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What Is Background in a Research Paper?

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

What is Background of the Study in Research

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

Why is Background of the Study Necessary in Research?

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

Providing Background Information

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

  • Are there any theories, concepts, terms, and ideas that may be unfamiliar to the target audience and will require you to provide any additional explanation?
  • Any historical data that need to be shared in order to provide context on why the current issue emerged?
  • Are there any concepts that may have been borrowed from other disciplines that may be unfamiliar to the reader and need an explanation?
Related: Ready with the background and searching for more information on journal ranking? Check this infographic on the SCImago Journal Rank today!

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

How to Write a Background of the Study

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

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

1. Identify Your Audience:

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

2. Understand the Research Problem:

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

3. Review Existing Literature:

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

4. Include Historical Data:

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

5. Identify Controversies and Gaps:

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

6. Select Key Components:

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

7. Craft a Logical Flow:

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

8. Highlight the Novelty of Your Research:

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

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

Example of a Research Background

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

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

What Makes the Introduction Different from the Background?

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

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

Points to Note

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

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

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

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

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

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

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What is the Background of a Study and How Should it be Written?

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Table of Contents

The background of a study is one of the most important components of a research paper. The quality of the background determines whether the reader will be interested in the rest of the study. Thus, to ensure that the audience is invested in reading the entire research paper, it is important to write an appealing and effective background. So, what constitutes the background of a study, and how must it be written?

What is the background of a study?

The background of a study is the first section of the paper and establishes the context underlying the research. It contains the rationale, the key problem statement, and a brief overview of research questions that are addressed in the rest of the paper. The background forms the crux of the study because it introduces an unaware audience to the research and its importance in a clear and logical manner. At times, the background may even explore whether the study builds on or refutes findings from previous studies. Any relevant information that the readers need to know before delving into the paper should be made available to them in the background.

How is a background different from the introduction?

The introduction of your research paper is presented before the background. Let’s find out what factors differentiate the background from the introduction.

  • The introduction only contains preliminary data about the research topic and does not state the purpose of the study. On the contrary, the background clarifies the importance of the study in detail.
  • The introduction provides an overview of the research topic from a broader perspective, while the background provides a detailed understanding of the topic.
  • The introduction should end with the mention of the research questions, aims, and objectives of the study. In contrast, the background follows no such format and only provides essential context to the study.

How should one write the background of a research paper?

The length and detail presented in the background varies for different research papers, depending on the complexity and novelty of the research topic. At times, a simple background suffices, even if the study is complex. Before writing and adding details in the background, take a note of these additional points:

  • Start with a strong beginning: Begin the background by defining the research topic and then identify the target audience.
  • Cover key components: Explain all theories, concepts, terms, and ideas that may feel unfamiliar to the target audience thoroughly.
  • Take note of important prerequisites: Go through the relevant literature in detail. Take notes while reading and cite the sources.
  • Maintain a balance: Make sure that the background is focused on important details, but also appeals to a broader audience.
  • Include historical data: Current issues largely originate from historical events or findings. If the research borrows information from a historical context, add relevant data in the background.
  • Explain novelty: If the research study or methodology is unique or novel, provide an explanation that helps to understand the research better.
  • Increase engagement: To make the background engaging, build a story around the central theme of the research

Avoid these mistakes while writing the background:

  • Ambiguity: Don’t be ambiguous. While writing, assume that the reader does not understand any intricate detail about your research.
  • Unrelated themes: Steer clear from topics that are not related to the key aspects of your research topic.
  • Poor organization: Do not place information without a structure. Make sure that the background reads in a chronological manner and organize the sub-sections so that it flows well.

Writing the background for a research paper should not be a daunting task. But directions to go about it can always help. At Elsevier Author Services we provide essential insights on how to write a high quality, appealing, and logically structured paper for publication, beginning with a robust background. For further queries, contact our experts now!

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Home » Background of The Study – Examples and Writing Guide

Background of The Study – Examples and Writing Guide

Table of Contents

Background of The Study

Background of The Study

Definition:

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

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

How to Write Background of The Study

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

Identify the Research Problem

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

Provide Context

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

Review Literature

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

Identify Research Gap

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

State Objectives

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

Discuss Significance

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

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

How to Write Background of The Study in Proposal

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

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

How to Write Background of The Study In Thesis

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

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

How to Write Background of The Study in Research Paper

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

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

Examples of Background of The Study

Here are some examples of the background of the study:

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

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

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

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

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

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

Edxample 3:

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

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

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

Examples of Background of The Study In Research

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

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

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

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

Examples of Background of The Study in Proposal

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

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

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

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

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

Examples of Background of The Study in Thesis

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

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

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

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

Examples of Background of The Study in Research Paper

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

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

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

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

Purpose of Background of The Study

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

More specifically, the background of the study aims to:

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

When to Write Background of The Study

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

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

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

Advantage of Background of The Study

The background of the study has several advantages, including:

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

Disadvantages of Background of The Study

Some Disadvantages of Background of The Study are as follows:

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

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What is the Background of the Study and How to Write It

background of research paper

What is the Background of the Study in Research? 

The background of the study is the first section of a research paper and gives context surrounding the research topic. The background explains to the reader where your research journey started, why you got interested in the topic, and how you developed the research question that you will later specify. That means that you first establish the context of the research you did with a general overview of the field or topic and then present the key issues that drove your decision to study the specific problem you chose.

Once the reader understands where you are coming from and why there was indeed a need for the research you are going to present in the following—because there was a gap in the current research, or because there is an obvious problem with a currently used process or technology—you can proceed with the formulation of your research question and summarize how you are going to address it in the rest of your manuscript.

Why is the Background of the Study Important?

No matter how surprising and important the findings of your study are, if you do not provide the reader with the necessary background information and context, they will not be able to understand your reasons for studying the specific problem you chose and why you think your study is relevant. And more importantly, an editor who does not share your enthusiasm for your work (because you did not fill them in on all the important details) will very probably not even consider your manuscript worthy of their and the reviewers’ time and will immediately send it back to you.

To avoid such desk rejections , you need to make sure you pique the reader’s interest and help them understand the contribution of your work to the specific field you study, the more general research community, or the public. Introducing the study background is crucial to setting the scene for your readers.

Table of Contents:

  • What is “Background Information” in a Research Paper?
  • What Should the Background of a Research Paper Include?
  • Where Does the Background Section Go in Your Paper?

background of the study, brick wall

Background of the Study Structure

Before writing your study background, it is essential to understand what to include. The following elements should all be included in the background and are presented in greater detail in the next section:

  • A general overview of the topic and why it is important (overlaps with establishing the “importance of the topic” in the Introduction)
  • The current state of the research on the topic or on related topics in the field
  • Controversies about current knowledge or specific past studies that undergird your research methodology
  • Any claims or assumptions that have been made by researchers, institutions, or politicians that might need to be clarified
  • Methods and techniques used in the study or from which your study deviated in some way

Presenting the Study Background

As you begin introducing your background, you first need to provide a general overview and include the main issues concerning the topic. Depending on whether you do “basic” (with the aim of providing further knowledge) or “applied” research (to establish new techniques, processes, or products), this is either a literature review that summarizes all relevant earlier studies in the field or a description of the process (e.g., vote counting) or practice (e.g., diagnosis of a specific disease) that you think is problematic or lacking and needs a solution.

Example s of a general overview

If you study the function of a Drosophila gene, for example, you can explain to the reader why and for whom the study of fly genetics is relevant, what is already known and established, and where you see gaps in the existing literature. If you investigated how the way universities have transitioned into online teaching since the beginning of the Covid-19 pandemic has affected students’ learning progress, then you need to present a summary of what changes have happened around the world, what the effects of those changes have been so far, and where you see problems that need to be addressed. Note that you need to provide sources for every statement and every claim you make here, to establish a solid foundation of knowledge for your own study. 

Describing the current state of knowledge

When the reader understands the main issue(s), you need to fill them in more specifically on the current state of the field (in basic research) or the process/practice/product use you describe (in practical/applied research). Cite all relevant studies that have already reported on the Drosophila gene you are interested in, have failed to reveal certain functions of it, or have suggested that it might be involved in more processes than we know so far. Or list the reports from the education ministries of the countries you are interested in and highlight the data that shows the need for research into the effects of the Corona-19 pandemic on teaching and learning.

Discussing controversies, claims, and assumptions

Are there controversies regarding your topic of interest that need to be mentioned and/or addressed? For example, if your research topic involves an issue that is politically hot, you can acknowledge this here. Have any earlier claims or assumptions been made, by other researchers, institutions, or politicians, that you think need to be clarified?

Mentioning methodologies and approaches

While putting together these details, you also need to mention methodologies : What methods/techniques have been used so far to study what you studied and why are you going to either use the same or a different approach? Are any of the methods included in the literature review flawed in such a way that your study takes specific measures to correct or update? While you shouldn’t spend too much time here justifying your methods (this can be summarized briefly in the rationale of the study at the end of the Introduction and later in the Discussion section), you can engage with the crucial methods applied in previous studies here first.

When you have established the background of the study of your research paper in such a logical way, then the reader should have had no problem following you from the more general information you introduced first to the specific details you added later. You can now easily lead over to the relevance of your research, explain how your work fits into the bigger picture, and specify the aims and objectives of your study. This latter part is usually considered the “ statement of the problem ” of your study. Without a solid research paper background, this statement will come out of nowhere for the reader and very probably raise more questions than you were planning to answer.   

Where does the study background section go in a paper?

Unless you write a research proposal or some kind of report that has a specific “Background” chapter, the background of your study is the first part of your introduction section . This is where you put your work in context and provide all the relevant information the reader needs to follow your rationale. Make sure your background has a logical structure and naturally leads into the statement of the problem at the very end of the introduction so that you bring everything together for the reader to judge the relevance of your work and the validity of your approach before they dig deeper into the details of your study in the methods section .

Consider Receiving Professional Editing Services

Now that you know how to write a background section for a research paper, you might be interested in our automated text editor at wordvice.ai. And be sure to receive professional editing services , including academic editing and proofreading , before submitting your manuscript to journals. On the Wordvice academic resources website, you can also find many more articles and other resources that can help you with writing the other parts of your research paper , with making a research paper outline before you put everything together, or with writing an effective cover letter once you are ready to submit.

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How to Write an Effective Background of the Study: A Comprehensive Guide

Madalsa

Table of Contents

The background of the study in a research paper offers a clear context, highlighting why the research is essential and the problem it aims to address.

As a researcher, this foundational section is essential for you to chart the course of your study, Moreover, it allows readers to understand the importance and path of your research.

Whether in academic communities or to the general public, a well-articulated background aids in communicating the essence of the research effectively.

While it may seem straightforward, crafting an effective background requires a blend of clarity, precision, and relevance. Therefore, this article aims to be your guide, offering insights into:

  • Understanding the concept of the background of the study.
  • Learning how to craft a compelling background effectively.
  • Identifying and sidestepping common pitfalls in writing the background.
  • Exploring practical examples that bring the theory to life.
  • Enhancing both your writing and reading of academic papers.

Keeping these compelling insights in mind, let's delve deeper into the details of the empirical background of the study, exploring its definition, distinctions, and the art of writing it effectively.

What is the background of the study?

The background of the study is placed at the beginning of a research paper. It provides the context, circumstances, and history that led to the research problem or topic being explored.

It offers readers a snapshot of the existing knowledge on the topic and the reasons that spurred your current research.

When crafting the background of your study, consider the following questions.

  • What's the context of your research?
  • Which previous research will you refer to?
  • Are there any knowledge gaps in the existing relevant literature?
  • How will you justify the need for your current research?
  • Have you concisely presented the research question or problem?

In a typical research paper structure, after presenting the background, the introduction section follows. The introduction delves deeper into the specific objectives of the research and often outlines the structure or main points that the paper will cover.

Together, they create a cohesive starting point, ensuring readers are well-equipped to understand the subsequent sections of the research paper.

While the background of the study and the introduction section of the research manuscript may seem similar and sometimes even overlap, each serves a unique purpose in the research narrative.

Difference between background and introduction

A well-written background of the study and introduction are preliminary sections of a research paper and serve distinct purposes.

Here’s a detailed tabular comparison between the two of them.

What is the relevance of the background of the study?

It is necessary for you to provide your readers with the background of your research. Without this, readers may grapple with questions such as: Why was this specific research topic chosen? What led to this decision? Why is this study relevant? Is it worth their time?

Such uncertainties can deter them from fully engaging with your study, leading to the rejection of your research paper. Additionally, this can diminish its impact in the academic community, and reduce its potential for real-world application or policy influence .

To address these concerns and offer clarity, the background section plays a pivotal role in research papers.

The background of the study in research is important as it:

  • Provides context: It offers readers a clear picture of the existing knowledge, helping them understand where the current research fits in.
  • Highlights relevance: By detailing the reasons for the research, it underscores the study's significance and its potential impact.
  • Guides the narrative: The background shapes the narrative flow of the paper, ensuring a logical progression from what's known to what the research aims to uncover.
  • Enhances engagement: A well-crafted background piques the reader's interest, encouraging them to delve deeper into the research paper.
  • Aids in comprehension: By setting the scenario, it aids readers in better grasping the research objectives, methodologies, and findings.

How to write the background of the study in a research paper?

The journey of presenting a compelling argument begins with the background study. This section holds the power to either captivate or lose the reader's interest.

An effectively written background not only provides context but also sets the tone for the entire research paper. It's the bridge that connects a broad topic to a specific research question, guiding readers through the logic behind the study.

But how does one craft a background of the study that resonates, informs, and engages?

Here, we’ll discuss how to write an impactful background study, ensuring your research stands out and captures the attention it deserves.

Identify the research problem

The first step is to start pinpointing the specific issue or gap you're addressing. This should be a significant and relevant problem in your field.

A well-defined problem is specific, relevant, and significant to your field. It should resonate with both experts and readers.

Here’s more on how to write an effective research problem .

Provide context

Here, you need to provide a broader perspective, illustrating how your research aligns with or contributes to the overarching context or the wider field of study. A comprehensive context is grounded in facts, offers multiple perspectives, and is relatable.

In addition to stating facts, you should weave a story that connects key concepts from the past, present, and potential future research. For instance, consider the following approach.

  • Offer a brief history of the topic, highlighting major milestones or turning points that have shaped the current landscape.
  • Discuss contemporary developments or current trends that provide relevant information to your research problem. This could include technological advancements, policy changes, or shifts in societal attitudes.
  • Highlight the views of different stakeholders. For a topic like sustainable agriculture, this could mean discussing the perspectives of farmers, environmentalists, policymakers, and consumers.
  • If relevant, compare and contrast global trends with local conditions and circumstances. This can offer readers a more holistic understanding of the topic.

Literature review

For this step, you’ll deep dive into the existing literature on the same topic. It's where you explore what scholars, researchers, and experts have already discovered or discussed about your topic.

Conducting a thorough literature review isn't just a recap of past works. To elevate its efficacy, it's essential to analyze the methods, outcomes, and intricacies of prior research work, demonstrating a thorough engagement with the existing body of knowledge.

  • Instead of merely listing past research study, delve into their methodologies, findings, and limitations. Highlight groundbreaking studies and those that had contrasting results.
  • Try to identify patterns. Look for recurring themes or trends in the literature. Are there common conclusions or contentious points?
  • The next step would be to connect the dots. Show how different pieces of research relate to each other. This can help in understanding the evolution of thought on the topic.

By showcasing what's already known, you can better highlight the background of the study in research.

Highlight the research gap

This step involves identifying the unexplored areas or unanswered questions in the existing literature. Your research seeks to address these gaps, providing new insights or answers.

A clear research gap shows you've thoroughly engaged with existing literature and found an area that needs further exploration.

How can you efficiently highlight the research gap?

  • Find the overlooked areas. Point out topics or angles that haven't been adequately addressed.
  • Highlight questions that have emerged due to recent developments or changing circumstances.
  • Identify areas where insights from other fields might be beneficial but haven't been explored yet.

State your objectives

Here, it’s all about laying out your game plan — What do you hope to achieve with your research? You need to mention a clear objective that’s specific, actionable, and directly tied to the research gap.

How to state your objectives?

  • List the primary questions guiding your research.
  • If applicable, state any hypotheses or predictions you aim to test.
  • Specify what you hope to achieve, whether it's new insights, solutions, or methodologies.

Discuss the significance

This step describes your 'why'. Why is your research important? What broader implications does it have?

The significance of “why” should be both theoretical (adding to the existing literature) and practical (having real-world implications).

How do we effectively discuss the significance?

  • Discuss how your research adds to the existing body of knowledge.
  • Highlight how your findings could be applied in real-world scenarios, from policy changes to on-ground practices.
  • Point out how your research could pave the way for further studies or open up new areas of exploration.

Summarize your points

A concise summary acts as a bridge, smoothly transitioning readers from the background to the main body of the paper. This step is a brief recap, ensuring that readers have grasped the foundational concepts.

How to summarize your study?

  • Revisit the key points discussed, from the research problem to its significance.
  • Prepare the reader for the subsequent sections, ensuring they understand the research's direction.

Include examples for better understanding

Research and come up with real-world or hypothetical examples to clarify complex concepts or to illustrate the practical applications of your research. Relevant examples make abstract ideas tangible, aiding comprehension.

How to include an effective example of the background of the study?

  • Use past events or scenarios to explain concepts.
  • Craft potential scenarios to demonstrate the implications of your findings.
  • Use comparisons to simplify complex ideas, making them more relatable.

Crafting a compelling background of the study in research is about striking the right balance between providing essential context, showcasing your comprehensive understanding of the existing literature, and highlighting the unique value of your research .

While writing the background of the study, keep your readers at the forefront of your mind. Every piece of information, every example, and every objective should be geared toward helping them understand and appreciate your research.

How to avoid mistakes in the background of the study in research?

To write a well-crafted background of the study, you should be aware of the following potential research pitfalls .

  • Stay away from ambiguity. Always assume that your reader might not be familiar with intricate details about your topic.
  • Avoid discussing unrelated themes. Stick to what's directly relevant to your research problem.
  • Ensure your background is well-organized. Information should flow logically, making it easy for readers to follow.
  • While it's vital to provide context, avoid overwhelming the reader with excessive details that might not be directly relevant to your research problem.
  • Ensure you've covered the most significant and relevant studies i` n your field. Overlooking key pieces of literature can make your background seem incomplete.
  • Aim for a balanced presentation of facts, and avoid showing overt bias or presenting only one side of an argument.
  • While academic paper often involves specialized terms, ensure they're adequately explained or use simpler alternatives when possible.
  • Every claim or piece of information taken from existing literature should be appropriately cited. Failing to do so can lead to issues of plagiarism.
  • Avoid making the background too lengthy. While thoroughness is appreciated, it should not come at the expense of losing the reader's interest. Maybe prefer to keep it to one-two paragraphs long.
  • Especially in rapidly evolving fields, it's crucial to ensure that your literature review section is up-to-date and includes the latest research.

