patients’ expectations of pain, stiffness and physical function utilizing the modified WOMAC scale [ 14 ]. These were measured prospectively and used a 5-point Likert scale. Two studies examined fulfillment of patients’ expectations after surgery [ 12 , 25 ]. Eisler et al. postoperatively assessed fulfillment of expectations with two questions and utilized a 4-point Likert scale. Zhang et al. used one postoperative question with a 6-point Likert scale. Only one study measured how this in turn correlated with patient satisfaction [ 12 ].

Patients’ expectations of pain were measured in two studies. Eisler et al. found that 92% of patients expected to have no pain or to have much less pain, and only 8% expected a slight reduction in pain. Haddad et al. reported an average score of 7.4/25 (CI 6.2–8.6) for pain, with a lower score conferring a low expectation of pain.

Function was assessed in two studies [ 12 , 14 ]. Eisler et al. noted that 82% of patients expected the same walking ability as after the first THA or markedly improved walking ability, 15%, slightly improved and 3%, no difference in walking ability. Haddad et al. reported an average expectation of 28.1/85 (CI 24.0–32.2) for physical activity, with a lower score indicating a higher expectation of function. Additionally, only Haddad et al. assessed expectations on stiffness, with an average expectation of 3.5/10 (CI 3.0–4.0) for stiffness, with a lower score indicating a lower expectation for stiffness.

Fulfilled expectations

Eisler et al. found that 55 and 69% of patients had fulfilled expectations regarding walking ability and pain. Furthermore, fulfilled expectations about pain and walking ability demonstrated a modest positive correlation with satisfaction ( r  = 0.46–0.47). The absence of complications was the only predictor of fulfilled pain expectations during the postoperative hospital period (odds ratio (OR) 4.8; 95% confidence interval (CI) 1.1–20.8). Zhang et al. found that at 6 months postoperatively, distressed patients had significantly lower rates of fulfilled expectations compared to non-distressed patients (64.5% vs. 94.1%, P  = 0.027). At 2 years postoperatively, this was no longer significantly different (63.6% vs. 79.3%, P  = 0.342).

Implant longevity

Two studies assessed patients’ expectations concerning the longevity of their revision THA [ 23 , 24 ]. Barrack et al. found that most patients, regardless of original implant longevity, expected their revision to last longer. In patients in whom the primary THA lasted < 5 years: 77% expected revision to last longer and in those where the primary lasted 5–10 years: 76% expected revision to last longer. If the primary lasted 10–15 years: 69% expected the revision to last longer and in those where the primary THA lasted > 15 years: 62% expected the revision to last longer. Hellman et al. found that 35% of patients expected the revision to last for the rest of their lives.

This review found that RTHA patients tend to have unrealistically high expectations regarding pain relief, improvement in movement, and implant longevity. Furthermore, distressed patients are less likely to have their expectations fulfilled postoperatively in the short term [ 25 ]. Given poorer outcomes with revision surgery versus primary THA, these expectations are unlikely to be fulfilled and may result in patient dissatisfaction [ 8 , 12 , 14 ]. Only one study [ 12 ] assessed how fulfillment of these expectations correlated with postoperative satisfaction, revealing a moderate positive correlation with expectations of pain and walking ability. However, overall, there is a paucity of research concerning expectations following RTHA procedures, despite the higher risk of complications [ 28 ]. Additionally, there is significant variability in the way expectations are measured.

Important areas that need to be addressed in future research include (1) The theoretical framework of expectations; (2) the measurement of expectations; (3) the correlation of psychological and other demographic factors and (4) the relationship between fulfilled expectations and satisfaction.

Firstly, none of the papers in this review provided a definition of patient expectations. The absence of a consistent theoretical framework for expectations lends itself to an increased propensity for the heterogeneous use of terminology and measurements. If left unaddressed, this can lead to research plagued by discontinuity and poor methodological quality. In the past, several reviews [ 29 , 30 , 31 ] have acknowledged patient expectations as being a complex multifaceted construct. Kravitz [ 31 ] made a distinct delineation between value (reflecting the patient’s wishes/hopes) and probability expectations (the likelihood that an event will occur). Furthermore, Bandura [ 32 ] separated efficacy from outcome expectations. Given the different perspectives on expectations, it is necessary to utilize a consistent framework to allow for accurate classification and subsequent assessment. For example, Hobbs et al. [ 33 ] successfully utilized the International Classification of Functioning, Disability and Health (ICF) framework to classify patients’ expectations in primary THA. This involved assigning patients’ expectations to one of three domains: activity limitations, impairments to bodily function and structure, and participation restrictions. It was found that patients generally focused more on the recovery of valued activities rather than the reversal of their functional impairment. In future RTHA research investigating patient expectations, researchers should aim to map their findings to each of the core ICF constructs. If performed consistently, this has the potential to lead to more uniformity of definitions, better integration of data amongst different studies and improved validation of measurement instruments. Additionally, this method could be used to ascertain whether certain expectation domains, e.g., impairment, activity limitations or participation restriction expectations are predictors of patient reported outcome measures (PROMs).

As mentioned previously, the lack of a consistent theoretical framework for patient expectations has likely contributed to the absence of a valid and standardized measurement tool. This prevents the effective integration and comparison of data across studies [ 22 ]. Each study in this review implemented a unique instrument that was only used for one investigation. They often lacked a rationale behind their development, or data on reliability and validity, which limits the credibility of evidence collected. This issue has affected both primary THA research and research in other fields such as psychotherapy, where, for example, Constantino et al. [ 34 ] reported that the majority (67%) of measurements were of poor quality. A possible strategy may be to either adapt an already well-established patient-reported outcome tool (such as the WOMAC) or use a theory-guided approach, with testing in independent samples to gather data on reliability, construct validity and predictive validity. Alternatively, the Hospital for Special Surgery Total Hip Replacement Expectations Survey (HSS-HRES) could be used for RTHA patients. This survey is a well-validated 18-question expectations survey that is graded on a 5-point Likert scale and has been used effectively in past THA research [ 35 ]. Regardless, future researchers should aim to use a validated instrument.

Additionally, half of the studies included in this review measured patients’ expectations in the postoperative period. This is not optimal and increases the risk of bias, as the patients may not be able to accurately recall their preoperative expectations due to the time elapsed [ 36 ]. Furthermore, since patient dissatisfaction is secondary to a disequilibrium between expectations and fulfilled expectations [ 37 ], patients may therefore alter their expectations to match their current status, to prevent dissatisfaction [ 38 ]. A Canadian study in 2006, reported this phenomenon regarding total knee arthroplasty, where 35% of patients over- or underestimated their preoperative level of functioning [ 39 ]. However, there is another issue purported by Haanstra et al. which pertains to the timing of expectation measurement [ 22 ]. Given that patients’ expectations are likely to be widely influenced by their doctor, it is possible that the longer the patient is in contact with them and the later their expectations are measured, the more realistic and reliable they may be. Currently no investigation has measured the influence of time of measurement, but it is a variable to keep in mind, which could be offset by collecting data at different time points.

Moreover, only one study in this review collected data in the pre- and postoperative period to assess the percentage of fulfilled expectations, and only this study analyzed the correlation between fulfilled expectations and satisfaction [ 12 ]. Whilst expectations are an important preoperative factor, it is the fulfillment of these expectations that has been shown to be the more significant determinant of patient-reported outcomes and satisfaction [ 40 ]. High expectations are not inherently detrimental, but unrealistic expectations are [ 40 ]. Therefore, it is important to assess the percentage of patients with fulfilled expectations, as this information can be used to foster realistic, high expectations through effective preoperative education.

If patients are to be measured in the postoperative period, the length of the follow-up period needs to be addressed, as it may influence findings. Barlow et al. found that expectations may take up to two years post-surgery before they are fulfilled, due to function having the potential to improve for up to two years, alluding to the existence of a timing bias [ 41 ].

Finally, half of the available literature did not include a multivariate analysis of confounding variables such as age, gender, ethnicity and preoperative education level despite their influence on patient expectations [ 35 , 42 ]. Furthermore, psychological factors (depression, optimism and catastrophizing), which may interact with expectations or treatment outcomes, were rarely analyzed [ 22 ]. Future research should try to delineate these factors for further consideration.

A promising area of focus for future research is the consenting process. Patient recall of the consenting process, and the relevant risks and outcomes, is frequently poor [ 43 ]. A recent study demonstrated that patients undergoing THA, who were consented with the generic consent form, only recalled 0.67 risks four weeks after surgery. In contrast, those who were given a surgery-specific consent form, recalled 1.43 risks on average [ 44 ]. This surgery-specific consent form listed potential adverse events alongside appropriate explanations. With regards to RTHA, this could be implemented with the addition of a section on postoperative outcomes. This would help to ensure that patients have a better comprehension of the procedure and retain more information. This may, therefore, lead to more realistic expectations that can be fulfilled.

This study has limitations that need to be considered. Firstly, a meta-analysis was not possible due to the heterogeneity in the papers included and the poor standard of reporting. And so, we performed a qualitative analysis. However, a thorough, definitive analysis of the data is not possible using this method. Secondly, only a limited number of studies were available for review, due to the lack of research in this area. As a result, there are limited data available to analyse, which may not fully represent patient expectations. The data were also relatively old, with only 2 references being < 10 years ago. Patient expectations may have improved since then with changes in perioperative information. Therefore, the strength of conclusions made in the paper may not be accurate and should be taken with caution. Although a limitation, this highlights a clear deficit in current research that needs to be addressed.

As conclusions from RTHA literature are limited, we can look at adjacent literature concerning total knee arthroplasty (TKA), to better understand what patients tend to expect with a joint replacement procedure. Similarly, TKA patients have been shown to have unrealistically high expectations regarding postoperative pain, function and recovery [ 45 ]. Moreover, patient satisfaction has been shown to be highly correlated with expectation fulfillment [ 45 ]. Recent research has demonstrated improvements in patients’ WOMAC pain and satisfaction scores at over 1 year post operation in TKA patients, by setting realistic expectations [ 46 ]. Although a different procedure/patient demographic, these findings are similar to the current evidence base for RTHA and reinforce the importance of setting appropriate baseline patient expectations through perioperative counselling, to foster better PROMs.

A definitive conclusion is limited by the sparse data available. However, the current literature demonstrates that revision THA patients tend to have unrealistic expectations with regards to pain relief, function and implant longevity. Realistic patient education prior to surgery is necessary to avoid expectation/outcome mismatch and hence dissatisfaction. Nevertheless, this review demonstrates the lack of adequate research on patients’ expectations in revision THA, both in terms of absolute numbers, and methodological quality. More research is needed, which utilizes a standardized approach in assessment, in order to foster a better understanding of the relationship between patient expectations and postoperative outcome measures. Only then, can this information be effectively applied clinically to improve the outcome of revision THAs. We suggest counselling of patients before surgery and using a procedure-specific consent. As to collection of pre- and postoperative data—postoperative data should be collected at different points of time as the patients’ outcomes improve with time and so will the outcome and expectations. Patients-reported outcomes are a better tool to assess the patient outcomes.

Availability of data and materials

Not applicable.

Abbreviations

Total Hip Arthroplasty

Revision Total Hip Arthroplasty

National Heart, Lung and Blood Institute

Western Ontario and McMaster Universities Arthritis Index

Patient reported outcome measure

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Mohammad, O., Shaarani, S., Mohammad, A. et al. Patients’ expectations surrounding revision total hip arthroplasty: a literature review. Arthroplasty 6 , 28 (2024). https://doi.org/10.1186/s42836-024-00250-6

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The Literature Review: A Foundation for High-Quality Medical Education Research

a  These are subscription resources. Researchers should check with their librarian to determine their access rights.

Despite a surge in published scholarship in medical education 1 and rapid growth in journals that publish educational research, manuscript acceptance rates continue to fall. 2 Failure to conduct a thorough, accurate, and up-to-date literature review identifying an important problem and placing the study in context is consistently identified as one of the top reasons for rejection. 3 , 4 The purpose of this editorial is to provide a road map and practical recommendations for planning a literature review. By understanding the goals of a literature review and following a few basic processes, authors can enhance both the quality of their educational research and the likelihood of publication in the Journal of Graduate Medical Education ( JGME ) and in other journals.

The Literature Review Defined

In medical education, no organization has articulated a formal definition of a literature review for a research paper; thus, a literature review can take a number of forms. Depending on the type of article, target journal, and specific topic, these forms will vary in methodology, rigor, and depth. Several organizations have published guidelines for conducting an intensive literature search intended for formal systematic reviews, both broadly (eg, PRISMA) 5 and within medical education, 6 and there are excellent commentaries to guide authors of systematic reviews. 7 , 8

• A literature review forms the basis for high-quality medical education research and helps maximize relevance, originality, generalizability, and impact.
• A literature review provides context, informs methodology, maximizes innovation, avoids duplicative research, and ensures that professional standards are met.
• Literature reviews take time, are iterative, and should continue throughout the research process.
• Researchers should maximize the use of human resources (librarians, colleagues), search tools (databases/search engines), and existing literature (related articles).
• Keeping organized is critical.

Such work is outside the scope of this article, which focuses on literature reviews to inform reports of original medical education research. We define such a literature review as a synthetic review and summary of what is known and unknown regarding the topic of a scholarly body of work, including the current work's place within the existing knowledge . While this type of literature review may not require the intensive search processes mandated by systematic reviews, it merits a thoughtful and rigorous approach.

Purpose and Importance of the Literature Review

An understanding of the current literature is critical for all phases of a research study. Lingard 9 recently invoked the “journal-as-conversation” metaphor as a way of understanding how one's research fits into the larger medical education conversation. As she described it: “Imagine yourself joining a conversation at a social event. After you hang about eavesdropping to get the drift of what's being said (the conversational equivalent of the literature review), you join the conversation with a contribution that signals your shared interest in the topic, your knowledge of what's already been said, and your intention.” 9

The literature review helps any researcher “join the conversation” by providing context, informing methodology, identifying innovation, minimizing duplicative research, and ensuring that professional standards are met. Understanding the current literature also promotes scholarship, as proposed by Boyer, 10 by contributing to 5 of the 6 standards by which scholarly work should be evaluated. 11 Specifically, the review helps the researcher (1) articulate clear goals, (2) show evidence of adequate preparation, (3) select appropriate methods, (4) communicate relevant results, and (5) engage in reflective critique.

Failure to conduct a high-quality literature review is associated with several problems identified in the medical education literature, including studies that are repetitive, not grounded in theory, methodologically weak, and fail to expand knowledge beyond a single setting. 12 Indeed, medical education scholars complain that many studies repeat work already published and contribute little new knowledge—a likely cause of which is failure to conduct a proper literature review. 3 , 4

Likewise, studies that lack theoretical grounding or a conceptual framework make study design and interpretation difficult. 13 When theory is used in medical education studies, it is often invoked at a superficial level. As Norman 14 noted, when theory is used appropriately, it helps articulate variables that might be linked together and why, and it allows the researcher to make hypotheses and define a study's context and scope. Ultimately, a proper literature review is a first critical step toward identifying relevant conceptual frameworks.

Another problem is that many medical education studies are methodologically weak. 12 Good research requires trained investigators who can articulate relevant research questions, operationally define variables of interest, and choose the best method for specific research questions. Conducting a proper literature review helps both novice and experienced researchers select rigorous research methodologies.

Finally, many studies in medical education are “one-offs,” that is, single studies undertaken because the opportunity presented itself locally. Such studies frequently are not oriented toward progressive knowledge building and generalization to other settings. A firm grasp of the literature can encourage a programmatic approach to research.

Approaching the Literature Review

Considering these issues, journals have a responsibility to demand from authors a thoughtful synthesis of their study's position within the field, and it is the authors' responsibility to provide such a synthesis, based on a literature review. The aforementioned purposes of the literature review mandate that the review occurs throughout all phases of a study, from conception and design, to implementation and analysis, to manuscript preparation and submission.

Planning the literature review requires understanding of journal requirements, which vary greatly by journal ( table 1 ). Authors are advised to take note of common problems with reporting results of the literature review. Table 2 lists the most common problems that we have encountered as authors, reviewers, and editors.

Sample of Journals' Author Instructions for Literature Reviews Conducted as Part of Original Research Article a

Common Problem Areas for Reporting Literature Reviews in the Context of Scholarly Articles

Locating and Organizing the Literature

Three resources may facilitate identifying relevant literature: human resources, search tools, and related literature. As the process requires time, it is important to begin searching for literature early in the process (ie, the study design phase). Identifying and understanding relevant studies will increase the likelihood of designing a relevant, adaptable, generalizable, and novel study that is based on educational or learning theory and can maximize impact.

Human Resources

A medical librarian can help translate research interests into an effective search strategy, familiarize researchers with available information resources, provide information on organizing information, and introduce strategies for keeping current with emerging research. Often, librarians are also aware of research across their institutions and may be able to connect researchers with similar interests. Reaching out to colleagues for suggestions may help researchers quickly locate resources that would not otherwise be on their radar.

During this process, researchers will likely identify other researchers writing on aspects of their topic. Researchers should consider searching for the publications of these relevant researchers (see table 3 for search strategies). Additionally, institutional websites may include curriculum vitae of such relevant faculty with access to their entire publication record, including difficult to locate publications, such as book chapters, dissertations, and technical reports.

Strategies for Finding Related Researcher Publications in Databases and Search Engines

Search Tools and Related Literature

Researchers will locate the majority of needed information using databases and search engines. Excellent resources are available to guide researchers in the mechanics of literature searches. 15 , 16

Because medical education research draws on a variety of disciplines, researchers should include search tools with coverage beyond medicine (eg, psychology, nursing, education, and anthropology) and that cover several publication types, such as reports, standards, conference abstracts, and book chapters (see the box for several information resources). Many search tools include options for viewing citations of selected articles. Examining cited references provides additional articles for review and a sense of the influence of the selected article on its field.

Box Information Resources

• Web of Science a
• Education Resource Information Center (ERIC)
• Cumulative Index of Nursing & Allied Health (CINAHL) a
• Google Scholar

Once relevant articles are located, it is useful to mine those articles for additional citations. One strategy is to examine references of key articles, especially review articles, for relevant citations.

Getting Organized

As the aforementioned resources will likely provide a tremendous amount of information, organization is crucial. Researchers should determine which details are most important to their study (eg, participants, setting, methods, and outcomes) and generate a strategy for keeping those details organized and accessible. Increasingly, researchers utilize digital tools, such as Evernote, to capture such information, which enables accessibility across digital workspaces and search capabilities. Use of citation managers can also be helpful as they store citations and, in some cases, can generate bibliographies ( table 4 ).

Citation Managers

Knowing When to Say When

Researchers often ask how to know when they have located enough citations. Unfortunately, there is no magic or ideal number of citations to collect. One strategy for checking coverage of the literature is to inspect references of relevant articles. As researchers review references they will start noticing a repetition of the same articles with few new articles appearing. This can indicate that the researcher has covered the literature base on a particular topic.

Putting It All Together

In preparing to write a research paper, it is important to consider which citations to include and how they will inform the introduction and discussion sections. The “Instructions to Authors” for the targeted journal will often provide guidance on structuring the literature review (or introduction) and the number of total citations permitted for each article category. Reviewing articles of similar type published in the targeted journal can also provide guidance regarding structure and average lengths of the introduction and discussion sections.

When selecting references for the introduction consider those that illustrate core background theoretical and methodological concepts, as well as recent relevant studies. The introduction should be brief and present references not as a laundry list or narrative of available literature, but rather as a synthesized summary to provide context for the current study and to identify the gap in the literature that the study intends to fill. For the discussion, citations should be thoughtfully selected to compare and contrast the present study's findings with the current literature and to indicate how the present study moves the field forward.

To facilitate writing a literature review, journals are increasingly providing helpful features to guide authors. For example, the resources available through JGME include several articles on writing. 17 The journal Perspectives on Medical Education recently launched “The Writer's Craft,” which is intended to help medical educators improve their writing. Additionally, many institutions have writing centers that provide web-based materials on writing a literature review, and some even have writing coaches.

The literature review is a vital part of medical education research and should occur throughout the research process to help researchers design a strong study and effectively communicate study results and importance. To achieve these goals, researchers are advised to plan and execute the literature review carefully. The guidance in this editorial provides considerations and recommendations that may improve the quality of literature reviews.

• Open access
• Published: 03 June 2024

Hotspots and trends in health-oriented physical literacy research: a visual analysis based on the WOS database

• Xinyuan Fang 1 &
• Zhen Zhang 1  

BMC Public Health volume  24 , Article number:  1480 ( 2024 ) Cite this article

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The World Health Organization has proposed that physical activity is a meaningful way to improve the quality of human life and reduce the probability of chronic non-communicable diseases and that humans should change their mindset from the actual effectiveness of physical activity in promoting health to the new view that “physical activity makes life more meaningful.” The introduction and development of physical literacy reveal the critical role of physical activity in improving human health and the importance of human initiative in physical activity for healthy development. Therefore, the objectives of this paper are (1) to conduct a bibliometric analysis of the literature on physical literacy, assessing the scope, frequency, and geographical distribution of research publications from various countries and institutions from 2015 to 2023; (2) to visualize keywords in articles on the topic of Physical literacy to analyze whether there is a link between physical literacy and health, and (3) based on the results of the visual analysis, we propose that proper health is built on the sense of physical literacy and further construct the circular path of physical literacy, physical activity, and physical health improvement.

Using VOSviewer software v.1.6.18, this study searched the core collection of the Web of Science database from 2015 to April 15, 2023, using “physical literacy” as a keyword to explore the current international research on physical literacy.

A total of 3,446 articles were included, and a correlation map was derived based on the co-occurrence frequency of keywords, which showed that physical literacy was highly correlated with six concepts: health literacy, physical activity, health, children, adolescents, and prevention.

Based on the analysis of literature visualization techniques, there is a high correlation between physical literacy and health, and international physical literacy research is in a trend of multi-point amplification, with research hotspots gradually shifting from the field of sports to the field of health and closely related to the field of health, indicating that physical literacy aims to promote the achievement of individual health by driving humans to increase physical activity.

