the importance of literature review in scientific research is

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

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

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

You identify:

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

It Also Helps You:

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

Great brief overview, from NCSU

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• Research Process

Literature Review in Research Writing

• 4 minute read
• 422.7K views

Table of Contents

Research on research? If you find this idea rather peculiar, know that nowadays, with the huge amount of information produced daily all around the world, it is becoming more and more difficult to keep up to date with all of it. In addition to the sheer amount of research, there is also its origin. We are witnessing the economic and intellectual emergence of countries like China, Brazil, Turkey, and United Arab Emirates, for example, that are producing scholarly literature in their own languages. So, apart from the effort of gathering information, there must also be translators prepared to unify all of it in a single language to be the object of the literature survey. At Elsevier, our team of translators is ready to support researchers by delivering high-quality scientific translations , in several languages, to serve their research – no matter the topic.

What is a literature review?

A literature review is a study – or, more accurately, a survey – involving scholarly material, with the aim to discuss published information about a specific topic or research question. Therefore, to write a literature review, it is compulsory that you are a real expert in the object of study. The results and findings will be published and made available to the public, namely scientists working in the same area of research.

How to Write a Literature Review

First of all, don’t forget that writing a literature review is a great responsibility. It’s a document that is expected to be highly reliable, especially concerning its sources and findings. You have to feel intellectually comfortable in the area of study and highly proficient in the target language; misconceptions and errors do not have a place in a document as important as a literature review. In fact, you might want to consider text editing services, like those offered at Elsevier, to make sure your literature is following the highest standards of text quality. You want to make sure your literature review is memorable by its novelty and quality rather than language errors.

Writing a literature review requires expertise but also organization. We cannot teach you about your topic of research, but we can provide a few steps to guide you through conducting a literature review:

• Choose your topic or research question: It should not be too comprehensive or too limited. You have to complete your task within a feasible time frame.
• Set the scope: Define boundaries concerning the number of sources, time frame to be covered, geographical area, etc.
• Decide which databases you will use for your searches: In order to search the best viable sources for your literature review, use highly regarded, comprehensive databases to get a big picture of the literature related to your topic.
• Search, search, and search: Now you’ll start to investigate the research on your topic. It’s critical that you keep track of all the sources. Start by looking at research abstracts in detail to see if their respective studies relate to or are useful for your own work. Next, search for bibliographies and references that can help you broaden your list of resources. Choose the most relevant literature and remember to keep notes of their bibliographic references to be used later on.
• Review all the literature, appraising carefully it’s content: After reading the study’s abstract, pay attention to the rest of the content of the articles you deem the “most relevant.” Identify methodologies, the most important questions they address, if they are well-designed and executed, and if they are cited enough, etc.

If it’s the first time you’ve published a literature review, note that it is important to follow a special structure. Just like in a thesis, for example, it is expected that you have an introduction – giving the general idea of the central topic and organizational pattern – a body – which contains the actual discussion of the sources – and finally the conclusion or recommendations – where you bring forward whatever you have drawn from the reviewed literature. The conclusion may even suggest there are no agreeable findings and that the discussion should be continued.

Why are literature reviews important?

Literature reviews constantly feed new research, that constantly feeds literature reviews…and we could go on and on. The fact is, one acts like a force over the other and this is what makes science, as a global discipline, constantly develop and evolve. As a scientist, writing a literature review can be very beneficial to your career, and set you apart from the expert elite in your field of interest. But it also can be an overwhelming task, so don’t hesitate in contacting Elsevier for text editing services, either for profound edition or just a last revision. We guarantee the very highest standards. You can also save time by letting us suggest and make the necessary amendments to your manuscript, so that it fits the structural pattern of a literature review. Who knows how many worldwide researchers you will impact with your next perfectly written literature review.

Know more: How to Find a Gap in Research .

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Literature reviews, what is a literature review, learning more about how to do a literature review.

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

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

• Sage Research Methods Core Collection This link opens in a new window SAGE Research Methods supports research at all levels by providing material to guide users through every step of the research process. SAGE Research Methods is the ultimate methods library with more than 1000 books, reference works, journal articles, and instructional videos by world-leading academics from across the social sciences, including the largest collection of qualitative methods books available online from any scholarly publisher. – Publisher

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• CAREER FEATURE
• 04 December 2020
• Correction 09 December 2020

How to write a superb literature review

Andy Tay is a freelance writer based in Singapore.

You can also search for this author in PubMed   Google Scholar

Literature reviews are important resources for scientists. They provide historical context for a field while offering opinions on its future trajectory. Creating them can provide inspiration for one’s own research, as well as some practice in writing. But few scientists are trained in how to write a review — or in what constitutes an excellent one. Even picking the appropriate software to use can be an involved decision (see ‘Tools and techniques’). So Nature asked editors and working scientists with well-cited reviews for their tips.

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doi: https://doi.org/10.1038/d41586-020-03422-x

Interviews have been edited for length and clarity.

Updates & Corrections

Correction 09 December 2020 : An earlier version of the tables in this article included some incorrect details about the programs Zotero, Endnote and Manubot. These have now been corrected.

Hsing, I.-M., Xu, Y. & Zhao, W. Electroanalysis 19 , 755–768 (2007).

Article   Google Scholar  

Ledesma, H. A. et al. Nature Nanotechnol. 14 , 645–657 (2019).

Article   PubMed   Google Scholar  

Brahlek, M., Koirala, N., Bansal, N. & Oh, S. Solid State Commun. 215–216 , 54–62 (2015).

Choi, Y. & Lee, S. Y. Nature Rev. Chem . https://doi.org/10.1038/s41570-020-00221-w (2020).

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Literature Reviews

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What is a Literature Review?

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

A literature review should: 

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

From  S age Research Methods

Purpose of a Literature Review

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

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

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

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

Limitations of a Literature Review

Some of the limitations of a literature review are:

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

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

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

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

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

Importance of a Good Literature Review

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

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

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

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

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

Types of Literature Reviews

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

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

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

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

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

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

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

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

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

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

Structure and Writing Style

I.  Thinking About Your Literature Review

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

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

The critical evaluation of each work should consider :

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

II.  Development of the Literature Review

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

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

III.  Ways to Organize Your Literature Review

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

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

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

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

IV.  Writing Your Literature Review

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

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

V.  Common Mistakes to Avoid

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

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

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

Writing Tip

Break Out of Your Disciplinary Box!

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

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

Another Writing Tip

Don't Just Review for Content!

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

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

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

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

Yet Another Writing Tip

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

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

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

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

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What is a literature review?

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

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

Why is it important?

A literature review is important because it:

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

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APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

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

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

2. Decide on the scope of your review

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

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

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

Make a list of the databases you will search. 

Where to find databases:

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

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

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

Review the literature

Some questions to help you analyze the research:

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

Tips: 

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

Can Meta-Analysis be Systematic Review?

Tips For How to Edit a Scientific Manuscript For Publication

Literature review forms the nucleus of all scientific research . As a systematic investigation to reach new conclusions and establish facts, every scientific research builds on existing knowledge. Unless one wants to reinvent the wheel, precise awareness on the extent of wisdom on a subject is necessary to carry on research that adds value to the field. “If I have seen further it is by standing on the shoulders of giants .” –Sir Issac Newton

A literature review for scientific research can be defined as a survey of scientific books, scholarly articles, and any other systematic scientific sources relevant to a particular issue, area of study, or theory, to provide a description, summary, and critical evaluation of a concept, school of thought, or ideas pertaining to the research question in investigation. In extension, the literature review familiarizes the author to the extent of knowledge in their field. When presented as a part of the paper, it establishes to the readers, the author’s depth of understanding and knowledge of their subject.   The scientifically relevant literature in a field consists of the previous studies in the area, established schools of thoughts, scholarly articles, and scientific journals among other things. The literature review varies from field to field. In hard sciences, the literature is mostly facts and the review may be simply a summary of the critical sources. While in soft sciences, the survey provides an overview and synthesis of various schools of thoughts and their interconnection. A summary or an overview is the brief account of all informational highlight from key sources, while synthesis is the restructuring or reorganization of the information in a way that informs of the dissertation’s plan of investigating the research problem.

The importance of literature review to scientific research can be condensed into its analytical feature. The reach of its significance, though, is multifold.

The following are reasons how literature review adds value and legitimacy to the study:

• Literature review enables the interpretation of old literature in the light of new developments in the field; this helps in establishing the consistency in knowledge and relevancy of older materials.
• The progress of knowledge in the field is mapped and how the dialectics of contradictions between various thoughts within the field helped establish facts is identified during the course of reviewing the literature. This helps in calculating the impact of new information in the field.
• The literature is primarily scrutinized to identify gaps in the knowledge of the field. This gap is further explored during the research to establish new facts or theories that add value to the field.
• The concept of conducting a scientific and systematic study necessitates scrutiny of existing knowledge, thus, facilitating the need for literature review
• The literature review also helps in identifying the current study’s place in the schema of the field.

The literature review also validates the study by providing information on its relevancy and coherency to the existing knowledge and methods in research . In turn, it establishes the author’s expertise in the field and provides legitimacy to carry forward the wisdom of the area using scientific and systematic methods.

The literature review while elucidating the continuance of knowledge, also point out areas that require further investigation and hence, aid as a starting point for future research.

Related Topics:

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Literature review vs research articles: how are they different.

Unlock the secrets of academic writing with our guide to the key differences between a literature review and a research paper! 📚 Dive into the world of scholarly exploration as we break down how a literature review illuminates existing knowledge, identifies gaps, and sets the stage for further research. 🌐 Then, gear up for the adventure of crafting a research paper, where you become the explorer, presenting your unique insights and discoveries through independent research. 🚀 Join us on this academic journey and discover the art of synthesizing existing wisdom and creating your own scholarly masterpiece! 🎓✨

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• Open access
• Published: 25 April 2024

A scoping review of academic and grey literature on migrant health research conducted in Scotland

• G. Petrie 1 ,
• K. Angus 2 &
• R. O’Donnell 2  

BMC Public Health volume  24 , Article number:  1156 ( 2024 ) Cite this article

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Migration to Scotland has increased since 2002 with an increase in European residents and participation in the Asylum dispersal scheme. Scotland has become more ethnically diverse, and 10% of the current population were born abroad. Migration and ethnicity are determinants of health, and information on the health status of migrants to Scotland and their access to and barriers to care facilitates the planning and delivery of equitable health services. This study aimed to scope existing peer-reviewed research and grey literature to identify gaps in evidence regarding the health of migrants in Scotland.

A scoping review on the health of migrants in Scotland was carried out for dates January 2002 to March 2023, inclusive of peer-reviewed journals and grey literature. CINAHL/ Web of Science/SocIndex and Medline databases were systematically searched along with government and third-sector websites. The searches identified 2166 journal articles and 170 grey literature documents for screening. Included articles were categorised according to the World Health Organisation’s 2016 Strategy and Action Plan for Refugee and Migrant Health in the European region. This approach builds on a previously published literature review on Migrant Health in the Republic of Ireland.

Seventy-one peer reviewed journal articles and 29 grey literature documents were included in the review. 66% were carried out from 2013 onwards and the majority focused on asylum seekers or unspecified migrant groups. Most research identified was on the World Health Organisation’s strategic areas of right to health of refugees, social determinants of health and public health planning and strengthening health systems. There were fewer studies on the strategic areas of frameworks for collaborative action, preventing communicable disease, preventing non-communicable disease, health screening and assessment and improving health information and communication.

While research on migrant health in Scotland has increased in recent years significant gaps remain. Future priorities should include studies of undocumented migrants, migrant workers, and additional research is required on the issue of improving health information and communication.

Peer Review reports

The term migrant is defined by the International Organisation for Migration as “ a person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons. The term includes several well-defined legal categories of people, including migrant workers; persons whose particular types of movements are legally-defined, such as smuggled migrants; as well as those whose status are not specifically defined under international law, such as international students.” [ 1 ] Internationally there are an estimated 281 million migrants – 3.6% of the world population, including 26.4 million refugees and 4.1 million asylum seekers – the highest number ever recorded [ 2 ]. The UN Refugee Society defines the term refugee as “ someone who has been forced to flee his or her country because of persecution, war or violence…most likely, they cannot return home or are afraid to do so .” The term asylum-seeker is defined as “someone whose request for sanctuary has yet to be processed.” [ 3 ].

Net-migration to Europe was negative in the 19th century due to higher levels of emigration, however in the mid-20th century immigration began to rise, because of an increase in migrant workers and following conflicts in the Middle East and North Africa [ 4 ]. Current migration drivers include conflicts alongside world-wide economic instability, exacerbated by the Covid-19 pandemic [ 5 ]. Environmental damage due to climate change is expected to inflate the number of asylum seekers entering Europe in future [ 6 ]. The increase in migration to Europe is not a short-term influx but a long-term phenomenon, and European nations must adapt and find solutions to resulting financial, safeguarding and health challenges [ 7 ].

Data on healthcare use by migrants in Europe is variable, which means cross-country comparisons are inadequate [ 8 ]. Many countries do not record migration information within health records and all use disparate criteria to classify migrant status. The lack of comparative data hinders public health surveillance and effective interventions [ 9 ]. Even where information is available, results can be contradictory due to the multifarious migrant population. Migrants have a wide range of origin countries, socio-economic position, age and journeys undertaken which can affect health status [ 10 ].

Migrants initially may have better health than the general population, known as the ‘Healthy Migrant effect’ [ 11 ]. However, health declines with increasing length of residence [ 12 ] and over time to levels comparable with the general population [ 13 ]. Second generation immigrants may have higher mortality than average [ 14 ]. The process of acculturation to the host country, with adoption of unhealthy lifestyle and behaviours, increases the risk for chronic disease [ 15 ]. In addition, inequalities in health of migrants compared to host populations has been confirmed by wide-ranging research [ 16 ].

Host countries may limit healthcare access, with undocumented migrants sometimes only entitled to emergency care [ 17 ]. Even when access is granted, inequitable services can affect quality of care due to language barriers and cultural factors [ 18 ]. Poor working/living conditions and discrimination can exacerbate health inequalities [ 12 ]. Processing facilities for asylum seekers are frequently overpopulated, stressful environments [ 19 ] and threat of deportation, lack of citizenship rights and integration can negatively affect health and access to care [ 20 ]. Undocumented workers are unprotected by health and safety legislation leading to dangerous working conditions and injuries [ 15 ].

A systematic review of migrant health in the European Union (EU) found migrants have worse self-perceived health than the general population [ 21 ]. Research evidence indicates increased prevalence of cardiovascular disease, diabetes, mental health disorders and adverse pregnancy outcomes. Exposure to conflict, harsh travel conditions and suboptimal vaccine programmes can mean higher risk of communicable disease [ 22 ]. Scoping reviews have also been conducted to describe trends within migration health research in the United Kingdom (UK) [ 23 ] and identify gaps for future research agendas in the UK [ 23 ] and in the Republic of Ireland [ 24 ].

Almost three-quarters (73%) of published migration health research in the UK has been conducted in England, focusing primarily on infectious diseases and mental health. There is limited evidence on the social determinants of health, access to and use of healthcare and structural and behavioural factors behaviours that influence migrant health in the UK [ 23 ]. By contrast, a large amount of the migration research conducted in the Republic of Ireland has focused on the social determinants of health, and on health system adaptations, with a paucity of research focusing on improving health information systems [ 24 ].

Migration and Health in Scotland

Immigration to Scotland began to rise in 2003 with the expansion of the EU [ 25 ]. The population in Scotland increased from 5.11 million to 5.47 million between 2005 and 2020 and is predicted to continue rising until 2028 [ 26 ] despite low birth rates, with the increased population resulting from inward migration [ 27 ]. Scotland’s population is becoming more ethnically diverse [ 28 ] and susceptibility to different health conditions varies by ethnic group, which has implications for the planning and provision of health services [ 29 ]. 7% of the current Scottish population are non-UK nationals and 10% were born outside Britain. The commonest countries of origin were Poland, Ireland, Italy, Nigeria and India [ 30 ].

Within Scotland, linking health data to ethnicity is standard in order to monitor and improve health of minority groups [ 31 ]. Ethnic background can differ from country of birth which means migration status cannot be assumed [ 32 ], although health inequalities experienced by migrants often extend to affect all ethnic minority groups [ 33 ]. The Scottish Health and Ethnicity Linkage Study (SHELS) linked census data to health records of 91% of the population which has provided information on mortality and morbidity by ethnic group and country of birth [ 34 ]. SHELS research indicates that the white-Scottish population have a higher mortality rate than other ethnic groups. This may be consequent to the comparatively poor health of the Scottish population relative to other European nations: high mortality rates in the general population may cause a perception that the health of minorities is more advantageous than in reality [ 35 ].

