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• Critical Reviews

How to Write an Article Review

Last Updated: September 8, 2023 Fact Checked

This article was co-authored by Jake Adams . Jake Adams is an academic tutor and the owner of Simplifi EDU, a Santa Monica, California based online tutoring business offering learning resources and online tutors for academic subjects K-College, SAT & ACT prep, and college admissions applications. With over 14 years of professional tutoring experience, Jake is dedicated to providing his clients the very best online tutoring experience and access to a network of excellent undergraduate and graduate-level tutors from top colleges all over the nation. Jake holds a BS in International Business and Marketing from Pepperdine University. There are 13 references cited in this article, which can be found at the bottom of the page. This article has been fact-checked, ensuring the accuracy of any cited facts and confirming the authority of its sources. This article has been viewed 3,086,875 times.

An article review is both a summary and an evaluation of another writer's article. Teachers often assign article reviews to introduce students to the work of experts in the field. Experts also are often asked to review the work of other professionals. Understanding the main points and arguments of the article is essential for an accurate summation. Logical evaluation of the article's main theme, supporting arguments, and implications for further research is an important element of a review . Here are a few guidelines for writing an article review.

Education specialist Alexander Peterman recommends: "In the case of a review, your objective should be to reflect on the effectiveness of what has already been written, rather than writing to inform your audience about a subject."

Things You Should Know

• Read the article very closely, and then take time to reflect on your evaluation. Consider whether the article effectively achieves what it set out to.
• Write out a full article review by completing your intro, summary, evaluation, and conclusion. Don't forget to add a title, too!
• Proofread your review for mistakes (like grammar and usage), while also cutting down on needless information. [1] X Research source

Preparing to Write Your Review

• Article reviews present more than just an opinion. You will engage with the text to create a response to the scholarly writer's ideas. You will respond to and use ideas, theories, and research from your studies. Your critique of the article will be based on proof and your own thoughtful reasoning.
• An article review only responds to the author's research. It typically does not provide any new research. However, if you are correcting misleading or otherwise incorrect points, some new data may be presented.
• An article review both summarizes and evaluates the article.

• Summarize the article. Focus on the important points, claims, and information.
• Discuss the positive aspects of the article. Think about what the author does well, good points she makes, and insightful observations.
• Identify contradictions, gaps, and inconsistencies in the text. Determine if there is enough data or research included to support the author's claims. Find any unanswered questions left in the article.

• Make note of words or issues you don't understand and questions you have.
• Look up terms or concepts you are unfamiliar with, so you can fully understand the article. Read about concepts in-depth to make sure you understand their full context.

• Pay careful attention to the meaning of the article. Make sure you fully understand the article. The only way to write a good article review is to understand the article.

• With either method, make an outline of the main points made in the article and the supporting research or arguments. It is strictly a restatement of the main points of the article and does not include your opinions.
• After putting the article in your own words, decide which parts of the article you want to discuss in your review. You can focus on the theoretical approach, the content, the presentation or interpretation of evidence, or the style. You will always discuss the main issues of the article, but you can sometimes also focus on certain aspects. This comes in handy if you want to focus the review towards the content of a course.
• Review the summary outline to eliminate unnecessary items. Erase or cross out the less important arguments or supplemental information. Your revised summary can serve as the basis for the summary you provide at the beginning of your review.

• What does the article set out to do?
• What is the theoretical framework or assumptions?
• Are the central concepts clearly defined?
• How adequate is the evidence?
• How does the article fit into the literature and field?
• Does it advance the knowledge of the subject?
• How clear is the author's writing? Don't: include superficial opinions or your personal reaction. Do: pay attention to your biases, so you can overcome them.

Writing the Article Review

• For example, in MLA , a citation may look like: Duvall, John N. "The (Super)Marketplace of Images: Television as Unmediated Mediation in DeLillo's White Noise ." Arizona Quarterly 50.3 (1994): 127-53. Print. [10] X Trustworthy Source Purdue Online Writing Lab Trusted resource for writing and citation guidelines Go to source

• For example: The article, "Condom use will increase the spread of AIDS," was written by Anthony Zimmerman, a Catholic priest.

• Your introduction should only be 10-25% of your review.
• End the introduction with your thesis. Your thesis should address the above issues. For example: Although the author has some good points, his article is biased and contains some misinterpretation of data from others’ analysis of the effectiveness of the condom.

• Use direct quotes from the author sparingly.
• Review the summary you have written. Read over your summary many times to ensure that your words are an accurate description of the author's article.

• Support your critique with evidence from the article or other texts.
• The summary portion is very important for your critique. You must make the author's argument clear in the summary section for your evaluation to make sense.
• Remember, this is not where you say if you liked the article or not. You are assessing the significance and relevance of the article.
• Use a topic sentence and supportive arguments for each opinion. For example, you might address a particular strength in the first sentence of the opinion section, followed by several sentences elaborating on the significance of the point.

• This should only be about 10% of your overall essay.
• For example: This critical review has evaluated the article "Condom use will increase the spread of AIDS" by Anthony Zimmerman. The arguments in the article show the presence of bias, prejudice, argumentative writing without supporting details, and misinformation. These points weaken the author’s arguments and reduce his credibility.

• Make sure you have identified and discussed the 3-4 key issues in the article.

Sample Article Reviews

Expert Q&A

You Might Also Like

• ↑ https://writing.wisc.edu/handbook/grammarpunct/proofreading/
• ↑ https://libguides.cmich.edu/writinghelp/articlereview
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548566/
• ↑ Jake Adams. Academic Tutor & Test Prep Specialist. Expert Interview. 24 July 2020.
• ↑ https://guides.library.queensu.ca/introduction-research/writing/critical
• ↑ https://www.iup.edu/writingcenter/writing-resources/organization-and-structure/creating-an-outline.html
• ↑ https://writing.umn.edu/sws/assets/pdf/quicktips/titles.pdf
• ↑ https://owl.purdue.edu/owl/research_and_citation/mla_style/mla_formatting_and_style_guide/mla_works_cited_periodicals.html
• ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548565/
• ↑ https://writingcenter.uconn.edu/wp-content/uploads/sites/593/2014/06/How_to_Summarize_a_Research_Article1.pdf
• ↑ https://www.uis.edu/learning-hub/writing-resources/handouts/learning-hub/how-to-review-a-journal-article
• ↑ https://writingcenter.unc.edu/tips-and-tools/editing-and-proofreading/

About This Article

If you have to write an article review, read through the original article closely, taking notes and highlighting important sections as you read. Next, rewrite the article in your own words, either in a long paragraph or as an outline. Open your article review by citing the article, then write an introduction which states the article’s thesis. Next, summarize the article, followed by your opinion about whether the article was clear, thorough, and useful. Finish with a paragraph that summarizes the main points of the article and your opinions. To learn more about what to include in your personal critique of the article, keep reading the article! Did this summary help you? Yes No

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• How to Write a Literature Review | Guide, Examples, & Templates

How to Write a Literature Review | Guide, Examples, & Templates

Published on January 2, 2023 by Shona McCombes . Revised on September 11, 2023.

What is a literature review? A literature review is a survey of scholarly sources on a specific topic. It provides an overview of current knowledge, allowing you to identify relevant theories, methods, and gaps in the existing research that you can later apply to your paper, thesis, or dissertation topic .

There are five key steps to writing a literature review:

• Search for relevant literature
• Evaluate sources
• Identify themes, debates, and gaps
• Outline the structure
• Write your literature review

A good literature review doesn’t just summarize sources—it analyzes, synthesizes , and critically evaluates to give a clear picture of the state of knowledge on the subject.

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Table of contents

What is the purpose of a literature review, examples of literature reviews, step 1 – search for relevant literature, step 2 – evaluate and select sources, step 3 – identify themes, debates, and gaps, step 4 – outline your literature review’s structure, step 5 – write your literature review, free lecture slides, other interesting articles, frequently asked questions, introduction.

• Quick Run-through
• Step 1 & 2

When you write a thesis , dissertation , or research paper , you will likely have to conduct a literature review to situate your research within existing knowledge. The literature review gives you a chance to:

• Demonstrate your familiarity with the topic and its scholarly context
• Develop a theoretical framework and methodology for your research
• Position your work in relation to other researchers and theorists
• Show how your research addresses a gap or contributes to a debate
• Evaluate the current state of research and demonstrate your knowledge of the scholarly debates around your topic.

Writing literature reviews is a particularly important skill if you want to apply for graduate school or pursue a career in research. We’ve written a step-by-step guide that you can follow below.

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Writing literature reviews can be quite challenging! A good starting point could be to look at some examples, depending on what kind of literature review you’d like to write.

• Example literature review #1: “Why Do People Migrate? A Review of the Theoretical Literature” ( Theoretical literature review about the development of economic migration theory from the 1950s to today.)
• Example literature review #2: “Literature review as a research methodology: An overview and guidelines” ( Methodological literature review about interdisciplinary knowledge acquisition and production.)
• Example literature review #3: “The Use of Technology in English Language Learning: A Literature Review” ( Thematic literature review about the effects of technology on language acquisition.)
• Example literature review #4: “Learners’ Listening Comprehension Difficulties in English Language Learning: A Literature Review” ( Chronological literature review about how the concept of listening skills has changed over time.)

You can also check out our templates with literature review examples and sample outlines at the links below.

Download Word doc Download Google doc

Before you begin searching for literature, you need a clearly defined topic .

If you are writing the literature review section of a dissertation or research paper, you will search for literature related to your research problem and questions .

Make a list of keywords

Start by creating a list of keywords related to your research question. Include each of the key concepts or variables you’re interested in, and list any synonyms and related terms. You can add to this list as you discover new keywords in the process of your literature search.

• Social media, Facebook, Instagram, Twitter, Snapchat, TikTok
• Body image, self-perception, self-esteem, mental health
• Generation Z, teenagers, adolescents, youth

Search for relevant sources

Use your keywords to begin searching for sources. Some useful databases to search for journals and articles include:

• Your university’s library catalogue
• Google Scholar
• Project Muse (humanities and social sciences)
• Medline (life sciences and biomedicine)
• EconLit (economics)
• Inspec (physics, engineering and computer science)

You can also use boolean operators to help narrow down your search.

Make sure to read the abstract to find out whether an article is relevant to your question. When you find a useful book or article, you can check the bibliography to find other relevant sources.

You likely won’t be able to read absolutely everything that has been written on your topic, so it will be necessary to evaluate which sources are most relevant to your research question.

For each publication, ask yourself:

• What question or problem is the author addressing?
• What are the key concepts and how are they defined?
• What are the key theories, models, and methods?
• Does the research use established frameworks or take an innovative approach?
• What are the results and conclusions of the study?
• How does the publication relate to other literature in the field? Does it confirm, add to, or challenge established knowledge?
• What are the strengths and weaknesses of the research?

Make sure the sources you use are credible , and make sure you read any landmark studies and major theories in your field of research.

You can use our template to summarize and evaluate sources you’re thinking about using. Click on either button below to download.

Take notes and cite your sources

As you read, you should also begin the writing process. Take notes that you can later incorporate into the text of your literature review.

It is important to keep track of your sources with citations to avoid plagiarism . It can be helpful to make an annotated bibliography , where you compile full citation information and write a paragraph of summary and analysis for each source. This helps you remember what you read and saves time later in the process.

Receive feedback on language, structure, and formatting

Professional editors proofread and edit your paper by focusing on:

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To begin organizing your literature review’s argument and structure, be sure you understand the connections and relationships between the sources you’ve read. Based on your reading and notes, you can look for:

• Trends and patterns (in theory, method or results): do certain approaches become more or less popular over time?
• Themes: what questions or concepts recur across the literature?
• Debates, conflicts and contradictions: where do sources disagree?
• Pivotal publications: are there any influential theories or studies that changed the direction of the field?
• Gaps: what is missing from the literature? Are there weaknesses that need to be addressed?

This step will help you work out the structure of your literature review and (if applicable) show how your own research will contribute to existing knowledge.

• Most research has focused on young women.
• There is an increasing interest in the visual aspects of social media.
• But there is still a lack of robust research on highly visual platforms like Instagram and Snapchat—this is a gap that you could address in your own research.

There are various approaches to organizing the body of a literature review. Depending on the length of your literature review, you can combine several of these strategies (for example, your overall structure might be thematic, but each theme is discussed chronologically).

Chronological

The simplest approach is to trace the development of the topic over time. However, if you choose this strategy, be careful to avoid simply listing and summarizing sources in order.

Try to analyze patterns, turning points and key debates that have shaped the direction of the field. Give your interpretation of how and why certain developments occurred.

If you have found some recurring central themes, you can organize your literature review into subsections that address different aspects of the topic.

For example, if you are reviewing literature about inequalities in migrant health outcomes, key themes might include healthcare policy, language barriers, cultural attitudes, legal status, and economic access.

Methodological

If you draw your sources from different disciplines or fields that use a variety of research methods , you might want to compare the results and conclusions that emerge from different approaches. For example:

• Look at what results have emerged in qualitative versus quantitative research
• Discuss how the topic has been approached by empirical versus theoretical scholarship
• Divide the literature into sociological, historical, and cultural sources

Theoretical

A literature review is often the foundation for a theoretical framework . You can use it to discuss various theories, models, and definitions of key concepts.

You might argue for the relevance of a specific theoretical approach, or combine various theoretical concepts to create a framework for your research.

Like any other academic text , your literature review should have an introduction , a main body, and a conclusion . What you include in each depends on the objective of your literature review.

The introduction should clearly establish the focus and purpose of the literature review.

Depending on the length of your literature review, you might want to divide the body into subsections. You can use a subheading for each theme, time period, or methodological approach.

As you write, you can follow these tips:

• Summarize and synthesize: give an overview of the main points of each source and combine them into a coherent whole
• Analyze and interpret: don’t just paraphrase other researchers — add your own interpretations where possible, discussing the significance of findings in relation to the literature as a whole
• Critically evaluate: mention the strengths and weaknesses of your sources
• Write in well-structured paragraphs: use transition words and topic sentences to draw connections, comparisons and contrasts

In the conclusion, you should summarize the key findings you have taken from the literature and emphasize their significance.

When you’ve finished writing and revising your literature review, don’t forget to proofread thoroughly before submitting. Not a language expert? Check out Scribbr’s professional proofreading services !

This article has been adapted into lecture slides that you can use to teach your students about writing a literature review.

Scribbr slides are free to use, customize, and distribute for educational purposes.

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If you want to know more about the research process , methodology , research bias , or statistics , make sure to check out some of our other articles with explanations and examples.

• Sampling methods
• Simple random sampling
• Stratified sampling
• Cluster sampling
• Likert scales
• Reproducibility

 Statistics

• Null hypothesis
• Statistical power
• Probability distribution
• Effect size
• Poisson distribution

Research bias

• Optimism bias
• Cognitive bias
• Implicit bias
• Hawthorne effect
• Anchoring bias
• Explicit bias

A literature review is a survey of scholarly sources (such as books, journal articles, and theses) related to a specific topic or research question .

It is often written as part of a thesis, dissertation , or research paper , in order to situate your work in relation to existing knowledge.

There are several reasons to conduct a literature review at the beginning of a research project:

• To familiarize yourself with the current state of knowledge on your topic
• To ensure that you’re not just repeating what others have already done
• To identify gaps in knowledge and unresolved problems that your research can address
• To develop your theoretical framework and methodology
• To provide an overview of the key findings and debates on the topic

Writing the literature review shows your reader how your work relates to existing research and what new insights it will contribute.

The literature review usually comes near the beginning of your thesis or dissertation . After the introduction , it grounds your research in a scholarly field and leads directly to your theoretical framework or methodology .

A literature review is a survey of credible sources on a topic, often used in dissertations , theses, and research papers . Literature reviews give an overview of knowledge on a subject, helping you identify relevant theories and methods, as well as gaps in existing research. Literature reviews are set up similarly to other  academic texts , with an introduction , a main body, and a conclusion .

An  annotated bibliography is a list of  source references that has a short description (called an annotation ) for each of the sources. It is often assigned as part of the research process for a  paper .  

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How to Write an Article Review: Tips and Examples

Did you know that article reviews are not just academic exercises but also a valuable skill in today's information age? In a world inundated with content, being able to dissect and evaluate articles critically can help you separate the wheat from the chaff. Whether you're a student aiming to excel in your coursework or a professional looking to stay well-informed, mastering the art of writing article reviews is an invaluable skill.

Short Description

In this article, our research paper writing service experts will start by unraveling the concept of article reviews and discussing the various types. You'll also gain insights into the art of formatting your review effectively. To ensure you're well-prepared, we'll take you through the pre-writing process, offering tips on setting the stage for your review. But it doesn't stop there. You'll find a practical example of an article review to help you grasp the concepts in action. To complete your journey, we'll guide you through the post-writing process, equipping you with essential proofreading techniques to ensure your work shines with clarity and precision!

What Is an Article Review: Grasping the Concept 

A review article is a type of professional paper writing that demands a high level of in-depth analysis and a well-structured presentation of arguments. It is a critical, constructive evaluation of literature in a particular field through summary, classification, analysis, and comparison.

If you write a scientific review, you have to use database searches to portray the research. Your primary goal is to summarize everything and present a clear understanding of the topic you've been working on.

Writing Involves:

• Summarization, classification, analysis, critiques, and comparison.
• The analysis, evaluation, and comparison require the use of theories, ideas, and research relevant to the subject area of the article.
• It is also worth nothing if a review does not introduce new information, but instead presents a response to another writer's work.
• Check out other samples to gain a better understanding of how to review the article.

Types of Review

When it comes to article reviews, there's more than one way to approach the task. Understanding the various types of reviews is like having a versatile toolkit at your disposal. In this section, we'll walk you through the different dimensions of review types, each offering a unique perspective and purpose. Whether you're dissecting a scholarly article, critiquing a piece of literature, or evaluating a product, you'll discover the diverse landscape of article reviews and how to navigate it effectively.

Journal Article Review

Just like other types of reviews, a journal article review assesses the merits and shortcomings of a published work. To illustrate, consider a review of an academic paper on climate change, where the writer meticulously analyzes and interprets the article's significance within the context of environmental science.

Research Article Review

Distinguished by its focus on research methodologies, a research article review scrutinizes the techniques used in a study and evaluates them in light of the subsequent analysis and critique. For instance, when reviewing a research article on the effects of a new drug, the reviewer would delve into the methods employed to gather data and assess their reliability.

Science Article Review

In the realm of scientific literature, a science article review encompasses a wide array of subjects. Scientific publications often provide extensive background information, which can be instrumental in conducting a comprehensive analysis. For example, when reviewing an article about the latest breakthroughs in genetics, the reviewer may draw upon the background knowledge provided to facilitate a more in-depth evaluation of the publication.

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Formatting an Article Review

The format of the article should always adhere to the citation style required by your professor. If you're not sure, seek clarification on the preferred format and ask him to clarify several other pointers to complete the formatting of an article review adequately.

How Many Publications Should You Review?

• In what format should you cite your articles (MLA, APA, ASA, Chicago, etc.)?
• What length should your review be?
• Should you include a summary, critique, or personal opinion in your assignment?
• Do you need to call attention to a theme or central idea within the articles?
• Does your instructor require background information?

When you know the answers to these questions, you may start writing your assignment. Below are examples of MLA and APA formats, as those are the two most common citation styles.

Using the APA Format

Articles appear most commonly in academic journals, newspapers, and websites. If you write an article review in the APA format, you will need to write bibliographical entries for the sources you use:

• Web : Author [last name], A.A [first and middle initial]. (Year, Month, Date of Publication). Title. Retrieved from {link}
• Journal : Author [last name], A.A [first and middle initial]. (Publication Year). Publication Title. Periodical Title, Volume(Issue), pp.-pp.
• Newspaper : Author [last name], A.A [first and middle initial]. (Year, Month, Date of Publication). Publication Title. Magazine Title, pp. xx-xx.

