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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.

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Nursing: Literature Review

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Good Place to Start: Citation Databases

Interdisciplinary Citation Databases:

A good place to start your research is to search a research citation database to view the scope of literature available on your topic.

TIP #1: SEED ARTICLE Begin your research with a "seed article" - an article that strongly supports your research topic. Then use a citation database to follow the studies published by finding articles which have cited that article, either because they support it or because they disagree with it.

TIP #2: SNOWBALLING Snowballing is the process where researchers will begin with a select number of articles they have identified relevant/strongly supports their topic and then search each articles' references reviewing the studies cited to determine if they are relevant to your research.

BONUS POINTS: This process also helps identify key highly cited authors within a topic to help establish the "experts" in the field.

Begin by constructing a focused research question to help you then convert it into an effective search strategy.

Identify keywords or synonyms
Type of study/resources
Which database(s) to search
Asking a Good Question (PICO)
PICO - AHRQ
PICO - Worksheet
What Is a PICOT Question?

Seminal Works: Search Key Indexing/Citation Databases

Google Scholar
Web of Science

TIP – How to Locate Seminal Works

DO NOT: Limit by date range or you might overlook the seminal works
DO: Look at highly cited references (Seminal articles are frequently referred to “cited” in the research)
DO: Search citation databases like Scopus, Web of Science and Google Scholar

Web Resources

What is a literature review?

A literature review is a comprehensive and up-to-date overview of published information on a subject area. Conducting a literature review demands a careful examination of a body of literature that has been published that helps answer your research question (See PICO). Literature reviewed includes scholarly journals, scholarly books, authoritative databases, primary sources and grey literature.

A literature review attempts to answer the following:

What is known about the subject?
What is the chronology of knowledge about my subject?
Are there any gaps in the literature?
Is there a consensus/debate on issues?
Create a clear research question/statement
Define the scope of the review include limitations (i.e. gender, age, location, nationality...)
Search existing literature including classic works on your topic and grey literature
Evaluate results and the evidence (Avoid discounting information that contradicts your research)
Track and organize references
How to conduct an effective literature search.
Social Work Literature Review Guidelines (OWL Purdue Online Writing Lab)

What is PICO?

The PICO model can help you formulate a good clinical question. Sometimes it's referred to as PICO-T, containing an optional 5th factor.

Search Example

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

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

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In This Article Expand or collapse the "in this article" section Literature Reviews

Introduction, what is a literature review.

Literature Reviews for Thesis or Dissertation
Stand-alone and Systemic Reviews
Purposes of a Literature Review
Texts on Conducting a Literature Review
Identifying the Research Topic
The Persuasive Argument
Searching the Literature
Creating a Synthesis
Critiquing the Literature
Building the Case for the Literature Review Document
Presenting the Literature Review

Other Subject Areas

Forthcoming articles expand or collapse the "forthcoming articles" section.

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Literature Reviews by Lawrence A. Machi , Brenda T. McEvoy LAST REVIEWED: 27 October 2016 LAST MODIFIED: 27 October 2016 DOI: 10.1093/obo/9780199756810-0169

Literature reviews play a foundational role in the development and execution of a research project. They provide access to the academic conversation surrounding the topic of the proposed study. By engaging in this scholarly exercise, the researcher is able to learn and to share knowledge about the topic. The literature review acts as the springboard for new research, in that it lays out a logically argued case, founded on a comprehensive understanding of the current state of knowledge about the topic. The case produced provides the justification for the research question or problem of a proposed study, and the methodological scheme best suited to conduct the research. It can also be a research project in itself, arguing policy or practice implementation, based on a comprehensive analysis of the research in a field. The term literature review can refer to the output or the product of a review. It can also refer to the process of Conducting a Literature Review . Novice researchers, when attempting their first research projects, tend to ask two questions: What is a Literature Review? How do you do one? While this annotated bibliography is neither definitive nor exhaustive in its treatment of the subject, it is designed to provide a beginning researcher, who is pursuing an academic degree, an entry point for answering the two previous questions. The article is divided into two parts. The first four sections of the article provide a general overview of the topic. They address definitions, types, purposes, and processes for doing a literature review. The second part presents the process and procedures for doing a literature review. Arranged in a sequential fashion, the remaining eight sections provide references addressing each step of the literature review process. References included in this article were selected based on their ability to assist the beginning researcher. Additionally, the authors attempted to include texts from various disciplines in social science to present various points of view on the subject.

Novice researchers often have a misguided perception of how to do a literature review and what the document should contain. Literature reviews are not narrative annotated bibliographies nor book reports (see Bruce 1994 ). Their form, function, and outcomes vary, due to how they depend on the research question, the standards and criteria of the academic discipline, and the orthodoxies of the research community charged with the research. The term literature review can refer to the process of doing a review as well as the product resulting from conducting a review. The product resulting from reviewing the literature is the concern of this section. Literature reviews for research studies at the master’s and doctoral levels have various definitions. Machi and McEvoy 2016 presents a general definition of a literature review. Lambert 2012 defines a literature review as a critical analysis of what is known about the study topic, the themes related to it, and the various perspectives expressed regarding the topic. Fink 2010 defines a literature review as a systematic review of existing body of data that identifies, evaluates, and synthesizes for explicit presentation. Jesson, et al. 2011 defines the literature review as a critical description and appraisal of a topic. Hart 1998 sees the literature review as producing two products: the presentation of information, ideas, data, and evidence to express viewpoints on the nature of the topic, as well as how it is to be investigated. When considering literature reviews beyond the novice level, Ridley 2012 defines and differentiates the systematic review from literature reviews associated with primary research conducted in academic degree programs of study, including stand-alone literature reviews. Cooper 1998 states the product of literature review is dependent on the research study’s goal and focus, and defines synthesis reviews as literature reviews that seek to summarize and draw conclusions from past empirical research to determine what issues have yet to be resolved. Theoretical reviews compare and contrast the predictive ability of theories that explain the phenomenon, arguing which theory holds the most validity in describing the nature of that phenomenon. Grant and Booth 2009 identified fourteen types of reviews used in both degree granting and advanced research projects, describing their attributes and methodologies.

Bruce, Christine Susan. 1994. Research students’ early experiences of the dissertation literature review. Studies in Higher Education 19.2: 217–229.

DOI: 10.1080/03075079412331382057

A phenomenological analysis was conducted with forty-one neophyte research scholars. The responses to the questions, “What do you mean when you use the words literature review?” and “What is the meaning of a literature review for your research?” identified six concepts. The results conclude that doing a literature review is a problem area for students.

Cooper, Harris. 1998. Synthesizing research . Vol. 2. 3d ed. Thousand Oaks, CA: SAGE.

The introductory chapter of this text provides a cogent explanation of Cooper’s understanding of literature reviews. Chapter 4 presents a comprehensive discussion of the synthesis review. Chapter 5 discusses meta-analysis and depth.

Fink, Arlene. 2010. Conducting research literature reviews: From the Internet to paper . 3d ed. Los Angeles: SAGE.

The first chapter of this text (pp. 1–16) provides a short but clear discussion of what a literature review is in reference to its application to a broad range of social sciences disciplines and their related professions.

Grant, Maria J., and Andrew Booth. 2009. A typology of reviews: An analysis of 14 review types and associated methodologies. Health Information & Libraries Journal 26.2: 91–108. Print.

DOI: 10.1111/j.1471-1842.2009.00848.x

This article reports a scoping review that was conducted using the “Search, Appraisal, Synthesis, and Analysis” (SALSA) framework. Fourteen literature review types and associated methodology make up the resulting typology. Each type is described by its key characteristics and analyzed for its strengths and weaknesses.

Hart, Chris. 1998. Doing a literature review: Releasing the social science research imagination . London: SAGE.

Chapter 1 of this text explains Hart’s definition of a literature review. Additionally, it describes the roles of the literature review, the skills of a literature reviewer, and the research context for a literature review. Of note is Hart’s discussion of the literature review requirements for master’s degree and doctoral degree work.

Jesson, Jill, Lydia Matheson, and Fiona M. Lacey. 2011. Doing your literature review: Traditional and systematic techniques . Los Angeles: SAGE.

Chapter 1: “Preliminaries” provides definitions of traditional and systematic reviews. It discusses the differences between them. Chapter 5 is dedicated to explaining the traditional review, while Chapter 7 explains the systematic review. Chapter 8 provides a detailed description of meta-analysis.

Lambert, Mike. 2012. A beginner’s guide to doing your education research project . Los Angeles: SAGE.

Chapter 6 (pp. 79–100) presents a thumbnail sketch for doing a literature review.

Machi, Lawrence A., and Brenda T. McEvoy. 2016. The literature review: Six steps to success . 3d ed. Thousand Oaks, CA: Corwin.

The introduction of this text differentiates between a simple and an advanced review and concisely defines a literature review.

Ridley, Diana. 2012. The literature review: A step-by-step guide for students . 2d ed. Sage Study Skills. London: SAGE.

In the introductory chapter, Ridley reviews many definitions of the literature review, literature reviews at the master’s and doctoral level, and placement of literature reviews within the thesis or dissertation document. She also defines and differentiates literature reviews produced for degree-affiliated research from the more advanced systematic review projects.

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Literature Reviews

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Meta-analysis
Systematized

Definition:

"A term used to describe a conventional overview of the literature, particularly when contrasted with a systematic review (Booth et al., 2012, p. 265).

Characteristics:

Provides examination of recent or current literature on a wide range of subjects
Varying levels of completeness / comprehensiveness, non-standardized methodology
May or may not include comprehensive searching, quality assessment or critical appraisal

Mitchell, L. E., & Zajchowski, C. A. (2022). The history of air quality in Utah: A narrative review. Sustainability , 14 (15), 9653. doi.org/10.3390/su14159653

Booth, A., Papaioannou, D., & Sutton, A. (2012). Systematic approaches to a successful literature review. London: SAGE Publications Ltd.

"An assessment of what is already known about a policy or practice issue...using systematic review methods to search and critically appraise existing research" (Grant & Booth, 2009, p. 100).

Assessment of what is already known about an issue
Similar to a systematic review but within a time-constrained setting
Typically employs methodological shortcuts, increasing risk of introducing bias, includes basic level of quality assessment
Best suited for issues needing quick decisions and solutions (i.e., policy recommendations)

Learn more about the method:

Khangura, S., Konnyu, K., Cushman, R., Grimshaw, J., & Moher, D. (2012). Evidence summaries: the evolution of a rapid review approach. Systematic reviews, 1 (1), 1-9. https://doi.org/10.1186/2046-4053-1-10

Virginia Commonwealth University Libraries. (2021). Rapid Review Protocol .

Quarmby, S., Santos, G., & Mathias, M. (2019). Air quality strategies and technologies: A rapid review of the international evidence. Sustainability, 11 (10), 2757. https://doi.org/10.3390/su11102757

Grant, M.J. & Booth, A. (2009). A typology of reviews: an analysis of the 14 review types and associated methodologies. Health Information & Libraries Journal , 26(2), 91-108. https://www.doi.org/10.1111/j.1471-1842.2009.00848.x

Developed and refined by the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), this review "map[s] out and categorize[s] existing literature on a particular topic, identifying gaps in research literature from which to commission further reviews and/or primary research" (Grant & Booth, 2009, p. 97).

Although mapping reviews are sometimes called scoping reviews, the key difference is that mapping reviews focus on a review question, rather than a topic

Mapping reviews are "best used where a clear target for a more focused evidence product has not yet been identified" (Booth, 2016, p. 14)

Mapping review searches are often quick and are intended to provide a broad overview

Mapping reviews can take different approaches in what types of literature is focused on in the search

Cooper I. D. (2016). What is a "mapping study?". Journal of the Medical Library Association: JMLA , 104 (1), 76–78. https://doi.org/10.3163/1536-5050.104.1.013

Miake-Lye, I. M., Hempel, S., Shanman, R., & Shekelle, P. G. (2016). What is an evidence map? A systematic review of published evidence maps and their definitions, methods, and products. Systematic reviews, 5 (1), 1-21. https://doi.org/10.1186/s13643-016-0204-x

Tainio, M., Andersen, Z. J., Nieuwenhuijsen, M. J., Hu, L., De Nazelle, A., An, R., ... & de Sá, T. H. (2021). Air pollution, physical activity and health: A mapping review of the evidence. Environment international , 147 , 105954. https://doi.org/10.1016/j.envint.2020.105954

Booth, A. (2016). EVIDENT Guidance for Reviewing the Evidence: a compendium of methodological literature and websites . ResearchGate. https://doi.org/10.13140/RG.2.1.1562.9842 .

"A type of review that has as its primary objective the identification of the size and quality of research in a topic area in order to inform subsequent review" (Booth et al., 2012, p. 269).

Main purpose is to map out and categorize existing literature, identify gaps in literature—great for informing policy-making
Search comprehensiveness determined by time/scope constraints, could take longer than a systematic review
No formal quality assessment or critical appraisal

Learn more about the methods :

Arksey, H., & O'Malley, L. (2005) Scoping studies: towards a methodological framework. International Journal of Social Research Methodology , 8 (1), 19-32. https://doi.org/10.1080/1364557032000119616

Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies: Advancing the methodology. Implementation Science: IS, 5, 69. https://doi.org/10.1186/1748-5908-5-69

Example :

Rahman, A., Sarkar, A., Yadav, O. P., Achari, G., & Slobodnik, J. (2021). Potential human health risks due to environmental exposure to nano-and microplastics and knowledge gaps: A scoping review. Science of the Total Environment, 757 , 143872. https://doi.org/10.1016/j.scitotenv.2020.143872

A review that "[compiles] evidence from multiple...reviews into one accessible and usable document" (Grant & Booth, 2009, p. 103). While originally intended to be a compilation of Cochrane reviews, it now generally refers to any kind of evidence synthesis.

Compiles evidence from multiple reviews into one document
Often defines a broader question than is typical of a traditional systematic review

Choi, G. J., & Kang, H. (2022). The umbrella review: a useful strategy in the rain of evidence. The Korean Journal of Pain , 35 (2), 127–128. https://doi.org/10.3344/kjp.2022.35.2.127

Aromataris, E., Fernandez, R., Godfrey, C. M., Holly, C., Khalil, H., & Tungpunkom, P. (2015). Summarizing systematic reviews: Methodological development, conduct and reporting of an umbrella review approach. International Journal of Evidence-Based Healthcare , 13(3), 132–140. https://doi.org/10.1097/XEB.0000000000000055

Rojas-Rueda, D., Morales-Zamora, E., Alsufyani, W. A., Herbst, C. H., Al Balawi, S. M., Alsukait, R., & Alomran, M. (2021). Environmental risk factors and health: An umbrella review of meta-analyses. International Journal of Environmental Research and Public Dealth , 18 (2), 704. https://doi.org/10.3390/ijerph18020704

A meta-analysis is a "technique that statistically combines the results of quantitative studies to provide a more precise effect of the result" (Grant & Booth, 2009, p. 98).