Example of an effective background of the study

Let's consider a topic: "The Impact of Online Learning on Student Performance." The ideal background of the study section for this topic would be as follows.

In the last decade, the rise of the internet has revolutionized many sectors, including education. Online learning platforms, once a supplementary educational tool, have now become a primary mode of instruction for many institutions worldwide. With the recent global events, such as the COVID-19 pandemic, there has been a rapid shift from traditional classroom learning to online modes, making it imperative to understand its effects on student performance.

Previous studies have explored various facets of online learning, from its accessibility to its flexibility. However, there is a growing need to assess its direct impact on student outcomes. While some educators advocate for its benefits, citing the convenience and vast resources available, others express concerns about potential drawbacks, such as reduced student engagement and the challenges of self-discipline.

This research aims to delve deeper into this debate, evaluating the true impact of online learning on student performance.

Why is this example considered as an effective background section of a research paper?

This background section example effectively sets the context by highlighting the rise of online learning and its increased relevance due to recent global events. It references prior research on the topic, indicating a foundation built on existing knowledge.

By presenting both the potential advantages and concerns of online learning, it establishes a balanced view, leading to the clear purpose of the study: to evaluate the true impact of online learning on student performance.

As we've explored, writing an effective background of the study in research requires clarity, precision, and a keen understanding of both the broader landscape and the specific details of your topic.

From identifying the research problem, providing context, reviewing existing literature to highlighting research gaps and stating objectives, each step is pivotal in shaping the narrative of your research. And while there are best practices to follow, it's equally crucial to be aware of the pitfalls to avoid.

Remember, writing or refining the background of your study is essential to engage your readers, familiarize them with the research context, and set the ground for the insights your research project will unveil.

Drawing from all the important details, insights and guidance shared, you're now in a strong position to craft a background of the study that not only informs but also engages and resonates with your readers.

Now that you've a clear understanding of what the background of the study aims to achieve, the natural progression is to delve into the next crucial component — write an effective introduction section of a research paper. Read here .

Frequently Asked Questions

The background of the study should include a clear context for the research, references to relevant previous studies, identification of knowledge gaps, justification for the current research, a concise overview of the research problem or question, and an indication of the study's significance or potential impact.

The background of the study is written to provide readers with a clear understanding of the context, significance, and rationale behind the research. It offers a snapshot of existing knowledge on the topic, highlights the relevance of the study, and sets the stage for the research questions and objectives. It ensures that readers can grasp the importance of the research and its place within the broader field of study.

The background of the study is a section in a research paper that provides context, circumstances, and history leading to the research problem or topic being explored. It presents existing knowledge on the topic and outlines the reasons that spurred the current research, helping readers understand the research's foundation and its significance in the broader academic landscape.

The number of paragraphs in the background of the study can vary based on the complexity of the topic and the depth of the context required. Typically, it might range from 3 to 5 paragraphs, but in more detailed or complex research papers, it could be longer. The key is to ensure that all relevant information is presented clearly and concisely, without unnecessary repetition.

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Background information identifies and describes the history and nature of a well-defined research problem with reference to contextualizing existing literature. The background information should indicate the root of the problem being studied, appropriate context of the problem in relation to theory, research, and/or practice , its scope, and the extent to which previous studies have successfully investigated the problem, noting, in particular, where gaps exist that your study attempts to address. Background information does not replace the literature review section of a research paper; it is intended to place the research problem within a specific context and an established plan for its solution.

Fitterling, Lori. Researching and Writing an Effective Background Section of a Research Paper. Kansas City University of Medicine & Biosciences; Creating a Research Paper: How to Write the Background to a Study. DurousseauElectricalInstitute.com; Background Information: Definition of Background Information. Literary Devices Definition and Examples of Literary Terms.

Importance of Having Enough Background Information

Background information expands upon the key points stated in the beginning of your introduction but is not intended to be the main focus of the paper. It generally supports the question, what is the most important information the reader needs to understand before continuing to read the paper? Sufficient background information helps the reader determine if you have a basic understanding of the research problem being investigated and promotes confidence in the overall quality of your analysis and findings. This information provides the reader with the essential context needed to conceptualize the research problem and its significance before moving on to a more thorough analysis of prior research.

Forms of contextualization included in background information can include describing one or more of the following:

  • Cultural -- placed within the learned behavior of a specific group or groups of people.
  • Economic -- of or relating to systems of production and management of material wealth and/or business activities.
  • Gender -- located within the behavioral, cultural, or psychological traits typically associated with being self-identified as male, female, or other form of  gender expression.
  • Historical -- the time in which something takes place or was created and how the condition of time influences how you interpret it.
  • Interdisciplinary -- explanation of theories, concepts, ideas, or methodologies borrowed from other disciplines applied to the research problem rooted in a discipline other than the discipline where your paper resides.
  • Philosophical -- clarification of the essential nature of being or of phenomena as it relates to the research problem.
  • Physical/Spatial -- reflects the meaning of space around something and how that influences how it is understood.
  • Political -- concerns the environment in which something is produced indicating it's public purpose or agenda.
  • Social -- the environment of people that surrounds something's creation or intended audience, reflecting how the people associated with something use and interpret it.
  • Temporal -- reflects issues or events of, relating to, or limited by time. Concerns past, present, or future contextualization and not just a historical past.

Background information can also include summaries of important research studies . This can be a particularly important element of providing background information if an innovative or groundbreaking study about the research problem laid a foundation for further research or there was a key study that is essential to understanding your arguments. The priority is to summarize for the reader what is known about the research problem before you conduct the analysis of prior research. This is accomplished with a general summary of the foundational research literature [with citations] that document findings that inform your study's overall aims and objectives.

NOTE : Research studies cited as part of the background information of your introduction should not include very specific, lengthy explanations. This should be discussed in greater detail in your literature review section. If you find a study requiring lengthy explanation, consider moving it to the literature review section.

ANOTHER NOTE : In some cases, your paper's introduction only needs to introduce the research problem, explain its significance, and then describe a road map for how you are going to address the problem; the background information basically forms the introduction part of your literature review. That said, while providing background information is not required, including it in the introduction is a way to highlight important contextual information that could otherwise be hidden or overlooked by the reader if placed in the literature review section.

Background of the Problem Section: What do you Need to Consider? Anonymous. Harvard University; Hopkins, Will G. How to Write a Research Paper. SPORTSCIENCE, Perspectives/Research Resources. Department of Physiology and School of Physical Education, University of Otago, 1999; Green, L. H. How to Write the Background/Introduction Section. Physics 499 Powerpoint slides. University of Illinois; Woodall, W. Gill. Writing the Background and Significance Section. Senior Research Scientist and Professor of Communication. Center on Alcoholism, Substance Abuse, and Addictions. University of New Mexico.  

Structure and Writing Style

Providing background information in the introduction of a research paper serves as a bridge that links the reader to the research problem . Precisely how long and in-depth this bridge should be is largely dependent upon how much information you think the reader will need to know in order to fully understand the problem being discussed and to appreciate why the issues you are investigating are important.

From another perspective, the length and detail of background information also depends on the degree to which you need to demonstrate to your professor how much you understand the research problem. Keep this in mind because providing pertinent background information can be an effective way to demonstrate that you have a clear grasp of key issues, debates, and concepts related to your overall study.

The structure and writing style of your background information can vary depending upon the complexity of your research and/or the nature of the assignment. However, in most cases it should be limited to only one to two paragraphs in your introduction.

Given this, here are some questions to consider while writing this part of your introduction :

  • Are there concepts, terms, theories, or ideas that may be unfamiliar to the reader and, thus, require additional explanation?
  • Are there historical elements that need to be explored in order to provide needed context, to highlight specific people, issues, or events, or to lay a foundation for understanding the emergence of a current issue or event?
  • Are there theories, concepts, or ideas borrowed from other disciplines or academic traditions that may be unfamiliar to the reader and therefore require further explanation?
  • Is there a key study or small set of studies that set the stage for understanding the topic and frames why it is important to conduct further research on the topic?
  • Y our study uses a method of analysis never applied before;
  • Your study investigates a very esoteric or complex research problem;
  • Your study introduces new or unique variables that need to be taken into account ; or,
  • Your study relies upon analyzing unique texts or documents, such as, archival materials or primary documents like diaries or personal letters that do not represent the established body of source literature on the topic?

Almost all introductions to a research problem require some contextualizing, but the scope and breadth of background information varies depending on your assumption about the reader's level of prior knowledge . However, despite this assessment, background information should be brief and succinct and sets the stage for the elaboration of critical points or in-depth discussion of key issues in the literature review section of your paper.

Background of the Problem Section: What do you Need to Consider? Anonymous. Harvard University; Hopkins, Will G. How to Write a Research Paper. SPORTSCIENCE, Perspectives/Research Resources. Department of Physiology and School of Physical Education, University of Otago, 1999; Green, L. H. How to Write the Background/Introduction Section. Physics 499 Powerpoint slides. University of Illinois; Woodall, W. Gill. Writing the Background and Significance Section. Senior Research Scientist and Professor of Communication. Center on Alcoholism, Substance Abuse, and Addictions. University of New Mexico.

Writing Tip

Background Information vs. the Literature Review

Incorporating background information into the introduction is intended to provide the reader with critical information about the topic being studied, such as, highlighting and expanding upon foundational studies conducted in the past, describing important historical events that inform why and in what ways the research problem exists, defining key components of your study [concepts, people, places, phenomena] and/or placing the research problem within a particular context. Although introductory background information can often blend into the literature review portion of the paper, essential background information should not be considered a substitute for a comprehensive review and synthesis of relevant research literature.

Hart, Cris. Doing a Literature Review: Releasing the Social Science Research Imagination . Thousand Oaks, CA: Sage, 1998.

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Writing a Research Paper Introduction | Step-by-Step Guide

Published on September 24, 2022 by Jack Caulfield . Revised on March 27, 2023.

Writing a Research Paper Introduction

The introduction to a research paper is where you set up your topic and approach for the reader. It has several key goals:

  • Present your topic and get the reader interested
  • Provide background or summarize existing research
  • Position your own approach
  • Detail your specific research problem and problem statement
  • Give an overview of the paper’s structure

The introduction looks slightly different depending on whether your paper presents the results of original empirical research or constructs an argument by engaging with a variety of sources.

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Table of contents

Step 1: introduce your topic, step 2: describe the background, step 3: establish your research problem, step 4: specify your objective(s), step 5: map out your paper, research paper introduction examples, frequently asked questions about the research paper introduction.

The first job of the introduction is to tell the reader what your topic is and why it’s interesting or important. This is generally accomplished with a strong opening hook.

The hook is a striking opening sentence that clearly conveys the relevance of your topic. Think of an interesting fact or statistic, a strong statement, a question, or a brief anecdote that will get the reader wondering about your topic.

For example, the following could be an effective hook for an argumentative paper about the environmental impact of cattle farming:

A more empirical paper investigating the relationship of Instagram use with body image issues in adolescent girls might use the following hook:

Don’t feel that your hook necessarily has to be deeply impressive or creative. Clarity and relevance are still more important than catchiness. The key thing is to guide the reader into your topic and situate your ideas.

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background of research paper

This part of the introduction differs depending on what approach your paper is taking.

In a more argumentative paper, you’ll explore some general background here. In a more empirical paper, this is the place to review previous research and establish how yours fits in.

Argumentative paper: Background information

After you’ve caught your reader’s attention, specify a bit more, providing context and narrowing down your topic.

Provide only the most relevant background information. The introduction isn’t the place to get too in-depth; if more background is essential to your paper, it can appear in the body .

Empirical paper: Describing previous research

For a paper describing original research, you’ll instead provide an overview of the most relevant research that has already been conducted. This is a sort of miniature literature review —a sketch of the current state of research into your topic, boiled down to a few sentences.

This should be informed by genuine engagement with the literature. Your search can be less extensive than in a full literature review, but a clear sense of the relevant research is crucial to inform your own work.

Begin by establishing the kinds of research that have been done, and end with limitations or gaps in the research that you intend to respond to.

The next step is to clarify how your own research fits in and what problem it addresses.

Argumentative paper: Emphasize importance

In an argumentative research paper, you can simply state the problem you intend to discuss, and what is original or important about your argument.

Empirical paper: Relate to the literature

In an empirical research paper, try to lead into the problem on the basis of your discussion of the literature. Think in terms of these questions:

  • What research gap is your work intended to fill?
  • What limitations in previous work does it address?
  • What contribution to knowledge does it make?

You can make the connection between your problem and the existing research using phrases like the following.

Now you’ll get into the specifics of what you intend to find out or express in your research paper.

The way you frame your research objectives varies. An argumentative paper presents a thesis statement, while an empirical paper generally poses a research question (sometimes with a hypothesis as to the answer).

Argumentative paper: Thesis statement

The thesis statement expresses the position that the rest of the paper will present evidence and arguments for. It can be presented in one or two sentences, and should state your position clearly and directly, without providing specific arguments for it at this point.

Empirical paper: Research question and hypothesis

The research question is the question you want to answer in an empirical research paper.

Present your research question clearly and directly, with a minimum of discussion at this point. The rest of the paper will be taken up with discussing and investigating this question; here you just need to express it.

A research question can be framed either directly or indirectly.

  • This study set out to answer the following question: What effects does daily use of Instagram have on the prevalence of body image issues among adolescent girls?
  • We investigated the effects of daily Instagram use on the prevalence of body image issues among adolescent girls.

If your research involved testing hypotheses , these should be stated along with your research question. They are usually presented in the past tense, since the hypothesis will already have been tested by the time you are writing up your paper.

For example, the following hypothesis might respond to the research question above:

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background of research paper

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The final part of the introduction is often dedicated to a brief overview of the rest of the paper.

In a paper structured using the standard scientific “introduction, methods, results, discussion” format, this isn’t always necessary. But if your paper is structured in a less predictable way, it’s important to describe the shape of it for the reader.

If included, the overview should be concise, direct, and written in the present tense.

  • This paper will first discuss several examples of survey-based research into adolescent social media use, then will go on to …
  • This paper first discusses several examples of survey-based research into adolescent social media use, then goes on to …

Full examples of research paper introductions are shown in the tabs below: one for an argumentative paper, the other for an empirical paper.

  • Argumentative paper
  • Empirical paper

Are cows responsible for climate change? A recent study (RIVM, 2019) shows that cattle farmers account for two thirds of agricultural nitrogen emissions in the Netherlands. These emissions result from nitrogen in manure, which can degrade into ammonia and enter the atmosphere. The study’s calculations show that agriculture is the main source of nitrogen pollution, accounting for 46% of the country’s total emissions. By comparison, road traffic and households are responsible for 6.1% each, the industrial sector for 1%. While efforts are being made to mitigate these emissions, policymakers are reluctant to reckon with the scale of the problem. The approach presented here is a radical one, but commensurate with the issue. This paper argues that the Dutch government must stimulate and subsidize livestock farmers, especially cattle farmers, to transition to sustainable vegetable farming. It first establishes the inadequacy of current mitigation measures, then discusses the various advantages of the results proposed, and finally addresses potential objections to the plan on economic grounds.

The rise of social media has been accompanied by a sharp increase in the prevalence of body image issues among women and girls. This correlation has received significant academic attention: Various empirical studies have been conducted into Facebook usage among adolescent girls (Tiggermann & Slater, 2013; Meier & Gray, 2014). These studies have consistently found that the visual and interactive aspects of the platform have the greatest influence on body image issues. Despite this, highly visual social media (HVSM) such as Instagram have yet to be robustly researched. This paper sets out to address this research gap. We investigated the effects of daily Instagram use on the prevalence of body image issues among adolescent girls. It was hypothesized that daily Instagram use would be associated with an increase in body image concerns and a decrease in self-esteem ratings.

The introduction of a research paper includes several key elements:

  • A hook to catch the reader’s interest
  • Relevant background on the topic
  • Details of your research problem

and your problem statement

  • A thesis statement or research question
  • Sometimes an overview of the paper

Don’t feel that you have to write the introduction first. The introduction is often one of the last parts of the research paper you’ll write, along with the conclusion.

This is because it can be easier to introduce your paper once you’ve already written the body ; you may not have the clearest idea of your arguments until you’ve written them, and things can change during the writing process .

The way you present your research problem in your introduction varies depending on the nature of your research paper . A research paper that presents a sustained argument will usually encapsulate this argument in a thesis statement .

A research paper designed to present the results of empirical research tends to present a research question that it seeks to answer. It may also include a hypothesis —a prediction that will be confirmed or disproved by your research.

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How to Write a Research Paper: Background Research Tips

  • Anatomy of a Research Paper
  • Developing a Research Focus
  • Background Research Tips
  • Searching Tips
  • Scholarly Journals vs. Popular Journals
  • Thesis Statement
  • Annotated Bibliography
  • Citing Sources
  • Evaluating Sources
  • Literature Review
  • Academic Integrity
  • Scholarship as Conversation
  • Understanding Fake News
  • Data, Information, Knowledge

Suggested Guidelines

*Your instructor will often provide you with an approximate number of source you will need.

Primary vs. Secondary Sources

A primary source is a document or physical object which was written or created at the time under study. 

Types of primary sources include: 

  • Original Documents: Diaries, speeches, manuscripts, letters, interviews, news film footage, autobiographies, and official records 
  • Creative Works: Poetry, drama, novels music, and art 
  • Relics of Artifacts: pottery, furniture, clothing, and buildings

A secondary source interprets and analyzes primary source. These sources are one or more steps removed from the event. Secondary sources may have pictures, quotes, or graphics of primary sources in them. 

Types of secondary sources include: 

  • Journal Articles 
  • Magazine Articles
  • Histories 
  • Criticisms 
  • Commentaries 
  • Encyclopedias

Tertiary sources  index, abstract, organize, compile, or digest other sources. They are not usually not credited to a particular author. 

Types of tertiary sources include: 

  • Dictionaries
  • Directories 

Keep Track of Resources

-Create the reference or Works Cited page as you gather your resources. This will save you time and effort because you will not have to search for the material again and you will have this part done as you work on the paper. 

-Annotate the reference list so you know why you printed out or saved the article.

