journal article review checklist

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How to conduct a review

1. before you begin.

Before you accept or decline an invitation to review, consider the following questions:

Does the article match your  area of expertise ? Only accept if you feel you can provide a high-quality review.

Do you have a potential  conflict of interest opens in new tab/window ? Disclose this to the editor when you respond.

Do you have  time ? Reviewing can be a lot of work — before you commit, make sure you can meet the deadline.

Do you need to find out more about reviewing and the peer review process ? If so, check out the free tutorials on the Elsevier Researcher Academy opens in new tab/window , especially the Certified Peer Reviewer course opens in new tab/window .

Respond to the invitation as soon as you can (even if it is to decline) — a delay in your decision slows down the review process and means more waiting for the author. If you do decline the invitation, it would be helpful if you could provide suggestions for alternative reviewers.

2. Managing your review

Confidential material.

If you accept, you must treat the materials you receive as confidential documents. This means you can’t share them with anyone without prior authorization from the editor. Since peer review is confidential, you also must not share information about the review with anyone without permission from the editors and authors.

Generative AI

Reviewing a scientific paper implies responsibilities that can only be attributed to humans. The critical thinking and assessment required for peer-review are outside the scope of generative AI and AI-assisted technologies, and there is a risk that the technology will generate incorrect, incomplete or biased conclusions. These considerations, together with the principle that submitted manuscripts are to be treated as confidential documents, underpins our Generative AI policies for reviewers and editors :

Reviewers or editors should not upload the manuscript or any part of it into a Generative AI tool, as there is no guarantee of where materials are being sent, saved, or viewed, or how they may be used in the future and this may violate the authors’ confidentiality, proprietary and/or data privacy rights. It may also violate the terms of use of the Generative AI tool.

This confidentiality requirement extends to the peer review report and any other communication about the manuscript, such as the notification or decision letters, as they may also contain confidential information about the manuscript and/or the authors. For this reason, they should not be uploaded into a Generative AI tool, even if it is just for the purpose of improving language and readability.

Generative AI should not be used to assist in the review, evaluation or decision-making process of a manuscript.

Elsevier embraces new AI-driven technologies that support reviewers and editors in the editorial process, such as those used during the screening process to conduct completeness and plagiarism checks and identify suitable reviewers. These identity-protected technologies conform to the  RELX Responsible AI Principles opens in new tab/window . We continue to develop and adopt in-house or licensed technologies that can assist editors and reviewers while respecting confidentiality, proprietary and data privacy rights.

How to log in and access your review

Your review will be managed via an Elsevier submission system such as  Editorial Manager opens in new tab/window . Elsevier journals use different submission systems so there is no one generic login link. To access the paper and deliver your review, click on the link in the invitation email you received which will bring you to the submission/reviewing system.

How to submit a review in Editorial Manager

Article- and journal-specific instructions.

When you sit down to write the review, make sure you familiarize yourself with any journal-specific guidelines (these will be noted in the journal’s guide for authors available on  each journal’s homepage ).

Some of our journals employ “structured peer review” whereby you will receive a series of questions to make it easier for you to convey recommendations for improvement in a structured manner. These questions address different aspects of the manuscript, such as the quality of the data analysis, reproducibility, and the overall clarity of the manuscript. You can find an overview of the core questions (note that journals may also employ additional journal-specific questions).

In any review, please keep the author (instead of the editor) in mind when preparing your replies as your comments will likely be included in the decision letter sent to the author. Also please make sure to reply to the questions in sufficient detail when you are submitting your report in Editorial Manager, to enable the author to most effectively improve the manuscript based on your comments.

If the journal in question does not require you to respond to a list of specific questions, you might find it useful to consider these questions and the below generic points when you are preparing your review report.

Full length research article

Examine the importance of the research question addressed in the manuscript (e.g., are objectives and justification clearly stated?)

Assess the originality (contribution, addition of knowledge to scientific literature or field) of the manuscript

Clearly identify the strengths and weaknesses of the method described in the manuscript

Make specific useful comments on the writing of the manuscript (e.g., writing, organization, figures, etc.)

Offer specific comments on the author’s interpretation of the results and conclusions drawn from the results

In case applicable, comment on the statistics (for example question if they are robust and fit-for-purpose and if the controls and sampling mechanisms are sufficient and well described)

Review article

Discuss the importance of the topic/scope of the review

Assess the originality of the review

Comment on the author's representation of the most relevant recent advances in the field; specifically, determine whether the references are relevant to the topic and cover both historical literature and more recent developments

Offer comments on the writing, organization, tables and figures of the manuscript

Comment on the author's interpretation of the results

In any case, your first task is to read the article. You might consider spot checking major issues by choosing which section to read first. Below we offer some tips about handling specific parts of the paper.

Methodology

If the manuscript you are reviewing is reporting an experiment, check the methods section first. The following cases are considered major flaws and should be flagged:

Unsound methodology

Discredited method

Missing processes known to be influential on the area of reported research

A conclusion drawn in contradiction to the statistical or qualitative evidence reported in the manuscript

For analytical papers examine the sampling report, which is mandated in time-dependent studies. For qualitative research make sure that a systematic data analysis is presented and sufficient descriptive elements with relevant quotes from interviews are listed in addition to the author’s narrative.

For more details and guidance you might find it helpful to view the  information on structured peer review .

Sex and gender reporting

Although it might sound late, given that the research has already been concluded and the data analyzed, the peer review process can still play an important role in ensuring effective, transparent and complete sex and gender reporting .

Assess manuscripts for inclusion of sex-disaggregated data and gender analysis. It could well be that the study was not designed to analyze sex and/or gender. Nevertheless, we recommend referees to consider if sex and gender are relevant to the topic of the study, and whether the study follows relevant guidelines, wherever applicable.

As a general principle,  the SAGER guidelines opens in new tab/window  recommend careful use of the words “sex” and “gender” in order to avoid confusing both terms. The use of common definitions will improve the ability to conduct meta-analyses of published and archived data. The term “sex” should be used as a classification of male or female based on biological distinction to the extent that this is possible to confirm.  Per Heidari et al. opens in new tab/window : "Gender refers to the socially constructed roles, behaviours and identities of female, male and gender-diverse people . It influences how people perceive themselves and each other, how they behave and interact and the distribution of power and resources in society. Gender is usually incorrectly conceptualized as a binary (female/ male) factor. In reality, there is a spectrum of gender identities and expressions defining how individuals identify themselves and express their gender."

Please check if authors have underlined in the methods section whether the sex of participants was defined based on self-report or assigned following external or internal examination of body characteristics, or through genetic testing or other means. In studies of animals, the term “sex” should be used. In cell biological, molecular biological or biochemical experiments, the origin and sex chromosome constitutions of cells or tissue cultures should be stated. If unknown, the reasons should be stated. In other disciplines, such as the testing of devices or technology, authors should explain whether it will be applied or used by all genders and if it has been tested with a user’s gender in mind. Please check whether the authors have done due diligence and reported any previous studies in the introductions that reveal or refute potential sex or gender differences, and the rationale why they have or have not examined these aspects in their study.

If the study included only one sex/gender, ensure this has been justified. If the study included more than one sex/gender, ensure data are reported for all the options that were recorded and that data disaggregated by sex/gender are reported in full, in the main text or in the appendix or supplementary materials. It is important to assess whether the methodology is appropriate to capture possible sex and gender aspects. As a peer reviewer you may request sub-group analysis if deemed necessary and check if all data are provided disaggregated by sex, as a minimum.

Finally, please also pay attention to whether authors have clearly justified in the discussion section any limitation of their study due to lack of any sex- and gender-based analysis and/or the implications on the generalizability and interpretation of their findings in light of that. It could be that the study was not designed to analyze sex and/or gender, nevertheless, it is important to consider if sex and gender are relevant to the topic of the study, and whether the study follows relevant guidelines, wherever applicable.

Research data and visualizations

Once you are satisfied that the methodology is sufficiently robust, examine any data in the form of figures, tables, or images. Authors may add  research data , including   data visualizations ,  to their submission to enable readers to interact and engage more closely with their research after publication. Please be aware that links to data might therefore be present in the submission files. These items should also receive your attention during the peer review process. Manuscripts may also contain database identifiers or accession numbers (e.g., genes) in relation to our  database linking program .

Critical issues in research data, which are considered to be major flaws can be related to insufficient data points, statistically non-significant variations and unclear data tables.

NB for certain types of visualization, preview tools are available, allowing you to inspect how files will display on ScienceDirect if the manuscript is accepted. For other data visualizations, there may be  other ways of inspecting the files .

Ethical considerations

Experiments including patient or animal data should properly be documented. Most journals require ethical approval by the author’s host organization. Please check journal-specific guidelines for such cases (available from the journal’s homepage,  accessible via the journal catalogue opens in new tab/window .

If you don’t spot any major flaws, take a break from the manuscript, giving you time to think. Consider the article from your own perspective. When you sit down to write the review, again make sure you familiarize yourself with any journal-specific guidelines (these will be noted in the journal’s guide for authors).

3. Structuring your review

Your review will help the editor decide whether or not to publish the article. It will also aid the author and allow them to improve their manuscript. Giving your overall opinion and general observations of the article is essential. Your comments should be courteous and constructive, and should not include any ad hominem remarks or personal details including your name (unless the journal you are invited to review for employs  open peer review ).

Providing insight into any deficiencies is important. You should explain and support your judgement so that both editors and authors are able to fully understand the reasoning behind your comments. You should indicate whether your comments are your own opinion or are reflected by the data and evidence.

The journal for which you are reviewing might have a specific format (e.g., questionnaire) or other instructions for how to structure your feedback. Below are some general tips on what to include/consider if no other guidelines apply. View the checklist .

Also, here is  an example of a published peer review report opens in new tab/window .

Your recommendation

When you make a recommendation, it is worth considering the categories the editor will likely use for classifying the article:

Reject (explain your reasoning in your report)

Accept without revision

Revise — either major or minor (explain the revision that is required, and indicate to the editor whether you would be happy to review the revised article); if you are recommending a revision, you must furnish the author with a clear, sound explanation of why this is necessary

Bear in mind that there will be the opportunity to direct separate comments to both the editor and author. Once you are ready to submit your report, follow the instructions in the email  or visit our support center opens in new tab/window  if you encounter any difficulties.

Access the support center opens in new tab/window for further help.

The final decision

The editor ultimately decides whether to accept or reject the article. Elsevier plays no part in this decision. The editor will weigh all views and may call for another opinion or ask the author for a revised paper before making a decision. The submission system provides reviewers with a notification of the final decision, if the journal has opted in to this functionality.

4. After your review

Once you have delivered your review, you might want to make use of  Elsevier’s Reviewer Hub opens in new tab/window  to ensure that you receive credit for your work. The platform provides a private profile page, certificates, editor recognition as well as discounts for Elsevier services.

Do not forget that, even after finalizing your review, you must treat the article and any linked files or data as confidential documents. This means you must not share them or information about the review with anyone without prior authorization from the editor.

Finally, we take the opportunity to thank you sincerely on behalf of the journal, editors and author(s) for the time you have taken to give your valuable input to the article.

Tools & resources

Free Certified Peer Reviewer course on Researcher Academy opens in new tab/window

Reviewer checklist opens in new tab/window

Articles from Reviewers' Update

Want to become a certified peer reviewer?

