what are the importance of literature review in research

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

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

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

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

The common perception of literature review and reality:

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

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

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

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

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

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

Importance of literature review in research:

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

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

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

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

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

References:

http://www.math.montana.edu/jobo/phdprep/phd6.pdf

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A Guide to Literature Reviews

Importance of a good literature review.

• Conducting the Literature Review
• Structure and Writing Style
• Types of Literature Reviews
• Citation Management Software This link opens in a new window
• Acknowledgements

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

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

The purpose of a literature review is to:

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

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

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

What are Literature Reviews?

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

Goals of Literature Reviews

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

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

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

What kinds of sources require a Literature Review?

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

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

Types of Literature Reviews

What kinds of literature reviews are written?

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

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

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

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

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

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

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

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

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Literature reviews, what is a literature review, learning more about how to do a literature review.

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

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

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Literature Review - what is a Literature Review, why it is important and how it is done

What are literature reviews, goals of literature reviews, types of literature reviews, about this guide/licence.

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

Source NC State University Libraries. This video is published under a Creative Commons 3.0 BY-NC-SA US license.

What are the goals of creating a Literature Review?

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

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

When do you need to write a Literature Review?

• When writing a prospectus or a thesis/dissertation
• When writing a research paper
• When writing a grant proposal

In all these cases you need to dedicate a chapter in these works to showcase what have been written about your research topic and to point out how your own research will shed a new light into these body of scholarship.

Literature reviews are also written as standalone articles as a way to survey a particular research topic in-depth. This type of literature reviews look at a topic from a historical perspective to see how the understanding of the topic have change through time.

What kinds of literature reviews are written?

• Narrative Review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.
• Book review essays/ Historiographical review essays : This is a type of review that focus on a small set of research books on a particular topic " to locate these books within current scholarship, critical methodologies, and approaches" in the field. - LARR
• Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L.K. (2013). Research in Communication Sciences and Disorders . San Diego, CA: Plural Publishing.
• Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M.C. & Ilardi, S.S. (2003). Handbook of Research Methods in Clinical Psychology . Malden, MA: Blackwell Pub.
• Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). "Qualitative meta-synthesis: A question of dialoguing with texts," Journal of Advanced Nursing , 53(3), 311-318.

Guide adapted from "Literature Review" , a guide developed by Marisol Ramos used under CC BY 4.0 /modified from original.

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

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

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

You identify:

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

It Also Helps You:

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

Great brief overview, from NCSU

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Research Methods

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Literature Review

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

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

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

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

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

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

A literature review is important because it:

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

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

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

Not an essay 

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

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

A literature review serves several purposes. For example, it

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

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

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

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

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

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

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

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

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

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

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

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

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

Systematic review or meta-analysis?

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

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

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

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

Not all systematic reviews contain meta-analysis. 

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

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

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

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

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Frequently asked questions

What is the purpose of a literature review.

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

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

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

Frequently asked questions: Academic writing

A rhetorical tautology is the repetition of an idea of concept using different words.

Rhetorical tautologies occur when additional words are used to convey a meaning that has already been expressed or implied. For example, the phrase “armed gunman” is a tautology because a “gunman” is by definition “armed.”

A logical tautology is a statement that is always true because it includes all logical possibilities.

Logical tautologies often take the form of “either/or” statements (e.g., “It will rain, or it will not rain”) or employ circular reasoning (e.g., “she is untrustworthy because she can’t be trusted”).

You may have seen both “appendices” or “appendixes” as pluralizations of “ appendix .” Either spelling can be used, but “appendices” is more common (including in APA Style ). Consistency is key here: make sure you use the same spelling throughout your paper.

The purpose of a lab report is to demonstrate your understanding of the scientific method with a hands-on lab experiment. Course instructors will often provide you with an experimental design and procedure. Your task is to write up how you actually performed the experiment and evaluate the outcome.

In contrast, a research paper requires you to independently develop an original argument. It involves more in-depth research and interpretation of sources and data.

A lab report is usually shorter than a research paper.

The sections of a lab report can vary between scientific fields and course requirements, but it usually contains the following:

• Title: expresses the topic of your study
• Abstract: summarizes your research aims, methods, results, and conclusions
• Introduction: establishes the context needed to understand the topic
• Method: describes the materials and procedures used in the experiment
• Results: reports all descriptive and inferential statistical analyses
• Discussion: interprets and evaluates results and identifies limitations
• Conclusion: sums up the main findings of your experiment
• References: list of all sources cited using a specific style (e.g. APA)
• Appendices: contains lengthy materials, procedures, tables or figures

A lab report conveys the aim, methods, results, and conclusions of a scientific experiment . Lab reports are commonly assigned in science, technology, engineering, and mathematics (STEM) fields.

The abstract is the very last thing you write. You should only write it after your research is complete, so that you can accurately summarize the entirety of your thesis , dissertation or research paper .

If you’ve gone over the word limit set for your assignment, shorten your sentences and cut repetition and redundancy during the editing process. If you use a lot of long quotes , consider shortening them to just the essentials.

If you need to remove a lot of words, you may have to cut certain passages. Remember that everything in the text should be there to support your argument; look for any information that’s not essential to your point and remove it.

To make this process easier and faster, you can use a paraphrasing tool . With this tool, you can rewrite your text to make it simpler and shorter. If that’s not enough, you can copy-paste your paraphrased text into the summarizer . This tool will distill your text to its core message.

Revising, proofreading, and editing are different stages of the writing process .

• Revising is making structural and logical changes to your text—reformulating arguments and reordering information.
• Editing refers to making more local changes to things like sentence structure and phrasing to make sure your meaning is conveyed clearly and concisely.
• Proofreading involves looking at the text closely, line by line, to spot any typos and issues with consistency and correct them.

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

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

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

Avoid citing sources in your abstract . There are two reasons for this:

• The abstract should focus on your original research, not on the work of others.
• The abstract should be self-contained and fully understandable without reference to other sources.

There are some circumstances where you might need to mention other sources in an abstract: for example, if your research responds directly to another study or focuses on the work of a single theorist. In general, though, don’t include citations unless absolutely necessary.

An abstract is a concise summary of an academic text (such as a journal article or dissertation ). It serves two main purposes:

• To help potential readers determine the relevance of your paper for their own research.
• To communicate your key findings to those who don’t have time to read the whole paper.

Abstracts are often indexed along with keywords on academic databases, so they make your work more easily findable. Since the abstract is the first thing any reader sees, it’s important that it clearly and accurately summarizes the contents of your paper.

In a scientific paper, the methodology always comes after the introduction and before the results , discussion and conclusion . The same basic structure also applies to a thesis, dissertation , or research proposal .

Depending on the length and type of document, you might also include a literature review or theoretical framework before the methodology.

Whether you’re publishing a blog, submitting a research paper , or even just writing an important email, there are a few techniques you can use to make sure it’s error-free:

• Take a break : Set your work aside for at least a few hours so that you can look at it with fresh eyes.
• Proofread a printout : Staring at a screen for too long can cause fatigue – sit down with a pen and paper to check the final version.
• Use digital shortcuts : Take note of any recurring mistakes (for example, misspelling a particular word, switching between US and UK English , or inconsistently capitalizing a term), and use Find and Replace to fix it throughout the document.

If you want to be confident that an important text is error-free, it might be worth choosing a professional proofreading service instead.

Editing and proofreading are different steps in the process of revising a text.

Editing comes first, and can involve major changes to content, structure and language. The first stages of editing are often done by authors themselves, while a professional editor makes the final improvements to grammar and style (for example, by improving sentence structure and word choice ).

Proofreading is the final stage of checking a text before it is published or shared. It focuses on correcting minor errors and inconsistencies (for example, in punctuation and capitalization ). Proofreaders often also check for formatting issues, especially in print publishing.

The cost of proofreading depends on the type and length of text, the turnaround time, and the level of services required. Most proofreading companies charge per word or page, while freelancers sometimes charge an hourly rate.

For proofreading alone, which involves only basic corrections of typos and formatting mistakes, you might pay as little as $0.01 per word, but in many cases, your text will also require some level of editing , which costs slightly more.

It’s often possible to purchase combined proofreading and editing services and calculate the price in advance based on your requirements.

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• Steps in Conducting a Literature Review

What is a literature review?

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

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

Why is it important?

A literature review is important because it:

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

APA7 Style resources

APA Style Blog - for those harder to find answers

1. Choose a topic. Define your research question.

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

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

2. Decide on the scope of your review

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

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

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

Make a list of the databases you will search. 

Where to find databases:

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

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

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

Review the literature

Some questions to help you analyze the research:

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

Tips: 

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

So, what is a literature review .

"A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available or a set of summaries." - Quote from Taylor, D. (n.d)."The Literature Review: A Few Tips on Conducting it".

• Citation: "The Literature Review: A Few Tips on Conducting it"

What kinds of literature reviews are written?

Each field has a particular way to do reviews for academic research literature. In the social sciences and humanities the most common are:

• Narrative Reviews: The purpose of this type of review is to describe the current state of the research on a specific research topic and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weaknesses, and gaps are identified. The review ends with a conclusion section that summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.
• Book review essays/ Historiographical review essays : A type of literature review typical in History and related fields, e.g., Latin American studies. For example, the Latin American Research Review explains that the purpose of this type of review is to “(1) to familiarize readers with the subject, approach, arguments, and conclusions found in a group of books whose common focus is a historical period; a country or region within Latin America; or a practice, development, or issue of interest to specialists and others; (2) to locate these books within current scholarship, critical methodologies, and approaches; and (3) to probe the relation of these new books to previous work on the subject, especially canonical texts. Unlike individual book reviews, the cluster reviews found in LARR seek to address the state of the field or discipline and not solely the works at issue.” - LARR

What are the Goals of Creating a Literature Review?

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 
• Baumeister, R.F. & Leary, M.R. (1997). "Writing narrative literature reviews," Review of General Psychology , 1(3), 311-320.

When do you need to write a Literature Review?

• When writing a prospectus or a thesis/dissertation
• When writing a research paper
• When writing a grant proposal

In all these cases you need to dedicate a chapter in these works to showcase what has been written about your research topic and to point out how your own research will shed new light into a body of scholarship.

Where I can find examples of Literature Reviews?

Note:  In the humanities, even if they don't use the term "literature review", they may have a dedicated  chapter that reviewed the "critical bibliography" or they incorporated that review in the introduction or first chapter of the dissertation, book, or article.

• UCSB electronic theses and dissertations In partnership with the Graduate Division, the UC Santa Barbara Library is making available theses and dissertations produced by UCSB students. Currently included in ADRL are theses and dissertations that were originally filed electronically, starting in 2011. In future phases of ADRL, all theses and dissertations created by UCSB students may be digitized and made available.

Where to Find Standalone Literature Reviews

Literature reviews are also written as standalone articles as a way to survey a particular research topic in-depth. This type of literature review looks at a topic from a historical perspective to see how the understanding of the topic has changed over time. 

• Find e-Journals for Standalone Literature Reviews The best way to get familiar with and to learn how to write literature reviews is by reading them. You can use our Journal Search option to find journals that specialize in publishing literature reviews from major disciplines like anthropology, sociology, etc. Usually these titles are called, "Annual Review of [discipline name] OR [Discipline name] Review. This option works best if you know the title of the publication you are looking for. Below are some examples of these journals! more... less... Journal Search can be found by hovering over the link for Research on the library website.