Using MLA Format

• Web : Last, First Middle Initial. “Publication Title.” Website Title. Website Publisher, Date Month Year Published. Web. Date Month Year Accessed.
• Newspaper : Last, First M. “Publication Title.” Newspaper Title [City] Date, Month, Year Published: Page(s). Print.
• Journal : Last, First M. “Publication Title.” Journal Title Series Volume. Issue (Year Published): Page(s). Database Name. Web. Date Month Year Accessed.

Enhance your writing effortlessly with EssayPro.com , where you can order an article review or any other writing task. Our team of expert writers specializes in various fields, ensuring your work is not just summarized, but deeply analyzed and professionally presented. Ideal for students and professionals alike, EssayPro offers top-notch writing assistance tailored to your needs. Elevate your writing today with our skilled team at your article review writing service !

The Pre-Writing Process

Facing this task for the first time can really get confusing and can leave you unsure of where to begin. To create a top-notch article review, start with a few preparatory steps. Here are the two main stages from our dissertation services to get you started:

Step 1: Define the right organization for your review. Knowing the future setup of your paper will help you define how you should read the article. Here are the steps to follow:

• Summarize the article — seek out the main points, ideas, claims, and general information presented in the article.
• Define the positive points — identify the strong aspects, ideas, and insightful observations the author has made.
• Find the gaps —- determine whether or not the author has any contradictions, gaps, or inconsistencies in the article and evaluate whether or not he or she used a sufficient amount of arguments and information to support his or her ideas.
• Identify unanswered questions — finally, identify if there are any questions left unanswered after reading the piece.

Step 2: Move on and review the article. Here is a small and simple guide to help you do it right:

• Start off by looking at and assessing the title of the piece, its abstract, introductory part, headings and subheadings, opening sentences in its paragraphs, and its conclusion.
• First, read only the beginning and the ending of the piece (introduction and conclusion). These are the parts where authors include all of their key arguments and points. Therefore, if you start with reading these parts, it will give you a good sense of the author's main points.
• Finally, read the article fully.

These three steps make up most of the prewriting process. After you are done with them, you can move on to writing your own review—and we are going to guide you through the writing process as well.

Outline and Template

As you progress with reading your article, organize your thoughts into coherent sections in an outline. As you read, jot down important facts, contributions, or contradictions. Identify the shortcomings and strengths of your publication. Begin to map your outline accordingly.

If your professor does not want a summary section or a personal critique section, then you must alleviate those parts from your writing. Much like other assignments, an article review must contain an introduction, a body, and a conclusion. Thus, you might consider dividing your outline according to these sections as well as subheadings within the body. If you find yourself troubled with the pre-writing and the brainstorming process for this assignment, seek out a sample outline.

Your custom essay must contain these constituent parts:

• Pre-Title Page - Before diving into your review, start with essential details: article type, publication title, and author names with affiliations (position, department, institution, location, and email). Include corresponding author info if needed.
• Running Head - In APA format, use a concise title (under 40 characters) to ensure consistent formatting.
• Summary Page - Optional but useful. Summarize the article in 800 words, covering background, purpose, results, and methodology, avoiding verbatim text or references.
• Title Page - Include the full title, a 250-word abstract, and 4-6 keywords for discoverability.
• Introduction - Set the stage with an engaging overview of the article.
• Body - Organize your analysis with headings and subheadings.
• Works Cited/References - Properly cite all sources used in your review.
• Optional Suggested Reading Page - If permitted, suggest further readings for in-depth exploration.
• Tables and Figure Legends (if instructed by the professor) - Include visuals when requested by your professor for clarity.

Example of an Article Review

You might wonder why we've dedicated a section of this article to discuss an article review sample. Not everyone may realize it, but examining multiple well-constructed examples of review articles is a crucial step in the writing process. In the following section, our essay writing service experts will explain why.

Looking through relevant article review examples can be beneficial for you in the following ways:

• To get you introduced to the key works of experts in your field.
• To help you identify the key people engaged in a particular field of science.
• To help you define what significant discoveries and advances were made in your field.
• To help you unveil the major gaps within the existing knowledge of your field—which contributes to finding fresh solutions.
• To help you find solid references and arguments for your own review.
• To help you generate some ideas about any further field of research.
• To help you gain a better understanding of the area and become an expert in this specific field.
• To get a clear idea of how to write a good review.

View Our Writer’s Sample Before Crafting Your Own!

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Steps for Writing an Article Review

Here is a guide with critique paper format on how to write a review paper:

Step 1: Write the Title

First of all, you need to write a title that reflects the main focus of your work. Respectively, the title can be either interrogative, descriptive, or declarative.

Step 2: Cite the Article

Next, create a proper citation for the reviewed article and input it following the title. At this step, the most important thing to keep in mind is the style of citation specified by your instructor in the requirements for the paper. For example, an article citation in the MLA style should look as follows:

Author's last and first name. "The title of the article." Journal's title and issue(publication date): page(s). Print

Abraham John. "The World of Dreams." Virginia Quarterly 60.2(1991): 125-67. Print.

Step 3: Article Identification

After your citation, you need to include the identification of your reviewed article:

• Title of the article
• Title of the journal
• Year of publication

All of this information should be included in the first paragraph of your paper.

The report "Poverty increases school drop-outs" was written by Brian Faith – a Health officer – in 2000.

Step 4: Introduction

Your organization in an assignment like this is of the utmost importance. Before embarking on your writing process, you should outline your assignment or use an article review template to organize your thoughts coherently.

• If you are wondering how to start an article review, begin with an introduction that mentions the article and your thesis for the review.
• Follow up with a summary of the main points of the article.
• Highlight the positive aspects and facts presented in the publication.
• Critique the publication by identifying gaps, contradictions, disparities in the text, and unanswered questions.

Step 5: Summarize the Article

Make a summary of the article by revisiting what the author has written about. Note any relevant facts and findings from the article. Include the author's conclusions in this section.

Step 6: Critique It

Present the strengths and weaknesses you have found in the publication. Highlight the knowledge that the author has contributed to the field. Also, write about any gaps and/or contradictions you have found in the article. Take a standpoint of either supporting or not supporting the author's assertions, but back up your arguments with facts and relevant theories that are pertinent to that area of knowledge. Rubrics and templates can also be used to evaluate and grade the person who wrote the article.

Step 7: Craft a Conclusion

In this section, revisit the critical points of your piece, your findings in the article, and your critique. Also, write about the accuracy, validity, and relevance of the results of the article review. Present a way forward for future research in the field of study. Before submitting your article, keep these pointers in mind:

• As you read the article, highlight the key points. This will help you pinpoint the article's main argument and the evidence that they used to support that argument.
• While you write your review, use evidence from your sources to make a point. This is best done using direct quotations.
• Select quotes and supporting evidence adequately and use direct quotations sparingly. Take time to analyze the article adequately.
• Every time you reference a publication or use a direct quotation, use a parenthetical citation to avoid accidentally plagiarizing your article.
• Re-read your piece a day after you finish writing it. This will help you to spot grammar mistakes and to notice any flaws in your organization.
• Use a spell-checker and get a second opinion on your paper.

The Post-Writing Process: Proofread Your Work

Finally, when all of the parts of your article review are set and ready, you have one last thing to take care of — proofreading. Although students often neglect this step, proofreading is a vital part of the writing process and will help you polish your paper to ensure that there are no mistakes or inconsistencies.

To proofread your paper properly, start by reading it fully and checking the following points:

• Punctuation
• Other mistakes

Afterward, take a moment to check for any unnecessary information in your paper and, if found, consider removing it to streamline your content. Finally, double-check that you've covered at least 3-4 key points in your discussion.

And remember, if you ever need help with proofreading, rewriting your essay, or even want to buy essay , our friendly team is always here to assist you.

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What Is A Review Article?

How to write an article review, how to write an article review in apa format, related articles.

How to write a good scientific review article

Affiliation.

• 1 The FEBS Journal Editorial Office, Cambridge, UK.
• PMID: 35792782
• DOI: 10.1111/febs.16565

Literature reviews are valuable resources for the scientific community. With research accelerating at an unprecedented speed in recent years and more and more original papers being published, review articles have become increasingly important as a means to keep up to date with developments in a particular area of research. A good review article provides readers with an in-depth understanding of a field and highlights key gaps and challenges to address with future research. Writing a review article also helps to expand the writer's knowledge of their specialist area and to develop their analytical and communication skills, amongst other benefits. Thus, the importance of building review-writing into a scientific career cannot be overstated. In this instalment of The FEBS Journal's Words of Advice series, I provide detailed guidance on planning and writing an informative and engaging literature review.

© 2022 Federation of European Biochemical Societies.

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A Step-by-Step Guide to Writing a Scientific Review Article

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Manisha Bahl, A Step-by-Step Guide to Writing a Scientific Review Article, Journal of Breast Imaging , Volume 5, Issue 4, July/August 2023, Pages 480–485, https://doi.org/10.1093/jbi/wbad028

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Scientific review articles are comprehensive, focused reviews of the scientific literature written by subject matter experts. The task of writing a scientific review article can seem overwhelming; however, it can be managed by using an organized approach and devoting sufficient time to the process. The process involves selecting a topic about which the authors are knowledgeable and enthusiastic, conducting a literature search and critical analysis of the literature, and writing the article, which is composed of an abstract, introduction, body, and conclusion, with accompanying tables and figures. This article, which focuses on the narrative or traditional literature review, is intended to serve as a guide with practical steps for new writers. Tips for success are also discussed, including selecting a focused topic, maintaining objectivity and balance while writing, avoiding tedious data presentation in a laundry list format, moving from descriptions of the literature to critical analysis, avoiding simplistic conclusions, and budgeting time for the overall process.

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• Research Process

Writing a good review article

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Table of Contents

As a young researcher, you might wonder how to start writing your first review article, and the extent of the information that it should contain. A review article is a comprehensive summary of the current understanding of a specific research topic and is based on previously published research. Unlike research papers, it does not contain new results, but can propose new inferences based on the combined findings of previous research.

Types of review articles

Review articles are typically of three types: literature reviews, systematic reviews, and meta-analyses.

A literature review is a general survey of the research topic and aims to provide a reliable and unbiased account of the current understanding of the topic.

A systematic review , in contrast, is more specific and attempts to address a highly focused research question. Its presentation is more detailed, with information on the search strategy used, the eligibility criteria for inclusion of studies, the methods utilized to review the collected information, and more.

A meta-analysis is similar to a systematic review in that both are systematically conducted with a properly defined research question. However, unlike the latter, a meta-analysis compares and evaluates a defined number of similar studies. It is quantitative in nature and can help assess contrasting study findings.

Tips for writing a good review article

Here are a few practices that can make the time-consuming process of writing a review article easier:

• Define your question: Take your time to identify the research question and carefully articulate the topic of your review paper. A good review should also add something new to the field in terms of a hypothesis, inference, or conclusion. A carefully defined scientific question will give you more clarity in determining the novelty of your inferences.
• Identify credible sources: Identify relevant as well as credible studies that you can base your review on, with the help of multiple databases or search engines. It is also a good idea to conduct another search once you have finished your article to avoid missing relevant studies published during the course of your writing.
• Take notes: A literature search involves extensive reading, which can make it difficult to recall relevant information subsequently. Therefore, make notes while conducting the literature search and note down the source references. This will ensure that you have sufficient information to start with when you finally get to writing.
• Describe the title, abstract, and introduction: A good starting point to begin structuring your review is by drafting the title, abstract, and introduction. Explicitly writing down what your review aims to address in the field will help shape the rest of your article.
• Be unbiased and critical: Evaluate every piece of evidence in a critical but unbiased manner. This will help you present a proper assessment and a critical discussion in your article.
• Include a good summary: End by stating the take-home message and identify the limitations of existing studies that need to be addressed through future studies.
• Ask for feedback: Ask a colleague to provide feedback on both the content and the language or tone of your article before you submit it.
• Check your journal’s guidelines: Some journals only publish reviews, while some only publish research articles. Further, all journals clearly indicate their aims and scope. Therefore, make sure to check the appropriateness of a journal before submitting your article.

Writing review articles, especially systematic reviews or meta-analyses, can seem like a daunting task. However, Elsevier Author Services can guide you by providing useful tips on how to write an impressive review article that stands out and gets published!

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How to Write an Article Review: Template & Examples

An article review is an academic assignment that invites you to study a piece of academic research closely. Then, you should present its summary and critically evaluate it using the knowledge you’ve gained in class and during your independent study. If you get such a task at college or university, you shouldn’t confuse it with a response paper, which is a distinct assignment with other purposes (we’ll talk about it in detail below).

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In this article, prepared by Custom-Writing experts, you’ll find: 

• the intricacies of article review writing;
• the difference between an article review and similar assignments;
• a step-by-step algorithm for review composition;
• a couple of samples to guide you throughout the writing process.

So, if you wish to study our article review example and discover helpful writing tips, keep reading.

❓ What Is an Article Review?

• ✍️ Writing Steps

📑 Article Review Format

🔗 references.

An article review is an academic paper that summarizes and critically evaluates the information presented in your selected article. 

The first thing you should note when approaching the task of an article review is that not every article is suitable for this assignment. Let’s have a look at the variety of articles to understand what you can choose from.

Popular Vs. Scholarly Articles

In most cases, you’ll be required to review a scholarly, peer-reviewed article – one composed in compliance with rigorous academic standards. Yet, the Web is also full of popular articles that don’t present original scientific value and shouldn’t be selected for a review.  

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Not sure how to distinguish these two types? Here is a comparative table to help you out.

Article Review vs. Response Paper

Now, let’s consider the difference between an article review and a response paper:

• If you’re assigned to critique a scholarly article , you will need to compose an article review .  
• If your subject of analysis is a popular article , you can respond to it with a well-crafted response paper .  

The reason for such distinctions is the quality and structure of these two article types. Peer-reviewed, scholarly articles have clear-cut quality criteria, allowing you to conduct and present a structured assessment of the assigned material. Popular magazines have loose or non-existent quality criteria and don’t offer an opportunity for structured evaluation. So, they are only fit for a subjective response, in which you can summarize your reactions and emotions related to the reading material.  

All in all, you can structure your response assignments as outlined in the tips below.

✍️ How to Write an Article Review: Step by Step

Here is a tried and tested algorithm for article review writing from our experts. We’ll consider only the critical review variety of this academic assignment. So, let’s get down to the stages you need to cover to get a stellar review.  

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Read the Article

As with any reviews, reports, and critiques, you must first familiarize yourself with the assigned material. It’s impossible to review something you haven’t read, so set some time for close, careful reading of the article to identify:

• Its topic.  
• Its type.  
• The author’s main points and message. 
• The arguments they use to prove their points. 
• The methodology they use to approach the subject. 

In terms of research type , your article will usually belong to one of three types explained below. 

Summarize the Article

Now that you’ve read the text and have a general impression of the content, it’s time to summarize it for your readers. Look into the article’s text closely to determine:

• The thesis statement , or general message of the author.  
• Research question, purpose, and context of research.  
• Supporting points for the author’s assumptions and claims.  
• Major findings and supporting evidence.  

As you study the article thoroughly, make notes on the margins or write these elements out on a sheet of paper. You can also apply a different technique: read the text section by section and formulate its gist in one phrase or sentence. Once you’re done, you’ll have a summary skeleton in front of you.

Evaluate the Article

The next step of review is content evaluation. Keep in mind that various research types will require a different set of review questions. Here is a complete list of evaluation points you can include.

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Write the Text

After completing the critical review stage, it’s time to compose your article review.

The format of this assignment is standard – you will have an introduction, a body, and a conclusion. The introduction should present your article and summarize its content. The body will contain a structured review according to all four dimensions covered in the previous section. The concluding part will typically recap all the main points you’ve identified during your assessment.  

It is essential to note that an article review is, first of all, an academic assignment. Therefore, it should follow all rules and conventions of academic composition, such as:

• No contractions . Don’t use short forms, such as “don’t,” “can’t,” “I’ll,” etc. in academic writing. You need to spell out all those words.  
• Formal language and style . Avoid conversational phrasing and words that you would naturally use in blog posts or informal communication. For example, don’t use words like “pretty,” “kind of,” and “like.”  
• Third-person narrative . Academic reviews should be written from the third-person point of view, avoiding statements like “I think,” “in my opinion,” and so on.  
• No conversational forms . You shouldn’t turn to your readers directly in the text by addressing them with the pronoun “you.” It’s vital to keep the narrative neutral and impersonal.  
• Proper abbreviation use . Consult the list of correct abbreviations , like “e.g.” or “i.e.,” for use in your academic writing. If you use informal abbreviations like “FYA” or “f.i.,” your professor will reduce the grade.  
• Complete sentences . Make sure your sentences contain the subject and the predicate; avoid shortened or sketch-form phrases suitable for a draft only.  
• No conjunctions at the beginning of a sentence . Remember the FANBOYS rule – don’t start a sentence with words like “and” or “but.” They often seem the right way to build a coherent narrative, but academic writing rules disfavor such usage.  
• No abbreviations or figures at the beginning of a sentence . Never start a sentence with a number — spell it out if you need to use it anyway. Besides, sentences should never begin with abbreviations like “e.g.”  

Finally, a vital rule for an article review is properly formatting the citations. We’ll discuss the correct use of citation styles in the following section.

When composing an article review, keep these points in mind:

• Start with a full reference to the reviewed article so the reader can locate it quickly.  
• Ensure correct formatting of in-text references.  
• Provide a complete list of used external sources on the last page of the review – your bibliographical entries .  

You’ll need to understand the rules of your chosen citation style to meet all these requirements. Below, we’ll discuss the two most common referencing styles – APA and MLA.

Article Review in APA

When you need to compose an article review in the APA format , here is the general bibliographical entry format you should use for journal articles on your reference page:  

• Author’s last name, First initial. Middle initial. (Year of Publication). Name of the article. Name of the Journal, volume (number), pp. #-#. https://doi.org/xx.xxx/yyyy

Horigian, V. E., Schmidt, R. D., & Feaster, D. J. (2021). Loneliness, mental health, and substance use among US young adults during COVID-19. Journal of Psychoactive Drugs, 53 (1), pp. 1-9. https://doi.org/10.1080/02791072.2020.1836435

Your in-text citations should follow the author-date format like this:

• If you paraphrase the source and mention the author in the text: According to Horigian et al. (2021), young adults experienced increased levels of loneliness, depression, and anxiety during the pandemic. 
• If you paraphrase the source and don’t mention the author in the text: Young adults experienced increased levels of loneliness, depression, and anxiety during the pandemic (Horigian et al., 2021). 
• If you quote the source: As Horigian et al. (2021) point out, there were “elevated levels of loneliness, depression, anxiety, alcohol use, and drug use among young adults during COVID-19” (p. 6). 

Note that your in-text citations should include “et al.,” as in the examples above, if your article has 3 or more authors. If you have one or two authors, your in-text citations would look like this:

• One author: “According to Smith (2020), depression is…” or “Depression is … (Smith, 2020).”
• Two authors: “According to Smith and Brown (2020), anxiety means…” or “Anxiety means (Smith & Brown, 2020).”

Finally, in case you have to review a book or a website article, here are the general formats for citing these source types on your APA reference list.

Article Review in MLA

If your assignment requires MLA-format referencing, here’s the general format you should use for citing journal articles on your Works Cited page: 

• Author’s last name, First name. “Title of an Article.” Title of the Journal , vol. #, no. #, year, pp. #-#. 