How to tackle your first review

Paving the way to increase diversity in journals – and research

Ten reasons to accept your (next) invitation to review

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Systematic Reviews: Checklists for review articles

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• Departments of Clinical Epidemiology and Biostatistics and of Family Medicine, McMaster University, Hamilton, Ontario, Canada L8S 4L8.

Preparing a review entails many judgments. The focus of the review must be decided. Studies that are relevant to the focus of the review must be identified, selected for inclusion and critically appraised. Information must be collected and synthesised from the relevant studies, and conclusions must be drawn. Checklists can help prevent important errors in this process. Reviewers, editors, content experts, and users of reviews all have a role to play in improving the quality of published reviews and promoting the appropriate use of reviews by decisionmakers. It is essential that both providers and users appraise the validity of review articles.

Why checklists?

When we think about flying, it is obvious why a checklist is used before take off. Airplanes are complex machines. Things can go wrong with them, and it is preferable that problems are discovered on the ground. However brilliant a pilot and crew might be, most of us would prefer that they use a checklist when preparing for take off, rather than relying on memory.

The need for checklists for review articles is less obvious, but the rationale is much the same. Preparing a review is a complex process entailing many judgements. The focus of the review must be decided. Studies that are relevant to the focus of the review must be identified, selected for inclusion, and critically appraised. Information must be collected and synthesised from the relevant studies, and conclusions must be drawn. Many decisions must be made throughout this process.

It is important to go through this process systematically to avoid errors. Explicitness about how decisions were made enables others to assess how well the process protected against errors. Checklists can help those doing and using reviews to avoid important errors.

Faulty reviews may not seem as perilous as faulty airplanes. However, if people are going to …

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Clinical research articles and case studies reviewer checklist

Use this checklist when you’re reviewing clinical research articles and case studies.

Begin your review with a first read-through for an overall understanding of the paper by using the ‘first read-through’ checklist. Then proceed to a more detailed review with the ‘detailed review – clinical articles’ checklist.

First read through

Is it clear what the authors want to communicate; can you understand the main aims and conclusions of the manuscript?

Are you concerned about the phrasing, the language, or the presentation? Are revisions needed to make it possible to review?

Are the authors reporting on a clinical trial, systematic review, or case study, or is it another type of article ?

How much impact do you think the study could have on how people think about this topic?

How novel or innovative is the work – either methodologically or in terms of the conclusions drawn?

Do you think the overall study design and approach meet the standards of your field?

Do you think the authors’ overall conclusions are in line with the analysis and the results?

Detailed review – Clinical articles

Please note that some of the points below may not apply to all articles. Take into consideration the field, as well as the focus and purpose of the work. 

Title 

Does the title express clearly what the manuscript is about? 

Does it contain the necessary keywords to make it “discoverable” by a reader in your field? 

Does it state the study design?

Does it contain any unnecessary description or jargon?

Would it be clear to someone with language barriers?

Abstract 

Is the abstract a short and clear summary of the aims, key methods, main findings, and conclusions?

Does it contain unnecessary information or undefined acronyms? 

Does it exaggerate or overstate the conclusions or their potential application/impact?

Introduction 

Does the introduction clearly summarize the current state of the topic? 

Does it address the limitations of current knowledge in this field?

Does it explain why the study was necessary?

Does it define the aim of the study and is this consistent with the rest of the manuscript?

Is the research question clear and appropriate?

Clinical trials methods

Are the study design and methods appropriate for the research question? 

Is it clear how participants were recruited and how samples were collected?

Is there any potential bias in the recruitment of participants?

Are the correct blinding and/or controls included?

Do you have any concerns about the ethics or consent processes?

Is there any risk of patients or participants being identified?

Have all the relevant supporting data been included?

Are the data described in the text consistent with the data in the figures and tables?

Have potential confounding factors been considered?

Has any randomization been done correctly?

Is the time frame of the study sufficient to see outcomes?

Is there sufficient power and appropriate statistical analysis?

Are any limitations of the study discussed?

Are any contradictory data discussed?

Does the paper conform to the relevant EQUATOR network guidance ?

If the paper is reporting on a clinical trial, was the study registered in a WHO approved registry prior to the enrollment of participants? Does the protocol of the trial match the registered study?

Systematic reviews 

Are the search terms and inclusion/ exclusion criteria clearly described?

Are the search terms and criteria correct to ensure all the relevant articles are included?

If a meta-analysis has been done, were previous studies combined appropriately?

Case reports 

Does the diagnosis appear to be correct?

Was the treatment reasonable for the diagnosis? 

Are the treatment and outcomes clearly described? 

As far as possible, is the patient anonymous? 

Are the conclusions reasonable and not attempting to generalize to a wider population?

Tables and figures 

Are data presented in a clear and appropriate manner? 

Is the presentation of tables and figures consistent with their description and interpretation in the text?

Do the figure legends and table headings clearly explain what is shown?

Do the figures and tables include measures of uncertainty, such as standard error or confidence intervals, where required? Do they state the sample size?

Do you have any concerns about inappropriate manipulation of data? 

Discussion and conclusion

Do the authors logically explain their findings?

Do the authors compare their findings with current findings in the research field? 

Are the implications of the findings for future research and potential applications discussed? 

Are the conclusions supported by the data presented? 

Are there any key references missing? 

Are there places where the authors cite a review but should cite the original paper?

Are the cited studies an up-to-date representation of current knowledge? 

Final checks – before you submit your report

Have you given a brief summary of the article as you understand it, and highlighted the key messages? 

Have you given positive/general feedback as well as constructive criticism? 

Have you made it clear which of your concerns are major (significant points, essential for publication) or minor (smaller issues, may not be essential for publication)? 

Are your concerns specific, with examples where possible? 

Have you numbered your comments and referred to page/ line numbers in the article to make it easy for the authors to address your points? 

Is your feedback constructive, and focused on the research? 

If you were the authors, would you understand how to improve the manuscript? 

If you were the editor, would the comments be detailed enough to help you to make a decision?

Have you checked the spelling and grammar in your report? 

Have you included your comments in the correct places in the online system – checking that any confidential comments for editors are in the right place – and have you answered all the questions? 

I still have questions

Please read our extensive frequently asked questions for answers to common questions on reviewing a manuscript.

FAQs before review

FAQs during review

FAQs after submitting your report

Further resources

Reviewer training

Peer review checklists

Guidelines for peer reviewers

Page Content

Overview of the review report format, the first read-through, first read considerations, spotting potential major flaws, concluding the first reading, rejection after the first reading, before starting the second read-through, doing the second read-through, the second read-through: section by section guidance, how to structure your report, on presentation and style, criticisms & confidential comments to editors, the recommendation, when recommending rejection, additional resources, step by step guide to reviewing a manuscript.

When you receive an invitation to peer review, you should be sent a copy of the paper's abstract to help you decide whether you wish to do the review. Try to respond to invitations promptly - it will prevent delays. It is also important at this stage to declare any potential Conflict of Interest.

The structure of the review report varies between journals. Some follow an informal structure, while others have a more formal approach.

" Number your comments!!! " (Jonathon Halbesleben, former Editor of Journal of Occupational and Organizational Psychology)

Informal Structure

Many journals don't provide criteria for reviews beyond asking for your 'analysis of merits'. In this case, you may wish to familiarize yourself with examples of other reviews done for the journal, which the editor should be able to provide or, as you gain experience, rely on your own evolving style.

Formal Structure

Other journals require a more formal approach. Sometimes they will ask you to address specific questions in your review via a questionnaire. Or they might want you to rate the manuscript on various attributes using a scorecard. Often you can't see these until you log in to submit your review. So when you agree to the work, it's worth checking for any journal-specific guidelines and requirements. If there are formal guidelines, let them direct the structure of your review.

In Both Cases

Whether specifically required by the reporting format or not, you should expect to compile comments to authors and possibly confidential ones to editors only.

Following the invitation to review, when you'll have received the article abstract, you should already understand the aims, key data and conclusions of the manuscript. If you don't, make a note now that you need to feedback on how to improve those sections.

The first read-through is a skim-read. It will help you form an initial impression of the paper and get a sense of whether your eventual recommendation will be to accept or reject the paper.

Keep a pen and paper handy when skim-reading.

Try to bear in mind the following questions - they'll help you form your overall impression:

• What is the main question addressed by the research? Is it relevant and interesting?
• How original is the topic? What does it add to the subject area compared with other published material?
• Is the paper well written? Is the text clear and easy to read?
• Are the conclusions consistent with the evidence and arguments presented? Do they address the main question posed?
• If the author is disagreeing significantly with the current academic consensus, do they have a substantial case? If not, what would be required to make their case credible?
• If the paper includes tables or figures, what do they add to the paper? Do they aid understanding or are they superfluous?

While you should read the whole paper, making the right choice of what to read first can save time by flagging major problems early on.

Editors say, " Specific recommendations for remedying flaws are VERY welcome ."

Examples of possibly major flaws include:

• Drawing a conclusion that is contradicted by the author's own statistical or qualitative evidence
• The use of a discredited method
• Ignoring a process that is known to have a strong influence on the area under study

If experimental design features prominently in the paper, first check that the methodology is sound - if not, this is likely to be a major flaw.

You might examine:

• The sampling in analytical papers
• The sufficient use of control experiments
• The precision of process data
• The regularity of sampling in time-dependent studies
• The validity of questions, the use of a detailed methodology and the data analysis being done systematically (in qualitative research)
• That qualitative research extends beyond the author's opinions, with sufficient descriptive elements and appropriate quotes from interviews or focus groups

Major Flaws in Information

If methodology is less of an issue, it's often a good idea to look at the data tables, figures or images first. Especially in science research, it's all about the information gathered. If there are critical flaws in this, it's very likely the manuscript will need to be rejected. Such issues include:

• Insufficient data
• Unclear data tables
• Contradictory data that either are not self-consistent or disagree with the conclusions
• Confirmatory data that adds little, if anything, to current understanding - unless strong arguments for such repetition are made

If you find a major problem, note your reasoning and clear supporting evidence (including citations).

After the initial read and using your notes, including those of any major flaws you found, draft the first two paragraphs of your review - the first summarizing the research question addressed and the second the contribution of the work. If the journal has a prescribed reporting format, this draft will still help you compose your thoughts.

The First Paragraph

This should state the main question addressed by the research and summarize the goals, approaches, and conclusions of the paper. It should:

• Help the editor properly contextualize the research and add weight to your judgement
• Show the author what key messages are conveyed to the reader, so they can be sure they are achieving what they set out to do
• Focus on successful aspects of the paper so the author gets a sense of what they've done well

The Second Paragraph

This should provide a conceptual overview of the contribution of the research. So consider:

• Is the paper's premise interesting and important?
• Are the methods used appropriate?
• Do the data support the conclusions?

After drafting these two paragraphs, you should be in a position to decide whether this manuscript is seriously flawed and should be rejected (see the next section). Or whether it is publishable in principle and merits a detailed, careful read through.

Even if you are coming to the opinion that an article has serious flaws, make sure you read the whole paper. This is very important because you may find some really positive aspects that can be communicated to the author. This could help them with future submissions.

A full read-through will also make sure that any initial concerns are indeed correct and fair. After all, you need the context of the whole paper before deciding to reject. If you still intend to recommend rejection, see the section "When recommending rejection."