Cezard et al’s [ 13 ] analysis of self-perceived health among people in Scotland found that being born abroad had a positive impact on health status. Health declined with increased length of residence, which may be explained by cultural convergence with the majority population. Allik et al. [ 36 ] compared health inequalities by ethnic background and found that with increasing age, health differences reduced thus people aged over 75 of all ethnicities had similar or worse health status than White-Scottish people. While working-age migrants appear to be healthier than the White Scottish population, it cannot be assumed that in future this would extend to older age groups.

Research has shown deprivation as a cause of heath inequalities among ethnic minority and migrant groups [ 37 ]. The socio-economic status of minority ethnic groups in Scotland is unusual, as most are of similar or higher status than the white-Scottish population [ 38 ]. Therefore, public health interventions targeting deprivation may not address risk-factors for ethnic minorities and migrants [ 36 ]. Further research on determinants of health in migrants can help with planning and design of inclusive policies.

The 2011 census indicated that 50% of immigrants lived in the cities of Edinburgh, Glasgow, and Aberdeen. Glasgow had a greater percentage of non-European immigrants due to participation in the Asylum dispersal programme [ 39 ]. 10% of UK asylum seekers are placed in Glasgow, but records are not kept following approval of asylum claims, therefore the size of the refugee population is unknown [ 40 ]. While immigration is controlled by the British government, in policy areas devolved to the Scottish government, refugees and asylum seekers have more rights than elsewhere in UK, including access to primary healthcare for undocumented migrants [ 40 ]. Despite the mitigating effect of Scottish policies, asylum seekers’ health is worsened by the asylum process and associated poverty, marginalisation, and discrimination [ 40 ]. Health deteriorates with increasing length of time in the asylum system [ 40 ] and asylum seekers and refugees have additional health needs and require enhanced support [ 41 ]. Research on the health needs of asylum seekers in Scotland is required to ensure adequate healthcare.

Aim and objectives

While scoping reviews on migrant health have been carried out in Europe [ 12 ], Ireland [ 24 ] and the UK [ 23 ] none are currently specific to the Scottish context. Given the devolved government of Scotland and demographics described above, a targeted review would help to clarify research priorities, with the aim of improving health and health care within the migrant community in Scotland. This work therefore builds on the published scoping review of migrant health in the Republic of Ireland [ 24 ]. The authors recommend replication of the study in other countries to facilitate cross-country comparison. Our aim was to scope peer-reviewed research and grey literature on migrant health conducted in Scotland and identify any gaps in the evidence. Our objectives were to: [1] understand the extent of the available research by topic area [2] summarise the types of research already conducted, populations studied, topics covered and approaches taken [3], map the existing research conducted in Scotland and [4] identify areas for future research based on any gaps in the evidence identified.

A scoping review was conducted as they can aid detection of evidence gaps [ 42 ] and allow incorporation of grey literature in topics with insufficient published research [ 43 ]. Arksey and O’Malley’s [ 44 ] five stage scoping review framework was used.

Stage 1: identifying the research question

Arskey and O’Malley [ 44 ] suggest maintaining a broad approach to identifying the research question, in order to generate breadth of coverage. On this basis, and in line with the research question identified in the Villarroel et al. [ 24 ] scoping review, our research question was framed as follows: What is the scope, main topics and gaps in evidence in the existing literature on health of international migrants living in Scotland? Arksey and O’Malley [ 44 ] highlight the importance of defining terminology at the outset of scoping reviews. For consistency, we used the broad definition of ‘migrant’ as per Villaroel et al. [ 24 ], from the International Organisation for Migration (IOM) [ 1 ]. References to refugees or asylum seekers followed the United Nations Refugee Agency definitions [ 3 ].

Stage 2: identifying relevant studies

Electronic database searches identified reports alongside a grey literature search, in line with Arskey and O’Malley’s [ 44 ] guidance to search for evidence via different sources. CINAHL, Web of Science, SocIndex and Medline academic databases were selected with input from co-authors. Search terms for the review were based upon those used by Villaroel et al. [ 24 ] with additional relevant terms from Hannigan et al. [ 9 ] The strategy combined three sets of terms for: Migrants (e.g., refugee, migrant, immigrant or newcomer), Scotland and Health. Both free text terms and index terms were used and adapted to the 4 academic databases and searches were run on 10th March 2023 (see Additional File 1 for database search strategies). Thirteen Government, University, and third-sector websites in Scotland were scoped for selection then hand-searched for grey literature (listed in Additional File 1 ).

Stage 3: study selection

Net-migration to Scotland increased in the 2000s [ 27 ] hence a date range of January 2002-March 2023 was used to identify evidence. The search was limited to English only. Inclusion/exclusion criteria for the studies were based on those used by Villaroel et al. [ 24 ] and expanded upon following discussion with co-authors (see Table  1 ). Reports were included if based on primary or secondary research on the health of international migrants in Scotland and used qualitative, quantitative or mixed methods research design. International or UK based reports were only included if Scottish results were documented separately. Reports on the health of ethnic minority groups in Scotland was included if place of birth was recorded. Research on internal (non-international) migrants within Scotland, either moving from one Scottish area to another or from another part of the United Kingdom to Scotland, were excluded.

Stage 4: data charting

All records were saved to RefWorks for screening. Records were first screened at title/abstract stage with 10% independently checked by the co-authors. The remaining reports were single screened using full text by the first author. Data from the included records was extracted and organised in tabular form under the following headings, which were agreed by team members: article type (peer-reviewed article or grey literature), publication date, geographical setting, study/intervention’s target population, funding, primary research focus on migrant health (y/n), study objective, data collection method, study design (qualitative/quantitative/mixed) and main finding. Reports were not critically appraised in this scoping review.

Stage 5: collating, summarising and reporting results

A report (either a peer-reviewed journal article or grey literature report) is used as our unit of analysis. In order to present the range of research identified, reports were grouped by the different headings in our data charting table and the outcomes considered for relevance to our scoping review’s aim. Our Results summarise the recency, focus, study designs and funding sources of the identified research, followed by the geographical settings and whether Scotland was included in international research reports. Reports were grouped by their study population and further sub-divided by publication type and geographical area for summarising. Finally, the WHO’s European strategy and action plan (SAAP) for refugee and migrant health [ 7 ] is a policy framework designed to help governments and other stakeholders monitor and improve migrant health in Europe. There are nine strategic areas in the WHO’s SAAP, which prioritise the most salient issues. In line with Villaroel et al’s [ 24 ] approach and in order to compare scoping review outcomes, these areas were used to categorise the findings of this review. Each report was matched to the most appropriate SAAP:

Establishing a Framework for Collaborative Action.

Advocating for the right to health of refugees.

Addressing the social determinants of health.

Achieving public health preparedness and ensuring an effective response.

Strengthening health systems and their resilience.

Preventing communicable disease.

Preventing and reducing the risks caused by non-communicable disease.

Ensuring ethical and effective health screening and assessment.

Improving health information and communication.

The primary focus (aims and objectives) of each report was used to identify the relevant SAAP area/areas. To improve reliability, results were compared using coding criteria used in Villaroel et al’s study (MacFarlane 2023, personal communication, 31st May). 10% of the reports were checked by one co-author to ensure consistent coding to SAAP categories. Any instances of uncertainty in mapping reports to the relevant SAAP area/areas were discussed and resolved by team members.

This scoping review of the literature on migrant health in Scotland identified 2166 records from academic literature databases, following duplicate removal, and 170 records from website searches (see Fig.  1 ). Following screening, a total of 71 peer-reviewed journal articles and 29 grey literature studies (totalling 100 reports) were included for analysis (Results table and reference list are presented in Additional File 2 ).

Flow chart illustrating the identification of sources of evidence included in the scoping review

Overall findings

The majority of reports were published between 2013 and 2022. Fifty-eight reports (58%) focused exclusively on migrant health [ 18 , 39 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 ]. 23 centred on health but included other populations in addition to migrants – for example research on ethnic minorities or other vulnerable groups [ 13 , 31 , 35 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 , 115 , 116 , 117 , 118 , 119 , 120 , 121 , 122 ]. Seventeen reports were included where the sample population were migrants, but the primary topic was not health – for example destitution, integration, and service needs [ 27 , 73 , 74 , 123 , 124 , 125 , 126 , 127 , 128 , 129 , 130 , 131 , 132 , 133 , 134 , 135 ]. Health data was reported as part of the wider subject matter. One report [ 136 ] looked at the social determinants of breastfeeding including migrant status and one [ 137 ] compared attitudes to aging and family support between countries.

Funding sources were not declared for 35 (35%) of reports. The Scottish Government funded 20 reports (20%) [ 13 , 27 , 32 , 39 , 45 , 46 , 47 , 66 , 77 , 88 , 99 , 100 , 101 , 102 , 113 , 116 , 119 , 121 , 129 , 134 ]. Other common sources of funding included Government funded public bodies ( n  = 13) [ 45 , 48 , 49 , 50 , 51 , 52 , 53 , 104 , 107 , 113 , 116 , 131 , 136 ], the Scottish Health Service ( n  = 18) (either the National Health Service (NHS) [ 13 , 54 , 56 , 57 , 58 , 59 , 102 , 113 , 116 ], local NHS trusts [ 45 , 60 , 61 , 77 , 102 , 103 , 112 ] or by Public Health Scotland [ 13 , 113 ]) Eleven reports (11%) were funded by Universities. The charity sector financed 15 (15%) reports [ 53 , 63 , 66 , 69 , 70 , 71 , 72 , 73 , 74 , 103 , 111 , 123 , 125 , 132 , 138 ] and the EU and Scottish local authorities funded four reports each [ 45 , 62 , 75 , 76 , 77 , 102 , 125 , 135 ]. Professional bodies financed one report [ 126 ] as did the Japanese government [ 64 ]. No reports received funding from the business sector. The biggest sources of funding for grey literature were Refugee charities (40%) and the Scottish government (30%) (see Fig. 2 ).

Sources of funding for migrant health research in Scotland

Research methods and data collection

52% of reports used qualitative research methods. Forty-five reports (86%) collected data using 1–1 interviews and 24 (46%) used focus groups. Other methods of data collection included questionnaires (six studies (11%)), workshops (two studies (3.85%)) and observation (two studies (3.85%)). Oral/written evidence, guided play sessions, family case studies and participatory activity sessions were used in one report each.

28% of reports used quantitative research methods, most commonly cross section design (ten studies (36%)) and cohort design (18 studies (64%)). Information was obtained from databases including medical records, Census data and national records in 21 reports (75%). Questionnaires were used in six reports (21%). Other methods including body measurements, food diaries, blood samples, interviews and case reviews were used in 1 report each.

20% of reports used mixed methods. The most common method of data collection was questionnaires in 14 reports (70%), interviews in ten reports (50%), focus groups in seven reports (35%), workshops in three reports (13.6%), and databases in three reports (13.6%). Other methods included literature review in two reports (10%), case note reviews in two reports (10%) and one reports each used mapping and school records.

Geographical areas of study

Ninety-one reports were situated in Scotland, of which 35 (38.5%) covered the whole country and 56 (61.5%) specified a city or area where research was undertaken. Some UK and international reports also specified the area of Scotland. The largest share of research within Scotland overall was in Glasgow with 36 reports, followed by Edinburgh with 16 reports, Lothian with six reports, Aberdeen with five reports and Grampian with three reports. The Northeast, Stirling, Highlands, Inverness, Lanarkshire, Motherwell and Selkirk had one report in each area.

There were seven international reports, three on mortality by country of birth [ 75 , 76 , 78 ], one on cross cultural communication [ 79 ], one on maternity care in Poland and Scotland [ 99 ], one comparing attitudes to aging in China and Scotland [ 137 ] and one on the link between birthweights and integration of migrants [ 64 ]. The remaining two reports were UK based, one on immunisation of Roma and traveller communities [ 117 ] and one on the link between ethnic diversity and mortality [ 104 ]. All the included international and UK reports documented the Scottish data separately within results.

Migrant population

Thirty-one reports included all migrants in the study population. The remaining reports included 30 studies on asylum seekers/refugees, 11 on Polish migrants, ten on Africans, six each on South Asians/Chinese/European, three on Arabs, and two on Roma populations (see Fig.  3 ). Most reports did not specify the country of origin for Asylum seekers and refugees - where country of birth was specified, reports were also included in the appropriate category.

Migrant populations studied in health research in Scotland

Grey literature and peer-reviewed reports differed in population focus. The most common populations of interest in grey literature were asylum seekers/refugees consisting of 18 reports (62%) [ 27 , 47 , 54 , 55 , 59 , 63 , 70 , 71 , 72 , 73 , 74 , 123 , 125 , 127 , 128 , 132 , 134 , 138 ] while for peer-reviewed journals 24 reports (34%) focused on all migrants [ 13 , 35 , 45 , 48 , 64 , 76 , 78 , 79 , 80 , 81 , 104 , 105 , 108 , 109 , 113 , 114 , 115 , 116 , 118 , 120 , 121 , 122 , 136 ].

Migrant study population also differed by local area; Glasgow city, where the majority of research occurred, had 18 reports of 36 (50%) on Asylum seekers/refugees [ 47 , 48 , 52 , 53 , 54 , 55 , 58 , 63 , 70 , 71 , 72 , 82 , 83 , 127 , 128 , 130 , 138 , 139 ] eight reports (22%) on Africans [ 52 , 53 , 84 , 85 , 86 , 87 , 106 , 107 ], seven reports (19%) on all migrants [ 45 , 48 , 80 , 102 , 104 , 105 , 121 ] and two reports (5.5%) on Roma migrants [ 103 , 117 ]. Other populations had one reports each. In Edinburgh five reports of 16 (31%) were on the Polish population [ 56 , 67 , 68 , 89 , 90 ], and two reports (12.5%) on Asylum seekers/refugees [ 60 , 133 ], Chinese [ 62 , 137 ], South Asian [ 46 , 119 ], all migrants [ 105 , 121 ] and Africans [ 87 , 107 ]. The remaining migrant groups had one report each. Other areas of Scotland show no clear pattern with studies in disparate migrant population groups.

Number of reports per Strategic and Action Plan (SAAP) Area

SAAP Area mapping

1. establishing a framework for collaborative action.

Nine reports had a primary focus on collaborative action and were categorised under SAAP area 1 (see Fig.  4 ) [ 66 , 70 , 72 , 73 , 103 , 125 , 129 , 132 , 134 ]. Four reports (33%) used a mixed methods study design, the remaining five reports (67%) used a qualitative design. One report [ 66 ] focused on the epidemiology of female genital mutilation and a proposed intervention strategy. One report [ 66 ] focused on the epidemiology of female genital mutilation and a proposed intervention strategy. One report [ 103 ] evaluated service provision to the Roma community in Glasgow. The remaining reports focused on refugees and asylum seekers: four [ 73 , 125 , 132 , 134 ] evaluations of refugee integration projects, one [ 70 ] on services available to pregnant women, and one [ 72 ] an assessment of a peer-education service. One report [ 129 ] was a review of service provisions for migrants during the Covid-19 pandemic. All reports in SAAP area 1 were grey literature and three (37.5%) had a primary focus on migrant health while four (50%) focused on integration, one (11%) included data on ethnic minorities and one (11%) on services during the covid-19 pandemic. The majority (seven reports (78%)) were also categorised to another SAAP area most commonly area 2 (five studies (55%)) or area 5 (four studies (44%)).

2. Advocating for the right to health of refugees

Nineteen reports focused on SAAP area 2, advocating for the right to health of refugees (see Fig.  4 ) [ 47 , 52 , 53 , 54 , 55 , 63 , 70 , 71 , 83 , 103 , 123 , 124 , 125 , 127 , 128 , 129 , 134 , 138 , 140 ]. Sixteen reports (84%) had a qualitative study design and the remaining three (16%) reports used mixed methods. Nine reports (47%) focused on the health impact of the asylum system [ 52 , 55 , 71 , 74 , 123 , 127 , 128 , 129 , 138 ], five (26%) on health and access to care [ 47 , 54 , 83 , 103 , 124 ], two (10.5%) on maternity care [ 63 , 70 ], two (10.5%) on integration services [ 125 , 134 ] and one report on mental health in HIV positive migrants [ 53 ]. Nine reports (47%) had a primary focus on migrant health while the remaining 10 (53%) also involved wider social issues. The majority (15 (79%)) of reports were grey literature. All the articles in this group overlapped with another SAAP area. Area 3 is the most common joint category with ten reports (53%) followed by area 5 with seven reports (37%), area 1 shares five reports (26%), while areas 4 and 8 share one report each (5%).