Horigian, Viviana E., et al. “Loneliness, Mental Health, and Substance Use Among US Young Adults During COVID-19.” Journal of Psychoactive Drugs , vol. 53, no. 1, 2021, pp. 1-9.

In-text citations in the MLA format follow the author-page citation format and look like this:

• According to Horigian et al., young adults experienced increased levels of loneliness, depression, and anxiety during the pandemic (6).
• Young adults experienced increased levels of loneliness, depression, and anxiety during the pandemic (Horigian et al. 6).

Like in APA, the abbreviation “et al.” is only needed in MLA if your article has 3 or more authors.

If you need to cite a book or a website page, here are the general MLA formats for these types of sources.

✅ Article Review Template

Here is a handy, universal article review template to help you move on with any review assignment. We’ve tried to make it as generic as possible to guide you in the academic process.

📝 Article Review Examples

The theory is good, but practice is even better. Thus, we’ve created three brief examples to show you how to write an article review. You can study the full-text samples by following the links.

📃 Men, Women, & Money   

This article review examines a famous piece, “Men, Women & Money – How the Sexes Differ with Their Finances,” published by Amy Livingston in 2020. The author of this article claims that men generally spend more money than women. She makes this conclusion from a close analysis of gender-specific expenditures across five main categories: food, clothing, cars, entertainment, and general spending patterns. Livingston also looks at men’s approach to saving to argue that counter to the common perception of women’s light-hearted attitude to money, men are those who spend more on average.  

📃 When and Why Nationalism Beats Globalism   

This is a review of Jonathan Heidt’s 2016 article titled “When and Why Nationalism Beats Globalism,” written as an advocacy of right-wing populism rising in many Western states. The author illustrates the case with the election of Donald Trump as the US President and the rise of right-wing rhetoric in many Western countries. These examples show how nationalist sentiment represents a reaction to global immigration and a failure of globalization.  

📃 Sleep Deprivation   

This is a review of the American Heart Association’s article titled “The Dangers of Sleep Deprivation.” It discusses how the national organization concerned with the American population’s cardiovascular health links the lack of high-quality sleep to far-reaching health consequences. The organization’s experts reveal how a consistent lack of sleep leads to Alzheimer’s disease development, obesity, type 2 diabetes, etc.  

✏️ Article Review FAQ

A high-quality article review should summarize the assigned article’s content and offer data-backed reactions and evaluations of its quality in terms of the article’s purpose, methodology, and data used to argue the main points. It should be detailed, comprehensive, objective, and evidence-based.

The purpose of writing a review is to allow students to reflect on research quality and showcase their critical thinking and evaluation skills. Students should exhibit their mastery of close reading of research publications and their unbiased assessment.

The content of your article review will be the same in any format, with the only difference in the assignment’s formatting before submission. Ensure you have a separate title page made according to APA standards and cite sources using the parenthetical author-date referencing format.

You need to take a closer look at various dimensions of an assigned article to compose a valuable review. Study the author’s object of analysis, the purpose of their research, the chosen method, data, and findings. Evaluate all these dimensions critically to see whether the author has achieved the initial goals. Finally, offer improvement recommendations to add a critique aspect to your paper.

• Scientific Article Review: Duke University  
• Book and Article Reviews: William & Mary, Writing Resources Center  
• Sample Format for Reviewing a Journal Article: Boonshoft School of Medicine  
• Research Paper Review – Structure and Format Guidelines: New Jersey Institute of Technology  
• Article Review: University of Waterloo  
• Article Review: University of South Australia  
• How to Write a Journal Article Review: University of Newcastle Library Guides  
• Writing Help: The Article Review: Central Michigan University Libraries  
• Write a Critical Review of a Scientific Journal Article: McLaughlin Library  
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How to Review a Journal Article

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For many kinds of assignments, like a  literature review , you may be asked to offer a critique or review of a journal article. This is an opportunity for you as a scholar to offer your  qualified opinion  and  evaluation  of how another scholar has composed their article, argument, and research. That means you will be expected to go beyond a simple  summary  of the article and evaluate it on a deeper level. As a college student, this might sound intimidating. However, as you engage with the research process, you are becoming immersed in a particular topic, and your insights about the way that topic is presented are valuable and can contribute to the overall conversation surrounding your topic.

IMPORTANT NOTE!!

Some disciplines, like Criminal Justice, may only want you to summarize the article without including your opinion or evaluation. If your assignment is to summarize the article only, please see our literature review handout.

Before getting started on the critique, it is important to review the article thoroughly and critically. To do this, we recommend take notes,  annotating , and reading the article several times before critiquing. As you read, be sure to note important items like the thesis, purpose, research questions, hypotheses, methods, evidence, key findings, major conclusions, tone, and publication information. Depending on your writing context, some of these items may not be applicable.

Questions to Consider

To evaluate a source, consider some of the following questions. They are broken down into different categories, but answering these questions will help you consider what areas to examine. With each category, we recommend identifying the strengths and weaknesses in each since that is a critical part of evaluation.

Evaluating Purpose and Argument

• How well is the purpose made clear in the introduction through background/context and thesis?
• How well does the abstract represent and summarize the article’s major points and argument?
• How well does the objective of the experiment or of the observation fill a need for the field?
• How well is the argument/purpose articulated and discussed throughout the body of the text?
• How well does the discussion maintain cohesion?

Evaluating the Presentation/Organization of Information

• How appropriate and clear is the title of the article?
• Where could the author have benefited from expanding, condensing, or omitting ideas?
• How clear are the author’s statements? Challenge ambiguous statements.
• What underlying assumptions does the author have, and how does this affect the credibility or clarity of their article?
• How objective is the author in his or her discussion of the topic?
• How well does the organization fit the article’s purpose and articulate key goals?

Evaluating Methods

• How appropriate are the study design and methods for the purposes of the study?
• How detailed are the methods being described? Is the author leaving out important steps or considerations?
• Have the procedures been presented in enough detail to enable the reader to duplicate them?

Evaluating Data

• Scan and spot-check calculations. Are the statistical methods appropriate?
• Do you find any content repeated or duplicated?
• How many errors of fact and interpretation does the author include? (You can check on this by looking up the references the author cites).
• What pertinent literature has the author cited, and have they used this literature appropriately?

Following, we have an example of a summary and an evaluation of a research article. Note that in most literature review contexts, the summary and evaluation would be much shorter. This extended example shows the different ways a student can critique and write about an article.

Chik, A. (2012). Digital gameplay for autonomous foreign language learning: Gamers’ and language teachers’ perspectives. In H. Reinders (ed.),  Digital games in language learning and teaching  (pp. 95-114). Eastbourne, UK: Palgrave Macmillan.

Be sure to include the full citation either in a reference page or near your evaluation if writing an  annotated bibliography .

In Chik’s article “Digital Gameplay for Autonomous Foreign Language Learning: Gamers’ and Teachers’ Perspectives”, she explores the ways in which “digital gamers manage gaming and gaming-related activities to assume autonomy in their foreign language learning,” (96) which is presented in contrast to how teachers view the “pedagogical potential” of gaming. The research was described as an “umbrella project” consisting of two parts. The first part examined 34 language teachers’ perspectives who had limited experience with gaming (only five stated they played games regularly) (99). Their data was recorded through a survey, class discussion, and a seven-day gaming trial done by six teachers who recorded their reflections through personal blog posts. The second part explored undergraduate gaming habits of ten Hong Kong students who were regular gamers. Their habits were recorded through language learning histories, videotaped gaming sessions, blog entries of gaming practices, group discussion sessions, stimulated recall sessions on gaming videos, interviews with other gamers, and posts from online discussion forums. The research shows that while students recognize the educational potential of games and have seen benefits of it in their lives, the instructors overall do not see the positive impacts of gaming on foreign language learning.

The summary includes the article’s purpose, methods, results, discussion, and citations when necessary.

This article did a good job representing the undergraduate gamers’ voices through extended quotes and stories. Particularly for the data collection of the undergraduate gamers, there were many opportunities for an in-depth examination of their gaming practices and histories. However, the representation of the teachers in this study was very uneven when compared to the students. Not only were teachers labeled as numbers while the students picked out their own pseudonyms, but also when viewing the data collection, the undergraduate students were more closely examined in comparison to the teachers in the study. While the students have fifteen extended quotes describing their experiences in their research section, the teachers only have two of these instances in their section, which shows just how imbalanced the study is when presenting instructor voices.

Some research methods, like the recorded gaming sessions, were only used with students whereas teachers were only asked to blog about their gaming experiences. This creates a richer narrative for the students while also failing to give instructors the chance to have more nuanced perspectives. This lack of nuance also stems from the emphasis of the non-gamer teachers over the gamer teachers. The non-gamer teachers’ perspectives provide a stark contrast to the undergraduate gamer experiences and fits neatly with the narrative of teachers not valuing gaming as an educational tool. However, the study mentioned five teachers that were regular gamers whose perspectives are left to a short section at the end of the presentation of the teachers’ results. This was an opportunity to give the teacher group a more complex story, and the opportunity was entirely missed.

Additionally, the context of this study was not entirely clear. The instructors were recruited through a master’s level course, but the content of the course and the institution’s background is not discussed. Understanding this context helps us understand the course’s purpose(s) and how those purposes may have influenced the ways in which these teachers interpreted and saw games. It was also unclear how Chik was connected to this masters’ class and to the students. Why these particular teachers and students were recruited was not explicitly defined and also has the potential to skew results in a particular direction.

Overall, I was inclined to agree with the idea that students can benefit from language acquisition through gaming while instructors may not see the instructional value, but I believe the way the research was conducted and portrayed in this article made it very difficult to support Chik’s specific findings.

Some professors like you to begin an evaluation with something positive but isn’t always necessary.

The evaluation is clearly organized and uses transitional phrases when moving to a new topic.

This evaluation includes a summative statement that gives the overall impression of the article at the end, but this can also be placed at the beginning of the evaluation.

This evaluation mainly discusses the representation of data and methods. However, other areas, like organization, are open to critique.

How to Write an Article Review That Stands Out

An article review is a critical assessment of another writer’s  research paper  or scholarly article. Such an activity aims to expand one’s knowledge by evaluating the original author’s research.

Of course, writing an article review could be tricky. But a few expert tips and tricks can get you on the right track. That’s what this interesting blog post is all about. So, ensure you read it till the end to make the most out of it.

Table of Contents

A Step-by-step Guide on How to Write an Article Review

Master the art of writing an article review with this step-by-step guide from professional  paper help  providers. 

Step 1: Select the Right Article

The first step is to pick a suitable article for a review. Choose a scholarly source that’s connected to your area of study. You can look for pieces printed in trustworthy journals or by respected authors.

For Example:

For reviewing an article on climate change, consider selecting one from scientific journals like Nature or Science.

Step 2: Read and Understand the Article

It’s super important to read and understand the article before writing your review. Read the article a few times and jot down the notes as you go. Focus on the main arguments, major points, evidence, and how it’s structured. 

Let’s say you’re looking at an article on how social media affects mental health. Ensure to take note of the following: 

• The number of people involved 
• How the data is analyzed 
• The Results 

Step 3: Structure and Introduction

To start a solid review, start with an introduction that gives readers the background info they need. Must include the article’s title, the author, and where it was published. Also, write a summary of the main point or argument in the article.

“In the article ‘The Impact of Social Media on Mental Health by John Smith, published in the Journal of Psychology: 

The author examines the correlation between excessive social media usage and adolescent mental health disorders.”

Step 4: Summarize the Article

In this part, you’ll need to quickly go over the main points and arguments from the article. Make it short but must cover the most important elements and the evidence that backs them up. Leave your opinions and analysis out of it for now. 

For instance, you could write:

“The author discusses various studies highlighting the negative effects of excessive social media usage on mental health.

Smith’s research reveals a significant correlation between 

Increased social media consumption and higher rates of anxiety, depression, and low self-esteem among teenagers. 

The article also explores the underlying mechanisms, such as social comparison and cyberbullying. All are contributing to the adverse mental health outcomes.”

Step 5: Critically Analyze and Evaluate

Now that you’ve given a rundown of the article, it’s time to take a closer look. Think about what the author did well and what could have been done better. 

Check out the proof they used and if it seems solid. Give a thorough assessment, and use examples from the text to support your thoughts. 

For Example

“While the article presents compelling evidence linking social media usage to mental health issues , it is important to acknowledge some limitations in Smith’s study. 

The sample size of the research was relatively small. It comprises only 100 participants, which may limit the generalizability of the findings. 

Additionally, the study primarily focused on one specific age group, namely adolescents. This way, there’s room for further research on other demographic groups.”

Step 6: Express Your Perspective

Here’s your chance to give your two cents and show off your smarts. Put your spin on the article by pointing out the pros, cons, and other potential improvements. Remember to back up your thoughts with facts and sound arguments.

Continuing with the Previous Example

Despite the limitations, Smith’s research offers valuable insights into the complex relationship between social media and mental health. 

Future studies could expand the sample size and include a more diverse range of age groups. It is better to understand the broader impact of social media on mental well-being. 

Furthermore, exploring strategies for developing digital literacy programs could be potential avenues for future research.

Step 7: Conclusion and Final Thoughts

At the end of your article review, wrap it up with a brief and powerful conclusion. Give a summary of your main points and overall thoughts about the article. 

Point out its importance to the field and the impact of the study. Finish off with a thought-provoking conclusion. Give the reader a sense of finality and emphasize the need for additional research or discussion.

For instance

“In conclusion, John Smith’s article provides valuable insights into the detrimental effects of excessive social media usage on adolescent mental health. 

While the research has limitations, it serves as a starting point for further investigation in this rapidly evolving field. 

By addressing the research gaps and implementing targeted interventions: 

We can strive to promote a healthier relationship between social media and mental well-being in our digitally connected society.”

Step 8: Editing and Proofreading

Before submission, set aside some time for editing and proofreading. 

Ensure everything makes sense and everything is correct. Check out how it reads and if your points come across clearly. Get feedback from other people to get a different point of view and make it even better.

Types of Article Reviews

In college, you might be asked to write different types of review articles, including: 

Narrative Review

This type of review needs you to look into the author’s background and experiences. You have to go through the specialist’s theories and practices and compare them. For the success of a narrative review, ensure that your arguments are qualitative and make sense.

Evidence Review

For a solid evidence paper, you got to put in the work and study the topic. You’ll need to research the facts, analyze the author’s ideas, their effects, and more. 

Systematic Review

This task involves reviewing a bunch of research papers and summarizing the existing knowledge about a certain subject. A systematic paper type uses an organized approach and expects you to answer questions linked to the research.

Tips for Writing a Great Article Review

Here are some expert tips you could use to write an exceptional article review:

1. Figure out the main points you want to cover and why they matter.

• It will help you zero in on the key points.

2. Look for and assess pertinent sources, both from the past and present.

• It will give you a better understanding of the article you’re looking at.

3. Come Up with a Catchy Title, Summarize Your Topic in an Abstract, and Select Keywords

• It will help people read your review and get a good idea of what it’s about.

4. Write the main point of a review along with introducing the topic. 

• It should help readers get a better grasp of the topic.

Outline for Writing a Good Article Review

Here’s an outline to write an excellent article review. 

Introduction

– Begin with a summary of the article 

– Put in background knowledge of the topic 

– State why you are writing the review 

– Give an overview of the article’s main points 

– Figure out why the author choose to write something 

– Look at the article and consider what it does well and what it could have done better.

– Highlight the shortcomings in the article

– Restate why you are writing the review 

– Sum up the main points in a few sentences 

– Suggest what could be achieved in the future research 

Review Article Example

Title: “The Power of Vulnerability: A Review of Brené Brown’s Daring Greatly”

Introduction:

In her revolutionary book “Daring Greatly,” 

Brené Brown, a renowned researcher and storyteller. Delves into vulnerability and how it can positively impact our lives, both professionally and personally. 

Brown’s work has gained lots of praise. Since it resonates with people looking to build real connections in a world that often feels isolated. 

This article looks to recap the main ideas and concepts from “Daring Greatly.” Also explains why it is such a captivating and insightful read.

Summary of Key Ideas:

“Daring Greatly” is all about how the vulnerability isn’t a sign of being weak. but it’s actually what it takes to be brave, strong and live a full life. 

Brene Brown examines how society and culture can make it hard to be vulnerable. And, how fear of being judged or shamed stops us from being our authentic selves.

The book puts a lot of emphasis on shame and how it affects us. 

Brown explains that shame thrives when it’s kept hidden away and can only be cured by being open, understanding, and compassionate. 

By admitting our weaknesses, we can create meaningful connections and a sense of community.

Brown looks into the connection between being open to vulnerability and unleashing creative leadership and innovation. 

She uses her own experiences and research to support her viewpoint. The book also gives useful advice on how to include vulnerability in different parts of life. Such as relationships, parenting, and the workplace.

Strengths of the Book:

Brown’s book is remarkable for her ability to mix her own experiences with comprehensive research. Combining her stories and evidence makes the material engaging and easy to understand. 

Plus, her writing style is so friendly that readers feel they’re being acknowledged and accepted.

There’s advice on how to be kind to yourself. Set your limits, and accept that things won’t always be perfect. It’s like a toolkit to help you build strength and make positive changes.

Final Verdict

This book is really helpful for everyone, no matter who you are. It can help you figure out how to grow in life, have better relationships, and become a better leader. Plus, since it applies to all kinds of people, everyone can get something out of it.

If you want to write a great article review, it’s important to pick the right article, understand and analyze it critically. Finally, express your thoughts on it clearly. Ensure to stay impartial, back up your points with evidence, and write clearly and coherently.

Still if you are having troubles writing an article review, don’t hesitate to count on the expertise of  our writers .

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
• << Previous: Getting Started
• Next: How to Pick a Topic >>
• Last Updated: Sep 21, 2022 2:16 PM
• URL: https://guides.lib.uconn.edu/literaturereview

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• BOOK REVIEW
• 29 March 2024

The great rewiring: is social media really behind an epidemic of teenage mental illness?

• Candice L. Odgers 0

Candice L. Odgers is the associate dean for research and a professor of psychological science and informatics at the University of California, Irvine. She also co-leads international networks on child development for both the Canadian Institute for Advanced Research in Toronto and the Jacobs Foundation based in Zurich, Switzerland.

You can also search for this author in PubMed   Google Scholar

You have full access to this article via your institution.

Social-media platforms aren’t always social. Credit: Getty

The Anxious Generation: How the Great Rewiring of Childhood is Causing an Epidemic of Mental Illness Jonathan Haidt Allen Lane (2024)

Two things need to be said after reading The Anxious Generation . First, this book is going to sell a lot of copies, because Jonathan Haidt is telling a scary story about children’s development that many parents are primed to believe. Second, the book’s repeated suggestion that digital technologies are rewiring our children’s brains and causing an epidemic of mental illness is not supported by science. Worse, the bold proposal that social media is to blame might distract us from effectively responding to the real causes of the current mental-health crisis in young people.

Haidt asserts that the great rewiring of children’s brains has taken place by “designing a firehose of addictive content that entered through kids’ eyes and ears”. And that “by displacing physical play and in-person socializing, these companies have rewired childhood and changed human development on an almost unimaginable scale”. Such serious claims require serious evidence.

Collection: Promoting youth mental health

Haidt supplies graphs throughout the book showing that digital-technology use and adolescent mental-health problems are rising together. On the first day of the graduate statistics class I teach, I draw similar lines on a board that seem to connect two disparate phenomena, and ask the students what they think is happening. Within minutes, the students usually begin telling elaborate stories about how the two phenomena are related, even describing how one could cause the other. The plots presented throughout this book will be useful in teaching my students the fundamentals of causal inference, and how to avoid making up stories by simply looking at trend lines.