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  • Last Updated: Sep 21, 2023 2:59 PM
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Organizing Academic Research Papers: Background Information

  • Purpose of Guide
  • Design Flaws to Avoid
  • Glossary of Research Terms
  • Narrowing a Topic Idea
  • Broadening a Topic Idea
  • Extending the Timeliness of a Topic Idea
  • Academic Writing Style
  • Choosing a Title
  • Making an Outline
  • Paragraph Development
  • Executive Summary
  • Background Information
  • The Research Problem/Question
  • Theoretical Framework
  • Citation Tracking
  • Content Alert Services
  • Evaluating Sources
  • Primary Sources
  • Secondary Sources
  • Tertiary Sources
  • What Is Scholarly vs. Popular?
  • Qualitative Methods
  • Quantitative Methods
  • Using Non-Textual Elements
  • Limitations of the Study
  • Common Grammar Mistakes
  • Avoiding Plagiarism
  • Footnotes or Endnotes?
  • Further Readings
  • Annotated Bibliography
  • Dealing with Nervousness
  • Using Visual Aids
  • Grading Someone Else's Paper
  • How to Manage Group Projects
  • Multiple Book Review Essay
  • Reviewing Collected Essays
  • About Informed Consent
  • Writing Field Notes
  • Writing a Policy Memo
  • Writing a Research Proposal
  • Acknowledgements

Background information identifies and describes the history and nature of a well-defined research problem with reference to the existing literature. Background information in your Introduction should indicate the root of the problem being studied, its scope, and the extent to which previous studies have successfully investigated the problem, noting, in particular, where gaps exist that your study attempts to address.  Introductory background information differs from a literature review in that it places the research problem in proper context rather than thoroughly examining pertinent literature.

Importance of Having Enough Background Information

Background information expands upon the key points stated in your introduction but is not the main focus of the paper. Sufficient background information helps your reader determine if you have a basic understanding of the research problem being investigated and promotes confidence in the overall quality of your analysis and findings.

Background information provides the reader with the essential context needed to understand the research problem . Depending on the topic being studied, forms of contextualization may include:

  • Cultural -- the issue placed within the learned behavior of specific groups of people.
  • Economic -- of or relating to systems of production and management of material wealth and/or business activities.
  • Historical -- the time in which something takes place or was created and how that influences how you interpret it.
  • Philosophical -- clarification of the essential nature of being or of phenomena as it relates to the research problem.
  • Physical/Spatial -- reflects the space around something and how that influences how you see it.
  • Political -- concerns the environment in which something is produced indicating it's public purpose or agenda.
  • Social -- the environment of people that surrounds something's creation or intended audience, reflecting how the people around something use and interpret it.
  • Temporal -- reflects issues or events of, relating to, or limited by time.

Background information can also include summaries of important, relevant research studies . The key is to summarize for the reader what is known about the specific research problem before you conducted your analysis. This is accomplished with a general review of the foundational research literature (with citations) that report findings that inform your study's aims and objectives.

NOTE : Research studies cited as part of the background information of your introduction should not include very specific, lengthy explanations. This should be discussed in greater detail in your literature review section.

Background of the Problem Section: What do you Need to Consider? Anonymous. Harvard University; Hopkins, Will G. How to Write a Research Paper . SPORTSCIENCE, Perspectives/Research Resources. Department of Physiology and School of Physical Education, University of Otago, 1999; Green, L. H. How to Write the Background/Introduction Section. Physics 499 Powerpoint slides. University of Illinois; Woodall, W. Gill. Writing the Background and Significance Section. Senior Research Scientist and Professor of Communication. Center on Alcoholism, Substance Abuse, and Addictions. University of New Mexico.  

Structure and Writing Style

Providing background information in the Introduction of a research paper serves as a bridge that links the reader to the topic of your study . But precisely how long and in-depth this bridge should be is largely dependent upon how much information you think the reader will need in order to understand the research problem being discussed and to appreciate why the issues you are investigating are important.

From another perspective, the length and detail of background information also depends on the degree to which you need to demonstrate to your professor how much you understand the topic. Keep this in mind because providing succinct background information can be an effective way to show that you have a clear grasp of key issues and concepts underpinning your overall study. Don't try to show off, though!

Given that the structure and writing style of your background information can vary depending upon the complexity of your research and/or the nature of the assignment, here are some questions to consider while writing :

  • Are there concepts, terms, theories, or ideas that may be unfamiliar to the reader and, thus, require additional explanation?
  • Are there historical elements that need to be explored in order to add needed context, to highlight specific people, issues, or events, or to lay a foundation for understanding the emergence of a current issue or event?
  • Is the research study unusual in some way that requires additional explanation, such as, a) your study uses a method never applied before to the research problem you are investigating; b) your study investigates a very esoteric or complex research problem; or, c) your study relies upon analyzing unique texts or documents, such as archival materials or primary documents like diaries or personal letters, that do not represent the established body of source literature on the topic.

Background of the Problem Section: What do you Need to Consider? Anonymous. Harvard University; Hopkins, Will G. How to Write a Research Paper . SPORTSCIENCE, Perspectives/Research Resources. Department of Physiology and School of Physical Education, University of Otago, 1999; Green, L. H. How to Write the Background/Introduction Section. Physics 499 Powerpoint slides. University of Illinois; Woodall, W. Gill. Writing the Background and Significance Section. Senior Research Scientist and Professor of Communication. Center on Alcoholism, Substance Abuse, and Addictions. University of New Mexico.

Writing Tip

Background Information vs. the Literature Review

Incorporating background information into the Introduction is intended to provide the reader with critical information about the topic being studied, such as highlighting and expanding upon foundational studies conducted in the past, important historical events that inform why and in what ways the research problem exists, or defining key components of your study [concepts, people, places, things]. Although in social sciences research introductory background information can often blend into the literature review portion of the paper, basic background information should not be considered a substitute for a comprehensive review and synthesis of relevant research literature.

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How to Write the Background of a Study

  • Research Process

The background to a study sets the scene . It lays out the “state of the art”. It tells your reader about other research done on the topic in question, via useful review papers and other summaries of the literature.

Updated on May 5, 2023

a pen by a pair of glasses and a notebook to prepare writing the background of a sutdy

The background to your study, sometimes called the ‘state of the art’ (especially in grant writing), sets the scene for a paper. This section shows readers why your research is important, relevant, and why they should continue reading. You must hook them in with a great background to your study, which is part of the overall introduction to your research paper.

In higher impact articles, such as those published in Nature or Science (which is what we are all aiming for, after all …), the study background is t he middle section of an essentially three-part introduction . This section is framed by a presentation of ‘the question’ (first part of the introduction) and a quick explanation of ‘what this paper will do’ (the third part of the introduction).

The introduction of a research paper should be “shaped” like an upside down triangle: 

Start broad. Set the scene with a large-scale general research area [e.g., why doing a PhD erases your writing skills (ha ha) or mental health in teenagers and why this is such a widespread global issue] and then focus down to the question your research addresses (e.g., how can writing skills be improved in PhD students, or brain scans and how these can be used in treatment).

Read on to learn more about framing your next research paper with a well-written and researched background section.

What is the background of a study?

The background to a study sets the scene . It lays out the “state of the art”. It tells your reader about other research done on the topic in question, via useful review papers and other summaries of the literature. 

A background is not a literature review: No one wants to read endless citations back-to-back in this section. You don’t need to list all the papers you’ve read, or all the work done in the past on this topic. 

Set the scene and frame your question in the context of the literature. Seek out review articles in particular. The aim of this section is to build on what has come before so your reader will be armed with all the information they need to understand the remainder of your article, and why - in context - the aims of your study are important.

How to write the background to your research paper

Cater to your audience.

It’s important to frame your background to the right audience.

The background of your study needs to be pitched differently depending on your target journal. A more subject-area specific journal (e.g. Journal of Brain Studies ) will be read by specialists in your field. Generally, less information to set up the paper in a wider context and less background information will be required. Your readers are already experts on the topic in question .

However, if you are aiming your paper at a more general audience (a journal like Nature or Science , for example) then you're going to need to explain more in your background. A reader of a specialized journal will know about the neocortex within the brain and where this is located, but a general reader will need you to set things up more.

Readers are always the most important people in research publishing, after all: If you want your work to be read, used, and cited (and therefore drive up your H-index as well as your institution’s ranking) you’ll need a well-pitched background of your study.

What is included in the background of a study?

Remember this section sits in the middle of the introduction. Here’s a handy template for what to include:

  • Existing research on the area of study (not everything, but a broad overview. Aim to cite review papers if you can). Start this section with preliminary data and then build it out;
  • Mention any controversies around your topic (either that you’ve identified, or that have been picked up by earlier work. Check the discussion sections of recent articles for pointers here);
  • Any gaps in existing research?, and;
  • How will your study fill these gaps? State your research methodologies. Any further research that needs to be done?

list of what's included in background of a study

Aim for one paragraph , or a series of short paragraphs within one section. The last two of the topics outlined above can be short, just one or two sentences. These are there to hook the reader in and to frame your background so that the text leads into the final section of the introduction where you explain ‘What your paper is going to do’.

Simple really.

And finally…some thoughts

I used to get really bogged down with article writing, especially the shape of the introduction.

Here’s a trick to keep in mind: Remember that the average length of an academic research paper published in a peer reviewed journal is around 4,000 - 5,000 words - not too long. 

This means that you're likely going to be aiming for an article of about this length the next time you sit down to write: Not too many words for an effective and well-structured introduction. You’ve got about 1,500 - 2,000 words maximum. And aim to keep it short (this will be enforced by word count limits, especially in higher impact journals like Nature and Science ). Editors at these journals are trained to cut down your writing to make sure your research fits in.

Less is more, in other words.

Keeping tight word count limits in mind means you can’t write an expansive, flowing background to your study that goes off in all directions and covers a huge amount of ground. Keep an eye on our tips for what to include, cite review papers, and keep your readers interested in the question your paper seeks to address.

A well written background to your study will ensure your paper gets read all the way through to the end. Can’t ask for more than that!

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  • A Research Guide
  • Research Paper Guide

How to Write a Background for a Research Paper

  • What is the background
  • Background structure
  • Literature review vs background
  • Step-by-step writing guide
  • Tips to avoid mistakes

Background information example

How to Write a Background for a Research Paper

The background of any academic paper is the academic backbone it relates to. Thus, you must carefully write the first section to keep the end goal clear for your reader.

We’ve got you covered if you need more time or writing skills to create a solid study paper! This article will provide the necessary information to write a background for a research paper. Let’s go!

What is the background of the study in research?

The research paper background refers to the section, component, or thesis that provides context and justification for conducting the study. It outlines the existing knowledge, gaps, and limitations in the field or topic you currently investigate.

The definition of “background” says it should begin with a general introduction to the subject matter, providing an overview of the broader scientific area. It aims to familiarize the reader with the topic and establish its significance and relevance in the existing body of knowledge.

Furthermore, the background of the study highlights the specific problem or knowledge gap that the current study aims to address. It emphasizes the need for further investigation, highlighting the unanswered questions or areas where you have to conduct an additional examination.

The background of the study also plays a crucial role in shaping the study objectives, questions, and hypotheses . By reviewing the existing literature and identifying gaps, academic associates can formulate clearer goals and design appropriate methodologies to address the specific problems.

The background of the study structure

The background statement can vary depending on the scientific field and the paper or thesis requirements. However, it generally follows a logical flow and includes several key components. Here is a standard structure for the background structure:

  • Introduction: Begin with a brief introduction that provides an overview of the chosen topic and its importance. This section should capture the reader’s interest and establish the context for the study.
  • Current problem: As an academic author, you must clearly identify the scientif problem or gap in the existing knowledge the study aims to address. Please explain why this problem is significant and why it requires further investigation.
  • Literature review: Review the relevant literature related to the research topic. Summarize critical theories, concepts, and findings from previous studies directly relevant to the research problem. Discuss the existing knowledge and highlight any limitations or gaps the current study aims to fill.
  • Research questions/objectives/hypotheses: To write background information, you should clearly state the research questions, objectives, or assumptions that guide the study. These should be directly derived from the research problem and align with the gaps identified in the literature review.
  • Study rationale: Explain the potential contributions and implications of the study. Discuss how the findings may advance knowledge, address practical issues, or have broader impacts in the field or society. Justify why the study is worth conducting and how it adds value to the existing body of knowledge.
  • Scope and limitations: Define the size of the study by outlining the boundaries and specific aspects you will cover. Discuss any limits or constraints impacting the study’s findings or generalizability.
  • Summary: Provide a concise summary or conclusion of the background section of a research paper, emphasizing the research problem, significance, and the need for further investigation.

It’s important to note that you can imply changes to the structure based on your requirements and the specific guidelines provided by your college advisor.

Difference between literature review and background

The literature review and the background of the study are two distinct components of a research paper or thesis, although they are closely related. Let’s explore the differences between these two sections:

Steps to write a good background section

When writing a background section for a research paper, you can follow these three steps to ensure a clear and compelling presentation:

Identify the Research Problem

  • Begin by clearly identifying and defining the research problem or gap in the existing knowledge that your study aims to address.
  • Consider the significance and relevance of the problem within your research field or discipline.
  • Briefly explain why the problem is essential and how addressing it can contribute to the existing body of knowledge.

Review the Relevant Literature

  • Conduct a thorough literature review to gather relevant information and understand the current state of knowledge on your research topic.
  • Summarize critical theories, concepts, and findings from previous studies that directly relate to your research problem.
  • Highlight any gaps, controversies, or limitations in the existing literature that your study aims to address.
  • Organize the literature review logically, either by themes, sub-topics, or chronologically, depending on what they mean for your research.

Provide Rationale and Objectives

  • Provide a clear rationale for conducting your study based on the research problem and the gaps identified in the literature review.
  • Explain why your research is essential and how it will contribute to filling the identified gaps or advancing knowledge in the field.
  • State the specific research objectives or questions your study aims to answer.
  • Align the objectives with the research problem and the gaps identified in the literature, demonstrating how your study will address those gaps.

Following these steps, you can create a well-structured and coherent background section that establishes your research’s context, significance, and rationale. Remember to provide sufficient background information and be concise yet informative in your presentation.

The main tips to avoid mistakes

Here are a few tips to help you avoid common mistakes when writing background paragraphs:

  • Focus on the research topic;
  • Be concise and clear;
  • Use credible and up-to-date sources;
  • Provide a logical flow;
  • Avoid excessive jargon and technical terms;
  • Balance breadth and depth;
  • Use citations appropriately;
  • Revise and proofread.

By following these tips, you can enhance the quality of your background section, ensuring that it effectively sets the stage for your research and engages the reader from the beginning of your paper.

To write the background of a research paper, you must understand the overall structure and know exactly how this section should look.

Let’s see an excellent example of a background section for a research paper on the topic of “The Impact of Social Media on Mental Health”:

“The rapid rise of social media platforms in recent years has transformed how people communicate, connect, and share information. Platforms such as Facebook, Instagram, Twitter, and Snapchat have become integral parts of daily life for millions of individuals worldwide. 

While social media offers numerous benefits, including increased social connectivity and access to diverse perspectives, concerns have been raised regarding its potential impact on mental health.

Numerous studies have investigated the relationship between social media use and mental health outcomes, focusing on depression, anxiety, and body image dissatisfaction. 

This study seeks to contribute to the existing knowledge by employing a longitudinal design and examining a broad range of mental health outcomes among a diverse sample of adults aged 18-45.

Research has shown that excessive use of social media and constant exposure to carefully curated and idealized representations of others’ lives can contribute to feelings of inadequacy, social comparison, and low self-esteem. 

Additionally, cyberbullying has emerged as a significant concern, as individuals may experience harassment, negative comments, and exclusion within the online environment”.

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How to Write the Background of Your Scientific Paper

Home » Writing the Manuscript » How to Write the Background of Your Scientific Paper

Backgorund #1

You can think of the background of your study as being like the story that preceded your own work. Usually, you will present this background in the introduction of your paper or thesis, although you also can elaborate on it in some cases in your discussion section. No matter where you give the background for your research, you should focus on some key goals in presenting it.

The reason you are giving your reader background is so that they understand why you asked the research question you did and how your findings add to this existing evidence. That means that as you walk the reader through the results that came before yours, you also need to show the reader where the gaps persist. One or more of these gaps is what you hope to fill with your own research.

Photo by   Drew Graham

Stay focused

Although it is tempting to begin any story at the very beginning, you need to choose the right starting point in the continuum of evidence for the story of your work. If the subject of your study is island biogeography, you do not need to begin your background information by describing the 19 th -century work of Alfred Russel Wallace. Instead, you’ll need to home in on fresher findings or more recent results that highlight persistent gaps in your field.

As you unspool the evidence that pointed the way to your own work, do not go into too much detail. Background information does not need to include every detail of previous findings, every step in a biochemical pathway, or every P value or odds ratio from clinical studies you cite. Give the main finding that’s relevant to your own work and why you pursued your research question.

Connect your ideas

For example, if your work is in cancer cell biology with a focus on a specific pathway, that pathway and the step or steps that you worked on are the theme. In presenting the background of this work, you should always use evidence that relates directly to that pathway, especially the specific steps your own research focused on. And you should avoid becoming more expansive and talking about other pathways or broader issues in cell or cancer biology.

Highlight the gaps

You asked a research question because it was an open question that needed an answer. That means that somewhere in the evidence that already existed, you found a gap. As you lay out the focused, relevant evidence that took you to your research question, be sure to point to these gaps. Do not be afraid to explicitly say that they are gaps and that your research is intended in some part to fill them.

Do not write a literature review

If you are writing a thesis, the background section is not the place for the literature review. Your background relates directly to what your work addresses and should retain a focus on that theme. A literature review is broader and can encompass anything even generally related to your work. It’s a place to take the publications you mention in the background and expand on their content and implications, giving them a fuller and more detailed treatment.

3 tips for writing your background section

1. Think: as you would for writing an introduction to a research paper, think about the direct chain of evidence that led to your own work. Make a list of the most important findings that make up that chain of evidence.

2. Organize: use only a few sentences to summarize each contribution to that chain, and then form them into a story that makes sense and stays on theme. Use connecting words and phrases, such as “then” or “after that discovery” or “following on these findings” to keep the connections obvious for the reader.

3. Delete: after you have written your first draft, go through it and delete anything that is not absolutely required for the reader to follow the chain of evidence that led to your research and the gap you’re addressing. Remember that if this is your thesis, you will be able to elaborate and add in plentiful detail in your literature review section. In fact, you can think of your background section in this situation as a sort of summary of your literature review.

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Critical Writing Seminar: Craft Of Prose (Spring 2024): Researching the White Paper

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Research the White Paper

Researching the White Paper:

The process of researching and composing a white paper shares some similarities with the kind of research and writing one does for a high school or college research paper. What’s important for writers of white papers to grasp, however, is how much this genre differs from a research paper.  First, the author of a white paper already recognizes that there is a problem to be solved, a decision to be made, and the job of the author is to provide readers with substantive information to help them make some kind of decision--which may include a decision to do more research because major gaps remain. 