3. Addressing the social determinants of health

Twenty-nine reports were categorised to SAAP area 3 – addressing the social determinants of health (see Fig.  4 ) [ 13 , 27 , 45 , 50 , 52 , 55 , 60 , 62 , 63 , 65 , 68 , 71 , 74 , 80 , 81 , 82 , 91 , 92 , 93 , 102 , 112 , 123 , 124 , 127 , 128 , 136 , 137 , 138 ]. The majority (14 (48%)) used a qualitative study method, eight (28%) used quantitative methodology and the remaining seven reports (24%) used mixed methods. Nineteen reports (65.5%) were peer-reviewed journals [ 13 , 45 , 50 , 52 , 60 , 62 , 63 , 65 , 68 , 80 , 81 , 82 , 91 , 92 , 93 , 104 , 112 , 124 , 136 , 137 ] and ten (34.5%) were grey literature [ 27 , 55 , 63 , 71 , 74 , 102 , 123 , 127 , 128 , 138 ]. Ten reports (34.5%) discussed the effects of the asylum system on health [ 27 , 52 , 63 , 71 , 74 , 123 , 124 , 127 , 128 , 137 ] and one (3.5%) migration and health [ 50 ]. Six reports (21%) focused on culture and ethnicity [ 82 , 92 , 102 , 104 , 112 , 137 ], five reports (17%) discussed economic and environmental determinants of health [ 13 , 45 , 67 , 81 , 93 ] and five reports (17%) the health impact of social activities [ 55 , 60 , 62 , 80 , 91 ]. Of the remaining reports, one [ 65 ] discussed Brexit and mental health of European migrants and one discussed the effect of coping strategies on wellbeing in Polish migrants [ 68 ]. Most reports, 18 (62%) had a primary focus on migrant health [ 45 , 50 , 52 , 55 , 60 , 62 , 63 , 65 , 67 , 68 , 71 , 80 , 81 , 82 , 91 , 92 , 93 , 102 ], six reports (21%) discussed wider social factors in addition to health [ 74 , 123 , 124 , 127 , 128 , 138 ]. Of the remaining reports three (10%) looked at ethnic background and country of birth [ 13 , 112 , 136 ], one [ 27 ] included other vulnerable groups and one [ 137 ] included people living in China and Chinese migrants to Scotland. Thirteen reports were also categorised to one or more additional SAAP area - ten (34%) were also applicable to area 2 [ 52 , 55 , 63 , 71 , 74 , 123 , 124 , 127 , 128 , 138 ], three (10%) to area 5 [ 63 , 82 , 92 ] and one (7%) to area 4 [ 27 ].

4. Achieving public health preparedness and ensuring an effective response

Twenty-one reports were assigned to SAAP area 4 (see Fig.  4 ) [ 27 , 31 , 35 , 39 , 47 , 57 , 64 , 75 , 76 , 77 , 78 , 94 , 104 , 108 , 109 , 111 , 113 , 114 , 116 , 120 , 135 ] of which fourteen (67%) used quantitative research methods, four (19%) mixed methods and three (14%) qualitative methods. Thirteen (62%) reports were peer-reviewed journals [ 35 , 59 , 64 , 75 , 78 , 104 , 108 , 109 , 111 , 113 , 114 , 116 , 120 ] and eight (38%) grey literature [ 27 , 31 , 39 , 47 , 57 , 77 , 94 , 135 ]. Most reports (12 (57%)) focused on morbidity and mortality in migrant populations [ 31 , 35 , 64 , 75 , 76 , 78 , 104 , 108 , 109 , 113 , 114 , 116 ]. Six (29%) investigated health status and healthcare needs in migrant groups in Scotland [ 39 , 47 , 57 , 77 , 94 , 135 ]. Two reports (9.5%) analysed the epidemiology of HIV infections [ 111 , 120 ] and the remaining report focused on the health needs of young people during the covid-19 pandemic [ 27 ]. Nine reports (43%) had a primary focus on migrant health [ 39 , 47 , 55 , 64 , 75 , 76 , 77 , 78 , 94 ] while eight (38%) also analysed data by ethnicity [ 31 , 35 , 104 , 108 , 109 , 113 , 114 , 116 ]. Of the remaining reports, three (14%) included other populations within Scotland [ 27 , 111 , 120 ] and one (5%) included other characteristics in addition to health information [ 135 ]. Ten reports (48%) were also categorised to another SAAP area; one to area 2 [ 47 ], one to area 3 [ 27 ], four to area 5 [ 47 , 57 , 77 , 135 ], two to area 6 [ 111 , 120 ] and two to area 9 [ 31 , 108 ].

5. Strengthening health systems and their resilience

Twenty-nine reports were assigned to SAAP area 5 (see Fig.  4 ) [ 18 , 47 , 48 , 49 , 54 , 57 , 63 , 69 , 70 , 72 , 77 , 79 , 82 , 83 , 92 , 95 , 96 , 97 , 99 , 101 , 103 , 118 , 119 , 126 , 129 , 131 , 133 , 135 , 141 ] of which 23 (79%) used qualitative research methods. Three reports used quantitative methods (10.3%) and the remaining three used mixed methods (10.3%). Twelve reports (41%) examined migrants needs and experiences of health care [ 47 , 49 , 54 , 57 , 58 , 77 , 83 , 95 , 103 , 119 , 129 , 135 ], eight (24%) focused on pregnancy and childcare [ 63 , 70 , 92 , 96 , 97 , 99 , 101 , 118 ] and two (7%) on barriers to healthcare access [ 48 , 131 ]. Two reports (7%) evaluated healthcare programmes [ 72 , 133 ] and two focused on communication in primary care [ 79 ] and maternity services [ 69 ]. The remaining three reports (10%) covered sexual health [ 82 ], health information needs of Syrian refugees [ 126 ] and general practitioner training [ 18 ]. Nineteen (65.5%) were peer reviewed journals [ 18 , 48 , 49 , 58 , 69 , 79 , 82 , 83 , 92 , 95 , 96 , 97 , 99 , 101 , 118 , 119 , 125 , 131 , 133 ] and ten (34.5%) were grey literature [ 47 , 54 , 57 , 63 , 70 , 72 , 77 , 103 , 129 , 135 ]. Twenty-one (72%) had a primary focus on migrant health [ 18 , 47 , 48 , 49 , 54 , 57 , 58 , 63 , 69 , 70 , 72 , 77 , 79 , 82 , 83 , 92 , 95 , 96 , 97 , 99 , 101 ]. Six reports (21%) included research on other characteristics or services [ 103 , 126 , 129 , 131 , 133 , 135 ]. The remaining two reports (7%) included ethnic groups as well as migrants in the data [ 118 , 119 ]. Nineteen reports (65.5%) were also assigned to one or more other category areas: five reports (17%) to area 1 [ 47 , 70 , 72 , 103 , 129 ], five reports (17%) to area 2 [ 54 , 63 , 83 , 103 , 129 ], three reports (10%) to area 3 [ 63 , 82 , 92 ], four reports (14%) to area 4 [ 47 , 57 , 77 , 135 ], one (3.5%) to area 7 [ 119 ] and one (3.5%) to area 9 [ 48 ].

6. Preventing communicable diseases

Fourteen reports were assigned to SAAP area 6 (see Fig.  4 ) [ 56 , 61 , 87 , 88 , 89 , 90 , 105 , 106 , 107 , 111 , 115 , 117 , 120 , 122 ] of which four (31%) used quantitative methods, five (38%) used qualitative methods and five (38%) used mixed methods. Five reports (38.5%) examined immunisation behaviour [ 56 , 61 , 89 , 90 , 117 ], five (38%) on epidemiology and treatment of HIV [ 106 , 107 , 111 , 120 , 122 ]. The remaining four reports (31%) focused on tuberculosis in healthcare workers [ 115 ], malaria [ 105 ] and sexual health services [ 87 , 88 ]. Only one reports was grey literature [ 88 ], the remainder were peer-reviewed journals. Six reports (46%) had a primary focus on migrant health [ 56 , 61 , 87 , 88 , 89 , 90 ] while seven reports (54%) also included other at-risk groups in the analysis. Four reports (31%) were also assigned to another SAAP category, two (15%) to area 4 [ 111 , 120 ] and two (15%) to area 8 [ 88 , 115 ].

7. Preventing and reducing the risks posed by non-communicable diseases

Eight reports were categorised to SAAP area 7 (see Fig.  4 ) [ 46 , 51 , 59 , 84 , 85 , 86 , 98 , 119 ] of which six (75%) used qualitative research methods, one (12.5%) used quantitative methods and one (12.5%) used mixed methods. Only one report (12.5%) was grey literature [ 59 ] the remaining seven reports (87.5%) were peer-reviewed journals [ 48 , 87 , 92 , 126 , 127 , 128 , 140 ]. Three reports (37.5%) focused on health behaviours [ 51 , 85 , 98 ], two (25%) on mental health, two (25%) on diabetes and one (12.5%) on chronic disease. Seven reports(87.5%) had a primary focus on migrant health [ 46 , 51 , 59 , 84 , 85 , 86 , 98 ], with the remaining report (12.5%) including ethnic minority groups [ 119 ]. One report (12.5%) was also assigned to SAAP area number 5 [ 119 ].

8. Ensuring ethical and effective health screening and assessment

There were six reports assigned to category 8 (see Fig.  4 ) [ 53 , 88 , 100 , 110 , 115 , 121 ] of which two (33%) used a quantitative research method, three (50%) used a qualitative method and one used mixed methods. One report (14%) was grey literature [ 88 ] the remaining five reports (83%) were peer reviewed journals [ 53 , 100 , 110 , 115 , 121 ]. Three reports (50%) focused on cancer screening in migrant women [ 21 , 100 , 110 ], one (17%) analysed access to HIV testing among African migrants [ 53 ], one (17%) on T.B in healthcare workers [ 72 ] and one (17%) on sexual health [ 36 ]. Three reports (50%) had a primary focus on migrant health [ 53 , 88 , 100 ] while the remaining three reports (50%) included other at-risk groups in the analysis [ 110 , 115 , 121 ]. There were three reports which overlapped with other SAAP areas: one [ 53 ] (17%) was categorised to area 2 while two [ 88 , 115 ] (33%) were categorised to area 6.

9. Improving health information and communication

Three reports were assigned to SAAP area 9 (see Fig.  4 ) [ 31 , 108 , 130 ]. One of these (33%) used a qualitative approach, one (33%) used a quantitative approach and one (33%) used mixed methods. Two [ 108 , 130 ] (66%) were peer-reviewed journal articles and one [ 31 ] (33%) was grey literature. Two reports (66%) focused on improving migrant demographics and health information using databases [ 31 , 108 ] while one (33%) described an information-needs matrix for refugees and asylum seekers [ 130 ]. Two [ 31 , 108 ] included ethnicities in the data while one [ 130 ] had a primary focus on migrant health. Two reports [ 31 , 108 ] (66%) also applied to SAAP area 4 while one report [ 130 ] (33%) was in SAAP area 9 only.

To our knowledge this is the first scoping review conducted on migrant health in Scotland. A previous rapid literature review [ 94 ] found most research focused on health behaviours, mental health, communicable disease and use of and access to healthcare; however, the review limited migrant definition to those who had immigrated within five years and asylum seekers were not included.

In our review, the majority of reports were published from 2013 onwards, aligning with the expansion in migrant research internationally [ 142 ]. 52% used qualitative research methods, 28% used quantitative methods and 20% used mixed methods. 58% focused on migrant health: the remaining papers included other populations or health as part of a wider remit. Research funding was mostly provided by the Scottish Government, NHS, refugee charities and Universities. No studies received funding from the private sector, although this sector has the potential resource and capacity to play a key role in funding future research to improve migrant health in Scotland. Geographically, most studies took place in Glasgow (36%), nationwide (38.5%) or Edinburgh (16%) – other areas were under-represented including Aberdeen (5%), despite being the city with the largest migrant population [ 30 ]. There was a lack of studies in rural localities. These findings concur with a UK migrant health review by Burns et al. [ 23 ] where research was concentrated in larger cities and data was sparse in rural areas relative to the migrant population.

Half of the research identified that was conducted in Glasgow focused on asylum seekers/refugees. Glasgow was previously the only Scottish city to host asylum seekers [ 143 ] and currently supports the most asylum seekers of any local authority in the UK [ 29 ]. In April 2022, the UK government widened the Asylum dispersal scheme to all local authorities [ 144 ]. Around 70% of Scotland’s refugee support services are based in Glasgow and the South-west [ 145 ]. As reduced access to services may impact the health of asylum seekers, research in Glasgow may not be generalizable to other regions of Scotland.

Almost one-third (30%) of all reports focused on asylum seekers and refugees – an overrepresentation given that only 18% of migrants to the UK are asylum seekers [ 146 ] and as low as 2% of all migrants in Scotland [ 147 ]. Asylum seekers and refugees are at risk of poor health due to trauma, difficult journeys, overcrowded camps, poor nutrition and lack of access to healthcare [ 148 ]. They have worse maternity outcomes and increased rates of mental illness [ 149 ]. Increased research on health of asylum seekers and refugees is necessary due to their additional vulnerabilities [ 142 ]. However, asylum seeker’s country of origin was generally not specified. Asylum seekers have heterogenic backgrounds [ 150 ] and nationality and trauma experience affect health status [ 151 ]. Further research focused on specific nationalities of asylum seekers would enhance understanding of the health needs in this population.

Almost one-third (31%) of studies did not specify a migrant group. This concurs with a Norwegian migrant health study by Laue et al. [ 152 ] where 36% of research did not identify country of birth. Where nationality was identified, Polish, African and South Asian were most prevalent. Poles are the largest migrant group in Scotland, however for the other most common immigrant groups of Irish, Italian and Nigerian [ 30 ] there was an absence of research. No studies took place on Nigerian migrants – nine studies indicated African populations, but country of birth was not specified. Since March 2022, 23,000 Ukrainians have migrated to Scotland [ 153 ], however no studies on Ukrainians were identified currently. Research may be underway which is yet to be published.

Only one study explored the impact of Brexit on European migrants’ health despite 56% of migrants to Scotland being EU nationals [ 30 ]. Again, research may be taking place currently, which is yet to be published. No studies involved undocumented migrants despite this populations’ high rates of poor physical/mental health exacerbated by poor housing and working conditions [ 154 ]. An estimated 7.2–9.5% of the workforce in the UK are migrant workers who have higher risks of poor working conditions and injury [ 155 ]. Scotland depends on a migrant workforce for some industries such as agriculture [ 156 ] but only two research papers specified migrant workers.

Most research papers related to the right to health of refugees (SAAP 2), social determinants of health (SAAP 3), public health planning (SAAP 4) and strengthening health systems (SAAP 5). Areas with less research were frameworks for collaborative action (SAAP 1), preventing communicable disease (SAAP 6), preventing non-communicable disease (SAAP 7) and health screening and assessment (SAAP 8). Only three studies related to improving health information and communication (SAAP 9). Lebano et al. [ 12 ] conducted a literature review of migrant health in Europe and found data collection unreliable and disorganised. There is a lack of data on the numbers and types of migrants entering Scotland and research tends not to differentiate between ethnic minorities and migrants [ 94 ]. As poor-quality information hinders surveillance and planning of services SAAP area 9 is an important consideration for increased research.

Villarroel et al. [ 24 ] also found more research in SAAP areas 3 to 5 and less in areas 6 to 9. However, their study returned no results in category 1, collaborative action, or 2, the right to health of refugees, while this study assigned 9% of articles to category 1 and 19% to category 2. Most articles in our study relating to categories 1 and 2 were grey literature, which was excluded from the original Irish scoping review. This highlights a potential difference in the focus of peer-reviewed articles compared to government/refugee charity commissioned reports. Collaborative action and the right to health of refugees and asylum seekers are entwined in Scotland due to the complex policy environment; the social determinants of health such as housing, education, welfare rights and social integration are influenced by a variety of UK and Scottish statutory bodies as well as third sector organisations [ 157 ]. Despite this complexity, organisations work well together [ 158 ]. Further academic research in this area would enhance joint working practices and networks.