Statistical technique for combining results of quantitative studies to provide more precise effect of results
Aims for exhaustive, comprehensive searching
Quality assessment may determine inclusion/exclusion criteria
May be conducted independently or as part of a systematic review

Berman, N. G., & Parker, R. A. (2002). Meta-analysis: Neither quick nor easy. BMC Medical Research Methodology , 2(1), 10. https://doi.org/10.1186/1471-2288-2-10

Hites R. A. (2004). Polybrominated diphenyl ethers in the environment and in people: a meta-analysis of concentrations. Environmental Science & Technology , 38 (4), 945–956. https://doi.org/10.1021/es035082g

A systematic review "seeks to systematically search for, appraise, and [synthesize] research evidence, often adhering to the guidelines on the conduct of a review" provided by discipline-specific organizations, such as the Cochrane Collaboration (Grant & Booth, 2009, p. 102).

Aims to compile and synthesize all known knowledge on a given topic
Adheres to strict guidelines, protocols, and frameworks
Time-intensive and often takes months to a year or more to complete
The most commonly referred to type of evidence synthesis. Sometimes confused as a blanket term for other types of reviews

Gascon, M., Triguero-Mas, M., Martínez, D., Dadvand, P., Forns, J., Plasència, A., & Nieuwenhuijsen, M. J. (2015). Mental health benefits of long-term exposure to residential green and blue spaces: a systematic review. International Journal of Environmental Research and Public Health , 12 (4), 4354–4379. https://doi.org/10.3390/ijerph120404354

"Systematized reviews attempt to include one or more elements of the systematic review process while stopping short of claiming that the resultant output is a systematic review" (Grant & Booth, 2009, p. 102). When a systematic review approach is adapted to produce a more manageable scope, while still retaining the rigor of a systematic review such as risk of bias assessment and the use of a protocol, this is often referred to as a structured review (Huelin et al., 2015).

Typically conducted by postgraduate or graduate students
Often assigned by instructors to students who don't have the resources to conduct a full systematic review

Salvo, G., Lashewicz, B. M., Doyle-Baker, P. K., & McCormack, G. R. (2018). Neighbourhood built environment influences on physical activity among adults: A systematized review of qualitative evidence. International Journal of Environmental Research and Public Health , 15 (5), 897. https://doi.org/10.3390/ijerph15050897

Huelin, R., Iheanacho, I., Payne, K., & Sandman, K. (2015). What’s in a name? Systematic and non-systematic literature reviews, and why the distinction matters. https://www.evidera.com/resource/whats-in-a-name-systematic-and-non-systematic-literature-reviews-and-why-the-distinction-matters/

Review Decision Tree - Cornell University For more information, check out Cornell's review methodology decision tree.
LitR-Ex.com - Eight literature review methodologies Learn more about 8 different review types (incl. Systematic Reviews and Scoping Reviews) with practical tips about strengths and weaknesses of different methods.
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Research article
Open access
Published: 14 April 2015

Rural definition of health: a systematic literature review

Charles Gessert 1 ,
Stephen Waring 1 ,
Lisa Bailey-Davis 2 ,
Pat Conway 1 ,
Melissa Roberts 3 &
Jeffrey VanWormer 4

BMC Public Health volume 15 , Article number: 378 ( 2015 ) Cite this article

16k Accesses

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The advent of patient-centered care challenges policy makers, health care administrators, clinicians, and patient advocates to understand the factors that contribute to effective patient activation. Improved understanding of how patients think about and define their health is needed to more effectively “activate” patients, and to nurture and support patients’ efforts to improve their health. Researchers have intimated for over 25 years that rural populations approach health in a distinct fashion that may differ from their non-rural counterparts.

We conducted a systematic review of the literature to assess the extent and strength of evidence for rural definition of health. Studies were eligible for inclusion if they were published in English, reported on original research and presented findings or commentary relevant to rural definition of health, were published over the last 40 years, and were based on observations of rural U.S., Canadian, or Australian populations. Two reviewers were assigned to each selected article and blinded to the other reviewer’s comments. For discordant reviews, a third blinded review was performed.

Of the 125 published articles identified from the literature, 34 included commentary or findings relevant to a rural definition of health. Of these studies, 6 included an urban comparison group. Few studies compared rural and urban definitions of health directly. Findings relevant to rural definition of health covered a broad range; however, good health was commonly characterized as being able to work, reciprocate in social relationships, and maintain independence.

This review largely confirmed many general characteristics on rural views of health, but also documented the extensive methodological limitations, both in terms of quantity and quality, of studies that empirically compare rural vs. urban samples. Most notably, the evidence base in this area is weakened by the frequent absence of parallel comparison groups and standardized assessment tools.

Conclusions

To engage and activate rural patients in their own healthcare, a better understanding of the health beliefs in rural populations is needed. This review suggests that rural residents may indeed hold distinct views on how to define health, but more rigorous studies are needed to confirm these findings.

Peer Review reports

The passage of the Affordable Care Act (ACA) in 2010 heralded a significant shift in American health care, with increased emphasis on population health, disease prevention, and cost containment. These new areas of emphasis are prominent in several initiatives that have emerged in the wake of the ACA, including Accountable Care Organizations (ACOs), which tie provider reimbursements to measures of quality of care and reductions in the total cost of care for assigned populations of patients. The Patient Centered Outcomes Research Institute (PCORI) also emerged, charged with examining the relative health outcomes, clinical effectiveness, and appropriateness of medical treatments. Underlying these initiatives is a renewed emphasis on patient engagement in health care and, more specifically, on patient activation.

While patient engagement and patient activation are often used interchangeably, patient engagement denotes the broad involvement of patients and caregivers in all aspects of health care is based on the principle of shared responsibility [ 1 ]. Patient activation , a component of patient engagement, emphasizes patients’ willingness and ability to take independent actions to manage their health and care [ 2 ]. Patient activation has been found to be associated with better health outcomes, better health care experiences, and reduced probability of adverse markers such as emergency department use, obesity, and smoking [ 2 , 3 ]. Health care systems are encouraging primary care providers to practice patient-centered care, employing strategies that engage with and activate patients. This approach is grounded in the perspective that care should focus on patients and finding a common ground between patients and clinicians when choosing preventive and treatment care pathways.

This focus on patient-centered care challenges policy makers, health care administrators, clinicians, and patient advocates to understand the factors that contribute to effective patient activation. Individuals define “health” on the basis of their personal health-related beliefs, values and knowledge. Improved understanding of how patients think about and define their health is needed to more effectively “activate” patients, and to nurture and support patients’ efforts to improve their health.

For more than 25 years, researchers have suggested that rural populations may have a distinct view of health that differs from other non-rural populations. Seminal research in 1987 by Weinert and Long reported that rural people predominantly associated health with “the ability to work” [ 4 ], but were less likely to regard cosmetic, comfort, or life-prolonging aspects of health as important. In subsequent work, Weinert and Burman concluded that the rural “function-based definition of health” may contribute to delays in seeking health care, even in the face of grave illness [ 5 ]. In a study of the health beliefs of rural elders, Davis et al. found that subjects described health in terms of autonomy and self-reliance; they feared loss of health primarily because it could lead to “being a burden to others” [ 6 ].

These early studies indicate the need for a richer understanding of rural “frames” for health, but they lacked a direct comparison to health views from non-rural counterparts. If rural and non-rural populations indeed commonly think about or define their health differently, then efforts to engage such populations in promoting and preserving health must be better informed, particularly as health care providers increasingly focus on patient-centered care. The purpose of this study was to systematically review and critique the extent and strength of the published literature regarding how persons living in rural areas define health. In addition, we sought comparisons between rural and urban concepts of health. We were interested in findings that could guide improved patient engagement and patient activation in rural communities of the United States and similar industrialized countries. We specifically examined health values and beliefs as constructs rather than knowledge per se , as knowledge generation is better understood as a continuous process influenced by values, beliefs, motivation, skills, and context [ 7 , 8 ].

We conducted a systematic review of the literature to assess the current scientific understanding of rural definitions of health [ 9 ]. The online databases PubMed, CINAHL, PsycINFO, AnthroSource, and Sociological Abstracts were searched, followed by a manual search of the reference sections of studies identified through the online database search. Key search terms that were used were “rural population, “attitude to health,” “health behavior,” “health promotion,” “health belief,” and “health values.” Studies were eligible for inclusion if they were published in English, reported on original research, presented findings or commentary relevant to rural definitions of health, were published over the last 40 years (01/01/1972-03/31/14), and were based on observations of rural U.S., Canadian, or Australian populations. These countries were selected because of their large rural populations, including remote/frontier communities, and their access to Western health care. No restrictions were placed on sample size, research design, or length of follow-up.

For data extraction and synthesis, two reviewers were assigned to each article and blinded to the other reviewer’s comments. For discordant reviews, a third blinded review was performed. Articles were reviewed for content, methodology and rigor, with information collected on study design, characteristics of the study population, whether articles related to rural definitions of health, the definition of rural, and whether there was a comparison group (e.g., rural vs. urban). All information was captured in a Microsoft Excel spreadsheet for summarizing and comparisons. Further details on the review process are provided in Additional file 1 .

The review process identified 34 articles as having fulfilled the criterion of assessing how rural residents define health. These articles were assigned an evidence grade of A, B, or C depending on methodological quality and supporting evidence of the conclusions, based on a previously used adaptation of the American Diabetes Association's (ADA) evidence grading system [ 10 , 11 ].

Because this was a retrospective review of data from previous published studies, no patient informed consent procedures were applicable, and the study was exempt from review by the Essentia Health Institutional Review Board.

Three hundred and eighty two articles were identified using the study’s search terms; an additional fifteen articles were identified as cited references during the review process. From these, 125 articles were selected for initial review by the lead author. Ninety-one articles were excluded because they did not report on original research or were outside of the scope of the current inquiry. Thirty-four were utilized for this review; 4 were commentaries about a rural definition of health [ 4 , 12 - 14 ] and 30 contained findings relevant to a rural definition of health (see Figure 1 ). Of the latter 30 studies, 6 [ 15 - 20 ] included an urban comparison group (see Table 1 ). The remaining 24 articles [ 6 , 21 - 43 ] did not include a comparison group. Few studies compared rural and urban definitions of health directly.

PRISMA diagram of literature review process.

The 6 studies that compared findings from both rural and urban populations were of primary interest. Findings relevant to a rural definition of health covered a broad range; however, good health was commonly characterized as being able to work, reciprocate in social relationships, and maintain independence (see Table 1 ). In a focus group study by Gessert et al., rural responders were more likely to express greater willingness to accept ill health and even death as natural phenomena, whereas urban residents expressed stronger aversion to death and greater insistence on aggressive end of life care [ 15 ]. In a study to examine factors influencing individual capacity to manage coronary artery disease risk, both gender and culture (rural vs urban) were identified [ 18 ]. Rural residents expressed belief that a “work hard, eat hard” attitude kept them healthy despite the stress of their work and living in a rural environment. Additionally, rural residents would only seek a physician’s help if physical functioning was severely impaired [ 18 ]. Rural vs. urban differences were also evident in driving behavior, with rural residents more likely to participate in risky behaviors and less likely to have confidence in the utility of safety interventions [ 16 ]. Another study found that persons living in the most remote environments were more likely to hold highly stigmatized attitudes toward mental health care and these views were strongly predictive of willingness to actually seek care [ 17 ].

Comments from participants in several of the reviewed studies (see Table 1 ) centered on three traits that influenced their definition of health: independence, stoicism, and fatalism. Thorson et al. found that rural elders were less likely than urban elders to turn to health care providers for issues they considered non-urgent, regardless of how long a particular symptom had been present [ 20 ]. Hoyt et al. concluded that the agrarian ideology of self-reliance and rugged independence, coupled with a lessened sense of confidentiality and increased pressure to conform due to the smaller, more intimate nature of smaller rural environments, was not conducive to seeking mental health care, particularly for males [ 17 ]. Attitudes of rural and urban residents toward seeking medical care were similar in the Harju et al. study [ 16 ], but were somewhat incongruent with self-reported care seeking behaviors. Fear of hospitals was associated with medical adherence in rural residents and good health habits in urbanites [ 16 ].

Original research articles that did not include a comparison group (n = 29) also revealed influential themes among rural residents’ definitions of health: autonomy, avoiding medical care, and spiritual health. Rural elders participating in a study in Alberta (Canada) reported that ability to work and ability to function, irrespective of symptoms or underlying illness, was their definition of “health” [ 29 ]. In a focus group study of individuals from rural communities in Wyoming, “cowboy up to continue doing what you have to do” was a prevailing theme in responses pertaining to how participants viewed health [ 34 ]. Arcury et al., reporting from interviews of elderly residents in two rural communities in North Carolina, concluded that the residents’ definition of health integrated physical, mental, spiritual, and social aspects of health [ 21 ]. Another study of rural elderly in New Mexico reported that the common definition of health consisted of remaining autonomous and independent, avoiding contact with the health care system [ 23 ]. Lastly, from a study that included interviews of rural health providers in Colorado, one provider’s perspective, based on a 90 year old patient still engaged in ranching, was that work at any age gave patients a sense of purpose that kept them going regardless of the physical challenges of getting around [ 35 ].

This review assessed the extent and strength of evidence regarding how rural people in the United States, Canada and Australia view health differently than their urban counterparts. The overarching objective of this review was to better understand rural definitions of health and how they might be applied in health education messaging and patient engagement/ activation strategies related to disease prevention and treatment. This review largely confirmed many general characteristics previously observed on rural views of health, but also documented the extensive methodological limitations of studies that empirically compared rural vs. urban samples. The evidence in this area is particularly weakened by the routine absence of parallel comparison groups and standardized assessment tools, among other limitations.

Despite these limitations, several consistent characteristics of a rural definition of health were identified. Rural populations tend to emphasize functional aspects of health, especially the preservation of the ability to work and to fulfill (traditional) social roles. Rural people tend to frame health in terms of independence and self-sufficiency, and to accept ill health with higher degrees of stoicism and seemingly more fatalism. If more rigorous future studies can confirm these findings in rural populations, health education and patient engagement/activation programs can be better structured in ways that capitalize on the strong underlying motivations to preserve independence through good health practices. Our findings suggest that rural populations might be more responsive to health messages that emphasize physical function, independence, self-sufficiency, and the ability to reciprocate in social roles and perceived obligations.