Once the paper has passed your first read and you've decided the article is publishable in principle, one purpose of the second, detailed read-through is to help prepare the manuscript for publication. You may still decide to recommend rejection following a second reading.

" Offer clear suggestions for how the authors can address the concerns raised. In other words, if you're going to raise a problem, provide a solution ." (Jonathon Halbesleben, Editor of Journal of Occupational and Organizational Psychology)

Preparation

To save time and simplify the review:

• Don't rely solely upon inserting comments on the manuscript document - make separate notes
• Try to group similar concerns or praise together
• If using a review program to note directly onto the manuscript, still try grouping the concerns and praise in separate notes - it helps later
• Note line numbers of text upon which your notes are based - this helps you find items again and also aids those reading your review

Now that you have completed your preparations, you're ready to spend an hour or so reading carefully through the manuscript.

As you're reading through the manuscript for a second time, you'll need to keep in mind the argument's construction, the clarity of the language and content.

With regard to the argument’s construction, you should identify:

• Any places where the meaning is unclear or ambiguous
• Any factual errors
• Any invalid arguments

You may also wish to consider:

• Does the title properly reflect the subject of the paper?
• Does the abstract provide an accessible summary of the paper?
• Do the keywords accurately reflect the content?
• Is the paper an appropriate length?
• Are the key messages short, accurate and clear?

Not every submission is well written. Part of your role is to make sure that the text’s meaning is clear.

Editors say, " If a manuscript has many English language and editing issues, please do not try and fix it. If it is too bad, note that in your review and it should be up to the authors to have the manuscript edited ."

If the article is difficult to understand, you should have rejected it already. However, if the language is poor but you understand the core message, see if you can suggest improvements to fix the problem:

• Are there certain aspects that could be communicated better, such as parts of the discussion?
• Should the authors consider resubmitting to the same journal after language improvements?
• Would you consider looking at the paper again once these issues are dealt with?

On Grammar and Punctuation

Your primary role is judging the research content. Don't spend time polishing grammar or spelling. Editors will make sure that the text is at a high standard before publication. However, if you spot grammatical errors that affect clarity of meaning, then it's important to highlight these. Expect to suggest such amendments - it's rare for a manuscript to pass review with no corrections.

A 2010 study of nursing journals found that 79% of recommendations by reviewers were influenced by grammar and writing style (Shattel, et al., 2010).

1. The Introduction

A well-written introduction:

• Sets out the argument
• Summarizes recent research related to the topic
• Highlights gaps in current understanding or conflicts in current knowledge
• Establishes the originality of the research aims by demonstrating the need for investigations in the topic area
• Gives a clear idea of the target readership, why the research was carried out and the novelty and topicality of the manuscript

Originality and Topicality

Originality and topicality can only be established in the light of recent authoritative research. For example, it's impossible to argue that there is a conflict in current understanding by referencing articles that are 10 years old.

Authors may make the case that a topic hasn't been investigated in several years and that new research is required. This point is only valid if researchers can point to recent developments in data gathering techniques or to research in indirectly related fields that suggest the topic needs revisiting. Clearly, authors can only do this by referencing recent literature. Obviously, where older research is seminal or where aspects of the methodology rely upon it, then it is perfectly appropriate for authors to cite some older papers.

Editors say, "Is the report providing new information; is it novel or just confirmatory of well-known outcomes ?"

It's common for the introduction to end by stating the research aims. By this point you should already have a good impression of them - if the explicit aims come as a surprise, then the introduction needs improvement.

2. Materials and Methods

Academic research should be replicable, repeatable and robust - and follow best practice.

Replicable Research

This makes sufficient use of:

• Control experiments
• Repeated analyses
• Repeated experiments

These are used to make sure observed trends are not due to chance and that the same experiment could be repeated by other researchers - and result in the same outcome. Statistical analyses will not be sound if methods are not replicable. Where research is not replicable, the paper should be recommended for rejection.

Repeatable Methods

These give enough detail so that other researchers are able to carry out the same research. For example, equipment used or sampling methods should all be described in detail so that others could follow the same steps. Where methods are not detailed enough, it's usual to ask for the methods section to be revised.

Robust Research

This has enough data points to make sure the data are reliable. If there are insufficient data, it might be appropriate to recommend revision. You should also consider whether there is any in-built bias not nullified by the control experiments.

Best Practice

During these checks you should keep in mind best practice:

• Standard guidelines were followed (e.g. the CONSORT Statement for reporting randomized trials)
• The health and safety of all participants in the study was not compromised
• Ethical standards were maintained

If the research fails to reach relevant best practice standards, it's usual to recommend rejection. What's more, you don't then need to read any further.

3. Results and Discussion

This section should tell a coherent story - What happened? What was discovered or confirmed?

Certain patterns of good reporting need to be followed by the author:

• They should start by describing in simple terms what the data show
• They should make reference to statistical analyses, such as significance or goodness of fit
• Once described, they should evaluate the trends observed and explain the significance of the results to wider understanding. This can only be done by referencing published research
• The outcome should be a critical analysis of the data collected

Discussion should always, at some point, gather all the information together into a single whole. Authors should describe and discuss the overall story formed. If there are gaps or inconsistencies in the story, they should address these and suggest ways future research might confirm the findings or take the research forward.

4. Conclusions

This section is usually no more than a few paragraphs and may be presented as part of the results and discussion, or in a separate section. The conclusions should reflect upon the aims - whether they were achieved or not - and, just like the aims, should not be surprising. If the conclusions are not evidence-based, it's appropriate to ask for them to be re-written.

5. Information Gathered: Images, Graphs and Data Tables

If you find yourself looking at a piece of information from which you cannot discern a story, then you should ask for improvements in presentation. This could be an issue with titles, labels, statistical notation or image quality.

Where information is clear, you should check that:

• The results seem plausible, in case there is an error in data gathering
• The trends you can see support the paper's discussion and conclusions
• There are sufficient data. For example, in studies carried out over time are there sufficient data points to support the trends described by the author?

You should also check whether images have been edited or manipulated to emphasize the story they tell. This may be appropriate but only if authors report on how the image has been edited (e.g. by highlighting certain parts of an image). Where you feel that an image has been edited or manipulated without explanation, you should highlight this in a confidential comment to the editor in your report.

6. List of References

You will need to check referencing for accuracy, adequacy and balance.

Where a cited article is central to the author's argument, you should check the accuracy and format of the reference - and bear in mind different subject areas may use citations differently. Otherwise, it's the editor’s role to exhaustively check the reference section for accuracy and format.

You should consider if the referencing is adequate:

• Are important parts of the argument poorly supported?
• Are there published studies that show similar or dissimilar trends that should be discussed?
• If a manuscript only uses half the citations typical in its field, this may be an indicator that referencing should be improved - but don't be guided solely by quantity
• References should be relevant, recent and readily retrievable

Check for a well-balanced list of references that is:

• Helpful to the reader
• Fair to competing authors
• Not over-reliant on self-citation
• Gives due recognition to the initial discoveries and related work that led to the work under assessment

You should be able to evaluate whether the article meets the criteria for balanced referencing without looking up every reference.

7. Plagiarism

By now you will have a deep understanding of the paper's content - and you may have some concerns about plagiarism.

Identified Concern

If you find - or already knew of - a very similar paper, this may be because the author overlooked it in their own literature search. Or it may be because it is very recent or published in a journal slightly outside their usual field.

You may feel you can advise the author how to emphasize the novel aspects of their own study, so as to better differentiate it from similar research. If so, you may ask the author to discuss their aims and results, or modify their conclusions, in light of the similar article. Of course, the research similarities may be so great that they render the work unoriginal and you have no choice but to recommend rejection.

"It's very helpful when a reviewer can point out recent similar publications on the same topic by other groups, or that the authors have already published some data elsewhere ." (Editor feedback)

Suspected Concern

If you suspect plagiarism, including self-plagiarism, but cannot recall or locate exactly what is being plagiarized, notify the editor of your suspicion and ask for guidance.

Most editors have access to software that can check for plagiarism.

Editors are not out to police every paper, but when plagiarism is discovered during peer review it can be properly addressed ahead of publication. If plagiarism is discovered only after publication, the consequences are worse for both authors and readers, because a retraction may be necessary.

For detailed guidelines see COPE's Ethical guidelines for reviewers and Wiley's Best Practice Guidelines on Publishing Ethics .

8. Search Engine Optimization (SEO)

After the detailed read-through, you will be in a position to advise whether the title, abstract and key words are optimized for search purposes. In order to be effective, good SEO terms will reflect the aims of the research.

A clear title and abstract will improve the paper's search engine rankings and will influence whether the user finds and then decides to navigate to the main article. The title should contain the relevant SEO terms early on. This has a major effect on the impact of a paper, since it helps it appear in search results. A poor abstract can then lose the reader's interest and undo the benefit of an effective title - whilst the paper's abstract may appear in search results, the potential reader may go no further.

So ask yourself, while the abstract may have seemed adequate during earlier checks, does it:

• Do justice to the manuscript in this context?
• Highlight important findings sufficiently?
• Present the most interesting data?

Editors say, " Does the Abstract highlight the important findings of the study ?"

If there is a formal report format, remember to follow it. This will often comprise a range of questions followed by comment sections. Try to answer all the questions. They are there because the editor felt that they are important. If you're following an informal report format you could structure your report in three sections: summary, major issues, minor issues.

• Give positive feedback first. Authors are more likely to read your review if you do so. But don't overdo it if you will be recommending rejection
• Briefly summarize what the paper is about and what the findings are
• Try to put the findings of the paper into the context of the existing literature and current knowledge
• Indicate the significance of the work and if it is novel or mainly confirmatory
• Indicate the work's strengths, its quality and completeness
• State any major flaws or weaknesses and note any special considerations. For example, if previously held theories are being overlooked

Major Issues

• Are there any major flaws? State what they are and what the severity of their impact is on the paper
• Has similar work already been published without the authors acknowledging this?
• Are the authors presenting findings that challenge current thinking? Is the evidence they present strong enough to prove their case? Have they cited all the relevant work that would contradict their thinking and addressed it appropriately?
• If major revisions are required, try to indicate clearly what they are
• Are there any major presentational problems? Are figures & tables, language and manuscript structure all clear enough for you to accurately assess the work?
• Are there any ethical issues? If you are unsure it may be better to disclose these in the confidential comments section

Minor Issues

• Are there places where meaning is ambiguous? How can this be corrected?
• Are the correct references cited? If not, which should be cited instead/also? Are citations excessive, limited, or biased?
• Are there any factual, numerical or unit errors? If so, what are they?
• Are all tables and figures appropriate, sufficient, and correctly labelled? If not, say which are not

Your review should ultimately help the author improve their article. So be polite, honest and clear. You should also try to be objective and constructive, not subjective and destructive.

You should also:

• Write clearly and so you can be understood by people whose first language is not English
• Avoid complex or unusual words, especially ones that would even confuse native speakers
• Number your points and refer to page and line numbers in the manuscript when making specific comments
• If you have been asked to only comment on specific parts or aspects of the manuscript, you should indicate clearly which these are
• Treat the author's work the way you would like your own to be treated

Most journals give reviewers the option to provide some confidential comments to editors. Often this is where editors will want reviewers to state their recommendation - see the next section - but otherwise this area is best reserved for communicating malpractice such as suspected plagiarism, fraud, unattributed work, unethical procedures, duplicate publication, bias or other conflicts of interest.