Thus, a white paper author would not “brainstorm” a topic. Instead, the white paper author would get busy figuring out how the problem is defined by those who are experiencing it as a problem. Typically that research begins in popular culture--social media, surveys, interviews, newspapers. Once the author has a handle on how the problem is being defined and experienced, its history and its impact, what people in the trenches believe might be the best or worst ways of addressing it, the author then will turn to academic scholarship as well as “grey” literature (more about that later).  Unlike a school research paper, the author does not set out to argue for or against a particular position, and then devote the majority of effort to finding sources to support the selected position.  Instead, the author sets out in good faith to do as much fact-finding as possible, and thus research is likely to present multiple, conflicting, and overlapping perspectives. When people research out of a genuine desire to understand and solve a problem, they listen to every source that may offer helpful information. They will thus have to do much more analysis, synthesis, and sorting of that information, which will often not fall neatly into a “pro” or “con” camp:  Solution A may, for example, solve one part of the problem but exacerbate another part of the problem. Solution C may sound like what everyone wants, but what if it’s built on a set of data that have been criticized by another reliable source?  And so it goes. 

For example, if you are trying to write a white paper on the opioid crisis, you may focus on the value of  providing free, sterilized needles--which do indeed reduce disease, and also provide an opportunity for the health care provider distributing them to offer addiction treatment to the user. However, the free needles are sometimes discarded on the ground, posing a danger to others; or they may be shared; or they may encourage more drug usage. All of those things can be true at once; a reader will want to know about all of these considerations in order to make an informed decision. That is the challenging job of the white paper author.     
 The research you do for your white paper will require that you identify a specific problem, seek popular culture sources to help define the problem, its history, its significance and impact for people affected by it.  You will then delve into academic and grey literature to learn about the way scholars and others with professional expertise answer these same questions. In this way, you will create creating a layered, complex portrait that provides readers with a substantive exploration useful for deliberating and decision-making. You will also likely need to find or create images, including tables, figures, illustrations or photographs, and you will document all of your sources. 

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  • Last Updated: Jan 22, 2024 3:53 PM
  • URL: https://guides.library.upenn.edu/c.php?g=1374611
  • Research article
  • Open access
  • Published: 17 January 2024

Experiences of hospital care for people with multiple long-term conditions: a scoping review of qualitative research

  • Sue Bellass   ORCID: orcid.org/0000-0001-9383-4116 1 ,
  • Thomas Scharf 2 ,
  • Linda Errington 3 ,
  • Kelly Bowden Davies 1 ,
  • Sian Robinson 4 , 5 ,
  • Adam Runacres 1 ,
  • Jodi Ventre 6 ,
  • Miles D. Witham 4 , 5 ,
  • Avan A. Sayer 4 , 5 &
  • Rachel Cooper 4 , 5  

BMC Medicine volume  22 , Article number:  25 ( 2024 ) Cite this article

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Multiple long-term conditions—the co-existence of two or more chronic health conditions in an individual—present an increasing challenge to populations and healthcare systems worldwide. This challenge is keenly felt in hospital settings where care is oriented around specialist provision for single conditions. The aim of this scoping review was to identify and summarise published qualitative research on the experiences of hospital care for people living with multiple long-term conditions, their informal caregivers and healthcare professionals.

We undertook a scoping review, following established guidelines, of primary qualitative research on experiences of hospital care for people living with multiple long-term conditions published in peer-reviewed journals between Jan 2010 and June 2022. We conducted systematic electronic searches of MEDLINE, CINAHL, PsycInfo, Proquest Social Science Premium, Web of Science, Scopus and Embase, supplemented by citation tracking. Studies were selected for inclusion by two reviewers using an independent screening process. Data extraction included study populations, study design, findings and author conclusions. We took a narrative approach to reporting the findings.

Of 8002 titles and abstracts screened, 54 papers reporting findings from 41 studies conducted in 14 countries were identified as eligible for inclusion. The perspectives of people living with multiple long-term conditions (21 studies), informal caregivers ( n  = 13) and healthcare professionals ( n  = 27) were represented, with 15 studies reporting experiences of more than one group. Findings included poor service integration and lack of person-centred care, limited confidence of healthcare professionals to treat conditions outside of their specialty, and time pressures leading to hurried care transitions. Few studies explored inequities in experiences of hospital care.

Conclusions

Qualitative research evidence on the experiences of hospital care for multiple long-term conditions illuminates a tension between the desire to provide and receive person-centred care and time pressures inherent within a target-driven system focussed on increasing specialisation, reduced inpatient provision and accelerated journeys through the care system. A move towards more integrated models of care may enable the needs of people living with multiple long-term conditions to be better met. Future research should address how social circumstances shape experiences of care.

Peer Review reports

Multiple long-term conditions (MLTC)—the co-existence of two or more long-term conditions in an individual—are becoming more common, with far-reaching consequences for populations and health services worldwide [ 1 , 2 , 3 ]. Although the definition and operationalisation of the concept of MLTC is highly variable [ 4 ] and a need for greater consistency has led to recent efforts to reach a consensus [ 5 ], the term MLTC is generally understood to be the experience of at least two long-term health conditions of long duration, including non-communicable diseases, infectious diseases and mental health conditions [ 2 ].

Inconsistencies in the definition and characterisation of MLTC have led to major variations in prevalence estimates [ 4 , 6 ]; however, it is estimated that one in four of UK adults live with MLTC [ 7 , 8 ] and that prevalence is increasing. The proportion of British adults aged over 65 years with MLTC is predicted to rise from 54% in 2015 to 68% by 2035 [ 9 ]. Multi-country studies suggest similarly high prevalence of MLTC in other high-income settings, with MLTC in low- and middle-income countries advancing towards equivalent levels [ 10 , 11 ]. The accumulating evidence of the current and anticipated scale of MLTC, and their impact on quality of life and demand for healthcare, have led to calls to prioritise MLTC research [ 2 ].

People living with MLTC are more likely to experience lower quality of life, lower healthy life expectancy and poorer health outcomes than people with no or a single long-term condition [ 12 , 13 ], and there is a growing awareness that clinical education, evidence-based guidelines and health services, typically oriented around single conditions, are fundamentally unsuited to the needs of this population [ 14 , 15 , 16 ]. This can be keenly observed in secondary and tertiary care, which, in recent years, have been characterised by greater specialisation [ 17 ]. While improving care and outcomes for single conditions, an increasing focus on specialised care may hinder the development of coordinated care able to address co-existing conditions in people with MLTC.

Recognising the need to better understand hospital care for MLTC, there is an important role for studies that can elucidate the lived experiences of receiving or delivering care. We therefore chose to focus in this review on qualitative research which, while encompassing a wide variety of methodological approaches and traditions, is characterised by the aim of producing a rich understanding of the ways in which people perceive and interpret social phenomena [ 18 , 19 ]. Existing systematic and scoping reviews have captured aspects of the experience of MLTC care from the perspectives of general practitioners [ 20 ] informal caregivers [ 21 ] and patients [ 22 ], while others have focussed on specific aspects of care such as coordination and integration [ 23 , 24 ]. However, no reviews known to the authors specifically explore and present the experiences of hospital care delivery and receipt from the perspectives of people living with MLTC, informal caregivers and healthcare professionals. To address this important gap, we undertook a scoping review to identify the breadth of relevant literature, describe the key concepts explored and highlight gaps in the knowledge base [ 25 , 26 ].

In line with the core objectives of scoping reviews [ 27 ], we specifically aimed to address the following three research questions:

What is the nature, range and extent of published qualitative literature exploring hospital care experiences of people living with MLTC, informal caregivers and healthcare professionals?

What experiences of hospital care have been reported in the literature?

What gaps exist in the knowledge base that might be addressed by future research?

Our approach to the review was informed by Arksey and O’Malley’s scoping review framework [ 25 ] and recently updated guidance on scoping review methodology [ 26 ]. In line with these frameworks and guidelines, a protocol was created which pre-specified the inclusion and exclusion criteria for the review (see Additional file 1 ) [ 4 , 25 , 28 , 29 , 30 , 31 , 32 , 33 , 34 ]. This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) [ 34 ].

Searching for relevant studies

Seven databases were searched systematically to identify eligible studies. The search strategies were formulated and executed by a medical librarian (LE) using the PICoS (Population-Phenomenon of Interest-Context- Study type) framework (see Table  1 ).

The search strategy involved combining both subject index and keyword terms covering the following concepts: MLTC, secondary care and qualitative research. Full details of the search strategies can be found in Additional file 2 . The following databases were independently searched from 1st Jan 2010 to 22nd June 2022: Medline, Embase and PsycINFO (via OVID), Web of Science, Scopus, CINAHL via EBSCO, and Social Science Premium via Proquest. We opted to restrict the date to 2010 onwards as, given regular restructuring of hospital services and the increasing prevalence of MLTC, we wished to identify studies that reflected experiences most likely to be relevant to the current context of hospital care. Study titles and abstracts were uploaded to systematic review management software (Covidence) where they were deduplicated and screened against inclusion and exclusion criteria (see Table  2 ). Consistent with scoping review methodology [ 26 ], published studies were not excluded from the review on the basis of poor methodological quality.

Screening of titles and abstracts was carried out independently by six members of the review team (SB, LE, KBD, AR, JV, RC) with two reviewers screening each record. Any uncertainty or disagreement about inclusion was resolved through in-depth discussion between SB and RC. The reference lists of eligible studies and results from forward citation tracking were screened to identify additional articles.

Once eligible studies had been identified, a data extraction chart (see Additional file 3 ) was created following discussions among three authors (SB, RC, TS) and populated by one author (SB). Extracted data included author(s), year of publication, journal, definition of MLTC, theoretical framework, aims, methods, setting, health conditions, participants, findings, and author conclusions. In line with established methodological guidance from Arksey and O’Malley [ 25 ] and Peters et al. [ 26 ], we did not conduct formal critical appraisal of the included studies.

Collating, summarising and reporting results

Using the data extracted, studies were categorised according to country of origin, diagnosis-specific and non-diagnosis-specific research and perspectives of participants (people living with MLTC, informal caregivers and healthcare professionals). Consistent with recent guidance on scoping review methodology [ 26 ], the results are summarised narratively rather than analysed thematically.

Overview of studies

We screened 8002 records from electronic database searches and a further 1613 records identified through citation tracking (see Fig.  1 ). A total of 54 papers [ 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 ] met the inclusion criteria for the review and these reported on findings from 41 unique studies (see Table  3 for a summary of these papers).

figure 1

PRISMA flow diagram

The studies were conducted in 14 countries, with the majority from the UK (9 studies, 14 papers) and Canada (6 studies, 8 papers). Four studies were conducted in low- and middle-income countries (Bangladesh, Iran, Pakistan and South Africa) with the remainder from high-income countries in Western Europe, Northern America or Australasia (Table  4 ). The key concepts underpinning studies were notably similar, despite the various contexts in which the studies were undertaken. Where there were clear differences between healthcare conditions, countries, or the perspectives of people with MLTC, informal caregivers or healthcare professionals, these are noted in the findings.

Around half of the studies ( n  = 21/41, 51.2%) were not diagnosis-specific, designating participants to be eligible on the basis of living with, informally supporting or delivering care for people with MLTC, or on the basis of diagnosis with at least two of a wide range of conditions. The other papers were diagnosis-specific, recruiting on the basis of two specified conditions (e.g. cancer and dementia; psychosis and diabetes) or a specified single condition with additional morbidities (e.g. HIV and multimorbidities; diabetes and multimorbidities), the latter grouping often being described as comorbidity. These study characteristics are summarised in Table  5 . The age of participants living with MLTC, where a range was reported, was between 23 and 100 years. A total of 15 studies (36.6%) explicitly used age as an orienting concept in their studies, aiming to understanding the experiences of “elderly” or “older” patients.

When exploring the perspectives of a single participant group, the majority of studies focussed on healthcare professionals ( n  = 17; 41.5%) compared with seven studies exploring solely the perspectives of people living with MLTC (17.1%) and two studying only the perspectives of informal caregivers (4.9%). Five studies explored views of both people living with MLTC and their caregivers (12.2%), while four (9.8%) focussed on people with MLTC and healthcare professionals, and one on informal caregivers and healthcare professionals (2.4%). Finally, five studies (12.2%) collected data on the perspectives of all three participant groups. Data collection was predominantly solely via interviews with a single person or dyad ( n  = 26; 63.4%) with some studies using focus groups ( n  = 7; 17.1%), or a combination of data collection methods, often including observation ( n  = 6; 14.6%). Most studies had a cross-sectional design ( n  = 33; 80.5%) with longitudinal designs including ethnographies ( n  = 4; 9.8%) or repeated interviews ( n  = 4; 9.8%). Sample sizes ranged from 5 to 116 for people living with MLTC, 2 to 33 for informal caregivers, and 5 to 65 for healthcare professionals. Professions represented included nurses ( n  = 21 studies; 51.2%), medical staff ( n  = 20; 48.8%), allied health professionals ( n  = 6, 14.6%), social care staff ( n  = 3; 7.3%), pharmacists ( n  = 2; 4.9%), policy makers ( n  = 1, 2.4%), or small numbers of other staff supporting people with MLTC in hospital settings such as chaplains or transport officers ( n  = 9; 22.0%).

A wide range of qualitative approaches were employed in the studies. Although the majority used generic qualitative designs that did not appear to adhere to a particular methodology ( n  = 25; 61.0%), other approaches included ethnography ( n  = 4; 9.8%), grounded theory ( n  = 4; 9.8%), and phenomenology / interpretative phenomenological analysis ( n  = 3; 7.3%). A small number of studies ( n  = 6; 14.6%) employed other methodological techniques including narrative approaches, case studies, and analysis of open-ended questions from in-person survey interviews. One study reported two designs. Studies largely did not state any underpinning theoretical framework; for those that did, the Theoretical Domains Framework ( n  = 2; 4.8%), socio-ecological framework ( n  = 2; 4.8%), and Health Outcomes Model ( n  = 1; 2.4%) guided the work. Similarly, few studies made reference to an underpinning philosophical or social theoretical stance; those that did cited phenomenology ( n  = 3, 7.3%), symbolic interactionism ( n  = 2, 4.8%), interpretivism ( n  = 2, 4.8%), pragmatism ( n  = 1; 2.4%), or Bourdieusian theory ( n  = 1; 2.4%).

Approaches to defining MLTC

The diagnosis-specific studies described the particular conditions they were exploring. Among the studies that were not oriented around specific diagnoses or that stated a range of conditions ( n  = 21), the most common definition of MLTC given was two or more chronic conditions in an individual ( n  = 9, 42.9%). One study used the definition of one or more chronic illness [ 64 ], although recruited participants with multiple conditions. Eleven studies involving non-diagnosis-specific populations (52.4%) did not enumerate health conditions, referring instead to polypharmacy, patient complexity, or making broad reference to multiple chronic conditions. Four studies (9.8%) provided a list of conditions in their participant inclusion criteria.

A few research teams qualified their definition of MLTC, referring to the duration of the conditions [ 65 ], the need for medical management [ 65 , 82 ], the lack of prioritisation of one condition over another [ 71 ], or the effect of MLTC on the person’s capabilities to carry out activities of daily living [ 64 , 65 , 67 ]. Three teams of authors highlighted the importance of the social context in which MLTC can occur [ 40 , 41 , 88 ], with one noting that defining MLTC in terms of medical complexity may obscure the influence of socioeconomic and sociocultural influences on the experience of MLTC [ 41 ].

Coordinating service delivery

Experiences relating to service coordination and care delivery formed the main element of the findings of this review. Of all studies in the review, thirty-one (75.6%) reported findings relating to processes of interprofessional communication and service integration in specialist care settings. Interestingly, findings from all three participant groups identified similar issues, such as the siloed nature of specialties leading to fragmented care [ 42 , 48 , 49 , 52 , 64 , 84 , 86 ] and poor care continuity [ 37 , 51 , 58 , 80 ], lack of clarity of responsibility [ 52 , 54 , 61 , 71 , 72 , 86 ], insufficient interprofessional communication [ 35 , 60 , 66 , 71 , 78 ] and a perception that specialists were unwilling to offer medical advice beyond their area of expertise [ 44 , 58 , 78 ]. Limited functionality of electronic health record systems was noted by healthcare professionals to perpetuate these experiences, impacting on the reliability of medication history [ 37 , 52 , 83 ] and, in some instances, positioning people living with MLTC as the source of information for healthcare professionals [ 37 , 46 ]. These challenges may be particularly acute between mental and physical healthcare services; studies including people living with dementia or psychosis reported a lack of service integration and lack of adaptation of physical health care delivery for people with mental health conditions [ 58 , 61 , 87 ]. Three studies, two conducted with patients and informal caregivers, and one with nurses, concluded that a named individual with responsibility for overseeing care for people living with MLTC would improve care coordination [ 49 , 50 , 78 ], although a barrier to creating and maintaining this role, noted by health care professionals, might be the structure of the funding arrangements and performance measurement for specialties [ 60 ]. Four studies (9.8%), three of which were conducted with healthcare professionals, and one with patients, and two of which were in low- and middle-income countries, highlighted under-resourcing in hospital care as a barrier to care coordination [ 42 , 53 , 64 , 88 ].

Eight studies (19.5%) highlighted lack of knowledge and experience of treating other conditions as a contributing factor to the lack of joined-up care in hospital settings. Guidelines for clinical practice were perceived by healthcare professionals to be limited [ 44 , 55 , 83 ], with the research evidence base lacking for older people or people with MLTC as a result of exclusion of these groups from clinical trials [ 44 , 48 ]. This led one study team to suggest that health care professionals treating people with MLTC do not “have a clear script to follow” [ 68 ] (p. 573) and, for another, that treatment recommendations may be more subjective rather than evidence-based due to the paucity of research evidence on MLTC populations [ 44 ]. Studies including people with dementia noted the lack of training, confidence, and experience of healthcare professionals to provide care for someone with cognitive impairment [ 44 , 57 ].

Time and pacing

Insufficient time in the hospital setting to provide care for people with MLTC was a focal point of 16 studies (39.0%), with people living with particular conditions including HIV and dementia perceived by healthcare professionals as needing longer and more frequent appointments [ 58 , 69 , 77 ].

Time and pacing seemed particularly salient in emergency departments and at the point of discharge. The emphasis on rapid and efficient pathways through emergency care, either to admission or discharge, was not perceived to be congruent with the need for more time to understand the needs of people with MLTC in studies involving healthcare professionals and people living with MLTC [ 37 , 53 , 67 , 70 ]. Observational data collected during an ethnographic study suggested this may lead to an over-simplification of chronic conditions and a lack of understanding of the cause of symptoms [ 36 ]. There were findings in two studies including healthcare professional participants that older people may be perceived by staff as resource-intensive and time-consuming in the emergency department [ 51 , 53 ]. Prescribing in emergency care settings was perceived by doctors and pharmacists in two studies to be hurried, creating a focus on prescribing for acute presentations which could lead to long-term conditions being overlooked [ 48 , 83 ].