A scoping review in the UK [ 23 ] found similar quantities of research corresponding to SAAP areas 3, 2 and 9. However in Scotland areas 1, 5 and 8 were a combined 44% of included papers compared with 27.8% of results on health systems and structures in Burns et al’s [ 23 ] study. Almost half of the articles in SAAP areas 1,5 and 8 were grey literature, which was not included in Burns et al’s [ 23 ] review. Conversely, Burns et al. [ 23 ] found 81.9% of research in the UK related to epidemiology, equivalent to SAAP categories 4,6 and 7. In a Norwegian scoping review of migrant health [ 152 ] 65% of research was related to epidemiological data on health and disease. Only 42% of the research in this current study related to epidemiological data; the quantity of evidence was reduced by excluding combined research from the UK. As Scotland has higher mortality and morbidity than elsewhere in the UK [ 29 ] it is important to undertake further epidemiological research limited to Scotland.

Strengths and weaknesses

Strengths of this review include the use of the WHO’s SAAP categories [ 7 ] to classify data, in accordance with the Villarroel et al’s [ 24 ] study: this means results are linked to policy on migrant health and facilitates comparability to the Irish study results. Additionally results include data on migrant groups, locality, and funding of included papers; these highlight potential omissions for future research consideration. Results include diverse research methods and published and grey literature giving a wide overview of available evidence, reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) checklist (see Additional File 3 ) [ 159 ].

Limitations included the lack of an open-access protocol and search limitations of English language and selected databases. This means some relevant reports may be omitted. Due to time and resource limitations no quality appraisal was planned for included reports. Whilst we did not synthesise the findings for each topic area and migrant group, future systematic reviews could be undertaken to address this limitation and build on this work.

Conclusions

Immigration and ethnic diversity in Scotland have increased since 2002 which is reflected in the expansion of migrant health research. This review highlights evidence gaps including a lack of research in rural areas, undocumented migrants and migrant workers. There is a tendency to cluster asylum seekers together rather than differentiate between national groups. Within the SAAP areas there is less evidence relating to collaborative action, preventing communicable disease, preventing non-communicable disease and health screening and assessment. Further research is required on improving health information and communication for migrant populations in Scotland – a significant omission given the importance of accurate information for health service planning.

Availability of data and materials

All data analysed during this review comes from the papers listed in Additional file 2 .

Abbreviations

European Union

Human Immunodeficiency Virus

National Health Service

Strategy and Action Plan

The Scottish Health and Ethnicity Linkage Study

United Kingdom

World Health Organisation

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Acknowledgements

Thank-you to Professor Anne MacFarlane and PHD student Anne Cronin, of the University of Limerick, Ireland for sharing the coding guidelines currently used in an update to Villarroel et. al’s 2019 study on Migrant Health in the Republic of Ireland.

No funding was received for this work, which was undertaken as G. Petrie’s Master of Public Health dissertation module at the University of Stirling.

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Petrie, G., Angus, K. & O’Donnell, R. A scoping review of academic and grey literature on migrant health research conducted in Scotland. BMC Public Health 24 , 1156 (2024). https://doi.org/10.1186/s12889-024-18628-1

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Breast cancer screening motivation and behaviours of women aged over 75 years: a scoping review

• Virginia Dickson-Swift 1 ,
• Joanne Adams 1 ,
• Evelien Spelten 1 ,
• Irene Blackberry 2 ,
• Carlene Wilson 3 , 4 , 5 &
• Eva Yuen 3 , 6 , 7 , 8  

BMC Women's Health volume  24 , Article number:  256 ( 2024 ) Cite this article

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This scoping review aimed to identify and present the evidence describing key motivations for breast cancer screening among women aged ≥ 75 years. Few of the internationally available guidelines recommend continued biennial screening for this age group. Some suggest ongoing screening is unnecessary or should be determined on individual health status and life expectancy. Recent research has shown that despite recommendations regarding screening, older women continue to hold positive attitudes to breast screening and participate when the opportunity is available.

All original research articles that address motivation, intention and/or participation in screening for breast cancer among women aged ≥ 75 years were considered for inclusion. These included articles reporting on women who use public and private breast cancer screening services and those who do not use screening services (i.e., non-screeners).

The Joanna Briggs Institute (JBI) methodology for scoping reviews was used to guide this review. A comprehensive search strategy was developed with the assistance of a specialist librarian to access selected databases including: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Web of Science and PsychInfo. The review was restricted to original research studies published since 2009, available in English and focusing on high-income countries (as defined by the World Bank). Title and abstract screening, followed by an assessment of full-text studies against the inclusion criteria was completed by at least two reviewers. Data relating to key motivations, screening intention and behaviour were extracted, and a thematic analysis of study findings undertaken.

A total of fourteen (14) studies were included in the review. Thematic analysis resulted in identification of three themes from included studies highlighting that decisions about screening were influenced by: knowledge of the benefits and harms of screening and their relationship to age; underlying attitudes to the importance of cancer screening in women's lives; and use of decision aids to improve knowledge and guide decision-making.

The results of this review provide a comprehensive overview of current knowledge regarding the motivations and screening behaviour of older women about breast cancer screening which may inform policy development.

Peer Review reports

Introduction

Breast cancer is now the most commonly diagnosed cancer in the world overtaking lung cancer in 2021 [ 1 ]. Across the globe, breast cancer contributed to 25.8% of the total number of new cases of cancer diagnosed in 2020 [ 2 ] and accounts for a high disease burden for women [ 3 ]. Screening for breast cancer is an effective means of detecting early-stage cancer and has been shown to significantly improve survival rates [ 4 ]. A recent systematic review of international screening guidelines found that most countries recommend that women have biennial mammograms between the ages of 40–70 years [ 5 ] with some recommending that there should be no upper age limit [ 6 , 7 , 8 , 9 , 10 , 11 , 12 ] and others suggesting that benefits of continued screening for women over 75 are not clear [ 13 , 14 , 15 ].

Some guidelines suggest that the decision to end screening should be determined based on the individual health status of the woman, their life expectancy and current health issues [ 5 , 16 , 17 ]. This is because the benefits of mammography screening may be limited after 7 years due to existing comorbidities and limited life expectancy [ 18 , 19 , 20 , 21 ], with some jurisdictions recommending breast cancer screening for women ≥ 75 years only when life expectancy is estimated as at least 7–10 years [ 22 ]. Others have argued that decisions about continuing with screening mammography should depend on individual patient risk and health management preferences [ 23 ]. This decision is likely facilitated by a discussion between a health care provider and patient about the harms and benefits of screening outside the recommended ages [ 24 , 25 ]. While mammography may enable early detection of breast cancer, it is clear that false-positive results and overdiagnosis Footnote 1 may occur. Studies have estimated that up to 25% of breast cancer cases in the general population may be over diagnosed [ 26 , 27 , 28 ].

The risk of being diagnosed with breast cancer increases with age and approximately 80% of new cases of breast cancer in high-income countries are in women over the age of 50 [ 29 ]. The average age of first diagnosis of breast cancer in high income countries is comparable to that of Australian women which is now 61 years [ 2 , 4 , 29 ]. Studies show that women aged ≥ 75 years generally have positive attitudes to mammography screening and report high levels of perceived benefits including early detection of breast cancer and a desire to stay healthy as they age [ 21 , 30 , 31 , 32 ]. Some women aged over 74 participate, or plan to participate, in screening despite recommendations from health professionals and government guidelines advising against it [ 33 ]. Results of a recent review found that knowledge of the recommended guidelines and the potential harms of screening are limited and many older women believed that the benefits of continued screening outweighed the risks [ 30 ].

Very few studies have been undertaken to understand the motivations of women to screen or to establish screening participation rates among women aged ≥ 75 and older. This is surprising given that increasing age is recognised as a key risk factor for the development of breast cancer, and that screening is offered in many locations around the world every two years up until 74 years. The importance of this topic is high given the ambiguity around best practice for participation beyond 74 years. A preliminary search of Open Science Framework, PROSPERO, Cochrane Database of Systematic Reviews and JBI Evidence Synthesis in May 2022 did not locate any reviews on this topic.

This scoping review has allowed for the mapping of a broad range of research to explore the breadth and depth of the literature, summarize the evidence and identify knowledge gaps [ 34 , 35 ]. This information has supported the development of a comprehensive overview of current knowledge of motivations of women to screen and screening participation rates among women outside the targeted age of many international screening programs.

Materials and methods

Research question.

The research question for this scoping review was developed by applying the Population—Concept—Context (PCC) framework [ 36 ]. The current review addresses the research question “What research has been undertaken in high-income countries (context) exploring the key motivations to screen for breast cancer and screening participation (concepts) among women ≥ 75 years of age (population)?

Eligibility criteria

Participants.

Women aged ≥ 75 years were the key population. Specifically, motivations to screen and screening intention and behaviour and the variables that discriminate those who screen from those who do not (non-screeners) were utilised as the key predictors and outcomes respectively.

From a conceptual perspective it was considered that motivation led to behaviour, therefore articles that described motivation and corresponding behaviour were considered. These included articles reporting on women who use public (government funded) and private (fee for service) breast cancer screening services and those who do not use screening services (i.e., non-screeners).

The scope included high-income countries using the World Bank definition [ 37 ]. These countries have broadly similar health systems and opportunities for breast cancer screening in both public and private settings.

Types of sources

All studies reporting original research in peer-reviewed journals from January 2009 were eligible for inclusion, regardless of design. This date was selected due to an evaluation undertaken for BreastScreen Australia recommending expansion of the age group to include 70–74-year-old women [ 38 ]. This date was also indicative of international debate regarding breast cancer screening effectiveness at this time [ 39 , 40 ]. Reviews were also included, regardless of type—scoping, systematic, or narrative. Only sources published in English and available through the University’s extensive research holdings were eligible for inclusion. Ineligible materials were conference abstracts, letters to the editor, editorials, opinion pieces, commentaries, newspaper articles, dissertations and theses.

This scoping review was registered with the Open Science Framework database ( https://osf.io/fd3eh ) and followed Joanna Briggs Institute (JBI) methodology for scoping reviews [ 35 , 36 ]. Although ethics approval is not required for scoping reviews the broader study was approved by the University Ethics Committee (approval number HEC 21249).

Search strategy

A pilot search strategy was developed in consultation with an expert health librarian and tested in MEDLINE (OVID) and conducted on 3 June 2022. Articles from this pilot search were compared with seminal articles previously identified by the members of the team and used to refine the search terms. The search terms were then searched as both keywords and subject headings (e.g., MeSH) in the titles and abstracts and Boolean operators employed. A full MEDLINE search was then carried out by the librarian (see Table  1 ). This search strategy was adapted for use in each of the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Web of Science and PsychInfo databases. The references of included studies have been hand-searched to identify any additional evidence sources.

Study/source of evidence selection

Following the search, all identified citations were collated and uploaded into EndNote v.X20 (Clarivate Analytics, PA, USA) and duplicates removed. The resulting articles were then imported into Covidence – Cochrane’s systematic review management software [ 41 ]. Duplicates were removed once importation was complete, and title and abstract screening was undertaken against the eligibility criteria. A sample of 25 articles were assessed by all reviewers to ensure reliability in the application of the inclusion and exclusion criteria. Team discussion was used to ensure consistent application. The Covidence software supports blind reviewing with two reviewers required at each screening phase. Potentially relevant sources were retrieved in full text and were assessed against the inclusion criteria by two independent reviewers. Conflicts were flagged within the software which allows the team to discuss those that have disagreements until a consensus was reached. Reasons for exclusion of studies at full text were recorded and reported in the scoping review. The Preferred Reporting Items of Systematic Reviews extension for scoping reviews (PRISMA-ScR) checklist was used to guide the reporting of the review [ 42 ] and all stages were documented using the PRISMA-ScR flow chart [ 42 ].

Data extraction

A data extraction form was created in Covidence and used to extract study characteristics and to confirm the study’s relevance. This included specific details such as article author/s, title, year of publication, country, aim, population, setting, data collection methods and key findings relevant to the review question. The draft extraction form was modified as needed during the data extraction process.

Data analysis and presentation

Extracted data were summarised in tabular format (see Table  2 ). Consistent with the guidelines for the effective reporting of scoping reviews [ 43 ] and the JBI framework [ 35 ] the final stage of the review included thematic analysis of the key findings of the included studies. Study findings were imported into QSR NVivo with coding of each line of text. Descriptive codes reflected key aspects of the included studies related to the motivations and behaviours of women > 75 years about breast cancer screening.

In line with the reporting requirements for scoping reviews the search results for this review are presented in Fig.  1 [ 44 ].

PRISMA Flowchart. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71

A total of fourteen [ 14 ] studies were included in the review with studies from the following countries, US n  = 12 [ 33 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ], UK n  = 1 [ 23 ] and France n  = 1 [ 56 ]. Sample sizes varied, with most containing fewer than 50 women ( n  = 8) [ 33 , 45 , 46 , 48 , 51 , 52 , 55 ]. Two had larger samples including a French study with 136 women (a sub-set of a larger sample) [ 56 ], and one mixed method study in the UK with a sample of 26 women undertaking interviews and 479 women completing surveys [ 23 ]. One study did not report exact numbers [ 50 ]. Three studies [ 47 , 53 , 54 ] were undertaken by a group of researchers based in the US utilising the same sample of women, however each of the papers focused on different primary outcomes. The samples in the included studies were recruited from a range of locations including primary medical care clinics, specialist medical clinics, University affiliated medical clinics, community-based health centres and community outreach clinics [ 47 , 53 , 54 ].

Data collection methods varied and included: quantitative ( n  = 8), qualitative ( n  = 5) and mixed methods ( n  = 1). A range of data collection tools and research designs were utilised; pre/post, pilot and cross-sectional surveys, interviews, and secondary analysis of existing data sets. Seven studies focused on the use of a Decision Aids (DAs), either in original or modified form, developed by Schonberg et al. [ 55 ] as a tool to increase knowledge about the harms and benefits of screening for older women [ 45 , 47 , 48 , 49 , 52 , 54 , 55 ]. Three studies focused on intention to screen [ 33 , 53 , 56 ], two on knowledge of, and attitudes to, screening [ 23 , 46 ], one on information needs relating to risks and benefits of screening discontinuation [ 51 ], and one on perceptions about discontinuation of screening and impact of social interactions on screening [ 50 ].

The three themes developed from the analysis of the included studies highlighted that decisions about screening were primarily influenced by: (1) knowledge of the benefits and harms of screening and their relationship to age; (2) underlying attitudes to the importance of cancer screening in women's lives; and (3) exposure to decision aids designed to facilitate informed decision-making. Each of these themes will be presented below drawing on the key findings of the appropriate studies. The full dataset of extracted data can be found in Table  2 .

Knowledge of the benefits and harms of screening ≥ 75 years

The decision to participate in routine mammography is influenced by individual differences in cognition and affect, interpersonal relationships, provider characteristics, and healthcare system variables. Women typically perceive mammograms as a positive, beneficial and routine component of care [ 46 ] and an important aspect of taking care of themselves [ 23 , 46 , 49 ]. One qualitative study undertaken in the US showed that few women had discussed mammography cessation or the potential harms of screening with their health care providers and some women reported they would insist on receiving mammography even without a provider recommendation to continue screening [ 46 ].

Studies suggested that ageing itself, and even poor health, were not seen as reasonable reasons for screening cessation. For many women, guidance from a health care provider was deemed the most important influence on decision-making [ 46 ]. Preferences for communication about risk and benefits were varied with one study reporting women would like to learn more about harms and risks and recommended that this information be communicated via physicians or other healthcare providers, included in brochures/pamphlets, and presented outside of clinical settings (e.g., in community-based seniors groups) [ 51 ]. Others reported that women were sometimes sceptical of expert and government recommendations [ 33 ] although some were happy to participate in discussions with health educators or care providers about breast cancer screening harms and benefits and potential cessation [ 52 ].