Hundreds of researchers, myself included, have searched for the kind of large effects suggested by Haidt. Our efforts have produced a mix of no, small and mixed associations. Most data are correlative. When associations over time are found, they suggest not that social-media use predicts or causes depression, but that young people who already have mental-health problems use such platforms more often or in different ways from their healthy peers 1 .

These are not just our data or my opinion. Several meta-analyses and systematic reviews converge on the same message 2 – 5 . An analysis done in 72 countries shows no consistent or measurable associations between well-being and the roll-out of social media globally 6 . Moreover, findings from the Adolescent Brain Cognitive Development study, the largest long-term study of adolescent brain development in the United States, has found no evidence of drastic changes associated with digital-technology use 7 . Haidt, a social psychologist at New York University, is a gifted storyteller, but his tale is currently one searching for evidence.

Of course, our current understanding is incomplete, and more research is always needed. As a psychologist who has studied children’s and adolescents’ mental health for the past 20 years and tracked their well-being and digital-technology use, I appreciate the frustration and desire for simple answers. As a parent of adolescents, I would also like to identify a simple source for the sadness and pain that this generation is reporting.

A complex problem

There are, unfortunately, no simple answers. The onset and development of mental disorders, such as anxiety and depression, are driven by a complex set of genetic and environmental factors. Suicide rates among people in most age groups have been increasing steadily for the past 20 years in the United States. Researchers cite access to guns, exposure to violence, structural discrimination and racism, sexism and sexual abuse, the opioid epidemic, economic hardship and social isolation as leading contributors 8 .

How social media affects teen mental health: a missing link

The current generation of adolescents was raised in the aftermath of the great recession of 2008. Haidt suggests that the resulting deprivation cannot be a factor, because unemployment has gone down. But analyses of the differential impacts of economic shocks have shown that families in the bottom 20% of the income distribution continue to experience harm 9 . In the United States, close to one in six children live below the poverty line while also growing up at the time of an opioid crisis, school shootings and increasing unrest because of racial and sexual discrimination and violence.

The good news is that more young people are talking openly about their symptoms and mental-health struggles than ever before. The bad news is that insufficient services are available to address their needs. In the United States, there is, on average, one school psychologist for every 1,119 students 10 .

Haidt’s work on emotion, culture and morality has been influential; and, in fairness, he admits that he is no specialist in clinical psychology, child development or media studies. In previous books, he has used the analogy of an elephant and its rider to argue how our gut reactions (the elephant) can drag along our rational minds (the rider). Subsequent research has shown how easy it is to pick out evidence to support our initial gut reactions to an issue. That we should question assumptions that we think are true carefully is a lesson from Haidt’s own work. Everyone used to ‘know’ that the world was flat. The falsification of previous assumptions by testing them against data can prevent us from being the rider dragged along by the elephant.

A generation in crisis

Two things can be independently true about social media. First, that there is no evidence that using these platforms is rewiring children’s brains or driving an epidemic of mental illness. Second, that considerable reforms to these platforms are required, given how much time young people spend on them. Many of Haidt’s solutions for parents, adolescents, educators and big technology firms are reasonable, including stricter content-moderation policies and requiring companies to take user age into account when designing platforms and algorithms. Others, such as age-based restrictions and bans on mobile devices, are unlikely to be effective in practice — or worse, could backfire given what we know about adolescent behaviour.

A third truth is that we have a generation in crisis and in desperate need of the best of what science and evidence-based solutions can offer. Unfortunately, our time is being spent telling stories that are unsupported by research and that do little to support young people who need, and deserve, more.

Nature 628 , 29-30 (2024)

doi: https://doi.org/10.1038/d41586-024-00902-2

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Miller, J., Mills, K. L., Vuorre, M., Orben, A. & Przybylski, A. K. Cortex 169 , 290–308 (2023).

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Competing Interests

The author declares no competing interests.

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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.

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Research: How Different Fields Are Using GenAI to Redefine Roles

• Maryam Alavi

Examples from customer support, management consulting, professional writing, legal analysis, and software and technology.

The interactive, conversational, analytical, and generative features of GenAI offer support for creativity, problem-solving, and processing and digestion of large bodies of information. Therefore, these features can act as cognitive resources for knowledge workers. Moreover, the capabilities of GenAI can mitigate various hindrances to effective performance that knowledge workers may encounter in their jobs, including time pressure, gaps in knowledge and skills, and negative feelings (such as boredom stemming from repetitive tasks or frustration arising from interactions with dissatisfied customers). Empirical research and field observations have already begun to reveal the value of GenAI capabilities and their potential for job crafting.

There is an expectation that implementing new and emerging Generative AI (GenAI) tools enhances the effectiveness and competitiveness of organizations. This belief is evidenced by current and planned investments in GenAI tools, especially by firms in knowledge-intensive industries such as finance, healthcare, and entertainment, among others. According to forecasts, enterprise spending on GenAI will increase by two-fold in 2024 and grow to $151.1 billion by 2027 .

• Maryam Alavi is the Elizabeth D. & Thomas M. Holder Chair & Professor of IT Management, Scheller College of Business, Georgia Institute of Technology .

Partner Center

• Open access
• Published: 02 April 2022

A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access

• Nicholas C. Coombs 1 ,
• Duncan G. Campbell 2 &
• James Caringi 1  

BMC Health Services Research volume  22 , Article number:  438 ( 2022 ) Cite this article

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Ensuring access to healthcare is a complex, multi-dimensional health challenge. Since the inception of the coronavirus pandemic, this challenge is more pressing. Some dimensions of access are difficult to quantify, namely characteristics that influence healthcare services to be both acceptable and appropriate. These link to a patient’s acceptance of services that they are to receive and ensuring appropriate fit between services and a patient’s specific healthcare needs. These dimensions of access are particularly evident in rural health systems where additional structural barriers make accessing healthcare more difficult. Thus, it is important to examine healthcare access barriers in rural-specific areas to understand their origin and implications for resolution.

We used qualitative methods and a convenience sample of healthcare providers who currently practice in the rural US state of Montana. Our sample included 12 healthcare providers from diverse training backgrounds and specialties. All were decision-makers in the development or revision of patients’ treatment plans. Semi-structured interviews and content analysis were used to explore barriers–appropriateness and acceptability–to healthcare access in their patient populations. Our analysis was both deductive and inductive and focused on three analytic domains: cultural considerations, patient-provider communication, and provider-provider communication. Member checks ensured credibility and trustworthiness of our findings.

Five key themes emerged from analysis: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US.

Conclusions

Inadequate access to healthcare is an issue in the US, particularly in rural areas. Rural healthcare consumers compose a hard-to-reach patient population. Too few providers exist to meet population health needs, and fragmented communication impairs rural health systems’ ability to function. These issues exacerbate the difficulty of ensuring acceptable and appropriate delivery of healthcare services, which compound all other barriers to healthcare access for rural residents. Each dimension of access must be monitored to improve patient experiences and outcomes for rural Americans.

Peer Review reports

Unequal access to healthcare services is an important element of health disparities in the United States [ 1 ], and there remains much about access that is not fully understood. The lack of understanding is attributable, in part, to the lack of uniformity in how access is defined and evaluated, and the extent to which access is often oversimplified in research [ 2 ]. Subsequently, attempts to address population-level barriers to healthcare access are insufficient, and access remains an unresolved, complex health challenge [ 3 , 4 , 5 ]. This paper presents a study that aims to explore some of the less well studied barriers to healthcare access, particularly those that influence healthcare acceptability and appropriateness.

In truth, healthcare access entails a complicated calculus that combines characteristics of individuals, their households, and their social and physical environments with characteristics of healthcare delivery systems, organizations, and healthcare providers. For one to fully ‘access’ healthcare, they must have the means to identify their healthcare needs and have available to them care providers and the facilities where they work. Further, patients must then reach, obtain, and use the healthcare services in order to have their healthcare needs fulfilled. Levesque and colleagues critically examined access conceptualizations in 2013 and synthesized all ways in which access to healthcare was previously characterized; Levesque et al. proposed five dimensions of access: approachability, acceptability, availability, affordability and appropriateness [ 2 ]. These refer to the ability to perceive, seek, reach, pay for, and engage in services, respectively.

According to Levesque et al.’s framework, the five dimensions combine to facilitate access to care or serve as barriers. Approachability indicates that people facing health needs understand that healthcare services exist and might be helpful. Acceptability represents whether patients see healthcare services as consistent or inconsistent with their own social and cultural values and worldviews. Availability indicates that healthcare services are reached both physically and in a timely manner. Affordability simplifies one’s capacity to pay for healthcare services without compromising basic necessities, and finally, appropriateness represents the fit between healthcare services and a patient’s specific healthcare needs [ 2 ]. This study focused on the acceptability and appropriateness dimensions of access.

Before the novel coronavirus (SARS-CoV-2; COVID-19) pandemic, approximately 13.3% of adults in the US did not have a usual source of healthcare [ 6 ]. Millions more did not utilize services regularly, and close to two-thirds reported that they would be debilitated by an unexpected medical bill [ 7 , 8 , 9 ]. Findings like these emphasized a fragility in the financial security of the American population [ 10 ]. These concerns were exacerbated by the pandemic when a sudden surge in unemployment increased un- and under-insurance rates [ 11 ]. Indeed, employer-sponsored insurance covers close to half of Americans’ total cost of illness [ 12 ]. Unemployment linked to COVID-19 cut off the lone outlet to healthcare access for many. Health-related financial concerns expanded beyond individuals, as healthcare organizations were unequipped to manage a simultaneous increase in demand for specialized healthcare services and a steep drop off for routine revenue-generating healthcare services [ 13 ]. These consequences of the COVID-19 pandemic all put additional, unexpected pressure on an already fragmented US healthcare system.

Other structural barriers to healthcare access exist in relation to the rural–urban divide. Less than 10% of US healthcare resources are located in rural areas where approximately 20% of the American population resides [ 14 ]. In a country with substantially fewer providers per capita compared to many other developed countries, persons in rural areas experience uniquely pressing healthcare provider shortages [ 15 , 16 ]. Rural inhabitants also tend to have lower household income, higher rates of un- or under-insurance, and more difficulty with travel to healthcare clinics than urban dwellers [ 17 ]. Subsequently, persons in rural communities use healthcare services at lower rates, and potentially preventable hospitalizations are more prevalent [ 18 ]. This disparity often leads rural residents to use services primarily for more urgent needs and less so for routine care [ 19 , 20 , 21 ].

The differences in how rural and urban healthcare systems function warranted a federal initiative to focus exclusively on rural health priorities and serve as counterpart to Healthy People objectives [ 22 ]. The rural determinants of health, a more specific expression of general social determinants, add issues of geography and topography to the well-documented social, economic and political factors that influence all Americans’ access to healthcare [ 23 ]. As a result, access is consistently regarded as a top priority in rural areas, and many research efforts have explored the intersection between access and rurality, namely within its less understood dimensions (acceptability and appropriateness) [ 22 ].

Acceptability-related barriers to care

Acceptability represents the dimension of healthcare access that affects a patient’s ability to seek healthcare, particularly linked to one’s professional values, norms and culture [ 2 ]. Access to health information is an influential factor for acceptable healthcare and is essential to promote and maintain a healthy population [ 24 ]. According to the Centers for Disease Control and Prevention, health literacy or a high ‘health IQ’ is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others, which impacts healthcare use and system navigation [ 25 ]. The literature indicates that lower levels of health literacy contribute to health disparities among rural populations [ 26 , 27 , 28 ]. Evidence points to a need for effective health communication between healthcare organizations and patients to improve health literacy [ 24 ]. However, little research has been done in this area, particularly as it relates to technologically-based interventions to disseminate health information [ 29 ].

Stigma, an undesirable position of perceived diminished status in an individual’s social position, is another challenge that influences healthcare acceptability [ 30 ]. Those who may experience stigma fear negative social consequences in relation to care seeking. They are more likely to delay seeking care, especially among ethnic minority populations [ 31 , 32 ]. Social media presents opportunities for the dissemination of misleading medical information; this runs further risk for stigma [ 33 ]. Stigma is difficult to undo, but research has shown that developing a positive relationship with a healthcare provider or organization can work to reduce stigma among patients, thus promoting healthcare acceptability [ 34 ].

A provider’s attempts to engage patients and empower them to be active decision-makers regarding their treatment has also been shown to improve healthcare acceptability. One study found that patients with heart disease who completed a daily diary of weight and self-assessment of symptoms, per correspondence with their provider, had better care outcomes than those who did not [ 35 ]. Engaging with household family members and involved community healers also mitigates barriers to care, emphasizing the importance of a team-based approach that extends beyond those who typically provide healthcare services [ 36 , 37 ]. One study, for instance, explored how individuals closest to a pregnant woman affect the woman’s decision to seek maternity care; partners, female relatives, and community health-workers were among the most influential in promoting negative views, all of which reduced a woman’s likelihood to access care [ 38 ].

Appropriateness-related barriers to care

Appropriateness marks the dimension of healthcare access that affects a patient’s ability to engage, and according to Levesque et al., is of relevance once all other dimensions (the ability to perceive, seek, reach and pay for) are achieved [ 2 ]. The ability to engage in healthcare is influenced by a patient’s level of empowerment, adherence to information, and support received by their healthcare provider. Thus, barriers to healthcare access that relate to appropriateness are often those that indicate a breakdown in communication between a patient with their healthcare provider. Such breakdown can involve a patient experiencing miscommunication, confrontation, and/or a discrepancy between their provider’s goals and their own goals for healthcare. Appropriateness represents a dimension of healthcare access that is widely acknowledged as an area in need of improvement, which indicates a need to rethink how healthcare providers and organizations can adapt to serve the healthcare needs of their communities [ 39 ]. This is especially true for rural, ethnic minority populations, which disproportionately experience an abundance of other barriers to healthcare access. Culturally appropriate care is especially important for members of minority populations [ 40 , 41 , 42 ]. Ultimately, patients value a patient-provider relationship characterized by a welcoming, non-judgmental atmosphere [ 43 , 44 ]. In rural settings especially, level of trust and familiarity are common factors that affect service utilization [ 45 ]. Evidence suggests that kind treatment by a healthcare provider who promotes patient-centered care can have a greater overall effect on a patient’s experience than a provider’s degree of medical knowledge or use of modern equipment [ 46 ]. Of course, investing the time needed to nurture close and caring interpersonal connections is particularly difficult in under-resourced, time-pressured rural health systems [ 47 , 48 ].

The most effective way to evaluate access to healthcare largely depends on which dimensions are explored. For instance, a population-based survey can be used to measure the barrier of healthcare affordability. Survey questions can inquire directly about health insurance coverage, care-related financial burden, concern about healthcare costs, and the feared financial impacts of illness and/or disability. Many national organizations have employed such surveys to measure affordability-related barriers to healthcare. For example, a question may ask explicitly about financial concerns: ‘If you get sick or have an accident, how worried are you that you will not be able to pay your medical bills?’ [ 49 ]. Approachability and availability dimensions of access are also studied using quantitative analysis of survey questions, such as ‘Is there a place that you usually go to when you are sick or need advice about your health?’ or ‘Have you ever delayed getting medical care because you couldn’t get through on the telephone?’ In contrast, the remaining two dimensions–acceptability and appropriateness–require a qualitative approach, as the social and cultural factors that determine a patient’s likelihood of accepting aspects of the services that are to be received (acceptability) and the fit between those services and the patient’s specific healthcare needs (appropriateness) can be more abstract [ 50 , 51 ]. In social science, qualitative methods are appropriate to generate knowledge of what social events mean to individuals and how those individuals interact within them; these methods allow for an exploration of depth rather than breadth [ 52 , 53 ]. Qualitative methods, therefore, are appropriate tools for understanding the depth of healthcare providers’ experiences in the inherently social context of seeking and engaging in healthcare.

In sum, acceptability- and appropriateness-related barriers to healthcare access are multi-layered, complex and abundant. Ensuring access becomes even more challenging if structural barriers to access are factored in. In this study, we aimed to explore barriers to healthcare access among persons in Montana, a historically underserved, under-resourced, rural region of the US. Montana is the fourth largest and third least densely populated state in the country; more than 80% of Montana counties are classified as non-core (the lowest level of urban/rural classification), and over 90% are designated as health professional shortage areas [ 54 , 55 ]. Qualitative methods supported our inquiry to explore barriers to healthcare access related to acceptability and appropriateness.

Participants

Qualitative methods were utilized for this interpretive, exploratory study because knowledge regarding barriers to healthcare access within Montana’s rural health systems is limited. We chose Montana healthcare providers, rather than patients, as the population of interest so we may explore barriers to healthcare access from the perspective of those who serve many persons in rural settings. Inclusion criteria required study participants to provide direct healthcare to patients at least one-half of their time. We defined ‘provider’ as a healthcare organization employee with clinical decision-making power and the qualifications to develop or revise patients’ treatment plans. In an attempt to capture a group of providers with diverse experience, we included providers across several types and specialties. These included advanced practice registered nurses (APRNs), physicians (MDs and DOs), and physician assistants (PAs) who worked in critical care medicine, emergency medicine, family medicine, hospital medicine, internal medicine, pain medicine, palliative medicine, pediatrics, psychiatry, and urgent care medicine. We also included licensed clinical social workers (LCSWs) and clinical psychologists who specialize in behavioral healthcare provision.

Recruitment and Data Collection

We recruited participants via email using a snowball sampling approach [ 56 ]. We opted for this approach because of its effectiveness in time-pressured contexts, such as the COVID-19 pandemic, which has made healthcare provider populations hard to reach [ 57 ]. Considering additional constraints with the pandemic and the rural nature of Montana, interviews were administered virtually via Zoom video or telephone conferencing with Zoom’s audio recording function enabled. All interviews were conducted by the first author between January and September 2021. The average length of interviews was 50 min, ranging from 35 to 70 min. There were occasional challenges experienced during interviews (poor cell phone reception from participants, dropped calls), in which case the interviewer remained on the line until adequate communication was resumed. All interviews were included for analysis and transcribed verbatim into NVivo Version 12 software. All qualitative data were saved and stored on a password-protected University of Montana server. Hard-copy field notes were securely stored in a locked office on the university’s main campus.

Data analysis included a deductive followed by an inductive approach. This dual analysis adheres to Levesque’s framework for qualitative methods, which is discussed in the Definition of Analytic Domains sub-section below. Original synthesis of the literature informed the development of our initial deductive codebook. The deductive approach was derived from a theory-driven hypothesis, which consisted of synthesizing previous research findings regarding acceptability- and appropriateness-related barriers to care. Although the locations, patient populations and specific type of healthcare services varied by study in the existing literature, several recurring barriers to healthcare access were identified. We then operationalized three analytic domains based on these findings: cultural considerations, patient-provider communication, and provider-provider communication. These domains were chosen for two reasons: 1) the terms ‘culture’ and ‘communication’ were the most frequently documented characteristics across the studies examined, and 2) they each align closely with the acceptability and appropriateness dimensions of access to healthcare, respectively. In addition, ‘culture’ is included in the definition of acceptability and ‘communication’ is a quintessential aspect of appropriateness. These domains guided the deductive portion of our analysis, which facilitated the development of an interview guide used for this study.