Projects designed to improve the health of rural populations face a number of challenges. At a macro level, rural settings are not homogenous in terms of culture, economic hardship, or sense of history/community. Accordingly, findings from one rural community or similar group of rural communities may not be applicable to other rural communities or regions. Much of the previous research on rural health reported findings from primarily agrarian samples, which is an increasingly small subset of rural settings and not necessarily similar to other rural areas that rely heavily on manufacturing, forestry, or subsistence occupations. This distinction has become more pronounced in recent years with the growth of rural recreation and retirement communities, as well as other rural environments where the agrarian economy or culture has limited influence.

Individual characteristics are also important in rural health attitudes and beliefs. Several investigators reported that religious or spiritual health was an integral part of the definition of health in the rural communities studied. Socioeconomic status is recognized as a key factor in health attitudes and practices, yet few studies in the current review controlled for the socioeconomic status of rural participants. Age and length of time in the community may also be important because some of the most distinctive rural definitions of health were held by older residents (particularly those who had a life-long history of rural residence). The current review also suggests that some work histories such as lifelong farming or ranching may be associated with the more distinct views of health framed by physical function and capacity to work. A better understanding of rural attitudes and beliefs is needed to engage and activate rural residents in managing their health and care. Thus, further study of how rural residents define health will contribute to the implementation of patient-centered care in rural communities.

This study was limited principally by its focus on industrialized Western countries. Additional research is needed both to examine rural concepts of health in a wider range of settings, especially in the developing world. This study was also limited by the paucity of rigorous studies that compared rural and urban perceptions of health directly. This is a rich arena for future research.

There is increasing interest in engaging and activating patients in their own healthcare. To do so effectively in rural areas, a better understanding of the health beliefs in rural populations is needed. This review suggests that rural residents may indeed define health in their own way (e.g., functional independence). However, a formal assessment of the risk of bias was not performed in this paper because the vast majority of studies were qualitative and did not include direct comparisons between rural vs. non-rural samples. As such, selection bias remains an overshadowing concern in this collective body of literature, highlighting the need for more rigorous studies to confirm our findings. Research on rural definitions of health is further complicated by continuously changing rural lifestyles and landscapes as demographics and economic emphases shift. Despite such challenges, however, further research on rural health beliefs and attitudes is critical as American healthcare reform legislation calls for broader, systems-based strategies to improve the public’s health. To better engage and activate rural patients in their own healthcare, a better understanding of the health beliefs of targeted rural populations is needed.

Abbreviations

Affordable Care Act

Accountable Care Organization

Patient Centered Outcomes Research Institute

Socioeconomic status

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Acknowledgements

The authors would like to acknowledge Allise Taran (Essentia Institute of Rural Health) for assisting with final preparation of the manuscript.

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Charles Gessert, Stephen Waring & Pat Conway

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Lisa Bailey-Davis

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All six of the authors participated actively in the conception and design of this review of the literature; the selection and review of articles from the literature; the drafting, review and editing of the manuscript; and the preparation of the final draft. All of the authors agree to be accountable for all aspects of the work. All authors read and approved the final manuscript.

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CG has conducted and published research on rural health issues, including access to care in rural areas and rural-urban differences in end-of-life care. SW currently conducts and publishes research on rural health issues, particularly in the elderly. LBD has conducted and published research that observed rural and urban disparities in the prevalence of childhood obesity while controlling for socio-economic factors. PC has conducted research regarding rural and tribal communities and health (including behavioral health) outcomes and prevention strategies. MR has focused on patient satisfaction with care as part of her chronic disease and primary care outcomes research. JV has led several studies on rural disparities in preventive healthcare, as well as a large rural health improvement initiative in Minnesota.

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Gessert, C., Waring, S., Bailey-Davis, L. et al. Rural definition of health: a systematic literature review. BMC Public Health 15 , 378 (2015). https://doi.org/10.1186/s12889-015-1658-9

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Rapid literature review: definition and methodology

Beata smela.

a Assignity, Cracow, Poland

Mondher Toumi

b Public Health Department, Aix-Marseille University, Marseille, France

Karolina Świerk

Clement francois, małgorzata biernikiewicz.

c Studio Slowa, Wroclaw, Poland

Emilie Clay

d Clever-Access, Paris, France

Laurent Boyer

Introduction: A rapid literature review (RLR) is an alternative to systematic literature review (SLR) that can speed up the analysis of newly published data. The objective was to identify and summarize available information regarding different approaches to defining RLR and the methodology applied to the conduct of such reviews.

Methods: The Medline and EMBASE databases, as well as the grey literature, were searched using the set of keywords and their combination related to the targeted and rapid review, as well as design, approach, and methodology. Of the 3,898 records retrieved, 12 articles were included.

Results: Specific definition of RLRs has only been developed in 2021. In terms of methodology, the RLR should be completed within shorter timeframes using simplified procedures in comparison to SLRs, while maintaining a similar level of transparency and minimizing bias. Inherent components of the RLR process should be a clear research question, search protocol, simplified process of study selection, data extraction, and quality assurance.

Conclusions: There is a lack of consensus on the formal definition of the RLR and the best approaches to perform it. The evidence-based supporting methods are evolving, and more work is needed to define the most robust approaches.

Introduction

A systematic literature review (SLR) summarizes the results of all available studies on a specific topic and provides a high level of evidence. Authors of the SLR have to follow an advanced plan that covers defining a priori information regarding the research question, sources they are going to search, inclusion criteria applied to choose studies answering the research question, and information regarding how they are going to summarize findings [ 1 ].

The rigor and transparency of SLRs make them the most reliable form of literature review [ 2 ], providing a comprehensive, objective summary of the evidence for a given topic [ 3 , 4 ]. On the other hand, the SLR process is usually very time-consuming and requires a lot of human resources. Taking into account a high increase of newly published data and a growing need to analyze information in the fastest possible way, rapid literature reviews (RLRs) often replace standard SLRs.

There are several guidelines on the methodology of RLRs [ 5–11 ]; however, only recently, one publication from 2021 attempted to construct a unified definition [ 11 ]. Generally, by RLRs, researchers understand evidence synthesis during which some of the components of the systematic approach are being used to facilitate answering a focused research question; however, scope restrictions and a narrower search strategy help to make the project manageable in a shorter time and to get the key conclusions faster [ 4 ].

The objective of this research was to collect and summarize available information on different approaches to the definition and methodology of RLRs. An RLR has been run to capture publications providing data that fit the project objective.

To find publications reporting information on the methodology of RLRs, searches were run in the Medline and EMBASE databases in November 2022. The following keywords were searched for in titles and abstracts: ‘targeted adj2 review’ OR ‘focused adj2 review’ OR ‘rapid adj2 review’, and ‘methodology’ OR ‘design’ OR ‘scheme’ OR ‘approach’. The grey literature was identified using Google Scholar with keywords including ‘targeted review methodology’ OR ‘focused review methodology’ OR ‘rapid review methodology’. Only publications in English were included, and the date of publication was restricted to year 2016 onward in order to identify the most up-to-date literature. The reference lists of each included article were searched manually to obtain the potentially eligible articles. Titles and abstracts of the retrieved records were first screened to exclude articles that were evidently irrelevant. The full texts of potentially relevant papers were further reviewed to examine their eligibility.

A pre-defined Excel grid was developed to extract the following information related to the methodology of RLR from guidelines:

Definition,
Research question and searches,
Studies selection,
Data extraction and quality assessment,
Additional information.

There was no restriction on the study types to be analyzed; any study reporting on the methodology of RLRs could be included: reviews, practice guidelines, commentaries, and expert opinions on RLR relevant to healthcare policymakers or practitioners. The data extraction and evidence summary were conducted by one analyst and further examined by a senior analyst to ensure that relevant information was not omitted. Disagreements were resolved by discussion and consensus.

Studies selection

A total of 3,898 records (3,864 articles from a database search and 34 grey literature from Google Scholar) were retrieved. After removing duplicates, titles and abstracts of 3,813 articles were uploaded and screened. The full texts of 43 articles were analyzed resulting in 12 articles selected for this review, including 7 guidelines [ 5–11 ] on the methodology of RLRs, together with 2 papers summarizing the results of the Delphi consensus on the topic [ 12 , 13 ], and 3 publications analyzing and assessing different approaches to RLRs [ 4 , 14 , 15 ].

Overall, seven guidelines were identified: from the World Health Organization (WHO) [ 5 ], National Collaborating Centre for Methods and Tools (NCCMT) [ 7 ], the UK government [ 8 ], the Oxford Centre for Evidence Based Medicine [ 9 ], the Cochrane group [ 6 , 11 ], and one multi-national review [ 10 ]. Among the papers that did not describe the guidelines, Gordon et al. [ 4 ] proposed 12 tips for conducting a rapid review in the right settings and discussed why these reviews may be more beneficial in some circumstances. The objective of work conducted by Tricco et al. [ 13 ] and Pandor et al. [ 12 ] was to collect and compare perceptions of rapid reviews from stakeholders, including researchers, policymakers, industry, journal editors, and healthcare providers, and to reach a consensus outlining the domains to consider when deciding on approaches for RLRs. Haby et al. [ 14 ] run a rapid review of systematic reviews and primary studies to find out the best way to conduct an RLR in health policy and practice. In Tricco et al. (2022) [ 15 ], JBI position statement for RLRs is presented.

From all the seven identified guidelines information regarding definitions the authors used for RLRs, approach to the PICOS criteria and search strategy development, studies selection, data extractions, quality assessment, and reporting were extracted.

Cochrane Rapid Reviews Methods Group developed methods guidance based on scoping review of the underlying evidence, primary methods studies conducted, as well as surveys sent to Cochrane representative and discussion among those with expertise [ 11 ]. They analyzed over 300 RLRs or RLR method papers and based on the methodology of those studies, constructed a broad definition RLR, one that meets a minimum set of requirements identified in the thematic analysis: ‘ A rapid review is a form of knowledge synthesis that accelerates the process of conducting a traditional systematic review through streamlining or omitting a variety of methods to produce evidence in a resource-efficient manner .’ This interpretation aligns with more than 50% of RLRs identified in this study. The authors additionally provided several other definitions, depending on specific situations or requirements (e.g., when RLR is produced on stakeholder’s request). It was additionally underlined that RLRs should be driven by the need of timely evidence for decision-making purposes [ 11 ].

Rapid reviews vary in their objective, format, and methods used for evidence synthesis. This is a quite new area, and still no agreement on optimal methods can be found [ 5 ]. All of the definitions are highlighting that RLRs are completed within shorter timeframes than SLRs, and also lack of time is one of the main reasons they are conducted. It has been suggested that most rapid reviews are conducted within 12 weeks; however, some of the resources suggest time between a few weeks to no more than 6 months [ 5 , 6 ]. Some of the definitions are highlighting that RLRs follow the SLR process, but certain phases of the process are simplified or omitted to retrieve information in a time-saving way [ 6 , 7 ]. Different mechanisms are used to enhance the timeliness of reviews. They can be used independently or concurrently: increasing the intensity of work by intensifying the efforts of multiple analysts by parallelization of tasks, using review shortcuts whereby one or more systematic review steps may be reduced, automatizing review steps by using new technologies [ 5 ]. The UK government report [ 8 ] referred to two different RLRs: in the form of quick scoping reviews (QSR) or rapid evidence assessments (REA). While being less resource and time-consuming compared to standard SLRs, QSRs and REAs are designed to be similarly transparent and to minimize bias. QSRs can be applied to rather open-ended questions, e.g., ‘what do we know about something’ but both, QSRs and REAs, provide an understanding of the volume and characteristics of evidence on a specific topic, allowing answering questions by maximizing the use of existing data, and providing a clear picture of the adequacy of existing evidence [ 8 ].

Research questions and searches

The guidelines suggest creating a clear research question and search protocol at the beginning of the project. Additionally, to not duplicate RLRs, the Cochrane Rapid Reviews Methods Group encourages all people working on RLRs to consider registering their search protocol with PROSPERO, the international prospective register of reviews; however, so far they are not formally registered in most cases [ 5 , 6 ]. They also recommend involving key stakeholders (review users) to set and refine the review question, criteria, and outcomes, as well as consulting them through the entire process [ 11 ].

Regarding research questions, it is better to structure them in a neutral way rather than focus on a specific direction for the outcome. By doing so, the researcher is in a better position to identify all the relevant evidence [ 7 ]. Authors can add a second, supportive research question when needed [ 8 ]. It is encouraged to limit the number of interventions, comparators and outcomes, to focus on the ones that are most important for decision-making [ 11 ]. Useful could be also reviewing additional materials, e.g., SLRs on the topic, as well as conducting a quick literature search to better understand the topic before starting with RLRs [ 7 ]. In SLRs researchers usually do not need to care a lot about time spent on creating PICOS, they need to make sure that the scope is broad enough, and they cannot use many restrictions. When working on RLRs, a reviewer may spend more or less time defining each of the components of the study question, and the main step is making sure that PICOS addresses the needs of those who requested the rapid review, and at the same time, it is feasible within the required time frame [ 7 ]. Search protocol should contain an outline of how the following review steps are to be carried out, including selected search keywords and a full strategy, a list of data sources, precise inclusion and exclusion criteria, a strategy for data extraction and critical appraisal, and a plan of how the information will be synthesized [ 8 ].

In terms of searches running, in most cases, an exhaustive process will not be feasible. Researchers should make sure that the search is effective and efficient to produce results in a timely manner. Cochrane Rapid Reviews Methods Group recommends involving an information specialist and conducting peer review of at least one search strategy [ 11 ]. According to the rapid review guidebook by McMaster University [ 7 ], it is important that RLRs, especially those that support policy and program decisions, are being fed by the results of a body of literature, rather than single studies, when possible. It would result in more generalizable findings applied at the level of a population and serve more realistic findings for program decisions [ 7 ]. It is important to document the search strategy, together with a record of the date and any date limits of the search, so that it can easily be run again, modified, or updated. Furthermore, the information on the individual databases included in platform services should always be reported, as this depends on organizations’ subscriptions and must be included for transparency and repeatability [ 7 , 8 ]. Good solution for RLRs is narrowing the scope or searching a limited number of databases and other sources [ 7 ]. Often, the authors use the PubMed/MEDLINE, Cochrane Library, and Embase databases. In most reviews, two or more databases are searched, and common limits are language (usually restricted to English), date, study design, and geographical area. Some RLRs include searching of grey literature; however, contact with authors is rather uncommon [ 5 , 8 ]. According to the flexible framework for restricted systematic review published by the University of Oxford, the search should be run in at least one major scientific database such as PubMed, and one other source, e.g., Google Scholar [ 9 ]. Grey literature and unpublished evidence may be particularly needed and important for intervention questions. It is related to the fact that studies that do not report the effects of interventions are less likely to be published [ 8 ]. If there is any type of evidence that will not be considered by the RLRs, e.g., reviews or theoretical and conceptual studies, it should also be stated in the protocol together with justification [ 8 ]. Additionally, authors of a practical guide published by WHO suggest using a staged search to identify existing SLRs at the beginning, and then focusing on studies with other designs [ 5 ]. If a low number of citations have been retrieved, it is acceptable to expand searches, remove some of the limits, and add additional databases and sources [ 7 ].