Social Sciences

• Annual Review of Anthropology
• Annual Review of Political Science
• Annual Review of Sociology
• Ethnic Studies Review

Hard science and health sciences:

• Annual Review of Biomedical Data Science
• Annual Review of Materials Science
• Systematic Review From journal site: "The journal Systematic Reviews encompasses all aspects of the design, conduct, and reporting of systematic reviews" in the health sciences.
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Literature Reviews

• Searching for Literature
• Organizing Literature and Taking Notes
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Organizing Your Paper

Before you begin writing your paper, you will need to decide upon a way to organize your information. You can organize your paper using a number of different strategies, such as the following:

• Topics and subtopics : Discussing your sources in relation to different topics and subtopics; probably the most common approach
• Chronologically : Discussing your sources from oldest to newest in order to show trends or changes in the approach to a topic over time
• Methods : Discussing your sources by different methods that are used to approach the topic

When literature reviews are incorporated into a research paper, they are often structured using the  funnel method , which begins with a broad overview of a topic and then narrows down to more specific themes before focusing in on the specific research question that the paper will address.

A literature review paper often follows this basic organization:

Introduction

• Describes the importance of the topic
• Defines key terms
• Describes the goals of the review
• Provides an overview of the literature to be discussed (e.g., methods, trends, etc.) (optional)
• Describes parameters of the review and particular search methods used (optional)
• Discusses findings of sources, as well as strengths, weaknesses, similarities, differences, contradictions, and gaps
• Divides content into sections (for longer reviews), uses headings and subheadings to indicate section divisions, and provides brief summaries at the end of each section
• Summarizes what is known about the topic
• Discusses implications for practice
• Discusses areas for further research

Synthesizing Sources

A literature review paper not only describes and evaluates the scholarly research literature related to a particular topic, but it also synthesizes that information. Synthesis  is the process of weaving together information from sources to arrive at new analyses and insights.

To help you prepare to synthesize sources in your paper, you can take the topic matrix that you prepared as you were organizing your sources, and flesh it out into a  synthesis matrix  that contains detailed notes from each source as they relate to different topics and subtopics of your literature review. Once you've completed your synthesis matrix, you can more easily identify ways that sources relate to each other in terms of their similarities and differences, methodological strengths and weakness, and contradictions and gaps. The video below shows how to create a synthesis matrix.

Video:  Synthesis Matrix Tutorial  by  Andrew Davis .

Writing Your Paper

A literature review paper should flow logically from one topic to the next. As you write your paper, consider these tips:

• Write in a formal voice and with an impartial tone.
• Define critical terms and describe key theories.
• Use topic sentences to clearly indicate what each paragraph is about.
• Use transitions to make links between sections.
• Introduce acronyms upon first using them.
• Call attention to seminal (i.e., highly influential; groundbreaking) studies.
• Clearly distinguish between your ideas and those of the authors you cite.
• Cite multiple sources for a single idea, if appropriate.
• Create a list of references that follows appropriate style guidelines.
• Give your paper a title that conveys what the literature review is about.
• Once you have written your paper, carefully proofread it for errors.
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• Open access
• Published: 22 July 2024

Symptom impact and health-related quality of life (HRQoL) assessment by cancer stage: a narrative literature review

• Karen C. Chung 1 ,
• Anushini Muthutantri 2 ,
• Grace G. Goldsmith 2 ,
• Megan R. Watts 2 ,
• Audrey E. Brown 2 &
• Donald L. Patrick 3  

BMC Cancer volume  24 , Article number:  884 ( 2024 ) Cite this article

209 Accesses

Metrics details

Cancer stage at diagnosis is an important prognostic indicator for patient outcomes, with detection at later stages associated with increased mortality and morbidity. The impact of cancer stage on patient-reported outcomes is poorly understood. This research aimed to understand symptom burden and health related quality of life (HRQoL) impact by cancer stage for ten cancer types: 1) ovarian, 2) lung, 3) pancreatic, 4) esophageal, 5) stomach, 6) head and neck, 7) colorectal, 8) anal, 9) cervical, and 10) liver and bile duct.

Ten narrative literature reviews were performed to identify and collate published literature on patient burden at different stages of disease progression. Literature searches were conducted using an AI-assisted platform to identify relevant articles published in the last five (2017–2022) or ten years (2012–2022) where articles were limited. Conference abstracts were searched for the last two years (2020–2022). The geographic scope was limited to the United States, Canada, Europe, and global studies, and only journal articles written in English were included.

A total of 26 studies with results stratified by cancer stage at diagnosis (and before treatment) were selected for the cancer types of lung, pancreatic, esophageal, stomach, head and neck, colorectal, anal, and cervical cancers. Two cancer types, ovarian cancer, and liver and bile duct cancer did not return any search results with outcomes stratified by disease stage. A general trend was observed for worse patient-reported outcomes in patients with cancer diagnosed at an advanced stage of disease compared with diagnosis at an earlier stage. Advanced disease stage was associated with greater symptom impact including general physical impairments such as pain, fatigue, and interference with functioning, as well as disease/region-specific symptom burden. Poorer HRQoL was also associated with advanced disease with commonly reported symptoms including anxiety and depression.

Conclusions

Overall, the general trend for greater symptom burden and poorer HRQoL seen in late stage versus early-stage disease across the included cancer types supports the importance for early diagnosis and treatment to improve patient survival and decrease negative impacts on disease burden and HRQoL.

Peer Review reports

Introduction

Cancer stage at diagnosis is an important prognostic indicator for patient outcomes, with detection at later stages associated with increased mortality and morbidity. An estimated 2,001,140 new cancer cases will occur in the United States in 2024 along with 611,720 cancer deaths [ 1 ]. Many cancers are diagnosed during late (distant) stage including 55% of ovarian cancer cases, 53% of lung cancer cases, 51% of pancreatic cancer cases, 38% of esophageal cancer cases, and 36% of stomach cancer cases [ 2 ]. Stage at diagnosis is an important predictor both for treatment efficacy and survival, but diagnosis times vary by cancer type [ 2 ].

The World Health Organization identified two strategies which allow for more effective cancer treatment: 1) diagnosing symptomatic cancer as early as possible, and 2) screening for asymptomatic cancer or pre-cancerous lesions in non-symptomatic target populations [ 3 ]. The US Preventive Services Task Force (USPSTF) recommends single cancer screening based on age and sex for lung (also risk-based), colon, and cervical cancers, among others [ 4 , 5 , 6 , 7 , 8 ]. For cancers with screening paradigms such as cervical cancer, most cases (43%) are diagnosed in early stage where 5-year survival rates are high (91.2%). However, for cancers without screening paradigms, such as pancreatic cancer, most cases (51%) are diagnosed in late stage, where 5-year survival rates are very low (3.2%) [ 2 ].

Currently, the level of invasiveness of cancer screening varies by cancer type and location, ranging from more invasive procedures such as colonoscopy for colorectal cancer and Papanicolaou test (pap smear) for cervical cancer, to less invasive procedures such as blood-based tests or imaging tests such as mammography or low-dose computed tomography. A key focus of current research for cancer screening is less invasive multi-cancer screening technologies, such as blood-based multi-cancer detection screening assays [ 9 ]. This multi-cancer early detection (MCED) approach has the potential to improve treatment outcomes through earlier diagnosis of a wide range of cancer types, in addition to improving health-related quality of life (HRQoL) for patients with a positive diagnosis.

Cancer type and cancer stage may be associated with specific symptomatology, with overall symptoms and symptom impact being greater in advanced disease stages [ 10 ]. Advanced cancer stage and increased symptoms are associated with worse HRQoL, which may be evaluated through patient reported outcome measures (PROMs). PROMs are self-reported questionnaires which provide a qualitative/quantitative measurement of various aspects of a patient’s health, including HRQoL, functional status, and symptoms and symptom burden, directly by the patient without clinician interpretation [ 11 ]. Inclusion of PROMs in clinical practice in oncology can be associated with benefits including improvements in care, prognosis, communication, patient safety, and risk identification such as symptom control and identification [ 12 ].

The purpose of this narrative review was to identify and collate published literature on symptom impact at different stages of disease progression for a range of 10 cancer types: 1) ovarian, 2) lung, 3) pancreatic, 4) esophageal, 5) stomach, 6) head and neck, 7) colorectal, 8) anal, 9) cervical, and 10) liver and bile duct. This will provide valuable information on symptom impact and HRQoL by cancer type and stage at diagnosis. In contrast to a systematic review, this narrative review was not intended to identify and report all the literature available for symptom impact but rather focused on the information most relevant to healthcare providers who are interested in understanding the burden of disease on patients with specific types of cancer.

Search strategy

Ten narrative literature reviews were performed to identify and collate published literature on patient burden at different stages of disease progression for the following cancer types: 1) ovarian, 2) lung, 3) pancreatic, 4) esophageal, 5) stomach, 6) head and neck, 7) colorectal, 8) anal, 9) cervical, and 10) liver and bile duct. Disease terms for each cancer type were run in an artificial intelligence (AI)-assisted platform (EVID PRO) [ 13 ] to identify relevant articles published within the last 5 years (January 2017—December 2022). Where the number of articles identified for a specific cancer type were limited to less than 10 articles, in the case of ovarian, esophageal, stomach, anal, cervical, and liver and bile duct cancers, this was extended to 10 years (January 2012—December 2022). The geographic scope was limited to the United States (U.S.), Canada, Europe and global studies, and only journal articles written in English were included. The EVID PRO tool automatically scans and pulls articles with any specific acronyms, scales, and/or PRO instruments. Electronic searches were supplemented with grey literature searches of relevant conference meeting abstracts restricted to the last 2 years (2020–2022). Congresses included: American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), and Professional Society for Health Economics and Outcomes Research (ISPOR) (for all indications), Digestive Disease Week (DDW) (GI cancers only), European Respiratory Society (ERS) (lung cancer), and American Head and Neck Society (AHNS) (head and neck).

Study selection

For each literature review, an initial screening was performed on the title and abstract of the identified articles followed by a full-text review of articles considered relevant. The PICOS (Population, Intervention, Comparison, Outcomes, Study Design) criteria are shown in Table 1 . Studies were considered for inclusion if patient staging information was reported; outcomes included impact of cancer-related symptoms by cancer type (by stage of disease preferred), as assessed by standardized/ validated instruments (e.g., EORTC QLQ-C30, MDASI); and met the geographic and language limits described above. Studies were excluded if the study population was pretreated (treatment may affect HRQoL/PRO and thus not reflect cancer specific symptoms/impact), if studies were conducted outside US/Europe (unless global), if outcomes reported were related to treatment or were only reported post intervention (no baseline scores), and if only instruments not previously validated were implemented.

Data extraction

Following selection of relevant literature from screening and full text review, data from publications meeting the PICOS elements were extracted into standardized extraction tables in an Excel workbook by one reviewer. A second author reviewed all data extractions for completeness and accuracy. Any discrepancies encountered were discussed and resolved by a third independent reviewer.

Across all cancer types, 150 articles reporting PRO data that included information on disease staging were selected. In most of these studies PRO data were not reported with results stratified by disease stage, and instead reported outcomes with patients of varying disease stages grouped together ( n  = 54) or included patients within a particular disease stage ( n  = 70). After excluding these studies, 26 studies across 8 cancer types reporting PRO results stratified by disease stage were selected for inclusion. Two cancer types, liver and bile duct, and ovarian did not return any search results with outcomes stratified by disease stage.