Peer Review reports

Introduction

In recent years, the rapid advancement of science and technology has led to the proliferation of automation, networking, and intelligent technologies in all major areas of human life and production [ 1 ]. These technologies gradually replace human physical activities, making a sedentary lifestyle the norm for many professionals and students [ 2 ]. This lack of physical activity has given rise to a global epidemic of physical inactivity disorder. According to the Global Physical Activity Report 2022 by the World Health Organization, 80% of adolescents and 27.5% of adults worldwide do not meet the recommended level of physical activity [ 3 ]. Modern society has trapped humans in a “fast-paced,” “stressful,” and “inactive” lifestyle, leading to frequent physical and mental health issues and a surge in “physical inactivity disorder “ [ 4 ]. This significantly reduces the quality of life and is associated with a range of chronic non-communicable diseases and premature death [ 5 ]. If the current global situation persists, nearly 500 million people are projected to suffer from heart disease, obesity, diabetes, and other chronic diseases due to physical inactivity between 2020 and 2030 [ 6 ].

In light of this, the report urges countries to incorporate physical activity into health-related policies as a strategic approach to improving health and tackling chronic diseases. Physical literacy, an emerging field of physical activity research, was reinterpreted by British scholar Whitehead in 1993 from a philosophical basis of phenomenology, existentialism, and embodied cognitive theory. This sparked a global surge in physical literacy research. The rapid spread of “physical literacy” in today’s world is primarily due to its novel approach to addressing the current health crisis that human society is struggling to cope with [ 7 ].

A note of physical literacy

The term “Physical literacy” first appeared in an article published in the American Journal of Health and Physical Education in 1938 [ 8 ]. However, it received little attention throughout the 20th century. In the present age of technology, where machines increasingly replace manual labor and simplify lifestyles, there is a crucial need to contemplate the significance of physical activity. If physical activity is solely considered as a means to promote physical health, there is a risk of overlooking its intrinsic value, particularly for the younger generation, which generally enjoys good physical and mental health [ 9 ]. Consequently, the pressing question of how to integrate physical activity as a “necessity” in daily life and a regular part of routines arises in the 21st century, an era marked by technological transformation [ 10 ]. In response to this question, “physical literacy” has gained prominence. Although the definition of physical literacy varies internationally, it generally aligns with the summary provided by the International Physical Literacy Association (IPLA) in 2017: Physical literacy empowers individuals with the motivation, confidence, physical competence, knowledge, and understanding to value and engage in physical activity as a lifelong habit [ 11 ]. This perspective attempts to shift from viewing physical activity as a means to an end to a subjective experience that individuals actively integrate into their pursuit of life values, potential development, and quality of life enhancement. By doing so, it aims to counteract the current decline in physical activity among humans and breathe new life into human health.

Physical literacy: a holistic approach to health and well-being

Physical literacy has received widespread academic attention because of its unique value in human physical and mental development. As an instrumental concept, it has led to a change in the thinking of physical education teachers, sports coaches, doctors, and other people concerned about physical and mental health development and influenced the formulation of related policies [ 12 ]. However, due to its complex philosophical basis and the holistic nature of mind-body unity, how physical literacy is promoted through physical activity depends mainly on the current interpretation and application of its concept in the educational community [ 13 ]. Physical literacy challenges the conventional dualism that separates the body from the mind. Instead, it espouses a monistic perspective, asserting the unity of mind and body [ 14 ]. This viewpoint posits that our physical experiences are intrinsically interwoven with our cognitive and emotional states. This monistic stance integral to physical literacy contests the traditional dualistic approach prevalent in education and health, which often segregates physical and mental development into disparate domains, completely marginalizing our body [ 15 ]. By championing the interconnection and mutual dependence of physical and mental facets of human experience, physical literacy fosters a more comprehensive, holistic approach to human development and well-being [ 16 ]. This philosophical underpinning of physical literacy has far-reaching implications for understanding, promoting, and engaging in physical activity [ 17 ]. It implies that physical activity is not merely a means for physical health enhancement but a critical element of overall personal development, cognitive function, emotional well-being, and social engagement. Therefore, the interpretation and application of physical literacy in education and health should embody this monistic philosophy [ 18 ]. It necessitates an educational and healthy approach that equally prioritizes physical and mental development, integrating physical activity into the broader context of personal growth and holistic well-being.

The definition of health has been the subject of extensive scholarly focus. According to the World Health Organization, health encompasses a four-dimensional state comprising physical, mental, social adaptability, and moral perfection. Stainton Rogers proposed that health is synonymous with “right living,” spiritual well-being, and divine care [ 19 ]. On the other hand, Schad defined health as an individual’s lifelong capacity to sustain a perfect life [ 20 ]. Interestingly, older Chinese Americans perceive health as a “balance of yin and yang” [ 21 ]. From the perspective of the British Greeks, health is an individual’s ability to work, perform household chores, and fulfill social obligations [ 22 ]. Mckague conceptualized health as a person’s capacity to meet expectations [ 23 ]. In recent years, an emerging viewpoint links health and well-being, suggesting that health is a state where physically fit individuals can effectively manage events and avoid undesirable states [ 24 ]. This perspective is rooted in a vision of human flourishing. In synthesizing these varied definitions, we contend that the essence of health aligns with the World Health Organization’s proposal of a four-dimensional state of completeness.

The realization of individual health requires attention and practice in schools, and leading students to understand the value of physical activity for physical and mental health is the basis for improving physical literacy and is the key to promoting individuals to develop a lifelong philosophy of physical education [ 25 ]. Schools should lead students to experience the enhancement of physical activity for individual well-being and to gain knowledge and understanding of the principles of holistic health to develop a clear position on the value of physical activity in enhancing overall health and well-being [ 26 ]. There are many aspects to maintaining overall health through physical literacy, including respecting the physical nature of the human condition, monitoring physical and mental well-being, building a balanced life comprised of various interests and activities, and finding a balance between new challenges and existing habits. Starting with a well-founded “standpoint” in the field of movement to understand opportunities can bring significant value in assessing personal well-being and making life choices [ 27 ].

Within the educational community, much of the literature addresses the dangers of physical inactivity disorders from the perspective of physical inactivity, with the most frequent being the serious academic consequences of physical inactivity [ 28 ]. The primary reason for the current social concern about physical health and people’s well-being is that due to the lack of physical activity, related physical activity deficiency disorder diseases are gradually appearing in more and more people, creating enormous financial pressure on the healthcare security systems of various countries [ 29 ]. This expense is borne to a large extent by people’s taxes, leading people into a physical activity deficiency disorder-access to health care-financial stress-taxation-decreased well-being circular path [ 30 ].It is evident that technology-driven society has led to an increasingly severe lack of human physical activity, and the lack of physical activity has a significant impact on human culture, healthcare, finance, education, and other fields [ 31 ], which seriously affects the realization of the vision of human prosperity. Less study based on bibliometric analysis has summarized the research progress of physical literacy from recent decades.

Utilizing bibliometric analysis, a methodology grounded in mathematical and statistical techniques, this study undertook a systematic review of articles pertaining to physical literacy over a span of time. The analysis presents comprehensive data on the countries or institutions producing these articles, co-authorship patterns, and the frequency of keywords crucial for deciphering the hotspots and trends in physical literacy research [ 32 ]. Collaboration among countries, authors, and institutions was scrutinized through tables and graphs to better discern the leading contributors to physical literacy research. This approach aids in comprehending the areas that have made significant progress and contributions. Furthermore, an examination of keywords related to physical literacy was conducted. Finally, publication trends in literature associated with physical literacy were explored using line charts. Through this study, our objective is to offer a more comprehensive and intuitive understanding of the shifts in developmental trends and popular research directions within international physical literacy research. This will serve as a valuable reference for shaping the future direction of physical literacy research.

Search strategy

To ensure the authority and scientific validity of the research subjects, the data source for this analysis was the Web of Science core collection (including SCIE/SSCI/A&HCI and ESCI, etc.) as the data source, which derived from Clarivate Analytics, contains more than 12,000 international academic journals and is recognized as a comprehensive and authoritative database [ 33 ].The data search strategy was as follows: (1) Subject="Physical literacy”; (2) Document type= (review or article); (3) Language="English”; (4) Search date = From January 1, 2015 to April 15, 2023. All data were obtained on April 15, 2023. A thematic search was used to balance accuracy and completeness, and a total of 3,439 documents were extracted. VOSviewer software v.1.6.18. was used to analyze the sample literature in order to obtain the evolutionary relationship between hotspots and trends in physical literacy research. For better use in VOSviewer analysis, this study exported the documents as Plain Text File with Record Content of Authors, Title, Source, Times Cited Count, Accession Number, and Abstract. The processing parameters were set as follows: annual interval 2015–2023, time slice of 1 year, and thematic sources as full citations and citation references.

About text preprocessing

VOSviewer software emerges as a robust tool for bibliometric analysis, boasting unique features that negate the necessity for extensive data preprocessing. Its strength lies in the seamless integration of the VOS mapping technique and an advanced viewer into a single, user-friendly computer program. With a distinct emphasis on graphical representation, VOSviewer offers an intuitive display for large bibliometric maps, as demonstrated in constructing a co-citation map involving 5,000 major scientific journals [ 34 , 35 ]. Notably, its efficiency in capturing current trends in science and technology surpasses traditional methods, evidenced by the swift analysis of articles, papers, and patents. Nees Jan van Eck and Ludo Waltman extensively explore the program’s functionality and technical intricacies in their respective papers [ 36 ].

Furthermore, VOSviewer’s inclusion of text mining functionality empowers users to analyze extensive textual data efficiently. Despite encountering some missing values and minimal anomalies, a deliberate decision was made to forgo data preprocessing, aiming to preserve the raw state of the data for a more authentic representation of real-world scenarios. Acknowledging the potential impact of unprocessed data on experiment results, this approach is chosen to provide a more genuine perspective on physical literacy in our study. This decision aligns with VOSviewer’s capabilities, making it a versatile and comprehensive tool for researchers and analysts in bibliometrics.

Date analysis

In analyzing the data, we evaluated the following aspects: (1) Country and institution of publication, analyzing the current status of international research on the topic by country and institution of publication; (2) Years of publication, highlighting the focus of the literature at different time points; (3) Concentration of keywords in the articles, highlighting the most frequently used keywords in the article collection; (4) Authors with the most published articles and the nationality of the authors; (5) WOS categories, analyzing the yearly trend of the literature on the topic of “physical literacy” and the correlation coefficient. (6) WOS categories, analyzing the publishers, publishers, and journals; (7) The annual trend of publications on the theme of “physical literacy” and the correlation coefficient analysis.

Country & institution analysis

The country was selected as the node type and ran to obtain a network map of the current international geographic contributions to physical literacy-related research. In the knowledge map, the size of the circle represents the citation history of the topic, and the larger the circle is, the higher the frequency of the topic’s appearance. First, regarding country analysis in Figs.  1 and 2 , the highest number of articles was 1,070 in the United States, 439 in Australia, 343 in Canada, and 270 in the United Kingdom. In terms of article relevance, the highest U.S., Canada, UK. In summary of the data the United States and the United Kingdom have more significant research on physical literacy and stronger correlations between them, indicating that the two countries have more theoretical and practical achievements in physical literacy research. From the analysis of its theoretical level, the theory of physical literacy was laid by the British scholar Whitehead from the philosophical level. The US research-related theories are primarily based on Whitehead’s theory of physical literacy. At the same time, Canada and Australia have developed many physical literacy assessment tools related to CAPL and PFL, which undoubtedly triggered the research enthusiasm of scholars in related fields.

Country co-existence time analysis map

Country co-existence map

In terms of the institutions that publish articles in Figs.  3 and 4 , higher education institutions are the main force of physical literacy-related research, concentrated in the United States, Canada, Australia, and other developed countries’ top universities, mainly including the University of Sydney, Deakin University, Stanford University, Columbia University, Newcastle University, Flinders University, University of California, University of Ottawa and so on. These universities have a medical and sports science-based. The authors of these articles are primarily students or faculty members of these two fields of study.

Issuing institutions time map

Issuing institutions co-current map

Keyword co-occurrence analysis

Keyword co-occurrence map

Keywords are usually the core content and methodological refinement of a paper, and the frequency of keywords in a field can visually reflect the distribution of research hotspot directions centered on that topic. The keyword network map of current physical literacy-related research was run by selecting the node types as keywords in Fig.  5 ; Table  1 . It can be seen that among the current literature on “physical literacy”, international research mainly focuses on adults, adolescents, and children, including health literacy, health, physical activity, exercise, prevention, behavioral habits, literacy, and other aspects. The time zone analysis chart more clearly shows the evolutionary path of the hotspots of physical literacy research. Although the formal definition of physical literacy is concise, its theoretical research has developed very fast, from the early focus on children and adolescents’ physical activity to the gradual development of individual physical literacy through education and the proliferation of the curriculum, policies, measurement tools, skills and knowledge, after which physical literacy is often associated with issues such as health levels, motivation, public health, physical activity deficit disorder, and human flourishing. Physical literacy and human health have recently become an emerging trend in international scholarship. In terms of changes in research hotspots, over time, research on physical literacy has seen a shift from a focus on individual motor skills to a focus on human health, and overall, physical literacy has become increasingly relevant to physical health as an essential literacy for human health.

Main authors and number of citations

Figure  6 ; Table  2 show the authors who have published more papers in “Physical Literacy”: Tremblay, Mark S. and Longmuir, Patricia E. from Canada with 23 and 24 papers, respectively, and Cairney, John from Australia with 36 papers. From the figure and table, we can learn the number of articles published by the first author of the paper and the number of citations to the article.

The first author of the article co-presents the figure

WOS categories

In the WOS core collection, all literature is divided into 191 categories, of which health and wellness is the category with the most significant number of articles (750), followed by education and teaching research (571), sports science (302), and health care science services (246). Table  3 shows, in addition to the categories with the highest number of articles, the journals and publishers with the highest number of papers published under the title “physical literacy.” The journal with the most articles was the International Journal of Environmental Research and Public Health, with 147 articles. In contrast, the publisher with the highest number of articles was Springer Nature, with 498 articles.

Annual publication trends

Trends in publications

Through the WOS core database, we found 3,446 articles published from 2015 to April 15, 2023, with 2022 being the most published year, with 686 articles published on “physical literacy.” Since 2015, the literature on “physical literacy” has shown an exponential increase with a fit rate of R²=96.74% in Fig.  7 .

This study aimed to analyze current international trends in physical literacy and research hotspots to provide a comprehensive and practical review to the scientific community in a visual manner. A bibliometric study of articles on physical literacy revealed that research on physical literacy and health has evolved rapidly from establishment to emergence. The various definitions of health provide a broad context, yet the concept of physical literacy, a critical aspect of overall health, still needs to be more adequately explored. Although Cairney constructed a circular argument framework based on health, physical literacy, and physical activity, physical literacy has yet to receive much attention [ 37 ]. This may be because the term “health literacy” has been commonly used in the academic community to describe the ability of individuals to maintain their physical health actively. Physical literacy is believed to be considered health literacy in the medical field [ 38 ]. Therefore, this study analyzes the relationship between “Physical literacy” and “Health literacy”. Based on these analyses, we investigate the concept of physical literacy as a meaningful concept based on physical activity and further argue for the circular enhancement pathway of health, physical literacy, and physical activity proposed by Cairney et al.

General information study

The upward trajectory of scholarly output on physical literacy since 2015, peaking in 2022, underscores the burgeoning interest within the academic community. Predominantly, developed nations such as the United States, Canada, Australia, and the United Kingdom have been at the forefront of this discourse, as depicted in Fig.  1 . The United States, in particular, exhibits a robust interconnection with international research efforts, signifying its pivotal role in advancing physical literacy scholarship. Regarding institutional contributions, a concentration of seminal work emanates from developed countries, with prestigious entities like the University of Sydney, Deakin University, Stanford University, and Columbia University leading the charge. This confluence of geographic and institutional provenance indicates that developed nations have established a significant lead in physical literacy research, outpacing their counterparts in the developing world, where research in this area is emerging and needs augmentation.

The disparity in research output can largely be attributed to the superior financial and infrastructural provisions available in developed countries, which foster environments rich in high-caliber research institutions, cutting-edge laboratory facilities, and comprehensive funding opportunities for physical activity research. Conversely, developing nations often grapple with resource allocation challenges, necessitating prioritization of immediate societal needs such as infrastructure over research endeavors. Moreover, the academic milieu in developed countries is inherently conducive to generating high-quality research, bolstered by a tradition of frequent academic discourse and international collaborations that enhance both the caliber and the innovative potential of scholarly work on physical literacy.

An analysis of the 3,439 articles published reveals that the top five journals account for 337 publications, representing approximately 11% of the total volume. John Cairney stands out as the most prolific author in the field, extensively exploring the interconnections between physical literacy, health, and physical activity, often employing a cyclical argumentative structure to encapsulate these interdependencies. The International Journal of Physical Literacy and Physical Activity is a frequent publisher in this domain. Meanwhile, the International Journal of Environmental Research and Public Health boasts the highest publication frequency (0.4%), reflecting a health-centric journal’s predilection for physical literacy topics, corroborated by the keyword analysis in Fig.  5 ; Table  1 . The analysis confirms a robust association between the literature on physical literacy and health-related themes, providing insights into the evolving trends and focal areas within the field. In the subsequent sections, the focus will be on the relationship between physical literacy and health.

Physical literacy and physical activity

The development of physical literacy allows participation in lifelong physical activity through improved motor skills and cognitive-emotional abilities [ 39 ]. From a biological perspective, life is how living things exist in the world, and as social beings, individual lives cannot meet the needs of social life. Therefore, to view life from the perspective of physical literacy is to perceive the world in terms of physical activity, to experience the meaning of life, and to relish it. Physical activity is ubiquitous in life; life is the basis of life, and the integrity and health of life depend on the subjective activities of human beings. Physical activity is the basis for human beings to achieve freedom and comprehensive development of life [ 40 ].

At present, the educational concept that physical literacy can effectively promote the healthy growth of youth and that physical activity can make life more meaningful has become a global consensus [ 41 ]. However, physical activity is not synonymous with childhood nor an exclusive term in education, but it is all those human beings do in their daily lives. Physical literacy plays a significant role in human beings’ lifelong physical participation and healthy development [ 42 ]. As actual human beings, we need to see ourselves as an existential whole, which is, in essence, how we interact with the world, that is, when the more physically active we are, the better we perceive the world [ 43 ], physical literacy provides a rational explanation for physical activity, and technological developments in contemporary society have increased the demand for physical activity, and a study has shown that An effective way to improve the level of physical literacy is to reduce the amount of sedentary time [ 44 ], this is because, while physical activity was once used to meet the needs of material life, physical activity nowadays is more about improving the quality of human life in terms of spiritual life, and although the human civilization system constructed by modern society has cultivated the inner qualities of rationality and solidarity, it has also to some extent suppressed the instinct of human beings as animals, which is the ability to be strong through physical skills to demonstrate muscular physique, proficiency, and thus spiritual satisfaction [ 45 ]. Physical literacy, as a lifelong concept, is proposed not only for the healthy growth of youth but also for the vision of prosperity of all human beings; its essence is the development of the individual and the realization of personal potential through physical activity to promote social development. Therefore, this section analyzes how physical literacy and physical activity are developed based on the elaboration of the role of physical literacy in the whole life cycle [ 20 ].

As can be seen from Table  4 , physical literacy, as a concept covering the whole life cycle, has different training modes and influencing factors at different ages. The training process of physical literacy is not an overnight process but a continuous process [ 46 ]. Based on monistic physical literacy, the concept of well-being from the perspective of the whole person is upheld. Exercise mode, mental skills for self-management, and basic health and nutrition knowledge are taken as essential components to achieve physical and mental health [ 47 ]. When carrying out physical activities, every movement must go through the procedure of “perceiving the world-processing information. Therefore, developing physical literacy is realized through constant autonomous human activity, a cognitive process in which we perceive the world through our bodies and judge it through our minds [ 48 ].

Physical activity and physical health

Guiding humans to understand the impact of physical inactivity on physical health remains the most significant challenge for the public health community today [ 49 ]. The World Health Organization has proposed that health is a four-dimensional state of physical, mental, social adaptability, and moral perfection, and whether the definition of health needs to be redefined for better understanding and use under new social conditions, physical activity provides a suitable explanation for health [ 50 ]. In 21st-century society, human beings are gradually domesticated by technology, and society is characterized by technological and instrumental rationality. Developed countries, led by the United States, the United Kingdom, and Switzerland, have been more severely affected by technology, with the United States experiencing a 32% decline in national physical activity from 1965 to 2009 and emerging countries rapidly following in its footsteps, with China experiencing a 45% decline in national physical activity from 1991 to 2009 [ 6 ].

The Lancet states that as of 2022, global progress in promoting physical activity remains stagnant, with more than 5 million deaths yearly due to physical inactivity [ 51 ]. The neglect of physical activity has led to the trivialization and even denial of physical education that promotes physical and mental health, weakening individual subjectivity and adversely affecting physical, mental, social interactions, and spiritual pursuits. The health benefits of appropriate physical activity, including reduced risk of cardiovascular disease, diabetes, and cancer, are well established [ 52 ]. Obesity, now the most prevalent disease in the world, arose from excessive energy intake and reduced energy expenditure, corresponding to unhealthy dietary habits and chronic physical inactivity, respectively [ 53 ]. It is now established that physical activity effectively reduces the risk of obesity [ 54 ]. It has been shown that dietary habits are associated with sedentary behavior, which is defined as static physical activity with low energy expenditure in a sitting, lying, or supine position, and that chronic sedentary behavior also increases the probability of non-communicable diseases and the risk of death, with sedentary time exceeding eight hours per day increasing mortality by nearly 8% [ 50 ]. The literature shows that active physical activity is strongly correlated with physical health and that regular physical activity is essential to achieving human health and improving quality of life [ 55 ].