Discharge was another point on the care pathway that was perceived as being problematic in terms of time. Discharge was described as being premature or rushed [ 45 , 49 , 63 , 79 ], which could leave people living with MLTC and their caregivers feeling ill-prepared to navigate life with multiple long-term conditions after an in-patient stay [ 38 , 45 , 49 , 65 ]. Eleven studies (26.8%), conducted in high-income countries, identified the recent trends in health policy towards shortened hospital stays, efficient discharges, and a prioritisation of highly specialised and measurable care for distinct conditions as disadvantageous for the MLTC population.

Person-centred care

Seventeen studies (41.5%) presented findings on person-centred care for people with MLTC in specialist settings. Despite being a common concept underpinning the body of literature, few authors offered a definition of person-centred care. Exceptions included a study in the US with healthcare professionals caring for people with HIV and HCV [ 69 ], which cited Mead and Bower’s (2000) conceptualisation, a study in Pakistan of nurses caring for people living with MLTC which adopted Morgan and Yoder’s (2012) biopsychosocial-spiritual definition [ 88 ], and a study conducted in Canada which cited Stewart’s (1995) model [ 64 ].

Knowing the person living with MLTC was identified by healthcare professionals as a crucial component of care in several studies [ 39 , 58 , 68 , 83 ]. However, in an example of divergence between professional and patient or family perspectives, studies reported that people living with MLTC and informal caregivers perceived a lack of individualised care [ 41 , 50 , 51 , 64 , 77 , 81 , 84 , 88 ]. Studies involving only people with MLTC reported findings of poor communication with clinicians [ 63 , 64 , 70 , 86 ], with staff perceived to prefer to focus on tangible symptoms [ 70 ] rather than on the whole person.

Twelve studies (29.3%), seven of which included people living with dementia, presented data relating to decision-making processes in hospital care for people with MLTC. Studies from the perspective of people living with MLTC highlighted the need for greater involvement in decision-making and the opportunity to share the important aspects of their conditions with healthcare professionals [ 50 , 66 , 70 ]. Building a trusting collaborative relationship between people with MLTC, informal caregivers, and staff was perceived to require time and consistency in two studies reporting the perspectives of staff and informal caregivers [ 69 , 74 ].

Mental capacity and decision-making

Studies including people with dementia highlighted the challenges that the condition presented for shared decision-making [ 57 , 76 ], particularly relating to cancer treatment, where concerns were raised over the person with cancer and dementia being unable to fully participate in treatment decision-making, communicate information about treatment side-effects, or recall their surgery. Decision-making led to an increased reliance on family members in studies exploring the perspectives of informal caregivers and healthcare professionals [ 39 , 87 ] which could cause additional stress [ 56 ]. Some studies reported that family members could feel excluded from engaging in decision-making processes [ 44 , 47 , 87 ].

Support from informal caregivers

Thirteen studies (31.7%) highlighted support from informal caregivers as a key element in the experience of MLTC hospital care, with some studies finding that family members assumed the roles of advocacy and care coordination [ 56 , 62 , 73 ]. In studies including the patient perspective, the absence of an involved family member could reduce access to support [ 44 , 66 , 82 ]. Two studies offering insights into caregiver perspectives suggested that healthcare professionals needed to understand the level of caregiver involvement, assess their ability to provide support to their relative and understand the impact of ageing on caregivers’ abilities to continue to provide support [ 56 , 75 ]. Some studies illuminated tensions in the provider-informal caregiver relationship; one study of healthcare professionals in Sweden, for example, noted that family members could create ethical dilemmas by asking the clinician not to report illness details to patients [ 51 ].

Broader social context

A small number of studies explored the broader social context of health conditions, highlighting conditions such as HIV and TB which may be normalised in hospital environments but stigmatised in the community [ 45 , 62 , 69 ]. Deep-rooted gender issues were described in the two studies conducted in South Asia, with women’s reliance on men to transport them to appointments [ 88 ], and poorer treatment of women with TB and depression [ 62 ] influencing access to and experience of hospital care. Socioeconomic status, poor housing, and lack of transport were seen as compounding the challenges associated with accessing services [ 41 , 45 , 62 , 63 ], and while gender was consistently reported in these four studies, with evenly balanced samples, other characteristics were less routinely described. All the participants in one study [ 45 ] were receiving financial support or government disability services, and, in another [ 41 ], were described as low or middle income. Occupation was reported in two studies, with approximately half of the participants not in paid employment [ 41 , 62 ], and housing status in one [ 45 ]. Ethnicity was less well-reported, with the exception of a study on Aboriginal and Torres Strait Islander peoples [ 63 ] which identified a need for culturally appropriate MLTC care.

Sociocultural understandings of health conditions may be reflected in clinical perspectives of dementia [ 44 ], with some perceptions of negative attitudes or stereotyping behaviour among staff caring for older people [ 51 ] or people with mental health conditions [ 35 ].

We undertook a scoping review of published qualitative studies on experiences of care for people living with MLTC in hospital care settings to identify the breadth and nature of qualitative literature, the key concepts underpinning the knowledge base, and to highlight gaps for future research. A key finding of our review, which identified 54 papers, underlines the complexity of specialist care provision for people with MLTC, and illuminates the tension between a desire to provide person-centred care that attends to the needs of people with MLTC and a target-driven system of specialist care subject to increasing pressures to accelerate care pathways [ 89 , 90 ].

Challenges to coordinating care across specialties were the most consistent finding in the review. With the exception of dementia and psychosis, which appeared to present additional challenges to integrating care, we observed little variation in findings across countries or health conditions, although this may require further interrogation in studies where MLTC, and the conditions included, are more clearly defined. Complementing existing evidence which suggests that care coordination is challenging in primary care for people with MLTC [ 91 , 92 ], this review indicates that the current specialist care provision in hospital settings is also poorly suited to the needs of people living with two or more long-term conditions, and that greater effort needs to be made to integrate services and to deliver care that is responsive to the needs of people with MLTC [ 16 ].

Person-centred care formed a key concept within the reviewed studies. However, in common with other health research adopting this concept [ 93 ], few authors offered a definition of person-centred care, and there was some variability in those put forward. In general, individualising care, being listened to by healthcare professionals, and being involved in decision-making processes was perceived as important by people living with MLTC and informal caregivers.

Similar to Ho et al.’s systematic review of quantitative studies of multimorbidity [ 4 ], we found that MLTC was typically defined as the co-existence of two or more long-term conditions in an individual, and was rarely afforded further clarification. It should be noted that some of these papers were more closely aligned with definitions of comorbidity [ 94 ]; however, in wishing to take an inclusive approach, these papers were included. Definitions founded on the number of body systems affected by morbidities (such as complex multimorbidity, defined by Harrison et al. [ 95 ] as three or more conditions affecting three or more body systems) were not in evidence in this literature. Moreover, around a quarter of studies in our review did not provide any definition of MLTC. In a field as complex and rapidly expanding as MLTC research, we concur with Ho et al. [ 4 ], that, while study populations may appropriately vary according to the research question, achieving greater consistency and transparency in the definition of MLTC will enhance coherence and comparability.

Social and health inequalities were not a core element of this body of literature, yet MLTC are known to be associated with socioeconomic deprivation, with earlier onset of MLTC among people living in socially deprived areas [ 7 , 96 ] and evidence that minority communities are disproportionately affected by MLTC [ 97 , 98 ]. While qualitative approaches cannot provide prevalence estimates, they nevertheless present an opportunity to gain insights into the ways in which people’s life circumstances might impinge on capacity to prioritise health and to access and engage with healthcare [ 99 ].

Of the five previous systematic or scoping reviews we identified on MLTC care [ 20 , 21 , 22 , 23 , 24 ], none had focussed on the hospital setting. However, all highlighted similar findings to our own, namely poorly coordinated healthcare and challenges delivering person-centred or holistic care. Lack of guidelines for MLTC care was also highlighted in two reviews [ 20 , 23 ] yet the important role informal caregivers may play was only emphasised in one [ 21 ]. Three of the reviews highlighted communication between primary and secondary care as a barrier to care coordination [ 20 , 21 , 23 ], with one in particular noting the potential antagonism between the holistic ethos of general practice and the specialist focus on individual body systems [ 20 ]. Time and pacing, a key finding from our review and perhaps more salient in the hospital setting, was not prominent in these other reviews, though limited time for GP consultations was noted as a potential barrier to optimal care [ 20 ].

Gaps in the knowledge base

The studies identified in this review have employed a range of qualitative approaches to provide insights into the experiences of hospital care for people living with MLTC from the perspectives of people receiving care, informal caregivers and healthcare providers. We can identify at least six clear gaps in the evidence base. Firstly, most studies were cross-sectional, capturing snapshots of experiences of hospital care rather than the experience of receiving or delivering hospital care over time. Studies that had a longitudinal design were either ethnographies [ 37 , 41 , 52 , 55 ] or collected data through repeated interviews. Of the latter, most data collection was conducted over a period of a few weeks [ 45 , 70 , 73 ], with one exception where patients were followed up for between 5 and 9 months [ 75 ]. Consequently the studies were limited in the extent to which they could generate understandings of interactions with hospital care systems over time and how these might be shaped by biographical influences.

Secondly, the studies tended to focus on older populations, with only a small number of studies recruiting people living with MLTC below the age of 40 [ 45 , 62 , 63 , 64 , 76 ]. While ageing is associated with higher risk of MLTC, a study in Scotland found that more than half of people with MLTC were younger than 65 years of age, and that this was socially patterned, with socioeconomic deprivation associated with younger age at onset of MLTC [ 7 , 96 ]. Further evidence suggests that MLTC are associated with ethnicity [ 100 , 101 ] and gender [ 102 ] yet with the notable exception of the Richmond Group of Charities Taskforce study on MLTC and health equity [ 99 ], how sociodemographic characteristics may intersect to structure the experience of MLTC remains under-researched, and is not explored in the reviewed studies. Insights into this could be gained through life course approaches which can investigate ageing with MLTC and engaging with hospital care over time.

Thirdly, although the review identified several studies on dementia co-existing with other conditions, there was little focus on other types of mental health condition such as severe mental illness or common mental health disorders, despite the fact that associations between, for example, severe mental illness and diabetes [ 103 ], and depression and comorbid long-term physical health conditions are well-established [ 104 ].

Fourthly, the importance of informal support for people with MLTC receiving hospital care was highlighted in around a third of studies, with informal caregivers assisting with care coordination, managing multiple appointments and medications, and having a role in decision-making, particularly when the person receiving care was living with dementia. However, studies focussed on the experiences of a single person providing support, which rests on the assumption that only one person undertakes a caregiving role, and neglects broader supportive networks that some people with MLTC may have. Only a few studies [ 44 , 66 ] articulated experiences of people with MLTC who did not have informal support. The limited evidence available suggests that lack of such support could affect access to services, which warrants further investigation.

Fifthly, with the exception of a study on cancer and dementia [ 32 ] which found that the hospital environment was not suited for people living with dementia, studies did not offer findings on the environment of the hospital as a physical institution in which care delivery took place. Experiences of navigating the hospital landscape with MLTC, which are associated with functional impairment [ 105 ] remain underexplored. In the context of greater centralisation of hospital services [ 106 ], and overcrowding in emergency departments leading to care being undertaken in corridors [ 107 ], there is an opportunity for future studies to illuminate the experience of the physical environment in which care takes place.

Finally, power dynamics of clinician-patient interactions in clinical spaces were only explored in depth in one study [ 47 ], and, while findings from the body of literature could be related to care quality, only two studies explicitly focussed on the concept of quality of care for MLTC [ 70 , 84 ].

Potential future directions

Strengths and limitations.

Our review was novel in aiming to identify and describe the findings from qualitative research on the experiences of hospital care for people with MLTC. We followed established methods for scoping reviews [ 25 , 26 ], including a systematic electronic search strategy supplemented with citation tracking and, as a result, were able to identify and summarise studies from 14 countries.

We recognise three main limitations of our review. First, we chose to focus on peer-reviewed literature published after 2010 to identify research reflecting experiences most likely to be relevant to the current context of hospital care, and we did not conduct searches of grey literature to ensure that the task of reviewing titles and abstracts was manageable in scale. However, we recognise that some relevant research, published earlier, or not published in peer-reviewed journals, may therefore have been missed. Additionally, although we used systematic searching methods and citation tracking, we did not contact authors or hand-search journals. Second, complexities around the definition and operationalisation of MLTC, and the frequent conflation of MLTC with age, meant that we were presented with a decision on whether to include a small number of studies that purported to study MLTC but recruited participants solely on the inclusion criterion of older age. We opted to exclude these studies as we could not be certain that the participants had MLTC and were reluctant to perpetuate notions of MLTC as an inevitable aspect of older age. Additionally, if we had wished to capture all studies of this nature, we would have had to expand our search terms to include all studies of older adults regardless of reported MLTC status. Third, in wishing to illuminate in-depth experiences, we focused our review on qualitative studies. We acknowledge that further valuable insights could be gained from quantitative surveys of the views and experiences of people living with MLTC, informal caregivers and healthcare professionals.

The accumulating evidence of the current and anticipated scale of MLTC, and its impact on quality of life and demand for healthcare, have led to calls to prioritise MLTC research. This review of qualitative studies has illuminated tensions between a drive to provide individualised person-centred care for people with MLTC in hospital settings, and a system which is moving towards greater clinical specialism and accelerated care pathways. More integrated models of care may enable the needs of people living with multiple long-term conditions to be better met in the hospital setting.

Availability of data and materials

No data were generated for this study. The study protocol, search strategies and data extraction template are available as Additional files .

Abbreviations

  • Multiple long-term conditions

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Acknowledgements

The authors wish to acknowledge the ADMISSION research collaborative’s Patient Advisory Group (PAG)—patients and carers with lived experience of multiple long-term conditions who have been involved at every stage of this research. The design of the ADMISSION research collaborative was informed by three workshop discussions to identify research priorities and to develop the scientific questions. ADMISSION’s PAG members have diverse experiences of hospital care and include two patients who joined the research team as public co-investigators. We work closely with the co-investigators and PAG members, who provide advice and guidance on all components of the research programme.

The authors also wish to acknowledge the invaluable contribution of their late colleague Dr Richard Dodds to the ADMISSION research collaborative.

This research was conducted as part of the ADMISSION research collaborative, funded by the Strategic Priority Fund “Tackling multimorbidity at scale” programme (grant number MR/V033654/1) delivered by the Medical Research Council and the National Institute for Health and Care Research in partnership with the Economic and Social Research Council and in collaboration with the Engineering and Physical Sciences Research Council. SB, TS, SR, MDW, AAS and RC acknowledge support from this funding award.

SR, MDW, AAS and RC also acknowledge support from the National Institute for Health and Care Research (NIHR) Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Foundation Trust, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust and Newcastle University.

RC also receives support as part of a generous donation made by the McArdle family to Newcastle University for research that will benefit the lives of older people in the UK.

The funders played no role in the design of the study and collection, analysis, and interpretation of data or in writing the manuscript. The views expressed in this publication are those of the authors and not necessarily those of UK Research and Innovation, the National Institute for Health and Care Research, the Department of Health and Social Care or the McArdle family.

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This review was conducted as part of a programme of research (ADMISSION) conceived by AAS, RC, TS, MDW and SR. SB, TS and RC conceived the idea for this review and developed its objectives. SB, TS, LE and RC devised the search strategy. LE conducted the searches and citation tracking and retrieved the articles. SB, LE, KBD, AR, JV and RC screened titles and abstracts. SB and RC screened full-text articles and SB extracted data from included studies. SB wrote the first draft of the manuscript with input from LE, which was revised by TS and RC. All authors critically revised subsequent iterations of the manuscript and approved the final version.

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Bellass, S., Scharf, T., Errington, L. et al. Experiences of hospital care for people with multiple long-term conditions: a scoping review of qualitative research. BMC Med 22 , 25 (2024). https://doi.org/10.1186/s12916-023-03220-y

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  • Multimorbidity
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  • Hospital care
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BMC Medicine

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background of research paper

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Published on 24.1.2024 in Vol 26 (2024)

Development and Evaluation of a Smartphone-Based Chatbot Coach to Facilitate a Balanced Lifestyle in Individuals With Headaches (BalanceUP App): Randomized Controlled Trial

Authors of this article:

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Original Paper

  • Sandra Ulrich 1 , MSc   ; 
  • Andreas R Gantenbein 2, 3 , MD   ; 
  • Viktor Zuber 1 , BSc   ; 
  • Agnes Von Wyl 1 , PhD   ; 
  • Tobias Kowatsch 4, 5, 6 * , PhD   ; 
  • Hansjörg Künzli 1 * , LicPhil  

1 School of Applied Psychology, Zurich University of Applied Sciences, Zurich, Switzerland

2 Pain and Research Unit, ZURZACH Care, Bad Zurzach, Switzerland

3 Department of Neurology, University Hospital Zurich, Zurich, Switzerland

4 Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland

5 School of Medicine, University of St.Gallen, St. Gallen, Switzerland

6 Centre for Digital Health Interventions, Department of Management, Technology, and Economics, ETH Zurich, Zurich, Switzerland

*these authors contributed equally

Corresponding Author:

Sandra Ulrich, MSc

School of Applied Psychology

Zurich University of Applied Sciences

Pfingstweidstrasse 96

Zurich, 8005

Switzerland

Phone: 41 58 934 ext 8451

Email: [email protected]

Background: Primary headaches, including migraine and tension-type headaches, are widespread and have a social, physical, mental, and economic impact. Among the key components of treatment are behavior interventions such as lifestyle modification. Scalable conversational agents (CAs) have the potential to deliver behavior interventions at a low threshold. To our knowledge, there is no evidence of behavioral interventions delivered by CAs for the treatment of headaches.

Objective: This study has 2 aims. The first aim was to develop and test a smartphone-based coaching intervention (BalanceUP) for people experiencing frequent headaches, delivered by a CA and designed to improve mental well-being using various behavior change techniques. The second aim was to evaluate the effectiveness of BalanceUP by comparing the intervention and waitlist control groups and assess the engagement and acceptance of participants using BalanceUP.

Methods: In an unblinded randomized controlled trial, adults with frequent headaches were recruited on the web and in collaboration with experts and allocated to either a CA intervention (BalanceUP) or a control condition. The effects of the treatment on changes in the primary outcome of the study, that is, mental well-being (as measured by the Patient Health Questionnaire Anxiety and Depression Scale), and secondary outcomes (eg, psychosomatic symptoms, stress, headache-related self-efficacy, intention to change behavior, presenteeism and absenteeism, and pain coping) were analyzed using linear mixed models and Cohen d. Primary and secondary outcomes were self-assessed before and after the intervention, and acceptance was assessed after the intervention. Engagement was measured during the intervention using self-reports and usage data.