Descriptions of the PRO instruments used in the 26 included studies are provided in Table  2 [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ]. For each study across the 8 cancer types with results stratified by disease stage, a description including study design, PRO instruments and results, and any statistical analyses performed is presented in Table  3 . The results for these 8 cancer types are organized by the primary stage at which each cancer type is most often diagnosed according to the National Cancer Institute SEER statistics: 1) late stage/distant, 2) regional stage, and 3) early stage/localized [ 34 ]. SEER statistics for the 10 cancer types included in the original scope of this review are presented in Table  4 .

Disease staging varied throughout the 26 included studies and is reported as described in each study. Disease staging may have been described descriptively (ex. early-stage vs advanced stage) or according to a staging system such as the TNM Classification of Malignant Tumors (TNM) developed by the Union for International Cancer Control (UICC). The TNM is used for describing cancer based on: 1) tumor size and tissue location (T0 indicating no evidence of a tumor and T1-T4 describing the progressive size and invasiveness), 2) spread to lymph nodes (N0 indicating no regional nodal spread and N1-N3 indicating progressively distal nodal spread), and 3) presence of metastases (M0 indicating no metastases and M1 indicating presence of metastases) [ 58 ]. The combination of these 3 factors from the TNM system can then be used for simplified cancer staging (Stages I, II, III, and IV) [ 58 ]. While categorization as early or advanced disease based on staging varies between cancer types, generally Stage I indicates localized cancer (T1-T2, N0, M0), stage II indicates early-stage locally advanced cancer (T2-T4, N0, M0), stage III indicates late-stage locally advanced cancer (T1-T4, N1-N3, M0), and stage IV indicates metastatic cancer (T1-T4, N1-N3, M1) [ 58 ].

Cancers predominantly diagnosed at distant stage

Lung cancer.

The primary stage of diagnosis for lung cancer is at a distant stage, accounting for 53% of diagnoses [ 34 ]. For lung cancer, HRQoL and symptom burden by disease stage was reported using PRO instruments including Patient-Reported Outcomes Measurement Information System (PROMIS) [ 35 ], Short-Form Survey-8 (SF-8) [ 36 ], 12-item anorexia/cachexia scale (A/CS-12) [ 37 ], Short-Form Survey-12 (SF-12) [ 38 ], Revised Psychosocial Screen for Cancer (PSSCAN-R) [ 39 ], MD Anderson Symptom Inventory (MDASI) [ 40 ], and quality of life (QoL) single item scales [ 40 ]. Overall, findings suggested that both physical and mental HRQoL were impaired in advanced stages compared with early-stage disease.

Patients with stage III or IV disease reported significantly poorer physical and mental HRQoL versus patients with stage I disease [ 38 ]. Physical HRQoL scores were 41.16 and 37.74 in patients with stage III or IV disease and 43.9 in patients with stage I disease (SF-12, P for trend < 0.001). Mental HRQoL scores were 46.26 and 45.22 in patients with stage III or IV disease and 49.28 in patients with stage I disease (SF-12, p for trend < 0.001). Additionally, between patients with advanced versus early stage disease, poorer HRQoL measured using single-item QoL scales was reported for emotional well-being (6.5 vs 7.1, P  < 0.03), physical well-being (5.7 vs 6.6, P  < 0.002), and overall QoL (6.3 vs 7.2, P  < 0.001) [ 40 ].

A correlation between advanced disease stage and poorer mental health was also reported in studies using other PRO instruments. Advanced disease stage was significantly associated with an increased prevalence of emotional problems (SF-8, P  < 0.001) [ 36 ]. Additionally, anxiety was more prevalent in patients with metastases versus those without metastases (PSSCAN-R, Odds Ratio (OR): 1.46, P  < 0.001), although this association was not found for depression (Odds Ratio (OR): 1.10, P  = 0.196) [ 39 ].

Greater symptom prevalence and impact were also associated with patients with advanced disease. Patients with stage III/IV disease reported worse fatigue versus patients with stage I/II disease (PROMIS, 54.6 vs 58.2) based on a clinically meaningful difference of 3 points (as defined by the study authors for the PROMIS instrument) [ 35 ]. Social function was also worse in patients with stage III/IV disease (47.2 vs 43.7), indicating that the higher symptom burden reported by patients with advanced disease also has a broader impact on patient functioning [ 35 ]. These results are supported by a second study that reported a greater prevalence of both physical and emotional symptoms (measured using the MDASI) in patients with advanced disease compared with patients with early-stage disease [ 40 ]. Symptoms significantly associated with advanced disease included sleep problems (3.5 vs 2.5, P  < 0.001), drowsiness (2.6 vs 1.6, P  < 0.001), fatigue (3.9 vs 2.2, P  < 0.001), sadness (2.9 vs 1.9, P  < 0.002), pain (3.5 vs 2.1, P  < 0.001), shortness of breath (3.2 vs 2.2, P  < 0.001), lack of appetite (2.1 vs 1.3, P  < 0.001), and dry mouth (1.9 vs 1.2, P  < 0.008). Advanced disease was also associated with increased symptom interference for the domains of work (4.4 vs 2.3, P  < 0.001), enjoying life (3.8 vs 2.3, P  < 0.001), general activity (3.9 vs 2.0, P  < 0.001), mood (3.4 vs 2.3, P  < 0.001), walking (3.4 vs 1.8, P  < 0.001), and relationships with others (2.2 vs 1.2, P  < 0.001). Risk for anorexia/cachexia was not significantly associated with disease stage (A/CS-12, P  = 0.09) [ 37 ].

Pancreatic cancer

The primary stage of diagnosis for pancreatic cancer is at distant stage, accounting for 51% of diagnoses [ 34 ]. HRQoL and symptom outcomes in patients with pancreatic cancer were evaluated using the SF-12 [ 41 ] and MDASI [ 42 ]. Worse physical HRQoL was associated with advanced tumor stage (I-IV) (SF-12, P for trend < 0.001), although this association was not significant for mental HRQoL (SF-12, P for trend 0.16) [ 41 ]. Additionally, patients in stage III/IV had higher symptom scores compared with patients in stage II/III (MDASI, 51.8 vs 47.3), indicating worse symptom severity, although no statistical tests or P values were reported [ 42 ].

Esophageal cancer

The primary stage of diagnosis for esophageal cancer is at distant stage, accounting for 38% of diagnoses [ 34 ]. For esophageal cancer, results stratified by disease stage were reported for the instruments Functional Assessment of Cancer Therapy-General (FACT-G) [ 43 ], FACT-Esophageal (FACT-E) [ 43 , 44 ], FACT-Esophageal Cancer Subscale (FACT-ECS) [ 43 , 44 ], and European Quality of Life Five Dimension questionnaire (EQ-5D-3L) [ 43 ].

Better HRQoL was reported in patients with stage II/III disease versus patients in stage IV [ 43 ]. Patients with stage II/ III disease reported a mean (SD) EQ-5D baseline utility score of 0.82 (0.13) compared with a score of 0.72 (0.18) in patients with stage IV or recurrent disease. Given a minimally important difference in EQ-5D Health Utility Score (HUS) of 0.07, this indicates that patients with stage IV or recurrent disease have clinically meaningful impaired HRQoL compared with patients with early-stage disease [ 43 ]. Poorer HRQoL with advanced disease stage was also reported using disease specific instruments. Patients in stage IV showed directionally poorer scores versus patients in stage II/III for symptoms associated with esophageal cancer (FACT-ECS, 40.2 vs 46.0) and HRQoL subscales such as emotional well-being (FACT-E, 13.6 vs 17.0). However, p values were not reported for these comparisons [ 43 ]. A statistically significant trend between higher T-stage and worse HRQoL was reported between patients with T4 disease versus T1 (FACT-ECS, 44.5 vs 58.7, P  < 0.002), however this trend was not significant for all instruments (FACT-E, P  = 0.65) [ 44 ].

Stomach cancer

The primary stage of diagnosis for stomach cancer is at distant stage, accounting for 36% of diagnoses [ 34 ]. A significantly greater prevalence of reported cancer symptoms was associated with advanced disease stage, with results stratified by both T stage (1–4) and UICC stage (I-IV) [ 45 ]. A higher prevalence of alarm symptoms (dysphagia, weight loss, bleeding, vomiting) was reported by patients with T-stage 3/4 versus T-stage 1/2 (OR: 2.54, P  < 0.0001), and for patients with UICC stage III/IV versus UICC stage I/II (OR: 3.02, P  < 0.0001).

Cancers predominately diagnosed at regional stage

Head and neck cancer.

The primary stage of diagnosis for head and neck cancer is at regional stage, accounting for 51% of diagnoses [ 34 ]. For head and neck cancer, results stratified by disease stage were reported for the PRO instruments National Comprehensive Cancer Network Distress Thermometer (NCCN DT) [ 47 ], Pittsburgh Sleep Quality Index (PSQI) [ 49 ], Apnea/Hypopnea Index (AHI) [ 48 ], and Eating Assessment Tool-10 (EAT-10) [ 46 ]. There was a significant correlation between advanced disease (higher T stage) and problems with swallowing (i.e., increased severity of swallowing impairment; EAT-10, P  < 0.02) [ 46 ]. No statistically significant differences based on disease stage were reported for distress (NCCN DT) [ 47 ], sleep quality [ 49 ], or apnea and hypoxia [ 48 ].

Colorectal cancer

The primary stage of diagnosis for colorectal cancer is at regional stage, accounting for 36% of diagnoses [ 34 ]. In colorectal cancer, HRQoL and symptom burden by disease stage was reported using a range of PRO assessments including SF-12 [ 50 , 51 ], PROMIS [ 35 ], FACT-Colorectal (FACT-C) and NSABP Symptom Checklist (SCL-17) [ 52 ], PERFORM fatigue questionnaire [ 53 ], and Hospital Anxiety and Depression Scale (HADS) [ 54 ]. Across all PRO assessments, advanced stage disease was generally associated with poorer HRQoL and increased symptomology and burden.

Significantly poorer physical and mental HRQoL was reported for patients with late-stage versus early-stage disease [ 50 ]. Comparing between patients in stage IV versus stage I, advanced disease was associated with significantly lower scores (poorer HRQoL) for both physical HRQoL (SF-12 PCS, 40.8 vs 46.9, P  < 0.001) and mental HRQoL (SF-12, 46.0 vs 50.1, P  < 0.001). Additionally, another study also evaluated ethnicity (white, black, or Hispanic) as a factor in HRQoL outcomes [ 51 ]. While advanced disease stage in all ethnicities was significantly associated with poorer physical HRQoL (SF-12 PCS, P  < 0.05, for all), worse mental HRQoL with advanced disease was not observed, regardless of ethnicity. In comparing HRQoL in patients with stage II vs stage III cancer, significantly poorer HRQoL was reported in patients with stage III cancer (FACT-C TOI, 66.1 vs 64.0, P  < 0.004) [ 52 ].