Searching for RLRs is an iterative process, and revising the approach is usually needed [ 7 ]. Changes should be confirmed with stakeholders and should be tracked and reflected in the final report [ 5 ].

The next step in the rapid review is the selection of studies consisting of two phases: screening of titles and abstracts, and analysis of full texts. Prior to screening initiation, it is recommended to conduct a pilot exercise using the same 30–50 abstracts and 5–10 full-texts for the entire screening team in order to calibrate and test the review form [ 11 ]. In contrast to SLRs, it can be done by one reviewer with or without verification by a second one. If verification is performed, usually the second reviewer checks only a subset of records and compares them. Cochrane Group, in contrast, recommends a stricter approach: at least 20% of references should be double-screened at titles and abstracts stage, and while the rest of the references may be screened by one reviewer, the excluded items need to be re-examined by second reviewer; similar approach is used in full-text screening [ 11 ]. This helps to ensure that bias was reduced and that the PICOS criteria are applied in a relevant way [ 5 , 8 , 9 , 11 ]. During the analysis of titles and abstracts, there is no need to report reasons for exclusion; however, they should be tracked for all excluded full texts [ 7 ].

Data extraction and quality assessment

According to the WHO guide, the most common method for data extraction in RLRs is extraction done by a single reviewer with or without partial verification. The authors point out that a reasonable approach is to use a second reviewer to check a random sample of at least 10% of the extractions for accuracy. Dual performance is more necessary for the extraction of quantitative results than for descriptive study information. In contrast, Cochrane group recommends that second reviewer should check the correctness and completeness of all data [ 11 ]. When possible, extractions should be limited to key characteristics and outcomes of the study. The same approach to data extraction is also suggested for a quality assessment process within rapid reviews [ 5 , 9 , 11 ]. Authors of the guidebook from McMaster University highlight that data extraction should be done ideally by two reviewers independently and consensus on the discrepancies should always be reached [ 7 ]. The final decision on the approach to this important step of review should depend on the available time and should also reflect the complexity of the research question [ 9 ].

For screening, analysis of full texts, extractions, and quality assessments, researchers can use information technologies to support them by making these review steps more efficient [ 5 ].

Before data reporting, a reviewer should prepare a document with key message headings, executive summary, background related to the topic and status of the current knowledge, project question, synthesis of findings, conclusions, and recommendations. According to the McMaster University guidebook, a report should be structured in a 1:2:20 format, that is, one page for key messages, two pages for an executive summary, and a full report of up to 20 pages [ 7 ]. All the limitations of the RLRs should be analyzed, and conclusions should be drawn with caution [ 5 ]. The quality of the accumulated evidence and the strength of recommendations can be assessed using, e.g., the GRADE system [ 5 ]. When working on references quoting, researchers should remember to use a primary source, not secondary references [ 7 ]. It would be worth considering the support of some software tools to automate reporting steps. Additionally, any standardization of the process and the usage of templates can support report development and enhance the transparency of the review [ 5 ].

Ideally, all the review steps should be completed during RLRs; however, often some steps may need skipping or will not be completed as thoroughly as should because of time constraints. It is always crucial to decide which steps may be skipped, and which are the key ones, depending on the project [ 7 ]. Guidelines suggest that it may be helpful to invite researchers with experience in the operations of SLRs to participate in the rapid review development [ 5 , 9 ]. As some of the steps will be completed by one reviewer only, it is important to provide them with relevant training at the beginning of the process, as well as during the review, to minimize the risk of mistakes [ 5 ].

Additional information

Depending on the policy goal and available resources and deadlines, methodology of the RLRs may be modified. Wilson et al. [ 10 ] provided extensive guidelines for performing RLR within days (e.g., to inform urgent internal policy discussions and/or management decisions), weeks (e.g., to inform public debates), or months (e.g., to inform policy development cycles that have a longer timeline, but that cannot wait for a traditional full systematic review). These approaches vary in terms of data synthesis, types of considered evidence and project management considerations.

In shortest timeframes, focused questions and subquestions should be formulated, typically to conduct a policy analysis; the report should consist of tables along with a brief narrative summary. Evidence from SLRs is often considered, as well as key informant interviews may be conducted to identify additional literature and insights about the topic, while primary studies and other types of evidence are not typically feasible due to time restrictions. The review would be best conducted with 1–2 reviewers sharing the work, enabling rapid iterations of the review. As for RLRs with longer timeline (weeks), these may use a mix of policy, systems and political analysis. Structure of the review would be similar to shorter RLRs – tabular with short narrative summary, as the timeline does not allow for comprehensive synthesis of data. Besides SLRs, primary studies and other evidence may be feasible in this timeframe, if obtained using the targeted searches in the most relevant databases. The review team should be larger, and standardized procedures for reviewing of the results and data extraction should be applied. In contrast to previous timeframe, merit review process may be feasible. For both timeframes, brief consultations with small transdisciplinary team should be conducted at the beginning and in the final stage of the review to discuss important matters.

For RLRs spanning several months, more comprehensive methodology may be adapted in terms of data synthesis and types of evidence. However, authors advise that review may be best conducted with a small review team in order to allow for more in-depth interpretation and iteration.

Studies analyzing methodology

There have been two interesting publications summarizing the results of Delphi consensus on the RLR methodology identified and included in this review [ 12 , 13 ].

Tricco et al. [ 13 ] first conducted an international survey and scoping review to collect information on the possible approaches to the running of rapid reviews, based on which, they employed a modified Delphi method that included inputs from 113 stakeholders to explore the most optimized approach. Among the six most frequent rapid review approaches (not all detailed here) being evaluated, the approach that combines inclusion of published literature only, a search of more than one database and limitations by date and language, study selection by one analyst, data extraction, and quality assessment by one analyst and one verifier, was perceived as the most feasible approach (72%, 81/113 responses) with the potentially lowest risk of bias (12%, 12/103). The approach ranked as the first one when considering timelines assumes updating of the search from a previously published review, no additional limits on search, studies selection and data extraction done by one reviewer, and no quality assessment. Finally, based on the publication, the most comprehensive RLRs can be made by moving on with the following rules: searching more than one database and grey literature and using date restriction, and assigning one reviewer working on screening, data extraction, and risk of bias assessment ( Table 1 ). Pandor et al. [ 12 ] introduced a decision tool for SelecTing Approaches for Rapid Reviews (STARR) that were produced through the Delphi consensus of international experts through an iterative and rigorous process. Participants were asked to assess the importance of predefined items in four domains related to the rapid review process: interaction with commissioners, understanding the evidence base, data extraction and synthesis methods, and reporting of rapid review methods. All items assigned to four domains achieved > 70% of consensus, and in that way, the first consensus-driven tool has been created that supports authors of RLRs in planning and deciding on approaches.

Six most frequent approaches to RLRs (adapted from Tricco et al. [ 13 ]).

Haby et al. [ 14 ] run searches of 11 databases and two websites and developed a comprehensive overview of the methodology of RLRs. With five SLRs and one RCT being finally included, they identified the following approaches used in RLRs to make them faster than full SLRs: limiting the number and scope of questions, searching fewer databases, limited searching of grey literature, restrictions on language and date (e.g., English only, most recent publications), updating the existing SLRs, eliminating or limiting hand searches of reference lists, noniterative search strategies, eliminating consultation with experts, limiting dual study selection, data extraction and quality assessment, minimal data synthesis with short concise conclusions or recommendations. All the SLRs included in this review were consistent in stating that no agreed definition of rapid reviews is available, and there is still no final agreement on the best methodological rules to be followed.

Gordon et al. [ 4 ] explained the advantages of performing a focused review and provided 12 tips for its conduction. They define focused reviews as ‘a form of knowledge synthesis in which the components of the systematic process are applied to facilitate the analysis of a focused research question’. The first tip presented by the authors is related to deciding if a focused review is a right solution for the considered project. RLRs will suit emerging topics, approaches, or assessments where early synthesis can support doctors, policymakers, etc., but also can direct future research. The second, third, and fourth tips highlight the importance of running preliminary searches and considering narrowing the results by using reasonable constraints taking into account the local context, problems, efficiency perspectives, and available time. Further tips include creating a team of experienced reviewers working on the RLRs, thinking about the target journal from the beginning of work on the rapid review, registering the search protocol on the PROSPERO registry, and the need for contacting authors of papers when data available in publications are missing or incongruent. The last three tips are related to the choice of evidence synthesis method, using the visual presentation of data, and considering and describing all the limitations of the focused review.

Finally, a new publication by Tricco et al. from 2022, describing JBI position statement [ 15 ] underlined that for the time being, there is no specific tool for critical appraisal of the RLR’s methodological quality. Instead, reviewers may use available tools to assess the risk of bias or quality of SLRs, like ROBIS, the JBI critical appraisal tools, or the assessment of multiple systematic reviews (AMSTAR).

Inconsistency in the definitions and methodologies of RLR

Although RLR was broadly perceived as an approach to quicken the conduct of conventional SLR, there is a lack of consensus on the formal definition of the RLR, so as to the best approaches to perform it. Only in 2021, a study proposing unified definition was published; however, it is important to note that the most accurate definition was only matching slightly over 50% of papers analysed by the authors, which underlines the lack of homogeneity in the field [ 11 ]. The evidence-based supporting methods are evolving, and more evidence is needed to define the most robust approaches [ 5 ].

Diverse terms are used to describe the RLR, including ‘rapid review’, focused systematic review’, ‘quick scoping reviews’, and ‘rapid evidence assessments’. Although the general principles of conducting RLR are to accelerate the whole process, complexity was seen in the methodologies used for RLRs, as reflected in this study. Also, inconsistencies related to the scope of the questions, search strategies, inclusion criteria, study screening, full-text review, quality assessment, and evidence presentation were implied. All these factors may hamper decision-making about optimal methodologies for conducting rapid reviews, and as a result, the efficiency of RLR might be decreased. Additionally, researchers may tend to report the methodology of their reviews without a sufficient level of detail, making it difficult to appraise the quality and robustness of their work.

Advantages and weaknesses of RLR

Although RLR used simplified approaches for evidence synthesis compared with SLR, the methodologies for RLR should be replicable, rigorous, and transparent to the greatest extent [ 16 ]. When time and resources are limited, RLR could be a practical and efficient tool to provide the summary of evidence that is critical for making rapid clinical or policy-related decisions [ 5 ]. Focusing on specific questions that are of controversy or special interest could be powerful in reaffirming whether the existing recommendation statements are still appropriate [ 17 ].

The weakness of RLR should also be borne in mind, and the trade-off of using RLR should be carefully considered regarding the thoroughness of the search, breadth of a research question, and depth of analysis [ 18 ]. If allowed, SLR is preferred over RLR considering that some relevant studies might be omitted with narrowed search strategies and simplified screening process [ 14 ]. Additionally, omitting the quality assessment of included studies could result in an increased risk of bias, making the comprehensiveness of RLR compromised [ 13 ]. Furthermore, in situations that require high accuracy, for example, where a small relative difference in an intervention has great impacts, for the purpose of drafting clinical guidelines, or making licensing decisions, a comprehensive SLR may remain the priority [ 19 ]. Therefore, clear communications with policymakers are recommended to reach an agreement on whether an RLR is justified and whether the methodologies of RLR are acceptable to address the unanswered questions [ 18 ].

Disclosure statement

No potential conflict of interest was reported by the author(s).

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Unleashing the potential of Health Promotion in primary care—a scoping literature review

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Adela Bisak, Martin Stafström, Unleashing the potential of Health Promotion in primary care—a scoping literature review, Health Promotion International , Volume 39, Issue 3, June 2024, daae044, https://doi.org/10.1093/heapro/daae044

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The purpose of this study is to gain a better understanding of the role and extent of health promotion lifestyle interventions targeting adults in primary care, and especially those who are considered overall healthy, i.e. to study the outcomes of research applying salutogenesis. We performed a literature review, with three specific aims. First, to identify studies that have targeted the healthy population in intervention within the primary health care field with health promotion activities. Second, to describe these interventions in terms of which health problems they have targeted and what the interventions have entailed. Third, to assess what these programs have resulted in, in terms of health outcomes. This scoping review of 42 studies, that applied salutogenesis in primary care interventions shows that health promotion targeting healthy individuals is relevant and effective. The PRISMA-ScR guidelines for reporting on scoping review were used. Most interventions were successful in reducing disease-related risks including CVD, CVD mortality, all-cause mortality, but even more importantly success in behavioural change, sustained at follow-up. Additionally, this review shows that health promotion lifestyle interventions can improve mental health, even when having different aims.

This article describes the importance of including healthy individuals in health promotion activities, applying salutogenesis, as there are significant positive health outcomes effects if they participate in health interventions.

The study amplifies that the prevention paradox should always be considered when designing health promotion interventions.

This article shows that the greatest effects when targeting healthy individuals are found in lower all-cause mortality and CVD risks, mainly because these programs manage to lead to long-lasting lifestyle changes.

Health Promotion is, according to Nutbeam and Muscat (2021 , p. 1580), ‘[…] the process of enabling people to increase control over, and to improve their health’. This process entails a comprehensive approach to change on all levels, from structures to individuals, improving health mainly through addressing the social determinants of health.

Whereas the most overarching processes are initiated on a structural level through global and national health policies ( Cross et al ., 2020 ), health promotion strategies are also widely employed in health interventions targeting individuals. It could entail smoking cessation programs, weight loss programs and adolescent alcohol use, just to mention some common health outcome target areas ( Green et al. , 2019 ). Even when deploying health promotion strategies at a national policy level, it is not uncommon that the programs designed to target individuals and groups are more inspired by pathogenesis, rather than salutogenesis ( Nutbeam and Muscat, 2021 ).

A widespread strategy in the latter programs is that individuals are screened for a need to receive an intervention, so-called secondary or indicated prevention programs, where those who report a riskier lifestyle, or test worse on psychometric or biometric indicators are eligible for receiving the intervention, and those not having the same risks are excluded from the program on the premise that they are, based on study protocol definitions, healthy individuals.

Based on the principles of salutogenesis, this is a somewhat inappropriate approach. Within the strategy of health promotion, it is assumed that all people, no matter their level of risk, would find feedback on their health valuable. Those in need of change should receive the necessary resources and tools to change, whereas those who do not have to change should have their lifestyles positively reinforced. In addition, the prevention paradox ( Rose, 1981 ) postulates that it is important to address the majority, as there will be plenty of adverse health outcomes stemming from them. In conventional indicated prevention programs, attention to those who are non-eligible for interventions is, thus, often completely disregarded.