At the same time, recent studies have reported that at least 20 min of moderate-to-vigorous physical activity per day can reduce the prevalence of cardiovascular disease in adults by 16–40% [ 56 , 57 ] and that a physically inactive an active lifestyle will increase the likelihood of chronic non-communicable diseases and increase the risk of cancer, which together raise the risk of death [ 58 ]. An American College of Sports Medicine created a physical activity guide chart for different populations based on the intensity and frequency of physical activity, aiming to promote the development of national physical activity habits and the level of national physical health through this guide [ 59 ]. The level of physical activity determined the mental health of individuals, with higher intensity of daily physical activity being associated with higher mental health scores in subjects [ 60 ]. From the literature related to physical activity and physical health, it is clear that physical activity is a determinant of physical health. If a person misses physical activity, he will be unhealthy or subhealthful [ 50 ]. This can redefine the concept of health from the perspective of physical literacy. That is, health is a complete state based on physical, mental, and social adaptability and morality based on physical activity. The overall improvement of physical literacy can lead to higher physical quality and a healthier lifestyle, thus achieving comprehensive physical and mental health development [ 61 ]. Recently, Japanese scholar INOUE Kosuke proposed a 14.9% reduction in all-cause mortality in people who performed 1–2 walks of 8000 steps or more per week and a 16.5% reduction in the risk of all-cause mortality in people who took 8000 steps or more 3–7 days per week based on 10-year-long follow-up data [ 62 ].

German scholar Lars Gabrys et al. suggested that long-term physical activity could improve cardiometabolic health, while abrupt interruptions in regular physical activity would increase the incidence of cardiometabolic disease [ 63 ]. Therefore, understanding physical activity as a determinant of health within this concept of health will be vital to developing effective interventions targeting public health [ 64 ]. Good levels of physical literacy are strongly correlated with maintaining a high frequency of physical activity, with physical literacy being a key indicator of promoting physical activity and health levels in secondary school students to help them maintain an active lifestyle [ 65 ]. A recent study by Caldwell et al. demonstrated that the determinants of physical health in adolescents are their possession of high levels of physical literacy, that these adolescents have a better quality of life, and that promoting physical health through physical activity helps them maintain a low risk of prevalence of chronic non-communicable diseases in the long run [ 66 ]. Another study showed a negative correlation between the intensity of physical activity and individual BMI. Those who are regularly physically active also have the initiative in body image management [ 67 ].

Physical health and physical literacy

Physical literacy describes “the value and responsibility of an individual’s motivation, confidence, ability, knowledge, and understanding of lifelong physical activity” [ 68 ], which is based on physical activity and integrates physical cognition and experience. Physical literacy holds a unique significance in promoting physical health, enabling individuals with proficient physical literacy to address existing health issues through physical activity and prevent the onset of diseases. In the discourse surrounding physical literacy, it is posited that its ultimate purpose is to cultivate individuals who are both healthy and holistically developed, thereby maximizing human potential [ 69 ]. The concept of physical literacy embraces the diversity of physical activities, acknowledging that not all are explicitly aimed at health outcomes. For instance, although fundamentally functional or mechanical, occupational tasks and everyday activities are pivotal in realizing value and engaging with the world as individuals interact with their environment [ 70 ]. Value is realized in mechanistic or functional physical activities. Within the framework of physical literacy, health-oriented physical activities should not be perceived as a coercive health-centric agenda. Instead, it fosters a comprehensive perspective on physical activity, recognizing multiple dimensions and benefits, with health being just one of many. The conception of health promoted by physical literacy aligns with the pursuit of human flourishing, where even mechanical or functional work is seen as an opportunity to enhance physical capabilities, confidence, and motivation. Physical activity is not solely a pursuit of health but is a pursuit of true freedom by humans as advanced intellectual animals. Physical literacy fosters a sense of bodily freedom, enabling us to navigate the world, interact with others, and fully participate in the variegated experiences of humanity [ 71 ]. Hence, mechanistic or functional physical activities are not the focus of physical literacy. Our bodies evolved to thrive in diverse environments, and advancing human technology aims to achieve greater freedom, not diminishing physical activity [ 2 ]. Our well-being is contingent on the diverse challenges and contexts within the world, and it is through engaging in these physical activities we find meaning in life and fulfill the ultimate aim of physical literacy [ 72 ].

The keyword co-occurrence shows that “health literacy” still appears more frequently in the literature on “physical literacy” because health literacy has been proposed earlier. However, there is a lack of “physical activity” transformation into “fitness activity.” This is because health literacy was introduced earlier but lacks the process of transforming “physical activity” into “fitness activity,” so physical literacy is different from health literacy in Fig.  8 . Chinese scholars such as Zhou Wansheng distinguished the connotation and relationship between physical literacy and health literacy from the perspective of sports ontology, pointing out that physical literacy comes from embodied human beings, which is the unity of body, mind, cognition, and behavior, and is used to describe the physical activities that human beings have to perform throughout their lives. In contrast, health literacy comes from the health education model established by human beings to promote health. Its fundamental purpose is to cultivate healthy human beings [ 73 ]. However, the ultimate purpose of physical literacy is to cultivate physically healthy and well-rounded people. Physical literacy and health literacy are interrelated, mutually influencing, and promoting each other rather than being separate individuals [ 74 ].

Physical literacy and health literacy

For many years, the Western world has been influenced by the Cartesian mind-body dichotomy, where physical activity has become less and less important, and sport is seen as a tool to achieve other purposes [ 75 ]. However, a growing body of research suggests that physical and mental development is integrated and that physical activity contributes to brain development during adolescence, where adolescents experience the world and enhance their perception of it through physical activity while also being able to develop basic motor patterns [ 14 ], which can be developed to lay the foundation for higher levels of physical activity and provide a great contribution to a full and high quality of life [ 76 ].

Therefore, the embodied and motor nature of humans is a critical pathway for our interaction with the world [ 77 ]. Developing physical literacy is fostering human initiative and stimulating individual potential, as well as developing individual self-esteem, self-confidence, and other abilities that have a positive correlation with attitudes toward physical activity [ 78 ], people with higher self-confidence and self-awareness will maintain a more positive attitude toward physical activity, physical literacy is intrinsic to life development, and there is growing evidence that the earlier the level of physical literacy is developed The more beneficial it is for physical activity in later life [ 14 ], a physical literacy development program in the United States that students should be provided with activities that are appropriate for them and allow them to feel the process of activity rather than the outcome [ 63 ], physical literacy is based on existentialism, phenomenology, and mind-body monism as theoretical foundations, and in recent years, physical literacy has been gradually viewed as an indirect factor of health, existential physical literacy, physical activity, physical health pathway, where improved physical literacy leads to more physical activity, and people with good physical literacy continuously engage in physical activity, resulting in positive physical, psychological, and social adaptations that improve individual physical health [ 37 ], based on Whitehead’s definition of physical literacy, physical literacy is true at all ages in humans [ 79 ], from infancy to old age, Hilary A.T., Caldwell et al. verified that physical literacy has a positive correlation with health through a combination of PLAY fun, PLAY self, and PLAY parent [ 80 ], and in Canada, children who met Canada’s own physical activity guidelines showed In Canada, children who met Canada’s national physical activity guidelines showed better fitness, motivation, and confidence [ 81 ], which could prove the purpose of physical literacy, which was proposed to reverse the current decline in human physical activity and to make life more meaningful and address the “existential crisis” people are currently facing [ 7 ].

Our study aims to comprehensively and intuitively map the evolving landscape of international physical literacy research, offering valuable guidance for future research trajectories in this area. By visualizing the data, this study found that since 2015, the trend of exponential growth of articles on the topic of “physical literacy” and the increasing trend of research on physical literacy for health indicates that the international scientific community is increasingly interested in the research on “physical literacy and is gradually exploring the possibility of promoting human health through physical activity and changing the current trend of declining quality of life. This indicates the international scientific community’s growing interest in “physical literacy” and the progressive exploration of physical activity to promote human health and change the declining quality of life. Regarding the sources of the articles, the International Journal of Environmental Research and Public Health, BMC Public Health, BMJ Open, and Journal of Medical Internet Research, the most significant number of articles was published in the Journal of Medical Internet Research, with more than 45 articles. Regarding the keywords of the articles, these papers mainly focused on physical activity, physical literacy, and health literacy, and the number of occurrences of these three keywords was 740, 608, and 258, respectively.

It is evident that physical literacy, as an emerging concept, has become a growing and crucial topic. In recent years, physical literacy has emerged as a scene to discuss the relevance of physical activity and health, to discuss that developing physical literacy can improve various domains (physical, cognitive, mental, and emotional) in which individuals participate in physical activity so that through the improvement of individual physical literacy they can better feel the pleasure and meaningfulness, increasing human confidence in performing physical activity, and thus increasing human attitudes toward having a more active and healthy lifestyle. However, the country mapping shows that the current research on physical literacy is more in developed countries such as the United States, Australia, Canada, etc. Most countries have studied physical literacy late and have not combined physical literacy with physical health, or some countries have only used physical literacy to study specific groups (elderly, disabled), which is contrary to physical literacy as an ability that all human beings have. This is contrary to the ability of physical literacy as a human individual. Based on the above, this study further demonstrates a circular pathway between physical literacy, physical health, and physical activity based on previous research.

Despite the insights this study provides into the research hotspots and trends in physical literacy, several limitations exist. This study is confined to the WOS core collection, and while extensive, our analysis may need to be more comprehensive. Secondly, our research is limited to articles written in English as the writing language. Thirdly, the study does not take into account the quality of the publications, a factor that could have an impact on the results. Finally, although the VOSviewer is a professional bibliometric analysis software tool that provides objective analysis, there may be some subjective deviation as researchers may have different perceptions and interpretations of the same content.

Data availability

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

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Fang, X., Zhang, Z. Hotspots and trends in health-oriented physical literacy research: a visual analysis based on the WOS database. BMC Public Health 24 , 1480 (2024). https://doi.org/10.1186/s12889-024-18951-7

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Adoption of mobile learning in the university context: Systematic literature review

Roles Conceptualization, Data curation, Visualization, Writing – review & editing

* E-mail: [email protected]

Affiliation School of Industrial Engineering, Universidad Señor de Sipán, Chiclayo, Perú

Roles Data curation, Investigation, Methodology, Writing – original draft, Writing – review & editing

Affiliation Centro de investigaciones, Institución Universitaria Escolme, Medellín, Colombia

Roles Formal analysis, Resources, Software, Writing – review & editing

Affiliation Coordinación de Investigaciones e Innovación, Fundación Universitaria Católica del Norte, Medellin, Colombia

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Affiliation Facultad de Ciencias Económicas Administrativas y Contables, Fundación Universitaria Católica del Norte, Medellín, Antioquía, Colombia

Roles Investigation, Software, Visualization, Writing – review & editing

Affiliation Instituto de Investigación y Estudios de la Mujer, Universidad Ricardo Palma, Lima, Peru

• Alejandro Valencia-Arias, 
• Sebastian Cardona-Acevedo, 
• Sergio Gómez-Molina, 
• Rosa María Vélez Holguín, 
• Jackeline Valencia

• Published: June 7, 2024
• https://doi.org/10.1371/journal.pone.0304116
• Peer Review
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The study on the adoption of mobile learning in university education reveals a growing interest in mobile technologies to improve the learning process; both the acceptance and rejection of these tools among students have been analyzed. However, there are gaps in the research that require a deeper exploration of the factors that influence the adoption and use of these technologies. Understanding these aspects is crucial to optimize mobile learning strategies and improve the educational experience in the university setting. The objective is to examine research trends regarding the topic. PRISMA-2020 is used in the Scopus and Web of Science databases. The results show the questionnaires as the main collection instruments; geographical contexts show that it has been researched predominantly in Asia; The studies have focused on university students; the most applied theories are TAM and UTAUT; and latent variables such as behavioral intention and attitude. The conclusions summarize the trends and patterns observed in the reviewed literature, as well as the research gaps identified, providing a solid foundation for future research and highlighting the importance of addressing this issue in the current context of digital education. The systematic review identifies key models and factors in the adoption of mobile learning in university settings, revealing both theoretical and practical implications. Furthermore, this text provides practical guidance for selecting effective data collection tools and making informed educational and policy decisions. However, it acknowledges limitations such as potential publication and language bias in the search process.

Citation: Valencia-Arias A, Cardona-Acevedo S, Gómez-Molina S, Vélez Holguín RM, Valencia J (2024) Adoption of mobile learning in the university context: Systematic literature review. PLoS ONE 19(6): e0304116. https://doi.org/10.1371/journal.pone.0304116

Editor: Eric Amankwa, Presbyterian University College, GHANA

Received: February 13, 2024; Accepted: May 6, 2024; Published: June 7, 2024

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

Data Availability: The data underlying the results presented in the study are available from https://doi.org/10.5281/zenodo.10655493

Funding: The author(s) received no specific funding for this work.

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

1. Introduction

The integration of mobile learning platforms in the university context is a significant topic of interest in contemporary educational research. With the growing prevalence of mobile devices and digital technologies, these platforms have been adopted to improve accessibility and flexibility of learning. Mobile learning is the use of mobile devices to facilitate the teaching and learning process. It has transformed educational dynamics by allowing students to access educational resources at any time and place [ 1 ]. This modality of education not only offers flexibility in terms of time and location but also provides opportunities for personalized learning, peer collaboration, and active student participation [ 2 ].

The acceptance and adoption of mobile learning among students and teachers is a crucial research topic that has generated a significant body of literature. Theoretical models have been proposed to understand the factors that influence students’ intention to use mobile learning. These models highlight elements such as previous experience with technology, perceived usefulness, and ease of use [ 3 ]. Recent research has also explored how factors such as mobile self-efficacy and 21st-century skills influence the willingness of teachers to adopt mobile learning technologies in their pedagogical practices [ 4 ].

Empirical analysis has identified reasons and perceptions that influence the adoption of mobile learning applications among students [ 5 ]. Investigating the changing dynamics and emerging contexts in the use of mobile learning is crucial, particularly in light of external events such as the COVID-19 pandemic, to understand students’ response to and experience with educational technologies [ 6 ].

The integration of mobile devices and digital technologies in university learning environments has made mobile learning an increasingly popular topic. This is due to its potential to improve the accessibility, flexibility, and effectiveness of learning. Mobile learning allows students to access educational resources conveniently and personalize their learning experience anytime and anywhere. Its adoption is important because it can transform traditional teaching methods and facilitate the creation of more dynamic and interactive learning experiences [ 7 ].

Recent research has investigated different aspects of mobile learning adoption in the university context. These studies have analyzed the factors that affect students’ perception of mobile learning and its impact on enhancing learning. For instance, researchers have analyzed mobile learning adoption models that consider student perceptions as key determinants for improving the learning process [ 8 ]. Additionally, studies have identified socioeconomic and cultural factors that influence students’ attitudes towards the use of mobile devices in learning, highlighting the importance of understanding contextual differences in the adoption of these technologies [ 9 ].

Understanding the factors that influence the adoption of mobile learning systems among university students is crucial for designing effective implementation and promotion strategies. Previous studies have examined the impact of theoretical models, such as the Technology Acceptance Model (TAM) and the SOR (Stimulus-Organism-Response) Model, on enhancing learning through mobile learning [ 10 ]. In 2023, the adoption of mobile learning systems in the Indonesian educational context was examined, emphasizing the significance of cultural and contextual factors in their implementation [ 11 ]. These studies underscore the importance of researching and understanding the adoption processes of mobile learning in the university context to optimize its potential as an educational tool.

The topic analyzed in this study has gaps that require attention and systematic analysis. Although various systematic reviews have been carried out in the field of mobile learning adoption, there is a need to delve into current trends and the factors that influence the acceptance and use of these technologies in specific university environments. For instance, while studies like Kumar and Chand [ 12 ] and Alsharida et al. [ 13 ] have explored the general adoption of mobile learning, further research is needed to examine how factors such as technostress and compatibility can impact the adoption of mobile learning among foreign language learners, as suggested by Wang et al. (insert year here). These gaps in the literature justify conducting a systematic review in 2022 that integrates and critically analyzes the available evidence. This will allow for the identification of emerging research areas and contribute to the theoretical and practical development of mobile learning adoption in specific university contexts. The purpose of this study is to analyze research trends in the adoption of mobile learning in the university context from 2013 to 2024. The following questions will guide the research:

• RQ1: What are the primary data collection instruments utilized in articles regarding the implementation of mobile learning in university settings?
• RQ2: In what geographical contexts has the implementation of mobile learning in university settings been studied?
• RQ3: What are the various population segments that have been the focus of research on the implementation of mobile learning in university settings?
• RQ4: What psychobehavioral theories are used to understand the adoption of mobile learning in the university context?
• RQ5: What are the primary latent variables or constructs used to comprehend the adoption of mobile learning in the university context?

This study compiles and synthesizes various theories, variables, and models used to understand the adoption of mobile learning in university educational environments. The aim is to identify predominant trends and approaches in research and offer a comprehensive vision of the factors that influence the acceptance and use of mobile learning in different university contexts worldwide. The study provides a solid foundation for building a unified mobile learning adoption model.

This study aims to identify the countries and populations that have been researched in this field. Recognizing geographical and demographic variations in the implementation and acceptance of this educational modality is important. The goal is to develop a conceptual framework based on the unified model that is applicable and relevant in various cultural and socioeconomic contexts. This integrative approach enables us to advance the theoretical understanding of mobile learning adoption in higher education and inform more effective and contextualized educational implications.

2. Methodology

Exploratory research was conducted using secondary sources. The methodology was based on the parameters and guidelines established by the PRISMA-2020 declaration, which provides a rigorous and transparent framework for conducting and presenting systematic reviews. Relevant studies were carefully selected, and key data were extracted to explore the factors that influence the adoption of mobile learning in specific university environments. This allowed for the identification of trends, research gaps, and areas of interest for future research in this emerging field of digital education.

2.1. Eligibility criteria

The eligibility criteria are divided into two sections. The first section includes inclusion criteria that mainly focus on titles and keywords as metadata. Specifically, it looks for the combination of terms such as ’mobile learning’ and ’university’ in various forms of citation, including variations such as ’m-learning’ and ’mobile learning’. These criteria allow for an exhaustive and precise search for relevant studies that address the adoption of mobile learning in university environments, ensuring the inclusion of the most relevant literature for analysis.

The exclusion process involves three phases. The first phase excludes all records with erroneous indexing or those not directly related to the study’s topic. The second phase of exclusion aims to eliminate all documents for which full text access is not available. This phase applies only to Systematic Literature Reviews since the review in question focuses exclusively on the analysis of metadata. Finally, the third phase, the Exclusion phase, is responsible for discarding documents that do not present a clearly defined or explicit mobile learning adoption model. These exclusion criteria ensure the rigor and quality of the ongoing systematic literature review’s study selection process.

2.2. Source of information

The Scopus and Web of Science databases were chosen as the primary sources of information. Scopus and Web of Science are considered the main bibliometric databases today due to their wide coverage and reputation in the academic and scientific fields. Research, such as that conducted by [ 14 ], has compared the quality and coverage of different bibliometric databases, concluding that Scopus and Web of Science are two of the most complete and reliable platforms available. Similarly, Tennant [ 15 ] conducted a study comparing the quality and coverage of different bibliometric databases, contributing to the understanding of the scope of platforms such as Scopus and Web of Science in the field of scientific knowledge collection. Although it is important to acknowledge that no database is entirely comprehensive, both Scopus and Web of Science provide a broad selection of academic and scientific journals, along with advanced search and analysis tools, making them ideal options for conducting a systematic literature review in a university setting.

2.3. Search strategy

To facilitate the search for relevant studies in the Scopus and Web of Science databases, two specialized search equations were designed. These equations were adapted to the defined inclusion criteria and the search characteristics of each platform. They were meticulously developed to ensure comprehensiveness and precision in identifying relevant articles on the adoption of mobile learning in the university context. The search equations were materialized on January 30, 2024, taking advantage of the advanced search functionalities of both databases to maximize the collection of relevant literature in the field of study.

For the Scopus database: (TITLE (("mobile learning") OR (mlearning) OR (m-learning)) AND TITLE (student OR scholar OR undergraduate OR learner) AND TITLE ((adoption) OR (use) OR (acceptance) OR tam OR tpb OR utaut)) OR (KEY (("mobile learning") OR (mlearning) OR (m-learning)) AND KEY (student OR scholar OR undergraduate OR learner) AND KEY ((adoption) OR (use) OR (acceptance) OR tam OR tpb OR utaut))

For the Web of Science database: (TI = ((“mobile learning”) OR (mlearning) OR (m-learning)) AND TI = (student OR scholar OR undergraduate OR learner) AND TI = ((adoption) OR (use) OR (acceptance) OR TAM OR TPB OR UTAUT)) OR (AK = ((“mobile learning”) OR (mlearning) OR (m-learning)) AND AK = (student OR scholar OR undergraduate OR learner) AND AK = ((adoption) OR (use) OR (acceptance) OR TAM OR TPB OR UTAUT))

2.4. Data management

The study utilized the Microsoft Excel® tool to extract, store, and process information from selected databases. This tool provided an organized structure to record relevant data from identified studies, allowing for efficient subsequent analysis. Each article obtained from the databases underwent an extensive and thorough full-text review to identify its relevance, contributions, and findings regarding the adoption of mobile learning in university settings. This systematic and detailed approach ensured completeness and quality in the collection and analysis of scientific literature relevant to the study’s topic.

2.5. Selection process

Following the PRISMA 2020 statement guidelines, it is crucial to utilize internal automatic classifiers to facilitate the systematic literature review study selection process [ 16 ]. This practice helps to mitigate the risk of missing studies or incorrect classifications when applying inclusion and exclusion criteria more efficiently. Additionally, it is essential to validate these classifiers internally or externally to understand and control the risk of bias in study selection. In this study, we utilized an automation tool created in Microsoft Excel® as an internal classifier. All researchers involved in the study independently applied this tool during the study selection process, using predefined inclusion and exclusion criteria. This approach helped to minimize the risk of missing studies or incorrect classifications by converging the results and carefully reviewing the extracted metadata.

Furthermore, we used a specific Microsoft Excel® tool to homogenize all the articles extracted from both sources of information. This facilitated the process of excluding duplicates and applying the predefined inclusion and exclusion criteria. This ensures clear and unambiguous identification of the texts that will be analyzed in-depth for this systematic literature review. It guarantees consistency in the selection process mentioned earlier and contributes to the study’s integrity and validity by minimizing the risk of missing relevant studies or making incorrect classifications.