An increase in symptoms and the impact of symptoms on functioning were also associated with advanced stage disease. Clinically meaningful differences (defined by the study authors as a difference of 3 points for the PROMIS instrument) were reported in patients with stage IV and stage III cancer versus stage I/II across a range of functions and symptoms. Poorer functioning was reported in patients with stage III and IV disease versus patients with stage I/II for physical (41.8 and 43.4 vs 46.5), social (45.4 and 48.0 vs 51.2), and cognitive function (49.1 and 49.7 vs 52.9) [ 35 ]. Symptoms of pain (56.5 vs 52.1, stage IV vs stage I/II) and fatigue (56.5 vs 50.8, stage IV vs stage I/II) were also clinically worse in patients with advanced disease [ 35 ]. However, other studies reported no significant difference in fatigue between early and advanced-stage disease using other PRO instruments (SF-36 vitality subscale [ 52 ] and PERFORM 12-item scale [ 53 ]). Symptom impact was also significantly associated with advanced disease stage. Patients with stage III reported greater symptom impact (pain, vision and hearing problems, and GI problems) compared with patients with stage II cancer (SCL-17, 8.5 vs 7.2, P  < 0.001) [ 52 ]. Additionally, depression was significantly more prevalent in patients with metastatic disease versus those without (HADS, 31% vs 23%, P  < 0.015), although this association was not statistically significant when comparing patients based on T stage or N stage [ 54 ].

Cancers predominately diagnosed at localized stage

Anal cancer.

The primary stage of diagnosis for anal cancer is at localized stage, accounting for 43% of diagnoses [ 34 ]. For anal cancer, symptom burden was described stratified by T-stage (T 1–4) [ 55 ]. Overall, the most common symptoms reported by patients with anal cancer were anal bleeding (78%), anal/perianal pain (29% and 24%, respectively), weight loss (31%), tumor on self-examination (26%), and foreign body sensation (22%). Patients with locally advanced cancer (T3/T4) reported significantly greater prevalence of constipation and abdominal pain ( P  < 0.02), and perianal pain and weight loss ( P  < 0.01). Meanwhile, pruritus was significantly more frequent in patients with early T stages ( P  < 0.01). Patients with more advanced disease reported significantly more symptoms than those with less advanced tumors (average total number of symptoms for T1 vs T4, 2.1 vs 4.4, P  < 0.01) indicating overall poorer HRQoL.

Cervical cancer

The primary stage of diagnosis for cervical cancer is at localized stage, accounting for 43% of diagnoses [ 34 ]. For cervical cancer, results stratified by disease stage were reported for the PRO instruments European Organization For Research And Treatment Of Cancer Core Quality of Life questionnaire (EORTC QLQ-C30) and EORTC cervical cancer questionnaire (EORTC QLQ-CX24) [ 56 ], PROMIS [ 35 ], and HADS [ 56 , 57 ]. In terms of global HRQoL (measured using EORTC QLQ-C30), there was no statistically significant association between cancer stage, early vs locally advanced, and global score (72.9 vs 76.1, P  = 0.264). Symptom burden was assessed through the PRO instruments, PROMIS, and HADS, and the disease-specific EORTC QLQ-CX24 instrument. Patients with locally advanced cancer reported significant impairments versus patients with early stage for sexual activity (EORTC QLQ-CX24, 9.1 vs 17.1, P  < 0.004) and sexual enjoyment (EORTC QLQ-CX24, 22.9 vs 52.1, P  < 0.006) [ 56 ]. Poorer mental and physical HRQoL was reported between patients with stage I cancer versus stage II/III/IV cancer for the PROMIS domains of pain interference (51.1 vs 56.1), fatigue (51.8 vs 56.6), anxiety (51.5 vs 54.9), depression (50.0 vs 53.6), physical function (48.4 vs 41.2), social function (52.6 vs 46.9), and cognitive function (51.7 vs 47.9) [ 35 ]. Depression and anxiety were evaluated based on FIGO staging in two studies [ 56 , 57 ]. No significant differences were reported for either anxiety or depression, although one study noted a directional trend of more patients with locally advanced disease reporting anxiety compared with patients with early-stage disease (HADS, 63% vs 53%) [ 56 ].

In this narrative literature review of patient reported outcomes assessing symptom impact and health-related quality of life across 10 different cancer types, a general trend was observed for worse PRO results in patients with cancer diagnosed at an advanced stage of disease versus patients diagnosed at an earlier stage. Advanced disease stage was associated with greater prevalence of symptoms and increased symptom impact including general physical impairments such as pain, fatigue, and interference with functioning, as well as disease/region-specific symptom burden. Poorer HRQoL was also associated with advanced disease with commonly reported symptoms including anxiety and depression.

HRQoL, measured using generic PRO instruments, was worse in patients with advanced stage disease compared with patients with early-stage disease across cancer types. A range of generic instruments were used to measure HRQoL including the SF-12, reported in 4 studies [ 36 , 39 , 46 , 48 ]. Clinically meaningful differences in HRQoL and symptoms were also reported for other PRO instruments such as PROMIS, with patients with advanced stage disease reporting worse HRQoL and more symptoms than patients with early stage disease [ 35 ]. Increased prevalence and/or interference of pain was correlated with advanced disease stage for colorectal cancer [ 35 ], lung cancer [ 35 , 40 ], cervical cancer [ 35 ], and anal cancer [ 55 ]. This included both general pain [ 35 , 40 ], and cancer type/site-specific pain such as perianal and abdominal pain in anal cancer [ 55 ]. Other general symptoms correlated with advanced disease included fatigue and sleep disturbances in lung, colorectal, and cervical cancers [ 35 , 40 ], impairments in physical and cognitive function in colorectal and cervical cancer [ 35 ], nausea, lack of appetite, or anorexia and cachexia for lung cancer [ 37 ] and anal cancer [ 55 ].

The results of this review also highlight the increased burden of disease-specific symptoms in patients with advanced stage disease. Results from cancer-type specific PRO instruments were reported for the cancer types of colorectal (FACT-C TOI), cervical (EORTC QLQ-CX24), and esophageal (FACT-ECS) cancers. For both colorectal and esophageal cancer, a statistically significant association was reported between advanced cancer stage and worse HRQoL scores, as measured by the relevant disease-specific PRO instrument [ 44 , 52 ]. For cervical cancer, advanced cancer stage was associated with statistically significant impairments in sexual activity and enjoyment [ 56 ]. In addition, disease-specific symptoms that correlated with advanced stage disease were seen in stomach cancer for alarm symptoms (dysphagia, weight loss, bleeding, vomiting) [ 45 ], and in head and neck cancer with trouble swallowing [ 46 ]. Together, these findings highlight the importance of using disease-specific PRO instruments to assess HRQoL and support the previously published observation that disease specific instruments are likely more sensitive to detect differences both between therapies [ 59 , 60 ], but also, in the case of this review, when comparing between patients in different disease stages [ 59 , 60 ].

Increased symptom burden can also impact a patient’s functional status, such as physical, emotional, or social functioning. Findings from this review show that advanced disease was associated with increased symptom interference in multiple areas including ability to work, walk, and general activity in lung cancer [ 40 ], and greater overall symptom burden in colorectal cancer [ 52 ] and anal cancer [ 55 ]. Increased prevalence or severity of emotional problems with more advanced disease was reported for multiple cancer types. Increased prevalence of emotional problems was correlated with advanced cancer stage for colorectal cancer [ 35 , 50 , 54 ], lung cancer [ 36 , 38 , 39 , 40 ], and cervical cancer [ 35 ]. Statistically significant trends for worse mental HRQoL with advanced disease stage were also reported for colorectal cancer [ 46 ] and lung cancer [ 36 ]. Additionally, there was a statistically significant association between metastatic disease in colorectal cancer and prevalence of depression, although results were non-significant when stratified by T-stage or N-stage [ 52 ]. However, in cervical cancer, a statistically significant association was not found between advanced disease stage and prevalence of anxiety or depression [ 54 , 55 ].

Across the 10 cancer types assessed in this review, 8 cancer types reported PRO results stratified by disease stage, while no studies were identified for the cancer types of liver and bile duct, or ovarian cancer. The number of studies found with results stratified by disease stage varied between cancer types and this is likely impacted by multiple variables including cancer prevalence and incidence, screening availability, distribution of cancer stage at diagnosis, treatment options, and efficacy and survival rates. The greatest number of studies found were for lung and colorectal cancer, returning 6 results each. Perhaps unsurprisingly, these cancers are the most prevalent of the 10 cancers included in the scope of this review: 1,388,422 for colorectal cancer, and 603,989 for lung cancer (Table  4 ) [ 34 ]. In contrast, no studies with results stratified by disease stage were found for the cancer types liver and bile duct, and ovarian, despite relatively high U.S. prevalence rates, 105,765 and 236,511, respectively (Table  4 ) [ 34 ]. The lack of results for these two cancers may be due to the lack of screening paradigms available for these cancers, thus resulting in the majority of cases being detected in later stages. Among the 10 cancers included in the scope of this narrative literature review, the stage at which each cancer type is primarily diagnosed varies. While stage distribution at diagnosis for colorectal cancer is more evenly distributed between early/localized stage (35% of cases), regional stage (36% of cases), and late/distant stage (23% of cases), other cancers are more highly skewed towards diagnosis at the advanced (distant) stage, including lung (53% of cases), pancreatic (51% of cases), esophageal (38% of cases), stomach (36% of cases), and ovarian (55% of cases) (Table  4 ) [ 34 ]. In general, 5-year survival rates are greater for those cancers that are more often diagnosed in earlier stages, although exceptions apply (e.g., liver and bile duct) [ 2 ]. Overall, data support the importance of early diagnosis and treatment to improve survival rates and reduce the negative impact of late diagnosis on patient symptom burden and HRQoL.

A few key limitations are present in this narrative literature review. First, while database searches were conducted in a systematic manner, this work was not intended to be a systematic review. Therefore, the studies selected are considered to be of most relevance to the question being addressed but may not include all relevant references. While the primary objective of this narrative literature review was to identify and collate published literature on patient burden at different stages of disease progression for the ten selected cancers, the secondary objective was to evaluate HRQoL based on cancer type and stage, within and between different cancer types. However, selected literature was heterogenous in terms of patient populations and study design. This review included both prospective and retrospective studies, the latter of which carries additional limitations including the potential for bias due to missing or misreported data. Also, while this review was focused on identifying patients with PRO assessments at the time of diagnosis and prior to treatment, the nature of retrospective claims analyses means that it is sometimes difficult to determine if patients may have previously received treatment. Additionally, studies may not have been powered for PRO endpoints. Statistical comparisons were not reported in all studies and few studies reported minimally important differences. Taken together, these factors limited the ability to draw strong conclusions.

The findings of this narrative literature review support the search for improvements in cancer screening and earlier detection and treatment. Studies with results stratified by disease stage were limited, likely due to some cancers primarily being detected at advanced stages. Although the HRQoL data lacked consistent stratification by cancer stage, advanced stage cancer at diagnosis and prior to treatment was generally associated with worse HRQoL. This observation was expected due to stage or spread of disease likely playing a significant role in symptom impact burden. Overall, this supports the importance of detecting and treating cancer at earlier stages when patients may be asymptomatic or have lower symptom burden to minimize the increased negative impact on HRQoL and functional status observed in cancers diagnosed in advanced stage.

Availability of data and materials

No datasets were generated or analysed during the current study.