One common arena for such programs is primary health care. There is a wide range of evidence-based programs that have shown efficacy in reducing the health risks among those who have the riskiest lifestyles in relation to, e.g. alcohol use ( Beyer et al ., 2019 ), smoking ( Cantera et al ., 2015 ), depression ( Bortolotti et al ., 2008 ), diabetes ( Galaviz et al ., 2018 ) and cardiovascular diseases ( Álvarez-Bueno et al. , 2015 ). The at-risk groups vary across the different diseases, but a vast majority of patients targeted in the above studies were identified after screening as non-eligible to participate in the intervention in question. From this follows that a large number of individuals do not receive any substantial health information, nor are their health outcomes measured as they are not included in the intervention. From a health promotion perspective, this seems like a lost opportunity. Additionally, this raises the question of whether a healthy population is systematically disadvantaged compared to those individuals at high risk, which might point to some less-known health inequities or disparities ( Braveman, 2006 ) present in primary care.

In order to gain a better understanding of the effects of health promotion as an overall approach, and to understand the implications of the prevention paradox, it would be pertinent to include the non-eligible group in both the feedback loop—mainly offering them structured positive reinforcement—and to subsequently measure their health and attributed lifestyles.

The purpose of this study is to gain a better understanding of the role and extent of health promotion lifestyle interventions targeting adults in primary care, especially those who are considered overall healthy. More precisely we aim to assess to what extent health promotion practices in primary care address healthy individuals, not only those who need to undergo a lifestyle change. In order to do so, we performed a literature review, with three specific aims. First, to identify studies that have only targeted the healthy population, or healthy population in addition to high-risk group in intervention within the primary health care field with health promotion activities. Second, to describe these interventions in terms of which health problems they have targeted and what the interventions have entailed. Third, to assess what the initiatives published in the research literature have resulted in terms of health outcomes.

Due to the width of the topic and study designs we chose to perform a scoping review, with the aim of summarizing and disseminating previous research and identifying research gaps in the literature ( Arksey and O’Malley, 2005 ). The search process was iterative and non-linear, reflecting upon the results from the literature search at each stage and then repeating steps where necessary to cover the literature more comprehensively ( Arksey and O’Malley, 2005 ).

A few terms demand some further definition within the scope of this review . Healthy individual is a fluid term varying across different studies and contexts, yet it is a key concept in this particular study. The term involves those without chronic disease, who are indicated as not being of an elevated risk of developing a disease linked to the health outcome they have been screened for, but they could very well be at risk for diseases beyond the scope of the study they have been examined within. Primary health care may in this review indicates different types of settings from the most common one relating to general practitioners and family doctors to occupational medicine or periodical work-related health check-ups but also dental health care. Health promotion interventions in this study are understood as interventions that aim to keep people healthy longer, by providing positive feedback in relation to current and new health behaviours, rather than controlling health status by medication use.

Search strategy

The search was done across two databases PubMed and Embase, by combining different strings related to keywords ‘health promotion’ and ‘primary care’, while the rest of the strings varied, more specific search queries are available in Supplementary Appendix A . The search was conducted during June and July 2023 and consisted of publications dated between July 2008 and July 2023 (i.e. the last 15 years). Additional studies were identified manually from references of the included articles and by ‘See all similar articles’ option in PubMed and ‘similar records’ in Embase. The article titles were scanned from databases, followed by screening titles and abstracts through the Covidence software, and then finally the full articles were read. Results were filtered for adult humans, defined as age 18–75, abstracts being available and the studies were authored in English.

Articles were included if (i) the population consisted of working-age adults, (ii) the population included those screened as healthy within a whole sample followed by an intervention or interventions ideally at follow-up, (iii) the study focused on primary prevention (iv) the study focused on lifestyle interventions, (v) the study examined lifestyle-related behaviours. Exclusion criteria for papers were (i) focused on children—below the age of 18 or elderly, (ii) addiction behaviours, (iii) excluding healthy individuals from intervention after screening or using them exclusively in the control group, (iv) using only high-risk population as healthy, (v) promoting only mental health, (vi) secondary prevention, (vii) screening is the only intervention, (viii) reviews and study protocols.

After full-text screening, the data charting process for reviewing, sorting and documenting information ( Arksey and O’Malley, 2005 ) was done using Covidence, Data Extraction version 2 recommended for scoping reviews. The Data Extraction Template included columns for article title, author, country in which the study was conducted, methods (aim, design, population description, inclusion and exclusion criteria) intervention description, outcome measures, relevant results, follow-up (yes/no), study setting (primary care, worksite/occupational, population-based), study category (lifestyle, physical activity and diet, cardiovascular disease, alcohol consumption) and a field for additional notes where needed.

Due to great inconsistencies between studies in the design, populations and outcomes, critical appraisal of individual sources of evidence—an optional step in PRISMA-ScR ( Tricco et al ., 2018 ) guideline list was not done, although concerning research aim it would be useful for assessing the quality of evidence. Although exclusion/inclusion criteria were respected, what was considered as ‘healthy’, ‘middle-’ or ‘high-risk population’ differed significantly in studies, due to differences in definition of terms. Moreover, this decision was made as the AMSTAR tool would not be an adequate choice due to the inclusion of a non-randomized design, and although the AMSTAR 2 tool could potentially be used, this review also included several economic evaluations and follow-ups ( Supplementary Table S1 for more details), or indicators differing highly across studies.

For the synthesis of results ( Tricco et al ., 2018 ), the studies were grouped by the type of the outcome—disease, i.e. CVD or lifestyle/behaviour: physical activity and diet or alcohol consumption. Furthermore, the studies were summarized by setting, risk group and follow-up. None of the systematic reviews with similar research aims were detected during the search.

The selection of sources of evidence ( Tricco et al ., 2018 ) was done as described: 353 references were imported for screening, 72 duplicates were removed, 268 studies were screened against title and abstract during which 198 studies were excluded while 69 studies were assessed for full-text eligibility, when 27 studies were excluded: 12 for wrong intervention, 8 for wrong patient population, 4 for wrong study design 1 was not in English, 1 for wrong indication and 1 for wrong setting, after which 42 studies were included. PRISMA of full screening is found in Figure 1 .

PRISMA of full screening strategy.

Lifestyle interventions

A summary of the study setting, samples and the main outcomes of the 42 studies analysed in this scoping review is presented in Supplementary Table S1 .

In general, the intervention studies analysed here had different main strategies, including: individually tailored programs ( Doumas and Hannah, 2008 ; Gram et al ., 2012 ; Watson et al ., 2015 ) risk-based, group-based ( Recio-Rodriguez et al ., 2016 ) or mixed variants ( Matano et al ., 2007 ; Matzer et al ., 2018 ).

Cardiovascular health

We found several different lifestyle interventions targeting CVD risk. There were a set of programs that addressed physical activity in the workplace, which significantly reduced the CVD risk in healthy participants adhering to the program ( Gram et al ., 2012 ; Dalager et al ., 2016 ; Eng et al ., 2016 ; Biffi et al ., 2018 ). In primary care, an observational study by Journath et al . (2020) , showed an association between healthy participant participation in a CVD prevention programme promoting physical activity and a healthy lifestyle with lower risk of CV events (12%), CV mortality (21%) and all-cause mortality (17%) after 20 years of follow-up.

Similarly, we found interventions in primary care settings that led to changes in physical activity and dietary patterns among all participants—not only those at high risk of CVD morbidity and mortality. These studies described generally decreased CVD risks ( Richardson et al ., 2008 ; Buckland et al ., 2009 ; Nguyen et al ., 2012 ; Gibson et al ., 2014 ; Bo et al ., 2016 ; Lidin et al ., 2018 ; Lingfors and Persson, 2019 ), CVD-related mortality ( Blomstedt et al ., 2011 ; Persson et al ., 2015 ; Jeong et al ., 2019 ) and all-cause mortality ( Blomstedt et al ., 2015 ; Bo et al ., 2016 ; Bonaccio et al ., 2019 ).

In a prospective observational study on healthy individuals and those with CVD conducted by Lidin et al . (2018) , the prevalence within the sample at risk of CVD decreased significantly at 12-month follow-up by 15%. In several studies, the changes in health behaviours among the participants showed to be sustained in follow-ups conducted after intervention discontinuation ( Buckland et al ., 2009 ; Gibson et al ., 2014 ; Baumann et al ., 2015 ; Blomstedt et al ., 2015 ; Lidin et al ., 2018 ), while some cardiovascular risk factors, such as salty diets and smoking, showed evidence of significant decrease in a relatively short period ( Nguyen et al ., 2012 ).

Physical activity and diet

In interventions addressing physical activity and diet, it was evident that healthy individuals were more likely to adhere to physical activity interventions ( Dalager et al ., 2016 ; Biffi et al ., 2018 ; Jeong et al ., 2019 ) compared to those with a disease. One community-based walking intervention ( Yang and Kim, 2022 ) affected not only the level of physical activity significantly but also a positive overall change towards a health-promoting lifestyle and decreased perceived stress. Similarly, several mental health measures including general mental health ( Oude Hengel et al ., 2014 ), anxiety and depression ( Gibson et al ., 2014 ) and stress ( Lingfors et al ., 2009 ; Matzer et al ., 2018 ) in participants improved during interventions and at follow-up when targeting physical activity and diet.

Additionally, concerning physical activity and diet outcomes, there were a higher feasibility of uptake among participants in health promotion programs compared to those only receiving standard care in primary care ( Lingfors et al ., 2009 ; Zabaleta-Del-Olmo et al ., 2021 ). Anokye et al. (2014) argued that brief advice intervention was more effective—leading to 466 QALYs gained, compared to standard care—implying greater cost-effectiveness.

Healthier lifestyles were also maintained at the follow-up. Reduction in risk factors was found to be sustained in follow-ups at 12 months ( Gibson et al ., 2014 ) or improvements in dietary outcomes over 5 years ( Baumann et al ., 2015 ), and sustained lower blood pressure over 6 years ( Eng et al ., 2016 ).

Several interventions promoting physical activity in primary care settings showed significant results in increasing it in all patients, not only in those with chronic disease diagnosis ( Robroek et al ., 2010 ; Gram et al ., 2012 ; Hardcastle et al ., 2012 ; Viester et al ., 2015 ; Byrne et al ., 2016 ; Dalager et al ., 2016 ; Eng et al ., 2016 ; Recio-Rodriguez et al ., 2016 ; Biffi et al ., 2018 ; Matzer et al ., 2018 ; Yang and Kim, 2022 ), and similar patterns were also found concerning a change towards a healthier diet ( Lingfors et al ., 2009 ; Wendel-Vos et al ., 2009 ; Robroek et al ., 2010 ; Baumann et al ., 2015 ; Viester et al ., 2015 ; Bo et al ., 2016 ; Byrne et al ., 2016 ; Kosendiak et al ., 2021 ).

There was disagreement among the above studies in relation to the effectiveness of these interventions among healthy individuals. For example, in the case of implementing a Mediterranean diet, one report argued that a healthy diet should be prioritized, indicating significant hazard ratios (HR) of attaining a Mediterranean diet for all-cause mortality (HR = 0.83), CV mortality (HR = 0.75) and CV events (HR = 0.79) among low-risk individuals ( Bo et al ., 2016 ). Others, however, claimed that there was no evidence of healthier participants being more susceptible to changes in physical activity and diet ( Robroek et al ., 2010 ).

Alcohol consumption

Interventions aimed at decreasing alcohol consumption were divided between those being most effective in high-risk drinkers ( Doumas and Hannah, 2008 ; Kirkman et al ., 2018 ), and both moderate and low-risk drinkers ( Matano et al ., 2007 ). These interventions were, at large, seen as cost-saving ( Watson et al ., 2015 ) and feasible in primary care ( Neuner-Jehle et al ., 2013 ). Some studies found a sustained decrease in alcohol consumption in those adhering to the interventions, compared to the control groups at 1 ( Pemberton et al ., 2011 ) and 4 months after the intervention ( Kirkman et al ., 2018 ), whereas others failed to find a significant difference between groups.

Intervention setting

The interventions took place in primary care settings, though these were either in community-based or occupational settings. The findings suggested that there were some discrepancies between these different settings.

When it comes to a community-based setting, the difference is made between interventions conducted on a sample of those visiting primary health care or a sample representative for a population of one community—town, or region. Primary care community-based studies tended to either include participants who were primary care visitors with a long follow-up period, or interventions conducted in primary care clinic centres with a shorter follow-up period, most often using experimental design, sampling individuals living in the community that did not necessarily had an intention to seek care ( Richardson et al ., 2008 ; Hardcastle et al ., 2012 ; Nguyen et al ., 2012 ; Grunfeld et al ., 2013 ; Baumann et al ., 2015 ; Bo et al ., 2016 ; Lidin et al ., 2018 ; Zabaleta-Del-Olmo et al ., 2021 ).

Overall, the community-based studies were conducted on a sample representative for a population of a smaller community ( Kosendiak et al ., 2021 ; Yang and Kim, 2022 ), region ( Lingfors et al ., 2009 ; Wendel-Vos et al ., 2009 ; Gibson et al ., 2014 ; Persson et al ., 2015 ; Bonaccio et al ., 2019 ; Jeong et al ., 2019 ; Lingfors and Persson, 2019 ; Journath et al ., 2020 ) or a country ( Buckland et al ., 2009 ; Blomstedt et al ., 2011 ; Neuner-Jehle et al ., 2013 ), often followed by a longer follow-up period. Finally, some studies were evaluations of previous interventions ( Richardson et al ., 2008 ; Anokye et al ., 2014 ).

Worksite interventions comprised of different occupational roles, often including several of those in the same sample ( Eng et al ., 2016 ), or segmenting based on how physically active the occupation was, e.g. office workers ( Dalager et al ., 2016 ), construction workers ( Gram et al ., 2012 ; Oude Hengel et al ., 2014 ; Viester et al ., 2015 ), sailors ( Hjarnoe and Leppin, 2013 ), farmers ( van Doorn et al ., 2019 ) or simply more active individuals ( Biffi et al ., 2018 ). This had the implication that approaches to intervention differed widely across the studies.

Several interventions were conducted online using a web-based interface, while others were in a professional setting ( Matano et al ., 2007 ; Doumas and Hannah, 2008 ; Robroek et al ., 2010 ; Pemberton et al ., 2011 ; Khadjesari et al ., 2014 ) or in some cases community-based ( Recio-Rodriguez et al ., 2016 ; Kirkman et al ., 2018 ).