Underlying attitudes to the importance of cancer screening at and beyond 75 years

Included studies varied in describing the importance of screening, with some attitudes based on past attendance and some based on future intentions to screen. Three studies reported findings indicating that some women intended to continue screening after 75 years of age [ 23 , 45 , 46 ], with one study in the UK reporting that women supported an extension of the automatic recall indefinitely, regardless of age or health status. In this study, failure to invite older women to screen was interpreted as age discrimination [ 23 ]. The desire to continue screening beyond 75 was also highlighted in a study from France that found that 60% of the women ( n  = 136 aged ≥ 75) intended to pursue screening in the future, and 27 women aged ≥ 75, who had never undergone mammography previously (36%), intended to do so in the future [ 56 ]. In this same study, intentions to screen varied significantly [ 56 ]. There were no sociodemographic differences observed between screened and unscreened women with regard to level of education, income, health risk behaviour (smoking, alcohol consumption), knowledge about the importance and the process of screening, or psychological features (fear of the test, fear of the results, fear of the disease, trust in screening impact) [ 56 ]. Further analysis showed that three items were statistically correlated with a higher rate of attendance at screening: (1) screening was initiated by a physician; (2) the women had a consultation with a gynaecologist during the past 12 months; and (3) the women had already undergone at least five screening mammograms. Analysis highlighted that although average income, level of education, psychological features or other types of health risk behaviours did not impact screening intention, having a mammogram previously impacted likelihood of ongoing screening. There was no information provided that explained why women who had not previously undergone screening might do so in the future.

A mixed methods study in the UK reported similar findings [ 23 ]. Utilising interviews ( n  = 26) and questionnaires ( n  = 479) with women ≥ 70 years (median age 75 years) the overwhelming result (90.1%) was that breast screening should be offered to all women indefinitely regardless of age, health status or fitness [ 23 ], and that many older women were keen to continue screening. Both the interview and survey data confirmed women were uncertain about eligibility for breast screening. The survey data showed that just over half the women (52.9%) were unaware that they could request mammography or knew how to access it. Key reasons for screening discontinuation were not being invited for screening (52.1%) and not knowing about self-referral (35.1%).

Women reported that not being invited to continue screening sent messages that screening was no longer important or required for this age group [ 23 ]. Almost two thirds of the women completing the survey (61.6%) said they would forget to attend screening without an invitation. Other reasons for screening discontinuation included transport difficulties (25%) and not wishing to burden family members (24.7%). By contrast, other studies have reported that women do not endorse discontinuation of screening mammography due to advancing age or poor health, but some may be receptive to reducing screening frequency on recommendation from their health care provider [ 46 , 51 ].

Use of Decision Aids (DAs) to improve knowledge and guide screening decision-making

Many women reported poor knowledge about the harms and benefits of screening with studies identifying an important role for DAs. These aids have been shown to be effective in improving knowledge of the harms and benefits of screening [ 45 , 54 , 55 ] including for women with low educational attainment; as compared to women with high educational attainment [ 47 ]. DAs can increase knowledge about screening [ 47 , 49 ] and may decrease the intention to continue screening after the recommended age [ 45 , 52 , 54 ]. They can be used by primary care providers to support a conversation about breast screening intention and reasons for discontinuing screening. In one pilot study undertaken in the US using a DA, 5 of the 8 women (62.5%) indicated they intended to continue to receive mammography; however, 3 participants planned to get them less often [ 45 ]. When asked whether they thought their physician would want them to get a mammogram, 80% said “yes” on pre-test; this figure decreased to 62.5% after exposure to the DA. This pilot study suggests that the use of a decision-aid may result in fewer women ≥ 75 years old continuing to screen for breast cancer [ 45 ].

Similar findings were evident in two studies drawing on the same data undertaken in the US [ 48 , 53 ]. Using a larger sample ( n  = 283), women’s intentions to screen prior to a visit with their primary care provider and then again after exposure to the DA were compared. Results showed that 21.7% of women reduced their intention to be screened, 7.9% increased their intentions to be screened, and 70.4% did not change. Compared to those who had no change or increased their screening intentions, women who had a decrease in screening intention were significantly less likely to receive screening after 18 months. Generally, studies have shown that women aged 75 and older find DAs acceptable and helpful [ 47 , 48 , 49 , 55 ] and using them had the potential to impact on a women’s intention to screen [ 55 ].

Cadet and colleagues [ 49 ] explored the impact of educational attainment on the use of DAs. Results highlight that education moderates the utility of these aids; women with lower educational attainment were less likely to understand all the DA’s content (46.3% vs 67.5%; P < 0.001); had less knowledge of the benefits and harms of mammography (adjusted mean ± standard error knowledge score, 7.1 ± 0.3 vs 8.1 ± 0.3; p < 0.001); and were less likely to have their screening intentions impacted (adjusted percentage, 11.4% vs 19.4%; p  = 0.01).

This scoping review summarises current knowledge regarding motivations and screening behaviours of women over 75 years. The findings suggest that awareness of the importance of breast cancer screening among women aged ≥ 75 years is high [ 23 , 46 , 49 ] and that many women wish to continue screening regardless of perceived health status or age. This highlights the importance of focusing on motivation and screening behaviours and the multiple factors that influence ongoing participation in breast screening programs.

The generally high regard attributed to screening among women aged ≥ 75 years presents a complex challenge for health professionals who are focused on potential harm (from available national and international guidelines) in ongoing screening for women beyond age 75 [ 18 , 20 , 57 ]. Included studies highlight that many women relied on the advice of health care providers regarding the benefits and harms when making the decision to continue breast screening [ 46 , 51 , 52 ], however there were some that did not [ 33 ]. Having a previous pattern of screening was noted as being more significant to ongoing intention than any other identified socio-demographic feature [ 56 ]. This is perhaps because women will not readily forgo health care practices that they have always considered important and that retain ongoing importance for the broader population.

For those women who had discontinued screening after the age of 74 it was apparent that the rationale for doing so was not often based on choice or receipt of information, but rather on factors that impact decision-making in relation to screening. These included no longer receiving an invitation to attend, transport difficulties and not wanting to be a burden on relatives or friends [ 23 , 46 , 51 ]. Ongoing receipt of invitations to screen was an important aspect of maintaining a capacity to choose [ 23 ]. This was particularly important for those women who had been regular screeners.

Women over 75 require more information to make decisions regarding screening [ 23 , 52 , 54 , 55 ], however health care providers must also be aware that the element of choice is important for older women. Having a capacity to choose avoids any notion of discrimination based on age, health status, gender or sociodemographic difference and acknowledges the importance of women retaining control over their health [ 23 ]. It was apparent that some women would choose to continue screening at a reduced frequency if this option was available and that women should have access to information facilitating self-referral [ 23 , 45 , 46 , 51 , 56 ].

Decision-making regarding ongoing breast cancer screening has been facilitated via the use of Decision Aids (DAs) within clinical settings [ 54 , 55 ]. While some studies suggest that women will make a decision regardless of health status, the use of DAs has impacted women’s decision to screen. While this may have limited benefit for those of lower educational attainment [ 48 ] they have been effective in improving knowledge relating to harms and benefits of screening particularly where they have been used to support a conversation with women about the value of screening [ 54 , 55 , 56 ].

Women have identified challenges in engaging in conversations with health care providers regarding ongoing screening, because providers frequently draw on projections of life expectancy and over-diagnosis [ 17 , 51 ]. As a result, these conversations about screening after age 75 years often do not occur [ 46 ]. It is likely that health providers may need more support and guidance in leading these conversations. This may be through the use of DAs or standardised checklists. It may be possible to incorporate these within existing health preventive measures for this age group. The potential for advice regarding ongoing breast cancer screening to be available outside of clinical settings may provide important pathways for conversations with women regarding health choices. Provision of information and advice in settings such as community based seniors groups [ 51 ] offers a potential platform to broaden conversations and align sources of information, not only with health professionals but amongst women themselves. This may help to address any misconception regarding eligibility and access to services [ 23 ]. It may also be aligned with other health promotion and lifestyle messages provided to this age group.

Limitations of the review

The searches that formed the basis of this review were carried in June 2022. Although the search was comprehensive, we have only captured those studies that were published in the included databases from 2009. There may have been other studies published outside of these periods. We also limited the search to studies published in English with full-text availability.

The emphasis of a scoping review is on comprehensive coverage and synthesis of the key findings, rather than on a particular standard of evidence and, consequently a quality assessment of the included studies was not undertaken. This has resulted in the inclusion of a wide range of study designs and data collection methods. It is important to note that three studies included in the review drew on the same sample of women (283 over > 75)[ 49 , 53 , 54 ]. The results of this review provide valuable insights into motivations and behaviours for breast cancer screening for older women, however they should be interpreted with caution given the specific methodological and geographical limitations.

Conclusion and recommendations

This scoping review highlighted a range of key motivations and behaviours in relation to breast cancer screening for women ≥ 75 years of age. The results provide some insight into how decisions about screening continuation after 74 are made and how informed decision-making can be supported. Specifically, this review supports the following suggestions for further research and policy direction:

Further research regarding breast cancer screening motivations and behaviours for women over 75 would provide valuable insight for health providers delivering services to women in this age group.

Health providers may benefit from the broader use of decision aids or structured checklists to guide conversations with women over 75 regarding ongoing health promotion/preventive measures.

Providing health-based information in non-clinical settings frequented by women in this age group may provide a broader reach of information and facilitate choices. This may help to reduce any perception of discrimination based on age, health status or socio-demographic factors.

Availability of data and materials

All data generated or analysed during this study is included in this published article (see Table  2 above).

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Acknowledgements

We would like to acknowledge Ange Hayden-Johns (expert librarian) who assisted with the development of the search criteria and undertook the relevant searches and Tejashree Kangutkar who assisted with some of the Covidence work.

This work was supported by funding from the Australian Government Department of Health and Aged Care (ID: Health/20–21/E21-10463).

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VDS conceived and designed the scoping review. VDS & JA developed the search strategy with librarian support, and all authors (VDS, JA, ES, IB, CW, EY) participated in the screening and data extraction stages and assisted with writing the review. All authors provided editorial support and read and approved the final manuscript prior to submission.

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Dickson-Swift, V., Adams, J., Spelten, E. et al. Breast cancer screening motivation and behaviours of women aged over 75 years: a scoping review. BMC Women's Health 24 , 256 (2024). https://doi.org/10.1186/s12905-024-03094-z

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Writing, reading, and critiquing reviews

Écrire, lire et revue critique, douglas archibald.

1 University of Ottawa, Ontario, Canada;

Maria Athina Martimianakis

2 University of Toronto, Ontario, Canada

Why reviews matter

What do all authors of the CMEJ have in common? For that matter what do all health professions education scholars have in common? We all engage with literature. When you have an idea or question the first thing you do is find out what has been published on the topic of interest. Literature reviews are foundational to any study. They describe what is known about given topic and lead us to identify a knowledge gap to study. All reviews require authors to be able accurately summarize, synthesize, interpret and even critique the research literature. 1 , 2 In fact, for this editorial we have had to review the literature on reviews . Knowledge and evidence are expanding in our field of health professions education at an ever increasing rate and so to help keep pace, well written reviews are essential. Though reviews may be difficult to write, they will always be read. In this editorial we survey the various forms review articles can take. As well we want to provide authors and reviewers at CMEJ with some guidance and resources to be able write and/or review a review article.

What are the types of reviews conducted in Health Professions Education?

Health professions education attracts scholars from across disciplines and professions. For this reason, there are numerous ways to conduct reviews and it is important to familiarize oneself with these different forms to be able to effectively situate your work and write a compelling rationale for choosing your review methodology. 1 , 2 To do this, authors must contend with an ever-increasing lexicon of review type articles. In 2009 Grant and colleagues conducted a typology of reviews to aid readers makes sense of the different review types, listing fourteen different ways of conducting reviews, not all of which are mutually exclusive. 3 Interestingly, in their typology they did not include narrative reviews which are often used by authors in health professions education. In Table 1 , we offer a short description of three common types of review articles submitted to CMEJ.

Three common types of review articles submitted to CMEJ

More recently, authors such as Greenhalgh 4 have drawn attention to the perceived hierarchy of systematic reviews over scoping and narrative reviews. Like Greenhalgh, 4 we argue that systematic reviews are not to be seen as the gold standard of all reviews. Instead, it is important to align the method of review to what the authors hope to achieve, and pursue the review rigorously, according to the tenets of the chosen review type. Sometimes it is helpful to read part of the literature on your topic before deciding on a methodology for organizing and assessing its usefulness. Importantly, whether you are conducting a review or reading reviews, appreciating the differences between different types of reviews can also help you weigh the author’s interpretation of their findings.

In the next section we summarize some general tips for conducting successful reviews.

How to write and review a review article

In 2016 David Cook wrote an editorial for Medical Education on tips for a great review article. 13 These tips are excellent suggestions for all types of articles you are considering to submit to the CMEJ. First, start with a clear question: focused or more general depending on the type of review you are conducting. Systematic reviews tend to address very focused questions often summarizing the evidence of your topic. Other types of reviews tend to have broader questions and are more exploratory in nature.

Following your question, choose an approach and plan your methods to match your question…just like you would for a research study. Fortunately, there are guidelines for many types of reviews. As Cook points out the most important consideration is to be sure that the methods you follow lead to a defensible answer to your review question. To help you prepare for a defensible answer there are many guides available. For systematic reviews consult PRISMA guidelines ; 13 for scoping reviews PRISMA-ScR ; 14 and SANRA 15 for narrative reviews. It is also important to explain to readers why you have chosen to conduct a review. You may be introducing a new way for addressing an old problem, drawing links across literatures, filling in gaps in our knowledge about a phenomenon or educational practice. Cook refers to this as setting the stage. Linking back to the literature is important. In systematic reviews for example, you must be clear in explaining how your review builds on existing literature and previous reviews. This is your opportunity to be critical. What are the gaps and limitations of previous reviews? So, how will your systematic review resolve the shortcomings of previous work? In other types of reviews, such as narrative reviews, its less about filling a specific knowledge gap, and more about generating new research topic areas, exposing blind spots in our thinking, or making creative new links across issues. Whatever, type of review paper you are working on, the next steps are ones that can be applied to any scholarly writing. Be clear and offer insight. What is your main message? A review is more than just listing studies or referencing literature on your topic. Lead your readers to a convincing message. Provide commentary and interpretation for the studies in your review that will help you to inform your conclusions. For systematic reviews, Cook’s final tip is most likely the most important– report completely. You need to explain all your methods and report enough detail that readers can verify the main findings of each study you review. The most common reasons CMEJ reviewers recommend to decline a review article is because authors do not follow these last tips. In these instances authors do not provide the readers with enough detail to substantiate their interpretations or the message is not clear. Our recommendation for writing a great review is to ensure you have followed the previous tips and to have colleagues read over your paper to ensure you have provided a clear, detailed description and interpretation.

Finally, we leave you with some resources to guide your review writing. 3 , 7 , 8 , 10 , 11 , 16 , 17 We look forward to seeing your future work. One thing is certain, a better appreciation of what different reviews provide to the field will contribute to more purposeful exploration of the literature and better manuscript writing in general.

In this issue we present many interesting and worthwhile papers, two of which are, in fact, reviews.

Major Contributions

A chance for reform: the environmental impact of travel for general surgery residency interviews by Fung et al. 18 estimated the CO 2 emissions associated with traveling for residency position interviews. Due to the high emissions levels (mean 1.82 tonnes per applicant), they called for the consideration of alternative options such as videoconference interviews.

Understanding community family medicine preceptors’ involvement in educational scholarship: perceptions, influencing factors and promising areas for action by Ward and team 19 identified barriers, enablers, and opportunities to grow educational scholarship at community-based teaching sites. They discovered a growing interest in educational scholarship among community-based family medicine preceptors and hope the identification of successful processes will be beneficial for other community-based Family Medicine preceptors.

Exploring the global impact of the COVID-19 pandemic on medical education: an international cross-sectional study of medical learners by Allison Brown and team 20 studied the impact of COVID-19 on medical learners around the world. There were different concerns depending on the levels of training, such as residents’ concerns with career timeline compared to trainees’ concerns with the quality of learning. Overall, the learners negatively perceived the disruption at all levels and geographic regions.

The impact of local health professions education grants: is it worth the investment? by Susan Humphrey-Murto and co-authors 21 considered factors that lead to the publication of studies supported by local medical education grants. They identified several factors associated with publication success, including previous oral or poster presentations. They hope their results will be valuable for Canadian centres with local grant programs.

Exploring the impact of the COVID-19 pandemic on medical learner wellness: a needs assessment for the development of learner wellness interventions by Stephana Cherak and team 22 studied learner-wellness in various training environments disrupted by the pandemic. They reported a negative impact on learner wellness at all stages of training. Their results can benefit the development of future wellness interventions.