Abbreviations

12-Item anorexia/cachexia scale

Apnea/Hypopnea Index

American Head and Neck Society

American Society of Clinical Oncology

Digestive Disease Week

Eating Assessment Tool-10

European Organization For Research And Treatment Of Cancer Core Quality of Life questionnaire

EORTC cervical cancer questionnaire

European Quality of Life Five Dimension questionnaire

European Respiratory Society

European Society for Medical Oncology

Functional Assessment of Cancer Therapy-Colorectal

Functional Assessment of Cancer Therapy-Esophageal

Functional Assessment of Cancer Therapy-Esophageal Cancer Subscale

Functional Assessment of Cancer Therapy-General

International Federation of Gynecology and Obstetrics

Hospital Anxiety and Depression Scale

Health-related quality of life

Health Utility Score

Professional Society for Health Economics and Outcomes Research

Multi-cancer early detection

Mental Component Summary

MD Anderson Symptom Inventory

National Comprehensive Cancer Network Distress Thermometer

Physical Component Summary

Population, Intervention, Comparison, Outcomes, Study Design

Patient-Reported Outcomes Measurement Information System

Patient reported outcome measures

Pittsburgh Sleep Quality Index

Revised Psychosocial Screen for Cancer

National Surgical Adjuvant Breast and Bowel Project (NSABP) Symptom Checklist

Short-Form Survey-12

Short-Form Survey-36

Short-Form Survey-8

Trial Outcome Index

Union for International Cancer Control

US Preventive Services Task Force

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Acknowledgements

Medical writing support was provided by Henry Blanton, an employee of Genesis Research Group.

This review was conducted by Genesis Research Group with funding provided by GRAIL, Inc.

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Karen C. Chung

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Anushini Muthutantri, Grace G. Goldsmith, Megan R. Watts & Audrey E. Brown

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K.C.C., A.M., G.G.G., M.R.W., and A.E.B. contributed to research design, synthesis and interpretation of findings. G.G.G. and M.R.W. contributed to acquisition, analysis, and interpretation of review data. K.C.C., G.G.G., A.E.B. and D.L.P. contributed to synthesis and interpretation of findings and critically reviewed draft manuscripts. All authors have read and approved the final manuscript.

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K.C.C. is an employee of GRAIL, Inc. with stock ownership in Illumina, Bristol Myers Squibb, Gilead, Baxter, and Bayer. A.E.B. and G.G.G. are current employees of Genesis Research Group, A.M. and M.R.W. are former employees of Genesis Research Group. D.L.P. provides consulting to GRAIL, Inc.

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Chung, K.C., Muthutantri, A., Goldsmith, G.G. et al. Symptom impact and health-related quality of life (HRQoL) assessment by cancer stage: a narrative literature review. BMC Cancer 24 , 884 (2024). https://doi.org/10.1186/s12885-024-12612-z

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A self-assessment maturity matrix to support large-scale change using collaborative networks in the New Zealand health system

• Kanchan M. Sharma 1 ,
• Peter B. Jones 2 ,
• Jacqueline Cumming 3 &
• Lesley Middleton 4  

BMC Health Services Research volume  24 , Article number:  838 ( 2024 ) Cite this article

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Metrics details

A maturity matrix can be a useful tool for organisations implementing large-system transformation (LST) initiatives in complex systems. Insights from implementation of a local LST initiative using collaborative networks, known as Alliances, highlighted a tool was needed to help health system leaders prompt discussions on how and where to focus their change efforts. In the New Zealand (NZ) health system, Alliances were introduced to integrate the planning and delivery of health care between primary and hospital care.

The aim of this research was to use insights from Alliance members to develop a learning tool that collaborative networks could use to assess and improve their readiness for change. We constructed a maturity matrix using the knowledge of senior NZ health system leaders, in a workshop setting. The maturity matrix was empirically tested and refined with three Alliances and with feedback from the NZ Ministry of Health Māori Health Strategy and Policy team.

The maturity matrix described the 10 key elements that had been found to support successful implementation of LST initiatives in the NZ health system, along with success indicators and different stages of maturity from beginning to excellence. Testing of the maturity matrix with three Alliances suggested that it functioned as a learning tool and stimulated collective thinking and reflection. The Māori Health Strategy and Policy team commented on the importance of such a tool to increase health system leaders’ responsiveness to improving Māori health outcomes. Comparisons with similar international matrices revealed common elements with ours. A strength of our maturity matrix is that it is specific to the NZ context and is the first practical tool to implement large-scale change in the health system that incorporates principles of the Government’s treaty with Māori, the indigenous people of NZ.

Conclusions

Through a regular self-assessment process, use of the maturity matrix may create feedback loops to support deliberate learning and knowledge sharing for senior health system leaders and collaborative networks. The maturity matrix fills an important gap in the NZ health system and contributes to implementation science literature internationally.

This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27,356). The research was supported by the Victoria University of Wellington research grant (222,809) and from the University of Auckland Department of Medicine research fund (H10779).

Peer Review reports

Research from the United Kingdom and Europe shows an emerging use of maturity matrices in health care settings as deliberate learning tools for organisations dealing with complex changes. These include uses in primary care and hospital settings to stimulate quality improvement and to improve communication and co-operation among teams; assess readiness for change; identify areas of improvement; share experiences; help organisations understand the local conditions that enable successful delivery of integrated care; and evaluate the delivery of integrated care [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 ]. Other uses of maturity matrices have included measuring performance or evaluating the success of interventions in specific health conditions or programmes, such as, evaluating the role of Cardiac Genetic Nurses in inherited cardiac conditions [ 12 ]; measuring success of health policies in local government [ 13 ]; and defining stages of development and maturity of medicine programmes in Canadian hospitals [ 14 ]. Evaluations on the use of maturity matrices confirm that a self-assessment matrix can be a useful tool to implement and sustain large-system transformation (LST) initiatives, as it helps health system agents recognise their strengths and weaknesses and identify areas of improvement needed for system transformation [ 1 , 3 , 4 , 9 , 11 , 15 ].

In this article we report on the development of a maturity matrix: a learning tool specifically designed for trust-based collaborative networks, such as Alliances, to improve communication and co-operation among health system leaders, assess readiness for change and identify areas for improvement to successfully implement LST initiatives in health systems. The purpose of this maturity matrix is to prompt discussions among senior health system leaders on where best to focus attention along an improvement pathway when implementing complex interventions in a complex adaptive system. By LST initiatives, we mean ‘interventions aimed at co-ordinated, system wide change affecting multiple organisations and care providers, with the goal of significant improvements in the efficiency of health care delivery, the quality of patient care, and population-level patient outcomes’ (p 422) [ 16 ].

In 2015, the New Zealand (NZ) Ministry of Health (Manatū Hauora) implemented the System Level Measures (SLM) programme to enhance a collaborative way of working beyond organisational and professional boundaries, as well as to address health inequities and encourage continuous learning and quality improvement [ 17 ]. The SLM programme was designed by Manatū Hauora with health system leaders from primary and secondary care. Alliances were collaborative networks that were responsible for leading the implementation of the programme in their districts. The implementation included development of an annual improvement plan using a collaborative approach underpinned by robust improvement science, and monitoring and reporting progress against successive plans [ 17 ].

A maturity matrix was constructed as part of a doctoral thesis that investigated the journey of the SLM programme, to better understand how the different elements coalesced to drive improvement in a complex adaptive system [ 18 , 19 ]. The research identified a set of 10 key elements needed in the NZ health system to increase the chances of success with implementation of LST initiatives. These are (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi Footnote 1 ; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whānau (family and extended family), and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time [ 18 , 19 ].

The preparedness of teams to engage with a maturity matrix reinforces the Alliance teams’ interest in continuous improvement and accords with the value of actions that support a learning culture. Work by others tracking the conditions that support large-scale transformation highlights four system enablers that have overlaps with our 10 key elements: (i) build an authorizing environment; (ii) provide relevant, authentic, timely, and meaningful data; (iii) designate and distribute leadership and decision making; and (iv) support the emergence of a learning culture [ 20 ].

New Zealand Alliances

At the time of this research, the NZ health system had 20 geographically based District Health Boards (DHBs) that delivered publicly funded hospital and specialist services and purchased primary care services from Primary Health Organisations (PHOs). DHBs funded PHOs (not-for-profit meso-layer organisations) to provide comprehensive primary care services through their member general practices. Citizens choose the general practice they enrol with and general practices choose which PHO to become a member of [ 21 ]. Manatū Hauora had overall leadership of the health and disability system. A simplified visual description of the NZ health system at the time of this research is shown in Supplementary Figure A.

An important context for the health and disability system relates to the rights and interests of Māori who are the indigenous population of NZ. The British Crown and Māori rangatira (chiefs) signed te Tiriti o Waitangi (the Treaty of Waitangi) for the populations to live together under a common set of laws and agreements [ 22 ]. Under te Tiriti o Waitangi (te Tiriti) principles, crown agents have responsibility to work together with iwi (Māori tribe), hapū (sub-tribe), whānau (family or extended family) and Māori to plan, develop, and deliver health and disability services. The purpose is to ensure Māori receive equitable health care and have equitable health outcomes as pākehā (non-Māori) while protecting Māori cultural concepts, values and practices [ 22 , 23 ].

Since 2013, Manatū Hauora contractually required all DHBs and PHOs in each district to form Alliances to deliver integrated patient-centred health care [ 24 , 25 ]. Manatū Hauora published an Alliance Charter, which outlined the rules of engagement that Alliance members pledged to [ 26 ]. It also outlined members’ commitment to act in good faith to develop an Alliance plan for their district and decide how to fund and deliver their agreed plan [ 26 ]. Members committed to actively engage in good faith, and honour confidentiality, shared responsibility, shared decision-making, and shared accountability, to enable open and transparent discussions [ 26 ].

Most DHBs had a single Alliance with PHOs in their district, the simplest being an Alliance between one DHB and one PHO. Some DHBs had multiple Alliances, typically for two reasons. The first reason was because a PHO provided primary care services in more than one DHB district resulting in one Alliance that involved the local DHB, the PHO and other local partners in a district and another Alliance with the PHO and all DHBs the PHO provided primary care services in. The second reason was where more than one PHO provided primary care services in a DHB district and, usually owing to their poor relationship and/or history of working together, the PHOs did not agree to forming a single Alliance. The DHB then formed separate Alliances with each of their PHOs.

Each Alliance was governed by an Alliance Leadership Team (ALT). ALT members were appointed by agreement between member DHBs and PHOs and were made up of senior operational and clinical leaders. Some ALTs included local iwi (Māori tribe), community representatives, and other health service providers such as ambulance services, pharmacy, and Māori and Pacific health providers. The most common type of ALT consisted of the DHB Chief Executive and/or planning and funding manager, the PHO Chief Executive, and DHB and PHO clinical leaders.

NZ Alliances were not legal entities and therefore could not commission (fund and contract for) services, nor did they have their own budgets for spending on health care. Instead, Alliances had access to a flexible funding pool, a portion of PHO funding set aside to provide management services, health promotion activities, services to improve access, services to manage chronic care in the community, and support rural health providers, and they could use this funding pool to support new initiatives [ 25 ]. ALTs agreed on a shared vision and goals for their local health system and agreed a work programme with their Alliance partners. DHBs were encouraged to contribute additional funding to the flexible funding pool to support the Alliance work programme [ 25 ].

NZ Alliances adapted over time, depending on local relationships, interactions, behaviours, and their history of working together; they therefore varied across the country in form, function, and maturity. For example, in response to the SLM programme, the three DHBs and the seven PHOs providing health services across the largest city, Auckland, formed a single Alliance.