Categorization of risk among participants

Many studies applied specific risk criteria based on the participants’ morbidity risks: including groups of low, middle, high risk ( Persson et al ., 2015 ; Bo et al ., 2016 ; Lingfors and Persson, 2019 ), low and high risk ( Baumann et al ., 2015 ), middle and high risk ( Gibson et al ., 2014 ). While some did not distinguish between risk groups ( Wendel-Vos et al ., 2009 ; Blomstedt et al ., 2011 ; Byrne et al ., 2016 ; Journath et al ., 2020 ). In some studies, however, the protocol included mixed populations of those who were healthy and those who had a chronic disease ( Anokye et al ., 2014 ; Bonaccio et al ., 2019 ). Finally, different studies came up with their own meaning of ‘healthy individual’ or ‘healthy population’ based on the health problem they addressed, i.e. having a sedentary lifestyle or high alcohol consumption. Other criteria for being a part of a healthy population were having a high risk for a disease, one or several risks but not the disease itself, or being above a reference value without having a diagnosis.

Ethical implications of healthy controls

Some interventions were screening-result-based, meaning that there was a difference in the treatment of those with good health and those with some complications. In other words, although not excluding healthy individuals, the study protocol included healthy individuals partially receiving full treatment, in the intervention. Studies that excluded those who were healthy from the sample after screening or used them as a control group were excluded from this review. However, some included studies had a healthy control group. Overall, the studies included in this review did not discuss the ethical implications of including healthy populations as controls, or when that was the case, the ethical impact of excluding healthy participants from an intervention.

This scoping review speaks not only of the role and extent of health promotion for healthy individuals in primary care but also of the importance and effects it has on population health. The results showing the association of lifestyle interventions with CVD risk show great implications for future use in primary care, different contexts and feasibility. Physical activity interventions were additionally found to be related to some improvements in mental health.

Interventions aimed at alcohol consumption were found successful in decreasing the amount of drinking sustainably, while the main discussion was based on whether they should be aimed at high-risk only, or at middle- and low-risk drinkers as well, due to mixed results in said groups. The majority of interventions were based in a worksite setting, meaning that this context might be useful for tackling the issue. This approach showed that outcomes might be beneficial even when not reaching the primary goal. Examples of this are findings showing that although not reducing CVD risk, changes in health behaviours were sustained in follow-up ( Baumann et al ., 2015 ), less drastic changes decreasing CVD risk in the healthy population ( Buckland et al ., 2009 ) and beneficial effects of physical activity intervention on worker’s health without an overall increase in physical activity ( McEachan et al ., 2011 ). Finally, in most cases, as mentioned, changes in health behaviours were associated with changes in CVD risk.

Some interventions showed that health promotion benefits could be even bigger ( Bo et al ., 2016 ) or that adherence is higher in healthy participants ( Dalager et al ., 2016 ; Biffi et al ., 2018 ; Jeong et al ., 2019 ), while other authors disagree ( Robroek et al ., 2010 ). This could be traced to the topic of prioritising primary care for healthy, versus only those at high risk/ already with a disease—secondary care approach according to this review definitions. Designing interventions only for high-risk can make them less successful in healthy participants, as displayed in a study by Blomstedt et al . (2011) where self-rated health decreased in 21% of the good baseline health participants at the 10-year follow-up. Furthermore, from the Rose’s (1981) term of prevention paradox—a great benefit for the population can be almost non-existent for an individual, while if we only focus on high-risk cases, many individuals at low-risk can mean worse health outcomes compared to a small number at high-risk ( Rose, 2001 ). In other words, by focusing only on high-risk population, the downsides are care that can be less efficient, less feasible, more expensive and lead to worse health outcomes. This choice should not be exclusive, as excluding either populations can cause ethical concerns. However, this article gives priority to early prevention, by health promotion for healthy individuals in primary care. Additionally, if it is shown that ‘ Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure… ’ ( Stange et al. , 2023 ), different treatment of those who are currently healthy presents an obstacle worth mentioning for achieving health equity in primary care. Furthermore, the role of promoting health to healthy populations and their inclusion in interventions is crucial for improving population health in the future.

Articles focusing on smoking cessation, alcoholism, substance misuse interventions were excluded from this scoping review as they represent addictions and are therefore different from lifestyle interventions. Originally, oral health and dental care interventions were to be included, but there were not enough studies matching the scoping review inclusion requirements.

As expected, the process of finding articles appropriate for inclusion was challenging. Even when the inclusion criteria, at first glance, were satisfied, most studies we came across had excluded healthy participants from the sample after screening for being asymptomatic or not having enough risk factors. They were, however, often a part of a control group, and usually received standard care or no care at all. This approach puts healthy individuals in a vulnerable position, by not addressing their needs to change lifestyles that eventually could contribute to an early death or becoming unwell. Our findings suggest that interventions that include healthy individuals could improve quality of life and health status both at the population and individual levels.

Due to studies using different risk criteria, as well as including many study designs and topics, it was hard to make general conclusions. Nevertheless, as a scoping review, we mapped the area of research by identifying the gaps in the evidence base, and summarizing and disseminating research findings ( Arksey and O’Malley, 2005 ), instead of appraising the quality of evidence in different studies.

Concerning the above, a big research gap was detected in studies focusing on, or even including healthy populations. Furthermore, there is a lack of a coherent or comprehensive methodology in assessing the effects of what is considered health promotion, which calls for a more specific approach and a clear definition of the term. Additionally, the question of intervention staff skills should be raised. Is it necessary that health promotion interventions should be conducted by clinically trained professionals or, innovatively, by staff trained in the topic at hand when possible? Another aspect that is important to problematize is whether it is ethical to exclude healthy individuals in health promotion intervention studies even if they would benefit from participating if included? Furthermore, if healthy individuals are systematically discriminated ( Braveman, 2006 ), receive worse treatment and have the risk of worse health outcomes in the future, it is critical to include them in interventions for achieving better health of populations. This has great practical implications for primary care. Similarly, from a cost-benefit perspective, research should address if excluding healthy individuals might affect the cost-effectiveness of health promotion interventions.

An apparent limitation within this review is the culturally uniform sample of studies. Most studies that we were able to identify were a result of research in the global north, with a strong emphasis on either North America or the EU. Only two studies were from less affluent settings in Southeast Asia ( Nguyen et al ., 2012 ; Bo et al ., 2016 ). Given that the findings suggest that these interventions are cost-effective and do not require substantial investments, these programs could have great potential in low-resource settings if more systematically researched.

This scoping review of 42 studies applying salutogenesis in primary care interventions shows that health promotion targeting healthy individuals is relevant and effective. Most interventions were successful in reducing disease-related risks including CVD, CVD mortality, all-cause mortality, but even more importantly success in behavioural change, sustained at follow-up. Additionally, this review shows that health promotion lifestyle interventions can improve mental health, even when having different aims.

Supplementary material is available at Health Promotion International online.

A.B. performed the literature search, performed most of the data analysis and was the major contributor in writing the Methods and Results sections of the manuscript. M.S. formulated the research questions and scope of the study. He gave considerable input to the data analysis, gave input on all sections of the study—including writing and editing—and was the main author of the Introduction and Discussion. Both authors read and approved the final manuscript.

We would like to express our gratitude to Maria Björklund, librarian, at the Faculty of Medicine Library, Lund University at CRC in Malmö, who assisted us in the literature search.

A.B.’s contribution was in part funded by a scholarship she received from the Faculty of Medicine and in part by internal funds at the Division of Social Medicine and Global Health, Lund University, the latter also funded M.S.’s contribution.

The data underlying this article are available in the article and in its online supplementary material.

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Published: 20 May 2024

Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations

Andrea Lavinio 1 , 2 ,
Jonathan P. Coles 1 , 2 ,
Chiara Robba 3 ,
Marcel Aries 4 , 5 ,
Pierre Bouzat 6 ,
Dara Chean 7 ,
Shirin Frisvold 8 , 9 ,
Laura Galarza 10 ,
Raimund Helbok 11 , 12 ,
Jeroen Hermanides 13 ,
Mathieu van der Jagt 14 ,
David K. Menon 1 , 2 ,
Geert Meyfroidt 15 ,
Jean-Francois Payen 6 ,
Daniele Poole 16 ,
Frank Rasulo 17 ,
Jonathan Rhodes 18 ,
Emily Sidlow 19 ,
Luzius A. Steiner 20 ,
Fabio Silvio Taccone 21 , 22 &
Riikka Takala 23 , 24

Critical Care volume 28 , Article number: 170 ( 2024 ) Cite this article

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Aims and scope

The aim of this panel was to develop consensus recommendations on targeted temperature control (TTC) in patients with severe traumatic brain injury (TBI) and in patients with moderate TBI who deteriorate and require admission to the intensive care unit for intracranial pressure (ICP) management.

A group of 18 international neuro-intensive care experts in the acute management of TBI participated in a modified Delphi process. An online anonymised survey based on a systematic literature review was completed ahead of the meeting, before the group convened to explore the level of consensus on TTC following TBI. Outputs from the meeting were combined into a further anonymous online survey round to finalise recommendations. Thresholds of ≥ 16 out of 18 panel members in agreement (≥ 88%) for strong consensus and ≥ 14 out of 18 (≥ 78%) for moderate consensus were prospectively set for all statements.

Strong consensus was reached on TTC being essential for high-quality TBI care. It was recommended that temperature should be monitored continuously, and that fever should be promptly identified and managed in patients perceived to be at risk of secondary brain injury. Controlled normothermia (36.0–37.5 °C) was strongly recommended as a therapeutic option to be considered in tier 1 and 2 of the Seattle International Severe Traumatic Brain Injury Consensus Conference ICP management protocol. Temperature control targets should be individualised based on the perceived risk of secondary brain injury and fever aetiology.

Conclusions

Based on a modified Delphi expert consensus process, this report aims to inform on best practices for TTC delivery for patients following TBI, and to highlight areas of need for further research to improve clinical guidelines in this setting.

Introduction

Traumatic brain injury (TBI) is a complex and heterogeneous disease, and a major cause of death and disability globally [ 1 , 2 , 3 ]. Amongst other common neurological diseases, TBI is estimated to have the highest prevalence and incidence, impacting up to 60 million people worldwide annually and representing a substantial public health burden [ 4 ].

TBI is defined as an alteration in brain function or other evidence of brain pathology caused by an external force [ 5 ], and requires immediate and sustained management strategies to optimise clinical outcome. The injury processes that follow from a TBI are divided into two stages: primary and secondary [ 6 ], where primary injury refers to the damage caused by the original physical impact, which can trigger a pathophysiological cascade resulting in secondary injury with deleterious effects on neurological outcome and survival [ 7 , 8 ]. In order to prevent or mitigate secondary injury, immediate treatment following severe TBI focuses on the prevention of further brain damage. As the brain remains susceptible to secondary injury from processes that extend beyond the zone of primary injury such as ischaemia, oedema, herniation, seizures and altered metabolism [ 9 ], immediate treatment following severe TBI focuses on prevention or mitigation of such injury. This is achieved through the control of intracranial pressure (ICP), and prompt treatment of systemic insults such as hypoxia, hypercapnia, and systemic hypotension [ 10 ].

In the neuro-intensive care unit (NICU), fever is a prevalent occurrence with heterogenous underlying causes, and it may contribute to secondary injury. Across patients with TBI, subarachnoid haemorrhage and stroke [ 11 , 12 , 13 ], hyperthermia has been found to increase the risk of complications and is believed to be associated with unfavourable clinical outcome including death [ 9 , 11 , 14 , 15 ].

Targeted temperature control (TTC) is a complex intervention that aims to control body or brain temperature to prevent further brain injury and improve neurological outcome [ 9 ]. The term TTC may refer to different degrees of temperature control, from fever prevention, maintenance of normothermia to the induction of hypothermia, at different levels [ 9 , 16 ]. In TBI, TTC can be used to modulate a range of important physiological parameters such as cerebral metabolism and ICP. However, its role in improving long-term outcome, as well as the appropriate indications, targets and duration of TTC in severe or moderate TBI are currently unknown.

This work aims to utilise a Delphi approach to develop best-practice consensus recommendations from international experts for the real-world application of TTC in severe TBI with ICP guided treatments.

Review of the literature and evidence quality assessment

Statements and questions were informed by a systematic review of the literature, which identified observational studies, meta-analyses and randomised controlled trials (RCTs) relevant to the topics under discussion. This review search focused on evidence released since 2013. Following this first review, the methodology group of ESICM conducted an independent systematic review of the literature, considering only published RCTs regarding TTC in TBI patients with ICP monitoring. This review confirmed the paucity of RCTs and the substantial clinical heterogeneity between them, which precluded meta-analytical combination. The outputs from the reviews were shared with the expert panel members ahead of the Delphi process. A detailed reporting of the literature reviews is provided as Additional files 1 and 4 .

Participants

The 18 expert attendees for the Delphi process were chosen from members of three professional societies: the Neuro Anaesthesia and Critical Care Society (NACCS), the European Society of Intensive Care Medicine (ESICM), and the European Society of Anaesthesiology and Intensive Care (ESAIC). Selection was based on a documented history of publications in the fields of traumatic brain injury and/or targeted temperature management, as well as their established professional profiles and expertise as leading intensive care practitioners in teaching university hospitals. We endeavoured to ensure balanced representation, covering the geographic areas of the EU, Switzerland, and the UK.

Delphi rounds

A modified Delphi consensus method was employed, involving a combination of an online survey (Round 1), a face-to-face meeting (Round 2), an additional online survey containing the refined questions from the previous steps, (Round 3) and post-meeting reviews of the consensus results. The questions asked at Round 1 can be found in the Additional file 2 , and the results following Round 3 are shown in Table 1 . Round 1 was conducted via the SmartSurvey® online platform, and Round 2 was held as a hybrid meeting in London, UK, on Tuesday 10th October 2023. AL acted as Chair, with an independent facilitator (ES) moderating the meeting. After the results from the final survey of Round 3 were received, the recommendations and final manuscript were developed, with documents shared by e-mail and feedback collected independently from each participant by the facilitator. The predefined agreed cut-off for strong consensus was to have ≥ 16 out of 18 (≥ 88%) of panel members in agreement, and for moderate consensus was to have ≥ 14 out of 18 (≥ 78%) of panel members in agreement. The Delphi methodology and process was adopted from the manuscript published by Lavinio et al. [ 17 ]. In a Delphi process, conflicting opinions are addressed through a structured framework that promotes consensus-building among experts. Initially, participants are asked to provide their views anonymously, which are then summarised and shared with the group. This approach facilitates open and unbiased input, as the anonymity helps mitigate the influence of dominant personalities or hierarchical pressures. When conflicting opinions emerge, they are documented and presented back to the participants, along with any common ground that has been identified. In subsequent rounds, individuals are encouraged to reconsider their positions in light of the collective feedback, which often leads to a convergence of opinions. If discrepancies persist, these are explored through further iterative rounds, with an emphasis on clarifying rationale and seeking areas of agreement. The Delphi method's iterative nature, combined with the feedback mechanism, effectively manages conflicting opinions by fostering a gradual move towards consensus, or at least a clearer understanding of the points of divergence. The process for the Delphi panel and subsequent manuscript development is visualised in Fig. 1 . A detailed overview of the iterative Delphi process is provided in the Additional files 2 and 3 .