Interviews were semi-structured to allow broad interpretations from participants and expand the open-ended characterization of study findings. Data were analyzed through a flexible coding approach proposed by Deterding and Waters [ 58 ]. Qualitative content analysis was used, a method particularly beneficial for analyzing large amounts of qualitative data collected through interviews that offers possibility of quantifying categories to identify emerging themes [ 52 , 59 ]. After fifty percent of data were analyzed, we used an inductive approach as a formative check and repeated until data saturation, or the point at which no new information was gathered in interviews [ 60 ]. At each point of inductive analysis, interview questions were added, removed, or revised in consideration of findings gathered [ 61 ]. The Standards for Reporting Qualitative Research (SRQR) was used for reporting all qualitative data for this study [ 62 ]. The first and third authors served as primary and secondary analysts of the qualitative data and collaborated to triangulate these findings. An audit approach was employed, which consisted of coding completed by the first author and then reviewed by the third author. After analyses were complete, member checks ensured credibility and trustworthiness of findings [ 63 ]. Member checks consisted of contacting each study participant to explain the study’s findings; one-third of participants responded and confirmed all findings. All study procedures were reviewed and approved by the Human Subjects Committee of the authors’ institution’s Institutional Review Board.

Definitions of Analytic Domains

Cultural considerations.

Western health systems often fail to consider aspects of patients’ cultural perspectives and histories. This can manifest in the form of a providers’ lack of cultural humility. Cultural humility is a process of preventing imposition of one’s worldview and cultural beliefs on others and recognizing that everyone’s conception of the world is valid. Humility cultivates sensitive approaches in treating patients [ 64 ]. A lack of cultural humility impedes the delivery of acceptable and appropriate healthcare [ 65 ], which can involve low empathy or respect for patients, or dismissal of culture and traditions as superstitions that interfere with standard treatments [ 66 , 67 ]. Ensuring cultural humility among all healthcare employees is a step toward optimal healthcare delivery. Cultural humility is often accomplished through training that can be tailored to particular cultural- or gender-specific populations [ 68 , 69 ]. Since cultural identities and humility have been marked as factors that can heavily influence patients’ access to care, cultural considerations composed our first analytic domain. To assess this domain, we asked participants how they address the unique needs of their patients, how they react when they observe a cultural behavior or attitude from a patient that may not directly align with their treatment plan, and if they have received any multicultural training or training on cultural considerations in their current role.

Patient-provider communication

Other barriers to healthcare access can be linked to ineffective patient-provider communication. Patients who do not feel involved in healthcare decisions are less likely to adhere to treatment recommendations [ 70 ]. Patients who experience communication difficulties with providers may feel coerced, which generates disempowerment and leads patients to employ more covert ways of engagement [ 71 , 72 ]. Language barriers can further compromise communication and hinder outcomes or patient progress [ 73 , 74 ]. Any miscommunication between a patient and provider can affect one’s access to healthcare, namely affecting appropriateness-related barriers. For these reasons, patient-provider communication composed our second analytic domain. We asked participants to highlight the challenges they experience when communicating with their patients, how those complications are addressed, and how communication strategies inform confidentiality in their practice. Confidentiality is a core ethical principle in healthcare, especially in rural areas that have smaller, interconnected patient populations [ 75 ].

Provider-Provider Communication

A patient’s journey through the healthcare system necessitates sufficient correspondence between patients, primary, and secondary providers after discharge and care encounters [ 76 ]. Inter-provider and patient-provider communication are areas of healthcare that are acknowledged to have some gaps. Inconsistent mechanisms for follow up communication with patients in primary care have been documented and emphasized as a concern among those with chronic illness who require close monitoring [ 68 , 77 ]. Similar inconsistencies exist between providers, which can lead to unclear care goals, extended hospital stays, and increased medical costs [ 78 ]. For these reasons, provider-provider communication composed our third analytic domain. We asked participants to describe the approaches they take to streamline communication after a patient’s hospital visit, the methods they use to ensure collaborative communication between primary or secondary providers, and where communication challenges exist.

Healthcare provider characteristics

Our sample included 12 providers: four in family medicine (1 MD, 1 DO, 1 PA & 1 APRN), three in pediatrics (2 MD with specialty in hospital medicine & 1 DO), three in palliative medicine (2 MDs & 1 APRN with specialty in wound care), one in critical care medicine (DO with specialty in pediatric pulmonology) and one in behavioral health (1 LCSW with specialty in trauma). Our participants averaged 9 years (range 2–15) as a healthcare provider; most reported more than 5 years in their current professional role. The diversity of participants extended to their patient populations as well, with each participant reporting a unique distribution of age, race and level of medical complexity among their patients. Most participants reported that a portion of their patients travel up to five hours, sometimes across county- or state-lines, to receive care.

Theme 1: A friction exists between aspects of patients’ rural identities and healthcare systems

Our participants comprised a collection of medical professions and reported variability among health-related reasons their patients seek care. However, most participants acknowledged similar characteristics that influence their patients’ challenges to healthcare access. These identified factors formed categories from which the first theme emerged. There exists a great deal of ‘rugged individualism’ among Montanans, which reflects a self-sufficient and self-reliant way of life. Stoicism marked a primary factor to characterize this quality. One participant explained:

True Montanans are difficult to treat medically because they tend to be a tough group. They don’t see doctors. They don’t want to go, and they don’t want to be sick. That’s an aspect of Montana that makes health culture a little bit difficult.

Another participant echoed this finding by stating:

The backwoods Montana range guy who has an identity of being strong and independent probably doesn’t seek out a lot of medical care or take a lot of medications. Their sense of vitality, independence and identity really come from being able to take care and rely on themselves. When that is threatened, that’s going to create a unique experience of illness.

Similar responses were shared by all twelve participants; stoicism seemed to be heavily embedded in many patient populations in Montana and serves as a key determinant of healthcare acceptability. There are additional factors, however, that may interact with stoicism but are multiply determined. Stigma is an example of this, presented in this context as one’s concern about judgement by the healthcare system. Respondents were openly critical of this perception of the healthcare system as it was widely discussed in interviews. One participant stated:

There is a real perception of a punitive nature in the medical community, particularly if I observe a health issue other than the primary reason for one’s hospital visit, whether that may be predicated on medical neglect, delay of care, or something that may warrant a report to social services. For many of the patients and families I see, it’s not a positive experience and one that is sometimes an uphill barrier that I work hard to circumnavigate.

Analysis of these factors suggest that low use of healthcare services may link to several characteristics, including access problems. Separately, a patient’s perceived stigma from healthcare providers may also impact a patient’s willingness to receive services. One participant put it best by stating

Sometimes, families assume that I didn’t want to see them because they will come in for follow up to meet with me but end up meeting with another provider, which is frustrating because I want to maintain patients on my panel but available time and resource occasionally limits me from doing so. It could be really hard adapting to those needs on the fly, but it’s an honest miss.

When a patient arrives for a healthcare visit and experiences this frustration, it may elicit a patient’s perceptions of neglect or disorganization. This ‘honest miss’ may, in turn, exacerbate other acceptable-related barriers to care.

Theme 2: Facilitating access to healthcare requires application of and respect for cultural differences

The biomedical model is the standard of care utilized in Western medicine [ 79 , 80 ]. However, the US comprises people with diverse social and cultural identities that may not directly align with Western conceptions of health and wellness. Approximately 11.5% of the Montana population falls within an ethnic minority group. 6.4% are of American Indian or Alaska Native origin, 0.5% are of Black or African American origin, 0.8% are of Asian origin and 3.8% are of multiple or other origins. [ 81 ]. Cultural insensitivity is acknowledged in health services research as an active deterrent for appropriate healthcare delivery [ 65 ]. Participants for this study were asked how they react when a patient brings up a cultural attitude or behavior that may impact the proposed treatment plan. Eight participants noted a necessity for humility when this occurs. One participant conceptualized this by stating:

When this happens, I learn about individuals and a way of life that is different to the way I grew up. There is a lot of beauty and health in a non-patriarchal, non-dominating, non-sexist framework, and when we can engage in such, it is really expansive for my own learning process.

The participants who expressed humility emphasized that it is best to work in tandem with their patient, congruently. Especially for those with contrasting worldviews, a provider and a patient working as a team poses an opportunity to develop trust. Without it, a patient can easily fall out of the system, further hindering their ability to access healthcare services in the future. One participant stated:

The approach that ends up being successful for a lot of patients is when we understand their modalities, and they have a sense we understand those things. We have to show understanding and they have to trust. From there, we can make recommendations to help get them there, not decisions for them to obey, rather views based on our experiences and understanding of medicine.

Curiosity was another reaction noted by a handful of participants. One participant said:

I believe patients and their caregivers can be engaged and loving in different ways that don’t always follow the prescribed approach in the ways I’ve been trained, but that doesn’t necessarily mean that they are detrimental. I love what I do, and I love learning new things or new approaches, but I also love being surprised. My style of medicine is not to predict peoples’ lives, rather to empower and support what makes life meaningful for them.

Participants mentioned several other characteristics that they use in practice to prevent cultural insensitivity and support a collaborative approach to healthcare. Table 1 lists these facilitating characteristics and quotes to explain the substance of their benefit.

Consensus among participants indicated that the use of these protective factors to promote cultural sensitivity and apply them in practice is not standardized. When asked, all but two participants said they had not received any culturally-based training since beginning their practice. Instead, they referred to developing skills through “on the job training” or “off the cuff learning.” The general way of medicine, one participant remarked, was to “throw you to the fire.” This suggested that use of standardized cultural humility training modules for healthcare providers was not common practice. Many attributed this to time constraints.

Individual efforts to gain culturally appropriate skills or enhance cultural humility were mentioned, however. For example, three participants reported that they attended medical conferences to discuss cultural challenges within medicine, one participant sought out cultural education within their organization, and another was invited by Native American community members to engage in traditional peace ceremonies. Participants described these additional efforts as uncommon and outside the parameters of a provider’s job responsibilities, as they require time commitments without compensation.

Additionally, eight participants said they share their personal contact information with patients so they may call them directly for medical needs. The conditions and frequency with which this is done was variable and more common among providers in specialized areas of medicine or those who described having a manageable patient panel. All who reported that they shared their personal contact information described it as an aspect of rural health service delivery that is atypical in other, non-rural healthcare systems.

Theme 3: Communication between healthcare providers is systematically fragmented

Healthcare is complex and multi-disciplinary, and patients’ treatment is rarely overseen by a single provider [ 82 ]. The array of provider types and specialties is vast, as is the range of responsibilities ascribed to providers. Thus, open communication among providers both within and between healthcare systems is vital for the success of collaborative healthcare [ 83 ]. Without effective communication achieved between healthcare providers, the appropriate delivery of healthcare services may be become compromised. Our participants noted that they face multiple challenges that complicate communication with other providers. Miscommunication between departments, often implicating the Emergency Department (ED), was a recurring point noted among participants. One participant who is a primary care physician said:

If one of my patients goes to the ER, I don’t always get the notes. They’re supposed to send them to the patient’s primary care doc. The same thing happens with general admissions, but again, I often find out from somebody else that my patient was admitted to the hospital.

This failure to communicate can negatively impact the patient, particularly if time sensitivity or medical complexity is essential to treatment. A patient’s primary care physician is the most accurate source of their medical history; without an effective way to obtain and synthesize a patient’s health information, there may be increased risk of medical error. One participant in a specialty field stated:

One of the biggest barriers I see is obtaining a concise description of a patient’s history and needs. You can imagine if you’re a mom and you’ve got a complicated kid. You head to the ER. The ER doc looks at you with really wide eyes, not knowing how to get information about your child that’s really important.

This concern was highlighted with a specific example from a different participant:

I have been unable to troubleshoot instances when I send people to the ER with a pretty clear indication for admission, and then they’re sent home. For instance, I had an older fellow with pretty severe chronic kidney disease. He presented to another practitioner in my office with shortness of breath and swelling and appeared to have newly onset decompensated heart failure. When I figured this out, I sent him to the ER, called and gave my report. The patient later came back for follow up to find out not only that they had not been admitted but they lost no weight with outpatient dialysis . I feel like a real opportunity was missed to try to optimize the care of the patient simply because there was poor communication between myself and the ER. This poor guy… He ended up going to the ER four times before he got admitted for COVID-19.

In some cases, communication breakdown was reported as the sole cause of a poor outcome. When communication is effective, each essential member of the healthcare team is engaged and collaborating with the same information. Some participants called this process ‘rounds’ when a regularly scheduled meeting is staged between a group of providers to ensure access to accurate patient information. Accurate communication may also help build trust and improve a patient’s experience. In contrast, ineffective communication can result in poor clarity regarding providers’ responsibilities or lost information. Appropriate delivery of healthcare considers the fit between providers and a patient’s specific healthcare needs; the factors noted here suggest that provider-provider miscommunication can adversely affect this dimension of healthcare access.

Another important mechanism of communication is the sharing of electronic medical records (EMRs), a process that continues to shift with technological advances. Innovation is still recent enough, however, for several of our study participants to be able to recall a time when paper charts were standard. Widespread adoption and embrace of the improvements inherent in electronic medical records expanded in the late 2000’s [ 84 ]. EMRs vastly improved the ability to retain, organize, safeguard, and transfer health information. Every participant highlighted EMRs at one point or another and often did so with an underlying sense of anger or frustration. Systematic issues and problems with EMRs were discussed. One participant provided historical context to such records:

Years back, the government aimed to buy an electronic medical record system, whichever was the best, and a number of companies created their own. Each were a reasonable system, so they all got their checks and now we have four completely separate operating systems that do not talk to each other. The idea was to make a router or some type of relay that can share information back and forth. There was no money in that though, so of course, no one did anything about it. Depending on what hospital, clinic or agency you work for, you will most likely work within one of these systems. It was a great idea; it just didn’t get finished.

Seven participants confirmed these points and their impacts on making coordination more difficult, relying on outdated communication strategies more often than not. Many noted this even occurs between facilities within the same city and in separate small metropolitan areas across the state. One participant said:

If my hospital decides to contract with one EMR and the hospital across town contracts with another, correspondence between these hospitals goes back to traditional faxing. As a provider, you’re just taking a ‘fingered crossed’ approach hoping that the fax worked, is picked up, was put in the appropriate inbox and was actually looked at. Information acquisition and making sure it’s timely are unforeseen between EMRs.

Participants reported an “astronomic” number of daily faxes and telephone calls to complete the communication EMRs were initially designed to handle. These challenges are even more burdensome if a patient moves from out of town or out of state; obtaining their medical records was repeatedly referred to as a “chore” so onerous that it often remains undone. Another recurring concern brought up by participants regarded accuracy within EMRs to lend a false sense of security. They are not frequently updated, not designed to be family-centered and not set up to do anything automatically. One participant highlighted these limitations by stating:

I was very proud of a change I made in our EMR system [EPIC], even though it was one I never should have had to make. I was getting very upset because I would find out from my nursing assistant who read the obituary that one of my patients had died. There was a real problem with the way the EMR was notifying PCP’s, so I got an EPIC-level automated notification built into our EMR so that any time a patient died, their status would be changed to deceased and a notification would be sent to their PCP. It’s just really awful to find out a week later that your patient died, especially when you know these people and their families really well. It’s not good care to have blind follow up.

Whether it be a physical or electronic miscommunication between healthcare providers, the appropriate delivery of healthcare can be called to question

Theme 4: Time and resource constraints disproportionately harm rural health systems

Several measures of system capacity suggest the healthcare system in the US is under-resourced. There are fewer physicians and hospital beds per capita compared to most comparable countries, and the growth of healthcare provider populations has stagnated over time [ 15 ]. Rural areas, in particular, are subject to resource limitations [ 16 ]. All participants discussed provider shortages in detail. They described how shortages impact time allocation in their day-to-day operations. Tasks like patient intakes, critical assessments, and recovering information from EMRs take time, of which most participants claimed to not have enough of. There was also a consensus in having inadequate time to spend on medically complex cases. Time pressures were reported to subsequently influence quality of care. One participant stated:

With the constant pace of medicine, time is not on your side. A provider cannot always participate in an enriching dialogue with their patients, so rather than listen and learn, we are often coerced into the mindset of ‘getting through’ this patient so we can move on. This echoes for patient education during discharge, making the whole process more arduous than it otherwise could be if time and resources were not as sparse.

Depending on provider type, specialty, and the size of patient panels, four participants said they have the luxury of extending patient visits to 40 + minutes. Any flexibility with patient visits was regarded as just that: a luxury. Very few providers described the ability to coordinate their schedules as such. This led some study participants to limit the number of patients they serve. One participant said:

We simply don’t have enough clinicians, which is a shame because these people are really skilled, exceptional, brilliant providers but are performing way below their capacity. Because of this, I have a smaller case load so I can engage in a level of care that I feel is in the best interest of my patients. Everything is a tradeoff. Time has to be sacrificed at one point or another. This compromise sets our system up to do ‘ok’ work, not great work.

Of course, managing an overly large number of patients with high complexity is challenging. Especially while enduring the burden of a persisting global pandemic, participants reflected that the general outlook of administering healthcare in the US is to “do more with less.” This often forces providers to delegate responsibilities, which participants noted has potential downsides. One participant described how delegating patient care can cause problems.

Very often will a patient schedule a follow up that needs to happen within a certain time frame, but I am unable to see them myself. So, they are then placed with one of my mid-level providers. However, if additional health issues are introduced, which often happens, there is a high-risk of bounce-back or need to return once again to the hospital. It’s an inefficient vetting process that falls to people who may not have specific training in the labs and imaging that are often included in follow up visits. Unfortunately, it’s a forlorn hope to have a primary care physician be able to attend all levels of a patient’s care.

Several participants described how time constraints stretch all healthcare staff thin and complicate patient care. This was particularly important among participants who reported having a patient panel exceeding 1000. There were some participants, however, who praised the relationships they have with their nurse practitioners and physician’s assistants and mark transparency as the most effective way to coordinate care. Collectively, these clinical relationships were built over long standing periods of time, a disadvantage to providers at the start of their medical career. All but one participant with over a decade of clinical experience mentioned the usefulness of these relationships. The factors discussed in Theme 4 are directly linked to the Availability dimension of access to healthcare. A patient’s ability to reach care is subject to the capacity of their healthcare provider(s). Additionally, further analysis suggests these factors also link to the Appropriateness dimension because the quality of patient-provider relationships may be negatively impacted if a provider’s time is compromised.

Theme 5: Profits are prioritized over addressing barriers to healthcare access in the US.

The US healthcare system functions partially for-profit in the public and private sectors. The federal government provides funding for national programs such as Medicare, but a majority of Americans access healthcare through private employer plans [ 85 ]. As a result, uninsurance rates influence healthcare access. Though the rate of the uninsured has dropped over the last decade through expansion of the Affordable Care Act, it remains above 8 percent [ 86 ]. Historically, there has been ethical criticism in the literature of a for-profit system as it is said to exacerbate healthcare disparities and constitute unfair competition against nonprofit institutions. Specifically, the US healthcare system treats healthcare as a commodity instead of a right, enables organizational controls that adversely affect patient-provider relationships, undermines medical education, and constitutes a medical-industrial complex that threatens influence on healthcare-related public policy [ 87 ]. Though unprompted by the interviewer, participants raised many of these concerns. One participant shared their views on how priorities stand in their practice:

A lot of the higher-ups in the healthcare system where I work see each patient visit as a number. It’s not that they don’t have the capacity to think beyond that, but that’s what their role is, making sure we’re profitable. That’s part of why our healthcare system in the US is as broken as it is. It’s accentuated focus on financially and capitalistically driven factors versus understanding all these other barriers to care.