2.6. Data collection process

As per the guidelines of [ 16 ], it is essential to specify the methods employed for collecting data from reports in a systematic literature review. In this study on the adoption of mobile learning in the university context, we used Microsoft Excel® as an automated tool for data collection from the selected databases, Scopus and Web of Science. The authors acted as reviewers for data validation, with each author conducting an independent evaluation to ensure an objective and thorough assessment of the information extracted from the studies. Subsequently, the authors collectively confirmed the data, comparing and contrasting the results obtained by each reviewer. The process was developed until achieving absolute convergence in the results, ensuring the reliability and integrity of the data collected in the literature review systematics.

2.7. Data elements

The objective was to gather data from all articles that met the research objective, which required adherence to the specialized search equation created for each database. This involved searching for results related to the implementation of mobile learning in the university context. The selected texts covered relevant measurements, time points, and analyses. However, if any information was missing or unclear, it was excluded as ’non-relevant texts’ since they do not contribute to the understanding of knowledge on the topic. The purpose and scope of the research were considered to ensure consistency, allowing for the inclusion of significant and relevant results for the analysis of the adoption of mobile learning in the university context.

2.8. Assessment of the risk of bias of the study

The process of assessing the risk of bias in the included studies was a collaborative effort among all authors. The authors used the same automated Microsoft Excel® tool for data collection and evaluation of included studies. Each author independently assessed the studies using predefined criteria to identify potential sources of bias. The use of this automated tool standardized the evaluation process, ensuring the quality and integrity of the results. This comprehensive and rigorous approach contributed to the validity and reliability of the systematic literature review on the adoption of mobile learning in the university context.

2.9. Measures of effect

It is relevant to specify that the effect measures traditionally used in primary research, such as the risk ratio or the difference in means, are not applicable in the analysis of secondary research sources. In this study, variables related to the data collection instruments, the geographical context of application of the study, the target population, the psychobehavioral theory used and latent variables within each evaluated model are analyzed. These aspects are addressed through the use of Microsoft Excel® to organize and analyze the data, as well as the use of VOSviewer® to determine thematic associations between the selected studies, this allows a deeper and more holistic understanding of the adoption of mobile learning in the university context, expanding the scope beyond conventional effect measures and providing a comprehensive view of the factors that influence this educational phenomenon.

2.10. Synthesis methods

It was established that all the studies included in the analysis had to be open access to ensure the availability of the full text and facilitate a thorough examination of each article. The data extracted from the selected studies were then stored in Microsoft Excel®. This tool provided a centralized platform to systematically tabulate and organize information, allowing for the comparison of study characteristics, preparation of data for presentation and synthesis, and efficient and coherent display of results. The use of Microsoft Excel® as a data management tool contributed to the rigorous organization and structured analysis of the information collected in this systematic review.

2.11. Assessment of reporting bias

When conducting a systematic literature review, it is important to be aware of potential biases towards certain synonyms found in thesauri, such as the IEEE. These biases may influence inclusion criteria, search strategy, and data collection, which could result in the exclusion of relevant studies that use alternative terms to describe the concept of mobile learning adoption. Additionally, excluding texts without a defined adoption model may lead to the omission of valuable information that could contribute to the understanding and construction of knowledge on the subject. Therefore, it is essential to take steps to mitigate the impact of these potential biases on the systematic literature review process.

2.12. Certainty evaluation

As part of this systematic investigation, we comprehensively and exhaustively evaluated the certainty of the body of evidence. We applied inclusion and exclusion criteria to each study to determine the suitability of the selected articles. Additionally, we conducted an individual evaluation of each article to identify any possible methodological biases or limitations of the study. These aspects were mentioned in both the description of the methodological designs and the discussion of the study’s limitations. This contributed to a comprehensive evaluation of the certainty of the body of evidence, ensuring the transparency and reliability of the results obtained in the systematic review of literature on the adoption of mobile learning in university contexts (see Fig 1 ).

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

Own elaboration based on Scopus and Web of Science.

https://doi.org/10.1371/journal.pone.0304116.g001

In this systematic literature review, the selection and exclusion of studies were carried out in several stages. First, we conducted an exhaustive search in selected information sources to identify relevant studies. Then, we eliminated duplicate records to ensure data integrity. Finally, we proceeded with the selection and exclusion of studies based on pre-defined criteria. Three exclusion phases were carried out, applying predefined criteria to discard studies that did not meet the research objectives and scope. After this rigorous selection process, 44 articles were included as pertinent and relevant to address the issue of mobile learning adoption in the university context.

The results section provides a comprehensive overview of the findings obtained from the systematic analysis of the relevant literature. This section presents the main emerging results of the review in an organized and structured manner. It addresses key aspects such as the instruments used for data collection, the geographical contexts where the phenomenon has been studied, the population segments under investigation, the theoretical models used, and the latent variables or constructs identified.

This systematic literature review examines the adoption of mobile learning in university environments, following the parameters established by the PRISMA-2020 declaration. The summary of the articles included in the study is presented in Table 1 , which includes only those that passed the inclusion phase and the three exclusion phases. This summary provides a clear and transparent understanding of the evidence base used in the analysis of the adoption of mobile learning in the university environment.

https://doi.org/10.1371/journal.pone.0304116.t001

Table 2 details the identification and classification of the data collection instruments used in the included studies. These instruments are essential for understanding how information related to the adoption of mobile learning is collected in the university context. The analysis reveals that questionnaires and surveys are the main data collection instruments used by researchers to gather information on the adoption of mobile learning in university environments. This provides a clearer understanding of the phenomenon.

https://doi.org/10.1371/journal.pone.0304116.t002

The study provides a comprehensive review of the geographical contexts in which various populations have been analyzed in relation to the adoption of mobile learning. Fig 2 presents these geographical contexts. The research highlights those Asian countries, including China, Turkey, Iran, India, Saudi Arabia, and Malaysia, among others, have been the most prominent in this field. Similarly, the topic has been extensively studied in Europe, with research conducted in countries such as Sweden, Spain, the United Kingdom, and Romania. This information offers a global perspective on the geographical distribution of research on mobile learning adoption in universities, highlighting worldwide areas of interest.

https://doi.org/10.1371/journal.pone.0304116.g002

In addition to the geographical analysis, the study provides context about the population that the different authors have researched to understand the determining factors of mobile learning adoption. This context is presented in Fig 3 . Research on the adoption of mobile learning in the university setting has primarily focused on university students in general, as well as students in various classifications. This suggests a broad and varied approach to understanding the topic. The information provides a clear vision of the interest groups in this field of research.

https://doi.org/10.1371/journal.pone.0304116.g003

Fig 4 outlines the theoretical frameworks and psychobehavioral models utilized by researchers to forecast the factors that influence the adoption of mobile learning. The authors predominantly use the Technology Acceptance Theory (TAM) followed by others such as the Unified Model of Acceptance and Use of Technology (UTAUT), Proprietary Models, Extended UTAUT, and Theory of Planned Behavior (TPB). This highlights the diversity of theoretical approaches used in research on the adoption of mobile learning in the university setting, contributing to a more complete understanding of this phenomenon.

https://doi.org/10.1371/journal.pone.0304116.g004

Fig 5 presents the main latent variables, factors, or constructs that different authors have adopted to understand the adoption of mobile learning among university populations in various geographical contexts. Researchers exploring the adoption of mobile learning in university settings have identified several key variables, including Behavioral Intention, Attitude, Expectation of Effort, Current Use, Compatibility, Confirmation, Academic Relevance, and Commitment. This information provides a deeper and more holistic understanding of the phenomenon.

https://doi.org/10.1371/journal.pone.0304116.g005

4. Discussion

This section provides a detailed analysis of the research results, presenting their relevance and meaning. The findings are discussed, and the theoretical and practical implications derived from the results are presented. The study’s limitations are also identified. The study identifies the main research gaps and proposes a research agenda based on the results. Additionally, a theoretical model on the adoption of mobile learning in university environments is presented, utilizing the main theories and variables identified. This section is crucial for contextualizing and providing meaning to the review results, as well as guiding future research in the field of university mobile learning.

4.1. Analysis of data collection instruments

The results section indicates that the primary data collection instruments used were questionnaires and surveys. Several studies have contributed significantly to the understanding of questionnaires as data collection instruments. For example, Kumar et al. (2022) examined the behavioral change among university engineering students in the acceptance of mobile learning after the pandemic, providing an insightful view on how students perceive and adopt this educational modality. Similarly, Camilleri and Camilleri [ 35 ] explored the utilitarian motivations and facilitating conditions for mobile learning, delving into the factors that influence the adoption of this technology.

Baghcheghi et al. [ 23 ] analyzed the factors that affect the adoption of mobile learning in health professional students using the Technology Acceptance Model. The study provided valuable information on students’ perceptions and attitudes towards the use of mobile devices for learning. This research, along with others in the literature, has significantly contributed to the understanding of the factors that influence the adoption of mobile learning in the university setting. It has been a key reference in this field of research.

4.2. Analysis of the geographical context of the adoption of mobile learning in the university context

The results section reveals that the theme has mainly occurred in Asia, including countries such as China, Turkey, Iran, India, Saudi Arabia, and Malaysia. It has also been observed in Europe, specifically in Sweden, Spain, the United Kingdom, and Romania. In China, Peng et al. [ 10 ] conducted a study on improving students’ English language learning through mobile learning, integrating the Technology Acceptance Model and the SOR Model. Kucuk et al. [ 1 ] proposed a model for medical students’ behavioral intention towards mobile learning in Turkey, examining their perceptions and attitudes in this educational field.

Azizi and Khatony [ 32 ] explored the factors that influence the intention of medical science students to adopt mobile learning in Iran, providing a detailed view of the variables that affect this decision. Gupta et al. [ 42 ] investigated Indian students’ perception of mobile learning as a tool for education during the COVID-19 pandemic. Alturki and Aldraiweesh [ 44 ] analyzed the use of mobile learning in higher education during the pandemic in Saudi Arabia, providing valuable insights into students’ experiences.

Saroia and Gao [ 34 ] investigated university students’ intention to use mobile learning management systems in Sweden, exploring their attitudes and perceptions towards this emerging technology. Additionally, Andujar et al. [ 31 ] examined the integration of flipped learning through mobile devices in Spain, exploring technological acceptance and the flipped learning experience. Abu-Al-Aish and Love [ 25 ] investigated the factors that influence the acceptance of mobile learning among students in the United Kingdom. Their study provides a detailed view of the elements that affect the adoption of this educational modality.

4.3. Analysis of the target population in the adoption of mobile learning in the university context

As previously mentioned, the topic has gained prominence in several countries including Jordan, Malaysia, Saudi Arabia, China, Spain, India, and Indonesia. The results section indicates that research on this topic has primarily focused on university students and students in general in these countries. Ismiyati et al. [ 48 ] conducted a study to investigate Semarang State University students’ intention to use mobile learning as an alternative to in-person learning during the COVID-19 pandemic. Alturki and Aldraiweesh [ 44 ] examined students’ perceptions of the actual use of mobile learning in higher education during the pandemic, providing a detailed view of their experiences.

Lo et al. [ 47 ] conducted a study on augmented reality-based learning for natural science inquiry activities in primary schools in Taiwan, from the perspective of sustainable development. The study focused on students in general. Research sheds light on the effectiveness and sustainability of AR-based learning in the Taiwanese school context. These investigations represent significant contributions to understanding the adoption and benefits of mobile learning in different educational contexts.

4.4. Analysis of psychometric theories in the adoption of mobile learning in the university context

The results section reveals that the main theories used to understand the factors that determine the adoption of mobile learning in the university context are TAM, UTAUT, Own Models, Extended UTAUT, and TPB. Within the scope of Technology Acceptance Theory (TAM), Almaiah et al. [ 24 ] examined the factors that affect the acceptance of a mobile learning application in higher education during the COVID-19 pandemic, using the Ann-Sem modeling technique. Alghazi et al. [ 29 ] developed an extended model to examine the effect of technical factors on the sustainable use of mobile devices as a learning tool, based on the Unified Technology Acceptance Model (UTAUT).

Pramana [ 11 ] investigated the determinants of mobile learning system adoption among university students in Indonesia. Similarly, Alfalah [ 26 ] explored the factors influencing the adoption and use of mobile learning management systems among students in Saudi Arabia. Azizi and Khatony [ 32 ] investigated the factors that affect students’ intention to adopt mobile learning in medical sciences, using the Extended UTAUT model and the Theory of Planned Behavior (TPB). The study provides a deep understanding of the underlying theories that influence the adoption of mobile learning in the university context.

4.5. Analysis of the main variables of adoption of mobile learning in the university context

The results indicate that the main latent variables used to determine adoption of mobile learning in the university context are Behavioral Intention, Attitude, Expectation of Effort, and Current Use. Regarding the Behavioral Intention variable, Andujar et al. [ 31 ] explored the integration of foreign language learning through mobile devices, focusing on technological acceptance and the flipped learning experience. As for the Attitude variable, Azizi and Khatony [ 32 ] investigated the factors that affect medical science students’ intention to adopt mobile learning, analyzing the influence of their attitude towards this educational modality.

Dahri et al. [ 3 ] investigated teachers’ acceptance of mobile learning technology, focusing on the influence of mobile self-efficacy and training based on 21st century skills, while Almaiah et al. [ 24 ] examined the factors affecting the adoption of a mobile learning application in higher education during the COVID-19 pandemic using the Ann-Sem modeling technique. These studies provide a deeper understanding of the latent variables that influence the adoption of mobile learning in the university environment.

In addition to the previously mentioned variables, other factors have emerged as significant in analyzing the adoption of mobile learning in university contexts. One such factor is Academic Relevance, which pertains to students’ perception of the usefulness and relevance of mobile learning for their academic training. The influence of the perception of usefulness and academic relevance on students’ intention to use learning management systems has been explored in studies such as Alfalah [ 26 ] and Saroia and Gao [ 34 ]. This study examines the use of mobile learning management systems in different university environments.

Another important factor to consider is engagement, which refers to the level of dedication and emotional connection that students have with mobile learning. This variable has been analyzed by Imlawi et al. [ 2 ] and Andujar et al. [ 31 ] to understand how student engagement influences their intention to use mobile learning management systems in university environments. It is important for the active involvement of students in the educational process.

Compatibility is a relevant variable that has been extensively studied in the context of mobile learning adoption. It refers to students’ perception of the agreement between mobile learning and their needs, skills, and technological environment [ 29 ]. This variable has been explored in studies such as those by Wang, Zhao, and Cheng [ 19 ] and Alghazi et al. The language used in the text is clear, concise, and objective, with a formal register and precise word choice. The text follows a logical structure with causal connections between statements. The grammar, spelling, and punctuation are correct. No changes were made to the content of the original text. Masa’deh et al. [ 45 ] and Chen [ 8 ] have investigated the impact of perceived compatibility on students’ adoption of mobile learning. They analyzed how technical factors, such as technological stress and available resources, affect students’ perceptions of mobile learning. It is important to consider the compatibility of mobile learning with your individual learning needs and expectations.

Finally, confirmation is another variable that has gained importance in the literature on the adoption of mobile learning in higher education. It is defined as the continuous evaluation that students make of the usefulness and effectiveness of mobile learning after its initial implementation. Mobile learning applications have been extensively studied to explore the factors that influence students’ confirmation of continuing to use them. These studies, such as those by Roslan et al. and Alowayr and Al-Azawei, highlight the impact of these factors on user satisfaction and intention to continue using these technologies. The language used is clear, objective, and value-neutral, with a formal register and precise word choice. The text follows conventional structure and adheres to formatting features and style guides. The grammar, spelling, and punctuation are correct. No changes in content have been made.

From another perspective, it is crucial to take into account the perspectives provided by Al-Adwan, Al-Adwan and Berger [ 50 ] and Al-Adwan, Al-Madadha and Zvirzdinaite [ 51 ], highlighting the importance of analyzing other factors that influence the adoption of mobile learning in higher education, highlighting the relevance of delving into factors such as student disposition and the enigmatic nature of adoption to unravel the complexities surrounding the adoption of mobile learning.

4.6. Main research gaps

Table 3 presents the main research gaps identified in the field of mobile learning in the university context that need to be addressed in future research. These gaps highlight areas where the existing literature may be insufficient or where greater depth is needed to fully understand the adoption of mobile learning and its implications in the university context.

https://doi.org/10.1371/journal.pone.0304116.t003

The identified gaps in research on the adoption of mobile learning in university contexts provide an opportunity for further exploration to enhance our understanding of this dynamic. One of the gaps identified is the lack of studies in Latin American countries, which highlights the need for specific investigation into the factors that influence the adoption of mobile learning in universities in this region. How do these factors differ from those identified in other geographic contexts? Examining these differences could provide insight into the cultural and socioeconomic factors that impact the adoption of these technologies in various regions of the world.

Additionally, there is a lack of application of emerging theories in the study of mobile learning adoption. While traditional theories like TAM and UTAUT have been extensively utilized, incorporating emerging theories could provide a more comprehensive and current understanding of the phenomenon. How do these new theoretical models compare to traditional ones in explaining the adoption of mobile learning in university contexts? Investigating this question could reveal new facets of the adoption process and provide innovative insights for the design of implementation and promotion strategies.

Another significant gap identified is the lack of consideration of accessibility in studies on mobile learning adoption. Accessibility is a crucial factor in ensuring the effectiveness and equity of technologies for all students. To design more inclusive and effective strategies, it is important to explore how the accessibility of mobile technologies affects the adoption of mobile learning among diverse student groups. What strategies can be implemented to improve the accessibility of mobile learning platforms? Investigating this question could lead to identifying practices and policies that encourage broader and more equitable adoption of mobile learning in university settings.

The gaps in research on the adoption of mobile learning in university settings not only highlight areas where current knowledge is limited but also point to the importance of addressing these gaps to promote more complete and balanced development in this field. By exploring and closing these gaps, we can advance our theoretical understanding of mobile learning adoption. This will enable us to more accurately inform educational policies and practices that encourage the effective and equitable integration of these technologies into teaching and learning at universities.

4.7. Theoretical implications

The evaluation of the data collection instruments used in the studies allows us to identify trends, methodological approaches, and possible biases in the measurement of key variables. Additionally, analyzing the geographical context of each study reveals regional patterns in the implementation and acceptance of mobile learning. This may suggest the influence of cultural, economic, and technological factors in the adoption of this educational modality.

Considering the target population of the studies provides valuable information on the demographic, academic, and socioeconomic characteristics of the university students involved in the adoption of mobile learning. Additionally, exploring the theoretical models used to understand the adoption phenomenon offers insights into the predominant theoretical perspectives and their applications in different educational contexts. Identifying the key factors used to approach the understanding of mobile learning in the university environment allows for a critical evaluation of the determinants that influence adoption and the effective use of this technology.

The systematic literature review, conducted using the PRISMA-2020 methodology, reveals the research gaps in the adoption of mobile learning in university contexts. Identifying gaps in research is crucial for future studies on mobile learning adoption in universities. These gaps may be due to a lack of research in certain geographic areas, scarcity of studies using emerging theories, absence of consideration of relevant factors, or the need to delve into specific aspects of the phenomenon. By identifying these gaps, efforts can be focused on areas where greater theoretical and empirical development is required to comprehensively understand mobile learning adoption in the university environment.

4.8. Practical implications

The current study has significant practical implications for both academics and decision-makers in the field of education. The evaluation of data collection instruments enables identification of the most effective ones for capturing relevant information on the adoption of mobile learning. This can guide academics in designing future research and developing evaluation tools for more accurate monitoring and measuring of progress in implementing this technology.

The analysis of the geographical context of each study provides a global view of the trends and specific challenges associated with the adoption of mobile learning in different regions of the world. This information is invaluable for decision-makers in the educational field as it allows them to identify geographic areas where greater support and resources are needed to promote the successful adoption of this educational modality, as well as to adapt implementation strategies to the local needs and realities of each context.

Consideration of the target population is crucial for understanding the specific characteristics and needs of university students in relation to mobile learning. This insight allows decision-makers to design educational programs and policies that best suit the preferences and abilities of the students, promoting greater participation and commitment to this learning modality.

The analysis of theoretical models and factors used to understand the adoption of mobile learning in the university context provides academics and decision-makers with a solid conceptual framework to design intervention strategies and training programs that encourage successful and sustainable adoption of this technology. Identifying research gaps is also essential as it highlights areas where further research and development are required to address specific challenges and maximize the impact of mobile learning in university education.

It provides educators and educational policy makers with a deep understanding of the trends, challenges, and best practices related to the integration of mobile learning in university environments. This allows them to make informed decisions about the implementation of educational technologies and design teaching strategies that make the most of the potential of mobile learning to improve the learning experience of students.

Furthermore, a systematic review can impact the allocation of resources and strategic planning in educational institutions. It identifies priority areas for investment in technological infrastructure, teacher training, and development of digital content. Additionally, it can guide the formulation of policies and support programs that promote equity of access and digital inclusion, particularly for students who may face socioeconomic or geographic barriers to accessing digital educational resources.

Understanding the factors that influence the adoption and effective use of mobile learning in university environments can inform training and professional development strategies in companies and organizations. This can help design mobile learning programs that align with the needs and expectations of today’s workforce. The practical implications can be extended to the industry and business sector.

Additionally, the review’s findings and recommendations can inform government decision-makers in formulating education and technology-related public policies. This can promote effective integration of mobile learning into national or regional educational systems, fostering innovation and continuous improvement in higher education.

4.9. Limitations

One limitation of this systematic literature review is the potential for publication bias, as only studies available in the Scopus and Web of Science databases were included. It is possible that relevant studies not indexed in these databases or available in other languages were not considered, leading to a limited selection of literature. Additionally, restricting articles to English may have excluded significant research conducted in other languages, potentially biasing the results towards a specific linguistic perspective.

Another limitation of this study is related to the search process. Although we used broad search criteria and explored multiple combinations of terms related to mobile learning adoption in university environments, it is possible that some relevant studies were not identified due to the complexity and diversity of the terminology used in this field. Additionally, the exclusion of studies not available in full text may have limited the inclusion of relevant research that was only available in abstract format or with restricted access. These limitations may have affected the exhaustiveness and representativeness of the systematic review, which could impact the generalization of the results and conclusions obtained.