However, this doesn't give reviewers permission to 'backstab' the author. Authors can't see this feedback and are unable to give their side of the story unless the editor asks them to. So in the spirit of fairness, write comments to editors as though authors might read them too.

Reviewers should check the preferences of individual journals as to where they want review decisions to be stated. In particular, bear in mind that some journals will not want the recommendation included in any comments to authors, as this can cause editors difficulty later - see Section 11 for more advice about working with editors.

You will normally be asked to indicate your recommendation (e.g. accept, reject, revise and resubmit, etc.) from a fixed-choice list and then to enter your comments into a separate text box.

Recommending Acceptance

If you're recommending acceptance, give details outlining why, and if there are any areas that could be improved. Don't just give a short, cursory remark such as 'great, accept'. See Improving the Manuscript

Recommending Revision

Where improvements are needed, a recommendation for major or minor revision is typical. You may also choose to state whether you opt in or out of the post-revision review too. If recommending revision, state specific changes you feel need to be made. The author can then reply to each point in turn.

Some journals offer the option to recommend rejection with the possibility of resubmission – this is most relevant where substantial, major revision is necessary.

What can reviewers do to help? " Be clear in their comments to the author (or editor) which points are absolutely critical if the paper is given an opportunity for revisio n." (Jonathon Halbesleben, Editor of Journal of Occupational and Organizational Psychology)

Recommending Rejection

If recommending rejection or major revision, state this clearly in your review (and see the next section, 'When recommending rejection').

Where manuscripts have serious flaws you should not spend any time polishing the review you've drafted or give detailed advice on presentation.

Editors say, " If a reviewer suggests a rejection, but her/his comments are not detailed or helpful, it does not help the editor in making a decision ."

In your recommendations for the author, you should:

• Give constructive feedback describing ways that they could improve the research
• Keep the focus on the research and not the author. This is an extremely important part of your job as a reviewer
• Avoid making critical confidential comments to the editor while being polite and encouraging to the author - the latter may not understand why their manuscript has been rejected. Also, they won't get feedback on how to improve their research and it could trigger an appeal

Remember to give constructive criticism even if recommending rejection. This helps developing researchers improve their work and explains to the editor why you felt the manuscript should not be published.

" When the comments seem really positive, but the recommendation is rejection…it puts the editor in a tough position of having to reject a paper when the comments make it sound like a great paper ." (Jonathon Halbesleben, Editor of Journal of Occupational and Organizational Psychology)

Visit our Wiley Author Learning and Training Channel for expert advice on peer review.

Watch the video, Ethical considerations of Peer Review

How to Review a Journal Article

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

IMPORTANT NOTE!!

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

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

Questions to Consider

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

Evaluating Purpose and Argument

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

Evaluating the Presentation/Organization of Information

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

Evaluating Methods

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

Evaluating Data

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• En español – ExME
• Em português – EME

Critical Appraisal: A Checklist

Posted on 6th September 2016 by Robert Will

Critical appraisal of scientific literature is a necessary skill for healthcare students. Students can be overwhelmed by the vastness of search results. Database searching is a skill in itself, but will not be covered in this blog. This blog assumes that you have found a relevant journal article to answer a clinical question. After selecting an article, you must be able to sit with the article and critically appraise it. Critical appraisal of a journal article is a literary and scientific systematic dissection in an attempt to assign merit to the conclusions of an article. Ideally, an article will be able to undergo scrutiny and retain its findings as valid.

The specific questions used to assess validity change slightly with different study designs and article types. However, in an attempt to provide a generalized checklist, no specific subtype of article has been chosen. Rather, the 20 questions below should be used as a quick reference to appraise any journal article. The first four checklist questions should be answered “Yes.” If any of the four questions are answered “no,” then you should return to your search and attempt to find an article that will meet these criteria.

Critical appraisal of…the Introduction

• Does the article attempt to answer the same question as your clinical question?
• Is the article recently published (within 5 years) or is it seminal (i.e. an earlier article but which has strongly influenced later developments)?
• Is the journal peer-reviewed?
• Do the authors present a hypothesis?

Critical appraisal of…the Methods

• Is the study design valid for your question?
• Are both inclusion and exclusion criteria described?
• Is there an attempt to limit bias in the selection of participant groups?
• Are there methodological protocols (i.e. blinding) used to limit other possible bias?
• Do the research methods limit the influence of confounding variables?
• Are the outcome measures valid for the health condition you are researching?

Critical appraisal of…the Results

• Is there a table that describes the subjects’ demographics?
• Are the baseline demographics between groups similar?
• Are the subjects generalizable to your patient?
• Are the statistical tests appropriate for the study design and clinical question?
• Are the results presented within the paper?
• Are the results statistically significant and how large is the difference between groups?
• Is there evidence of significance fishing (i.e. changing statistical tests to ensure significance)?

Critical appraisal of…the Discussion/Conclusion

• Do the authors attempt to contextualise non-significant data in an attempt to portray significance? (e.g. talking about findings which had a  trend  towards significance as if they were significant).
• Do the authors acknowledge limitations in the article?
• Are there any conflicts of interests noted?

This is by no means a comprehensive checklist of how to critically appraise a scientific journal article. However, by answering the previous 20 questions based on a detailed reading of an article, you can appraise most articles for their merit, and thus determine whether the results are valid. I have attempted to list the questions based on the sections most commonly present in a journal article, starting at the introduction and progressing to the conclusion. I believe some of these items are weighted heavier than others (i.e. methodological questions vs journal reputation). However, without taking this list through rigorous testing, I cannot assign a weight to them. Maybe one day, you will be able to critically appraise my future paper:  How Online Checklists Influence Healthcare Students’ Ability to Critically Appraise Journal Articles.

Feature Image by Arek Socha from Pixabay

Robert Will

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No Comments on Critical Appraisal: A Checklist

Hi Ella, I have found a checklist here for before and after study design: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools and you may also find a checklist from this blog, which has a huge number of tools listed: https://s4be.cochrane.org/blog/2018/01/12/appraising-the-appraisal/

What kind of critical appraisal tool can be used for before and after study design article? Thanks

Hello, I am currently writing a book chapter on critical appraisal skills. This chapter is limited to 1000 words so your simple 20 questions framework would be the perfect format to cite within this text. May I please have your permission to use your checklist with full acknowledgement given to you as author? Many thanks

Thank you Robert, I came across your checklist via the Royal College of Surgeons of England website; https://www.rcseng.ac.uk/library-and-publications/library/blog/dissecting-the-literature-the-importance-of-critical-appraisal/ . I really liked it and I have made reference to it for our students. I really appreciate your checklist and it is still current, thank you.

Hi Kirsten. Thank you so much for letting us know that Robert’s checklist has been used in that article – that’s so good to see. If any of your students have any comments about the blog, then do let us know. If you also note any topics that you would like to see on the website, then we can add this to the list of suggested blogs for students to write about. Thank you again. Emma.

i am really happy with it. thank you very much

A really useful guide for helping you ask questions about the studies you are reviewing BRAVO

Dr.Suryanujella,

Thank you for the comment. I’m glad you find it helpful.

Feel free to use the checklist. S4BE asks that you cite the page when you use it.

I have read your article and found it very useful , crisp with all relevant information.I would like to use it in my presentation with your permission

That’s great thank you very much. I will definitely give that a go.

I find the MEAL writing approach very versatile. You can use it to plan the entire paper and each paragraph within the paper. There are a lot of helpful MEAL resources online. But understanding the acronym can get you started.

M-Main Idea (What are you arguing?) E-Evidence (What does the literature say?) A-Analysis (Why does the literature matter to your argument?) L-Link (Transition to next paragraph or section)

I hope that is somewhat helpful. -Robert

Hi, I am a university student at Portsmouth University, UK. I understand the premise of a critical appraisal however I am unsure how to structure an essay critically appraising a paper. Do you have any pointers to help me get started?

Thank you. I’m glad that you find this helpful.

Very informative & to the point for all medical students

How can I know what is the name of this checklist or tool?

This is a checklist that the author, Robert Will, has designed himself.

Thank you for asking. I am glad you found it helpful. As Emma said, please cite the source when you use it.

Greetings Robert, I am a postgraduate student at QMUL in the UK and I have just read this comprehensive critical appraisal checklist of your. I really appreciate you. if I may ask, can I have it downloaded?

Please feel free to use the information from this blog – if you could please cite the source then that would be much appreciated.

Robert Thank you for your comptrehensive account of critical appraisal. I have just completed a teaching module on critical appraisal as part of a four module Evidence Based Medicine programme for undergraduate Meducal students at RCSI Perdana medical school in Malaysia. If you are agreeable I would like to cite it as a reference in our module.

Anthony, Please feel free to cite my checklist. Thank you for asking. I hope that your students find it helpful. They should also browse around S4BE. There are numerous other helpful articles on this site.

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Checklists for review articles.

Preparing a review entails many judgments. The focus of the review must be decided. Studies that are relevant to the focus of the review must be identified, selected for inclusion and critically appraised. Information must be collected and synthesised from the relevant studies, and conclusions must be drawn. Checklists can help prevent important errors in this process. Reviewers, editors, content experts, and users of reviews all have a role to play in improving the quality of published reviews and promoting the appropriate use of reviews by decisionmakers. It is essential that both providers and users appraise the validity of review articles.

Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (890K), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References .

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

• Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts. Treatments for myocardial infarction. JAMA. 1992 Jul 8; 268 (2):240–248. [ PubMed ] [ Google Scholar ]
• L'Abbé KA, Detsky AS, O'Rourke K. Meta-analysis in clinical research. Ann Intern Med. 1987 Aug; 107 (2):224–233. [ PubMed ] [ Google Scholar ]
• Oxman AD, Guyatt GH. Guidelines for reading literature reviews. CMAJ. 1988 Apr 15; 138 (8):697–703. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. Incorporating variations in the quality of individual randomized trials into meta-analysis. J Clin Epidemiol. 1992 Mar; 45 (3):255–265. [ PubMed ] [ Google Scholar ]
• Gøtzsche PC. Methodology and overt and hidden bias in reports of 196 double-blind trials of nonsteroidal antiinflammatory drugs in rheumatoid arthritis. Control Clin Trials. 1989 Mar; 10 (1):31–56. [ PubMed ] [ Google Scholar ]
• Emerson JD, Burdick E, Hoaglin DC, Mosteller F, Chalmers TC. An empirical study of the possible relation of treatment differences to quality scores in controlled randomized clinical trials. Control Clin Trials. 1990 Oct; 11 (5):339–352. [ PubMed ] [ Google Scholar ]
• Laird NM, Mosteller F. Some statistical methods for combining experimental results. Int J Technol Assess Health Care. 1990; 6 (1):5–30. [ PubMed ] [ Google Scholar ]
• Eddy DM. Clinical decision making: from theory to practice. Anatomy of a decision. JAMA. 1990 Jan 19; 263 (3):441–443. [ PubMed ] [ Google Scholar ]
• Grady D, Rubin SM, Petitti DB, Fox CS, Black D, Ettinger B, Ernster VL, Cummings SR. Hormone therapy to prevent disease and prolong life in postmenopausal women. Ann Intern Med. 1992 Dec 15; 117 (12):1016–1037. [ PubMed ] [ Google Scholar ]
• Yusuf S, Wittes J, Probstfield J, Tyroler HA. Analysis and interpretation of treatment effects in subgroups of patients in randomized clinical trials. JAMA. 1991 Jul 3; 266 (1):93–98. [ PubMed ] [ Google Scholar ]
• Oxman AD, Guyatt GH. A consumer's guide to subgroup analyses. Ann Intern Med. 1992 Jan 1; 116 (1):78–84. [ PubMed ] [ Google Scholar ]
• Sackett DL. Second thoughts. Proposals for the health sciences--I. Compulsory retirement for experts. J Chronic Dis. 1983; 36 (7):545–547. [ PubMed ] [ Google Scholar ]
• Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992 Nov 4; 268 (17):2420–2425. [ PubMed ] [ Google Scholar ]
• Guyatt GH, Rennie D. Users' guides to the medical literature. JAMA. 1993 Nov 3; 270 (17):2096–2097. [ PubMed ] [ Google Scholar ]
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Empowering Peer Reviewers: A roadmap for effective manuscript evaluation

Peer review has always been an essential part of scholarly publishing; serving as a rigorous quality control mechanism. It ensures that research articles meet high standards of accuracy, validity, and add value to existing knowledge. As a peer reviewer, you bear the responsibility of upholding research integrity by providing critical feedback – one that helps authors enhance the quality and impact of their work for the advancement in research.