Program directors’ reflections on national policy change in medical education: insights on decision-making, accreditation, and the CanMEDS framework by Dore, Bogie, et al. 23 invited program directors to reflect on the introduction of the CanMEDS framework into Canadian postgraduate medical education programs. Their survey revealed that while program directors (PDs) recognized the necessity of the accreditation process, they did not feel they had a voice when the change occurred. The authors concluded that collaborations with PDs would lead to more successful outcomes.

Experiential learning, collaboration and reflection: key ingredients in longitudinal faculty development by Laura Farrell and team 24 stressed several elements for effective longitudinal faculty development (LFD) initiatives. They found that participants benefited from a supportive and collaborative environment while trying to learn a new skill or concept.

Brief Reports

The effect of COVID-19 on medical students’ education and wellbeing: a cross-sectional survey by Stephanie Thibaudeau and team 25 assessed the impact of COVID-19 on medical students. They reported an overall perceived negative impact, including increased depressive symptoms, increased anxiety, and reduced quality of education.

In Do PGY-1 residents in Emergency Medicine have enough experiences in resuscitations and other clinical procedures to meet the requirements of a Competence by Design curriculum? Meshkat and co-authors 26 recorded the number of adult medical resuscitations and clinical procedures completed by PGY1 Fellow of the Royal College of Physicians in Emergency Medicine residents to compare them to the Competence by Design requirements. Their study underscored the importance of monitoring collection against pre-set targets. They concluded that residency program curricula should be regularly reviewed to allow for adequate clinical experiences.

Rehearsal simulation for antenatal consults by Anita Cheng and team 27 studied whether rehearsal simulation for antenatal consults helped residents prepare for difficult conversations with parents expecting complications with their baby before birth. They found that while rehearsal simulation improved residents’ confidence and communication techniques, it did not prepare them for unexpected parent responses.

Review Papers and Meta-Analyses

Peer support programs in the fields of medicine and nursing: a systematic search and narrative review by Haykal and co-authors 28 described and evaluated peer support programs in the medical field published in the literature. They found numerous diverse programs and concluded that including a variety of delivery methods to meet the needs of all participants is a key aspect for future peer-support initiatives.

Towards competency-based medical education in addictions psychiatry: a systematic review by Bahji et al. 6 identified addiction interventions to build competency for psychiatry residents and fellows. They found that current psychiatry entrustable professional activities need to be better identified and evaluated to ensure sustained competence in addictions.

Six ways to get a grip on leveraging the expertise of Instructional Design and Technology professionals by Chen and Kleinheksel 29 provided ways to improve technology implementation by clarifying the role that Instructional Design and Technology professionals can play in technology initiatives and technology-enhanced learning. They concluded that a strong collaboration is to the benefit of both the learners and their future patients.

In his article, Seven ways to get a grip on running a successful promotions process, 30 Simon Field provided guidelines for maximizing opportunities for successful promotion experiences. His seven tips included creating a rubric for both self-assessment of likeliness of success and adjudication by the committee.

Six ways to get a grip on your first health education leadership role by Stasiuk and Scott 31 provided tips for considering a health education leadership position. They advised readers to be intentional and methodical in accepting or rejecting positions.

Re-examining the value proposition for Competency-Based Medical Education by Dagnone and team 32 described the excitement and controversy surrounding the implementation of competency-based medical education (CBME) by Canadian postgraduate training programs. They proposed observing which elements of CBME had a positive impact on various outcomes.

You Should Try This

In their work, Interprofessional culinary education workshops at the University of Saskatchewan, Lieffers et al. 33 described the implementation of interprofessional culinary education workshops that were designed to provide health professions students with an experiential and cooperative learning experience while learning about important topics in nutrition. They reported an enthusiastic response and cooperation among students from different health professional programs.

In their article, Physiotherapist-led musculoskeletal education: an innovative approach to teach medical students musculoskeletal assessment techniques, Boulila and team 34 described the implementation of physiotherapist-led workshops, whether the workshops increased medical students’ musculoskeletal knowledge, and if they increased confidence in assessment techniques.

Instagram as a virtual art display for medical students by Karly Pippitt and team 35 used social media as a platform for showcasing artwork done by first-year medical students. They described this shift to online learning due to COVID-19. Using Instagram was cost-saving and widely accessible. They intend to continue with both online and in-person displays in the future.

Adapting clinical skills volunteer patient recruitment and retention during COVID-19 by Nazerali-Maitland et al. 36 proposed a SLIM-COVID framework as a solution to the problem of dwindling volunteer patients due to COVID-19. Their framework is intended to provide actionable solutions to recruit and engage volunteers in a challenging environment.

In Quick Response codes for virtual learner evaluation of teaching and attendance monitoring, Roxana Mo and co-authors 37 used Quick Response (QR) codes to monitor attendance and obtain evaluations for virtual teaching sessions. They found QR codes valuable for quick and simple feedback that could be used for many educational applications.

In Creation and implementation of the Ottawa Handbook of Emergency Medicine Kaitlin Endres and team 38 described the creation of a handbook they made as an academic resource for medical students as they shift to clerkship. It includes relevant content encountered in Emergency Medicine. While they intended it for medical students, they also see its value for nurses, paramedics, and other medical professionals.

Commentary and Opinions

The alarming situation of medical student mental health by D’Eon and team 39 appealed to medical education leaders to respond to the high numbers of mental health concerns among medical students. They urged leaders to address the underlying problems, such as the excessive demands of the curriculum.

In the shadows: medical student clinical observerships and career exploration in the face of COVID-19 by Law and co-authors 40 offered potential solutions to replace in-person shadowing that has been disrupted due to the COVID-19 pandemic. They hope the alternatives such as virtual shadowing will close the gap in learning caused by the pandemic.

Letters to the Editor

Canadian Federation of Medical Students' response to “ The alarming situation of medical student mental health” King et al. 41 on behalf of the Canadian Federation of Medical Students (CFMS) responded to the commentary by D’Eon and team 39 on medical students' mental health. King called upon the medical education community to join the CFMS in its commitment to improving medical student wellbeing.

Re: “Development of a medical education podcast in obstetrics and gynecology” 42 was written by Kirubarajan in response to the article by Development of a medical education podcast in obstetrics and gynecology by Black and team. 43 Kirubarajan applauded the development of the podcast to meet a need in medical education, and suggested potential future topics such as interventions to prevent learner burnout.

Response to “First year medical student experiences with a clinical skills seminar emphasizing sexual and gender minority population complexity” by Kumar and Hassan 44 acknowledged the previously published article by Biro et al. 45 that explored limitations in medical training for the LGBTQ2S community. However, Kumar and Hassen advocated for further progress and reform for medical training to address the health requirements for sexual and gender minorities.

In her letter, Journey to the unknown: road closed!, 46 Rosemary Pawliuk responded to the article, Journey into the unknown: considering the international medical graduate perspective on the road to Canadian residency during the COVID-19 pandemic, by Gutman et al. 47 Pawliuk agreed that international medical students (IMGs) do not have adequate formal representation when it comes to residency training decisions. Therefore, Pawliuk challenged health organizations to make changes to give a voice in decision-making to the organizations representing IMGs.

In Connections, 48 Sara Guzman created a digital painting to portray her approach to learning. Her image of a hand touching a neuron showed her desire to physically see and touch an active neuron in order to further understand the brain and its connections.

Influence of political tensions on scientific productivity, citation impact, and knowledge combinations

• Published: 23 April 2024

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• Moxin Li 1 &
• Yang Wang   ORCID: orcid.org/0000-0002-0092-927X 1  

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Over the past decades, international scientific collaborations have thrived as a vital avenue for generating new knowledge and advancing scientific breakthroughs. However, recent political tensions between the United States and China have raised concerns about potential ramifications on scientific productivity and innovation. While existing research highlighted the adverse effects of these tensions on scientific collaborations, limited attention focused on knowledge combinations. Drawing upon large-scale bibliometric datasets, we conduct a systematic study to examine the effects of the “China Initiative” on Chinese scientists’ productivity, citation impact, and knowledge combinations at the individual level. Firstly, we find the “China Initiative” has shown detrimental effects on scientific productivity and citation impact of Chinese scientists collaborating with U.S. scientists. Moreover, scientists from prestigious Chinese institutions and those with dual affiliations from both countries experienced greater negative impacts from the “China Initiative”. Furthermore, we explore knowledge combination patterns and find that Chinese scientists who collaborated with US scientists published less novel and interdisciplinary papers after the “China Initiative”. Interestingly, we observe a shift in collaborative behaviors, with an increase in the quantity and citations of domestic papers and collaborative papers with countries other than the United States. By shedding light on the influence of the “China Initiative”, our study contributes to the understanding of the complex interplay between political dynamics and scientific progress, highlighting the importance of an open academic environment in an era of geopolitical challenges.

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Acknowledgements

We thank the referees for their valuable comments. This work was supported by the National Natural Science Foundation of China under Grant Nos. 72004177, L2324122, the Shaanxi Provincial Project of the Soft Science Fund (2024ZC-YBXM-100), and the Fundamental Research Funds for the Central Universities.

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Policies to prevent zoonotic spillover: a systematic scoping review of evaluative evidence

• Chloe Clifford Astbury 1 , 2 , 3 ,
• Kirsten M. Lee 1 , 2 ,
• Ryan Mcleod 1 ,
• Raphael Aguiar 2 ,
• Asma Atique 1 ,
• Marilen Balolong 4 ,
• Janielle Clarke 1 ,
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• Arne Ruckert 5 ,
• Priyanka Sibal 6 ,
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• A. M. Viens 1 , 3 ,
• Mary Wiktorowicz 1 , 2 ,
• Marc K. Yambayamba 7 ,
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• Tarra L. Penney 1 , 2 , 3  

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Emerging infectious diseases of zoonotic origin present a critical threat to global population health. As accelerating globalisation makes epidemics and pandemics more difficult to contain, there is a need for effective preventive interventions that reduce the risk of zoonotic spillover events. Public policies can play a key role in preventing spillover events. The aim of this review is to identify and describe evaluations of public policies that target the determinants of zoonotic spillover. Our approach is informed by a One Health perspective, acknowledging the inter-connectedness of human, animal and environmental health.

In this systematic scoping review, we searched Medline, SCOPUS, Web of Science and Global Health in May 2021 using search terms combining animal health and the animal-human interface, public policy, prevention and zoonoses. We screened titles and abstracts, extracted data and reported our process in line with PRISMA-ScR guidelines. We also searched relevant organisations’ websites for evaluations published in the grey literature. All evaluations of public policies aiming to prevent zoonotic spillover events were eligible for inclusion. We summarised key data from each study, mapping policies along the spillover pathway.

Our review found 95 publications evaluating 111 policies. We identified 27 unique policy options including habitat protection; trade regulations; border control and quarantine procedures; farm and market biosecurity measures; public information campaigns; and vaccination programmes, as well as multi-component programmes. These were implemented by many sectors, highlighting the cross-sectoral nature of zoonotic spillover prevention. Reports emphasised the importance of surveillance data in both guiding prevention efforts and enabling policy evaluation, as well as the importance of industry and private sector actors in implementing many of these policies. Thoughtful engagement with stakeholders ranging from subsistence hunters and farmers to industrial animal agriculture operations is key for policy success in this area.

This review outlines the state of the evaluative evidence around policies to prevent zoonotic spillover in order to guide policy decision-making and focus research efforts. Since we found that most of the existing policy evaluations target ‘downstream’ determinants, additional research could focus on evaluating policies targeting ‘upstream’ determinants of zoonotic spillover, such as land use change, and policies impacting infection intensity and pathogen shedding in animal populations, such as those targeting animal welfare.

The increasing incidence of zoonotic emerging infectious diseases (EIDs) has been attributed to behavioural practices and ecological and socioeconomic change, and is predicted to continue in the coming years [ 1 ]. Higher levels of anthropogenic activity, including agricultural intensification, urbanisation and other forms of land use change, have led to increased interactions between wildlife, humans and livestock, increasing the risk of cross-species transmission [ 2 , 3 , 4 ]. Meanwhile, accelerating rates of globalisation and urbanisation, leading to increased global movement of people and goods and more dense human settlements, have made outbreaks of disease in human populations more difficult to contain [ 5 ]. In response, a call has been issued by leading organisations and experts, including the United Nations Environment Programme, the International Livestock Research Institute and the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services, to complement reactive policy responses with policies that prevent zoonotic EIDs [ 1 , 6 , 7 , 8 , 9 , 10 ]. This approach, sometimes called deep prevention, would need to target upstream drivers to reduce the risk of outbreaks occuring [ 11 ].

Zoonotic spillover, defined as the transmission of a pathogen from an animal to a human, depends on the alignment of ecological, epidemiological and behavioural factors [ 12 ]. Zoonotic pathogens must be transmitted across a spillover pathway (Fig.  1 ) in order to induce infections in humans [ 12 , 13 ]. This involves meeting a series of conditions including appropriate density and distribution of reservoir hosts, pathogen prevalence, infection intensity and human exposure [ 12 ]. Across this pathway, a number of drivers of zoonotic spillover have been identified, including changes in wildlife and livestock populations [ 14 ]; deforestation, urbanisation and other forms of land use change [ 15 , 16 ]; bushmeat consumption [ 17 , 18 , 19 ]; and a variety of human practices including hunting, farming, animal husbandry, mining, keeping of exotic pets and trade [ 8 , 9 , 20 , 21 , 22 ]. These large-scale changes have repeatedly given rise to spillover events [ 2 , 15 , 23 ], sometimes involving pathogens with epidemic or pandemic potential [ 24 ].

Spillover pathway adapted from Plowright et al. [ 12 , 13 ]

The responsibility for addressing zoonotic disease frequently spans multiple sectors of governance due to its relevance for both animals and humans. A One Health perspective, which recognises the health of humans, animals and the environment as being closely linked and inter-dependent [ 25 ], can be useful in understanding the spillover pathway and drivers of spillover events, as well as informing policy and governance approaches to address this cross-sectoral problem. At the international level, the World Health Organization, the Food and Agriculture Organization, the World Organisation for Animal Health and the United Nations Environment Programme have endorsed a One Health approach to policymaking to respond to zoonotic infectious diseases, emphasising collaboration between agencies [ 26 ].

Operationalising a One Health approach to policy

While One Health is a promising approach to preventing zoonotic EIDs, operationalising this concept remains a challenge. Evaluative evidence exists around the effectiveness of interventions to prevent spillover events [ 13 , 27 , 28 , 29 ], however these have often been implemented as short- to medium-term programmes or academic investigations [ 8 ]. In some cases, zoonoses have re-emerged after successful programmes have ended [ 29 ]. As a result, experts have argued for the incorporation of successful interventions into policy frameworks, providing interventions with the sustainability required for long-term disease control [ 8 , 10 ].

Operationalising a One Health approach to policy involves understanding the policy options, identifying the stakeholders involved and developing insights into how to successfully implement and evaluate these policies. Although the longevity and scope of government actions may make policy an effective vehicle for prevention of emerging diseases, implementing policy is a complex process involving numerous actors with competing views and interests [ 30 ]. This context presents challenges for policy development and implementation. Where relevant policies are designed and implemented in isolation, opportunities for co-benefits may be missed and interventions may produce unintended consequences [ 31 ]. Finally, while evaluative evidence is key to informing future policy decisions, the complex systems in which policies are often implemented make evaluation challenging [ 32 ].

Aims and scope

To provide insights around how to use policy to successfully prevent zoonotic spillover events, it is necessary to synthesise the available evaluative evidence. A One Health perspective allows this evidence synthesis to incorporate a wide range of policy instruments and actors and to identify approaches to successfully implementing and evaluating policies in this complex, multi-sectoral context.

Approaches to managing epidemic and pandemic infectious pathogens when they have entered human populations have been systematically catalogued in the medical literature [ 33 , 34 , 35 , 36 , 37 , 38 , 39 ]. These measures include hand washing, face masks, school closures, contact tracing, vaccination and case isolation. Further upstream, systematic reviews of interventions targeting the spillover pathway have predominantly focused on programmes rather than policies, and have been restricted by various characteristics such as geographic region [ 28 ] or pathogen type [ 29 ], or focused on programmes with an explicit endorsement of a One Health approach [ 27 ]. In consequence, a comprehensive understanding of what policies to prevent zoonotic spillover have been evaluated, what actors are involved, and how to successfully implement and evaluate them, is lacking. To address these research gaps, our objective was to synthesise the existing evaluative evidence around policies that target the determinants of zoonotic spillover.