Finally, a limitation of this study is that important databases, such as ERIC, were excluded. ERIC is recognized as one of the main sources of information in the field of education. The omission of this database may have resulted in a lack of access to relevant studies that could have further enriched the analysis and understanding of the topic. Therefore, future studies should aim to include a wider range of databases to ensure a comprehensive review of the literature and a more complete representation of available research.

4.10. Agenda for future research

Several recommendations for future research can be derived from the obtained results, which could enhance the understanding of this emerging field. Firstly, longitudinal studies are suggested to track the evolution of mobile learning adoption over time and assess its long-term impact on academic achievement and the student experience. These investigations could provide a more complete understanding of how attitudes and behaviors towards mobile learning change over time and identify predictors of sustained adoption.

Furthermore, it is recommended to expand the geographical scope of research to include less explored contexts, such as Africa, Latin America, and Eastern Europe. Comparative studies between different geographical regions could help identify common patterns and significant differences in the factors that influence mobile learning adoption.

To improve the impact of mobile learning on diverse university student populations, it is recommended to conduct research that analyzes the needs and preferences of different demographic groups, including students from various disciplines, educational levels, and socioeconomic backgrounds. This will enable the design of more personalized interventions that are better adapted to the needs of each group.

Regarding theoretical models, researchers are encouraged to validate new conceptual frameworks that accurately capture the underlying processes that influence mobile learning adoption. It is also recommended to integrate multiple theoretical models and approaches to obtain a more holistic and multidimensional understanding of this complex phenomenon.

Finally, it is recommended to investigate emerging and under-researched variables that may impact the adoption of mobile learning, such as digital accessibility, technological inclusion, data privacy, and cybersecurity. These aspects are crucial to ensure fair and sustainable adoption of mobile learning in university environments and can lead to new areas of research that address emerging needs and concerns in this constantly evolving field.

4.11. Main adoption model of mobile learning in the university context

Fig 6 shows the main theoretical models and variables used to understand or predict the adoption of mobile learning in the university context. The TAM and the UTAUT are consolidated conceptual frameworks that have been widely used to understand the attitudes, perceptions, and behaviors of university students towards the use of mobile technologies in their educational processes. Theoretical models, along with associated variables such as perceived ease of use, perceived usefulness, attitude toward use, social influence, and intention to use, have been crucial in contextualizing and analyzing the adoption of mobile learning in various university environments.

https://doi.org/10.1371/journal.pone.0304116.g006

This systematic literature review examines the adoption of Mobile Learning in the university context and proposes a comprehensive model that combines the UTAUT Model and the TAM. The model incorporates external variables for a holistic understanding of Mobile Learning adoption in university environments.

The proposed model integrates additional variables, such as Academic Relevance, Confirmation, and Compatibility factors, into the conceptual pillars of UTAUT and TAM. These variables are of vital importance in the academic field as they evaluate the relevance of Mobile Learning in the university educational context and determine the acceptance and effective use of this technology. This theoretical contribution provides a comprehensive and contextualized analytical framework for understanding the determinants that influence the adoption of Mobile Learning in the university environment. It can aid in the formulation of informed and relevant strategies in the higher education field.

5. Conclusions

The research has produced significant conclusions that address the research questions. The analysis indicates that questionnaires are the primary data collection instruments used in the studies, indicating a preference for quantitative methods to gather information on the adoption of mobile learning.

In terms of geographical contexts, research in the field of mobile learning has been primarily focused on Asia and Europe. Countries such as Saudi Arabia, China, the United Kingdom, and Spain have been leading this research. This finding emphasizes the global nature of mobile learning adoption and the importance of considering diverse contexts in future research.

Research on mobile learning adoption focuses mainly on university students, highlighting the importance of understanding the needs and perceptions of this demographic group when integrating mobile technologies in education. The identified theoretical models were TAM, UTAUT, and own models. This highlights the importance of understanding users’ attitudes and perceptions towards mobile learning from a consolidated theoretical framework.

The main variables used to understand the adoption of mobile learning in university contexts are behavioral intention, attitude, effort expectation, current use, and compatibility. The article highlights the need to develop integrative theoretical models that address the factors influencing the adoption of mobile learning. It is also recommended to explore new variables and geographical contexts to enrich the understanding of the phenomenon.

Regarding future research, it is recommended to investigate the impact of mobile learning in various fields of study and educational contexts. Additionally, it is important to examine the influence of contextual and cultural factors on the adoption of these technologies.

A theoretical model is presented that integrates the main theoretical models and variables identified in the review, providing a conceptual structure for future research in the field of mobile learning adoption in the university context.

Supporting information

S1 checklist. prisma 2020 checklist..

https://doi.org/10.1371/journal.pone.0304116.s001

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Maritime shipping ports performance: a systematic literature review

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• Published: 04 June 2024
• Volume 5 , article number  108 , ( 2024 )

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• L. Kishore 1 ,
• Yogesh P. Pai 2 ,
• Bidyut Kumar Ghosh 1 &
• Sheeba Pakkan 3  

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The maritime sector has evolved as a crucial link in countries' economic development. Given that most of the trade across regions takes place through naval transportation, the performance of the seaports has been one of the focus areas of research. As the publication volume has significantly grown in the recent past, this study critically examines the publications related to the performance of ports for exploring the evolution, identifying the trends of articles, and analyzing the citations covering the publications based on relevant keywords in Scopus database for the period 1975–April 2024. Bibliometric and scientometric analysis was done using R, Python, and VOS software tools. Results indicate the core subject areas as “port efficiency”, “data envelopment analysis” (DEA), “port competitiveness”, “simulation”, “port governance”, and “sustainability,” with "sustainability" as the most discussed and highly relevant theme that has evolved in the last five years. Bibliometric data analysis on the subject area, yearly trends, top journals of publications, citation and author analysis, impact analysis, country-wise publication, and thematic analysis with clusters are also performed to outline future research directions. The analysis indicates an exponential rise in publications in recent times and with sustainability-related studies gaining more importance, especially for empirical research on port performance and demands for future empirical research on sustainability and smart port performance subject area. The study's findings are helpful for researchers, academicians, policymakers, and industry practitioners working towards a sustainable maritime port industry.

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1 Introduction

Maritime trade and seaports have evolved as an integral part of global economic development, with the trade through sea comprising more than 80 percent of the volume of international merchandise trade [ 1 ] and connecting developing countries with developed as well as between various modes of global logistics and transportation [ 2 , 3 , 4 , 5 ]. Given the critical role of maritime seaports in the worldwide supply chain, there has been an exponential rise in research in maritime seaport-related studies covering diverse topics and themes. With the burgeoning volumes of publications, as recommended by Moral-Muñoz et al. [ 6 ], bibliometric and systematic studies are helpful in scientifically tracking the growth trend of publications and in evaluating the essential characteristics and attributes of the research studies, supported by various contemporary statistical analysis software tools. Junquera et al. [ 7 ] highlighted the benefit of bibliometric data analysis in assisting the exploration of different characteristics and attributes related to the study area, such as publication trends, authors in the field, themes of ongoing research along country-specific details which are essential to understanding and enhancing the body of knowledge on the topic of interest, the ongoing trend, and aid in exploring the characteristics associated with different themes related to the subject of study.

Numerous bibliometric and systematic review studies by multiple authors discuss the synthesis of reviews on port management, port governance, port economics, digitization and new-age automation technology adoption in ports, and port choice selection topics. In their novel bibliometric study, Pallis et al. [ 8 ] identified significant emerging themes under various categories of port-related research. A large number of bibliometric and systematic review studies were published in the recent decade [ 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 ] that covered many of the themes and categories, including “green port”, “container port terminal”, “seaport competitiveness”, “port sustainability” “dry port”, “port management”, “digitization of port operations”, “smart port.”

However, a holistic bibliometric data analysis on the “port performance” topic could not be traced in the extant publications. For shipping ports, which act as the backbone of the maritime transportation ecosystem [ 23 , 24 ], the port’s competitiveness and performance are considered one of the most critical elements [ 25 ]. For the growth and sustenance of the global maritime trade, the performance of the ports plays a crucial role. Numerous studies [ 5 , 24 , 25 , 26 , 27 ] have proven the positive impact of the performance of ports on the economic development of a country and how poorly performing ports result in lower trade volumes, especially in developing or less-developed countries. Given ports' vital role in economic development through boosted production-consumption in the value chain and increasing global trade, along with the interest of academicians, researchers, and policymakers in the field, the literature on port performance has been growing [ 5 ]. Bibliometric and systematic analysis can give an overview of the studies on port performance. It can demonstrate a broad understanding of ongoing research work and themes since the first publication will benefit researchers and practitioners in port management.

Therefore, this study aims to explore the bibliometric data of research articles related to the performance of ports and identify the trend and ongoing themes of research through bibliometric data analysis. The study also attempts to analyze scholarly publications' evolution and critical insights on port performance-related fields regarding themes or topics, subject areas, leading journals, citations, and country-wise contributions, along with collaboration and outline future research directions. This novel study explores the bibliometric data on the “port performance” studies published in the Scopus database. It analyzes the data through creative visualizations to identify trends, establish ongoing research themes, and outline future research.

The following sections cover the literature overview on port-related bibliometric studies to trace the ongoing research and identify the gap along with framing research questions, then describe the methodology adopted in the current bibliometric survey, followed by results and discussion, leading to drawing conclusions along with contributions and outlining the implications and future research directions.

2 Review of literature

The literature review of the extant body of knowledge on port-related bibliometric analysis studies identified many significant contributions in the Scopus database. The keywords search using the combination “TITLE-ABS-KEY ("port" OR "seaport" OR "shipping port" OR "maritime port" OR "maritime shipping port" OR "container port" AND bibliometric OR scientometric) AND (LIMIT-TO (LANGUAGE, "English"))” identified 48 articles. After the screening, 25 bibliometric data analyses published since 2010 were shortlisted and reviewed in detail. Among those, eight were published in 2023 and 7 in just the first quarter of 2024, indicating the pace with which research is burgeoning in port-related fields. Elsevier is the leading publisher, with about nine publications covering around 30% of the total publications. Springer and Routledge share the second spot with four publications each. “Maritime Policy and Management” and “Sustainability” were the leading sources, with 4 and 2 bibliometric articles published, respectively. Table 1 summarises the literature reviewed, along with their source and citations.

The bibliometric studies on port-related topics commenced with the review article of Pallis et al. (2010), who conducted a bibliometric analysis of port economics and management policy-related topics to unravel the emerging research field based on the papers published between 1997 and 2008 in multiple scholarly databases such as ScienceDirect, JSTOR, Google Scholar, and Econlit. They concluded that research on port-related studies is rapidly emerging, international collaboration is rising, and the majority were on container port terminals. We could also identify the recent trend of literature on port-related studies getting focussed on container terminals discussing innovation and digital automation of container terminal operations and the application of new-age big-data technologies, Artificial Intelligence (AI), and Machine learning techniques (ML), and Internet-of-things platforms for productivity improvement and real-time port operations management.

Along the lines of technology development and integration in port management, the study of Li et al. [ 34 ] focused on the novel technology integrated ports with the concept of Smart ports incorporating intelligent digital technology and infrastructure comprising of cloud computing technology, big data analytics, Internet of things (IoT), and AI-based applications for capacity and resource optimization as a new-age solution to cope with the challenges faced in the dynamic port industry. The most recent publication on the maritime port sector is the bibliometric analysis study by Diniz et al. [ 22 ] on the United Nations’ Sustainable Development Goals (SDG), wherein they used IRaMuTeQ and VOSviewer software tool to evaluate the trends through a systematic literature review. In the years 2023 and 2024 till the 20th of April, published six articles each year, the highest number of bibliometric-related publications since 2010. The highest citation of 177 was received for the study by Davarzani et al. [ 9 ] on “green ports,” followed by 122 citations for the study of Pallis et al. [ 8 ] on port economics and management.

Many studies [ 42 , 43 , 44 , 45 ] have pointed out the dynamic nature of maritime business. Amidst the dynamic nature of the port sector, as highlighted by Mantry and Ghatak [ 46 ], the country’s economic development is impacted by poor port performance. As per the United Nations Conference on Trade and Development (UNCTAD) [ 1 , 47 ], more than 80% of the international trade volume is handled through maritime transportation. [ 23 , 48 ] Studies have emphasized the significance of ports in the economic growth of a country. Given ports' vital contributions to economic development and global trade, along with the increasing interest of academicians, researchers, and policymakers, the literature on port performance has grown exponentially, especially in the last decade.

OConnor et al. [ 5 ] systematically reviewed port performance-related studies to identify performance dimensions and discussed port performance as a multi-dimensional construct. However, the study should have addressed the other characteristics and attributes that cause and impact the performance of ports. Notably, Wang et al. [ 35 ] were the first to use the WoS database exclusively for collecting bibliometric data for the period 2000 to 2020 and analyzing the data using the CiteSpace software tool. Their study focused on visual mapping of bibliometric data to uncover insights into trends of publications and authors along with their affiliations and countries and keyword analysis to derive more frequently discussed topics and themes. Though future research directions were indicated in the studies and many themes were highlighted, there needs to be more on the performance of ports and related variables for enhancing port performance. The scientometric analysis and computational text analysis by Sung-Woo et al. [ 49 ] were specific to port performance-related bibliometric study; however, they focused mainly on port and shipping along with supply chain logistics-related high-quality publications between 2000 and 2018 in journals listed in the Science Citation Index (SCI), Science Citation Index Expanded (SCIE), and Social Science Citation Index (SSCI) available in the Scopus and the WoS scholarly databases only. Since the number of articles was 1947 in the count, they adopted topic modeling using a text mining technique called “Latent Dirichlet Allocation (LDA)” to uncover significant research topics.

The qualitative study by Somensi et al. [ 50 ] analyzed the bibliographical characteristics of evaluating port performance studies published during 2000—2016 and discussed management practices and organizational performance aspects. Bibliographical data comprising 3112 articles for their research was collected from popular scholarly databases, and a series of keywords were used to search for performance, evaluation, and management-specific articles. Bibliographical portfolio selection and analysis were done using the Knowledge Development Process-Constructivist (ProKnow-C) tool developed at the Federal University of Santa Catarina. They selected 37 articles at the end of the portfolio selection procedure to analyze further regarding an author, journal, topic, and country analysis. They suggested increasing the research by extending the analysis period and conducting a more in-depth systematic analysis as the future research direction.

To address the gap identified, bibliometric data analysis can be adopted to explore the hidden characteristics and attributes related to the study area, such as publication trends, authors in the field, themes of ongoing research along with country-specific details and help with deep insights on the continuing trend, and identify the characteristics associated with different themes related to the topic of study. Therefore, a holistic bibliometric data-based exploratory study on “port performance” can give an overview of all the studies on port performance to date and demonstrate a broad understanding of ongoing research work and themes since the first publication. Further, the previous studies have not discussed co-occurrence or co-citation in articles published on port performance.

In this backdrop and taking a cue from shortcomings identified through the literature review, this study focuses on the following research questions:

What is the trend and evolution of research publications in maritime port performance?

What are the dynamics of journals publishing articles and citations of articles related to port performance?

Which countries have given utmost importance to port performance-related studies?

How are the citations, authorship, and collaborations shaping up?

What are the new and emerging topics and themes related to port performance studies?

3 Methodology

Akbari et al. [ 51 ] discuss how bibliometric analysis has recently received greater importance and hailed bibliometric analysis methods over traditional methods due to the benefits associated with conducting bibliometric analysis. The authors adopted an exploratory research approach by analyzing the bibliometric data downloaded from the most popular scholarly database, Scopus, to assess the trend and existing scenario of port performance-related studies, leading to the researcher's analysis and interpretation of visualized data in various plots and diagrams using relevant software tools. Scopus is one of the leading scholarly databases that has witnessed increasing citable articles and multi-disciplinary publications that provide quick and authoritative access to high-quality, comprehensive, and reliable content in multi-disciplinary fields [ 52 , 53 , 54 ].

In the first phase of the bibliometric study, we started with the search for scholarly articles in the Scopus database using an initial set of keywords and Boolean operator combinations to retrieve the relevant and possible publications available in the Scopus database. After multiple trials, the keyword combination was identified as "port performance" OR "performance of port" OR "performance of the port." With the identified keywords and boolean operators, the search in the Scopus database was conducted using the combination of keywords and Boolean operators as “ALL (("maritime port" OR "sea-port" OR "sea? port" OR "seaport" OR "shipping port" OR "container port" OR "container terminal port") AND ("port performance" OR "performance of port" OR "performance of the port" OR "performance of the shipping port" OR "performance of the maritime port" OR "performance of the seaport" OR "performance of shipping port" OR "performance of seaport")) AND (EXCLUDE (SUBJAREA, "PHAR") OR EXCLUDE (SUBJAREA, "NURS") OR EXCLUDE (SUBJAREA, "VETE") OR EXCLUDE (SUBJAREA, "NEUR") OR EXCLUDE (SUBJAREA, "MEDI") OR EXCLUDE (SUBJAREA, "CHEM") OR EXCLUDE (SUBJAREA, "BIOC") OR EXCLUDE (SUBJAREA, "PHYS")) AND (EXCLUDE (DOCTYPE, "no") OR EXCLUDE (DOCTYPE, "er") OR EXCLUDE (DOCTYPE, "tb") OR EXCLUDE (DOCTYPE, "ed")) AND (LIMIT-TO (LANGUAGE, "English")).” The scope of the study was limited to research, review, book, and conference publication articles available in English. The search was conducted on the 20th of April, 2024.

In the second phase, the filtered documents available after the search were downloaded from the Scopus database in CSV and Bib file formats for further bibliometric data analysis. Scopus database also provides a quick, ready-to-use results analysis option with basic diagrams representing documents per year, by source, by author, affiliation, country, type, and subject area, and by funding agency. These results are also available for download in CSV file format for customized data visualization and extended analysis. This was followed by a distinct analysis of the downloaded datasets in the third phase to analyze and interpret, leading to the discussion and conclusion in the fourth phase. Further, scientometric analysis was performed based on co-authorship and co-occurrence using the VOSviewer software tool [ 55 ]. VOSviewer is acknowledged as a scientific tool for data visualization to perform exploratory data analysis on various aspects of publication, such as keywords, countries of research activity, and its density [ 56 ]. Bibliometric data related to the subject area, yearly trend, journal, author, citation, and country-wise publication was visualized and analyzed using open-source R and Python software tools and relevant available libraries and packages. “bibliometrix” package available in R was the primary tool used for importing the raw bibliometric data and later developing many visualizations supported with Python for data cleaning before further analysis and developing visualizations.

The evolution themes developing over time were analyzed with three cutting points in 2008, 2014, and 2020, representing an equal distribution from 2008 to April 2024. The first cutting point of 2008 was fixed as the number of publications saw an upswing after 2007 as per the preliminary analysis and hence could be the milestone to start with further analysis as the first cutting point. Following the benchmark values adopted by Cobo et al. [ 57 ] and Wang et al. [ 58 ] in their bibliometric analysis study, the word count was set to default as 200, minimum cluster frequency of 5 per thousand documents, the number of labels for each cluster as 4 for optimal mapping with minimum weight index as 0.1 and thematic analysis using the Louvain clustering algorithm since past studies [ 59 , 60 ] have proven the Louvain algorithm’s consistency of performance and better results of modularity when compared with other clustering algorithm approaches. Informative trends and patterns identified through the analysis were discussed, and conclusions were outlined, leading to future research directions and highlighting emerging focus fields in port performance-related studies. A co-occurrence analysis for the country was performed to identify the density of research activities in different countries. In the co-authorship analysis for the country, the minimum number of documents was set as 75 to get the overlay of visualization of the top 20 countries, and the country-specific citation minimum threshold was zero, considering the score of the average number of publications per year. Further, the co-occurrence of the keywords was analyzed to create the network using Louvin’s algorithm while limiting the number of nodes to 30 and the minimum number of edges to 0.

4 Results and analysis

In this section, the visualizations of bibliometric data based on citation metrics, co-citation, and co-occurrences are discussed along with bibliometric data analysis comprising the trend in publications, publication subject areas highlights, country of research work, author analysis, collaboration, and the journals publishing the relevant articles, to derive meaningful insights.

4.1 Descriptive analysis

The keyword search in the database identified 2245 articles published collectively from 691 sources of scientific publications from 1979 till April 20th, 2024. Of 4189 authors who contributed to publications in the port performance field, close to 29% had international co-authorship, and 274 had single-authored publications. The annual growth rate was 10.62%, and average citation was 20.24 per document. The descriptive summary of the bibliometric data is given in Table  2 .

4.2 Trend of publications

Descriptive analysis of the bibliometric data shows a phenomenal annual growth rate of 10.62% in research publications related to port performance. The trend of published articles, along with the mean total citations per year from the first article published in 1979 till 20th April 2024, is shown in Fig.  1 . There has been a spike in the number of publications since 2007, as indicated in the figure, and the number of publications has exponentially increased after that, suggesting that port performance is one of the most focused research areas in the recent decade.

Publication trend and citations from 1975 till 2023

Ahrens' [ 61 ] novel research on the engineering performance of ports outlined the importance of management training through audio-visual techniques for improving port performance in developing countries. The trend of core engineering-related performance studies continued till Thomas [ 62 ] discussed the strategic management of ports and their development. Roll et al. [ 63 ] introduced the application of the DEA methodology in port performance comparison with a sample of 20 selected ports. Later, a noticeable surge in port performance studies started after Lin et al. [ 64 ] studied the operation performance of major container ports in the Asia–Pacific region and applied the DEA approach to evaluate the operational performance of ports based on their operation efficiency.

4.3 Subject area of publication analysis

The percentage share of the articles published in different subject areas of research is shown in Fig.  2 . “Social Sciences,” “Engineering,” and “Business, Management, and Accounting” areas contribute more than 50% of the overall and are followed by the “Environmental Science,” Decision Sciences, and Economics, Econometrics and Finance,” and “Computer Science,” subject area and so on, out of which “Business, Management, and Accounting” areas account around 12%. Other areas include “Earth and Planetary Sciences,” “Energy,” “Mathematics,” “Agricultural and Biological Sciences”, “Arts and Humanities,” “Materials Science,” “Multidisciplinary,” “Chemical Engineering,” and “Psychology.”