Eight participants echoed a similar concept, that addressing barriers to healthcare access in their organizations is largely complicated because so much attention is directed on matters that have nothing to do with patients. A few other participants supported this by alluding to a “cherry-picking” process by which those at the top of the hierarchy devote their attention to the easiest tasks. One participant shared an experience where contrasting work demands between administrators and front-line clinical providers produces adverse effects:

We had a new administrator in our hospital. I had been really frustrated with the lack of cultural awareness and curiosity from our other leaders in the past, so I offered to meet and take them on a tour of the reservation. This was meant to introduce them to kids, families and Tribal leaders who live in the area and their interface with healthcare. They declined, which I thought was disappointing and eye-opening.

Analysis of these factors suggest that those who work directly with patients understand patient needs better than those who serve in management roles. This same participant went on to suggest an ulterior motive for a push towards telemedicine, as administrators primarily highlight the benefit of billing for virtual visits instead of the nature of the visits themselves.

This study explored barriers and facilitators to healthcare access from the perspective of rural healthcare providers in Montana. Our qualitative analysis uncovered five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. Themes 2 and 3 were directly supported by earlier qualitative studies that applied Levesque’s framework, specifically regarding healthcare providers’ poor interpersonal quality and lack of collaboration with other providers that are suspected to result from a lack of provider training [ 67 , 70 ]. This ties back to the importance of cultural humility, which many previous culture-based trainings have referred to as cultural competence. Cultural competence is achieved through a plethora of trainings designed to expose providers to different cultures’ beliefs and values but induces risk of stereotyping and stigmatizing a patient’s views. Therefore, cultural humility is the preferred idea, by which providers reflect and gain open-ended appreciation for a patient’s culture [ 88 ].

Implications for Practice

Perhaps the most substantial takeaway is how embedded rugged individualism is within rural patient populations and how difficult that makes the delivery of care in rural health systems. We heard from participants that stoicism and perceptions of stigma within the system contribute to this, but other resulting factors may be influential at the provider- and organizational-levels. Stoicism and perceived stigma both appear to arise, in part, from an understandable knowledge gap regarding the care system. For instance, healthcare providers understand the relations between primary and secondary care, but many patients may perceive both concepts as elements of a single healthcare system [ 89 ]. Any issue experienced by a patient when tasked to see both a primary and secondary provider may result in a patient becoming confused [ 90 ]. This may also overlap with our third theme, as a disjointed means of communication between healthcare providers can exacerbate patients’ negative experiences. One consideration to improve this is to incorporate telehealth programs into an existing referral framework to reduce unnecessary interfacility transfers; telehealth programs have proven effective in rural and remote settings [ 91 ].

In fact, telehealth has been rolled out in a variety of virtual platforms throughout its evolution, its innovation matched with continued technological advancement. Simply put, telehealth allows health service delivery from a distance; it allows knowledge and practice of clinical care to be in a different space than a patient. Because of this, a primary benefit of telehealth is its impact on improving patient-centered outcomes among those living in rural areas. For instance, text messaging technology improves early infant diagnosis, adherence to recommended diagnostic testing, and participant engagement in lifestyle change interventions [ 92 , 93 , 94 ]. More sophisticated interventions have found their way into smartphone-based technology, some of which are accessible even without an internet connection [ 95 , 96 ]. Internet accessibility is important because a number of study participants noted internet connectivity as a barrier for patients who live in low resource communities. Videoconferencing is another function of telehealth that has delivered a variety of health services, including those which are mental health-specific [ 97 ], and mobile health clinics have been used in rural, hard-to-reach settings to show the delivery of quality healthcare is both feasible and acceptable [ 98 , 99 , 100 ]. While telehealth has potential to reduce a number of healthcare access barriers, it may not always address the most pressing healthcare needs [ 101 ]. However, telehealth does serve as a viable, cost-effective alternative for rural populations with limited physical access to specialized services [ 102 ]. With time and resource limitations acknowledged as a key theme in our study, an emphasis on expanding telehealth services is encouraged as it will likely have significant involvement on advancing healthcare in the future, especially as the COVID-19 pandemic persists [ 103 ].

Implications for Policy

One could argue that most of the areas of fragmentation in the US healthcare system can be linked to the very philosophy on which it is based: an emphasis on profits as highest priority. Americans are, therefore, forced to navigate a health service system that does not work solely in their best interests. It is not surprising to observe lower rates of healthcare usage in rural areas, which may be a result from rural persons’ negative views of the US healthcare system or a perception that the system does not exist to support wellness. These perceptions may interact with ‘rugged individualism’ to squelch rural residents’ engagement in healthcare. Many of the providers we interviewed for this study appeared to understand this and strived to improve their patients’ experiences and outcomes. Though these efforts are admirable, they may not characterize all providers who serve in rural areas of the US. From a policy standpoint, it is important to recognize these expansive efforts from providers. If incentives were offered to encourage maximum efforts be made, it may lessen burden due to physician burnout and fatigue. Of course, there is no easy fix to the persisting limit of time and resources for providers, problems that require workforce expansion. Ultimately, though, the current structure of the US healthcare system is failing rural America and doing little to help the practice of rural healthcare providers.

Implications for Future Research

It is important for future health systems research efforts to consider issues that arise from both individual- and system-level access barriers and where the two intersect. Oftentimes, challenges that appear linked to a patient or provider may actually stem from an overarching system failure. If failures are critically and properly addressed, we may refine our understanding of what we can do in our professional spaces to improve care as practitioners, workforce developers, researchers and advocates. This qualitative study was exploratory in nature. It represents a step forward in knowledge generation regarding challenges in access to healthcare for rural Americans. Although mental health did not come up by design in this study, future efforts exploring barriers to healthcare access in rural systems should focus on access to mental healthcare. In many rural areas, Montana included, rates of suicide, substance use and other mental health disorders are highly prevalent. These characteristics should be part of the overall discussion of access to healthcare in rural areas. Optimally, barriers to healthcare access should continue to be explored through qualitative and mixed study designs to honor its multi-dimensional stature.

Strengths and Limitations

It is important to note first that this study interviewed healthcare providers instead of patients, which served as both a strength and limitation. Healthcare providers were able to draw on numerous patient-provider experiences, enabling an account of the aggregate which would have been impossible for a patient population. However, accounts of healthcare providers’ perceptions of barriers to healthcare access for their patients may differ from patients’ specific views. Future research should examine acceptability- and appropriateness-related barriers to healthcare access in patient populations. Second, study participants were recruited through convenience sampling methods, so results may be biased towards healthcare providers who are more invested in addressing barriers to healthcare access. Particularly, the providers interviewed for this study represented a subset who go beyond expectations of their job descriptions by engaging with their communities and spending additional uncompensated time with their patients. It is likely that a provider who exhibits these behavioral traits is more likely to participate in research aimed at addressing barriers to healthcare access. Third, the inability to conduct face-to-face interviews for our qualitative study may have posed an additional limitation. It is possible, for example, that in-person interviews might have resulted in increased rapport with study participants. Notwithstanding this possibility, the remote interview format was necessary to accommodate health risks to the ongoing COVID-19 pandemic. Ultimately, given our qualitative approach, results from our study cannot be generalizable to all rural providers’ views or other rural health systems. In addition, no causality can be inferred regarding the influence of aspects of rurality on access. The purpose of this exploratory qualitative study was to probe research questions for future efforts. We also acknowledge the authors’ roles in the research, also known as reflexivity. The first author was the only author who administered interviews and had no prior relationships with all but one study participant. Assumptions and pre-dispositions to interview content by the first author were regularly addressed throughout data analysis to maintain study integrity. This was achieved by conducting analysis by unique interview question, rather than by unique participant, and recoding the numerical order of participants for each question. Our commitment to rigorous qualitative methods was a strength for the study for multiple reasons. Conducting member checks with participants ensured trustworthiness of findings. Continuing data collection to data saturation ensured dependability of findings, which was achieved after 10 interviews and confirmed after 2 additional interviews. We further recognize the heterogeneity in our sample of participants, which helped generate variability in responses. To remain consistent with appropriate means of presenting results in qualitative research however, we shared minimal demographic information about our study participants to ensure confidentiality.

The divide between urban and rural health stretches beyond a disproportionate allocation of resources. Rural health systems serve a more complicated and hard-to-reach patient population. They lack sufficient numbers of providers to meet population health needs. These disparities impact collaboration between patients and providers as well as the delivery of acceptable and appropriate healthcare. The marker of rurality complicates the already cumbersome challenge of administering acceptable and appropriate healthcare and impediments stemming from rurality require continued monitoring to improve patient experiences and outcomes. Our qualitative study explored rural healthcare providers’ views on some of the social, cultural, and programmatic factors that influence access to healthcare among their patient populations. We identified five key themes: 1) a friction exists between aspects of patients’ rural identities and healthcare systems; 2) facilitating access to healthcare requires application of and respect for cultural differences; 3) communication between healthcare providers is systematically fragmented; 4) time and resource constraints disproportionately harm rural health systems; and 5) profits are prioritized over addressing barriers to healthcare access in the US. This study provides implications that may shift the landscape of a healthcare provider’s approach to delivering healthcare. Further exploration is required to understand the effects these characteristics have on measurable patient-centered outcomes in rural areas.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to individual privacy could be compromised but are available from the corresponding author on reasonable request.

Ethics approval and consent to participate.

All study procedures and methods were carried out in accordance with relevant guidelines and regulations from the World Medical Association Declaration of Helsinki. Ethics approval was given by exempt review from the Institutional Review Board (IRB) at the University of Montana (IRB Protocol No.: 186–20). Participants received oral and written information about the study prior to interview, which allowed them to provide informed consent for the interviews to be recorded and used for qualitative research purposes. No ethical concerns were experienced in this study pertaining to human subjects.

Consent for publication.

The participants consented to the publication of de-identified material from the interviews.

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Acknowledgements

This research was supported by the Center for Biomedical Research Excellence award (P20GM130418) from the National Institute of General Medical Sciences of the National Institute of Health. The first author was also supported by the University of Montana Burnham Population Health Fellowship. We would like to thank Dr. Christopher Dietrich, Dr. Jennifer Robohm and Dr. Eric Arzubi for their contributions on determining inclusion criteria for the healthcare provider population used for this study.

 This research did not receive any specific grant from funding agencies in the public, commercial, and not-for-profit sectors. 

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The authors confirm contribution to the paper as follows: study conception and design: NC and JC; data collection: NC; analysis and interpretation of results: NC and JC; draft manuscript preparation: NC, DC and JC; and manuscript editing: NC, DC and JC. All authors reviewed the results and approved the final version of the manuscript.

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Coombs, N.C., Campbell, D.G. & Caringi, J. A qualitative study of rural healthcare providers’ views of social, cultural, and programmatic barriers to healthcare access. BMC Health Serv Res 22 , 438 (2022). https://doi.org/10.1186/s12913-022-07829-2

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Retirement planning – a systematic review of literature and future research directions

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Rising life expectancy and an aging population across nations are leading to an increased need for long-term financial savings and a focus on the financial well-being of retired individuals amidst changing policy framework. This study is a systematic review based on a scientific way of producing high-quality evidence based on 191 articles from the Scopus and Web of Science databases. It adopts the Theory, Context, Characteristics, and Method (TCCM) framework to analyze literature. This study provides collective insights into financial decision-making for retirement savings and identifies constructs for operationalizing and measuring financial behavior for retirement planning. Further, it indicates the need for an interdisciplinary approach. Though cognitive areas were studied extensively, the non-cognitive areas received little attention. Qualitative research design is gaining prominence in research over other methods, with the sparse application of mixed methods design. The study’s TCCM framework explicates several areas for further research. Furthermore, it guides the practice and policy by integrating empirical evidence and concomitant findings. Coherent synthesis of the extant literature reconciles the highly fragmented field of retirement planning. No research reports prospective areas for further analysis based on the TCCM framework on retirement planning, which highlights the uniqueness of the study.

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Acknowledgment.

Elderly population is defined as a population aged 65 years and over.

Defined benefit plan guarantees benefits to the employee, while defined contribution plan requires employees to decide on their own investment and bear the financial risks identified with it.

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Insulin resistance in polycystic ovary syndrome across various tissues: an updated review of pathogenesis, evaluation, and treatment

• Han Zhao 1 ,
• Jiaqi Zhang 1 ,
• Xiangyi Cheng 1 ,
• Xiaozhao Nie 1 &
• Bing He 1  

Journal of Ovarian Research volume  16 , Article number:  9 ( 2023 ) Cite this article

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Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by chronic ovulation dysfunction and overabundance of androgens; it affects 6–20% of women of reproductive age. PCOS involves various pathophysiological factors, and affected women usually have significant insulin resistance (IR), which is a major cause of PCOS. IR and compensatory hyperinsulinaemia have differing pathogeneses in various tissues, and IR varies among different PCOS phenotypes. Genetic and epigenetic changes, hyperandrogenaemia, and obesity aggravate IR. Insulin sensitization drugs are a new treatment modality for PCOS. We searched PubMed, Google Scholar, Elsevier, and UpToDate databases in this review, and focused on the pathogenesis of IR in women with PCOS and the pathophysiology of IR in various tissues. In addition, the review provides a comprehensive overview of the current progress in the efficacy of insulin sensitization therapy in the management of PCOS, providing the latest evidence for the clinical treatment of women with PCOS and IR.

Polycystic ovary syndrome (PCOS) is currently recognized as the most common endocrine disorder in women of reproductive age, with a worldwide prevalence ranging from 6 to 21%, depending on the diagnostic criteria [ 1 , 2 , 3 , 4 , 5 ]. PCOS is a heterogeneous disease characterized by hyperandrogenism, dysfunctional ovulation, and polycystic ovary morphology, accompanied by metabolic abnormalities, such as insulin resistance (IR) and obesity. However, the underlying pathogenesis of PCOS remains unclear. Recent studies have suggested that genetics, epigenetic changes, environmental factors, oxidative stress, chronic low-grade inflammation, mitochondrial dysfunction, and metabolic disorders are involved in PCOS, thus damaging normal ovarian function [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 ]. IR and compensatory hyperinsulinaemia (HI) are considered major drivers of PCOS pathophysiology and are involved in the development of hyperandrogenaemia and reproductive dysfunction by various mechanisms [ 14 ].

IR and compensatory hyperinsulinaemia (HI) are present in 65–95% of women with PCOS, including the vast majority of overweight and obese women and more than half of women of normal weight. IR is independent of and exacerbated by obesity [ 14 , 15 , 16 , 17 , 18 ]. Currently, there are four commonly recognized phenotypes of PCOS: type A, polycystic ovary (PCO), chronic oligo-anovulation (OA) and hyperandrogenism (HA); type B, OA and HA; type C, PCO and HA; and type D, PCO and OA [ 19 ]. IR is present in all phenotypes, and insulin sensitivity varies according to the PCOS phenotype. IR is the most common classical phenotype (Types A and B) (80%), followed by ovulating PCOS (65%) and non-hyperandrogenaemic PCOS (38%) [ 20 ]. Women with PCOS and IR have a significantly increased risk of adverse pregnancy outcomes [ 21 , 22 ] and chronic diseases, such as type 2 diabetes mellitus (T2DM), cardiovascular disease, and metabolic syndrome, which seriously affect the physical and mental health of women of childbearing age, increasing their social burden [ 23 , 24 , 25 ]. However, the root cause of IR in PCOS is largely unknown and the underlying mechanism remains to be elucidated. Therefore, recognizing the strong influence of IR on the occurrence and development of PCOS, accurate assessment of insulin sensitivity in the early stages of PCOS, and effective intervention on IR are essential to reduce the risk of long-term complications. Lifestyle change is the treatment of choice for all women with PCOS, and insulin sensitization is a promising choice for the chronic treatment of women with PCOS. This paper aims to summarize recent findings on the involvement of IR in the occurrence and development of PCOS and the mechanism of IR in various tissues. Furthermore, we aim to summarize and provide an update on the current research status of insulin sensitization therapy for women with PCOS to provide more effective and reasonable clinical treatment.

An extensive literature search was performed up to July 2022 in PubMed, Google Scholar, Elsevier, and UpToDate databases. Keywords and subject terms included (“PCOS” AND “insulin”) OR (“PCOS” AND “insulin” AND “tissues”) OR (“PCOS” AND “insulin” AND “pathogenesis”) OR (“PCOS” AND “insulin” AND “diagnosis”) OR (“PCOS” AND “insulin” AND “evaluation”) OR (“PCOS” AND “insulin” AND “therapy”). Only English-language research papers were considered. In addition, publications focus on the new ones (since 2018) and exclude those without full manuscripts.

Pathogenesis of insulin resistance in polycystic ovary syndrome

Genetics and foetal origin.

PCOS is an autosomal dominant genetic disease with various expression patterns that begins in early life, and metabolic changes precede reproductive abnormalities. A clustering analysis of 893 women with PCOS identified the metabolic subtype of PCOS, which was characterized by higher BMI and glucose and insulin levels with relatively low SHBG and LH levels [ 5 ]. IR is one of the prominent phenotypic characteristics of PCOS [ 26 ]. Twin and family cluster studies have suggested HI has a genetic component in PCOS, and a family history of T2DM is associated with significant insulin secretion defects [ 27 , 28 ]. The daughters of women with PCOS develop HI and lower adiponectin levels before puberty [ 29 ], which persist throughout adolescence [ 30 ].

PCOS is associated with specific gene mutations, and most gene variants identified in genome-wide association studies are involved in regulating sheath steroid production, follicular maturation, or insulin signalling through the modified proteins they encode, such as insulin receptors, LH/HCG receptor activators, cell traffic proteins, and transcription factors [ 31 , 32 ]. Genome-wide association studies on European, Chinese, and Indian populations have established that some insulin receptor (INSR) gene variants (rs2059807 and rs1799817) are significantly associated with IR in women with PCOS [ 33 , 34 ]. Studies of Indian women suggest that C/T polymorphisms in the INSR tyrosine kinase domain may be susceptible variants in women with normal-weight PCOS, contributing to the development of IR and compensatory HI [ 35 ]. A meta-analysis showed that the Gly972Arg polymorphism in insulin receptor substrate 1 (IRS-1) mediates the pathogenesis of PCOS by increasing fasting glucose levels and is a risk factor for susceptibility to PCOS [ 36 , 37 ]. However, the genetic assessment of insulin-related genes is affected by the diagnostic criteria and genotyping methods employed with patients, resulting in different results [ 38 ]. Exposure to adverse intrauterine environments can lead to varying degrees of IR and HI. Exposure to dihydrotestosterone and insulin in the second trimester of pregnancy produces a PCOS-like phenotype and increases the risk of miscarriage [ 39 ]. Intrauterine growth restriction can affect foetal insulin secretion, and insulin resistance trends in PCOS may be involved in developmental origin and preprogramming as a nutritional compensation mechanism [ 40 , 41 ]. Adolescents and young women with a history of low birth weight are more likely than normal women to have PCOS-like manifestations of IR and high androgen levels [ 42 , 43 ].