Two authors (KMS and PBJ) led the development and implementation of the SLM programme from Manatū Hauora and gained first-hand insights and knowledge on the inner workings of NZ Alliances. They identified three clusters of Alliances as a result of their day-to-day interactions over a period of five years and through assessing the improvement plans and monitoring Alliances’ progress with implementation of the SLM programme.

First, there were high-functioning Alliances. These were seen to have an agreed shared vision and common goals for their local system, were clinically led, had an independent chair, and placed people and their communities at the centre of their decision-making. The high-functioning Alliances established Service Level Alliance Teams (SLATs) or other informal working groups, such as consumer councils and clinical leadership forums, as necessary to deliver on the Alliances’ work programme. SLATs were workstreams within the Alliance structure (e.g., child health SLAT, youth health SLAT, rural SLAT) and reported to the Alliance. Each SLAT was made up of a diverse group of people relevant to the workstream that included clinicians, managers, analysts, service users, and Māori and Pacific representatives. SLATs used improvement science methods to identify problems and co-design solutions to improve health service delivery. ALTs considered recommendations from SLATs and then made recommendations to the DHB executive team on activities and services to meet the Alliance vision and goals. Upon agreement, DHBs and PHOs commissioned change through their contractual processes to give effect to the Alliance priorities [ 25 ]. ALTs monitored outcomes of Alliance activities and fed the information back to their member organisations. They refreshed their work programme and membership at least annually.

The second cluster of Alliances existed simply to meet the contractual requirement for there to be an Alliance, and which allowed partner PHOs and their contracted providers access to the flexible funding pool. These Alliances were constrained by their capability to lead change and improvement initiatives and lacked insight as to their strengths and weaknesses. From our observations they did not know what a high-functioning Alliance looked like, how they compared with other Alliances, or what they needed to do to become high-functioning to implement and sustain LST initiatives.

The third cluster of Alliances were dysfunctional, either owing to a lack of leadership from the DHB and/or the PHO or a lack of understanding about the alliancing concept. These Alliances were seen to have had a poor history of working together and low-trust relationships between senior managers of DHBs and PHOs, and between senior managers and clinicians in DHBs and PHOs. They were further hampered by a lack of capability for improvement and therefore lacked awareness of their inability to be functional.

To help the second and third cluster of Alliances, we identified that a maturity matrix had the potential to focus attention on the features that will put the lesser performing Alliances on a developmental pathway to become high functioning. We expected a maturity matrix would enable Alliances to assess their readiness for change, measure improvement progress over time, and to identify their development areas. We aimed to:

Search the literature for existing matrices that could be adopted for the NZ context.

Use the insights from Alliance members to refine and develop a NZ specific maturity matrix.

This research was conducted between November 2018 and December 2019 and included four phases.

Phase 1 – Literature search

The published and grey literature was searched using keywords in the OVID and PUBMED databases using the keywords: maturity audit or checklist or matrix or framework or stages or self-assess or tool or models, stages of organisational maturity, and quality assurance or indicator. The search was limited to English language from 1946 to 2018. Grey literature was searched using Google and visiting known quality improvement websites in the United States, United Kingdom, Canada, Australia, and NZ. These included websites such as the King’s Fund, Nuffield Trust, Institute of Healthcare Improvement, and the Health Quality & Safety Commission. The search was further refined using keywords self-assessment and performance and was limited from 2008 to 2018. A total of 22 articles were identified from which 12 were deemed relevant and examined further.

Three maturity matrices were considered for use in the NZ health system: (i) a self-assessment maturity matrix used in Danish general practices to stimulate quality improvement, which was later refined and used in general practices across the UK and the Europe [ 1 , 2 ]; (ii) the Development for Integrated Care (DMIC), a web-based self- evaluation tool used in Netherlands [ 9 ]; and (iii) the Scaling Integrated Care in Context (SCIROCCO) maturity matrix, an online self-assessment tool used across health and social care systems in the European Union [ 10 ]. Nine other matrices were studied for their conceptual frameworks for defining stages of maturity and measuring progress along the maturity scale that could be adapted for NZ [ 5 , 7 , 8 , 12 , 13 , 14 , 27 , 28 ].

None of the 12 overseas maturity matrices studied were considered suitable to be adopted for use in the NZ health system. Most were limited in their scope to one service or setting, and while the SCIROCCO and DMIC maturity matrices had a multi-disciplinary team focus and contained useful domains, they did not feature rights of indigenous people nor considered an indigenous treaty or partnership such as te Tiriti o Waitangi.

Of the 12 maturity matrices examined, the conceptual framework and the development process to construct a maturity matrix for the NZ health system was adapted from Kirk, Simpson, et al. [ 12 ]. This study provided a simple and practical framework to construct a maturity matrix that described the outcome sought, key indicators to measure the outcome, and description of maturity along the scale of beginning, emerging, established, and excellence. We believed the consensus approach used by Kirk, Simpson, et al. [ 12 ] was a useful and pragmatic way to elicit information from research participants with limited availability who would also be users of the matrix.

Phase 2 – Workshop

Senior clinical and operational leaders from the NZ health system constructed the maturity matrix in a workshop setting ( n  = 10). Participants involved were those with significant experience in the design and implementation of LST initiatives and those charged with making major strategic decisions about resourcing these initiatives in their organisations. These included DHB planning and funding managers, PHO Chief Executives, hospital and primary care clinical leaders, senior managers from Manatū Hauora and the Health Quality and Safety Commission, and Māori and Pacific community leaders who held senior roles in the health system.

The workshop was facilitated by one of the authors (PBJ) who was the SLM Programme clinical lead and had the relevant skills, subject matter expertise and credibility to elicit information from participants. Table  1 shows the framework, adapted from Kirk, Simpson, et al. [ 12 ], that was used to construct the maturity matrix. Participants worked in groups to identify the outcomes, success indicators and the maturity scale for all 10 elements: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whānau (family and extended family), and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. [ 18 , 19 ]. An iterative approach was used to reach consensus among participants.

The first version of the maturity matrix constructed at the workshop was shared with workshop participants following the workshop for their feedback. The second version of the maturity matrix that incorporated post-workshop feedback from participants was used for field testing with the ALTs.

Phase 3 – Field testing

The aim of this phase was to empirically test the maturity matrix with three ALTs that represented the three clusters. The test aimed to determine the extent to which the maturity matrix functioned as a learning tool, helped Alliances see where they were on the improvement journey and identify areas of improvement, acted as a resource for collective thinking and reflection, and if it was easy and practical to use. ALTs were purposefully sampled based on the size of the population the DHB was serving, the number of PHOs providing services in the district, the membership of the ALT, and the knowledge and insights on the maturity and functionality of ALTs from the two authors (KMS and PBJ) involved in the development and implementation of the SLM programme. ALTs 1 and 3 had a broad membership that included senior DHB and PHO managers and clinicians, consumer advocates, and representatives from community health services such as pharmacy, Māori and Pacific providers and district nursing. ALT 1 had one PHO providing primary care services in the district while ALT 3 had multiple PHOs in their Alliance. ALT 2 had limited membership with only DHB and PHO managers and clinicians. The order of input was determined by the ALTs’ availability to meet for the testing.

The testing process was facilitated by one of the co-authors (PBJ) for ALTs 1 and 3. PBJ was unavailable to facilitate testing for ALT 2, so a workshop participant facilitated this session. KS was present at all three ALT testing sessions as an observer. Written consent was provided by all participants. Group discussions were used to collate feedback from participants on the content of the maturity matrix. Ideas for improvement from ALT 1 was tested with ALT 2, and ideas from ALTs 1 and 2 were tested with ALT 3 to discuss different perceptions, consolidate ideas, and to refine the maturity matrix. Some changes were made to the matrix as it progressed through the testing with three ALTs to improve efficacy. The final version of the matrix was shared with all three ALTs. This is fully discussed in the results section.

Phase 4 – Input from Manatū Hauora Māori Health Strategy and Policy (MHSP) team

Following testing with the three ALTs, the maturity matrix was revised and shared with Manatū Hauora MHSP team to seek their feedback on the matrix to ensure that te Tiriti principles were accurately reflected across the maturity scale for all the key elements, with particular attention to two elements: commitment to te Tiriti o Waitangi; and understanding of equity. All feedback was incorporated, and the revised maturity matrix was shared with the MHSP team manager to ensure its accuracy, which was confirmed. Figure  1 summarises how the maturity matrix was developed, tested, and refined over the four phases.

Iterative process for developing and refining the maturity matrix

Results were drawn from phases three and four of the testing (Fig.  1 ). Testing of the maturity matrix with the ALTs was an important part of the research process. It allowed us to check if the matrix covered all the key elements that Alliances believed were important to support them with implementation of LST initiatives; if the level of detail enabled the ALTs to assess their capability; and if the self-assessment process stimulated collective thinking and reflection on contextual factors that enable or constrain Alliances’ success with change efforts.

The version tested with the ALTs (V2) had scores for each maturity stage, i.e., beginning = 0, emerging = 1, established = 2, and excellence = 3. The scores, along with other structural components of the matrix (the conceptual framework, 10 elements, and maturity scales), remained unchanged throughout phase 3. However, there were changes made following each ALT testing to improve the layout (e.g., adding a row to add up scores for each element), descriptive details of elements and their outcomes, and the tone of the matrix to be empowering and inclusive. The iterative approach allowed us to improve the efficacy of the matrix without making substantive changes to the design and core content.

All ALTs rigorously debated the scores, for example, whether they were 1 or 1.5 and some participants found it challenging to look beyond their organisation when scoring. ALT 3 recommended removing the scores to take the focus away from getting the ‘right’ score and focussing on improvement instead. The ALT felt the scores were meaningless and removing them shifted the conversation to factors important for transformation such as, leadership, trust, and relationships.

As a suggestion for the tool , remove the numbers. Because you’re not a two or three , the power is in the words and the discourse and what you’ll end up with is people ending up with is people averaging across three of the sections and say , we’re a 2.33 and that is absolutely meaningless. That’s what happens if you put numbers on these sorts of scales that people do that. So , if you take the numbers off then people have to use words and the words mean something. (ALT 3 participant).

The testing process with ALTs was influenced by local contextual factors. For example, for ALT 1, which had high-trust relationships and a positive history of working together, the focus of testing was on their readiness for change and to identify areas of improvement for the Alliance. The ALT was motivated to use the matrix regularly for continuous improvement. In ALT 2, which did not have a history of working together constructively and where trust was low between the DHB and service providers, the focus was on getting the right score, debating the maturity scale, and whether a larger range of scores was needed to enable Alliances to accurately score. Further, this Alliance placed an emphasis on performance of individual providers or Alliance member organisations rather than a collectively assessment of their Alliance. For example, DHB and PHO members blaming each other for past failures of the Alliance’s efforts. We also observed a lack of trust between DHB/PHO management and clinical leaders, and Manatū Hauora (i.e., suspicion that Alliances’ results from the assessment would be used against them, or at least, for judgement of ALT performance). ALT 3 was initially reticent to use the matrix as they believed they were already high functioning and therefore did not need to self-assess against a tool. We observed a command-and-control leadership style of DHB members in this Alliance. However, once the facilitator started the testing process and encouraged participation from non-DHB members, the ALT completed the self-assessment process, identified areas of improvement and said that they found the tool useful to reflect and stimulate open and honest communication among the members.