Results: A total of 198 participants (mean age 38.7, SD 12.14 y; n=172, 86.9% women) participated in the study (intervention group: n=110; waitlist control group: n=88). After the intervention, the intention-to-treat analysis revealed evidence for improved well-being (treatment: β estimate=–3.28, 95% CI –5.07 to –1.48) with moderate between-group effects (Cohen d =–0.66, 95% CI –0.99 to –0.33) in favor of the intervention group. We also found evidence of reduced somatic symptoms, perceived stress, and absenteeism and presenteeism, as well as improved headache management self-efficacy, application of behavior change techniques, and pain coping skills, with effects ranging from medium to large (Cohen d =0.43-1.05). Overall, 64.8% (118/182) of the participants used coaching as intended by engaging throughout the coaching and completing the outro.

Conclusions: BalanceUP was well accepted, and the results suggest that coaching delivered by a CA can be effective in reducing the burden of people who experience headaches by improving their well-being.

Trial Registration: German Clinical Trials Register DRKS00017422; https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00017422

Introduction

Primary headaches, including tension-type headaches (TTHs) and migraine, are among the most prevalent neurological illnesses [ 1 ]. TTH and migraine are ranked as the third and sixth most common diseases, respectively, worldwide in both women and men [ 2 ]. The physical, social, and mental burden of headaches, defined as the summation of all negative consequences [ 3 ], is substantial. In addition, it is important to consider the quality of life impacted by headaches, defined as the subjective assessment of general well-being, position, and prospects in life. Individuals who have recurrent headaches are often afraid of the next headache attack, which can lead to avoidance behaviors, such as the cancelation of social activities or not even planning them [ 4 ].

The economic costs of headaches are substantial, primarily manifesting as indirect and intangible costs. This includes work absences because of headaches (absenteeism), reduced on-the-job performance while experiencing headaches (presenteeism), reduced quality of life, and increased pain outside the workplace [ 5 - 7 ]. In the European Union, the total annual costs associated with headaches among adults are estimated at €173 billion (US $189 billion; 64% migraine, 12% TTH, and 24% other types of headaches) [ 8 ]. A more recent study conducted in Canada estimated the total annual cost associated with migraine to be CAD $23,756.04 (US $17,750.50) per patient [ 9 ]. Given the high personal and financial costs, there is an urgent need for effective management of headaches.

Headaches are multifactorial, and besides physiological factors, lifestyle factors, such as stress or sleep, play a significant role in the development and retention of a headache [ 10 - 12 ]. Insufficient perception of stress reactions, individual attitudes toward stress (eg, high-performance orientation and anxiety), or coping strategies, such as avoidance versus endurance, are seen as dysfunctional stress-coping in relation to headaches [ 13 , 14 ]. The belief that pain-related factors are outside one’s control and the perceived inability to control these factors (ie, low self-efficacy) are further dysfunctional coping mechanisms associated with poor adjustment to headache and psychological functioning [ 15 , 16 ]. Among people who have headache, stress, stress regulation, and mental tension are perceived as critical triggers of a headache [ 14 , 17 - 19 ], and headache itself serves as a stressor that negatively affects well-being [ 20 ]. However, there are controversial findings regarding the association between lifestyle and headache, and individuals differ in the extent to which these factors interact with headache [ 21 ].

Guidelines recommend pharmacological and nonpharmacological interventions as standard therapy [ 22 ], including behavioral treatment, which has been shown to be effective in both face-to-face and web-based settings [ 22 - 25 ]. These treatments incorporate psychoeducation, relaxation techniques, physical activity, triggers management, and cognitive behavioral therapy elements, focusing on stress management and coping strategies to modify negative and dysfunctional cognitions, emotions, and behavior related to headaches [ 26 , 27 ]. A person-centered approach that integrates various intervention components is more effective [ 28 , 29 ] and may enhance personal control and efficacy in headache management [ 14 ]. However, challenges such as cost, access, motivation [ 18 ], and stigma hinder engagement [ 30 ]. Despite this, consistent care using nonmedical options has proven beneficial [ 31 ].

In addition to traditional evidence-based treatment modalities, mindfulness-based interventions have gained research interest, showing enhanced well-being in various settings [ 32 - 34 ], particularly for coping with chronic conditions, such as chronic pain [ 35 - 37 ]. Studies have demonstrated that mindfulness interventions benefit individuals with headaches by improving psychological functioning [ 38 - 40 ]. Furthermore, they help improve affective conditions, such as anxiety and depression, which are often related to poorer treatment outcomes [ 41 , 42 ]. Improvements in these conditions, even if subclinical, may improve coping skills for headaches and increase treatment adherence. In addition, individuals without a psychiatric diagnosis may experience headache-attributed disability, defined as physical, cognitive, and mental incapacities imposed by headaches [ 3 ], such as disabling anxiety related to fear of headaches and perceived triggers [ 43 ].

Over the past few years, the adoption of app-based interventions for headache management has increased [ 44 , 45 ]. These interventions primarily take the form of electronic headache diary apps, which offer practical solutions for data monitoring [ 46 ]. Furthermore, app-based interventions have improved our understanding of the relationship between lifestyle factors and headaches [ 21 ]. Apps are also suitable for providing guideline-compliant therapeutic options [ 23 ], such as psychoeducation, relaxation techniques, endurance sports, and other elements of behavioral therapy (eg, stress reduction). However, evidence of the effectiveness of app-based behavioral interventions for managing headaches remains weak [ 44 , 47 ].

Conversational agents (CAs), also known as chatbots or digital assistants, are increasingly being applied in both clinical [ 48 - 50 ] and nonclinical [ 51 - 53 ] health care settings to support disease management and behavioral lifestyle interventions. CAs engage users in humanlike conversations [ 48 , 54 - 56 ], enabling factual, relational, and emotional communication. This interactive style enhances engagement by establishing a working alliance between the users and the CAs [ 57 , 58 ], reflecting the collaborative relationship between shared treatment goals and tasks [ 59 ], which is crucial for treatment success in psychotherapy and counseling [ 60 ]. In contrast, conventional mobile health (mHealth) interventions may lack a therapist relationship and suffer from noncommittal timing [ 61 ], may not be used as intended [ 62 ], and engagement may often be low [ 63 - 65 ]. Nevertheless, CA-based coaching offers the potential to deliver personalized, accessible, and scalable content via web-based or mobile-based apps [ 56 , 66 ].

To our knowledge, there is no evidence of mHealth coaching interventions delivered by CAs for the treatment of headaches. Building on a successful pilot study [ 67 ], we designed BalanceUP, a smartphone-based and CA-delivered intervention aimed at supporting a healthy lifestyle in people with headache. BalanceUP aims to improve mental well-being by promoting behavior change techniques (BCTs) in behaviors, emotions, thoughts, and beliefs related to headaches while ensuring low-threshold access and scalability. Using smartphone apps’ technical potential, scalable interventions can be beneficial in supporting individuals [ 68 ]. Consequently, this study had the following objectives: (1) to develop a smartphone-based and CA-delivered intervention for people with headache and (2) to evaluate its effectiveness, engagement, and acceptance.

App Development

BalanceUP, developed for iOS (Apple Inc) and Android (Google LLC) platforms using MobileCoach [ 54 , 69 , 70 ], provides a chat-based interface for communicating with the CA ( Figure 1 B). The communication between users and the server is encrypted. The chat feature offers predefined answer options and free-text input, guiding conversations along dynamic paths to individualized tasks. The CA also shares videos and pictures elaborating on the psychoeducational content. Using the sidebar, users can access the (1) chat channel; (2) audio library (eg, relaxation, mindfulness, and imagination exercises); (3) illustrations; (4) working materials (eg, energy balance and coping circle); (5) video library (eg, animated psychoeducational videos); and (6) frequently asked questions about the study and BalanceUP app ( Figure 1 D).

background of research paper

Coaching Intervention

Drawing on the best practice from behavior therapy, BalanceUP is based on the cognitive behavior change migraine therapy manual (Cognitive-Behavioral Therapy for Migraine Management [Kognitiv-verhaltenstherapeutisches Migränemanagement]; MIMA) [ 13 ], which has been demonstrated to be feasible [ 71 ] and effective, showing results similar to those of the active control group at a 12-month follow-up [ 72 ]. BalanceUP comprises 7 consecutive modules: (1) headaches, (2) relaxation, (3) balance, (4) fear, (5) coping, (6) trigger, and (7) stress (refer to Multimedia Appendix 1 for an overview of the coaching), with a procedure similar to MIMA: (1) feedback on tasks, (2) psychoeducation, (3) reflection of behavior, (4) behavioral intention, (5) action planning, and (6) relaxation and imagination (refer to Figure 2 for further details). Each module contains 3 to 4 units ( Figure 3 ), and users can work through these units during sessions with the CA according to their preferences, allowing completion within 24 to 60 days. Examples of the session flow can be found in Figure 4 . After completion, users can still access the materials. A diagram showing the intervention flow is presented in Multimedia Appendix 2 .

background of research paper

Behavior Change

To foster health-promoting behaviors, various BCTs [ 73 ] have been considered (eg, gamification for reward, action planning, and prompts to perform an exercise). A complete list of BCTs and their specific applications is outlined in Multimedia Appendix 3 [ 73 ]. BCTs are intervention ingredients designed to alter or redirect causal processes that regulate behavior [ 74 ]. Their specific implementation enables accurate replication, precise specification of the intervention content, and investigation of possible mechanisms of action [ 74 ].

Tailoring (at a subgroup level) and personalization (at an individual level) are essential for promoting trust, engagement, adherence, and effectiveness in mHealth interventions [ 63 , 75 ]. Both tailoring (eg, psychoeducation material based on headache types) and personalization (eg, coach selection [ Figure 1 A] personal greeting, personalized goals, and individual appointments with the CA) were applied in BalanceUP. Reminders ( Figure 1 C) are an effective way of improving engagement, especially when they address specific needs [ 76 , 77 ]; refer to Multimedia Appendix 4 [ 49 , 56 , 68 , 78 - 81 ] for the detailed aspects of the engagements implemented.

Intended Use

The intended use of BalanceUP, which is the extent to which an individual needs to experience the content to derive maximum benefit from the intervention [ 81 ], is determined by reaching the outro and completing the postsurvey. Users can skip a module or elements based on their diagnosis (migraine vs TTH) and preferences. For instance, participants can skip psychoeducation within a unit and proceed to behavior reflection, whereas relaxation exercises, videos, and worksheets are optional. This procedure offers flexibility in line with the recommended mHealth intervention strategies [ 82 , 83 ] and is similar to the dose-response rate in pharmaceutical research, where medication dosage can vary depending on the patient’s condition and characteristics. Furthermore, we base this approach on the self-determination theory [ 84 ], which emphasizes autonomy, competence, and engagement.

Study Design and Procedure

We conducted an unblinded, 2-arm, randomized controlled trial (RCT). After onboarding, eligible participants were asked to provide electronic informed consent. Participants who provided consent proceeded to complete the baseline survey (T1), while those who were ineligible were directed to a farewell conversation with the CA. Those meeting the inclusion criteria and consenting were randomly assigned with a 1:1 allocation ratio to either the intervention or waitlist control group using random numbers (0-1) generated by the BalanceUP app, with numbers below 0.5 assigned to the intervention group. The intervention group immediately began with the coaching. The postintervention survey (T2) was conducted 24 to 60 days after randomization. The waitlist control group received weekly reminders from the CA during the 42-day waiting period. After this, they completed the postintervention survey (T2) and were given the option to access coaching or proceed to the outro ( Figure 5 ). Throughout the study, self-reported primary and secondary outcomes were collected within the BalanceUP app and via the in-app survey tool, LimeSurvey (version 3.4). Refer to Multimedia Appendix 5 for outcome details and data collection times.

background of research paper

Study Participants

Participants were self-recruited in Switzerland, Germany, and Austria between April and November 2022 (German-speaking parts) via the study website. The link to the website was shared via social media by headache organizations, insurance companies, and health care institutions. This recruitment strategy allowed participation from all German-speaking countries. The study website provided study information and app download links. Inclusion criteria were being an adult (aged ≥ 18 y) with a smartphone (eg, iOS [Apple Inc] or Android [Google LLC]), fluent German-speaking skills, and experiencing regular headaches for at least 3 months with a minimum of 4 incidents per month. These criteria were assessed using the BalanceUP app during onboarding.

Mental Well-Being

To measure effectiveness, we defined mental well-being as the primary outcome, measured by the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) [ 85 ]. The PHQ-ADS is a composite of the Patient Health Questionnaire-9 (PHQ-9) [ 86 ] and General Anxiety Disorder Scale-7 (GAD-7) [ 87 ]. Scores can range from 0 to 48, with higher scores indicating more severe depression and anxiety; 3 to 4 points were considered the minimum clinically important difference. Cutoff scores of 10, 20, and 30 denoted mild, moderate, and severe degrees of depression and anxiety, respectively.

To assess psychological functioning, multiple secondary outcome measures were used in accordance with the established guidelines [ 88 ].

Secondary Outcomes

The PHQ-9 [ 86 ] consists of 9 items for evaluating depressive symptoms, rated on a 4-point Likert scale ranging from 0 (not at all) to 3 (nearly every day). Higher scores indicate higher symptom severity, with scores ranging from 0 to 4 indicating no symptoms of depression and scores from 5 to 9, 10 to 14, 15 to 19, and 20 to 27 indicating mild, moderate, moderately severe, and severe depression, respectively.

The GAD-7 [ 87 ] is used for evaluating symptoms of generalized anxiety disorder. It comprises 7 items. Similar to PHQ-9, answers are rated on a 4-item Likert scale ranging from 0 (not at all) to 3 (nearly every day). Higher scores indicate higher levels of anxiety, and the total score ranges from 0 to 21. Scores from 0 to 4, 5 to 9, 10 to 14, and 15 to 21 denoted minimal, mild, moderate, and severe anxiety, respectively.

Somatic Symptoms

We measured somatic symptoms using the Patient Health Questionnaire-15 (PHQ-15) [ 89 ]. It is a 15-item self-report questionnaire that can be scored on a scale from 0 (not impaired) to 2 (severely impaired). A total score of ≥15 on the PHQ-15 indicates a high level of impairment owing to somatic symptoms [ 90 ]. For this study, we adopted 2 items from the PHQ-9 because the items were similar. However, the answer scale of the 2 items differed between the PHQ-9 and PHQ-15 and had to be converted according to the manual.

We measured stress with the German version of the Perceived Stress Scale-10 [ 91 ]. The 10-item questionnaire can be rated on a scale from 0 (never) to 4 (very often); higher scores reflect a higher level of perceived stress, and scores can range from 0 to 40.

Self-Efficacy

To assess headache-related self-efficacy, we used the German short form of the Headache Management Self-Efficacy (HMSE-G-SF) Scale [ 92 ]. The measurement consists of 6 items assessing self-efficacy beliefs related to headaches. Answer scales range from 1 (do not agree) to 7 (agree). Higher scores implied higher self-efficacy expectations, and summed scores <19 indicated below-average self-efficacy expectations compared with other people experiencing headache.

Intention to Change Behavior

To assess participants’ intention to change behavior, we used the health action process approach model [ 93 ], which categorizes behavior change into 3 stages: nonintenders, intenders, and actors. In this study, participants indicated their use of psychological techniques for headache treatment by choosing 1 of the 5 possible answers: (1) no, and I do not intend to do so (nonintender); (2) no, but I am considering it (nonintender); (3) no, but I have the intention to do so (intender); (4) yes, but it is not easy (actor); and (5) yes, and it is easy (actor).

Absenteeism and Presenteeism

To measure work-related impairment due to headaches, we applied 4 out of 5 questions from the Migraine Disability Assessment [ 94 ]. These questions assessed days with complete loss and days with at least 50% reduced productivity (eg, work, household, and school) for the past 3 months. Given the study’s runtime and potential recall challenge [ 94 ], participants reported headache days for a 1-month period instead of 3 months.

Pain Processing

We applied the Questionnaire for the Assessment of Pain Processing (questionnaire to assess pain management; Fragebogen zur Erfassung der Schmerzverarbeitung) to measure pain coping strategies [ 95 ]. This tool assesses coping strategies in individuals with persistent pain and is comprised of 2 parts. In this study, we used the first part to evaluate cognitive and behavioral coping using 24 items. The cognitive coping subscale included the dimensions “action planning skills,” “cognitive restructuring,” and “experience of competence.” The behavioral coping subscale included “mental distraction,” “counteracting activities,” and “rest and relaxation techniques.” Answers were scored from 1 (not at all true) to 6 (always true), with higher scores indicating better pain processing.

Sociodemographics

We collected data on age, sex, level of education, parallel app use for headache tracking, concurrent psychotherapy, commitment to the program, and headache diagnosis at baseline to describe the study population. We further assessed participants’ sensitivity to triggers and tendency to avoid triggers optionally in module 6 (Trigger) using the German short version of the Headache Triggers Sensitivity and Avoidance Questionnaire [ 96 ]. Mean scores <2.03 indicate below-average trigger sensitivity and scores >3.19 indicate above-average trigger sensitivity, respectively. For avoidance, mean scores <2.09 indicate below-average trigger avoidance and scores >3.23 indicate above-average trigger avoidance, respectively.

According to a systematic review conceptualizing engagement with digital behavior change interventions [ 64 ], engagement is both a multidimensional concept and a dynamic process. Engagement consists of 2 parts: (1) the extent of use (eg, amount, frequency, duration, and depth) and (2) a subjective experience characterized by attention, interest, and affect. By using this multidimensional approach, we aimed to capture the various aspects of engagement, as defined by Perski et al [ 64 ].

Extent of Use

The following use data were recorded during the coaching intervention: total minutes spent on in-app relaxation and imagination exercises, total reminders sent to participants in cases of inactivity, and the average number of days taken to complete 1 coaching module. In addition, the percentage of answered conversational turns between the participant and the CA coach was calculated, where a higher number indicated higher engagement with the intervention. We also assessed intended use, that is, the number of participants who completed the outro.

Subjective Experience

To gather the subjective experiences of the participants, we used 4 items from the German Group Therapy Session Evaluation by Patients [ 97 ] with statements about personal involvement, active participation, perceived comprehensibility, and perceived benefit on a 5-point Likert scale ranging from 1 (disagree) to 5 (agree). Furthermore, we measured perceived enjoyment by applying a single-item measure from technology acceptance research [ 98 , 99 ] (“Did you enjoy the last unit?”), ranging from 1 (not at all) to 5 (very much).

We assessed participants’ commitment to changing their behavior with 1 question (“How committed are you towards changing your behavior?”) on a scale of 1 to 10.

We used a modified version of the Session Alliance Inventory—Patient Version [ 100 , 101 ] to repeatedly measure the working alliance between the participant and the CA. It consists of 3 items for the Bond Scale and 3 items for the Task and Goal Scale. In this study, we used the items of the validated German version of the Working Alliance Inventory-Short Revised [ 102 ], which features a 5-point answer scale ranging from 1 (seldom) to 5 (always). In addition, we contextualized the Session Alliance inventory by replacing the term “therapist” with the CA’s name.