Subject-wise publication share

4.4 Journal of publication analysis

The distribution of the articles published in journals is shown in Fig.  3 for journals that have published more than 30 articles. “Maritime Policy and Management” journal is the leading source, with about 156 publications, followed by “Maritime Economics and Logistics” and “Sustainability” journals, together contributing to 5% of the total publications to date. “Research in Transportation and Management,” “Asian Journal of Shipping and Logistics,” and International Journal of Shipping and Transport Logistics” are closely competing with only one-third of the publications from the “Maritime Policy and Management” journal.

Top publishers with more than 30 publications

To get a deeper understanding of the growth of sources, source dynamics were analyzed using a trend line, as shown in Fig.  4 . Accordingly, it was identified that although “Maritime Policy and Management,” “Maritime Economics and Logistics”, “Sustainability”, “Research in Transportation Business and Management”, “Asian Journal of Shipping and Logistics”, “International Journal of Shipping and Logistics”, “Ocean and Coastal Management”, and “Transport policy” are the leaders in terms of total publications in the given order. Phenomenal growth was achieved by the “Sustainability” journal, which was at the bottom in 2007 and has shown exponential growth since then, reaching the third position in annual publications growth, overtaking the “Research in Transportation Business and Management” journal.

The trend of annual publications in top sources

4.5 Author publication and citation analysis

The publications from the leading authors based on their number of publications and their citations are shown in Fig.  5 . Lam JSL occupies the top position, with 27 publications commencing with the first publication in 2006. At the same time, the top author with the highest citation is Cullinane K, with the first publication in 2002 and contributing 21 publications in the last 20 years. Six of his publications in 2006 alone have received 822 citations so far.

Number of Publications and Citation to Publication ratio for top authors

The authors’ collaboration network diagram is shown in Fig.  6 . Some top authors, especially Cullinane, Pallis, Lam, Chen J, Ducruet, and Song, collaborate highly, leading to higher quality publications with increasing citations.

Author's network diagram

4.6 Country of research analysis

The distribution of articles published across the top 15 countries based on publications and based on citations is shown in Figs.  7 and 8 , respectively. China has the highest contribution, close to 24%, followed by the US and UK, with 8.6% and 4.6% of publications, respectively. Somensi et al. [ 50 ] also highlighted China as the highest contributor with the most significant port performance-related studies. India-centric publications are merely 3.47%, a mere 15% of that of China, which has 571 publications, followed by the US and the UK, with 205 and 110 publications, respectively. China is again the leader in citations with 8116 citations, followed by the US and UK 5189 and 4819 citations, respectively. However, Spain overtook Italy with 1843 citations from 93 articles, with 1628 citations from 94 publications.

Country-wise publication

Country-wise citation

The scatter plot in Fig.  9 shows China, the USA, and Korea leading mainly with single-country publications, compared with Singapore and the UK, which have more multi-country collaborated publications. Among the top 10 countries in collaboration aspects, India has higher single-country publications and only a few multi-country collaborated publications.

Scatter plot of single and multi-country publications

4.7 Co-authorship and country-collaboration analysis

We considered the publications where the minimum number of publications was set as two, and the maximum number of countries counted as 25. Thus, among the 105 countries published, 77 meet this threshold. When calculating the total strength of the co-authorship links with other countries, only the countries with the greatest total link strength will be selected. The visualization of country-wise coauthorship and publication network in Fig.  10 shows that China has the highest density compared to other countries, indicating intense research on port and port performance.

Country-wise overlay of co-authorship

4.8 Impact metrics analysis

The “Research Metrics Guidebook” provides a comprehensive list of metrics to assess the research impact at various levels, including journal, article, author, and affiliated institutional level productivity, citation, and collaboration based on scholarly content in the Scopus database [ 65 ]. Table 3 shows the citation impact metrics since 2018.

“Field-weighted citation Impact” (FWCI) metric is a comparative metric that calculates the citations received by a document compared to the expected citations. It is a normalized bibliometric indicator that factors in the type of document, subject area, and publication period [ 66 ]. As we can see, the FWCI has been fluctuating; overall, it is at 1.12, indicating that the impact is 12 percent above the global average. Further break-up analysis on the authorship impact, as shown in Table  4 , suggests more than 50 percent impact above the worldwide average of international collaboration. Industry-institute collaboration has significantly increased in 2024. “Outputs in Top Citation Percentiles” shows that 11.5 percent of the publications are in the top 10 percent. International collaboration has seen close to 30 percent collaboration over the years. The top fifteen country impact metrics, as shown in Table  5 , indicate China is leading with the highest number of views and citations, along with an FWCI of 1.85, suggesting they are 85 percent above the global average. Spain, India, and Indonesia are 15, 18, and 36 percent below the global average.

4.9 Co-occurrence analysis

The co-occurrence of the keywords was analyzed for keywords having a minimum of 40 occurrences to create cluster-based density visualization based on the weight of occurrences, as shown in Fig.  11 . The core subject areas with the highest occurrences in the field of port performance-related studies are “Data Envelopment Analysis”, “efficiency”, “simulation”, “container terminal”, “port competitiveness”, “port governance”, “port management”, and “sustainability”. DEA and efficiency are the most weighted labels in the performance-related studies, with counts of 55 and 53, respectively. DEA and efficiency labels were followed by a simulation of the performance of seaports and container terminals and then the constructs related to performance, such as competitiveness, governance, management, and sustainability practices. In the computations text analysis of Sung-Woo et al. [ 49 ], the LDA output indicated DEA methodology as the most weighted term.

Density visualization of co-occurrences using VOSViewer

4.10 Keyword analysis

The scatter plot in Fig.  12 with size measures showing the frequency count of the top trending words indicates that the trending words with the highest frequency in the last ten years are “port operations”, followed by “Container terminal”, “Data Envelopment Analysis”, “efficiency”, and “Sustainability” with the count as 341, 168, 155,136 and 92 respectively. Automation has been the trending word in recent years, with the previous years trending with the COVID-19 keyword, followed by performance, port automation, and economic development.

Top Trending words

4.11 Thematic evolution analysis

Thematic evolution using a longitudinal map (alluvial graph) divides the timespan of the research field into slices of time duration prescribed based on the developments in the field. It illustrates the continuation and discontinuation of identified themes, thus explaining the conceptual structure of the field of interest [ 67 , 68 ]. The thematic evolution shown in Fig.  13 demonstrates the evolution of the themes with three cutting points in the years 2008, 2014, and 2020. 2008 was set as the first cutting point as the publications trend showed an exponential increase after 2007. Then, the remaining cutting points were set as equal intervals to assess the thematic evolution. The word count was set to default as 200, with a minimum cluster frequency of 5, the number of labels for each cluster as 4 with a minimum weight index of 0.1, and thematic analysis using the Louvain algorithm.

Thematic evolution since 1979 using R-bibliometrix package

Callon et al. [ 69 ] developed the co-word analysis technique based on the centrality and density matrix to analyze and explain word interactions in any research field over some time. According to Cobo et al. [ 57 ], the thematic map comprises four quadrants on which the themes are placed based on the centrality and density of the themes over the years. Centrality demonstrates the theme's importance or relevance within the given study area, whereas density represents the development of the theme over the selected timespan. The bubbles in the graph indicate the size of the occurrence within the cluster, comprised of interacting words demonstrating the co-occurrence network. Each quadrant has its characteristics based on the degree of centrality and density measures. Motor themes are those of high importance and development happening in the field. Niche themes are, by and large, isolated and highly developed combined with negligible, low, or limited importance. Emerging or declining themes are of low significance, and the density of the theme needs to be vigorously developed. Basic themes are characterized by high-importance and relevant and low-density themes. They are reasonably crucial for research since those topics still need to be fully developed and, therefore, potential issues for conducting future research [ 57 , 69 , 70 , 71 ]. The recent 4th stage of the thematic map is shown in Fig.  14 for the 2019 to 2024 time span.

Thematic map of the 4th stage from 2018 till date using R-bibliometric package

The thematic map resulted in nine clusters in the 4th stage, as tabulated in Table  6 , summarising the themes and the related topics associated with each cluster.

The theme with the highest centrality, complimented with high density, is “sustainability” among the topics mapped. To get more insight into the theme of “sustainability” topic identified, the trend of sustainability keywords in the previous two decades was visualized as shown in Fig. 15 . Through the review of literature, it was also determined that the surge in usage of sustainability terms in research started after the pioneering work of Yap et al. [ 72 ], who initiated the focused discussions on sustainability-related topics, and after that, the usage has steadily grown exponentially.

Frequency Trend of Sustainability keyword

5 Discussions

This study focused on bibliometric analysis of port performance-related studies based on the bibliometric data available on the Scopus database. This article critically examined bibliometric data of studies related to the performance of ports to explore the evolution, identify trends of articles published from 1975 till April 20th, 2024, the leading authors, top journals, impact metrics, and leading countries in terms of publications, and thereby highlight the research directions on port performance studies. From the trend of publications, it is evident that there has been a significant spike in the number of publications after 2007. After that, it has been exponentially increasing in concurrence with the findings of Pallis et al. [ 8 ], indicating that port performance is one of the highly focused research areas in recent times with over 10 percent annual growth rate. OConnor et al. [ 5 ] also highlighted the growing desire of policymakers and stakeholders in port performance evaluation and policy development, keeping in mind the interests of the public as well. The average citations were over 20 per document; however, the citations fluctuated with irregular peaking and flattening patterns. The timespan from 2000 to 2007 saw the highest number of citations and, after that, has been moderate but more significant than the rate of publications over the years except for the last two years, where the citations are yet to pick up due to the recently published articles. A review of publications gives insight into the fact that the articles are predominantly on port efficiency-related studies, with many articles starting to focus on DEA methodology application on port efficiency and port performance evaluation studies. Other studies [ 49 , 50 ] also found that DEA-based studies have the highest number of publications and citations.

Among the various pre-defined subject areas of port-performance-related publications in Scopus, “Business, Management, and Accounting” contributes close to 12 percent, about half of the contribution in the “Social Sciences” subject area and, indicating “Business, Management, and Accounting” as a highly potential subject area for focused contribution in the port performance related field. Somensi et al. [ 50 ] also highlighted the need to enhance the research on business management. Among the sources of publications, “Maritime Policy & Management” leads the race in publications, with close to 7 percent of the publications. Our findings concur with the observations of Somensi et al. [ 50 ], who found similar results in their systematic literature review on the performance of the port topic. In their content analysis study, Notteboom et al. [ 49 ] highlighted 267 articles published in the “Maritime Policy & Management” journal, and the leading and continuous contributions of studies related to port were highlighted in the journal. Therefore, “Maritime Policy & Management” should be one of the primary journals researchers must subscribe to for notifications and regularly track updates on port research. The publications in “Maritime Policy & Management” are equal to the publications in “Maritime Economics and Logistics” and “Sustainability” journals. In the source of publication analysis, “Maritime Economics and Logistics” and “Sustainability” were identified as the sources with the highest growth rate for publications related to port performance. These two journals were at the bottom during 2000 and have shown exponential growth, especially the “Maritime Economics and Logistics” journal, which has reached second in annual publications growth, closely followed by the exponentially growing “Sustainability” journal, which has been gaining momentum since 2015. The “Sustainability” journal is growing steadily and exponentially compared to other trailing journals behind “Maritime Policy & Management”. The findings of Zhou et al. [ 73 ] also confirm that “Sustainability” and “Maritime Policy & Management” journals are the leading journals in port-related studies.

Among the authors contributing, Lam JSL, Notteboom, Song DW, Pallis, Ng AKY, Yang Z, and Ducruet C are a few critical leading authors with the highest contribution and co-citation in port performance-related studies. Zhou et al. [ 73 ] have a fascinating insight into the changing pattern of research hot spots in port-related studies and their associated dynamics. The study of Wang et al. [ 35 ] also identified LSL Lam as the most productive contributor with the highest number of publications. The collaborations network shows collaborations happening in some pockets within the US, UK, some parts of Europe, and South Korea to a greater level, thus taking international collaboration to 30% share. Although the US is ahead of the UK in publications, the normalized FWCI for the UK is higher by 30% at 1.75 compared to the US. It is worth highlighting that in addition to the multi-country-author collaboration, industry-institute collaboration is also improving and uplifting the impact further. Analyzing the country of publications, with about 20% contributions, China is the only developing economy in the leading countries of publications and citations, followed by the US, UK, Korea, Spain, and Italy. However, regarding citations, the UK has dominated other countries with the highest citations, followed by China and the US. This finding confirms the past conclusions [ 35 , 73 ], where China was identified as the leading country regarding the number of publications, followed by the US and South Korea.

Density visualization of co-occurrences categorized the keywords into 3 clusters centered around the port operation, container terminal, and efficiency topics. The port operations-centered cluster had related keywords: performance assessment, competitiveness, sustainability, sustainable port development, decision-making, and policy. The container terminal-centered cluster had container cargo handling and computer simulation aspects. Lastly, the port efficiency-centered cluster had DEA, benchmarking, and productivity aspects. In the top ten labels based on occurrence frequency, DEA and efficiency are the most weighted labels, which aligns with the findings of the past conclusions [ 49 , 50 ]. An overview of existing literature on port performance research also shows the studies were predominantly based on applying DEA methodology to compute the efficiency of the port, simulation modeling followed by critical dimensions such as port competitiveness, port performance, and sustainability, along with port governance and strategic management. DEA and efficiency labels were followed by a simulation of the performance of seaports and container terminals and then the constructs related to performance, such as competitiveness, governance, management, and sustainability practices.

Remarkably, thematic evolution shows the absence of DEA methodology after the cutting point in 2018, where it peaked and was later taken over by the sustainability theme. The sustainability theme started to evolve in 2013, far below DEA, and attained the top position from 2019 to 2024. The DEA theme, which has evolved since 2008, has been taken over by the port performance theme since 2019. The thematic analysis has also shed light on the themes revolving around the port hinterland theme, which have evolved through DEA methodology and recently, since 2017, into sustainability-related themes along with port performance. Container terminal and port governance have been themes that have continued to exist since 2008. The “COVID-19 pandemic” and “automatic detection systems” (AIS) were the latest themes that have explicitly evolved. As the entire world faced the wrath and impact of the global pandemic, the port industry was also not left free, and many studies [ 74 , 75 , 76 , 77 , 78 ] have evaluated the impact of COVID-19 on the port sector. Alongside this, most industries have adopted automation technologies to overcome the challenges and effects of the pandemic. This phenomenon is confirmed by the top trending words “automation” and “technology adoption” in 2023 and 2024. The application of robotics and other AIS in port operations became eminent, leading to many studies [ 79 , 80 , 81 , 82 ] exploring innovative applications and opportunities for automation and digital technology adoption. Even the keywords analysis indicates that technology adoption and automation have been the topics that have been highly discussed in recent times.

Yang et al. [ 81 ] also highlighted the increasing popularity of AIS in their review work on AIS and big data in maritime research. Ashrafi et al. [ 83 ] discussed the design of games to address various contain terminal problems. They proposed using virtual and augmented reality and Global Positioning System (GPS) technologies through simulation games in the dynamic port industry that can train and develop professionals who handle port planning, operations, and management. Meanwhile, Lee et al. [ 84 ] underlined the crucial role of AI and computer vision technology in response to dynamics in the port industry, specifically focusing on intelligent traffic management and parking space and container operations optimization in maritime ports. Applications of AIS and IoT through the “Smart Port” concept were detailed by Rajabi et al. [ 82 ] to overcome the challenges in port operations in the dynamic environment within which the port operates. Similar to the Industry 4.0 framework, the new-age innovative automation and robotics applications in seaport operations were conceptualized under the Shipping 4.0 framework in the study of Muhammad et al. [ 79 ].

The most trending words with the highest frequency in the last five years were identified as “Sustainability”, similar to the findings of Sung-Woo et al. [ 49 ], who highlighted the term as a core focus area in port-related research since 2010. They reviewed port-related research works applying the computational text analysis approach to the articles available in both the Scopus database and WoS database related to port research and published in international journals indexed in the Science Citation Index and Korea Citation Index also highlighted the need for sustainable port development and more focus on environmental sustainability alongside the development of port competitiveness. A similar finding was underscored by Wagner (2019) in the bibliometric data-based study on port cities. Sustainability is the new theme that has taken center stage, with a high density of publications and high importance and greater centrality, indicating the relevance of the studies in the current context. Most recent studies have spotted sustainability in the maritime industry as a topic of focused interest, as pointed out by Lee et al. [ 85 ], ever since the term was used at the first Earth Summit in 1992. It is emphasized as the need of the hour, supported by SDGs of the UN’s 2030 Agenda on emission reduction and sustainable maritime operations that have put significant pressure on maritime seaports, thereby demanding regulator compliance and sustainability reporting. Sustainability and intelligent ports were part of the motor theme cluster, indicating the theme of high importance and development happening in the field. AIS and ML were part of Motor cum niche cross-over themes indicating they are developed in isolation but are niche in nature. Similarly, the blockchain technology keyword in the niche theme is a highly developed concept, but it is isolated from the application in port in the development and growth stage.

We identified some of the major theoretical foundations that were adopted in port-related studies, such as “Business model innovation theory”, “resilience theory”, “resource dependence theory” and “stakeholder theory”. Ashrafi et al. [ 83 ] adopted stakeholder theory to synthesize the drivers of sustainability in maritime ports in the systematic review study. They discussed the sustainability strategies grouped into different clusters based on multi-stakeholder perspectives to integrate into port planning and operations as a response to the changing industry dynamics. Denktas-Sakar et al. [ 86 ] adopted the “resource dependence theory” to conceptualize a framework to integrate the relationships between the supply chain and port stakeholders to identify the impact on the sustainability of ports. Giudice et al. [ 13 ] adopted the “Business model innovation theory” and “resilience theory” to determine the innovative technologies and digitization of port operations as a solution for the economic, environmental, and social sustainability of ports in line with the description of Elkington [ 87 ] who coined the “Triple Bottom Line” foundations of sustainability. No specific definition of sustainability has been universally accepted, even though many have attempted to define it [ 88 , 89 , 90 , 91 ]; however, there is a common understanding from different schools of thought [ 88 , 89 ] that sustainability encompasses most frequently related dimensions which are termed as the three pillars of sustainability have respective practices, viz economic sustainability practices, environmental sustainability practices, and social sustainability practices, that facilitate and lead towards sustainable development through practicing these practices. Recently, Jugović et al. [ 32 ] highlighted the emerging concept of a green port governance model of adopting sustainability practices in the port. Many studies [ 92 , 93 , 94 , 95 ] defined sustainability practices as the practices that aid organizations in developing opportunities and, at the same time, managing the three dimensions of organizational processes—economic, environmental, and social aspects in value creation over the long term.

Furthermore, Bjerkan et al. [ 96 ] highlighted the need for more port sustainability-related studies and empirical research on port sustainability. Adding to that, Lim et al. [ 97 ] also emphasized the importance of sustainable port performance in their systematic review of port sustainability and performance-related studies. They raised the flag on the focus of extant studies, mainly on environmental sustainability, and the need for more importance placed on social and economic sustainability in research studies. Multiple studies [ 98 , 99 , 100 ] have pointed out the uncertainty and lack of clarity among industry professionals and other research-oriented consultants and academicians on approaches to excel in sustainable performance and whether there are any significant positive results on performance due to sustainability. This considerable gap must be addressed and indicates the dire need for research incorporating sustainability concepts within the framework related to port performance. Many studies [ 14 , 49 , 101 , 102 ] also acknowledged sustainability as one of the primary factors contributing to port competitiveness and performance enhancement. The report by UNCTAD [ 1 ] highlights the expectations of ports to consider sustainability aligned with port performance through strategic and operational steps as it has become a priority in overall maritime shipment. The report also opined that ports operating with higher sustainability have greater chances of attracting investments and increased support from various port stakeholders. Lim et al. [ 97 ] also highlighted the importance of sustainable port performance in their systematic review of port sustainability and performance. They mentioned the focus on only environmental sustainability and the need for more importance on social and economic sustainability in research studies. A similar emphasis on the ecological sustainability of green and sustainable ports was found in other studies [ 103 , 104 ]. However, their studies also mentioned incorporating sustainability's economic and social dimensions in future research. Lee et al. [ 85 ] also outlined the need to explore the methodologies adopted in sustainability-related studies in their proposed future research directions.

Even though Sung-Woo et al. [ 49 ] highlighted quality and sustainability as the focus areas of port-related research since 2010, [ 99 ] opined that sustainability is an emerging concept that has yet to be overlooked. They also raised doubts about practitioners' and researchers' need for more clarity on whether the sustainability concept can yield positive results or has been successful. Broccardo et al. [ 100 ] also highlight the concern and crucial gap of need for clarity among academicians and researchers on the excellence that can be achieved in sustainability and performance. Further, in the review of tools and technologies work by Bjerkan et al. [ 96 ], empirical data-based research on the sustainability of ports was demanded due to the need for more sufficient studies related to experiences on implementation and associated challenges in port operations. More importantly, empirical data-driven research on sustainability-related topics and port performance will be critical to the growing body of knowledge.

Summarising the above discussions and findings, the insight drawn indicates that sustainability” is the most highlighted and evolving theme in recent years in port performance-related studies. [ 105 ] also pointed out the increased focus and evolution of sustainability in the context of society, industry as well as regulatory bodies in line with the argument of Broccardo et al. [ 100 ], who highlighted the concern and gap of lack of clarity among academicians and researchers on the excellence that can be achieved in sustainability and performance and emphasizes on addressing this crucial gap. Further, although companies are becoming increasingly involved in sustainability [ 106 ], academic researchers still need to make clear how to excel in sustainability and performance [ 98 ], thus highlighting a gap that must be addressed. This has resulted in a gush of publications on topics related to sustainability, as highlighted by [ 107 ].

6 Conclusion and future research directions

To the best of the researcher's knowledge, this study is novel due to its holistic coverage of the span of publications and growth and the thematic evolution of publications in maritime port performance-related studies. The bibliometric exploratory data analysis of articles published from 1979 to April 2024 was conducted to review the trend, explore the existing characteristics of port performance-related studies, and identify opportunities for future research. The increasing number of publications related to port performance indicates the extreme importance and focus on the performance of ports and related topic areas, especially from 2008 onwards.