The feedback from ALTs helped improved consistency of language and tone used in the matrix to strengthen the intent of maturity matrix as a learning tool that is empowering, inclusive of all health system agents and focuses on wellbeing outcomes (rather than just health outcomes).

The three ALTs agreed that the key elements provided adequate coverage of the areas considered important to the Alliance and that the maturity matrix stimulated collective thinking, reflection, and improvement, “…. certainly , a useful exercise to go through and it makes you think and reflect on where you’ve got to and where you might go to next ” (ALT 3 participant). Table  2 summarises key suggestions from ALTs to improve the matrix.

Feedback from Manatū Hauora Māori health and strategy (MHSP) team

Manatū Hauora MHSP team reviewed version five of the maturity matrix (following testing with ALTs) from an equity and te Tiriti perspective and provided feedback. Overall, their feedback was positive and commended equity and te Tiriti being embedded in the maturity matrix, both as key elements and as indicators of maturity. They commented on the necessity of a maturity matrix such as this to increase the understanding and responsiveness of health system leaders and Alliances towards fulfilling their obligation to te Tiriti and improving Māori health outcomes. Table  3 summaries feedback from the team to strengthen descriptions in the matrix and to strengthen the alignment with Whakamaua, the Māori Health Action Plan.

The final version of the maturity matrix is supplied as Additional file 2 – Table A.

Testing with ALTs revealed that the maturity matrix stimulated collective thinking and reflection for Alliances on key elements and conditions that increase chances of success with implementation of LST initiatives. The matrix acted as a compass for Alliances to see where they were along the maturity scale and identify areas of improvement. The self-assessment process could be used prospectively to gauge readiness for change, in real time when implementing change, and retrospectively to understand failures or partial successes of change efforts, a finding supported by evaluation of maturity matrices used in other settings [ 1 , 3 , 4 , 9 , 11 , 15 ]. A continuous use of the self-reflection process, along with key actions to improve, should build capability of health system leaders and networks to implement and sustain LST initiatives [ 8 , 12 , 13 , 14 , 15 , 27 , 28 ].

Having a non-judgemental facilitator who was familiar with the maturity matrix and had creditability with ALTs proved to be an important enabler of the testing process, a finding supported by evidence in literature [ 4 ]. The facilitator was able to assist with interpretation of the maturity matrix and move teams along if they got stuck on one element or indicator. The facilitator’s credibility was important as this meant that ALT members knew the facilitator, their experience in the health system and the history of their way of working. This knowledge and experience created trust with ALTs and enabled them to assess their strengths and weaknesses sincerely and not worry about presenting their better side or being judged on their discussions or results of their assessment.

The elements, maturity levels, and the self-assessment approach of this maturity matrix can be compared to the two international matrices designed to help organisations understand the local conditions that enable successful delivery of integrated care (the DMIC tool [ 9 ] and the SCIROCCO project [ 10 ]).

The DMIC tool focuses on delivery of integrated care for a condition (such as stroke or diabetes services) at an organisational level. It is comprehensive with a total of 89 elements grouped in nine clusters. This tool is different to our maturity matrix as it is designed for those involved in the delivery of services (co-ordinators, managers and professionals) to develop, evaluate and improve the delivery of integrated care. Ours is designed to implement LST initiatives that are broad and widespread across geographical and professional boundaries, seek paradigm shifts in mindsets and relies on building and sustaining high trust relationships among senior system leaders who oversee design, funding and delivery of health services.

The SCIROCCO is a project co-funded by the Health Programme of the European Union. It is a self-assessment tool that enables those working in the health and social care system across the European Union to assess their readiness to deliver integrated care. The tool aims to help European regions to understand their strengths, weaknesses and potential areas of improvement, adopt and scale up integrated care solutions, facilitate multi-stakeholder discussions on progress and delivery of integrated care and facilitate coaching to help regions and organisations understand the local conditions that enable successful delivery of integrated care. One of the important components of this model is that regions share their experience and assessments with others through a web-based platform. This facilitates sharing of knowledge between the regions.

Elements common across these two matrices and ours include involvement of citizens, a continuous improvement approach, a population health approach to address health inequities, a collaborative way of working, integrated data and analytical capability, integration of health and social care services, and dedicated resources in the form of funding, time, and change management teams.

All three matrices aim to facilitate discussions among multi-disciplinary teams to build a shared understanding of their readiness to implement LST initiatives in the health system and to identify areas of improvement.

We considered adopting the SCIROCCO matrix for NZ, however health system leaders at the workshop felt that while the SCIROCCO domains were useful and related to the key elements they had identified, the assessment scale of the model contained generic statements that did not have sufficient detail to enable self-assessment for Alliances. This matrix did not encompass the NZ context, especially te Tiriti.

A strength of our maturity matrix is that it is specific to the NZ context and is underpinned by the principles of te Tiriti and equity in a multifaceted way by identifying them as separate elements and as indicators for each element. There are frameworks that outline how NZ government agencies should engage with Māori [ 29 , 30 ], however, this maturity matrix is the first that provides a practical tool incorporating te Tiriti principles for collaborative networks to use to implement and sustain LST initiatives in the health system.

The 2022 reform of the NZ health system replaced Alliances with localities. Localities are local networks comprising of local health service providers, social sector agencies, non-government organisations, iwi, local authorities, and consumers and communities [ 31 ]. Te Whatu Ora - Health NZ has a legislative responsibility to ensure all of NZ is covered by a locality, that there is a plan outlining priority outcomes and services for the locality, and that Te Aka Whai Ora – Māori Health Authority and Iwi Māori Partnership Boards are involved in the development, implementation and review of the locality plan [ 32 ]. Localities are responsible for working together to meet local health needs and wellbeing outcomes for their population [ 32 ]. Localities are not legal entities, do not have a budget, and cannot commission services. Like Alliances, localities are mandated from the centre and will be guided by national policies and operating rules. Te Whatu Ora is responsible for commissioning services to deliver on the locality plans.

However, the new Government elected in October 2023 disestablished Te Aka Whai Ora with the intent of moving decisions closer to the community, home and the hapū [ 33 ]. It is unclear how functions of Te Aka Whai Ora will be incorporated across Te Whatu Ora and Manatū Hauora and what will become of localities.

Nonetheless, regardless of how the health systems are structured, collaboration between primary and secondary care, and other providers to improve delivery of health services, outcomes and equity remain important. In a recent NZ study, some DHB and PHO leaders said that Manatū Hauora’s mandate for them to form Alliances resulted in successful implementation of integrated work programmes that shifted siloed thinking [ 34 ].

While those with a positive history of working together or a willingness to share power and resources to improve outcomes for their population will continue to see the benefits of collaborative networks, there are those that will need a push in a form of mandate (push) or incentive (pull). The form and name of these collaborative networks are not important. It is the depth of processes, strong relationships, a high-level of trust, and the ability to work collectively towards a shared vision that add value to and success of these networks. These behaviours cannot be driven from the centre and will require iterative practice cycles that include an ability to collectively self-reflect, assess strengths and weaknesses, and learn. The iterative practice cycles create feedback loops and facilitate conscious and deliberate learning that refines and distributes knowledge gained by experience in a practical way. Collaborative networks, in whichever form they exist, will benefit from tools like this maturity matrix to foster deliberate learning and knowledge sharing to help them perform as cohesive high-functioning networks and to develop and deliver on their plans.

A limitation of this maturity matrix is that it was constructed with a small group of people and tested with three ALTs. More work is required to test, improve, and increase its fidelity, accessibility, and adoption. However, development of this maturity matrix makes an important contribution to implementation science literature in and beyond the NZ health system.

This research broke new ground for NZ health system with the creation of a tool in the form of a self-assessment maturity matrix using the knowledge of senior system leaders to increase chances of success with implementation of LST initiatives. The maturity matrix provides an important tool for collaborative networks to support deliberate learning and knowledge sharing in a practical way. LST initiatives are not short on excellent conceptual and theoretical work on why improvement matters and how networked governance can support change. The contribution made by this work is to profile the value of supporting leaders with tools to manage the hard task of reaching and sustaining a state of maturity across all the elements needed to embed change.

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Acknowledgements

All the research participants from New Zealand. Kristie Saumure, senior librarian at the NZ Ministry of Health who helped with the literature search.Andy Inder who contributed to the early conceptual design of the research and helped with recruitment of research participants for the workshop.

The research was supported by the Victoria University of Wellington research grant 222809 and from the University of Auckland Department of Medicine research fund (H10779).

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Kanchan M. Sharma

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Peter B. Jones

Health Services Research Centre, Faculty of Health, Victoria University of Wellington, Kelburn Parade, Kelburn, Wellington, 6012, New Zealand

Jacqueline Cumming

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KMS collected, analysed, and interpreted all research data and wrote the manuscript. PBJ contributed to conception of the research, shared his knowledge and insights as the clinical lead for the System Level Measures programme, assisted with data collection (by facilitating the workshop), and provided editorial advice for the manuscript. JC and LM were doctorate research supervisors and contributed to the research design and interpretation of data and provided editorial advice for the manuscript. All authors read and approved the final manuscript.

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This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27356). All methods in the study were carried out in accordance with relevant guidelines and regulations, including the Declaration of Helsinki and the New Zealand Health and Disability Ethics Committee. All participants provided written Informed consent prior to participation in this study.

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Sharma, K.M., Jones, P.B., Cumming, J. et al. A self-assessment maturity matrix to support large-scale change using collaborative networks in the New Zealand health system. BMC Health Serv Res 24 , 838 (2024). https://doi.org/10.1186/s12913-024-11284-6

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Effects of consumer suspicion: a review and agenda for future research

• Artemis Panigyraki , Athanasios Polyportis
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Systematically Reviewing the Literature: Building the Evidence for Health Care Quality

There are important research and non-research reasons to systematically review the literature. This article describes a step-by-step process to systematically review the literature along with links to key resources. An example of a graduate program using systematic literature reviews to link research and quality improvement practices is also provided.

Introduction

Systematic reviews that summarize the available information on a topic are an important part of evidence-based health care. There are both research and non-research reasons for undertaking a literature review. It is important to systematically review the literature when one would like to justify the need for a study, to update personal knowledge and practice, to evaluate current practices, to develop and update guidelines for practice, and to develop work related policies. 1 A systematic review draws upon the best health services research principles and methods to address: What is the state of the evidence on the selected topic? The systematic process enables others to reproduce the methods and to make a rational determination of whether to accept the results of the review. An abundance of articles on systematic reviews exist focusing on different aspects of systematic reviews. 2 – 9 The purpose of this article is to describe a step by step process of systematically reviewing the health care literature and provide links to key resources.

Systematic Review Process: Six Key Steps

Six key steps to systematically review the literature are outlined in Table 1 and discussed here.

Systematic Review Steps

1. Formulate the Question and Refine the Topic

When preparing a topic to conduct a systematic review, it is important to ask at the outset, “What exactly am I looking for?” Hopefully it seems like an obvious step, but explicitly writing a one or two sentence statement of the topic before you begin to search is often overlooked. It is important for several reasons; in particular because, although we usually think we know what we are searching for, in truth our mental image of a topic is often quite fuzzy. The act of writing something concise and intelligible to a reader, even if you are the only one who will read it, clarifies your thoughts and can inspire you to ask key questions. In addition, in subsequent steps of the review process, when you begin to develop a strategy for searching the literature, your topic statement is the ready raw material from which you can extract the key concepts and terminology for your strategies. The medical and related health literature is massive, so the more precise and specific your understanding of your information need, the better your results will be when you search.