We assessed the acceptance of BalanceUP with a slightly modified and translated version of the Mobile App Rating Scale (uMARS) [ 103 ] assessing engagement (eg, entertainment, interest, customization, interactivity, and target group of the app); information (eg, quality of information, quantity of information, visual information, and credibility of source); perceived quality (eg, recommendation, use, payment, and overall rating); and perceived impact (eg, awareness, knowledge, attitudes, behavior change, seeking help, and intention to change). All subscales used a 5-point Likert scale ranging from 1 to 5, with higher scores indicating a more favorable judgment.

In addition to the uMARS, the questions “What did you like most about the BalanceUP app?” and “What would you like to see improved about the BalanceUP app?” could be answered in free text.

Impression of Change and Adverse Events

We assessed adverse events with the Patients Global Impression of Change Scale [ 104 ]. It is a 7-point scale depicting the perceived overall improvement in general health, rated from 1 (much improved) to 7 (very much worse). In this study, for scores ≥5, we also assessed whether participants believed these changes occurred because of coaching or whether other circumstances (eg, professional situation and conflicts in the social sphere) caused these changes. Participants were asked to note the adverse changes if coaching was given as a reason.

Sample Size Calculation

We estimated the sample size based on the primary outcome (mental well-being) measured by the PHQ-ADS for a linear mixed model (LMM) and a repeated measure ANOVA (within-between interaction). Consistent with previous headache and chronic pain research [ 105 - 107 ], we assumed a small-to-medium effect size for the primary outcome. Statistical power calculation using G*Power 3 software revealed that a sample size of 90 (45 for each group) would be sufficient, with a power of 0.80 to detect a small-to-medium time×group interaction effect size (Cohen d =0.35) with an α of .05 and based on 2 measurements. According to our pilot study, we estimated a dropout rate of 40% and aimed to recruit approximately 150 participants.

Data Analysis

The analysis was performed using SPSS (version 28.0; IBM Corp) and R software (version 4.2.2; R Foundation for Statistical Computing) including the lme4 . For the primary outcome (PHQ-ADS) from before the intervention (T1) to after the intervention (T2), the LMMs were used, considering time (T1 and T2), group (intervene and wait), and their interaction as fixed effects, with participants as a random factor. Secondary outcomes (ie, PHQ-9, GAD-7, PHQ-15, Perceived Stress Scale-10, Questionnaire for the Assessment of Pain Processing, HMSE-G-SF, Migraine Disability Assessment, and health action process approach) were analyzed accordingly. Missing data were managed using LMM, which is based on all observed data and accounts for data missing at random [ 108 - 110 ]. According to the CONSORT (Consolidated Standards of Reporting Trials) guidelines, we reported the LMM analysis for the (1) intention-to-treat (ITT) analysis, in which all randomized participants were included, regardless of whether they used the coaching and (2) per-protocol (PP) analysis of complete cases. Calculations of within- and between-group effect sizes (Cohen d ) were based on the pooled SD of complete cases only and labeled as small (Cohen d =0.2), medium (Cohen d =0.5), and large (Cohen d =0.8). The influence of predictors on outcomes was explored using the LMM, including the primary outcome (PHQ-ADS), with a focus on the 3-way interaction. Change in engagement over time was analyzed via repeated-measures ANOVA, and the effect of early engagement [ 64 ] on treatment outcomes was analyzed using linear regression. Descriptive statistics were used to summarize participant characteristics at baseline, and 2-tailed t tests were used to assess baseline differences. We applied qualitative content analysis [ 111 , 112 ] to answer the open-ended questions.

Ethical Considerations

The Swiss Ethics Committee Zurich reviewed the research project and confirmed (Swiss Ethics BASEC-Nr. Req-2021-01365) that it does not fall within the scope of the Human Research Act. This research project was registered in the World Health Organization–accredited German Clinical Trials Register (DRKS00017422). We performed this trial based on the CONSORT-EHEALTH guidelines.

Participant Flow and Baseline Characteristics

During the recruitment phase, from April to November 2020, 405 individuals downloaded the BalanceUP app. Of these, 223 (55.1%) were assessed for eligibility and 7 (1.7%) were excluded from the study. Of those eligible, 198 (48.9%) individuals completed the baseline survey and were randomized into the intervention (n=110) and control (n=88) groups. The full participant flow is presented in Figure 6 . The dropout rate for randomized participants after the treatment was 29.1% (32/110) for the intervention group and 18% (16/88) for the waitlist control group and thus can be considered low, particularly for a fully unguided mHealth intervention [ 113 ] and in comparison with our pilot study.

background of research paper

As presented in Table 1 , most of the participants were women (180/198, 90.9%) with a mean age of 38.7 (SD 12.14) years, and more than half had a university degree (104/198, 52.5%). Migraine was the most prevalent diagnosis, accounting for 72.2% (143/198) of the sample. Approximately half of the participants (95/198, 48%) reported using headache diaries to track their symptoms. Few participants (32/198, 16.2%) reported attending psychotherapy and using the coaching app. In general, participants reported an average of 6.66 (SD 7.34) days of work per month missed because of headaches and 11.82 (SD 9.77) days per month when their performance was reduced by half or more (including work, school, and household). Compared with other individuals who had headaches [ 92 ], the study participants reported average levels of headache-related self-efficacy. On average, participants were classified as “intenders,” indicating that they had the intention to change their behavior (as opposed to “nonintenders” or “actors”). On average, the participants had mild depression (mean 9.06, SD 4.24), mild anxiety (mean 6.76, SD 3.87), and moderate psychosomatic symptoms (mean 10.92, SD 4.34). There was no difference between the groups in any of the outcomes.

a Baseline group comparison between intervention and waitlist control groups using the 2-tailed t test and chi-square test.

b TTH: tension-type headache.

c MIDAS: Migraine Disability Assessment conducted for a period of 1 month.

d Waitlist control group: n=83 and intervention group: n=102 (outliers removed).

e FESV: questionnaire to assess pain management (Fragebogen zur Erfassung der Schmerzverarbeitung).

f HMSE-G-SF: German short form of the Headache Management Self-Efficacy.

g Application of behavior change techniques based on the health action process approach stages of change: 1 to 2=nonintenders, 3=intenders, and 4 to 5=actors.

h PHQ-9: Patient Health Questionnaire-9.

i GAD-7: General Anxiety Disorder Scale-7.

j PHQ-15: Patient Health Questionnaire-15.

k PSS: Perceived Stress Scale.

Effectiveness

Primary outcome.

Table 2 presents the results of the LMM analyses for the ITT and PP analyses. For both the ITT and PP analyses, we found evidence of a treatment effect (group by time interaction) for the PHQ-ADS after the intervention (t 342 =–3.6; P <.001, 95% CI –5.06 to –1.47 and t 294 =–3.58; P <.001, 95% CI –5.11 to –1.49, respectively). BalanceUP significantly affected mental well-being, as shown by the change in the PHQ-ADS. However, the waitlist control group did not improve with time (Cohen d =–0.07, 95% CI –0.23 to 0.08), the intervention group improved from before the intervention to after the intervention with a medium effect (Cohen d =0.62, 95% CI –0.84 to –10.39).

a Outcomes of the PP analyses: only participants who completed the outro (ie, intended use).

b Outcomes of the ITT analyses: all participants who were randomized into groups.

c PHQ-ADS: Patient Health Questionnaire Anxiety and Depression Scale.

d N/A: not applicable.

e Time effect represents the rate of improvement for both intervention and waitlist control groups.

f Group effect represents intervention or waitlist control group.

g Treatment effect is represented by group and time interaction.

k PSS-10: Perceived Stress Scale-10.

l HMSE-G-SF: German short form of the Headache Management Self-Efficacy.

m Application of behavior change techniques, based on the health action process approach stages of change: 1 to 2=nonintenders, 3=intenders, 4 to 5=actors.

n HAPA: health action process approach.

o Assessment of absenteeism and presenteeism based on Migraine Disability Assessment, conducted for a period of 1 month.

p MIDAS: Migraine Disability Assessment.

q FESV: questionnaire to assess pain management (Fragebogen zur Erfassung der Schmerzverarbeitung).

Changes in the PHQ-ADS score differed significantly between groups with a medium effect (Cohen d =0.66, 95% CI –0.99 to –0.33); refer to Table 3 for observed means and effect sizes (Cohen d ) for participants who completed the coaching intervention as intended (PP).

a Effect size according to Cohen d .

b PHQ-ADS: Patient Health Questionnaire Anxiety and Depression Scale.

c N/A: not applicable.

d PHQ-9: Patient Health Questionnaire-9.

e GAD-7: General Anxiety Disorder Scale-7.

f PHQ-15: Patient Health Questionnaire-15.

g PSS-10: Perceived Stress Scale-10.

h HMSE-G-SF: German short form of the Headache Management Self-Efficacy.

i Application of behavior change techniques based on the health action process approach stages of change: 1 to 2=nonintenders, 3=intenders, 4 to 5=actors.

j HAPA: health action process approach.

k Assessment of absenteeism and presenteeism based on Migraine Disability Assessment conducted for a period of 1 month.

l MIDAS: Migraine Disability Assessment.

m FESV: questionnaire to assess pain management (Fragebogen zur Erfassung der Schmerzverarbeitung).

Regarding secondary outcomes, the ITT LMM analyses demonstrated evidence of treatment effects for depression (t 342 =–3.56; P <.001, 95% CI –2.79 to –0.80), somatic symptoms (t 348 =–4.48; P <.001, 95% CI –3.35 to –1.31), stress (t 341 =–3.07; P =.003, 95% CI –4.25 to –0.94), headache-related self-efficacy (t 342 =4.08; P <.001, 95% CI 2.10-5.99), application of BCTs (t 342 =4.82; P <.001, 95% CI 0.45-1.07), presenteeism and absenteeism (t 317 =–3.00; P =.003, 95% CI –7.96 to –1.68), cognitive pain coping (t 341 =4.96; P <.001, 95% CI 3.38-7.79), behavioral coping (t 341 =5.18; P <.001, 95% CI 3.11-6.89), and suggestive evidence for anxiety (t 342 =–2.73; P =.007, 95% CI –2.50 to –0.40). The PP analyses showed similar results ( Table 2 ). The effect sizes of secondary outcomes between groups after the intervention were medium (eg, depression, anxiety, somatic symptoms, stress, absenteeism and presenteeism, and pain coping) and large (eg, headache-related self-efficacy and application of BCTs). Refer to Table 3 for further details.

We also explored whether diagnostic status (participants diagnosed with migraine vs participants with other or no headache-related diagnosis), concurrent psychotherapy, concurrent tracking of headaches, and headache-related self-efficacy influenced the pre- and postintervention effects. We did not find evidence of a 3-way interaction among group, time, and predictors. There was no evidence of a difference in the decrease of the PHQ-ADS score between the intervention and waitlist control groups for participants with a diagnosis of migraine (t 338 =–0.81; P =.42, 95% CI –5.93 to 2.48), concurrent psychotherapy (t 338 =–0.45; P =.65, 95% CI –5.69 to 3.57), concurrent headache tracking (t 338 =–1.92; P =.06, 95% CI –6.99 to 0.09), and self-efficacy at baseline (t 338 =–1.50; P =.14, 95% CI –0.48 to 0.06).

Table 4 shows the rate of the intended use of the BalanceUP coaching app among participants who started module 1 (n=182), that is, participants from the intervention group (n=110) and participants who started coaching after the waiting time (n=72). As anticipated, the highest dropout rates occurred during module 1 (34/182, 18.7%), with a subsequent decrease in dropout rates during the subsequent modules. Of the 182 participants who began the coaching program with module 1, 118 (64.8%) completed the coaching and thus used it as intended. A visual inspection of the engagement data related to subjective experience revealed that participants who discontinued using the app did not show differences in active participation, internal engagement, perceived benefit, or comprehensibility compared with those who continued using BalanceUP (refer to Multimedia Appendix 6 ).

a Participants from the intervention group and waitlist control group who optionally participated after a waiting period.

b Measured after every session using 1 item of the Patient Session Evaluation Questionnaire.

c Measured randomly at the end of a unit using 1 items of the Patient Session Evaluation Questionnaire.

d Measured 3 times during coaching using the question “How committed are you to changing your behavior?”

e Measured randomly during coaching by a single item (“Did you enjoy the last unit?”) from technology acceptance research.

f Measured 3 times during coaching using the Session Alliance Inventory Scale.

g Measured postcoaching intervention via Mobile Application Rating Scale.

We measured engagement among the participants with intended use based on the extent of use (use data) and subjective experience (self-reported data). The use data analysis showed that 86.3% (101/117) of the participants completed all 7 modules, taking an average of 6.9 (SD 1.5) days to work through a module. Participants replied in an average of 77.8% (SD 3.73%) conversational turns. In the event of inactivity, across the entire study period, participants were sent an average of 11.70 (SD 5.99) push notifications for no activity for a 1-hour period and 8.95 (SD 5.87) notifications for no activity for a 2-hour period, with a subsequent decrease in reminders sent for 1, 3, 5, and 10 days of no activity. Participants spent an average of 113.44 (SD 182.51) minutes on relaxation exercises. Refer to Table 4 for further details.

Participants self-reported a mean commitment to change their behavior of 8.15 (SD 5.46). The reported commitment to change behavior significantly increased with time ( F 2,192 =8.17; P <.001) with a medium effect (Cohen f =0.29), and evidence of higher commitment toward the end of the coaching (mean 8.17, SD 1.49) than in the middle (mean 7.57, SD 1.55, mean difference 0.60, 95% CI 0.31-0.89; P <.001) or beginning of the intervention (mean 7.61, SD 1.57, mean difference 0.56, 95% CI 0.21-0.91; P =.002). A linear regression (β=.05, SE 0.42; P =.67) with pre- to posttreatment PHQ-ADS changes showed that early reported commitment did not predict before improvement to after improvement of mental well-being. The mean perceived alliance with the CA was 3.94 (SD 0.82). The alliance significantly increased with time ( F 2,200 =10.66; P <.001) with a medium-large effect (Cohen f =0.32), with the evidence of alliance becoming higher toward the end of the coaching (mean 4.07, SD 0.83; P <.001) than at the beginning (mean 3.83, SD 0.83, mean difference 0.23, 95% CI 0.12-0.34; P <.001); refer to Table 5 . A linear regression (β=.11, SE 0.80; P =.36) with pre- to posttreatment PHQ-ADS change showed that early reported alliance with the CA did not predict pre- to posttreatment improvement of mental well-being.

a Measured during module 1 (commitment to change) and module 2 (alliance).

b Measured during module 3 (commitment to change) and module 4 (alliance).

c Measured during module 6.

d Measured by the question “How committed are you to changing your behavior” (n=97).

e Measured using Session Alliance Inventory Scale (n=101).

Participants with intended use rated the quality of BalanceUP in terms of engagement (eg, personalization and interactivity), information quality (eg, source and credibility), perceived subjective quality (eg, recommend app and pay for app), and perceived impact (eg, knowledge and awareness). The highest-rated subscale was information quality, with a mean of 4.47 (SD 0.47), followed by perceived impact (mean 4.00, SD 0.62), engagement (mean 3.72, SD 0.65), and subjective quality (mean 3.56, SD 0.77).

We found evidence of an improved perceived global impression of change in the Patient Global Impression of Change Scale from module 1 to module 7 (t 101 =8.45; P <.001; Cohen d =–0.62, 95% CI –0.91 to –0.33), indicating an improvement in perceived general health. Of the participants who reported worsening of their general condition in module 1 (6/142, 4.2%), only 1 participant reported that this was because of the current coaching intervention and provided the following explanation:

Dealing with migraine triggers constant self-monitoring, which may cause slight discomfort and prevents me from feeling completely free from them. However, in the long term, it is worth pursuing education and behavior change.

The remaining 5 participants reported that the worsening was because of other reasons, such as job and social conflicts. In module 7, only 2% (2/102) of the participants reported worsening of their general condition; however, all cited other reasons as the cause.

Participants rated their sensitivity to trigger with a mean of 2.51 (SD 1.09) and avoidance with a mean of 2.32 (SD 1.07), indicating average sensitivity and avoidance compared with a sample of people who have headache [ 96 ].

Qualitative Evaluation

We further assessed the BalanceUP app's positive ( Figure 7 ) and negative ( Figure 8 ) aspects using qualitative content analysis. We used a deductive approach to identify themes based on insights from our pilot study and the existing literature. When examining the positive aspects, participants expressed a strong appreciation for the extensive and comprehensive information provided, which included various types of exercises and the delivery mode of the intervention. When evaluating negative aspects, participants expressed a desire for more flexibility in their interactions with the CA.

background of research paper

Principal Findings

This study aimed to describe the development and evaluation of the effectiveness of the BalanceUP app. This is the first RCT of a fully unguided coaching intervention delivered by a rule-based CA to facilitate mental well-being in individuals with headaches. We described the BalanceUP app's evidence-based design and systematic evaluation.

With regard to effectiveness, we found evidence of improved mental well-being, as measured by the PHQ-ADS, in individuals with frequent headaches who received BalanceUP, with a medium to large between-group effect size (Cohen d =–0.66). Participants who interacted with BalanceUP experienced a clinically important improvement, reporting, on average, a 3.9 (SD 5.59) point reduction [ 85 ] of perceived depression and anxiety symptoms after the intervention. In contrast, participants in the waitlist control group did not show substantial changes in their mental well-being (0.6-point reduction on the PHQ-ADS score). Moreover, we found evidence of reduced anxiety, somatic symptoms, perceived stress, and absenteeism and presenteeism, as well as improved HMSE-G-SF, application of BCTs, and pain coping skills, with effects ranging from medium (Cohen d =0.43) to large (Cohen d =1.05). Diagnostic status, concurrent psychotherapy, concurrent tracking of headaches, and headache-related self-efficacy did not influence the effects of chatbot coaching.

No notable adverse effects were observed owing to the use of BalanceUP. Among the participants who initiated the coaching by starting the first module, a substantial portion (118/182, 64.8%) successfully adhered to the program. Participants who used BalanceUP as intended established a pronounced working alliance with the CA, which significantly improved with time.

In terms of acceptance, the program’s information content received the highest rating, followed by the perceived impact, engagement, and subjective quality of BalanceUP. Its overall average rating, on a scale of 1 to 5 stars, was 3.91 (SD 0.67), indicating a high level of acceptance. Participants expressed their willingness to recommend the app to individuals who might benefit, with a mean rating of 4.02 (SD 1.05), reflected by the following statement in the uMARS questionnaire: “There are many people I would recommend this app to.”