• Insulin signal transduction pathway

Insulin is a small peptide receptor-binding hormone released by pancreatic beta cells, which binds to cell surface receptors. INSR is a heterotetramer composed of α- and β-subunits linked by disulphide bonds. The extracellular α-subunit is responsible for binding to the ligands. The β-subunit is a glycoprotein spanning the cell membrane with tyrosine kinase activity [ 44 ]. Insulin binding to receptors induces specific tyrosine autophosphorylation, which phosphorylates intracellular substrates, including IRS1-4, SRC homologues, and collagen homologues (Shc), leading to a complex intracellular cascade that initiates insulin signal transduction [ 45 ]. Insulin has two main signalling pathways: metabolism and mitosis. Metabolism is primarily mediated through phosphatidylinositol 3-kinase (PI3-K) and serine/threonine kinase Akt/protein kinase B (PKB), also known as the PI3-K pathway. Through these pathways, insulin stimulates glucose uptake by promoting the translocation of glucose transporter 4 (GLUT4) from intracellular vesicles to the cell surface [ 46 ] and leads to the inactivation of serine phosphorylation of glycogen synthase kinase 3 (GSK3), increasing glycogen, fatty acid, and protein synthesis. It also activates mammalian target of rapamycin (mTOR) to regulate protein synthesis and degradation [ 46 ]. The mitotic pathway is the mitogen-activated protein kinase-extracellular signal-regulated kinase (MAPK-ERK) pathway, which is activated by insulin receptor-mediated phosphorylation of Shc or IRS. This progressively stimulates the translocation of cascade erk1/2 to the nucleus and phosphorylates transcription factors to stimulate cell growth and differentiation and regulate gene expression [ 47 , 48 ]. Increased serine phosphorylation and decreased tyrosine phosphorylation of insulin receptors and IRS can terminate insulin action, resulting in post-binding defects in insulin signal transduction and leading to insulin dysfunction in women with PCOS [ 49 , 50 ].

Hyperinsulinaemia and tissue insulin resistance

IR in PCOS is caused by impaired insulin action in various target tissues, which is characterized by basal compensatory HI and a reduced insulin response to glucose overload. PCOS affects the majority of organ systems and tissues. Insulin plays different roles in different tissues in balancing the supply and demand of nutrients. HI caused by tissue IR is central to PCOS pathology [ 51 ]. IR in women with PCOS selectively and mutually affects metabolism or mitotic pathways in classical insulin target tissues (e.g., liver, skeletal muscle, and adipose tissue) and non-classical insulin target tissues (e.g., ovary, pituitary gland) [ 52 ]. In addition, androgen overload, lipid deposition, inflammatory cytokines, and other systemic factors are also involved in the IR process of peripheral tissues [ 53 ] (Fig.  1 ).

A summary of the most representative impact of IR and HI in women with PCOS. Abbreviations: SHBG: sex hormone-binding globulin; LH: luteinizing hormone; IGF1: insulin growth factor 1; GnRH: gonadotropin-releasing hormone; ACTH: adrenocorticotropic hormone; HPO: Hypothalamus-pituitary-ovary; HPA: Hypothalamus–pituitary–adrenal

Adipose tissue

Adipose tissue plays a central role in systemic glucose metabolism and insulin sensitivity. Compared with body mass index (BMI)-matched control women, women with PCOS showed systemic fat accumulation and significantly increased subcutaneous fat cell volume, whereas visceral fat volume was only increased in PCOS phenotype A [ 54 , 55 , 56 ]. The increase in adipose tissue volume, especially visceral adipose tissue volume, is closely associated with whole-body IR [ 57 ]. The IR of adipose tissue results in decreased glucose uptake and lipid accumulation, and significantly inhibits lipid decomposition. Excessive fatty acids flow into skeletal muscle and liver, resulting in lipid storage and aggravating IR of skeletal muscle and the liver [ 58 ].

Adipose tissue IR in women with PCOS is influenced by circulating androgen levels and excessive energy intake. Androgens induce adipocyte IR by affecting the phosphorylation of insulin-stimulated protein kinase C (PKC), leading to a decrease in insulin-induced GLUT-4 content in PCOS abdominal subcutaneous adipocytes and a decrease in insulin-stimulated serine phosphorylation of GSK3, indicating the presence of insulin receptor binding or phosphorylation defects in adipocyte IR [ 59 ]. This impairs the effect of insulin on glucose metabolism but does not affect insulin-induced mitosis [ 59 ]. Androgens also regulate lipid metabolism and adipocyte differentiation, and induce the accumulation of abdominal adipose tissue. Animal models have shown that prenatal and postnatal exposure to androgens can lead to enlargement of adipocytes, accumulation of visceral fat, and decreased insulin sensitivity in women [ 60 , 61 ]. In addition, testosterone is specific to catecholamine-stimulated lipolysis and can reduce the sensitivity of human subcutaneous fat cells but not visceral fat cells [ 62 ].

Type 1C3 aldosterone reductase (AKR1C3) is the only enzyme expressed in adipose tissue that can convert androstenedione into testosterone, which is widely expressed in the adipose tissue of patients with PCOS [ 63 ]. Studies have shown that AKR1C3 is the main driver of active androgen production in PCOS adipose tissue [ 63 ]. In addition, AKR1C3 expression is regulated by insulin [ 64 ], suggesting a significant correlation between testosterone and circulating insulin levels in adipose tissue. Increased androgen production in adipose tissue and subsequent lipid accumulation and fat mass can lead to systemic IR and lipotoxic organ damage in patients with PCOS [ 63 ]. HI further exacerbates hyperandrogenaemia, resulting in a vicious cycle that exacerbates poor metabolic performance [ 63 ]. In addition, free testosterone seen in PCOS is inversely proportional to the serum level of high-molecular-weight adiponectin, a collagen-like protein synthesized only by adipose cells, which has insulin sensitization and anti-inflammatory effects and decreases with adipose tissue volume [ 65 ]. Decreased adiponectin levels result in decreased PKC activity and insulin signalling [ 66 ]. Adiponectin also stimulates the secretion of hepatic sex hormone-binding globulin (SHBG), suggesting that the effect of androgen’on adipose IR may be influenced by hepatic SHBG through serum free testosterone levels [ 66 ]. Increased adipose tissue and its dysfunction may exacerbate physiological factors and cytokine levels, such as leptin, interleukin 6, and tumour necrosis factor alpha, thereby promoting low-level inflammation, interfering with insulin signalling, causing adipose tissue to release free fatty acids, increasing ectopic fat deposition, and aggravating IR on one’s own and other organizations [ 67 , 68 , 69 ].

Skeletal muscle

Skeletal muscle is responsible for most peripheral glucose uptake regulation, and almost two thirds of the glucose intake after meals is absorbed by skeletal muscle through insulin-dependent mechanisms, making it the most important insulin-resistant tissue [ 70 ]. Muscle insulin-mediated glucose processing, as measured by a normal glucose clamp, was significantly reduced in all women with PCOS compared to women without PCOS [ 71 ]. Skeletal muscle IR in women with PCOS is reflected by impaired insulin-stimulated glucose processing, which is a major risk factor for T2DM in women with PCOS [ 51 ]. However, human studies have not yet determined the molecular mechanism of PCOS-specific IR in skeletal muscle, and there have been many conflicting findings. The potential mechanisms currently considered include genetic and epigenetic programming, signalling pathway and mitochondrial dysfunction, intracellular and extracellular lipid accumulation, and organ system crosstalk [ 72 ].

Initial studies of muscle tissue and cultured myoducts and fibroblasts [ 73 , 74 ] found elevated phosphorylation of serine residues on IRS1/2, resulting in the translocation of GLUT4 and reduced glucose uptake, suggesting defective signalling at the proximal insulin site. Skeletal muscle biopsies of women with PCOS revealed a significant decrease in insulin-mediated IRS1-related PI3-K activation, with an increase in IRS2 abundance as a compensatory change after targeted IRS1 destruction. Subsequent skeletal muscle studies showed decreased phosphorylation of Akt/PKB and the Akt substrate 160-KDA (AS160) [ 75 ]. These studies in obese women with PCOS suggest that possible PCOS-specific defect in insulin signaling of skeletal muscle is proximal and distal to IRS1/2. Hansen et al. studied molecular mechanisms in skeletal muscle underlying IR in normal-weight women with PCOS, finding that decreased insulin sensitivity may only play a role in skeletal muscle IR through AMPK and is associated with low circulating adiponectin levels [ 76 ]. In addition, a lack of insulin-stimulated pyruvate dehydrogenase activation in skeletal muscle may lead to reduced systemic metabolic flexibility and mediation of IR through metabolic signalling pathways [ 76 ]. Furthermore, constitutive activation of the mitotic signal MAPK-ERK1/2 has also been found in skeletal muscle biopsies of women with PCOS, which promotes serine phosphorylation of IRS1 and reduces metabolic signalling in PCOS myotube [ 77 ], suggesting that IR may impact both the metabolic and mitotic pathways in skeletal muscle of women with PCOS.

Animal studies have shown that hyperandrogenaemia promotes IR by increasing serine phosphorylation of Akt/PKB, mTOR ribosomal S6 kinase, and IRS1 in myotubes and promoting visceral fat accumulation [ 78 ]. In addition, hyperandrogenaemia may increase inflammation by activating nuclear factor kappa B (NF-κB), which in turn affects intracellular enzyme pathways associated with insulin receptors [ 51 ]. A recent meta-analysis suggested that obesity, but not HA or IR, appears to predict skeletal muscle mass in reproductive-aged women with PCOS [ 79 ]. Intramuscular lipid accumulation within muscle cells or between fibres may account for a small percentage of skeletal muscle IR [ 80 ]. PCOS is associated with abnormal skeletal muscle gene expression, and it is affected by specific changes in DNA methylation [ 72 ]. Furthermore, a link between TGF-β superfamily ligand signalling and extracellular matrix deposition in PCOS-specific IR results in inappropriate crossing between these cells and their host organs, suggesting that epigenetic as well as tissue crossing is involved in skeletal muscle metabolic abnormalities [ 72 ]. Mitochondrial oxidative phosphorylation genes are downregulated in the skeletal muscle of women with PCOS, suggesting that mitochondrial dysfunction is involved in PCOS-specific IR formation [ 72 , 81 ].

Liver tissue

The liver is also the main site of glucose uptake and storage, accounting for one third of postprandial glucose processing, and the main site of insulin clearance [ 81 ]. Insulin in the liver promotes glycogen synthesis and de novo lipogenesis while also inhibiting gluconeogenesis. PCOS-related hepatic IR is usually only present in obese women, leading to a deficiency in insulin-stimulated liver glycogen synthesis and insulin-mediated inhibition of hepatic glucose production [ 82 ]. IR and compensatory HI can directly inhibit the synthesis of liver SHBG and insulin growth factor 1 (IGF1) binding protein. The former is a glycoprotein synthesized mainly in the liver, and its reduced synthesis leads to increased free testosterone levels [ 83 ]. The reduction of the latter increases the circulating concentration of IGF1, which not only triggers the ovarian membrane cells to produce more androgens, but also reduces specific microRNAs, thus accelerating the apoptosis of granulosa cells and inhibiting follicular development. These two effects together lead to hyperandrogenaemia and follicular development disorders in PCOS [ 13 ].

Insulin in the liver can directly regulate glucose and lipid metabolism and can also be indirectly regulated by fat and muscle insulin action. Direct effects activate de novo lipogenesis, convert excess carbohydrate substrates to triglycerides, and promote liver triglyceride delivery to adipose tissue [ 82 ]. Indirect effects are mainly caused by insulin-mediated inhibition of lipolysis in adipose tissue, which leads to an increase in circulating plasma non-fatty acids in the liver and promotes fat deposition in the liver. Approximately 59% of the lipids in hepatocytes are derived from non-fatty acids produced by adipolysis [ 82 ]. The liver-specific insulin receptor knockout (LIRKO) mouse model suggests that the insulin signalling is essential for the regulation of glucose homoeostasis in the liver and maintenance of normal liver function [ 84 ]; further, it is also a prerequisite for the indirect regulation of adipose insulin. LIRKO mice still showed obvious IR, severe glucose intolerance, and resistance to insulin’s ability to inhibit liver sugar production under the premise of normal insulin signal transduction in fat and muscle tissues [ 82 ]. In addition, hepatic lipid accumulation activates diacylglycerol/PKC and inhibits insulin receptors, affecting insulin signalling and subsequent gluconeogenesis, thereby exacerbating hepatic IR [ 53 ].

In vitro and in vivo studies of liver-specific androgen receptor (AR) gene knockout have found that AR signalling in liver cells mediates hepatic IR in hyperandrogenaemia-induced female mice through a cascade of changes in hepatic insulin signalling and phosphorylation, suggesting that androgens are involved in hepatic IR [ 85 ]. Long-term androgen excess can induce hepatic insulin resistance and steatosis in PCOS-like rats. Under hepatic IR, excessive androgens can promote the development of non-alcoholic fatty liver disease (NAFLD) through apoptosis and autophagy in the liver mitochondria [ 86 ]. NAFLD, a metabolic syndrome characterized by abnormal fat accumulation, is now considered the most common chronic liver disease in the United States, and its prevalence in PCOS has increased significantly in recent years [ 87 ]. Several human studies have shown a close association between NAFLD and liver IR, and IR is an important risk factor for NAFLD in PCOS [ 88 , 89 , 90 ].

The ovaries and uterus

Ovarian androgen overload is the core of PCOS. HI enhances intrathecal steroid production and leads to impaired follicular maturation. Insulin receptors are widely distributed in stromal and follicular ovarian cells, and there is considerable evidence for the direct ovarian effect of insulin on steroid production and the importance of insulin-signalling pathways in ovulation control [ 91 , 92 ]. Under physiological conditions, insulin acts as a helper gonadotropin through its homologous receptor to increase LH-induced androgen synthesis in membrane cells, and LH induces luteinization in granulosa cells [ 93 ]. HI can lead to androgen-dependent anovulation via different mechanisms. Membrane cells are the main site of androgen production in the ovaries. Insulin acts on the membrane cells of the ovary to directly trigger androgen synthesis by increasing the activity of cytochrome P450c17α, a key enzyme that regulates androgen biosynthesis encoded by CYP17. Insulin can also cooperate with LH. The 17α-hydroxylase activity of P450c17 is activated by PI3-K signalling to induce androgen synthesis in membrane cells [ 94 , 95 , 96 , 97 ]. The membrane cells of women with PCOS are more sensitive to the hyperandrogenic effects of insulin than healthy women [ 51 ]. In anovulatory PCOS granulosa cells, the synergistic effect of high insulin and LH levels may induce premature expression of LH receptors in small follicular subsets, leading to premature differentiation of granulosa cells and follicular growth stagnation [ 98 ]. The effect of insulin on glucose metabolism was significantly reduced in granular lutein cells isolated from the ovaries of women with typical PCOS phenotypes, whereas the effect of insulin on steroid production was unchanged [ 98 ]. Reduced phosphorylation of MEk1/2 and MApK-ERk1/2 in PCOS was associated with increased P450c17 expression compared with that in normal membrane cells, contrary to the findings of increased phosphorylation of MEk1/2 and MApK-ERk1/2 in PCOS skeletal muscle [ 74 ]. These results suggest the existence of selective insulin resistance in PCOS ovarian tissue.

Energy metabolism is also critical for normal endometrial function, and endometrial studies of patients with PCOS have shown that IR and HI also negatively affect endometrial physiology. Endometrial tissues express molecules involved in insulin signalling pathways, and the expression of insulin receptors, IRS proteins, AS160, PKC, and GLUT4 in the endometrium of women with PCOS is impaired and associated with adverse reproductive outcomes [ 39 ]. Hyperinsulinaemia can impair decidualization of endometrial stromal cells in vitro through the transcriptional inhibition of FOXO-1 [ 99 ]. In addition, hyperandrogenaemia plays a role in the insulin signalling pathway of the endometrium, reducing the expression of INRS-1 and GLUT-4 in endometrial glandular epithelial cells [ 100 ]. The insulin sensitizer metformin promotes GLUT4 transcription by increasing AMPK, improves IR, and indirectly restores endometrial function in PCOS patients [ 101 ].

Central nervous system

Insulin affects the hypothalamic-pituitary system and can increase the frequency and amplitude of gonadotropin-releasing hormone (GnRH) release pulses through MAPK and increase GnRH gene expression, thereby increasing LH release, enhancing androgen biosynthesis in the ovary, and impairing ovarian function [ 102 ]. Insulin signalling in the central nervous system plays an important role in normal reproduction and body weight regulation. Female mice with neuron-specific destruction of IR genes show increased food intake, disrupted LH release, and impaired ovarian follicle maturation [ 103 , 104 ]. Leptin, one of the earliest known adipokines, is essential in the hypothalamus for maintaining normal body weight and insulin sensitivity [ 105 ]. Specific knockout of insulin receptors and leptin receptors in hypothalamic proopiomelanocortin neurons induces a PCOS phenotype [ 106 ]. The pituitary gland is one of the most important components of the PCOS insulin. Insulin can directly stimulate LH secretion, leading to abnormal reproductive function in PCOS patients [ 107 ]. In addition, IR- and HI-mediated reduction of pituitary sensitivity to GnRH and disruption of pituitary insulin receptors can lead to anovulation [ 108 ]. Women with PCOS had a higher ACTH response to corticotropin-releasing hormone (CRH) stimulation than women who ovulate normally, which was strongly associated with HI severity [ 109 ]. IR and compensatory HI can increase adrenal androgen levels and aggravate PCOS hyperandrogenaemia by increasing adrenal sensitivity to ACTH [ 110 ].

Women with PCOS show hyperactivation of the AR in the preoptic area, hypothalamus, and other limbic structures [ 110 ]. Animal studies have found that male mice with neuronal AR deletions exhibit hypothalamic IR, suggesting that androgens may also promote IR by acting on the central nervous system [ 111 ]. In addition, increased leptin expression in the hypothalamus can aggravate obesity, and enhanced leptin secretion by adipocytes can further contribute to the induction of IR [ 48 ]. the two interact to cause metabolic disorders in PCOS.

Factors affecting insulin resistance in polycystic ovary syndrome

Epigenetic changes (DNA methylation, histone status, and miRNA expression) are involved in the regulation of IR in women with PCOS. A study identified 79 differentially methylated genes in women who have PCOS with or without IR [ 112 ], and hypermethylation of the LAMIN gene promoter was associated with IR in PCOS [ 113 ]. MicroRNAs (miRNAs) are small non-coding RNA involved in the post-transcriptional regulation of genes. As regulators of gene expression, miRNAs are essential genes involved in the control of androgen synthesis, inflammation, adipogenesis, and signalling [ 114 ]. There are significant differences in miRNA expression levels between women with PCOS and healthy women [ 114 ]. Studies have shown that microRNAs secreted into the circulation by adipocyte exosomes and adipose tissue macrophages affect the PI3K/Akt-GLUT4 signalling pathway [ 115 ]. Mir-155-5p and related target genes of PCOS are concentrated in the insulin-sensitive pathway of the ovary, and Mir-222 is also positively correlated with serum insulin levels, suggesting their potential value as biomarkers of PCOS [ 115 ].

Insulin sensitivity can also be negatively affected by changes in diet, the environment, and mood. Recent studies suggest that an imbalance of intestinal flora and abnormal levels of metabolites produced by bacteria in individuals with may lead to insulin receptor signalling deficiency, leading to IR by causing immune system dysfunction, the development of chronic low-grade inflammation, and the enhancement of proinflammatory cytokine synthesis [ 116 ]. Vitamin D deficiency can also affect insulin signalling in tissues by affecting intracellular calcium regulation and exacerbating inflammatory responses [ 117 , 118 ]. Melatonin is involved in regulating insulin secretion, and decreased melatonin secretion at night is associated with increased IR [ 119 ]. In addition, melatonin’s action is mediated by the melatonin receptor (MTNR), and activation of the MTNR1B signalling pathway in pancreatic beta cells reduces insulin secretion [ 120 , 121 , 122 ]. A meta-analysis also showed that MTNR1B RS1083096 and RS2119882 are involved in the pathogenesis of IR in Chinese women with PCOS [ 123 ]. Advanced glycation end products alter cellular translocation of insulin intracellular signalling and glucose transporters in PCOS through a variety of mechanisms, leading to tissue IR [ 124 ]. The endocrine disruptor bisphenol A also disrupts glucolipid metabolism and induces IR in PCOS by altering insulin secretion, adipocyte differentiation, and adipokine secretion [ 125 ]. In addition, chronic stress can trigger the release of cortisol from the hypothalamic–pituitary–adrenal axis, which can stimulate visceral fat accumulation, gluconeogenesis, and lipolysis, leading to IR [ 126 , 127 ].