The study contributes in the following ways. Firstly, it contributes to the overall understanding of the introduction and growth of port performance-related studies worldwide. Secondly, it provides exploratory data analysis on key characteristics such as the occurrence of keywords, research subject areas, top publishing journals, and country-wise research publications. Lastly, the findings give possible future research directions and opportunities. This is also a pioneer study that demonstrated the use of Python software and relevant packages for creating advanced visualizations using bibliometric data and the Bibliometrix package of the R-programming tool.

The study and the outcome discussions are bound with limitations, as in most research, and future research can address the shortcomings. Primarily, this study was limited to articles published in the Scopus database alone. Even institutional ranking agencies like Quacquarelli Symonds (QS) and Times Higher Education (THE) are adopting indexing matrices from Scopus due to its popularity and reliability of peer-reviewed publications in reputed journals. However, future research could integrate articles from other databases like WoS, ProQuest, IEEE, and Google Scholar for a holistic view of research publications available in other leading scholarly databases. An extended scoping review study can be conducted to understand better the underlying themes and the antecedents of port performance variables. Also, the studies should be focused on port management, competitiveness, and sustainability constructs to keep in line with the growing number of studies on these important and relevant labels related to sustainable port performance management. As recommended by Jeevan et al. [ 14 ], topic modeling, also termed LDA, to uncover the specific themes in port performance can be explored for further thematic research and comparing the studies between countries. Further, the digital and technology revolution has given way to innovative technologies and automation systems that aid resource optimization in various port operations and management. The extent of AI and ML applications supported with big data and blockchain concepts could also be explored for technology-aided sustainable development.

Despite the limitations mentioned above, the study contributes to the body of knowledge in terms of the evolution and trend of ongoing research in port performance, the leading journals of publication, publication citations, the most prolific authors, the co-authorship and occurrence network, top frequently used labels and topics, the thematic evolution and subject areas of study which will be of significant review and reference to researchers, academicians, and industry practitioner giving future directions of research on port performance and increased focus on a sustainability theme.

Data availability

The data for analysis in the study was based on the bibliometric data downloaded from the scholarly database Scopus and was limited to published research and review articles in English till March 2024. The datasets generated during and analyzed during the current study are private for some as the bibliometric data search is available for subscribed users but from the corresponding author at a reasonable request.

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Kishore L conceptualized the manuscript, collected the data, performed analysis, and authored the manuscript. Dr. Yogesh Pai P conducted an in-depth literature review of the bibliometric studies available in the Scopus database, authored the manuscript, and contributed to the results and discussion chapter along with justifications. Dr.Bidyut Kumar Ghosh co-authored the analysis and discussion chapter of the manuscript. Dr. Sheeba Pakkan contributed to co-occurrence, co-authorship network analysis, citation impact-related data collection, analysis, and discussion.

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Kishore, L., Pai, Y.P., Ghosh, B.K. et al. Maritime shipping ports performance: a systematic literature review. Discov Sustain 5 , 108 (2024). https://doi.org/10.1007/s43621-024-00299-y

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Tools for measuring curriculum integration in health professions’ education: a systematic review

• Soumaya Allouch 1   na1 ,
• Raja Mahamade Ali 1   na1 ,
• Noor Al-Wattary 2 ,
• Michail Nomikos 1 &
• Marwan F. Abu-Hijleh 1  

BMC Medical Education volume  24 , Article number:  635 ( 2024 ) Cite this article

Metrics details

Curriculum integration is an important educational concept widely implemented by various educational institutions, particularly within the healthcare field. Its significance lies in enhancing the preparation of future healthcare professionals. The assessment of these integrated curricula is imperative to guarantee their effectiveness. Consequently, the aim of this systematic review is to delve into existing literature, with the goal of identifying instruments designed to assess the extent of curriculum integration in health professions’ education.

A comprehensive search was conducted to identify peer-reviewed papers and grey literature describing the development, validation, or use of instruments measuring the degree of integration in a curriculum. Eight databases were searched: PubMed, Scopus, Google Scholar, CINAHL Ultimate, Web of Science, Cochrane, ProQuest Central and EMBASE. Grey literature was also included. Titles, abstracts, and full text screening was conducted. Data extraction was done using a data extraction tool developed by our research team.

The search resulted in the identification of 2094 references. After the removal of duplicates and title and abstract screening, 16 articles were deemed suitable for inclusion in this systematic review. Twenty-two instruments were extracted from these articles. The identified instruments assessed either integration attributes, perceptions about the integrated curriculum characteristics, process and outcomes, or curriculum integration level. Two of the instruments were focused on assessing horizontal integration ( Basic Science Curriculum Assessment Instrument and the integration characteristic tool). In addition, one instrument was developed to assess integration within a single session only, while other instruments assessed curriculum integration level. Two of the integration instruments ( The Session Integration Tool and Integration Ladder Questionnaire) provided scales for calculating integration levels. Validation of the integration assessment instruments was infrequent, with only 9 of 22 instruments validated for their psychometric properties.

Our findings reveal the existence of diverse instruments designed to assess the extent of curriculum integration within health professions’ curricula. The majority of identified instruments were focused on participants’ perceptions towards the attributes of the integrated curriculum, and a significant number of these tools lacked validation.

Peer Review reports

Curriculum integration is a concept which has been frequently discussed in educational literature for the past 3 decades [ 1 ]. Introduction of this concept was accompanied by attempts to reform medical curriculum from the traditional discipline-based curriculum to an integrated one; with the first documented attempt in McMaster University, Canada [ 1 ]. The primary reason for this shift is the recognition that conventional discipline-based curricula fall short in equipping medical students with the necessary skills to effectively apply their acquired knowledge in clinical practice [ 2 ]. While the term ‘integration’ is commonly used throughout the literature, a clear consensus on its definition within medical curriculum remains elusive. For instance, a recent systematic review by Matinho et al. (2022) on integrated learning in health professions’ education found that only 37% of relevant studies provided a clear definition of integration [ 3 ]. These definitions belonged to one of three main categories which described integrated learning as: (1) the extent to which educators from different disciplines co-present knowledge, beliefs or skills to students; (2) the organizational approach that informs how curricular elements are structured and arranged; and (3) the description of the cognitive or metacognitive processes occurring within the learners’ mind. The first category is well aligned with Harden’s definition, which states that integration is ‘the organisation of teaching matter to interrelate or unify subjects frequently taught in separate academic courses or department’ [ 4 ]. The second category identified in the systematic review aligns with Brauer & Ferguson’s perspective on integrated curriculum, which views it as ‘ a fully synchronous, trans-disciplinary delivery of information between the foundational sciences and the applied sciences throughout all years of a medical school curriculum’ [ 1 ].

Matinho et al.’s (2022) systematic review also highlights the practical implementation of this definition through vertical, horizontal, and spiral integration [ 3 ]. Horizontal integration refers to the integration across different subject areas within a finite period of time, while vertical integration refers to the integration between basic and clinical disciplines across time [ 2 , 5 ]. In vertical integration the amount of time spent on classroom education tends to decrease gradually as more clinical practice experience is introduced [ 5 ]. Integration in its most ideal form represents a combination of both horizontal and vertical, uniting integration across time and across disciplines, which has often been termed as ‘spiral integration’ [ 1 , 6 ]. These levels of integration in medical curricula are described as a continuum, or spectrum. This ranges from traditional curriculum design, where contents are taught as separate disciplines, to a highly innovative integrated approach where disciplinary boundaries are abandoned [ 7 ].

In the integrated curricula, teaching revolves around themes upon which the content of individual units is developed [ 8 ]. This approach encourages students to see the link between different subjects and helps them understand applications of this knowledge in practice. An important model of integration, which was developed for curriculum planning and review, is the Student-Centered, Problem-Based, Integrated, Community-Based, Elective, Systematic (SPICES) model [ 4 ]. This model describes a set of six educational strategies arranged in a continuum across two extremes, ranging from the least desirable traditional curriculum to the most desirable innovative curriculum. In the new integrated curriculum students are the focus of the learning experience, and they are given liberty to determine their learning objectives, learning resources, and sequence of their learning content under instructors’ guidance [ 4 ]. Problem-based learning (PBL) is the learning tool of choice in this model. PBL is a small group learning approach (8–10 students), in which students are provided with a problem they need to solve through conducting research, reviewing relevant resources, and integrating theory within practice [ 9 ]. The process is facilitated by a tutor who supports students and provides a thorough debriefing at the end of the PBL session [ 9 ]. Another important model of integration is Harden’s integration ladder, which consists of eleven steps describing the integration degree of a curriculum on a continuum ranging from isolation (no integration) to multidisciplinary (fully integrated curriculum) [ 10 ]. A more detailed model is Fogarty’s integration model which classifies integration levels according to where integration is adopted into three broad categories; within single disciplines, across several disciplines and within and across learners [ 11 ]. This model generated ten integration levels ranging from fragmented curricula, in which integration is absent, to networked curricula, in which integration of knowledge occurs within and across the learners’ mind as they direct the integration process both internally and externally (determining needed resource, expert matter experts…etc.) [ 11 , 12 ]. All these models can be used to guide the planning, development, or evaluation of integrated curricula.

Several studies report that integrated medical curricula demonstrate greater effectiveness compared to conventional curricula [ 13 , 14 , 15 ]. Students from integrated medical programs were shown to perform better in examinations of medicine, pediatrics, obstetrics and gynecology subjects when compared to students from traditional curricula [ 14 , 16 ]. Additionally, it was reported that graduates from integrated curricula tend to make definitive career choices earlier, are more likely to be accepted at residency positions faster and are more confident in their readiness for practice [ 13 ]. Similarly, PBL was found to be superior to traditional learning methods in enhancing students’ social and communication skills, as well as advancing their problem solving and self-learning skills [ 17 ]. It was also reported that students from integrated curricula and those exposed to PBL have superior diagnostic skills compared to students from traditional curricula [ 15 ]. Learning theories suggest that the integrated approach of teaching and learning enhances students’ learning, engages adult learners’ interest in meaningful learning, and improves retention of knowledge [ 18 , 19 , 20 ]. Integrated curricula are designed to encourage students to establish connections between various subjects, thus enabling them to recognize how their knowledge can be applied to real-world patient cases [ 8 ]. In addition, integrated curricula provide students with opportunity to engage in self-directed learning and develop clinical reasoning skills. This also allows students to express their personal identities and individual qualities while learning, and as a result helps them in developing their individual attributes as future healthcare providers [ 8 ].

Despite the challenges of defining integration, there are domains and dimensions to the construct that provide guidance and boundaries for defining what constitutes integration [ 21 ]. The general assumption is that integration should promote retention of knowledge and acquisition of skills through repetitive and progressive development of concepts and their applications [ 1 ]. Different educational institutions, particularly in the health profession field, adopted integration in their curriculum to prepare their students for practice [ 3 ]. However, for these curricula to be effective, it is a paramount to evaluate them and assess the degree and extent of curriculum integration following its implementation using appropriate tools. These tools will help educators and curriculum developers in identifying gaps in their curriculum design pertaining to integration and provide suitable solutions. Therefore, the aim of this systematic review is to explore the current literature to identify tools, instruments, or surveys, which have been developed to assess the degree of curriculum integration in health professions education.

The research question

What tools, instruments, or surveys are available for measuring the degree of curriculum integration in health professions education?

Methodology

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist for systematic reviews 2020 [ 22 ].

Search strategy

A comprehensive search was conducted in 8 large databases: PubMed, Scopus, google scholar, CINAHL Ultimate, Web of science, Cochrane, ProQuest central and EMBASE. The aim was to identify peer-reviewed papers and grey literature describing the development, validation, or use of instruments measuring the degree of integration in health professions’ curriculum. To identify relevant articles, the search was conducted in these eight databases using different combinations of the keywords listed below:

Tool, instrument, survey, questionnaire, scale, measure.

Curriculum delivery, curriculum evaluation, curriculum assessment.

Integrated curriculum, vertical integration, horizontal integration, spiral integration, basic sciences integration, clinical sciences integration, clinical and basic sciences’ integration.

Medical education, medical school, medical college, health professions education.

Problem based learning, PBL, student centered curriculum.

The full search strategy for the PubMed database can be found in Additional file 1 .

Inclusion and exclusion criteria

Peer-reviewed articles or grey literature published in English up until October 2, 2023 were included in the search. Grey literature (e.g., conference proceedings, thesis, dissertation etc.), relevant to our study identified through the search was also included. Evidence, including questionnaires or instruments assessing the degree of curriculum integration (as the construct of the instrument or one of the main constructs if the instrument consists of multiple constructs/domains) in health professions’ education, was included in this study. Studies were eligible for inclusion if they incorporated the questionnaire or questions assessing the degree of integration within the article. Studies describing such tools and their questions (whether validated or not) were also included. Articles not fulfilling our inclusion criteria were excluded from this systematic review.

In the first phase, one researcher screened titles yielded from the database search, aiming to identify relevant articles for inclusion in the study. In the second phase, three researchers independently screened abstracts and keywords of articles identified in step one. In the final step, three researchers thoroughly reviewed the full texts of papers that successfully passed the previous screening. Only papers that presented or described an instrument, tool or survey assessing curriculum integration were considered eligible for inclusion. Additionally, we conducted a manual search to identify any additional relevant papers which might have been missed. All eligible articles, once identified, underwent screening for inclusion. Any conflict or disagreement between reviewers at any stage of the review was resolved through discussion or involvement of a third researcher who was involved in the study since early stages and is aware of the inclusion and exclusion criteria. Reasons for exclusion of citations were documented and are reported in the results section of this systematic review. The search process is reported in detail per the PRISMA flow diagram [ 22 ]. Characteristics of included papers :

This study only included observational studies describing the development and/or use of an instrument evaluating curriculum integration (e.g. cross-sectional studies, longitudinal studies, cohort studies etc.). Following the search of the selected databases, all identified citations were uploaded to Mendeley citation management software 2.95/2023 (©2023 Mendeley Ltd., Elsevier), and duplicates were removed [ 23 ]. Articles were then transferred to Rayyan, which is a web application that facilitates the process of abstract and full text screening of articles included in a review by different team members [ 24 ]. The tool also identifies and highlights disagreements between different researchers, and documents decisions made regarding articles screened.

Data collection process

We extracted data from studies that met the inclusion criteria using a data extraction tool developed by our research team. The extracted data included information about the papers, such as authors’ names and publication years, and data on the instruments, including their names, objectives, main domains measured, and other details such as number of items, scale, and scoring system. If the instrument was utilized within a sample, details about this sample were extracted from the relevant paper and are reported in this review. Psychometric properties were also extracted if they were reported in the retrieved articles.

Quality assessment

The quality of the papers included in this review were assessed using the Risk of Bias Utilized for Survey Tool (ROBUST) [ 25 ]. The tool consists of 8 criteria which measures sample frames, participant recruitment, exclusion rate, sample size, measurement validity, setting and data management. If the study met the criteria a score of 1 corresponding to “yes” is given while a score of “0” corresponding to “No” are assigned for studies which fails to meet the criteria. For the purpose of this study, we modified the tool by removing the “exclusion rate” item as this element is not reported in our studies. Additionally, the criteria for sample characteristics have been modified as in our study (response “yes” represents reporting the college and academic year/s). The total score for quality ranges between 0 and 7; such that 0 represent the lowest level of confidence in the results and 7 the highest confidence level.

The search resulted in the identification of 2094 references. Six additional articles were identified through manual search. After eliminating duplicates, a total of 1905 references were retained and underwent title and abstract screening. After full text screening, 16 articles fulfilled this study’s inclusion criteria and were deemed suitable for inclusion in this systematic review. Details of the search strategy are presented in Fig.  1 . Twenty-two instruments assessing curriculum integration in health professions’ education were extracted from these articles.

PRISMA flow diagram summarizing the search strategy followed to identify instruments assessing the degree of curriculum integration in health professions’ education

The papers included in this review were published between 1980 and 2023, with the majority published after 2010 ( n  = 12). All identified instruments were questionnaires developed to assess participants’ perception of curriculum integration or integration level, except for one instrument, which was administered as an assessment rubric of integration competency during an Objective Structured Clinical Examination (OSCE) [ 26 ]. Additionally, all instruments identified focused on assessing integration on a curricular level except for one instrument; the Session Integration Tool (SIT), which was developed to measure the level of integration between different disciplines in a single session [ 27 ].

Most of the included papers were centered on capturing students’ perceptions and experiences with curriculum integration ( n  = 11) [ 26 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 ]. In contrast, some were specifically designed to investigate faculty members’ opinions and evaluations of the curricula and its level of integration [ 27 , 37 , 38 , 39 ]. Notably, in seven studies, integration-assessing questionnaires were distributed to both students and faculty members to benefit from the perceptions and unique experiences of each group [ 26 , 29 , 30 , 31 , 33 , 35 , 36 ]. Only two studies focused on evaluations of academic leaders and expert evaluators [ 40 , 41 ].

Half of the integration assessment questionnaires identified in this review were developed to evaluate integration in medical curricula ( n  = 11), and targeted either students, faculty members or integrated course’s developers or directors at medical schools. The remaining questionnaires ( n  = 11) were developed to assess integration in other health professions’ curricula namely physical therapy, nursing, pharmacy, dentistry, radiography and health sciences. More details of integration instruments and the samples in which they were used is provided in Tables  1 and 2 .

In terms of the instruments’ content, the number of questions varied widely, with the lowest reported being 4 in the Integrated standardized patient examination assessment rubric [ 37 ], while the largest set of questions was found in the Integrated curriculum in nursing inventory consisting of 138 questions divided into 3 different Sect [ 26 ]. The integrated curriculum in nursing inventory is a comprehensive questionnaire that evaluates the participant understanding of curriculum integration, their perception of the current integrated curriculum, and their views on how an integrated curriculum should be. The response options for all close-ended questions in the identified instruments within this review were presented using a Likert scale. Notably, the 5-point Likert scale was the most commonly employed scale in this systematic review.

Our findings suggest that the validation of instruments’ assessing integration was uncommon. Of the 22 instruments identified in this review, only 9 underwent assessment for psychometric properties. The most frequently reported psychometric property among the included instruments was content validity ( n  = 7). The instruments analyzed in this study can be classified into three main groups based on their objectives:

Instruments assessing integration attributes through students’ performance (outcome of curriculum integration).

Instruments assessing participants’ (students or faculty members) perception about the integrated curriculum characteristics, process, and outcomes .

Instruments evaluating curriculum integration level based on participants’ experiences (e.g. reviewing integration introduction in the health professions’ curricula of a country, assessing the level of curriculum integration in an institution).

Instruments assessing integration attributes

Three instruments assessing students’ ability to integrate knowledge were identified in this review. These instruments were developed by Panzarella (2003) to assess integration attributes of physical therapy students during an OSCE exam [ 26 ]. One of these instruments is the Integrated Standardized Patient Examination (ISPE), which functions as an assessment rubric for integration. It evaluates students’ competency in integration by assessing their responses to integration-related questions posed by standardized patients. The remaining two instruments were questionnaires designed to investigate perceptions of students’ performance, specifically regarding integration competencies, during the OSCE interaction with the standardized patients (SP). These questionnaires were intended for both students and expert evaluators. The ISPE was validated for validity and reliability measures. A definition of integration was provided in the beginning of the feedback assessing instruments. Detailed findings are reported in Table  1 .

Instruments assessing perceptions about integrated curriculum characteristics, process, and outcomes

Instruments in this category evaluate integrated curricula’s characteristics, including aspects of delivery and implementation. Several of these instruments also explore participants’ perceptions about the usefulness of the curriculum in terms of achieving desired outcomes of curriculum integration. The majority of questionnaires identified in this review fall into this category ( n  = 16) [ 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 40 ]. Many of these instruments explore participants’ opinions on different aspects of the integrated curriculum, such as the content, delivery, time-management, and teaching methods. Examples of these instruments include The Questionnaire Assessing Students’ Perception Regarding an Integrated Curriculum at a Public Sector Medical Colleg e, The Integration Characteristic Tool and The Basic Science Curriculum Assessment Instrument [ 28 , 30 , 34 ]. Some instruments like The Integrated Curriculum Implementation Inventory and Student and Faculty Online Survey Questionnaires developed by Le BK [ 31 ]. assess the degree of integrated curriculum implementation. One unique instrument within this category is The Integrated Curriculum in Nursing Inventory , which assesses the respondent’s view and understanding of the “integrated curriculum” concept at the beginning of the questionnaire before evaluating their perception of the current curriculum [ 37 ]. Additionally, this is the only instrument which enables the participants to express their perceptions of the required changes for an ideal integrated curriculum.

Two of the identified instruments; The integration survey [ 38 ] and Faculty perception of curricular integration survey [ 40 ] were developed to assess curricular integration in pharmacy programs on a national level. Therefore, the target sample for these instruments are faculty members involved in the delivery of integrated curricula and academic leaders from institutions adopting integrated curricula. Many of the studies cited in this review assessed curriculum integration through the perceptions of students, faculty members and academic leaders.

Instruments evaluating curriculum integration levels

This category includes three instruments, The Integrated Curriculum Evaluation Instrument by Howard et al. (2009), the Integration Ladder Questionnaire , and The Session Integration Tool (SIT) [ 27 , 39 , 41 ]. These three instruments are the most specific tools among all the integration instruments identified as they assess the degree of curriculum integration and provide a detailed description of the curriculum integration level. The first two of these instruments ( The Integrated Curriculum Evaluation Instrument by Howard et al., Integration Ladder Questionnaire ) were developed based on established integration models; the Fogarty models for curriculum integration [ 11 ] and Harden’s integration ladder [ 10 ] respectively.

Unlike the other two instruments in this category, the SIT has a narrower scope as it assesses the degree of integration within one session and not across the whole curriculum [ 27 ]; however, it has been adequately validated and has a clear score calculation approach. The scores are then interpreted into one of four categories each representing a level of integration. Likewise, The integration ladder questionnaire [ 39 ] has a reported method for integration score calculation, the mean score is then used to determine the integration level on Harden’s ladder. Further details about the instruments and their psychometric properties are described in Table  2 .