Remember that your role as a peer reviewer is beyond identifying flaws; it is about contributing to the advancement of knowledge itself. Your comments and insights can either make or break the development of emerging theories. The impact of your work as a reviewer extends far beyond the manuscript you evaluate; it influences the entire scientific discourse.

Hence, it is crucial to ensure that a peer review follows a thorough process without any errors. So, here’s your trusty companion — The Peer Review Checklist by Enago Academy. Divided into two parts, it caters to both newcomers and seasoned reviewers. Part 1 guides new reviewers, ensuring they embark on their journey with confidence. Part 2, the Comprehensive Assessment Toolkit, equips experienced reviewers with advanced strategies for in-depth evaluations. Whether you are a seasoned expert or new to the role of a peer reviewer, this checklist serves as a structured tool to assess manuscripts across various disciplines and article types. It ensures you uphold the highest standards of rigor, ethics, and excellence in your role as a peer reviewer. Elevate your role as a peer reviewer with this essential resource.

Click on the links below to download the checklists for FREE!

Part – 1: The Peer Review Checklist: A beginner’s guide

Part – 2: The Peer Review Checklist: Comprehensive assessment toolkit

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Open Access

Peer-reviewed

Research Article

Factors influencing the uptake of public health interventions delivery by community pharmacists: A systematic review of global evidence

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya

Roles Conceptualization, Methodology

Roles Conceptualization, Supervision, Writing – review & editing

Affiliations Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom

Roles Supervision

Affiliation Department of Health Services, Policy, Planning, Management, and Economics, School of Public Health, University for Development Studies, Tamale, Ghana

Roles Conceptualization, Supervision, Validation, Writing – review & editing

Affiliations Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Program, Nairobi, Kenya, Liverpool School of Tropical Medicine, Liverpool, United Kingdom

• Audrey Mumbi, 
• Peter Mugo, 
• Edwine Barasa, 
• Gilbert Abotisem Abiiro, 
• Jacinta Nzinga

• Published: August 1, 2024
• https://doi.org/10.1371/journal.pone.0298713
• Reader Comments

Community pharmacies are the first point of contact for most people seeking treatment for minor illnesses globally. In recent years, the role of community pharmacists has evolved, and they play a significant role in the delivery of public health interventions (PHIs) aimed at health promotion and prevention such as smoking cessation services, weight management services, HIV prevention, and vaccination. This review aims to explore the evidence on the factors that influence community pharmacists to take up the role of delivery of such interventions.

Three electronic databases namely, Embase (1947-December 2023), Medline (1975-December 2023), and Scopus (1823-December 2023) were searched for relevant literature from the inception of the database to December 2023. Reference lists of included articles were also searched for relevant articles. A total of 22 articles were included in the review based on our inclusion and exclusion criteria. The data were analyzed and synthesized using a thematic approach to identify the factors that influence the community pharmacist’s decision to take up the role of PHI delivery. Reporting of the findings was done according to the PRISMA checklist.

The search identified 10,927 articles of which 22 were included in the review. The main factors that drive the delivery of PHIs by community pharmacists were identified as; training and continuous education, remuneration and collaboration with other healthcare professionals. Other factors included structural and workflow adjustments and support from the government and regulatory bodies.

Conclusions

Evidence from this review indicates that the decision to expand the scope of practice of community pharmacists is influenced by various factors. Incorporating these factors into the design of policies and public health programs is critical for the successful integration of community pharmacists in the delivery of broader public health to meet the rising demand for health care across health systems.

Citation: Mumbi A, Mugo P, Barasa E, Abiiro GA, Nzinga J (2024) Factors influencing the uptake of public health interventions delivery by community pharmacists: A systematic review of global evidence. PLoS ONE 19(8): e0298713. https://doi.org/10.1371/journal.pone.0298713

Editor: Naeem Mubarak, Lahore Medical and Dental College, PAKISTAN

Received: January 29, 2024; Accepted: May 28, 2024; Published: August 1, 2024

Copyright: © 2024 Mumbi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its supporting information files.

Funding: This research was funded in whole, or in part by the Wellcome Trust 223658/Z/21/Z For the purpose of open access, the author has applied a CC BY public copyright license to any Author Accepted Manuscript version arising from this submission.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Community pharmacies are the first point of contact with the health system for most people seeking treatment for minor illnesses globally [ 1 – 3 ]. They are easily accessible, widely distributed, provide quicker services, open for longer hours, and are relatively cheaper than other private health facilities [ 4 – 6 ]. Additionally, they provide a more casual setting for individuals by offering services over the counter for those who do not wish to seek health services from health facilities [ 7 ].

The traditional role of community pharmacists has mainly been product-oriented. This entails dispensing prescription and non-prescription medicine, however, this role has evolved to include the provision of various Public Health Interventions (PHIs) due to the increased health demands of the population [ 1 ]. This evolution has been endorsed by the International Pharmaceutical Federation (FIP) and is recognized in several income high-income countries such as Australia, the United States, United Kingdom where it has been integrated into existing healthcare models [ 8 ]. Low and middle-income countries (LMICs) on the other hand are also recognizing the contribution of community pharmacists to public health however, this role is not well integrated into the broader health system.

Public health entails three main domains; health improvement, health protection, and health service delivery and community pharmacists provide PHIs which contribute greatly to all three domains [ 9 ]. These interventions include smoking cessation services such as Nicotine Replacement Therapy (NRT) and counselling services [ 10 ]; provision of interventions aimed at promoting health and well-being through changing lifestyle habits, healthy weight management services, advice on healthy living, and participation in health promotion campaigns [ 11 , 12 ]. In regards to health protection, community pharmacists offer disease control measures, screening for risk factors for non-communicable diseases such as Cardiovascular Disease (CVD) [ 13 , 14 ], Sexually Transmitted Infections (STIs) screening [ 15 ], Human Immune deficiency Virus (HIV) screening [ 16 ], provision of immunization services and communicating information on threats to health to patients and the public in general [ 9 ]. Health service quality entails the provision of innovative quality pharmacy services to improve health outcomes for instance through medication therapy management services and supporting the safe and effective use of medicine [ 9 ]. This review mainly focuses on public health interventions aimed at promoting health and preventing disease as the community pharmacists’ roles are clearly defined in literature.

The delivery of PHIs through community pharmacies not only leads to improved health outcomes but also reduces health inequalities. This is because they are accessible to individuals who lack the resources to access conventional healthcare providers [ 17 ]. It also reduces the burden on the health system in two folds; first, it reduces the burden on healthcare providers in facilities with a shortage of healthcare workers [ 18 ]. Second, by provision of vaccine and screening services, it reduces the burden of preventable disease in the health care system [ 19 ]. Furthermore, the provision of these interventions through community pharmacies leads to reduction of medical treatment costs which leads to savings in healthcare costs [ 20 ].

Despite the evidence of such benefits, there is a gap in knowledge on the factors driving community pharmacists to take up this role. Understanding the factors that influence their decision to take up the role is essential for the design of policies in a manner that aligns with their incentives and for the successful implementation of PHI programs. This review therefore aims to explore the factors that influence the community pharmacist’s decision to take up the extended role of PHI delivery.

Research question

What are the factors that influence community pharmacists’ decision to take up the role of PHI delivery?

The objective of this study was to systematically review available global evidence on the factors that influence community pharmacists’ decision to take up the role of delivery of Public Health Interventions.

A protocol for our review can be found in the Open Science Framework [ 21 ]. We conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [ 22 ] and adhered to the PRISMA checklist S1 Checklist .

Search strategy

We searched the literature from July-December 2023 in 3 databases namely: Embase (1947-December 2023), Scopus (18230December 2023), and Medline (1975-December 2023) to identify relevant literature. Both Medical Subject Heading (Mesh) and keywords, Boolean and proximity (e.g. adj2) operators, truncations (*) were used in the search. The search terms used were: “Community Pharmacy” “Private pharmacy” OR “Retail pharmacy” AND “preventive health services” OR “public health services” OR “health promotion” OR “screening” OR “testing” OR “Case finding” AND “cardiovascular disease” OR “Diabetes” OR “Blood pressure” OR “drug use” OR “substance use” OR “mental health” OR “sexual health” OR “vaccination” OR “Immunization” OR “Family planning” OR “Contraception”. This search strategy and terms were modified for Embase and Scopus as appropriate. The search strategy was discussed with the librarian for inclusion sensitivity. Detailed search strategy can be found in the supplementary information S1 Table .

We also searched for relevant literature from reference lists of identified studies. The search results from each database were uploaded to End Note 2.0 reference software and duplicates were removed.

Study selection

Studies were eligible for inclusion if they: 1) reported on interventions delivered in community pharmacies, which are also referred to as private or retail pharmacies. Community pharmacies refer to generally small to medium-sized businesses providing typical pharmacy services such as filling of prescriptions, over-the-counter products, and point-of-care (POC) testing or self-testing kits for common diseases. We included studies conducted in both chain and independent pharmacies. 2) reported on factors that influence the uptake of the delivery of PHIs. 3) interventions were provided by registered pharmacists and/or pharmacy technicians (in some cases referred to as pharmacy assistants); 4) were published in the English language.

Studies were excluded if they: 1) reported on interventions delivered in pharmacies in hospitals, clinics and online pharmacies; 2) reported on interventions aimed at antimicrobial resistance as this is beyond the scope of the broader study, improving treatment and management of diseases, self-medication or management interventions without screening or diagnosis components; 3) Book chapters, reviews, commentaries, letters to the editor, and conference papers.

Data screening, extraction and analysis

Titles and abstracts were screened by AM in two steps. First, following the removal of duplicates, titles and abstracts were screened against the inclusion and exclusion criteria. Studies that did not meet the criteria were deemed to be irrelevant and excluded. Second, the full articles of the potentially relevant studies were retrieved, and a detailed screening was conducted based on the inclusion and exclusion criteria.

Relevant data from the selected articles were extracted into Ms. Excel by AM with accuracy checks performed on selected articles by JN and any conflict was resolved through discussion of the justification of the inclusion and exclusion criteria. We extracted information on the study title, first author, year of study, study country, PHI and factors influencing the uptake of PHI delivery.