Our approach to identifying and analysing this literature was informed by a One Health perspective, acknowledging the inter-connectedness of human, animal and environmental health.

We conducted a systematic scoping review of evaluations of policies aimed at preventing zoonotic spillover events, based on a previously published protocol [ 40 ]. Results are reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews [ 41 ]. The scoping review was conducted in line with guidelines published by Arksey and O’Malley and refined by Levac and colleagues [ 42 , 43 , 44 ], which emphasise an iterative approach suited to an exploratory research question.

The One Health perspective guided the development of the review methodology. This included the search strategy and inclusion criteria, which allow for the inclusion of policies focused on human, animal or environmental health (or any combination of these areas) and with leadership from one or more of these sectors, and the research questions, which seek to outline the policies and the range of sectors involved in implementation. While our focus on the spillover pathway meant we only included policies that had been evaluated in terms of their impacts on animal and human population distributions, health and interactions, we explicitly searched for environment-focused policies (e.g., protection of wetlands and other wildlife habitats) that might have been evaluated from this perspective. We also aimed to interrogate the One Health approach to governance, by assessing to what extent cross-sectoral collaboration – a key tenet of One Health practice [ 25 ] – emerged as a reason for policy success.

Stage 1: identifying the research question

Informed by our research objective, our research questions were:

What policies aimed at preventing zoonotic spillover (i.e., policies that target the determinants of zoonotic spillover included in the spillover pathway [ 12 ]: population distribution, health and interactions) have been evaluated?

What are the types of policies?

Which policy actors (single department, multi-sectoral, whole of government) are involved?

What are the reasons for policy success and failure, and the unintended consequences of implementing these policies?

How has evaluation of these policies been approached in the literature?

What are the methods or study designs used?

What are the outcomes?

What are the opportunities and challenges for evaluation?

Stage 2: identifying relevant studies

We systematically searched four electronic databases (Medline, Scopus, Web of Science, Global Health) in May 2021. The search strategy was organized by the main concepts in our research question: the spillover pathway; public policy; prevention; and zoonotic pathogens. The search strategy was developed iteratively, informed by existing systematic reviews focused on related concepts [ 28 , 45 , 46 , 47 , 48 , 49 ] and known indicator papers meeting inclusion criteria. We also searched the websites of 18 organisations involved in the prevention of zoonotic spillover to identify relevant grey literature. The choice of organisations was informed by an actor mapping exercise in which we identified key international organisations working on the prevention of emerging zoonoses using network sampling [ 50 ]. We searched the websites of a subset of these organisations, focusing on inter-governmental organisations and organisations whose main focus was zoonotic disease. See Supplementary File 1 for details of academic database and grey literature search strategies.

Stage 3: study selection

Studies were included if they met the following criteria:

Primary empirical study with an English-language abstract from any country or region (reviews were excluded);

Study reporting empirical findings from an evaluation of any sort; and.

Study focused on a policy implemented by government that targets the determinants of zoonotic spillover.

Academic records identified through the searches were collated and double screened using the online platform Covidence [ 51 ]. Two researchers (CCA and KML) initially screened titles and abstracts. Title and abstract screening of an initial set of 100 papers was undertaken by both researchers independently. Results were compared to ensure consistency in decisions around study eligibility, and discrepancies were resolved through consensus. This process was repeated until an acceptable level of agreement (> 90%) was reached. The remaining papers were then screened by one of the two reviewers. Full-text screening was undertaken by two independent researchers and discrepancies were resolved by consensus. Studies with full-texts in any language were eligible for inclusion if they include an English-language abstract. Full-text studies published in French, Spanish or Chinese were single-screened by a member of the research team fluent in that language (CCA or AY). Studies published in other languages were translated as necessary.

Grey literature was screened by one researcher (CCA) to determine whether it met the inclusion criteria. Publications were initially screened by looking at titles, tables of contents and executive summaries. Where these indicated that the publication might be eligible, documents were read in full to determine if inclusion criteria were met.

In line with published guidelines, the approach to study selection was refined iteratively when reviewing articles for inclusion [ 42 , 43 , 44 ].

Stage 4: charting the data

Data charting was conducted using a form designed to identify the information required to answer the research question and sub-research questions (see Supplementary File 2). Data charting focused on characteristics of the study, the policy, and the evaluation. For each policy, this included identifying which determinant of zoonotic spillover situated along the spillover pathway was being targeted. For the purpose of this study, we used a model of the spillover pathway adapted from Plowright et al.’s work [ 12 , 13 ], in which we differentiated between wildlife and domesticated animals (Fig.  1 ). This differentiation is important in the policy context, as the wildlife-domesticated animal interface is an important site for intervention, as well as the human-animal interface.

The data charting form was piloted with ten records to ensure that it was consistent with the research question, and revised iteratively [ 42 , 43 , 44 ]. Data charting was conducted by one researcher (CCA, RM, JC, AD or PS) and checked by a second researcher (CCA or KML). Discrepancies were resolved by consensus.

Stage 5: collating, summarising and reporting the results

Our protocol stated that we would use the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project [ 52 ] to assess study quality [ 40 ]. However, on reviewing the included studies we selected two tools that were more appropriate to their characteristics: (1) ROBINS-I [ 53 ] for quantitative outcome evaluations and (2) a tool developed by the authors of a previous review [ 54 ] – based on Dixon-Woods et al.’s approach to assessing study credibility and contribution [ 55 ] – for all other study types. Two researchers (CCA and KML) assessed study quality independently for an initial set of 10 studies, before comparing assessments and reaching agreement where discrepancies occurred. This process was repeated until an adequate level of agreement was reached (> 90%). The remaining studies were assessed by a single researcher (CCA or KML). Records were not excluded based on quality assessment. Instead, assessments were primarily used to help synthesize the literature on how policies were evaluated. Quality assessment was not performed on grey literature due to the wide variability in the format and comprehensiveness of included publications.

We analysed the charted data, presenting a numerical summary of the included studies in table form, allowing us to describe the range of policy interventions that have been evaluated, aspects of policy implementation and approaches to evaluation. Based on the charted data, we inductively grouped evaluated policies with similar characteristics into policy types and assigned a policy instrument to each policy type: communication/marketing, guidelines, fiscal, regulation, legislation, environmental/social planning or service provision. We mapped policy types onto the spillover pathway shown in Fig.  1 to outline the policies that have been used to target each of these determinants. Thematic analysis was conducted using the approach described by Braun and Clarke where the focus is guided by the researcher’s analytic interests [ 56 ], with five overarching themes chosen as an a priori coding framework: (1) reasons for policy success; (2) reasons for policy failure; (3) unintended consequences of policy implementation; (4) opportunities for policy evaluation; and (5) challenges for policy evaluation. We selected these themes based on our research questions and previous familiarisation with the included articles during the process of article selection, data extraction and quality assessment. Sub-themes were subsequently identified through close reading and coding of the included articles. Thematic analysis was conducted by one researcher (RM) using the qualitative data analysis software Dedoose [ 57 ] and reviewed by the lead author (CCA).

Study characteristics

After removing duplicates, our searches identified a total of 5064 academic records. After screening titles and abstracts, we considered 330 records for full-text review. We also identified 11 relevant publications through our grey literature search. Grey literature reports were published by five organisations: four organisations focused on health and disease, including an intergovernmental organisation (the World Organisation for Animal Health) and three non-governmental organisations (the One Health Commission, the Global Alliance for Rabies Control and EcoHealth Alliance); and one non-governmental organisation focused on wildlife trade (TRAFFIC). In total, we included 95 publications in this review (PRISMA diagram in Fig.  2 ) [ 58 ].

We excluded studies which assessed the unintended consequences of policies to prevent zoonotic spillover without evaluating their effectiveness. This included studies that looked exclusively at the mental health impacts of mandatory livestock culls on farm workers [ 59 ]; studies which focused on potentially relevant factors, such as the wildlife trade, but with no consideration of outcomes situated on the spillover pathway [ 60 ]; and studies which assessed the detection power of surveillance systems without assessing the impact of associated policy interventions [ 61 , 62 , 63 ].

Policy characteristics

The characteristics of the policies evaluated in the included studies are presented in Supplementary File 3 and summarised in Table  1 . Some studies evaluated more than one policy, particularly modelling studies which compared the impacts of several policy options and process evaluations focused on a range of activities undertaken by a single government. Therefore, the number of evaluated policies (n = 111) is greater than the number of included studies (n = 95).

Most policies were evaluated for their impact on human exposure (21%), pathogen prevalence in domesticated animals (18%), barriers within domesticated animals (15%), and pathogen survival and spread in domesticated animals (9%). There were also a number of multi-component policies studies across multiple stages of the spillover pathway (18%). Fewer studies focused on wildlife health and populations, and none of the included studies evaluated policies for their impact on infection intensity and pathogen release in either domesticated animals or wildlife.

Where the government department responsible for implementing a policy was identified in the paper, most policies were implemented by a single department (35%), although there were a number of multi-sectoral efforts (24%). The range of government sectors responsible for implementing policies to prevent zoonotic spillover included human health, animal health, food safety, agriculture, conservation, national parks, forestry, fisheries, environmental protection, border control and foreign affairs. Policies were predominantly intended to be implemented by private sector actors, including individuals and organisations working in trade, retail, hunting and animal agriculture. However, some policies were also implemented by public sector actors working in public health, veterinary public health and environmental conservation.

Most policies were situated in high-income (49%) and upper middle-income (28%) countries, with studies from East Asia and the Pacific (43%) and Europe and Central Asia (19%) dominating. Publications focused on policies targeting various zoonotic diseases, with the most common being avian influenza (50%), rabies (19%), brucellosis (11%) and Hendra virus (4%).

Most policies were evaluated using process (38%) or outcome (31%) evaluation. The most frequently used policy instrument was legislation (59%), particularly for managing pathogen spread in domesticated animals through measures such as mandatory vaccination, culls or disinfection protocols. Meanwhile, communication and marketing or service provision was more typically used to reduce risk in wildlife and human populations, for example by providing guidance around recommended hygiene protocol, by distributing oral vaccination in wildlife habitat or by offering vaccination to human populations.

PRISMA 2020 diagram [ 58 ]

What policies aimed at preventing zoonotic spillover have been evaluated?

Policy types targeted different determinants across the pathway to zoonotic spillover and used various approaches with different evidence of success (Table  2 ). We identified policy options including culling – both general and targeted – of wild and domesticated animals; habitat protection (limiting activities such as agriculture and animal husbandry in wildlife habitats); supplemental feeding to control wildlife movements; vaccination of both wildlife, domesticated animals and human populations with occupational exposure to animals; policies to improve biosecurity in sites where animals are kept, slaughtered and sold, including mandates and information campaigns; live animal market closures; and bans on hunting and selling wildlife. Where outcomes or impacts were evaluated, most policies saw some level of success (i.e., outcome measures were found to vary in a direction that indicated policy success), though relative effectiveness was not assessed due to variation in study design and outcome measure. Policies with consistent evidence of effectiveness – where outcome measures varied in a direction that indicated policy success in all studies included in the review – included culling and sterilisation of wildlife populations, habitat protection, vaccination in wildlife and domesticated animal populations and mandated disinfection protocols. Policies with equivocal evidence of success (i.e., outcome measures varied in different directions or studies had different findings, some indicating success and some indicating failure) included supplemental feeding of wildlife, pre-emptive livestock culls, live animal market closures and bans on wildlife hunting, trade and consumption. For many policies, there were no impact or outcome evaluations identified in this review.

What are the reasons for policy success?

The evidence from the identified impact and outcome evaluations suggests that most of the policies succeeded to some extent. A range of factors contributed to policy success. First, studies emphasized the importance of effective collaboration and coordination between various agencies, disciplines, and levels of government in the execution of policy directives [ 114 , 115 ], in line with a One Health approach to policy and governance. Policy success was attributed, in part, to strong working relationships that encouraged effective communication between various government agencies, and facilitated timely and appropriate policy responses [ 115 ]. Synergy between agencies responsible for surveillance and the execution of control strategies was also reported to be beneficial. For example, prompt communication and effective collaboration between laboratories testing samples and agencies implementing culls in the field was seen as important in the control of highly pathogenic avian influenza in Nigeria [ 116 ]. Similarly, authors also identified the importance of private-public relations and private sector contributions to implementing policies to prevent zoonotic spillover [ 112 ]. This included stronger government engagement with private veterinarians as a factor for success in reducing the spillover of Hendra virus in Queensland [ 109 ], and with farmers, poultry companies and national farming and poultry processing associations in Ghana as part of a successful campaign to reduce risk from highly pathogenic avian influenza [ 112 ]. Studies suggest that the inclusion of private sector stakeholders in the policy process has the potential to improve compliance through transparent dialogue around disease ecology, risk and risk mitigation [ 90 , 91 , 103 , 117 ]; and highlight the utility of participatory approaches in prompting behaviour changes [ 91 ].

Second, authors emphasised the significance of economic incentives, suggesting that policy impact is dependent on private actors’ appraisal of costs and benefits. Studies illustrated how incentives, including compensation, subsidies, rebates, and fines, have had varying degrees of success [ 91 , 97 , 112 , 115 ]. Compensation levels [ 104 , 114 ] and enforcement practices [ 92 ] were identified as salient factors for compliance and adherence. For example, fear of sanctions for bushmeat hunting while a ban was in place in some parts of West Africa were identified as a stronger incentive to avoid bushmeat hunting than the fear of contracting Ebola virus [ 97 ]. Culls were seen as particularly challenging in this regard: while the long-term benefits for farmers may outweigh the financial loss [ 104 ], authorities need to be conscientious of the substantial economic impacts when considering policies that mandate culling or safe disposal [ 95 ]. The direct losses related to compliance (time, labour and expenses) and indirect losses due to price fluctuations and decreases in trade volume, as well as losses to associated industries, are substantial [ 88 , 96 , 113 , 118 ].

Third, trust in government and public support for implemented policy were specified as critical factors influencing the effectiveness of disease control strategies, and research suggests that strategic engagement to facilitate compliance is a necessary step in the policy process [ 97 ]. Participatory approaches that attempt to identify and understand factors influencing compliance have been consistently used to overcome resistance to policy, as insights from engagement and consultation can lead to solutions that facilitate behaviour change at the population level [ 91 , 103 ]. For example, a World Health Organization initiative to reduce avian influenza transmission in poultry markets in Indonesia worked alongside market vendors to achieve its aims, carrying out repeated consultations with the vendors and implementing market infrastructure (such as energy and running water in the market) in collaboration with local authorities to support vendor behaviour change [ 91 ].

Fourth, studies also demonstrated the importance of public communication. The quality of information, as well as the volume, complexity and delivery of public health messages, were key factors [ 75 , 114 ]. Authors contend that communication strategies must understand the target audience and how they interpret and engage with messages [ 97 ], for example by building on relationships where there is exiting trust, such as between veterinarians advising animal vaccination and animal owners [ 117 ]. Homogenously delivered communication strategies were ineffectual: they limited opportunities for open discourse; discounted contradictory lived experiences and expressions of uncertainty; and ultimately contributed to scepticism surrounding implemented policies [ 97 , 117 ].

Finally, studies underscored the importance of surveillance infrastructure to inform intervention strategies. Surveillance programs with the ability to collect and operationalize relevant data were essential to the development of appropriate interventions that are responsive to each unique context [ 115 , 119 ]. Implementing effective surveillance programmes requires the appropriate evaluation tools [ 120 ] and trained personnel [ 81 ].

What are the reasons for policy failure?

Studies showed that perceptions of acceptability and appropriateness were crucial to the effectiveness of implemented policies [ 101 , 104 ]. Several factors were identified that negatively affected acceptability and appropriateness, including: additional expenses for private sector actors without sufficient support [ 75 , 100 , 104 , 112 , 114 ], particularly were culls were demanded but reimbursement for farmers was slow and inadequate, as in a brucellosis eradication campaign in Macedonia [ 81 ]; lack of affordable alternatives [ 97 ]; impracticality of implemented strategies [ 75 , 101 ]; lack of cultural understanding in designing policy interventions [ 97 , 100 ], for example the distribution of footwear to pig farmers in a Polynesian context where footwear was not traditionally worn [ 100 ]; lack of understanding of viral ecology [ 100 ]; as well as public scepticism and distrust [ 97 , 114 ].