Diagnosis and evaluation of insulin resistance in polycystic ovary syndrome

The glucose clamp technique is the ‘gold standard’ for evaluating metabolic insulin resistance in vivo. The amount of glucose injected in the steady state was equal to the amount of glucose absorbed by the peripheral tissue, which can be used to measure peripheral sensitivity to insulin [ 128 ]. Minimal model analysis using a frequently sampled intravenous glucose tolerance test (FSIGT) is an alternative to the simplified clamp procedure for assessing insulin secretion in insulin sensitivity experiments [ 129 ]. However, both the clamp test and FSIGT are complex, time-consuming, and expensive sampling procedures that are unsuitable for clinical practice. In recent years, clinical practice has developed many simple, cheap, and effective alternative quantitative indicators, such as BMI, waist circumference, waist-to-hip ratio, wrist circumference [ 130 ]and other anthropometric markers; fasting insulin, oral glucose tolerance test (OGTT), glucose/insulin ratio (G/I), homoeostasis model assessment of insulin resistance (HOMA-IR), quantitative insulin sensitivity test index (QUICKI) [ 131 ], lipid/lipoprotein ratio [ 132 , 133 , 134 ]and other biomarkers. These indices are reasonably correlated with each other and with the gold standard clamp technique. HOMA-IR is currently the best and most widely validated marker, but the cut-off point for the diagnosis of PCOS-IR is still not universally accepted [ 135 ]. Studies suggest that a more complex evaluation of the decrease in insulin sensitivity as a continuous variable is required in clinical practice [ 10 ]. In addition, owing to the strong association between inflammation and IR, inflammatory markers such as interleukin-6 (IL-6) [ 136 ] and ferritin [ 137 ] are becoming increasingly popular in the evaluation of IR, while cytokines such as leptin [ 138 ] and adiponectin [ 139 ] have also been proposed as new IR markers. However, conflicting data limit their use in clinical settings, and more studies are needed to clarify their suitability as IR markers in patients with PCOS [ 140 ].

Treatment of insulin resistance in polycystic ovary syndrome

Lifestyle change.

Guidelines recommend that once women are diagnosed with PCOS and have decreased insulin sensitivity, they should make lifestyle changes and start insulin sensitivity treatment immediately, even if there are no significant changes in glucose tolerance [ 141 ]. The first step in managing IR is lifestyle change, which is the cornerstone of improving multiple endocrine and metabolic disorders in women with PCOS [ 142 ] and can be achieved through appropriate diet and exercise recommendations [ 143 ]. Studies on the relationship between caloric intake and expenditure in women with PCOS have been inconsistent, with preliminary data suggesting that the diets of women with PCOS tend to be high in carbohydrates and fat [ 144 ], with decreased satiety and increased sweet cravings [ 145 ]. Calorie-restricted diets may be the best option for reducing IR and improving body composition [ 146 ]. Studies have shown that the Mediterranean diet—which emphasizes a high intake of vegetables, fruits, seafood, legumes, and nuts; whole grains as staple foods; and the promotion of vegetable oils—combined with a low-carbohydrate regimen improves endocrine disorders and menstrual cycles in overweight patients with PCOS [ 147 ]. International evidence-based guidelines recommend that all women with PCOS, especially those who are overweight or obese, engage in at least 150 min of aerobic exercise per week, including more than 90 min of vigorous exercise [ 148 ]. There have been conflicting conclusions regarding the efficacy of the choice of optimal exercise mode in improving insulin sensitivity in women with PCOS. The heterogeneity of PCOS necessitates individualization of treatment options, and it appears that exercise combined with additional dietary/drug intervention is better for improving insulin sensitivity than either intervention alone [ 149 , 150 , 151 ].

Sleep deprivation is associated with an increased risk of IR, obesity, and T2DM in women with PCOS; therefore, sleep management should also be part of lifestyle change in women with PCOS [ 152 ]. Ensuring adequate, high-quality sleep can be an important initial change in women with PCOS. Since IR is strongly and independently associated with depression in PCOS, lifestyle interventions should be supported by mental health professionals who can provide appropriate psychological care for women with PCOS [ 25 ]. PCOS treatment is a long-term process, and diet and physical exercise require high self-discipline, are time-consuming, and are prone to relapse. Targeting IR is an effective strategy for treating PCOS. Clinical and experimental studies in recent years have explored several promising new therapies for improving IR in women with PCOS. Common pharmacological approaches for reducing IR in women with PCOS are outlined in the chart below (Table 1 ).

• Insulin sensitization therapy

Metformin, the most widely used insulin sensitizer for PCOS, reduces hepatic glucose production, inhibits gluconeogenesis and adipogenesis, improves peripheral tissue sensitivity to insulin, and prevents excessive insulin activity in the ovary [ 153 ]. Numerous studies have shown that metformin not only reduces weight and metabolic disorders but also corrects menstrual patterns, restores ovulation, and even improves chances of pregnancy [ 154 ]. Evidence-based guidelines recommend the use of metformin in obese, insulin-resistant women with PCOS to manage weight and endocrine and metabolic disorders, in conjunction with lifestyle adjustments [ 155 , 156 ]. Metformin improves insulin sensitivity, alleviates metabolic disorders, and ameliorates polycystic symptoms in mice with PCOS by increasing the translocation of the glucose transporters GLUT1 and GLUT4 to cell membranes [ 157 ], activating the AMPK signalling pathway [ 158 ], and reconstructing the role of endogenous insulin-sensitizing molecules, such as adiponectin, in endometrial tissues under pathological conditions [ 159 ]. However, metformin use may be limited by gastrointestinal side effects [ 160 ].

Thiazolidinediones

Thiazolidinediones (TZDs) and peroxisome proliferator-activated receptor γ (PPAR-γ) agonists are true insulin sensitizers. PPAR-γ is a nuclear receptor that enhances insulin activity through a post-insulin receptor mechanism, primarily by improving insulin sensitivity in the adipose tissue and skeletal muscle [ 213 ]. TZDs can be used as alternative drug therapy for PCOS-related metabolic and reproductive abnormalities in women who cannot tolerate or respond poorly to metformin [ 161 , 162 , 213 ]. TZDs are effective as treatments for HI and IR in both lean and obese women with PCOS as well as in improving abnormal glucose tolerance, hyperandrogenaemia, and ovulation disorders in women with PCOS. Several studies and our mesh meta-analysis suggest that TZDs improve IR and dyslipidaemia in PCOS more than metformin does [ 163 , 214 , 215 ]. In addition, the combination of metformin and TZDs has a synergistic effect in the treatment of women with PCOS, conferring greater improvement in IR and menstrual frequency in PCOS than metformin alone [ 215 ]. Women with dyslipidaemia and PCOS may also consider rosiglitazone alone or in combination with low-dose metformin and lifestyle changes [ 119 ]. Compared to trioglitazone and rosiglitazone, pioglitazone shows a higher affinity for the specific receptor PPAR-γ, has more effective insulin sensitization and lower hepatotoxicity, but does not promote weight loss [ 109 ].

New antidiabetic drugs

Many new antidiabetic drugs have shown positive effects in the treatment of PCOS. Glucagon-like peptide-1 analogues (GLP-1RAs) mimic the incretin secreted by the distal small intestine, bind to insulin receptors on beta cells, stimulate insulin secretion, reduce glucagon secretion, inhibit hunger centres, and delay gastric emptying. They also exhibit anti-inflammatory properties [ 216 , 217 ]. Recent studies have shown that GLP-1RAs therapy has excellent therapeutic effects in improving hyperandrogenaemia, increasing menstrual frequency, reducing manifestations of metabolic disorders such as obesity and IR, and reducing long-term cardiovascular risk in obese women with PCOS [ 164 , 166 ]. The combination of GLP-1RAs and metformin appears to be superior to any single agent in reducing body weight, hyperandrogenaemia, IR, and ovulation disorders in women with PCOS and may even improve metabolic outcomes in women who previously had an inadequate response to metformin [ 162 , 217 ]. However, most GLP-1RAs are administered subcutaneously. Simultaneously, correct administration of medication is crucial to reduce the occurrence of adverse reactions [ 164 , 165 , 167 , 168 , 218 ]. Sitagliptin, a DPP-4 inhibitor, enhances early insulin secretion by reducing incretin and GLP-1 degradation, reduces peak glucose after oral glucose intake in overweight women with PCOS, and improves visceral obesity [ 169 ].

Sodium-glucose cotransporter type 1 and type 2 inhibitors (SGLT1/2is) play important roles in glucose homoeostasis by reducing HI and improving IR by acting on glucose (heavy) absorption in the gut and kidney, respectively [ 219 ]. Although the mechanism of action of SGLT1/2is in PCOS has not been fully investigated, weight loss and HI, improved IR and glucose metabolism, and cardioprotective effects are beneficial in PCOS, suggesting that SGLT1/2is may be a novel treatment option [ 170 , 171 , 172 ]. In clinical trials, the SGLT2 inhibitor canagliflozin was not inferior to metformin in reducing HOMA-IR, and canagliflozin also significantly improved menstruation and body weight and reduced triglyceride levels, suggesting that it should be considered an effective treatment for patients with PCOS and IR [ 173 ]. Urinary symptoms are major adverse events associated with SGLT2 inhibitors, and more large-scale randomized controlled trials are expected to be published in the future to explore their therapeutic potential for PCOS [ 220 ].

Natural molecules and dietary supplements

Inositol is a compound with nine forms (sugar alcohols), of which inositol (MI) and d -chiral inositol (DCI) are the most abundant forms present in humans, playing important biological roles in mediating various effects of insulin. Several scientific studies have confirmed that it has excellent insulin sensitization efficiency in women with PCOS and promotes ovulation [ 180 ]. Given that inositol administration is safe and effective in ameliorating the reproduction and metabolism of patients with PCOS, it may be used not only as a treatment for infertile women but also as a preventive treatment during pregnancy [ 180 , 181 , 182 , 183 ]. Appropriate application of MI and a suitable proportion of DCI improves the health of organs and tissues, while long-term high-dose DCI monotherapy in women with PCOS has a negative impact [ 184 ]. Therefore, inositol treatment should be evaluated according to the specific situation and needs of patients, while its optimal ratio still needs to be further clarified and supported by large-scale clinical trials and pharmacokinetic studies to better adjust supplement doses [ 185 ].

Alpha-lipoic acid [ 186 ] and omega-3 fatty acids are two supplements that improve lipid and insulin sensitivity in women through their anti-inflammatory and antioxidant properties, although omega-3 fatty acids are high in calories [ 187 ]. Studies suggest that coenzyme Q10 has beneficial effects on glucose and lipid metabolism, insulin, HOMA-IR, and total testosterone levels in women with PCOS and can also improve ovarian function [ 188 , 189 , 190 ]. Vitamin E combined with coenzyme Q10 can improve IR and serum SHBG levels in PCOS [ 191 , 192 ]. Supplementation with probiotics, prebiotics, and synbiotics in women with PCOS can improve IR, protect the intestinal barrier, and regulate the immune system, lipid profile, and other metabolic disorders [ 193 , 194 ]. Recent studies have also found that a high-fibre diet consisting of whole grains, traditional Chinese medicinal foods, and prebiotics combined with the α-glucosidase inhibitor acarbose improved reproductive endocrine disorders, HI, and IR in women with PCOS compared with a high-fibre diet alone [ 195 ]. Animal studies have shown that aloe gel extract can act as a potential metabolic regulator of PCOS by controlling glucose homoeostasis, improving insulin secretion, and enhancing insulin-mediated glucose uptake to reduce glucose tolerance [ 221 , 222 ]. Clinical trials have also shown that l -carnitine supplementation effectively improves PCOS-IR by improving fatty acid β-oxidation and carbohydrate metabolism [ 194 , 195 , 221 ]. A recent trial showed that metformin combined with pioglitazone and acetylcarnitine improved IR and ovulation in women with PCOS more than metformin plus pioglitazone [ 199 ].

Traditional Chinese medicine

Traditional Chinese medicine (TCM) is often an important complement to modern Western medicine. Compounds isolated from Chinese herbs are particularly beneficial in improving metabolic disorders. Berberine (BBR) is an alkaloid that can relieve IR and treat PCOS by acting on a variety of insulin signalling pathways, including PPAR, MAPK, and AMPK. In recent years, it has been regarded as a safe and effective insulin sensitizer, although clinical data are lacking. BBR in combination with metformin appears to improve insulin sensitivity more [ 200 , 201 , 202 ]. Plant polysaccharides have many different pharmacological effects, and Dendrobium officinale has been shown to be effective in alleviating IR in PCOS [ 203 ]. Astragalus polysaccharides may improve insulin sensitivity in PCOS model rats by upregulating serum adiponectin levels and it may play an important role in the treatment of IR [ 204 ]. In clinical trial studies, saffron had a significant protective effect on FBG, HOMA-IR, and inflammatory levels of women with PCOS [ 205 , 206 ]. Pharmacological studies have also found that hehuan yin tang and yijing tang, as key components of various TCM prescriptions, can regulate androgen and insulin levels and improve PCOS-IR symptoms through various pharmacological pathways [ 207 , 223 ].

Acupoint application was also effective in improving metabolism and IR in obese women with PCOS [ 205 , 224 ]. Acupuncture is an important component of TCM. Systematic evaluation and some studies have shown that electroacupuncture may increase systemic glucose uptake and improve insulin sensitivity by activating the PCOS sympathetic nervous system and part of the parasympathetic nervous system [ 208 , 209 , 210 , 211 ], but it may not be as effective as metformin in improving insulin sensitivity in women with PCOS [ 212 ]. More large-sample clinical trials are needed to explore TCM as a potential treatment option for PCOS.

In general, women with PCOS develop IR owing to abnormal insulin signalling and metabolic dysfunction in insulin-responsive tissues, with a high incidence of IR in PCOS and a significant negative impact on health. Here, we discuss the molecular mechanisms, diagnosis, and protocol of IR-based PCOS. The pathogenesis of IR in PCOS is not completely clear, and apparently includes genetic and epigenetic changes, deficiency of insulin signal transduction, hyperandrogenaemia, obesity, and inflammation. IR in different PCOS tissues can selectively affect metabolic or mitotic pathways in many tissues, including the ovaries. Therefore, effective prevention and treatment options should be evaluated to improve IR in PCOS patients. Lifestyle interventions and insulin sensitization therapy can be effective strategies for improving insulin sensitivity, while increasing ovulation and reducing androgen levels. Among all of the insulin sensitizers, metformin is the most widely used in PCOS. However, all mentioned drugs for PCOS are still off-label and further studies with larger sample sizes are needed to evaluate the efficacy of these new treatments and provide new insights into the molecular mechanisms of IR in PCOS. 

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

• Insulin resistance
• Polycystic ovary syndrome

Hyperinsulinaemia

Hyperandrogenism

Oligo-anovulation

Luteinizing hormone

Insulin receptor

Protein kinase B

Body mass index

Frequently sampled intravenous glucose tolerance

Homoeostasis model assessment of insulin resistance

Liver-specific insulin receptor knockout

Nonalcoholic fatty liver disease

Sex hormone-binding globulin

Glycogen synthase kinase 3

Mammalian target of rapamycin

Glucose transporter 4

Mitogen-activated protein kinase-extracellular signal-regulated kinase

Protein kinase C

D -chiral inositol

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Acknowledgements

This work was supported by a grant from the National Natural Science Foundation of China (Grant no. 81570765), the Joint Program of Liaoning Provincial Department of Science and Technology on Livelihood science and Technology, and the 345 Talent Project of ShengJing Hospital of China Medical University.

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Department of Endocrinology, Shengjing Hospital, China Medical University, Shenyang, Liaoning, 110000, People’s Republic of China

Han Zhao, Jiaqi Zhang, Xiangyi Cheng, Xiaozhao Nie & Bing He

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BH and HZ conceived the idea; HZ reviewed the literature; HZ designed the study and wrote the manuscript and designed the figures and tables; BH, JZ, XC, and XN critically revised the manuscript. All authors participated in the revision the manuscript. All authors participated in the discussion of the analysis and interpretation of data in this article. The author(s) read and approved the final manuscript.

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Zhao, H., Zhang, J., Cheng, X. et al. Insulin resistance in polycystic ovary syndrome across various tissues: an updated review of pathogenesis, evaluation, and treatment. J Ovarian Res 16 , 9 (2023). https://doi.org/10.1186/s13048-022-01091-0

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Received : 07 July 2022

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DOI : https://doi.org/10.1186/s13048-022-01091-0

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The use and impact of surveillance-based technology initiatives in inpatient and acute mental health settings: A systematic review

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Background: The use of surveillance technologies is becoming increasingly common in inpatient mental health settings, commonly justified as efforts to improve safety and cost-effectiveness. However, the use of these technologies has been questioned in light of limited research conducted and the sensitivities, ethical concerns and potential harms of surveillance. This systematic review aims to: 1) map how surveillance technologies have been employed in inpatient mental health settings, 2) identify any best practice guidance, 3) explore how they are experienced by patients, staff and carers, and 4) examine evidence regarding their impact. Methods: We searched five academic databases (Embase, MEDLINE, PsycInfo, PubMed and Scopus), one grey literature database (HMIC) and two pre-print servers (medRxiv and PsyArXiv) to identify relevant papers published up to 18/09/2023. We also conducted backwards and forwards citation tracking and contacted experts to identify relevant literature. Quality was assessed using the Mixed Methods Appraisal Tool. Data were synthesised using a narrative approach. Results: A total of 27 studies were identified as meeting the inclusion criteria. Included studies reported on CCTV/video monitoring (n = 13), Vision-Based Patient Monitoring and Management (VBPMM) (n = 6), Body Worn Cameras (BWCs) (n = 4), GPS electronic monitoring (n = 2) and wearable sensors (n = 2). Twelve papers (44.4%) were rated as low quality, five (18.5%) medium quality, and ten (37.0%) high quality. Five studies (18.5%) declared a conflict of interest. We identified minimal best practice guidance. Qualitative findings indicate that patient, staff and carer perceptions and experiences of surveillance technologies are mixed and complex. Quantitative findings regarding the impact of surveillance on outcomes such as self-harm, violence, aggression, care quality and cost-effectiveness were inconsistent or weak. Discussion: There is currently insufficient evidence to suggest that surveillance technologies in inpatient mental health settings are achieving the outcomes they are employed to achieve, such as improving safety and reducing costs. The studies were generally of low methodological quality, lacked lived experience involvement, and a substantial proportion (18.5%) declared conflicts of interest. Further independent coproduced research is needed to more comprehensively evaluate the impact of surveillance technologies in inpatient settings, including harms and benefits. If surveillance technologies are to be implemented, it will be important to engage all key stakeholders in the development of policies, procedures and best practice guidance to regulate their use, with a particular emphasis on prioritising the perspectives of patients.

Competing Interest Statement

AS and UF have undertaken and published research on BWCs. We have received no financial support from BWC or any other surveillance technology companies. All other authors declare no competing interests.

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Funding Statement

This study is funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (grant no. PR-PRU-0916-22003). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ARG was supported by the Ramon y Cajal programme (RYC2022-038556-I), funded by the Spanish Ministry of Science, Innovation and Universities.

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I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

The template data extraction form is available in Supplementary 1. MMAT quality appraisal ratings for each included study are available in Supplementary 2. All data used is publicly available in the published papers included in this review.

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