The coding process was conducted manually in MS Excel. Data were analyzed using thematic analysis which entailed 4 phases [ 23 ]. Phase 1: familiarization with the identified articles through reading and re-reading, Phase 2: generation of initial codes that were used to develop the coding framework, Phase 3: coding the contents of the articles onto the coding framework, and Phase 4: generation of themes by identifying patterns and relationships across the identified codes. We used established themes to summarize the findings descriptively and summary tables.

Quality assessment

The studies were assessed for quality independently by AM using the Critical Appraisal Skills Programme (CASP) which uses a standardized checklist to assess the adequacy, trustworthiness, and relevance of the evidence reported in the articles [ 24 , 25 ]. The CASP checklist evaluates articles on methodological quality, participant recruitment, data collection and analysis, bias, ethical considerations, and the value of the research. For each of the studies a score of 1 (Response of Yes) or 0 (response of No/Can’t tell) was assigned to each of the items assessed, with a maximum score of 10. We classified studies as high (8–10) moderate (6–8) or low (4–6). Studies that scored 6 and above were included in the review. (See S1 Table for more information). The appraisal tool for Cross-Sectional Studies (AXIS tool) to assess for quality of cross-sectional studies [ 26 ]. AXIS task contains 20 Yes, No/Somewhat questions to assess the aims, methods, results, and conclusion reported in each study. A score greater than 75% is considered to be high quality, a score of 60%-70% is considered to be of moderate quality and a score less than 60% is considered to be of low quality. The information on quality assessment is in the supplementary files S1 File .

Our search yielded 10,927 articles from the three databases, of these 4,434 were duplicates, 6,436 were excluded after the screening of the title and abstracts,157 articles were included in the full-text review, and we included 22 studies in the final review. This selection process is demonstrated in Fig 1 .

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0298713.g001

Characteristics of the selected studies

Table 1 shows the characteristics of the studies included in the review. Twenty-two studies were selected for the review. Out of the 22, 4 studies were conducted in United Kingdom (UK), 2 in United States of America (USA), 3 in Australia, 4 in Canada, and 1 from Nigeria, Poland, Portugal, Austria, Lebanon, Malaysia, Pakistan, United Arab Emirates (UAE) and Qatar. The main public health interventions identified from the review were; vaccination services (6), healthy weight management (4), Emergency hormonal Contraceptives (EHC) (4), chlamydia screening (2), Cardiovascular screening (CVS) (2), HIV services (2), Health education (1), Pre-exposure prophylaxis screening (PrEP) (1), Diabetes screening (1).

https://doi.org/10.1371/journal.pone.0298713.t001

Quality of evidence

All the included studies had clear statements on the aims, methods used, research design and data collection procedures, data analysis and made significant contributions to existing knowledge and discussed the transferability of the findings to other contexts. However, the relationship between the researchers and participants was not adequately described in 14/16 articles. It was therefore difficult to determine how this relationship may have impacted the findings. For cross-sectional studies assessed using the AXIS tool, the studies met most of the criteria on the tool. However, 5/6 of the studies did not report on measures taken to address non-response bias.

Despite this, we decided to include all the studies in the review as they adequately met the inclusion criteria and contributed to our review objective. (The full details are in the S2 and S3 Tables in S1 File ).

Synthesis of results

We identified 6 major themes from this review: training and education (19/22), structural and organizational adjustments (11/22), remuneration (9/22), collaboration with other health care professionals (6/22), support from government and professional bodies (4/22).

Training and continuous education

Pharmacists are qualified to provide health care services, however, the reviewed literature suggests that they feel incompetent in taking up this role and would benefit from additional training on the provision of specific PHIs [ 27 , 29 – 35 , 37 – 47 ]. Pharmacists in the UK received training on how to deliver chlamydia testing by attending a sexual health learning training session and through the completion of an online learning module [ 27 ]. Elsewhere, Moore S et al found that 70% (21/30) of pharmacists acquired health promotion training in their undergraduate degree and informally through reading articles in professional journals rather than attending a formal training program [ 29 ]. In Canada, vaccination training was provided to pharmacists through online learning modules and live day training [ 41 ]. Almukdad et al, exploring the attitudes of pharmacists in the role of offering weight management services found that pharmacists would benefit from regular and structural training to promote their expertise [ 34 ]. Pharmacists in Malaysia reported they would prefer to have at least 1 or 2 days of short training workshops [ 35 ].

Pharmacists in Pakistan and Poland expressed a gap in formal training in the undergraduate curriculum and they recommended the inclusion of more practical training sessions in the curriculum [ 30 , 31 ]. They also expressed concern about the high fees of the courses, and they suggested the need for funding opportunities for free courses. Community pharmacists in Australia and Malaysia reported willingness to provide vaccination services after having received additional short training that covers aspects of needle size gauge and landmarking [ 41 ], vaccine storage, technique, and handling of emergency cases [ 35 ], with a 2 year renewal interval [ 43 ]. Training was suggested for both pharmacists and their assistants in 4 studies to facilitate task shifting of responsibilities [ 29 , 33 , 41 , 44 ].

Remuneration

The provision of PHIs was viewed as an additional workload on top of the dispensing and pharmaceutical-based services and remuneration is a pre-requisite for further activity [ 28 , 29 , 31 , 33 – 35 , 40 , 41 ]. Pharmacists in Poland expressed they would like to be compensated through an increase in salary to motivate them to take up the role of a health educator [ 31 ]. Elsewhere, pharmacists in the UK reported they would prefer to be compensated through a fee-for-service model by the Kingston & Richmond Family Health Service Authority (FHSA) [ 29 ]. Pharmacy assistants in Australia viewed remuneration as a tangible recognition for the provision of Chlamydia screening and participation in the training program, in addition to receiving a certificate [ 33 ]. None of the other studies reported on the modes of remuneration but there was consensus that remuneration was a means of motivating pharmacists. For instance, pharmacists in the UAE reported that remuneration would motivate them to screen more clients for STIs [ 28 ]. There was also an agreement among pharmacists in Australia and the UAE that screening services should be offered at minimal or no costs, funded through government subsidies [ 28 ].

Structural and workflow adjustments

Structural adjustments such as the establishment of a dedicated space for private consultation and as an enabler for the adoption of this role. This was indicated in 8 studies; [ 29 – 31 , 34 – 36 , 39 , 44 ]. For example, community pharmacists in Nigeria reported that having a designated space for offering patient counseling would encourage them to participate in more public health services [ 44 ], similar to findings by Almukdad et al where pharmacists proposed having a private area for counseling as an internal strategy to improve the provision of weight management services (WMS) [ 34 ]. The need for a designated space with proper equipment to measure obesity-related parameters for screening blood pressure, weight measurement and cholesterol measurement was reported in Pakistan [ 30 ]. For provision of vaccination services pharmacists expressed the need for a specified area for provision of the vaccine services and storage of vaccines under the right temperatures [ 35 , 41 ]. However, none of the studies detailed how this could be achieved.

Elsewhere organizational adjustments such as having a time dedicated time for delivery of PHIs to avoid disruption of the normal dispensing activities [ 29 , 31 , 35 , 36 , 40 ] was reported as an enabler for uptake of PHI delivery. Providing training to pharmacy assistants on how to handle pharmacy-based activities was reported as a strategy to free up time for pharmacists to be involved in the delivery of PHIs [ 31 , 44 ], as well as scheduling appointments for the PHIs [ 36 ].

Collaboration with other healthcare professionals

Pharmacists expressed that the provision of additional services (i.e. delivery of PHIs) would require a multidisciplinary approach [ 29 , 30 , 34 , 37 , 46 ], especially for cases that required referral and consultation with other health care professionals such as obesity cases [ 46 ]. Pharmacists reported they would prefer having multi-disciplinary training courses as a way of forming links between different professional groups [ 29 ]. Pharmacists in Canada expressed low awareness among general physicians on pharmacists’ capabilities in providing PHIS and suggested having a shared electronic medical record with physician to facilitate an integrated model of care [ 37 ]. Elsewhere in Qatar, pharmacists viewed offering Weight Management Services as complex and they highlighted the need for collaboration with dieticians and physicians for referral purposes [ 34 ]. However, the findings from these studies were mainly aspirational, and none reported on an existing collaboration model.

Support from the government and professional bodies

Support from governing bodies was identified as crucial in the implementation of public health programs in four studies [ 30 , 34 , 35 , 37 ]. For example, in Pakistan pharmacists reported there was low awareness of the role pharmacists play in public health and the government could play a role in promoting awareness to the public which in turn would enhance trust from the public [ 30 ]. These findings were similar in Canada where pharmacists expressed that professional associations could play a role in creating awareness of this role [ 37 ]. Pharmacists in Qatar expressed the need for the Ministry of Health to establish guidelines for pharmacists to facilitate the adoption of Weight Management Services (WMS) [ 34 ]. Elsewhere in Malaysia, pharmacists expressed that the government could support them in this role by offering free training and resources to facilitate the vaccination role and professional bodies by advocating for the roles of CPs to be included in vaccination programs [ 35 ].

To the best of our knowledge, this is the first review highlighting the factors that influence community pharmacists to expand their scope of practice and deliver PHIs from a global perspective. The findings from this review reaffirm that pharmacists are willing to expand their practice beyond dispensing and take up the role of PHI delivery.

The core finding of this review was that offering additional training to community pharmacists on the delivery of specific PHIs is a requirement to boost the uptake of this role. Training could augment pharmacists’ knowledge and skills as well as empower them to be more competent and confident in the delivery of PHI. The benefits of training pharmacists on PHI delivery include elevating their confidence and competence in service delivery and thus improved health outcomes [ 49 , 50 ] For instance community pharmacists who received training on provision of smoking cessation services in Thailand reported feeling more confident in offering such services in the future [ 51 , 52 ]. Similarly, community pharmacists in Australia reported feeling confident in screening clients for risk of cardiovascular disease after receiving training in their pharmacies [ 53 ]. Policymakers should therefore put efforts to ensure that community pharmacy providers are qualified and have access to regular training. There was no reported standardized model in place for training pharmacists on PHI delivery from the studies reviewed. Nevertheless, various training models have been adopted elsewhere although these differ by context and the PHI under consideration [ 54 – 57 ].

These training models include peer learning, which has the potential to influence the practitioner’s behaviour [ 54 ], learning at work [ 55 , 56 ], and formal certification to become specialists [ 57 ]. These trainings are delivered through different formats such as face-to-face learning (onsite/off-site), and online learning (webinars-learning modules and activities). Face-to-face training has been reported as the preferred mode of delivery by pharmacists in Ethiopia [ 55 ], UAE [ 58 ], and USA [ 59 ], as it offers an opportunity for quick feedback from the instructor, and provides an opportunity for peer networking, which could enhance collaboration with healthcare professionals in other fields. Online training on the other hand has been reported as a preferred mode of delivery by pharmacists in Australia [ 60 ], as it offers the convenience of pharmacists completing modules at their own pace and schedule. Blending diverse training methods and modes by pharmacists’ preferences is key to ensuring that pharmacists are well-equipped to take up the role of delivery of PHI. Additionally, modifications of the undergraduate curriculum to include public health modules is a starting point to improving professional skills and perceptions of pharmacists towards taking up this extended role [ 61 , 62 ].