Summary of the Delphi process. ESAIC European Society of Anaesthesiology and Intensive Care, ESICM European Society of Intensive Care Medicine, NACCS Neuro Anaesthesia and Critical Care Society

Definitions

To guide discussions during the Delphi process, clinical terms were defined with the values as shown below.

Declarations and conflicts of interest

The face-to face meeting in London was supported by Becton, Dickinson and Company (“BD”) through the provision of travel costs, meeting space and refreshments. Representatives from BD were allowed to silently observe the conference, without any interaction with the panellists or the process. No donors or other outside parties influenced any portion of these recommendations. There was no industry input into recommendation development, and no panel member received honoraria for their involvement. Panellists completed conflict of interest forms relevant to TBI management. There were no conflicts mandating recusal of any participant. No funding was provided by the societies involved.

The results of the final consensus are presented in Table 1 . We highlight and expand upon statements in which consensus was reached in the discussion section. Some consideration is added to statements in which consensus was not reached, proposing them as potential areas for valuable future research.

To date, there is a lack of definitive evidence regarding the use of TTC with an automated feedback-controlled device for managing temperature in severe TBI. This underlines the importance of consensus discussion in identifying areas of uncertainty where evidence is lacking, and in encouraging harmonised care delivery across different settings.

Pathophysiology

Temperature measurement and control is an essential aspect of high-quality care in patients with severe TBI

In patients with impending cerebral herniation, temperature control is essential

As an introduction to the discussions, the group debated the recommendation for temperature measurement and control following severe TBI and, after extensive discussion, concluded that core temperature measurement and control is essential for the provision of high-quality care, especially in patients perceived to be at high risk of secondary brain injury. Noting the phrasing of ‘temperature control’ in the recent guidelines for temperature control following cardiac arrest [ 18 ], the group agreed that as an entry point into high-quality care following TBI, the notion of temperature measurement and control is key, opening the door to the full practice of targeted temperature management. This nuanced phrasing was intended to set the scene for the group’s work, with the specifics of the TTC process such as temperature ranges and duration of control being addressed throughout the remainder of the discussions.

Highlighting the wealth of physiological data available on the management of temperature in stroke and cardiac arrest, the group noted that the guidelines for temperature management in TBI are less specific. Fundamentally, the group agreed that high-quality TBI care does include monitoring temperature and implementing some form of temperature control, recognising its potential role in optimising outcome. The group highlighted the importance of treatment titration based on an individualised risk–benefit assessment and stratification. In particular, it was noted that in patients with exhausted intracranial compensatory reserve and at risk of cerebral herniation or ischaemia—there exists an extreme susceptibility to secondary brain injury precipitated by suboptimal temperature control.

Cerebral herniation is a life-threatening event that requires early diagnosis and prompt management in order to prevent irreversible pathological cascades that can lead to death [ 19 ]. Increases in brain temperature have been linked to a linear rise in ICP, with the relationships between temperature, ICP and cerebral perfusion pressure (CPP) becoming more apparent with rapid temperature changes. The impact of temperature on ICP supports the recommendation from the group that temperature control is an essential aspect of care in patients at risk of herniation [ 20 ]. The group agreed that while control of ICP and prevention of herniation were important reasons for TTC in TBI, benefits of TTC in the acute phase of TBI also extended to patients without intracranial hypertension.

During the discussions the group highlighted that different pathologies often dictate different patient management. For example, patients in whom fluctuations in ICP are well-tolerated (e.g., patients with high intracranial compliance) will be managed differently to patients with obliterated basal cisterns, obliterated cortical sulci, and midline shift (e.g., intracranial mass effect). In patients with exhausted intracranial volume-buffering reserve, strict control of physiological parameters such as CO 2 and temperature, is strongly recommended.

Continuous temperature monitoring is preferable over intermittent temperature measurements in patients with severe TBI.

Monitoring core temperature (e.g., bladder, oesophageal, brain) is strongly recommended over measuring or monitoring superficial temperature (e.g., skin, tympanic) in severe TBI.

When brain temperature monitoring is in place, it is advisable to assess an additional source of core temperature monitoring (i.e. oesophageal, bladder).

The group widely agreed, in line with supporting literature, that continuous temperature monitoring is preferable over intermittent temperature measurements with severe TBI. Intermittent monitoring and recording of temperature can result in large fluctuations in temperature being missed, as highlighted by supporting literature investigating the use of TTC following cardiac arrest, TBI and stroke [ 17 , 21 , 22 ].

Discussions amongst the group drew attention to the fact that inaccurately measured temperatures can negatively impact patient care and outcome. Several temperature monitoring sites are available for TTC, and the group widely agreed that core temperature measurements, i.e., bladder and oesophageal sites, are strongly preferred over superficial measurements such as those taken at skin and tympanic sites. Following acknowledgement of their limitations [ 23 ], bladder and oesophageal were singled out as favoured core temperature measurements. The group acknowledged the widespread use of oesophageal probes due to their relative ease of insertion and the challenges of finding MRI compatible bladder probes. Confirmation of preference between the two was acknowledged as being beyond the scope of the group due to these nuances. Rectal temperature monitoring was widely regarded as impractical for reasons such as the lag time and a high rate of dislocation [ 16 , 23 ]. Peripheral sites were unanimously deemed to be insufficiently accurate to guide temperature treatment [ 16 ].

Some panel members argued that monitoring target organ (i.e. brain) temperature could add a layer of clinical safety, improve pathophysiological understanding and allow selective and individualised titration of treatment (i.e. selective brain cooling). It was, however, agreed by the group that more research is needed into optimum methods for measuring brain temperature and its interpretation from both a clinical and resource-availability perspective. In particular, it was highlighted that temperature thresholds for harm are less well defined for brain temperature than core temperature. When brain temperature monitoring is available and in place, the group advised that core temperature should also be assessed with bladder or oesophageal probes since this is part of routine practice and has been studied to a greater extent than brain temperature. The group noted the importance of having a dual source of temperature monitoring when using automated TTC devices to reduce the risk of probe malfunction and subsequent over or undercooling [ 24 ].

After TBI, brain temperature has often been shown to be higher than systemic temperature and can vary independently, with literature noting a difference of as much as 2 °C depending on the individual characteristics of brain pathology and/or probe location, making a consistent and accurate link between the two challenging and possibly inaccurate [ 25 , 26 ]. The group highlighted that targeting brain temperature may allow precise titration of treatment dose, including titration of selective brain cooling with brain temperature management technologies, theoretically reducing side effects associated with systemic hypothermia, whilst delivering neuroprotection and brain temperature management. However, it was concluded that further research is needed in this regard and that not enough evidence exists to support practical recommendations.

ICP management

Temperature control is a key component of ICP management in severe TBI.

Controlled normothermia (i.e., target core temperature 36.0–37.5 °C) should be included as an addition to the Tier 1 and Tier 2 treatments defined within the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) 2019 guidelines.

Therapeutic hypothermia (i.e., target core temperature ≤ 36.0 °C) should be considered in cases where tier 1 and 2 treatments (as per SIBICC guidance) have failed to control ICP.

If hypothermia is considered to control ICP, target temperature should be managed as close to normothermia as possible.

ICP monitoring remains a critical component in the management of severe TBI [ 27 , 28 ]. The group unanimously agreed that temperature control is a key aspect of managing ICP, highlighting that an increase in temperature can lead to an increase in cerebral metabolism and augmented cerebral blood flow, and a simultaneous increase in cerebral blood volume. In cases of exhausted compensatory mechanisms, these factors can precipitate intracranial hypertension [ 20 ], which in turn can have a deleterious effect on overall outcome.

Because there is often no single pathophysiological pathway of ICP elevation, its management is complex. The most recent versions of the Brain Trauma Foundation TBI guidelines do not contain treatment protocols, in part due to a lack of solid evidence around the relative efficacy of available interventions [ 27 ]. To address this, the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC) developed a consensus-based practical algorithm for tiered management of severe TBI guided by ICP measurements [ 28 ].

One of the most impactful outcomes from this consensus meeting was the acknowledgement of the essential role of temperature control for ICP management in severe TBI, and the recommendation that controlled normothermia (i.e., target core temperature 36.0–37.5 °C) should be considered in addition to Tier 1 and Tier 2 treatments. The group was keen to harmonise this output with SIBICC by suggesting a more aggressive and specific management with the addition of controlled normothermia in Tiers 1 and 2, adding a layer of clinical safety beyond merely the avoidance of fever over 38.0 °C in Tier 0, as shown in Fig. 2 . In cases when hypothermia is considered (i.e., SIBICC Tier 3), the group recommended that target temperature be managed as close to normothermia as possible, based on an individualised risk–benefit assessment [ 29 ].

Intracranial pressure management algorithm for severe TBI edited from SIBICC 2019 [ 28 ]. * Including TTC in tiers 1 and 2 is the suggested addition from the TTC-TBI group to the original SIBICC tiers (green bars). *When possible, the lowest tier should be used. It is not necessary to use all modalities in a previous tier before moving to the next tier. Consider repeat CT and surgical options for space occupying lesions. CPP cerebral perfusion pressure, CT computed tomography, EEG electroencephalography, Hb haemoglobin, kPa kilopascal, mmHg milimetre of mercury, PaCO 2 arterial partial pressure of carbon dioxide, SpO 2 arterial oxygen saturation

No consensus was reached on whether hypothermia was a viable temporising strategy in patients with impending cerebral herniation, in patients awaiting haematoma evacuation or decompression, or before consideration of barbiturate coma. Whilst the group acknowledged that therapeutic hypothermia can be effective in reducing ICP, there was no consensus on whether this could be induced rapidly enough in these circumstances, and it was felt that insufficient evidence was available to provide pragmatic recommendations on its indication in these extreme clinical circumstances.

Whilst the majority of experts indicated 35.0 °C as the lowest target temperature to be considered in these circumstances, no consensus was reached. The discussion highlighted that insufficient evidence exists to support practical recommendations and highlighted the importance of an individualised risk–benefit assessment. It was also noted that centres might have a varying degree of familiarity with different therapeutic options, including ease of access to neurosurgical options (i.e. ventricular drainage, decompression) and this may have an impact on clinician preference for hypothermia as a temporising therapeutic modality.

The group also discussed the indication of barbiturates in the context of ICP control following severe TBI, not reaching consensus on whether therapeutic hypothermia should be attempted before considering barbiturates. The group noted that both barbiturate-induced burst-suppression and therapeutic hypothermia have distinctive side effects and concluded that no recommendations for standard clinical practice could be made beyond what was already stated in SIBICC guidance.

Neurogenic fever (core temperature > 37.5 °C) driven by neurological dysregulation in the absence of sepsis or a clinically significant systemic inflammatory process is relatively common in TBI, and it should be promptly detected and treated (i.e., with controlled normothermia targeting 36.0 °C to 37.5 °C), irrespective of ICP level.

Controlled normothermia should be considered when pyrexia is secondary to sepsis or inflammatory processes, and when the patient is perceived to be at risk of secondary brain injury, especially in the acute phase of TBI.

Uncontrolled fever (neurogenic or secondary to inflammation or infection) can precipitate secondary brain injury in patients with severe TBI.

It was widely agreed that neurogenic fever, defined here as core temperature > 37.5 °C driven by neurological dysregulation in the absence of sepsis or a clinically significant inflammatory process is common in intensive care and it has been found to be associated with an increased risk of complications and unfavourable outcome [ 9 , 14 , 15 ]. In the setting of neurogenic fever developing in comatose patients with acute traumatic encephalopathies, controlled normothermia targeting 36.0–37.5 °C was recommended in tier 1 and 2 of the ICP management algorithm.

Correctly differentiating central fever against fever of infectious origin is both challenging and clinically important due to the impact of failing to identify a treatable condition, the negative consequences of antibiotic overuse, and the detrimental effect of hyperthermia on brain-injured patients [ 17 , 30 , 31 ]. However, the group noted that physiological processes such as brain metabolic rate of oxygen, CO 2 control, brain tissue oxygenation (P bt O 2 ) and ICP are directly related to temperature, and that the deleterious effects and likelihood of secondary injury may occur irrespective of whether temperature is raised due to infection or impaired thermoregulation. This therefore highlights the need for acute management of temperature regardless of the source of the pyrexia, although added focus must be placed on the management of nuanced patient characteristics such as those with severe TBI with impending herniation and/or obliterated basal cisterns, as opposed those with low ICP and preserved intracranial compliance.

In line with current research [ 9 , 11 , 32 ], it was agreed that the development of fever is common in TBI cases, and that it can precipitate secondary brain injury and adversely affect patient outcome. It is therefore of utmost importance to prevent or promptly treat fever when detected. The group agreed that while some degree of controlled pyrexia may be allowed during the subacute phase of disease, ‘uncontrolled’ fever requires urgent management in the acute phase as long as the patient is still perceived to be at significant risk of secondary brain injury.

Fever control is recommended in patients with severe TBI who have seizures or are perceived to be at high risk of seizures.

In patients with severe TBI who are sedated and ventilated, controlled normothermia, irrespective of ICP, should be initiated reactively when fever is detected.

When neurogenic fever is detected in TBI cases, controlled normothermia should be continued for as long as the brain remains at risk of secondary brain damage.

The group strongly recommended that fever control and controlled normothermia are of particular relevance in patients perceived to be at high risk of seizures and, more in general, secondary brain injury. The assessment of whether an individual patient should be considered ‘at risk of seizures’ or ‘at risk of secondary brain injury’ remains the responsibility of the managing physician. The group defined risk factors for seizures as a history of seizures, the presence of temporal contusions or depressed skull fractures. Features associated with a higher ‘risk of secondary brain injury’ included labile ICP, obliterated basal cisterns, midline shift or subfalcine herniation, and other signs of exhausted intracranial volume buffering reserve. While no consensus was reached on a specific temperature range to target during controlled normothermia, the group agreed that the reactive initiation of temperature control was important in sedated and ventilated TBI patients, with agreement on a pragmatic setting of a target core temperature range of 36.0–37.5 °C to accommodate expected fluctuations of ± 0.5 °C while avoiding spikes over 38.0 °C [ 28 ].

Hypothermic TTC induction

It is recommended that the rapid induction of hypothermia in traumatic brain injury cases should be achieved with automated feedback-controlled temperature management devices.