Comparison With Prior Work

Evidence on the effectiveness of mobile interventions for headaches is limited, despite their wide availability [ 47 ]. Minen et al [ 44 ] found that, despite a trend toward mHealth, most studies using electronic behavioral interventions to treat headaches did not use mobile devices. Only 1 single-arm study explored mHealth migraine behavioral therapy but with potential bias owing to missing diary entries. A recent study by Grazzi et al [ 114 ] demonstrated the feasibility and effectiveness of an mHealth mindfulness program for chronic migraineurs (headaches for ≥15 d in a month), resulting in a 50% retrospective reduction in migraine days and medication intake.

With regard to internet-based headache treatments, 1 pilot study by Day et al [ 115 ] showed improvement in self-efficacy (Cohen d =0.82) and pain acceptance (Cohen d =0.82), although there was no evidence of headache reduction. An RCT by Bromberg et al [ 105 ] assessed a web-based intervention for migraine self-management and coping, revealing improvements in multiple outcomes, including depression, stress, headache self-efficacy, pain catastrophizing, and coping strategies, although without changes in anxiety and disability. Another study on web-based behavioral training for migraine self-management found no difference in headache attack frequency but found evidence for improved migraine self-efficacy and locus of control [ 116 ].

This study’s results align with face-to-face behavior change interventions for headaches. Cognitive behavioral therapy, relaxation, or mindfulness interventions have effectively improved the cognitive, behavioral, anxiety, and stress-related aspects associated with headaches [ 30 , 117 ]. Notably, the evaluation of MIMA [ 72 ], the basis of our coaching, found limited improvement in headache-related outcomes, except for headache self-efficacy. Furthermore, BalanceUP was extended to address TTH (eg, onset of headache, course of headache, and medication). Although migraine was predominant among participants, we found no evidence that diagnostic status affected treatment outcomes. Tailoring allowed BalanceUP to effectively address both types of headaches.

There was no evidence of the influence of concurrent psychotherapy on coaching effectiveness in this study, which is noteworthy given prior suggestions of potential benefits of combining face-to-face and digital interventions [ 118 , 119 ]. The hypothesized role of headache-related self-efficacy in treatment outcome [ 120 ] remained unconfirmed in this study.

The BalanceUP app’s evidence-based design and systematic evaluation contribute to the growing body of evidence on the acceptance and effectiveness of interventions involving CAs in health care. A recent meta-analysis examined 32 RCTs focusing on mental health and CA use [ 121 ]. Short-term effects on outcomes such as depressive and generalized anxiety symptoms, quality of life, well-being, and stress were found, with effect sizes ranging from Hedges g =0.24 to Hedges g= 0.62. However, the long-term effects remained unclear. Personalization and empathetic responses emerged as crucial effectiveness facilitators, with longer CA interactions linked to larger effect sizes. These findings align with those of another meta-analysis [ 122 ], showing the effectiveness of CAs in outcomes related to lifestyle changes, smoking cessation, substance misuse, and medication adherence. Notably, <50% of the participants reported overall satisfaction with the CA, content likeability, and future use. However, many studies had a pre- and postintervention design or were feasibility trials, indicating the need for further RCTs in this field. Abd-Alrazaq et al [ 123 ] evaluated the effectiveness of CAs in 12 clinical and nonclinical RCTs. Weak evidence of reduced depression, stress, or agoraphobia rates, but not improved mental well-being, was found. However, bias, low-quality evidence, small sample size, or contradictory results limited the conclusions, necessitating further high-quality RCTs following the guidelines.

Contextual factors, such as psychological traits, motivation, personal relevance, and attributes of digital behavior change interventions themselves (eg, content, reminders, delivery, support, and personalization) influencing engagement [ 64 ]. BalanceUP integrates personalization and tailoring (eg, relevant topic selection and adjustment of interaction length) to empower participants and promote a sense of control and ownership over the coaching process. Emotional support, encouragement, or validation from the CA also expresses empathy, reinforcing participants’ feelings (eg, “This is excellent news, well done, keep on track” and “I am sorry to hear, but setbacks are also part of a change process”). Qualitative feedback confirms program flexibility and suggests that addressing individual preferences can enhance satisfaction and further improve the coaching experience.

In BalanceUP, we observed that 65% of the participants used coaching as intended by completing the outro. In behavioral headache treatment, engagement has yet to be thoroughly assessed in terms of dose and duration; however, earlier studies reported high dropout rates [ 124 ].

Consistent with previous research [ 67 , 125 ], participants using BalanceUP established a strong alliance with the CA, which improved significantly with time. This finding aligns with studies conducted in in-person, digital, and group settings [ 126 - 128 ] and with individuals with recurrent headaches [ 129 ]. However, contradictory to findings in internet-based therapy studies [ 130 , 131 ], the alliance was unrelated to improvements in participants’ mental well-being. These results suggest that, although the alliance between participants and the CA was established and strengthened throughout the coaching program, other factors may significantly influence treatment effectiveness.

Limitations and Future Work

This study had several limitations. First, guidelines for trials of behavioral headache treatments [ 88 ] recommend using headache frequency as the primary outcome. However, they also urge investigators to use standardized disability, functional status, or quality of life measures. A recent Delphi study by Leudtke et al [ 132 ] emphasized the need for outcome measures that truly reflect patients’ experiences. Therefore, the inclusion of functional disability, quality of life, and associated symptoms should be considered in nonpharmacological interventions. BalanceUP aimed to capture the biopsychosocial impact of headaches by addressing various lifestyle factors.

Second, the self-selection of the participants limits the generalizability of our findings and introduces potential self-selection bias. Participants’ particular interest in the subject matter might make them nonrepresentative of the broader population. Caution is needed when extending these findings to a broader context because of the possibility of differing preexisting characteristics.

Third, it is important to acknowledge potential improvements for enhanced interactions in BalanceUP. The current rule-based nature of the CA allowed for the implementation of an evidence-based program. However, participants’ desire for more flexible interactions with the ability to input personal responses was evident. Previous research [ 133 ] indicates user preference for a combination of predefined answer options and text input to enhance perceived interactivity. To enhance text processing in BalanceUP, integrating artificial intelligence (AI)–based technology, such as large language models or natural language processing, could be considered. Natural language processing and large language models enable the CA to interpret user inputs more dynamically, yet existing AI-based chatbots struggle with unforeseen user responses [ 133 , 134 ]. Furthermore, ethical aspects related to AI technology should be considered, as they could lead to misjudgments and potential risks. Research has highlighted a lack of transparency in describing the handling of input data and algorithms, affecting the reliability and validity of findings [ 122 , 135 ]. One approach might involve using AI technology for specific tasks (eg, providing content that humans will select or tailor) while maintaining a rule-based approach for other tasks (eg, handling sensitive information and following guidelines), ensuring predictability and preventing harm.

Fourth, it is worth noting that most participants in this study were women (86%), in line with the higher prevalence of headache in women [ 136 ]. Approximately half of them had university degrees, consistent with our pilot study [ 67 ]. However, the trial’s sociographic distribution may not fully represent the general population. Future studies should seek greater diversity using a more representative sample.

Fifth, a potential limitation is the digital placebo effect [ 137 ]. In this unblinded trial, participants might attribute improvements to using an mHealth intervention rather than interventionist ingredients. Expectations and engagement could bias outcomes positively. Future research should carefully design control conditions, considering active control groups or sham interventions [ 138 ].

Sixth, participants needing a smartphone introduced a limitation [ 139 ]. Although mHealth usability is favored by a substantial proportion of middle-aged individuals with headache in German-speaking countries, the exclusion of smartphone-less individuals may impact generalizability [ 4 ]. Ownership rates are high, for example, 92% in Switzerland and 91% in Europe [ 140 ].

Seventh, a small number of participants (28/198, 14.1%) in this study encountered technical issues, such as missing audio tones in videos or loss of internet connection. Although technical support was provided to address these problems, it is likely that these technical issues may have had a negative impact on participants’ engagement.

Finally, the primary objective of developing this app was to enhance the mental well-being outcomes of individuals with headache. The app was specifically designed for this research project. Currently, it is freely available for public use. However, the future availability of the app is uncertain because of ongoing support costs and a lack of collaboration with potential providers. We recognize the potential value of making such interventions accessible in the future, and discussions regarding their availability are ongoing. It is essential to note that the university’s role is not to provide the app as a service but to contribute through accompanying research. The sustainability of digital health interventions, particularly with limited public health funding, remains challenging [ 141 , 142 ]. Clear cost-benefit outcomes and accountability strategies should be addressed in future research.

Conclusions

This study represents the first empirical evaluation of an evidence-based and CA-delivered coaching intervention (BalanceUP) designed to promote a healthy lifestyle among individuals with headaches. The findings provide evidence of the positive impact of BalanceUP on participants’ mental well-being, as indicated by improvements in depression and anxiety symptoms. The establishment of a strong alliance between participants and the CA, along with their high commitment to the program, further reinforces the potential effectiveness of this intervention. The scalability and accessibility of automated coaching through a CA highlight its potential as an engaging and effective tool for behavior change. Further research is needed to explore the long-term effects, intensity, and duration of delivery of coaching interventions for lifestyle modifications in the health sector. Therefore, the applicability of mHealth interventions in diverse populations should be investigated. Understanding these aspects will contribute to the development of effective and inclusive interventions that promote positive health outcomes.

Acknowledgments

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

Data Availability

The data sets generated and analyzed during this study are available from the corresponding author upon reasonable request.

Authors' Contributions

SU designed the study and was supervised by HK and ARG. SU drafted the ethics application and registered with the trial. SU oversaw the design of the coaching program, with assistance from VZ. Technical implementation was a collaborative effort supported from Zurich University of Applied Sciences (ZHAW) and Swiss Federal Institute of Technology Zurich (ETH). Statistical analyses were performed by SU and supervised by HK, including consultation with a statistician from ZHAW. Interpretation and discussion of the results were led by SU in consultation with TK and ARG. SU wrote the manuscript, and TK critically reviewed the entire manuscript. All the authors approved the final manuscript.

Conflicts of Interest

TK is affiliated with the Centre for Digital Health Interventions, a joint initiative of the Institute for Implementation Science in Health Care, University of Zurich; the Department of Management, Technology, and Economics at Swiss Federal Institute of Technology Zurich; and the Institute of Technology Management and School of Medicine at the University of St. Gallen. The Centre for Digital Health Interventions is funded in part by CSS, a Swiss health insurer; Mavie Next, an Austrian health insurer; and MTIP, a Swiss digital health investor. TK is also a cofounder of Pathmate Technologies, a university spin-off company that creates and delivers digital clinical pathways. However, neither CSS nor Pathmate Technologies were involved in this research. ARG has no conflicts of interest to report to this publication. He is a board member of the Swiss Headache Society. All other authors declare no other conflicts of interest.

Overview of the coaching intervention.

Intervention flow.

Behavior change techniques implemented.

Aspects of engagement.

Outcomes and time points.

Engagement with subjective experience dropout versus intended use.

CONSORT-EHEALTH Checklist.

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Abbreviations

Edited by T de Azevedo Cardoso; submitted 27.06.23; peer-reviewed by C Gaul, R Davis-Martin, P Wicks; comments to author 16.08.23; revised version received 20.09.23; accepted 12.12.23; published 24.01.24

©Sandra Ulrich, Andreas R Gantenbein, Viktor Zuber, Agnes Von Wyl, Tobias Kowatsch, Hansjörg Künzli. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 24.01.2024.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on https://www.jmir.org/, as well as this copyright and license information must be included.

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Title: efficient constrained $k$-center clustering with background knowledge.

Abstract: Center-based clustering has attracted significant research interest from both theory and practice. In many practical applications, input data often contain background knowledge that can be used to improve clustering results. In this work, we build on widely adopted $k$-center clustering and model its input background knowledge as must-link (ML) and cannot-link (CL) constraint sets. However, most clustering problems including $k$-center are inherently $\mathcal{NP}$-hard, while the more complex constrained variants are known to suffer severer approximation and computation barriers that significantly limit their applicability. By employing a suite of techniques including reverse dominating sets, linear programming (LP) integral polyhedron, and LP duality, we arrive at the first efficient approximation algorithm for constrained $k$-center with the best possible ratio of 2. We also construct competitive baseline algorithms and empirically evaluate our approximation algorithm against them on a variety of real datasets. The results validate our theoretical findings and demonstrate the great advantages of our algorithm in terms of clustering cost, clustering quality, and running time.

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  1. What Is Background in a Research Paper?

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

  2. What is the Background of a Study and How Should it be Written?

    The background of a study is the first section of the paper and establishes the context underlying the research. It contains the rationale, the key problem statement, and a brief overview of research questions that are addressed in the rest of the paper.

  3. Background of The Study

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

  4. What is the Background of the Study in a Research Paper?

    The background of the study is the first section of a research paper and gives context surrounding the research topic. The background explains to the reader where your research journey started, why you got interested in the topic, and how you developed the research question that you will later specify.

  5. How to Write an Effective Background of the Study

    The background of the study is placed at the beginning of a research paper. It provides the context, circumstances, and history that led to the research problem or topic being explored. It offers readers a snapshot of the existing knowledge on the topic and the reasons that spurred your current research.

  6. Background Information

    Background information does not replace the literature review section of a research paper; it is intended to place the research problem within a specific context and an established plan for its solution. Fitterling, Lori. Researching and Writing an Effective Background Section of a Research Paper.

  7. How to write the background of your study

    The background should be written as a summary of your interpretation of previous research and what your study proposes to accomplish. How to make the background engaging As the background includes a lot of information, it can become a long drag, causing the readers to lose interest.

  8. Writing a Research Paper Introduction

    Step 1: Introduce your topic Step 2: Describe the background Step 3: Establish your research problem Step 4: Specify your objective (s) Step 5: Map out your paper Research paper introduction examples Frequently asked questions about the research paper introduction Step 1: Introduce your topic

  9. How to write the Introduction and the background for a research paper

    Answer: The Introduction section sets the context for your research work, explains the research problem, and indicates the purpose behind the study. The Introduction also highlights how your research contributes to knowledge in your field and builds on previous similar studies. You need to ensure that your Introduction does the following:

  10. What is the Background in a Research Paper?

    What is the Background in a Research Paper? An effective Background section in your manuscript establishes the context for your study. And while original research requires novel findings, providing the necessary background information for these findings may be just as important.

  11. What is the Background of a Study and How to Write It

    The background of a study in a research paper helps to establish the research problem or gap in knowledge that the study aims to address, sets the stage for the research question and objectives, and highlights the significance of the research.

  12. Q: How to write the background to the study in a research paper?

    Answer: The background of the study provides context to the information that you are discussing in your paper. Thus, the background of the study generates the reader's interest in your research question and helps them understand why your study is important. For instance, in case of your study, the background can include a discussion on how ...

  13. How to Write a Research Paper: Background Research Tips

    1-2 pages. 2-3 sources (articles or websites) 3-5 pages. 4-8 sources (books, articles, and websites) Annotated Bibliography. 6-15 sources (books, articles, and websites) 10-15 pages. 12-20 sources (books, articles, and websites) *Your instructor will often provide you with an approximate number of source you will need.

  14. How to Write a Background for a Research Paper: Tips

    In essence, the background section of a research paper outlines the existing understanding of the field or topic being investigated while also highlighting any gaps or limitations in the current knowledge. Doing so underscores the need for further investigation and presents the specific problem or knowledge gap the study aims to address.

  15. Organizing Academic Research Papers: Background Information

    Providing background information in the Introduction of a research paper serves as a bridge that links the reader to the topic of your study.

  16. How to Write the Background of a Study

    A well written background to your study will ensure your paper gets read all the way through to the end. Can't ask for more than that! The background to a study sets the scene. It lays out the "state of the art". It tells your reader about other research done on the topic in question, via useful review papers and other summaries of the ...

  17. How to Write a Background for a Research Paper

    The research paper background section is more concise and directly precedes the thesis. It provides a brief overview of the research topic and the significance of the study. Steps to write a good background section. When writing a background section for a research paper, you can follow these three steps to ensure a clear and compelling ...

  18. Writing a Research Paper for Your Science Fair Project

    The short answer is that the research paper is a report summarizing the answers to the research questions you generated in your background research plan. It's a review of the relevant publications (books, magazines, websites) discussing the topic you want to investigate.

  19. How to Write the Background of Your Scientific Paper

    3 tips for writing your background section. 1. Think: as you would for writing an introduction to a research paper, think about the direct chain of evidence that led to your own work. Make a list of the most important findings that make up that chain of evidence. 2.

  20. What is Background in a Research Paper?

    The background of your study will provide context to the information discussed throughout the research paper. Background information may include both important and relevant studies.

  21. What Is the Importance of Background Research?

    Published Aug 10, 2022 Last Updated Jun 19, 2023 Listen to this article Background research is an important part of research, and while it should not be the only research done for an academic paper, it should also not be omitted from your research process. Let's explore background research in more detail! What Is Background Research?

  22. PDF Research Questions

    Research Questions, Fall 2023. 1 of 4 Research Questions A research question is a clear, concise, and open-ended question that centers your research for a paper, project, or literature review. It forms the foundation of a research-based assignment and helps guide the entire research process. A well-made research question is essential to define the

  23. How do I write the background of a research in a historical and

    The background is the first part of the introduction and has to set the context for the research. So, you need to talk about the existing research in the area and the gaps in this research. Based on this, the background has to lead to the purpose of the research and thus talk about the goals of the research. Therefore, in your case, you could ...

  24. Researching the White Paper

    The research you do for your white paper will require that you identify a specific problem, seek popular culture sources to help define the problem, its history, its significance and impact for people affected by it. You will then delve into academic and grey literature to learn about the way scholars and others with professional expertise ...

  25. Experiences of hospital care for people with multiple long-term

    Background Multiple long-term conditions—the co-existence of two or more chronic health conditions in an individual—present an increasing challenge to populations and healthcare systems worldwide. This challenge is keenly felt in hospital settings where care is oriented around specialist provision for single conditions. The aim of this scoping review was to identify and summarise published ...

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    From August 19, 2022, to December 16, 2022, a total of 1208 patients were enrolled at 35 research sites in China; 603 were assigned to receive simnotrelvir plus ritonavir, and 605 were assigned to ...

  27. Journal of Medical Internet Research

    Background: Primary headaches, including migraine and tension-type headaches, are widespread and have a social, physical, mental, and economic impact. Among the key components of treatment are behavior interventions such as lifestyle modification. Scalable conversational agents (CAs) have the potential to deliver behavior interventions at a low threshold.

  28. Efficient Constrained $k$-Center Clustering with Background Knowledge

    Efficient Constrained. k. -Center Clustering with Background Knowledge. Center-based clustering has attracted significant research interest from both theory and practice. In many practical applications, input data often contain background knowledge that can be used to improve clustering results. In this work, we build on widely adopted k ...