Government support to community pharmacies is crucial in enhancing the uptake of PHI delivery. This can be through the provision of resources to facilitate the adoption of PHI delivery through, for example, the provision of materials to promote awareness and offering equipment at a subsidized price that is affordable to pharmacists [ 63 ]. The vital role that community pharmacies play in improving health indicators is recognized globally, however, their inclusion in the design of policies, countries’ health strategies, regulations and monitoring is minimal [ 64 ]. The government can therefore play a role by establishing clear guidelines, policies, and regulatory frameworks to guide the integration of this role into broader health systems tailored to the unique landscape of each country. For instance, in Saudi Arabia, MoH has developed specific guidelines on the provision of immunization services within community pharmacies [ 65 ]. Elsewhere in Kenya, MOH through the National AIDS and STI Control Programme (NASCOP) launched guidelines which advocated for the delivery of HIV-Self test kits in community pharmacies [ 66 ]. Furthermore, the government and professional bodies could promote national campaigns to create awareness of the crucial role that pharmacists play in public health.

Whilst integrating community pharmacist PHI delivery role into the broader health system, it’s important that they generally operate independently of other healthcare providers in a retail environment [ 67 ]. Therefore, training sessions could create an avenue to foster interprofessional collaborations between pharmacists and other healthcare professionals.

Interprofessional collaboration between physicians and pharmacists has resulted in improved patient outcomes and a reduction of health system inefficiencies and costs [ 68 , 69 ]. This has led to the establishment of Collaborative Practice Agreements (CPAs) in the USA where community pharmacists conduct screening for chronic infections in the pharmacies and hand off the reactive cases to general physicians. This helps to close the gap of loss to follow-up patients [ 70 ]. Elsewhere in UK general physicians have communication channels for referral of patients for a same day consultation with community pharmacists and vice versa [ 71 ]. Interprofessional collaboration has been described as an evolving process that progresses through a series of stages described by various collaboration models. For instance, a GP- pharmacist model by McDonough and Doucette [ 72 ] describes it as a progression in 4 main stages: stage 0- professional awareness, stage 1- professional recognition, stage 2- exploration and trial stage, stage 3- professional relationship expansion, stage 4- a commitment to the collaborative working relationship and is influenced by different factors such as proximity, time, clinical knowledge, communication, mutual interests and professional equality. Other models have been adopted for collaboration between pharmacists and GPs and are similar in that collaboration progresses from brief interactions to a clearly defined relationship where the roles of both cadres are well defined [ 73 , 74 ]. Role clarity has been shown to influence the adoption of role expectations and task performance [ 75 , 76 ].

Community pharmacies are private retail businesses operating within a competitive market and aim to maximize profits to survive in the market, it is therefore not surprising that remuneration influences the uptake of the additional role. Delivery of PHI is viewed as an additional role and pharmacists have few incentives to deliver the expanded services if the compensation is inadequate. Although the remuneration of community pharmacists has mainly been based on their retailing and dispensing functions, a few countries have introduced payment mechanism reforms as a means of encouraging the adoption of this role [ 77 ]. For instance, the fee-for-service model has been adopted to encourage pharmacists to provide smoking cessation services [ 78 ], influenza vaccination [ 79 ], and diabetes-related education, training and monitoring in the community settings [ 80 ] and was more preferred by pharmacists as it was easy to implement and integrate into the existing business model [ 81 ]. Pay-for-performance model has been used in a UK program, where pharmacies were renumerated based on the number of people who successfully quit smoking [ 82 ]. However, there is a gap in knowledge on the preferred payment model in various contexts. Understanding the payment model preferences of community pharmacists is a crucial knowledge gap as it has major implications on the implementation, adoption, and potential impact of pharmacists’ payment model.

Finally, structural and workflow adjustments such as having a designated space and having a dedicated time play a role in community pharmacists taking up the role of PHI. The importance of a private room has been stressed in several studies as a way of building trust and maintaining confidentiality for patients who want to discuss sensitive medical issues such as requests for EHC, screening for STIs, Prep, and HIV screening [ 83 , 84 ]. Evidence suggests that community pharmacists have a preference for having a private consultation room to provide services for diabetes management to preserve patients’ privacy and confidentiality [ 85 ]. This can be achieved through the establishment by development of policies and standards for the physical space of pharmacies such as having a designated space for conducting PHIs. For instance, having a private space has been incorporated as a requirement in Western Australia section 7 of Pharmacy Regulations 2010, which specifies that, “ The premises are to have an area in which a consultation conducted by a pharmacist is not reasonably likely to be overheard by a person not a party to the consultation” [ 86 ]. These guidelines are backed up by the professional body code of ethics as a means to ensure that the client’s right to privacy and confidentiality is maintained [ 87 ]. Workflow adjustments such as having time dedicated to PHIs would allow pharmacists to plan efficiently and allocate sufficient time to deliver high-quality services. However, evidence shows that community pharmacists have a general preference for being easily accessible to patients by taking walk-in clients [ 85 ].

Limitations

One limitation of this review was that most of the findings from were mainly aspirational and therefore minimal data on various mechanisms that have been applied to facilitate the role of PHI delivery by community pharmacists, however, this will be addressed by a broader study. Second, the findings from this review were mainly in studies conducted in high-income countries and therefore the findings may not be contextually replicable in low-income settings as factors vary across different contexts. To overcome these limitations, further empirical work in LMIC settings is required to determine the key drivers, policy, and practical considerations for delivery of PHIs. Finally, the studies included in this review were those published in English language and there is a likelihood that we might have missed some articles that may be relevant to our review. Despite these limitations, this manuscript provides crucial information that has great potential to inform the design of public health policies targeting community pharmacists.

Study implications

This review highlights the different factors that play a key role in influencing community pharmacists’ decision to take up the role of PHI delivery. However further research is needed to generate evidence on how these factors interact to influence implementation practices and sustainability. This research could entail identifying context specific barriers and facilitators of PHI delivery in community pharmacies particularly in LMICs. This information could inform the design of implementation strategies that can enhance sustainability of PHI programs adopted in community pharmacies. Such research is crucial for two reasons: first, it will ensure that policies are designed in a manner that incentivizes community pharmacists to take up this role. Second, it will facilitate the establishment of guidelines to standardize community pharmacy practice and integration of this role into broader health systems which will in turn enhance the contribution of community pharmacists to public health.

This review sheds light on the various factors that influence the decision of community pharmacists to expand the scope of practice and take up the role of delivery of public health interventions. Incorporating these factors into the design of policies and public health programs is crucial for the successful integration of community pharmacists into broader public health initiatives. However, these findings do not indicate the relative importance that is placed on each of the factors by community pharmacists. The findings from this review will inform the design of a discrete choice experiment to elicit context-specific preferences of community pharmacists for the identified factors, which will in turn contribute to the design of policies that will enhance the contribution of community pharmacists to public health.

Supporting information

S1 checklist. prisma 2020 checklist..

https://doi.org/10.1371/journal.pone.0298713.s001

S1 Table. Search strategy.

https://doi.org/10.1371/journal.pone.0298713.s002

S1 File. Quality assessment findings.

https://doi.org/10.1371/journal.pone.0298713.s003

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• Published: 02 August 2024

The prevalence of spontaneous resolution among pediatric trigger thumb: a systematic review and meta-analysis

• QingSong Tang 1   na1 ,
• XinLing Miao 2   na1 ,
• Kang Zhao 1 ,
• Jie Hu 1 &
• Xiang Ren 1  

Journal of Orthopaedic Surgery and Research volume  19 , Article number:  461 ( 2024 ) Cite this article

Metrics details

Trigger thumb is a prevalent hand condition observed in children, and its management remains a topic of considerable debate, ranging from mere observation to surgical intervention. In recent times, there has been a growing interest in exploring nonoperative treatments as alternatives to surgical procedures for managing pediatric trigger thumb. Gaining insight into the prevalence of spontaneous resolution in pediatric trigger thumb is of paramount importance. However, the literature presents a wide variation in estimates regarding the prevalence of this spontaneous resolution, highlighting the need for further investigation and consensus. The aim of this review was to estimate the overall prevalence of spontaneous resolution among pediatric trigger thumb.

This study meticulously followed the PRISMA guidelines and registered in the PROSPERO. The PubMed, Embase, and Cochrane Library databases were searched for all relevant studies up to May 2024.Inclusion criteria were studies reported only observation spontaneous resolution pediatric trigger thumb, aged up to 14 years, reported at least 10 thumbs and followed up time at least 3 months. Confounded intervention treatment measure studies were excluded. To synthesize the prevalence rates from individual studies, we employed a random-effects meta-analysis. In order to uncover the sources of heterogeneity and to compare prevalence estimates across different groups, we performed sensitivity and subgroup analyses. To meticulously evaluate the quality of the included studies, the Joanna Briggs Institute’s quality assessment checklist was employed. Furthermore, to assess the heterogeneity among the studies, both Cochran’s Q test and the I² statistic were utilized.

A total of eleven studies were included for the final analysis, with 599 pediatric trigger thumbs. Our final meta-analysis showed that more than one-third of these pediatric trigger thumb cases resolved spontaneously, with a resolution rate of 43.5% (95% CI 29.6–58.6). Subgroup analyses showed that in terms of age at the first visit, the prevalence of spontaneous resolution in the less than 24 months group and in the 24 months or older group was 38.7%(95% CI 18.1–64.4)and 45.8%(95% CI 27.4–65.4), respectively. There was no significant difference between the two groups( P  = 0.690). When analyzing follow up time, the prevalence of spontaneous resolution in the 24 months or longer group and in the less than 24 months group was 58.9%(95% CI 41.6–74.2)and 26.8%(95% CI 14.7–43.8), respectively.There was significant statistical differences between the two groups( P  = 0.009). Based on the initial severity of interphalangeal (IP) joint flexion contracture, the prevalence of spontaneous resolution in the 30 degrees or less group and in the other measurements group was 54.1%(95% CI 31.5–75.1)and 37.1%(95% CI 21.9–55.4), respectively.There was no significant difference between the two groups( P  = 0.259).

Our study demonstrates that a significant proportion of pediatric trigger thumbs resolve spontaneously. This finding highlights the benefits of early observation in managing this condition. By prioritizing non-operative observation, both parents and surgeons are better equipped to make informed decisions regarding the treatment of pediatric trigger thumb, potentially reducing the need for surgical intervention.

Introduction

Research findings indicate that the prevalence of pediatric trigger thumb (PTT) ranges from 0 to 3.3 per 1,000 live births [ 1 , 2 ].The etiology of pediatric trigger thumb remains ambiguous, with some scholars suggesting a combination of congenital and acquired factors [ 2 , 3 ]. It is plausible that the actual prevalence acquired may be higher than congenital, as numerous cases manifest after the age of 12 months. Typically, the average age at diagnosis falls between 6 and 24 months [ 4 ].The primary concern revolves around a developmental discordance between the flexor pollicis longus tendon and its encompassing sheath. Historically, the surgical release of the A1 pulley has been the conventional approach for treating pediatric trigger thumb. However, emerging research indicates that a non-surgical observational strategy may result in spontaneous resolution of the condition. Study has reported over half of the affected children can anticipate a natural recovery without surgical intervention, typically within an average follow up time of approximately four years [ 5 ]. In addition, surgical intervention involving A1 pulley release has demonstrated successful outcomes for children over the age of five, irrespective of their age at the time of the procedure [ 6 ]. However, national data reveal that the surgical management of pediatric trigger thumb is often conducted more frequently and at younger ages than what the current literature advocates. This tendency toward over-treatment not only poses potential harm to patients but also imposes unwarranted financial burdens on healthcare systems [ 7 ].