2. Search, Retrieve, and Select Relevant Articles

The retrieval tools chosen to search the literature should be determined by the purpose of the search. Questions to ask include: For what and by whom will the information be used? A topical expert or a novice? Am I looking for a simple fact? A comprehensive overview on the topic? Exploration of a new topic? A systematic review? For the purpose of a systematic review of journal research in the area of health care, PubMed or Medline is the most appropriate retrieval tool to start with, however other databases may be useful ( Table 2 ). In particular, Google Scholar allows one to search the same set of articles as PubMed/MEDLINE, in addition to some from other disciplines, but it lacks a number of key advanced search features that a skilled searcher can exploit in PubMed/MEDLINE.

Examples of Electronic Bibliographic Databases Specific to Health Care

Note: These databases may be available through university or hospital library systems.

An effective way to search the literature is to break the topic into different “building blocks.” The building blocks approach is the most systematic and works the best in periodical databases such as PubMed/MEDLINE. The “blocks” in a “building blocks” strategy consist of the key concepts in the search topic. For example, let’s say we are interested in researching about mobile phone-based interventions for monitoring of patient status or disease management. We could break the topic into the following concepts or blocks: 1. Mobile phones, 2. patient monitoring, and 3. Disease management. Gather synonyms and related terms to represent each concept and match to available subject headings in databases that offer them. Organize the resulting concepts into individual queries. Run the queries and examine your results to find relevant items and suggest query modifications to improve your results. Revise and re-run your strategy based on your observations. Repeat this process until you are satisfied or further modifications produce no improvements. For example in Medline, these terms would be used in this search and combined as follows: cellular phone AND (ambulatory monitoring OR disease management), where each of the key word phrases is an official subject heading in the MEDLINE vocabulary. Keep detailed notes on the literature search, as it will need to be reported in the methods section of the systematic review paper. Careful noting of search strategies also allows you to revisit a topic in the future and confidently replicate the same results, with the addition of those subsequently published on your topic.

3. Assess Quality

There is no consensus on the best way to assess study quality. Many quality assessment tools include issues such as: appropriateness of study design to the research objective, risk of bias, generalizability, statistical issues, quality of the intervention, and quality of reporting. Reporting guidelines for most literature types are available at the EQUATOR Network website ( http://www.equator-network.org/ ). These guidelines are a useful starting point; however they should not be used for assessing study quality.

4. Extract Data and Information

Extract information from each eligible article into a standardized format to permit the findings to be summarized. This will involve building one or more tables. When making tables each row should represent an article and each column a variable. Not all of the information that is extracted into the tables will end up in the paper. All of the information that is extracted from the eligible articles will help you obtain an overview of the topic, however you will want to reserve the use of tables in the literature review paper for the more complex information. All tables should be introduced and discussed in the narrative of the literature review. An example of an evidence summary table is presented in Table 3 .

Example of an evidence summary table

Notes: BP = blood pressure, HbA1c = Hemoglobin A1c, Hypo = hypoglycemic, I = Internet, NS = not significant, PDA = personal digital assistant, QOL = quality of life, SMBG = self-monitored blood glucose, SMS = short message service, V = voice

5. Analyze and Synthesize Data and information

The findings from individual studies are analyzed and synthesized so that the overall effectiveness of the intervention can be determined. It should also be observed at this time if the effect of an intervention is comparable in different studies, participants, and settings.

6. Write the Systematic Review

The PRISMA 12 and ENTREQ 13 checklists can be useful resources when writing a systematic review. These uniform reporting tools focus on how to write coherent and comprehensive reviews that facilitate readers and reviewers in evaluating the relative strengths and weaknesses. A systematic literature review has the same structure as an original research article:

TITLE : The systematic review title should indicate the content. The title should reflect the research question, however it should be a statement and not a question. The research question and the title should have similar key words.

STRUCTURED ABSTRACT: The structured abstract recaps the background, methods, results and conclusion in usually 250 words or less.

INTRODUCTION: The introduction summarizes the topic or problem and specifies the practical significance for the systematic review. The first paragraph or two of the paper should capture the attention of the reader. It might be dramatic, statistical, or descriptive, but above all, it should be interesting and very relevant to the research question. The topic or problem is linked with earlier research through previous attempts to solve the problem. Gaps in the literature regarding research and practice should also be noted. The final sentence of the introduction should clearly state the purpose of the systematic review.

METHODS: The methods provide a specification of the study protocol with enough information so that others can reproduce the results. It is important to include information on the:

• Eligibility criteria for studies: Who are the patients or subjects? What are the study characteristics, interventions, and outcomes? Were there language restrictions?
• Literature search: What databases were searched? Which key search terms were used? Which years were searched?
• Study selection: What was the study selection method? Was the title screened first, followed by the abstract, and finally the full text of the article?
• Data extraction: What data and information will be extracted from the articles?
• Data analysis: What are the statistical methods for handling any quantitative data?

RESULTS: The results should also be well-organized. One way to approach the results is to include information on the:

• Search results: What are the numbers of articles identified, excluded, and ultimately eligible?
• Study characteristics: What are the type and number of subjects? What are the methodological features of the studies?
• Study quality score: What is the overall quality of included studies? Does the quality of the included studies affect the outcome of the results?
• Results of the study: What are the overall results and outcomes? Could the literature be divided into themes or categories?

DISCUSSION: The discussion begins with a nonnumeric summary of the results. Next, gaps in the literature as well as limitations of the included articles are discussed with respect to the impact that they have on the reliability of the results. The final paragraph provides conclusions as well as implications for future research and current practice. For example, questions for future research on this topic are revealed, as well as whether or not practice should change as a result of the review.

REFERENCES: A complete bibliographical list of all journal articles, reports, books, and other media referred to in the systematic review should be included at the end of the paper. Referencing software can facilitate the compilation of citations and is useful in terms of ensuring the reference list is accurate and complete.

The following resources may be helpful when writing a systematic review:

CEBM: Centre for Evidence-based Medicine. Dedicated to the practice, teaching and dissemination of high quality evidence based medicine to improve health care Available at: http://www.cebm.net/ .

CITING MEDICINE: The National Library of Medicine Style Guide for Authors, Editors, and Publishers. This resource provides guidance in compiling, revising, formatting, and setting reference standards. Available at http://www.ncbi.nlm.nih.gov/books/NBK7265/ .

EQUATOR NETWORK: Enhancing the QUAlity and Transparency Of health Research. The EQUATOR Network promotes the transparent and accurate reporting of research studies. Available at: http://www.equator-network.org/ .

ICMJE RECOMMENDATIONS: International Committee of Medical Journal Editors Recommendations for the Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals. The ICJME recommendations are followed by a large number of journals. Available at: http://www.icmje.org/about-icmje/faqs/icmje-recommendations/ .

PRISMA STATEMENT: Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Authors can utilize the PRISMA Statement checklist to improve the reporting of systematic reviews and meta-analyses. Available at: http://prisma-statement.org .

THE COCHRANE COLLABORATION: A reliable source for making evidence generated through research useful for informing decisions about health. Available at: http://www.cochrane.org/ .

Examples of Systematic Reviews To Link Research and Quality Improvement

Over the past 17 years more than 300 learners, including physicians, nurses, and health administrators have completed a course as part of a Master of Health Administration or a Master of Science in Health Informatics degree at the University of Missouri. An objective of the course is to educate health informatics and health administration professionals about how to utilize a systematic, scientific, and evidence-based approach to literature searching, appraisal, and synthesis. Learners in the course conduct a systematic review of the literature on a health care topic of their choosing that could suggest quality improvement in their organization. Students select topics that make sense in terms of their core educational competencies and are related to their work. The categories of topics include public health, leadership, information management, health information technology, electronic medical records, telehealth, patient/clinician safety, treatment/screening evaluation cost/finance, human resources, planning and marketing, supply chain, education/training, policies and regulations, access, and satisfaction. Some learners have published their systematic literature reviews 14 – 15 . Qualitative comments from the students indicate that the course is well received and the skills learned in the course are applicable to a variety of health care settings.

Undertaking a literature review includes identification of a topic of interest, searching and retrieving the appropriate literature, assessing quality, extracting data and information, analyzing and synthesizing the findings, and writing a report. A structured step-by-step approach facilitates the development of a complete and informed literature review.

Suzanne Austin Boren, PhD, MHA, (above) is Associate Professor and Director of Academic Programs, and David Moxley, MLIS, is Clinical Instructor and Associate Director of Executive Programs. Both are in the Department of Health Management and Informatics at the University of Missouri School of Medicine.

Contact: ude.iruossim.htlaeh@snerob

None reported.

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A review of foot–terrain interaction mechanics for heavy-duty legged robots.

1. Introduction

2. supporting feet of heavy-duty legged robots, 2.1. supporting foot configurations of heavy-duty legged robots, 2.1.1. feet with passive adaptive joints, cylindrical supporting foot configurations, semi-cylindrical supporting foot configurations, spherical supporting foot configurations, hemispherical supporting foot configurations, square supporting foot configurations, special supporting foot configurations, 2.1.2. feet with active driving joints, 2.2. plantar patterns of supporting foot of legged robots, 3. dynamics analysis of robot, 3.1. models of pressure–sinkage for mobile robot, 3.1.1. models for pressure–sinkage at zero slip conditions, a theoretical exploration of the wheeled robots, a theoretical exploration of the wheel-legged composite robots, a theoretical exploration of the legged robots, 3.1.2. models for pressure–sinkage at non-zero slip conditions, 3.2. tangential force models, 4. further research, 4.1. configuration research of biomimetic supporting feet, 4.1.1. application of bionic technology in supporting feet design, 4.1.2. design and distribution of plantar patterns of supporting feet, 4.2. study of effective contact area between irregular foot and dynamic deformable terrain, 4.3. mechanical behavior modeling of interaction between supporting feet and extreme/dynamic environments, 4.3.1. construction of nonlinear tangential force mathematical model, 4.3.2. construction of resultant force mathematical model, 4.4. parameterization research of soil characteristics in extreme/dynamic environments, 4.5. cross-application of multimodal information fusion and foot–terrain interaction mechanics, 5. conclusions, author contributions, conflicts of interest, nomenclature.

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Zhuang, H.; Wang, J.; Wang, N.; Li, W.; Li, N.; Li, B.; Dong, L. A Review of Foot–Terrain Interaction Mechanics for Heavy-Duty Legged Robots. Appl. Sci. 2024 , 14 , 6541. https://doi.org/10.3390/app14156541

Zhuang H, Wang J, Wang N, Li W, Li N, Li B, Dong L. A Review of Foot–Terrain Interaction Mechanics for Heavy-Duty Legged Robots. Applied Sciences . 2024; 14(15):6541. https://doi.org/10.3390/app14156541

Zhuang, Hongchao, Jiaju Wang, Ning Wang, Weihua Li, Nan Li, Bo Li, and Lei Dong. 2024. "A Review of Foot–Terrain Interaction Mechanics for Heavy-Duty Legged Robots" Applied Sciences 14, no. 15: 6541. https://doi.org/10.3390/app14156541

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