In line with current research [ 17 ], the group widely agreed on the reactive use of an automated feedback-controlled device for the application of optimal TTC. The TTC process can be divided into three phases: induction, maintenance, and rewarming [ 9 , 16 ]. As explained in existing literature, varying availability of devices and financial aspects may dictate choice, and while non-automated methods of temperature control are cheaper and easier to apply, the level of control offered is poor and their use should be limited to the induction phase, as adjuncts to automated devices. [ 17 , 33 ] Whilst antipyretics such as acetaminophen (paracetamol) or nonsteroidal anti-inflammatory drugs (NSAIDs) are widely acknowledged in intensive care unit (ICU) settings for their role in fever management, it is recognised that in the context of severe TBI, the efficacy of antipyretics in controlling fever and minimising temperature variability is limited. The application of therapeutic hypothermia requires constant monitoring of core body temperature in order to achieve an accurate target temperature during induction to prevent overcooling, to assess variations during the maintenance phase, and to ensure a steady, controlled rewarming phase [ 16 ].

There was no agreed recommendation from the group as to whether ICUs should stock readily available ice-cold NaCl solutions of different concentrations for the management of ICP crises, citing a lack of clear evidence to draw upon. The group did however highlight the fact that the rapid infusion of ice-cold saline is an inexpensive and readily available option for lowering core body temperature [ 9 ], with the rapidity of response to ice-cold infusions being regarded as a valuable aspect of TTC induction.

TTC maintenance

An automated feedback-controlled TTC device that enables precise temperature control is desirable for the initiation of TTC and maintenance at target temperature in patients with severe TBI.

The maximum temperature variation that a patient should experience during normothermia is less than or equal to +/− 0.5 °C per hour and ≤ 1 °C per 24-hperiod

When hypothermia is indicated, treatment should be continued for as long as the brain is considered to be at risk of secondary brain injury.

Automated feedback-controlled devices for TTC are powerful tools, encouraging the delivery of quality care and aiming to improve neurological outcome [ 13 , 17 ], minimising the chances of temperature variability. Temperature variability is the deviation of patient temperature outside of the goal, typically reported as mean deviation or percent of time outside of target [ 9 ]. The group noted that there is a level of pragmatism to be adopted in TTC maintenance, discussing that while more time spent in fever can negatively impact neurological outcome, fluctuations in temperature may also affect outcome [ 17 ], and consensus was reached on the importance of maintaining temperature at as consistent a level as possible with the group settling on a fluctuation range of less than or equal to ± 0.5 °C per hour and ≤ 1 °C per 24-h period. In instances where an automated feedback-controlled device is not available, the group noted the importance of increased staff awareness of patient status to ensure fluctuations outside of this range are appropriately managed. The group highlighted that a dedicated protocol for sedation, analgesia and shivering management might be helpful to ensure consistent application of optimal TTC.

The group agreed that when indicated, hypothermia should be continued for as long as the individual practitioner considers the brain to be at risk of secondary injury. These considerations were supported with a suggestion that it should be maintained for as short a time as possible.

Rewarming following hypothermic TTC

Obtaining an interval scan and/or an alternative assessment of intracranial compliance, in addition to the absolute number of ICP, is recommended before rewarming.

Rebound hyperthermia should be prevented whenever possible or promptly treated in cases when the brain is perceived to be at risk of secondary brain injury.

In cases in which the patient is being rewarmed from therapeutic hypothermia (core temperature lower than 36.0 °C), the group agreed that once ICP has been maintained within controlled limits and de-escalation of treatment intensity is considered, it is sensible to ensure the patient has sufficient intracranial volume buffering reserve through the use of an interval scan and/or an alternative measure of intracranial compliance, before commencing the rewarming process. The group also noted the high prevalence and potential risks associated with rebound hyperthermia when TTC is discontinued following therapeutic hypothermia, highlighting the importance of continued vigilance and careful temperature control in the rewarming phase.

Whilst no consensus was reached on recommended rewarming rates, the group agreed that controlled rewarming with an automated feedback-controlled device may reduce the risk of rapid temperature variations and rebound pyrexia that can precipitate secondary brain injury and compromise care [ 16 , 33 ]. The group highlighted how controlled rewarming may improve the ability of clinicians to more effectively control important inter-dependent clinical variables such as PaCO 2 , ventilation settings and depth of sedation.

TTC for shivering

It is important to assess, document and manage shivering in severe TBI patients.

Whenever ICP is labile and shivering is detected, neuromuscular blockers should be considered after ensuring appropriate depth of sedation.

In self-ventilating patients in the subacute phase of severe TBI, an individualised risk–benefit assessment should be undertaken regarding the strict indications of controlled normothermia.

Permissive hyperthermia should be considered in cases where risk of secondary brain injury resulting from pyrexia is thought to be low, and when shivering cannot be controlled with first line treatments such as NSAIDs, opiates, magnesium or counter warming.

In line with current literature, it was widely agreed that shivering should be managed in patients following severe TBI. Shivering can reduce brain tissue oxygenation leading to cerebral metabolic stress, which may therefore negate the neuroprotective benefits of TTC [ 9 , 34 , 35 , 36 ].

Titration of sedation and the use of neuromuscular blocking agents provides intensivists with readily available and effective options for shivering control in critically ill patients [ 37 ]. To ensure appropriate and effective use however, treating staff must be aware of the nuances of selecting the correct agent, monitoring the depth of neuromuscular blockade, and ensuring adequate skeletal muscle recovery once therapy with neuromuscular blockers has ceased. In cases of shivering when ICP is labile, the group agreed in line with current literature that ensuring depth of sedation before administering neuromuscular blockers is of utmost importance [ 37 , 38 ]. When using pharmacologic agents for shivering management, treating staff must consider potential pharmacokinetic and pharmacodynamic variation and monitor for efficacy (i.e. shivering control) and safety (i.e. adverse events and drug-drug interactions) [ 9 ].

The group agreed that in patients who are perceived to be at relatively lower risk of secondary brain injury (i.e. self-ventilating patients in the sub-acute phase of severe TBI), permissive hyperthermia may be considered over TTC, especially if the latter therapeutic option would require sedation or other invasive interventions. The group agreed that an individualised risk–benefit assessment should ultimately be undertaken before commencing controlled normothermia in such patients.

‘Time within target range’, ‘burden of fever’ and similar metrics can be considered as indicators of quality of temperature management.

‘Time within target range’ and ‘burden of fever’ were considered by the group to be appropriate metrics of quality temperature management. It was widely acknowledged that these metrics should be weighed by patient length of stay and/or duration of monitoring for appropriate statistical interpretation. The group was also careful to note that the administrative burden on physicians is already high and acknowledged the fact that some centres may not have access to electronic patient data management systems, so it was agreed that it was unrealistic for this group to issue prescriptive recommendations on auditing practices. In light of the high heterogeneity across centres [ 9 ], here the group were keen to clarify that wherever possible, documenting metrics such as ‘time within target range’ and ‘burden of fever’ may improve their ability to deliver data-driven service improvement and temperature control.

This consensus review was undertaken to evaluate current evidence on the application of TTC in the management of severe TBI in a critical care setting, and to develop a set of practical recommendations to address identified gaps in current published evidence.

As highlighted by the SIBICC 2020 group, the gap between published evidence and management protocols is bridged by expert opinion [ 39 ]. The optimal method for the provision of high-quality TTC remains unknown, and barriers to its consistent implementation include the lack of evidence-based treatment protocols, knowledge deficiencies, limited access to equipment, lack of financial resources and staff workload. This document aims to address key practice gaps and optimise patient care through multimodal assessment following TBI.

Strengths and limitations

The Delphi process has a number of strengths. Participants are able to reconsider their views in light of the evolving discussions, allowing for an element of reflection that isn’t regularly seen in other studies involving a single time point such as interviews or focus groups [ 40 ]. The element of anonymity offered to the panellists in the survey rounds avoids group conformity and promotes honesty, and the controlled and iterative discussions offer a flexible approach to gathering expert viewpoints on the set research questions. The Delphi method is an iterative process allowing the anonymous inclusion of a number of individuals across diverse locations and areas of expertise and avoiding dominance by any one individual. It uses a systematic progression of repeated rounds of voting and is an effective process for determining expert group consensus where there is little or no definitive evidence and where opinion is important [ 41 , 42 ]. The modified Delphi approach used here combined the early flow of structured information and submission of anonymous responses with the (hybrid) face-to-face discussion and further voting to gain consensus (or establish lack thereof) and expert insight into usual practice regarding non-pharmacological TTC with an automated feedback-controlled device. As cited in existing literature however [ 13 , 17 ], the Delphi process has limitations. The process is vulnerable to drop-outs and technical issues, with the online voting process during our meeting seeing some participants unable to cast their votes on a number of questions, leading to the need for a final anonymous survey round. The group opinions during the meeting may have been impacted by social bias, and the voices across the in-person and online participants may not have been equally heard, highlighting a potential need to ensure consistency in attendance in the same format in future panel meetings.

Our recommendations for the use of automated feedback-controlled TTC devices are based on expert consensus and theoretical benefits, such as precise temperature control and reduced temperature variability, which are thought to potentially improve outcomes in severe TBI management. We acknowledge the current evidence gap and strongly emphasise the need for rigorous research to evaluate the effectiveness of these devices, especially in diverse healthcare settings, including lower-income countries where resource limitations are critical. Future updates to these best-practice recommendations will incorporate emerging evidence to ensure relevance and applicability across different healthcare contexts, aiming for the highest standards of care within the constraints of available resources. While automated feedback-controlled TTC devices represent a significant advancement in the management of temperature in severe TBI patients, offering potential benefits in terms of precision and consistency, it is imperative to recognise the value and applicability of a wide range of temperature management approaches. These include both manual methods and simpler devices, which remain vital in many clinical settings around the world. Our guidelines advocate for the adaptation and implementation of TTC principles based on the specific resources, capabilities, and needs of each clinical setting.

This report has been developed by an expert panel comprised of specialists in neuro-critical care experienced in the management of severe TBI, therefore the recommendations focus on patients managed in a critical care environment. An individualised risk–benefit assessment should be undertaken for each domain to accommodate the high levels of heterogeneity seen across TBI patients, local practice settings, staff training and equipment availability [ 9 ].

TTC is a therapy that has a role in ICP management and may reduce secondary injury and improve long-term neurological outcome for victims of TBI [ 9 ]. Appropriate methods for the implementation of TTC across widely heterogenous clinical settings and patient populations are relatively understudied, and due to a lack of consistent and high-quality evidence, remain largely unknown. Areas of consensus emerging from the Delphi process included TTC being recognised as an essential aspect of high-quality TBI care. Controlled normothermia (36.0–37.5 °C) was strongly recommended as a therapeutic option to be considered in Tier 1 and 2 of the SIBICC ICP management protocol. Temperature management targets should be individualised based on the perceived risk of secondary brain injury and fever aetiology.

Availability of data and materials

All data generated or analysed during this study are included in this article and its supplementary information files.

Abbreviations

Cerebral perfusion pressure

Computed tomography

Electroencephalography

European Society of Anaesthesiology and Intensive Care

European Society of Intensive Care Medicine

Haemoglobin

Intracranial pressure

Intensive care unit

Neuro Anaesthesia and Critical Care Society

Sodium chloride

Neuro-intensive care unit

Nonsteroidal anti-inflammatory drugs

Arterial partial pressure of carbon dioxide

Brain tissue oxygenation

Randomised controlled trial

Seattle International Severe Traumatic Brain Injury Consensus Conference

Arterial oxygen saturation

Traumatic brain injury
Targeted temperature control

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Acknowledgements

The group would like to acknowledge the support of Page & Page, London UK in facilitating the Delphi meeting.

The Delphi Panel meeting in October 2023 was facilitated (through the provision of travel costs, meeting space and refreshments) by Becton, Dickinson and Company. The development of these consensus recommendations was conducted with strict measures to ensure independence from its sponsor. The research team independently conducted all data analyses and drafted the manuscript. The role of BD was limited to providing logistical support for the Delphi panel meeting held in London, including travel costs, meeting space, and refreshments, without any influence over the study's content or conclusions. The Delphi voting process was conducted anonymously, ensuring that panel members could freely express their professional opinions without bias or influence from the sponsoring body or among panel members. The manuscript's drafting, review, and revision processes were carried out independently of BD. The sponsor had no editorial control, ensuring that the recommendations are based on the authors’ independent, professional expertise in targeted temperature management following traumatic brain injury. This article contains the personal and professional opinions of the individual authors and does not necessarily reflect the views and opinions of Becton, Dickinson and Company (“BD”) or any Business Unit or affiliate of BD. If drugs and/or medical devices are cited in the article, please consult package insert and instructions for use of them to know indications, contraindications, and any other more detailed safety information.

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Andrea Lavinio, Jonathan P. Coles & David K. Menon

Department of Anaesthesia and Critical Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK

IRCCS Policlinico San Martino, Genoa, Italy

Chiara Robba

Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands

Marcel Aries

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Supplementary Information

Additional file 1.

. Evaluation of five randomized controlled trials by the ESICM Methodology Group evaluates evulating cooling strategies against traditional interventions. The evaluation highlights methodological heterogeneities and evidential challenges.

Additional file 2

. Delphi questionnaire: Round 1.

Additional file 3

. Delphi questionnaire. Round 3.

Additional file 4

. Systematic review of the literature on targeted temperature control in traumatic brain injury, covering clinical studies from 2013 to 2023.

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Lavinio, A., Coles, J.P., Robba, C. et al. Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations. Crit Care 28 , 170 (2024). https://doi.org/10.1186/s13054-024-04951-x

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Objective: This article reviews doulas' scope of practice, perinatal outcomes associated with doula-assisted care, and their impact on alleviating racial disparities in maternal-infant outcomes.

Evidence acquisition: A literature search using the search engine PubMed was done. The search terms included ([Doula OR doulas OR labor coach] AND [Preterm OR prenatal care OR race OR racial OR racism OR Black OR African American]). Studies had to be written in English.

Results: The search resulted 90 articles of which 18 original articles and 16 review articles were reviewed. The literature demonstrates that doula support increases vaginal delivery while decreasing preterm birth and low birth weight. Studies also show that doula support is uniquely effective for Black patients and is a promising strategy to reduce health care inequities.

Conclusions and relevance: Doulas may provide significant perinatal benefit for birthing patients and their infants, with advantages also noted for Black patients. The current article provides an overview of the literature focused on doula support.

Publication types

Infant, Newborn
Labor, Obstetric*
Parturition
Premature Birth*
Prenatal Care

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Nursing: Literature Review

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Literature Reviews by Lawrence A. Machi , Brenda T. McEvoy LAST REVIEWED: 27 October 2016 LAST MODIFIED: 27 October 2016 DOI: 10.1093/obo/9780199756810-0169

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Rapid literature review: definition and methodology

Mondher Toumi

Karolina Świerk

Emilie Clay

Laurent Boyer

Introduction

Studies selection

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Studies analyzing methodology

Inconsistency in the definitions and methodologies of RLR

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Unleashing the potential of Health Promotion in primary care—a scoping literature review

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Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations

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