The majority of the studies included in the review were found to have low risk of bias with 2 instruments scoring 7 while many of them scoring between 5 and 6 out of the 7 overall score ( n  = 9). On the other hand, five of the papers had score of 4 or less. Details of the quality assessment results are reported in Table  3 .

This systematic review successfully addresses the research question by identifying articles that report on instruments evaluating the degree of curriculum integration in health professions’ education. This review identified twenty-two instruments focused on evaluating the degree of curriculum integration in health professions’ curricula. Curriculum evaluation is a process which focuses on obtaining information about different components of the curriculum [ 42 ]. There are various sources for information regarding the curriculum; however, the majority of instruments identified in our review focus on obtaining the input of students and faculty members who are the end users of a health professions curriculum.

The studies reviewed in this analysis examined the curricula of various health professions, with a predominant emphasis on medical education programs. This outcome was anticipated, as the concept of “curriculum integration” has traditionally been closely associated with medical education. However, it’s noteworthy that the concept’s application has gradually extended beyond medical training to encompass other fields within healthcare education [ 1 ]. The instruments were classified based on the objective of their assessment into three categories; instruments assessing integration attributes, instruments assessing perceptions about integrated curriculum characteristics, processes and outcomes, and instruments assessing integration level.

The first category focuses on instruments evaluating students’ integration competency within the context of an OSCE assessment. ISPE , is a rubric that assesses integration competency through students’ responses to integration specific questions asked by the SP [ 26 ]. Integration competency fulfillment represents the ultimate objective of an integrated curriculum. Here, integration occurs within the student’s mind as they synthesize all acquired knowledge and skills from across the curriculum. The comprehensive understanding enables the students to effectively apply the integrated knowledge in making informed decisions during clinical practice. This also represents the highest level of integration in both Harden’s and Fogarty’s integration models; known as the transdisciplinary level (or fusion) and the immersed model, respectively [ 10 , 11 ]. The ISPE rubric stands out as a highly effective tool for evaluating curriculum integration due to its unique focus on assessing the outcome of integration. By objectively examining students’ integrative capacity and their proficiency in applying knowledge and skills across diverse contexts within the curriculum, including real-world scenarios, the ISPE rubric offers a comprehensive evaluation framework. Its emphasis on evaluating not just the process of integration, but also its tangible impact on students’ abilities to navigate real-world challenges, underscores the robustness and relevance of the ISPE rubric in educational assessment. This makes it a valuable resource for educators measuring the effectiveness of curriculum integration efforts and the practical readiness of students for professional practice [ 26 ].

Intriguingly, student performance in the ISPE was also evaluated using questionnaires designed to solicit feedback from students and other observers who have witnessed the interaction. Considering the importance of reflection as an effective strategy for enriching the learning experience in complex subjects and fostering a deeper understanding of professional values [ 43 ]. The student feedback questionnaire is an excellent instrument which provides students with opportunity to reflect on their performance and determine areas requiring improvement.

The second category of the integration assessing instruments is the largest; containing 16 instruments developed for students, faculty members, and other academic staff. These instruments explore participants’ views on the integrated curriculum, its characteristics, implementation, and outcomes. The characteristics of integrated curricula assessed were related to the content of the curriculum, delivery, teaching methods, and student assessment ( n  = 9). An important component of curriculum integration, which was evaluated by many of the identified instruments, was content coherence. Content coherence is a necessary pre-requisite for realizing full curriculum integration as the whole curriculum cannot be correlated and made more meaningful to the learner if individual components are not coherent [ 42 ]. Integration in education involves the seamless blending of existing knowledge with new learning, creating a cohesive and interconnected educational experience. This process emphasizes the importance of organizing curriculum content in a coherent manner, where different subjects, concepts, and skills are coordinated and presented in a unified framework. By aligning learning objectives, topics, and activities across various disciplines and modules, educators can facilitate a more holistic understanding of the subject matter. Content coherence ensures that students can recognize connections between different topics and apply their learning in diverse contexts, promoting deeper comprehension and more effective transfer of knowledge and skills. Additionally, it fosters a sense of coherence and continuity in the curriculum, enhancing the overall learning experience for students. The tools mentioned above can thus serve as a crucial framework for curriculum development and as a standard for improving curricular quality. Many of the instruments extracted in this study explored opinions on integrated curriculum delivery including teaching and learning methods, preparation for class, and interactions between students and faculty within class. These elements are important as they impact the extent to which integration is achieved within individual sessions and in the curriculum as a whole. Some of the items also assessed faculty development activities which prepare them to contribute to curriculum integration. Faculty members’ preparation for their role within an integrated program is crucial because the success of integration is impacted by the instructors’ understanding of their role, the role of others, and how they can coordinate with other faculty members to help students understand the link between different subjects and disciplines [ 42 , 44 ].

Two of the identified instruments; the integration characteristic tool [ 30 ] and the Basic Science Curriculum Assessment Instrument [ 34 ] only measure horizontal integration as they were developed to assess perceptions regarding integration in basic science curricula. These instruments could be used during initial stages of integration for institutions introducing horizontal integration within the basic science discipline. A study published by Brynhildsen J et al. (2002) has shown that both students and faculty members view horizontal and vertical integration as important components of medical curricula, with a general belief that horizontal integration might be more important [ 45 ]. Revisiting foundational knowledge from basic sciences during clinical courses and practical experiences results in deeper understanding of basic knowledge, especially when it is linked with real life applications.

The implementation of integrated curricula was assessed in two of the instruments; The Integrated Curriculum Implementation Inventory by Strandell C. (1980) [ 37 ], and the Students’ and Faculty’s Online Survey Questionnaires developed by Le B. (2018) [ 31 ]. The aforementioned tools included meticulously crafted questions assessing how integration was implemented before and during class, as well as during lectures and student assessments. This is very useful in providing valuable insights into the effectiveness and thoroughness of integration efforts within the curriculum. Additionally, these instruments also evaluated the preparedness of faculty members to facilitate curriculum integration, a crucial aspect in integrated medical curricula [ 44 ]. .

The last category of the instruments identified by this review evaluate the degree or level of curriculum integration. Two of these instruments; The Integrated Curriculum Evaluation Instrument by Howard et al. (2009) [ 41 ] and the Integration Ladder Questionnaire [ 39 ] were developed based on Fogarty’s model for curriculum integration and Harden’s integration ladder, respectively [ 10 , 11 ]. While Howard’s Integrated curriculum evaluation instrument assesses the extent of vertical and horizontal integration, its main limitation is that it provides a qualitative assessment of the curriculum which cannot be standardized and might be more susceptible to bias, and its use is restricted to course directors [ 41 ]. The integration Ladder Questionnaire [ 39 ] is a user-friendly, quantitative instrument whose target audience are educators and faculty members. This questionnaire consists of 11 close-ended questions, each of which represents a step on the integration ladder. The lowest step of the ladder represents a subject-based curriculum, with increased integration as you move you up the ladder. This instrument has been ratified for validity and reliability measures, and was found to have adequate internal consistency. The SIT is the last instrument in this category, which assesses integration within a single session. This is a quantitative instrument which has a simple and clear criterion to assess the degree of curriculum integration within a session [ 27 ]. This instrument was assessed for content and construct validity, inter-rater reliability, and factor analysis.

Our systematic review reveals that the topic of integration assessing instruments’ development is an active research area, which has become popular with increased adoption of integrated educational models. More than half of the studies included in this review were published after 2010. Although many instruments have been identified in the literature, only a few were validated to assess their psychometric properties. This is a limitation for the use of these instruments for future curriculum evaluation since their reliability and validity is still unknown. Therefore, this is an area which needs to be explored and studied further in future.

Notably, the majority of the identified assessment tools are limited in their ability to measure the degree of curriculum integration. Rather than providing quantitative evaluations of integration levels, these tools primarily focused on gathering qualitative data in the form of perceptions and feedback from stakeholders. This sheds the light on a substantial gap in the field of integrative medical curriculum assessment. The identified shortcoming necessitates the development of more robust evaluation methods capable of quantitatively assessing the degree of integration within medical curricula. Addressing this gap is essential for ensuring that educational programs effectively meet the goals of integration and adequately prepare students for the complex challenges of contemporary healthcare practice. To our knowledge, this systematic review is the first study in the literature to identify and describe the characteristics of tools assessing the degree of curriculum integration. Our search was comprehensive and included 8 major academic databases, in addition to further manual searching, although there is a possibility that relevant studies published in languages other than English might have been missed. In addition, qualitative instruments that assess curriculum integration were not included as our review focused on identifying quantitative instruments. Our inclusion criteria were very specific, excluding instruments not assessing the degree of curriculum integration such as those focused on assessing PBL [ 46 , 47 , 48 , 49 ]. Our study revealed the scarcity of validated instruments assessing curriculum integration in the literature, which highlights the need for more validation studies on currently available instruments.

Curriculum integration is a contemporary concept in the field of medical education which has been widely adopted by different health professions schools globally to optimize the students’ educational experience and prepare them for practice. To assess the extent to which integration has been fulfilled within these curricula, different instruments were developed. Our study aimed to identify these instruments and extract their psychometric properties. The results of this systematic review report on numerous instruments designed to assess the extent of curriculum integration within health professions’ educational programs. The majority of these instruments explore participants’ perceptions of the characteristics of the integrated curriculum including assessment of curricular content, delivery, and implementation. This study also identified tools which provide a broad approach for integration score calculation and determination of integration level. It is important to note that the majority of these instruments have not been validated and therefore further assessment of their psychometric properties is required. Furthermore, there is a necessity to create instruments that are both sensitive and specific, and are tailored to accurately gauge the level of curriculum integration within medical curriculum.

Data availability

Data is provided within the manuscript or supplementary information files.

Abbreviations

Case Based Learning

Integrated Learning Curriculum

The Integrated Standardized Patient Examination

Large Group Interactive Sessions

Bachelor of Medicine, Bachelor of Surger

Multiple Choice Questions

Not Reported

Objective Structured Clinical Examination

Problem based Learning

The Preferred Reporting Items for Systematic reviews and Meta-Analyses

Self- directed Learning

Small Group Discussions

Session Integration Tool

Student-centered, Problem-based, Integrated, Community-based, Elective, Systematic

Team Based Learning

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Soumaya Allouch, Raja Mahamade Ali, Michail Nomikos & Marwan F. Abu-Hijleh

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Allouch, S., Ali, R.M., Al-Wattary, N. et al. Tools for measuring curriculum integration in health professions’ education: a systematic review. BMC Med Educ 24 , 635 (2024). https://doi.org/10.1186/s12909-024-05618-5

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The four building blocks of change

Large-scale organizational change has always been difficult, and there’s no shortage of research showing that a majority of transformations continue to fail. Today’s dynamic environment adds an extra level of urgency and complexity. Companies must increasingly react to sudden shifts in the marketplace, to other external shocks, and to the imperatives of new business models. The stakes are higher than ever.

So what’s to be done? In both research and practice, we find that transformations stand the best chance of success when they focus on four key actions to change mind-sets and behavior: fostering understanding and conviction, reinforcing changes through formal mechanisms, developing talent and skills, and role modeling. Collectively labeled the “influence model,” these ideas were introduced more than a dozen years ago in a McKinsey Quarterly article, “ The psychology of change management .” They were based on academic research and practical experience—what we saw worked and what didn’t.

Digital technologies and the changing nature of the workforce have created new opportunities and challenges for the influence model (for more on the relationship between those trends and the model, see this article’s companion, “ Winning hearts and minds in the 21st century ”). But it still works overall, a decade and a half later (exhibit). In a recent McKinsey Global Survey, we examined successful transformations and found that they were nearly eight times more likely to use all four actions as opposed to just one. 1 1. See “ The science of organizational transformations ,” September 2015. Building both on classic and new academic research, the present article supplies a primer on the model and its four building blocks: what they are, how they work, and why they matter.

Fostering understanding and conviction

We know from research that human beings strive for congruence between their beliefs and their actions and experience dissonance when these are misaligned. Believing in the “why” behind a change can therefore inspire people to change their behavior. In practice, however, we find that many transformation leaders falsely assume that the “why” is clear to the broader organization and consequently fail to spend enough time communicating the rationale behind change efforts.

This common pitfall is predictable. Research shows that people frequently overestimate the extent to which others share their own attitudes, beliefs, and opinions—a tendency known as the false-consensus effect. Studies also highlight another contributing phenomenon, the “curse of knowledge”: people find it difficult to imagine that others don’t know something that they themselves do know. To illustrate this tendency, a Stanford study asked participants to tap out the rhythms of well-known songs and predict the likelihood that others would guess what they were. The tappers predicted that the listeners would identify half of the songs correctly; in reality, they did so less than 5 percent of the time. 2 2. Chip Heath and Dan Heath, “The curse of knowledge,” Harvard Business Review , December 2006, Volume 8, Number 6, hbr.org.

Therefore, in times of transformation, we recommend that leaders develop a change story that helps all stakeholders understand where the company is headed, why it is changing, and why this change is important. Building in a feedback loop to sense how the story is being received is also useful. These change stories not only help get out the message but also, recent research finds, serve as an effective influencing tool. Stories are particularly effective in selling brands. 3 3. Harrison Monarth, “The irresistible power of storytelling as a strategic business tool,” Harvard Business Review , March 11, 2014, hbr.org.

Even 15 years ago, at the time of the original article, digital advances were starting to make employees feel involved in transformations, allowing them to participate in shaping the direction of their companies. In 2006, for example, IBM used its intranet to conduct two 72-hour “jam sessions” to engage employees, clients, and other stakeholders in an online debate about business opportunities. No fewer than 150,000 visitors attended from 104 countries and 67 different companies, and there were 46,000 posts. 4 4. Icons of Progress , “A global innovation jam,” ibm.com. As we explain in “Winning hearts and minds in the 21st century,” social and mobile technologies have since created a wide range of new opportunities to build the commitment of employees to change.

Reinforcing with formal mechanisms

Psychologists have long known that behavior often stems from direct association and reinforcement. Back in the 1920s, Ivan Pavlov’s classical conditioning research showed how the repeated association between two stimuli—the sound of a bell and the delivery of food—eventually led dogs to salivate upon hearing the bell alone. Researchers later extended this work on conditioning to humans, demonstrating how children could learn to fear a rat when it was associated with a loud noise. 5 5. John B. Watson and Rosalie Rayner, “Conditioned emotional reactions,” Journal of Experimental Psychology , 1920, Volume 3, Number 1, pp. 1–14. Of course, this conditioning isn’t limited to negative associations or to animals. The perfume industry recognizes how the mere scent of someone you love can induce feelings of love and longing.

Reinforcement can also be conscious, shaped by the expected rewards and punishments associated with specific forms of behavior. B. F. Skinner’s work on operant conditioning showed how pairing positive reinforcements such as food with desired behavior could be used, for example, to teach pigeons to play Ping-Pong. This concept, which isn’t hard to grasp, is deeply embedded in organizations. Many people who have had commissions-based sales jobs will understand the point—being paid more for working harder can sometimes be a strong incentive.

Despite the importance of reinforcement, organizations often fail to use it correctly. In a seminal paper “On the folly of rewarding A, while hoping for B,” management scholar Steven Kerr described numerous examples of organizational-reward systems that are misaligned with the desired behavior, which is therefore neglected. 6 6. Steven Kerr, “On the folly of rewarding A, while hoping for B,” Academy of Management Journal , 1975, Volume 18, Number 4, pp. 769–83. Some of the paper’s examples—such as the way university professors are rewarded for their research publications, while society expects them to be good teachers—are still relevant today. We ourselves have witnessed this phenomenon in a global refining organization facing market pressure. By squeezing maintenance expenditures and rewarding employees who cut them, the company in effect treated that part of the budget as a “super KPI.” Yet at the same time, its stated objective was reliable maintenance.

Even when organizations use money as a reinforcement correctly, they often delude themselves into thinking that it alone will suffice. Research examining the relationship between money and experienced happiness—moods and general well-being—suggests a law of diminishing returns. The relationship may disappear altogether after around $75,000, a much lower ceiling than most executives assume. 7 7. Belinda Luscombe, “Do we need $75,000 a year to be happy?” Time , September 6, 2010, time.com.

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Money isn’t the only motivator, of course. Victor Vroom’s classic research on expectancy theory explained how the tendency to behave in certain ways depends on the expectation that the effort will result in the desired kind of performance, that this performance will be rewarded, and that the reward will be desirable. 8 8. Victor Vroom, Work and motivation , New York: John Wiley, 1964. When a Middle Eastern telecommunications company recently examined performance drivers, it found that collaboration and purpose were more important than compensation (see “Ahead of the curve: The future of performance management,” forthcoming on McKinsey.com). The company therefore moved from awarding minor individual bonuses for performance to celebrating how specific teams made a real difference in the lives of their customers. This move increased motivation while also saving the organization millions.

How these reinforcements are delivered also matters. It has long been clear that predictability makes them less effective; intermittent reinforcement provides a more powerful hook, as slot-machine operators have learned to their advantage. Further, people react negatively if they feel that reinforcements aren’t distributed fairly. Research on equity theory describes how employees compare their job inputs and outcomes with reference-comparison targets, such as coworkers who have been promoted ahead of them or their own experiences at past jobs. 9 9. J. S. Adams, “Inequity in social exchanges,” Advances in Experimental Social Psychology , 1965, Volume 2, pp. 267–300. We therefore recommend that organizations neutralize compensation as a source of anxiety and instead focus on what really drives performance—such as collaboration and purpose, in the case of the Middle Eastern telecom company previously mentioned.

Developing talent and skills

Thankfully, you can teach an old dog new tricks. Human brains are not fixed; neuroscience research shows that they remain plastic well into adulthood. Illustrating this concept, scientific investigation has found that the brains of London taxi drivers, who spend years memorizing thousands of streets and local attractions, showed unique gray-matter volume differences in the hippocampus compared with the brains of other people. Research linked these differences to the taxi drivers’ extraordinary special knowledge. 10 10. Eleanor Maguire, Katherine Woollett, and Hugo Spires, “London taxi drivers and bus drivers: A structural MRI and neuropsychological analysis,” Hippocampus , 2006, Volume 16, pp. 1091–1101.

Despite an amazing ability to learn new things, human beings all too often lack insight into what they need to know but don’t. Biases, for example, can lead people to overlook their limitations and be overconfident of their abilities. Highlighting this point, studies have found that over 90 percent of US drivers rate themselves above average, nearly 70 percent of professors consider themselves in the top 25 percent for teaching ability, and 84 percent of Frenchmen believe they are above-average lovers. 11 11. The art of thinking clearly, “The overconfidence effect: Why you systematically overestimate your knowledge and abilities,” blog entry by Rolf Dobelli, June 11, 2013, psychologytoday.com. This self-serving bias can lead to blind spots, making people too confident about some of their abilities and unaware of what they need to learn. In the workplace, the “mum effect”—a proclivity to keep quiet about unpleasant, unfavorable messages—often compounds these self-serving tendencies. 12 12. Eliezer Yariv, “‘Mum effect’: Principals’ reluctance to submit negative feedback,” Journal of Managerial Psychology , 2006, Volume 21, Number 6, pp. 533–46.

Even when people overcome such biases and actually want to improve, they can handicap themselves by doubting their ability to change. Classic psychological research by Martin Seligman and his colleagues explained how animals and people can fall into a state of learned helplessness—passive acceptance and resignation that develops as a result of repeated exposure to negative events perceived as unavoidable. The researchers found that dogs exposed to unavoidable shocks gave up trying to escape and, when later given an opportunity to do so, stayed put and accepted the shocks as inevitable. 13 13. Martin Seligman and Steven Maier, “Failure to escape traumatic shock,” Journal of Experimental Psychology , 1967, Volume 74, Number 1, pp. 1–9. Like animals, people who believe that developing new skills won’t change a situation are more likely to be passive. You see this all around the economy—from employees who stop offering new ideas after earlier ones have been challenged to unemployed job seekers who give up looking for work after multiple rejections.

Instilling a sense of control and competence can promote an active effort to improve. As expectancy theory holds, people are more motivated to achieve their goals when they believe that greater individual effort will increase performance. 14 14. Victor Vroom, Work and motivation , New York: John Wiley, 1964. Fortunately, new technologies now give organizations more creative opportunities than ever to showcase examples of how that can actually happen.

Role modeling

Research tells us that role modeling occurs both unconsciously and consciously. Unconsciously, people often find themselves mimicking the emotions, behavior, speech patterns, expressions, and moods of others without even realizing that they are doing so. They also consciously align their own thinking and behavior with those of other people—to learn, to determine what’s right, and sometimes just to fit in.

While role modeling is commonly associated with high-power leaders such as Abraham Lincoln and Bill Gates, it isn’t limited to people in formal positions of authority. Smart organizations seeking to win their employees’ support for major transformation efforts recognize that key opinion leaders may exert more influence than CEOs. Nor is role modeling limited to individuals. Everyone has the power to model roles, and groups of people may exert the most powerful influence of all. Robert Cialdini, a well-respected professor of psychology and marketing, examined the power of “social proof”—a mental shortcut people use to judge what is correct by determining what others think is correct. No wonder TV shows have been using canned laughter for decades; believing that other people find a show funny makes us more likely to find it funny too.

Today’s increasingly connected digital world provides more opportunities than ever to share information about how others think and behave. Ever found yourself swayed by the number of positive reviews on Yelp? Or perceiving a Twitter user with a million followers as more reputable than one with only a dozen? You’re not imagining this. Users can now “buy followers” to help those users or their brands seem popular or even start trending.

The endurance of the influence model shouldn’t be surprising: powerful forces of human nature underlie it. More surprising, perhaps, is how often leaders still embark on large-scale change efforts without seriously focusing on building conviction or reinforcing it through formal mechanisms, the development of skills, and role modeling. While these priorities sound like common sense, it’s easy to miss one or more of them amid the maelstrom of activity that often accompanies significant changes in organizational direction. Leaders should address these building blocks systematically because, as research and experience demonstrate, all four together make a bigger impact.

Tessa Basford is a consultant in McKinsey’s Washington, DC, office; Bill Schaninger is a director in the Philadelphia office.

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