Additionally, policy ineffectiveness was associated with poor planning and execution of intervention strategies, including lack of clear direction [ 114 ]; incomplete or inconsistent implementation of control measures (17); limited scope of intervention [ 114 ]; and poor enforcement [ 92 ]. A lack of adequate resources to implement strategies also contributed to policy failure [ 81 ]. Adequate financial resources were necessary to hire and train staff to run surveillance and control operations [ 81 ]. Financial resources were also necessary to fund compensation mechanisms that facilitate compliance. Willingness to adopt policy-prescribed disposal practices was found to be associated with compensation levels (incentives) as a proportion of production price, dependency on income from activities driving zoonotic risk, and contact with prevention staff [ 92 ].

What are the unintended consequences of implementing policies to prevent zoonotic spillover?

A small number of the included studies collected data on the unintended consequences of policies to prevent zoonotic spillover (n = 18). In some instances, unintended consequences were due to disease ecology or human behaviour as a result of policy failure. For example, a study assessing the impacts of the closure of a live poultry market found that, following the closure, vendors travelled to neighbouring markets to sell their animals [ 94 ]. As a result, while cases of avian influenza decreased in the area surrounding the closed market, cases increased in these neighbouring markets, leading to the wider geographic spread of the disease. In another study, elk were provided with supplementary feeding grounds to discourage them from coming into contact with the livestock who shared their range [ 65 ]. While this intervention had the intended consequence of reducing the transmission of brucellosis between elk and livestock, the spread of brucellosis between the elk using the supplementary feeding grounds – who were gathering in larger, tighter groups for longer periods, resulting in higher within-herd transmission – and other elk populations in the area increased. This resulted in an increasing prevalence of brucellosis among the elk, potentially increasing the risk of spillover to livestock. These examples illustrate the complexity of the social and ecological systems in which these policies are implemented, further suggesting the need for a One Health approach to policies to prevent zoonotic spillover.

A key unintended consequence can be attributed to the loss of profits and livelihoods sometimes associated with policies to prevent zoonotic spillover, as described above. The losses incurred by complying with regulations made farmers, hunters and other private sector actors reluctant to report potential infections, contributing to increased unauthorized or illegal activity, and unrestrained spread of disease [ 90 , 92 , 94 , 98 , 112 , 114 ]. Studies investigated the creative ways policy enforcement was circumvented, including hiding hunting equipment on the outskirts of towns or developing informal trade markets and networks [ 97 , 98 ]. Unintended consequences identified in the included evaluations emphasize an opportunity for policymakers to improve sector compliance through public education, levying the influence of consumer attitudes on industry standards [ 104 , 113 ].

A range of study designs were used to evaluate policies. Outcome evaluations (n = 33) used time series or repeat cross-sectional data to conduct evaluations of natural experiments, though most studies did not include a control group for comparison. Outcome evaluations also used case-control and modelling approaches to assess policy impact on an outcome of interest. Process evaluations (n = 30) used cross-sectional and qualitative approaches, as well as study designs combining multiple sources of data, to understand aspects of policy implementation such as the extent to which the policy was being implemented as designed, and the responses and attitudes of stakeholders involved in policy implementation. Economic evaluations (n = 11) included cost-benefit analyses, risk-benefit analyses and modelling studies. Formative evaluations (n = 17) used modelling approaches to estimate what the impacts of a proposed policy option would be in a specific context.

Outcome variables interpreted as indicators of policy success were also numerous and represented determinants along the spillover pathway. As expected, many studies assessed impact on disease transmission, including disease prevalence and incidence, disease eradication, case numbers, and basic reproduction number in human and animal populations, as well as evidence of disease in environmental samples, such as in live animal markets or at carcass disposal sites. Studies also assessed impacts on intermediate factors indicative of successful implementation of specific policies, such as the availability of wild species in markets where a trade ban had been implemented, or knowledge and practices of stakeholders in response to an educational or information campaign.

While most studies found a reduced risk of zoonotic spillover following policy implementation, comparing the magnitude of these impacts was challenging due to the variety of study designs and outcome measures used in the included studies. However, we identified several studies which used modelling to directly compare the impacts of policy options. These studies evaluated various policy scenarios: different combinations within multi-component policy interventions [ 121 ]; culling versus vaccinating wildlife [ 122 ] and livestock [ 84 , 85 ] populations; targeting strategies to humans exclusively versus targeting humans and livestock [ 108 ]; and altering the parameters for culling and vaccination strategies, for example by modelling different ranges for culling and vaccination near infected farms [ 85 ]. These studies often highlighted trade-offs between the effectiveness of policy measures and their cost. For example, estimates of the number of infected flocks were lower when incorporating a ring cull (cull of animals on farms surrounding an outbreak) into a multi-component control strategy for highly pathogenic avian influenza [ 121 ]. However, livestock vaccination was estimated to be a highly effective strategy, with one study findings livestock vaccination to be as or more effective than a pre-emptive cull for outbreak control purposes (depending on the extent of vaccination coverage), while minimising the number of animals culled [ 85 ]. One study jointly modelled costs and benefits of strategies, and found that livestock vaccination had a higher cost-benefit ratio than a wildlife cull [ 122 ]. A final study highlighted the potential of holistic approaches, with drug administration in humans and livestock having a lower cost per disability-adjusted life year averted than intervention in humans alone [ 108 ].

Study authors noted a number of challenges encountered while evaluating policies to prevent zoonotic spillover. One study noted the difficulty of determining the impact of policies aiming to reduce spillover events between wildlife, livestock and humans, as the number of spillover events is often relatively small [ 65 ]. This highlights the importance of considering upstream determinants and risk factors as outcome measures in attempting to evaluate these policies, particularly where spillover events may happen infrequently or not at all during the period of observation. Studying changes in risk factors for spillover can provide insight on the effectiveness of different policies in tackling spillover risk.

Lack of suitable data was a frequently cited barrier to policy evaluation. As policies to prevent zoonotic spillover are often reactive, being implemented in response to an outbreak in animal populations, accessing data from before a policy was implemented was challenging. Studies highlighted the value of routinely collected data, which was often the only data available and was frequently used for policy evaluation [ 65 , 66 , 94 , 115 , 119 , 123 ]. However, in many contexts routine data on animal health is not collected [ 80 ]. Routine testing data from livestock can sometimes be used for evaluation where it exists, but it does not always provide sufficient detail for examining the potential for a policy to prevent zoonotic spillover. For example, some tests do not differentiate between current and past infection, making it difficult to identify where and when spillover occurred [ 65 ], and animal health data may not be granular enough for policy evaluation, particularly in terms of evaluating local policies [ 94 ]. Studies also highlighted instances where the private sector may own data sets reporting disease prevalence and transmission, but may be reluctant to share the data for evaluation purposes [ 121 ]. In such instances, open communication and good relationships with the private sector may be facilitators to evaluation.

Beyond the lack of baseline data, studies highlighted the difficulty in collecting information about policy compliance. As failing to comply often puts farmers and hunters at risk of fines or imprisonment, they were reluctant to disclose information about non-compliance or participation in illegal trade and sale of animals [ 86 , 92 , 97 , 112 ]. This made it difficult to determine policy effectiveness.

Quality assessment

Of the 44 quantitative evaluations, 37 were evaluated as being at moderate or higher risk of bias (see Supplementary File 4), given the possibility of bias in the assessment of intervention impact due to the presence of confounding effects. A small number of studies were determined to be at serious (n = 6) or critical (n = 1) risk of bias, for two main reasons: only having data from after the intervention was implemented; or using a case-control study model without measuring and adjusting for important potential confounders, such as the prevalence of a targeted disease prior to policy implementation. These limitations may reflect the nature of zoonotic spillover events and policy responses, which can happen quickly and leave little time for baseline data collection. Many of the included studies relied on surveillance data, but where such data sets are not available, post-test and case-control study designs may be the only options.

The quality of studies assessed with the tool developed based on Dixon-Woods’ approach [ 55 ] was high overall (n = 41, see Supplementary file 5). Most studies were rated as high in terms of clearly and comprehensively presenting their results (n = 37), analysis (n = 34), research design (n = 33), aims (n = 32) and research process (n = 28). Most studies also had a high relevance to the research question (n = 31), indicating that the research was embedded in policy, being commissioned, co-designed or conducted in partnership with government stakeholders.

We identified a range of policies targeting different parts of the spillover pathway implemented by various policy and governance sectors, including some multi-sectoral initiatives. Policies tended to rely heavily on private sector actors (including actors ranging from small-scale farmers and hunters to larger commercial operations) for implementation, suggesting that open communication and collaboration with these actors was essential for successful policy implementation. Policy success was undermined by lack of collaboration between government agencies; lack of communication between surveillance and control operations; poor understanding of the context in which policies were implemented; and inadequate financial compensation for private sector actors who lost profits and incurred additional costs by complying with policies. Where policies were ineffective, this tended to be due to unintended consequences relating to complex dynamics within the social and ecological systems where policies were implemented. Lack of appropriate data was a key obstacle to policy evaluation, and studies emphasised the importance of robust surveillance infrastructure in evaluating policies that tended to be implemented reactively, in response to an outbreak of zoonotic disease in animal or human populations.

Implications for policy and practice

The key role that the private sector and industry actors play in implementing policies to prevent zoonotic spillover is an important consideration for policymakers. Our findings suggest that many of these policies must be complied with by farmers – from subsistence and smallholder farmers to large corporations – as well as by other actors, such as hunters. Lack of awareness as well as financial costs of compliance among these groups present key barriers to policy success in this area. This set of stakeholders is complex as some may make very marginal profits, if any, and may struggle to afford the additional costs of implementing preventive policies. However, powerful actors and profitable industries are also involved, including large-scale farms and primary resource extraction enterprises [ 22 ]. Acknowledging the differences across these stakeholder groups, and in particular assessing their capacity to bear some of the costs related to prevention, emerges as crucial in successful policy implementation.

Finally, our findings highlight the importance of disease surveillance in efforts to reduce the risk of spillover events. As well as acting as an early warning system, surveillance provides a source of data to evaluate the impact of preventive policies. We found the availability of surveillance data to be a key enabling factor in evaluating policies. In addition, close collaboration between agencies responsible for disease surveillance and control efforts was key to policy success. National surveillance efforts, as well as cross-country collaboration to support global efforts, such as the United States Agency for International Development’s PREDICT program supporting surveillance in areas at high risk for zoonotic disease outbreaks [ 124 ], must be sustained and expanded. In complex areas such as the prevention of zoonotic spillover, approaches to surveillance which encompass risk factors and transmission pathways [ 125 ], as well as One Health surveillance systems which harmonise and integrate data collection and analysis from across human, animal and environmental sectors [ 126 ], are promising approaches to developing surveillance systems that support risk. This context also involves a need to strengthen surveillance capacity in remote and rural locations, as communities living in these contexts may have exposure to numerous pathogens of wildlife origin. This will require strengthening clinical and diagnostic capacity in these settings, as well as engaging with stakeholders such as community human and animal health workers and wildlife or national park rangers [ 127 ].

Comparison with existing literature

This review sought to map the range of policies implemented to reduce the risk of zoonotic spillover, and the various approaches taken to evaluation, and identify factors behind the success and failure of policy implementation and evaluation. Due to this broad scope, comparing relative effectiveness of policy interventions was challenging. Existing systematic reviews with a more specific focus could apply meta-analysis to determine which interventions were most effective. For example, a review of market-level biosecurity measures aiming to reduce the transmission of avian influenza found that reducing market size, separating poultry species, cleaning and disinfecting premises, closing markets and banning overnight storage were highly effective interventions [ 45 ]. However, our findings suggest that studies focused on the control of avian influenza dominate the literature in this space (55 out of 111 evaluated policies), and many of these are focused on market-level measures. Systematic reviews focused on other approaches to reduce spillover risk, such as on-farm biosecurity [ 47 ]; biosecurity for backyard poultry rearing [ 46 ]; and community-based interventions [ 28 ] comment on the paucity of high-quality evidence around the impacts of such approaches. By taking a broad perspective, we hope our findings will provide policy options for consideration in a number of contexts, and guide researchers in focusing their efforts on areas where evidence is lacking.

Strengths and weaknesses of the study

To our knowledge, this is the first attempt to systematically identify and document evaluations of policies aiming to prevent the spillover of zoonotic pathogens into human populations. However, because of the complex drivers of spillover events, some potentially relevant policy evaluations may be excluded where their outcome measures are too far removed from zoonotic spillover. While relevant, such evaluations will be difficult to systematically identify as they make no reference to zoonotic disease.

In addition, this review focused on policy evaluations that have been reported in the peer-reviewed literature and the grey literature published by international agencies and organisations working on these topics. Policies that have been implemented but not evaluated, or evaluated but not published in these literatures, will therefore be excluded from this review. As a result, potentially effective and important policies in the prevention of zoonotic spillover events may not have been identified. However, we hope that the findings from this review will highlight these gaps in the evaluative evidence. We also hope that this review, by extracting practical dimensions, such as study design, outcome measures and the challenges encountered in the evaluation process, will support policymakers and researchers in carrying out further policy evaluations in this space.

Unanswered questions and future research

Our findings highlight several important gaps in the evidence. First, while observational evidence emphasises the importance of upstream determinants such as environmental and ecosystem health in the increasing rate of zoonotic spillover [ 1 , 15 ], we only identified a single evaluation of a policy attempting to target one of these upstream determinants: an evaluation carried out in China to assess the impact of the Ramstar wetland protection program on avian influenza in migratory waterfowl [ 66 ]. This study found that proximity to protected wetlands reduced outbreak risk. Authors hypothesised that this effect was due to the separation of wild waterfowl and poultry populations and the diversion of wild waterfowl away from human-dominated landscapes and toward protected natural habitats. Our findings support existing calls for more quantitative and mechanistic studies of the impact of interventions supporting environmental and ecosystem health on zoonotic spillover risk [ 128 ], as well as calls for greater integration of the environment into One Health research, policy and practice [ 31 ]. Further evaluations of environment and habitat protection policies would strengthen our understanding of this area. In addition, the impact of policies to reduce deforestation or expand forest coverage, such as China’s Grain-to-Green program [ 129 ], on the spillover pathway could be evaluated. Such evaluations might consider potential unintended consequences, as these policies could promote healthier wildlife populations with better disease resistance, but may also facilitate wildlife population growth and higher rates of wildlife-human encounters [ 130 ].

There is also a lack of evaluation of policies targeting infection intensity and pathogen release in either wildlife or domesticated animals. These could include approaches such as improving animal health and welfare to make these populations more resistant to disease [ 13 ]. While arguments have been made for strengthening legal structures supporting animal welfare in order to reduce the risk of zoonotic pathogen transmission [ 131 ], there is a need to evaluate policies that take this approach.

Our review found publications evaluating a wide range of policy interventions spanning the spillover pathway, including habitat protection; trade regulations; border control and quarantine procedures; farm and market biosecurity measures; public information campaigns; and vaccination programmes for wildlife and domesticated animals, as well as human populations with occupational exposure to animals. A wide range of governance sectors implemented these policies, highlighting the prevention of zoonotic spillover as a cross-sectoral issue, though most policies were implemented by a single sector. Our findings highlight the importance of industry and private actors in implementing policies to prevent zoonotic spillover, and the need for thoughtful and effective engagement with this wide range of actors, from subsistence hunters and farmers through to industrial animal agriculture operations to address their concerns through a range of incentives. We also identified the centrality of surveillance data in evaluating policies that are often implemented reactively, and effective collaboration between surveillance and control operations as a central factor in successful policy implementation.

Data Availability

All data generated or analysed during this study are included in this published article and its supplementary information files. Analysis code for descriptive characteristics of included policies is available on GitHub.

Abbreviations

Emerging infectious disease

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CCA, JC and TLP acknowledge internal research support from York University. MW and CCA acknowledge internal research support from the Dahdaleh Institute for Global Health Research. KML acknowledges funding from the Canadian Institutes of Health Research through a Health System Impact Fellowship. AY is funded by the BBSRC through the Mandala project (grant number BB/V004832/1). AMV acknowledges support from York University through a York Research Chair in Population Health Ethics & Law. This review was undertaken as part of a project funded by the Canadian Institutes of Health Research, Grant Reference Number VR5-172686. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Clifford Astbury, C., Lee, K.M., Mcleod, R. et al. Policies to prevent zoonotic spillover: a systematic scoping review of evaluative evidence. Global Health 19 , 82 (2023). https://doi.org/10.1186/s12992-023-00986-x

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