Therefore, comprehending the authentic rate of spontaneous resolution in pediatric trigger thumbs is of paramount importance. This understanding is essential for considering early observation as a viable approach, which could alleviate suffering and mitigate associated negative outcomes. Broadly speaking, the reported prevalence rates of spontaneous resolution exhibit considerable variability across different studies, ranging from no occurrences to nearly four out of every five cases resolving on their own [ 8 , 9 , 10 ].

No systematic review or meta-analysis has thoroughly estimated the consolidated incidence of spontaneous resolution in pediatric trigger thumb. Evidence derived from such a meta-analysis would offer robust insights into the epidemiology of spontaneous resolution in pediatric trigger thumb. This information could be invaluable for both parents and surgeons, aiding them in making informed decisions regarding the choice between nonoperative and operative treatments for pediatric trigger thumb.Therefore, the objective of this review is to undertake a comprehensive analysis of existing literature on the prevalence of spontaneous resolution in pediatric trigger thumb, employing both qualitative and quantitative methodologies.

Research design and method

This study meticulously followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines throughout its protocols. The systematic process of searching, assessing eligibility, evaluating quality, extracting data, and analyzing data was rigorously executed based on a predesigned protocol. Moreover, the study protocol was duly registered on the International Prospective Register of Systematic Reviews (PROSPERO) prior to the commencement of data extraction (Registration CRD42024550745).

Data source and selection process

The literature search was conducted on May, 2024, utilizing three major databases: PubMed, Embase, and The Cochrane Library. The search strategy employed a combination of MeSH terms and keywords, specifically targeting the following phrases: “spontaneous resolution” or “observe” or “conservative” and “child” or “infant” or “newborn” or “pediatric”and “trigger finger” or “trigger thumb”.To ensure comprehensive coverage, additional relevant studies were meticulously identified by thoroughly reviewing the reference lists of the selected eligible studies.

Eligibility criteria and study selection

In this comprehensive review, we included studies that adhered to the following criteria: (i) The study participants were children diagnosed with pediatric trigger thumb, aged up to 14 years, reported at least 10 thumbs and followed up time at least 3 months; (ii) The study either reported the prevalence of spontaneous resolution or provided sufficient data to calculate this prevalence; and (iii) The study was published in the English language. We excluded followed up time less than 3 months, confounded intervention treatment measure studies, reviews, commentaries, case reports, and studies conducted on animal subjects. Additionally, letters to the editor, conference papers, books, editorials, and notes were also excluded from our analysis.

Methods for data extraction and quality assessment

Two independent authors meticulously extracted pertinent data from the selected studies. The information collected from each study encompassed the following details: the name of the first author(s), the sample size, the year of publication, the age at the initial visit, the follow up time, the initial severity of interphalangeal (IP) joint flexion contracture, as well as the number of spontaneous resolution among pediatric trigger thumb and their corresponding prevalence estimates.

All search results were aggregated and subsequently subjected to an independent eligibility screening by two of the authors. In instances of disagreement, a third author intervened during a meeting with the screening authors to mediate and resolve conflicts. This was achieved by attentively listening to the arguments presented and fostering discussions until a consensus was reached. The screening process entailed a meticulous review of the abstracts for each result. Following the initial screening and elimination of duplicates, the studies deemed potentially relevant were subjected to a thorough full-text review to ascertain their suitability for inclusion.

To assess the quality of the studies incorporated into the final analysis, we employed the Joanna Briggs Institute Quality Assessment Tool. This tool evaluates individual studies based on frequency scales, with responses categorized as ‘yes,’ ‘no,’ ‘not clear,’ and ‘not applicable.’ The total quality score for each study was meticulously calculated by summing the number of positive responses.

Data synthesis and analysis

In this research, all statistical analyses were meticulously performed utilizing the Comprehensive Meta-Analysis Software, version 3.0. The prevalence rates derived from the individual studies were amalgamated through the application of a random-effects meta-analysis model [ 11 ].To evaluate the degree of heterogeneity between the studies, the I² statistic was employed [ 11 ].The interpretation of the I² values is as follows: a value of 75% indicates high heterogeneity, 50% signifies medium heterogeneity, and 25% denotes low heterogeneity [ 12 ]. To assess potential sources of heterogeneity across the studies, we considered three key factors: the age at the initial visit, the duration of follow-up, and the initial severity of interphalangeal (IP) joint flexion contracture. To evaluate the risk of publication bias, we employed Egger’s regression tests and funnel plots. For all statistical analyses, a P-value of 0.05 was established as the statistical significance.

Identifcation of relevant studies

Our comprehensive and meticulous search process initially identified a total of 123 studies. However, upon closer examination, we found that 52 of these were duplicates and consequently excluded them from our analysis. Subsequently, during the evaluation phase focusing on titles and abstracts, we removed an additional 47 records—24 based on their titles and 23 based on their abstracts—as they failed to meet our stringent inclusion criteria. As a result, we retained the full texts of 24 publications for more in-depth scrutiny. Ultimately, out of these, 11 publications were deemed suitable and qualified for inclusion in our current systematic review and meta-analysis(Fig.  1 ).

PRISMA flowchart of review search

Characteristics of included studies

The fundamental attributes of the studies encompassed in this systematic review and meta-analysis are delineated in Table  1 . In total, 11 articles [ 5 , 8 , 9 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 ] were incorporated into the final analysis, encompassing 599 cases of pediatric trigger thumb that exhibited spontaneous resolution. The studies reviewed were published over a substantial period, spanning from 1974 to 2021. The sample sizes of these included studies varied significantly, ranging from as few as 12 pediatric cases to as many as 107. Furthermore, the age of the children at their initial visit for these studies spanned from 18 months to 57 months. The mean follow-up duration for the studies included in our analysis varied significantly, ranging from 3 months to an extended period of 59 months. Among these studies, four meticulously documented the average initial flexion deformity of the interphalangeal joint. This deformity was precisely measured using a goniometer, ensuring accuracy and consistency in the recorded data.

Quality of included studies

Table  2 presents a detailed analysis of the quality and potential biases inherent in the studies included in this review. Notably, four studies, representing 36% of the total, utilized an adequate sample size to accurately determine the prevalence of spontaneous resolution. Furthermore, approximately six studies, accounting for 54.5%, received positive evaluations concerning their response rates. Remarkably, all of the studies, encompassing 100%, employed appropriate statistical analyses to investigate the prevalence of spontaneous resolution. Drawing upon the Joanna Briggs Institute’s quality evaluation checklist, the articles selected for the final analysis exhibited a mean quality score of 7.36, with individual scores spanning from five to nine. Notably, five studies, constituting 45% of the total, were classified as high-quality, each achieving a score of 7.36 or above. The remaining articles, which scored between five and 7.36, were deemed to be of fair quality.

The prevalence of spontaneous resolution among pediatric trigger thumb (metaanalysis)

The pooled prevalence estimate of spontaneous resolution among pediatric trigger thumb was determined to be 43.5% (95% CI: 29.6–58.6), follow up time ranged from 3 to 59 months. However, significant heterogeneity was observed across the studies included in this analysis (I² = 90.462%; P  = 0.000) (Fig.  2 ). Subgroup analyses showed that in terms of age at the first visit, the prevalence of spontaneous resolution in the less than 24 months group and in the 24 months or older group was 38.7%(95% CI 18.1–64.4)and 45.8%(95% CI 27.4–65.4), respectively. There was no significant difference between the two groups( P  = 0.690)(Table  3 ). When analyzing follow up time, the prevalence of spontaneous resolution in the 24 months or longer group and in the less than 24 months group was 58.9%(95% CI 41.6–74.2)and 26.8%(95% CI 14.7–43.8), respectively.There was significant statistical differences between the two groups( P  = 0.009)(Table  3 ). Based on the initial severity of interphalangeal (IP) joint flexion contracture, the prevalence of spontaneous resolution in the 30 degrees or less group and in the other measurements group was 54.1%(95% CI 31.5–75.1)and 37.1%(95% CI 21.9–55.4), respectively.There was no significant difference between the two groups( P  = 0.259) (Table  3 ).

The prevalence of spontaneous resolution among pediatric trigger thumb: a random-effect meta-analysis (I 2  = 90.462%; P  = 0.000;based on random effect model)

Sensitivity analysis

To identify potential sources of heterogeneity across the studies and to examine the differences between groups estimating spontaneous resolution among pediatric trigger thumb, we conducted a stratified analysis by categorizing participants based on three key variables: age at the first visit (less than 24 months versus 24 months or older), follow-up duration (less than 24 months versus 24 months or longer), and the initial severity of interphalangeal (IP) joint flexion contracture (30 degrees or less versus other measurements).

This analysis revealed that the observed variation in the prevalence of spontaneous resolution among pediatric trigger thumb, when examined across the aforementioned three variables (groups), did not show statistical significance for age at the first visit (less than 24 months versus 24 months or older) and initial severity of IP joint flexion contracture (30 degrees or less versus other measurements) ( P  > 0.05)(Table  3 ). However, the follow up time (less than 24 months versus 24 months or longer) demonstrated a statistically significant difference ( P  = 0.009)(Table  3 ). To further investigate the potential sources of heterogeneity among the studies included in our analysis, we conducted a leave-one-out sensitivity analysis. This rigorous approach demonstrated that the primary findings are robust and not unduly influenced by any single study. Upon excluding each study one at a time, the pooled estimated prevalence of spontaneous resolution among pediatric trigger thumb ranged from 39.6% (95% CI: 27.2–53.6) to 47.8% (95% CI: 34.8–61.2), thus affirming the stability of our results.

Publication bias

In our comprehensive systematic review and meta-analysis, we uncovered no indications of potential publication bias concerning the prevalence of spontaneous resolution in pediatric trigger thumb. This conclusion is substantiated by the symmetrical appearance of the funnel plot and corroborated by the results of regression tests associated with the funnel plot analysis(Egger’s test) (B = − 789, SE = 3.87, P  = 0.843)(Fig.  3 ).

Funnel plot of the risk of publication bias for the prevalence of spontaneous resolution among pediatric trigger thumb

Key findings

To the best of our knowledge, this study represents the first comprehensive systematic review and meta-analysis aimed at estimating the prevalence of spontaneous resolution in pediatric trigger thumb. Our review encompassed 11 studies that investigated this phenomenon. Both our qualitative and quantitative analyses revealed that the existing scientific evidence on the prevalence of spontaneous resolution in pediatric trigger thumb exhibits substantial variability depending on the follow up time, the age at the initial consultation, and the initial severity of interphalangeal (IP) joint flexion contracture.

Our comprehensive meta-analysis revealed the pooled prevalence estimate of spontaneous resolution among pediatric trigger thumb was determined to be 43.5%. Notably, the follow up time played a crucial role, the prevalence of spontaneous resolution in the 24 months or longer group and in the less than 24 months group was 58.9%(95% CI 41.6–74.2)and 26.8%(95% CI 14.7–43.8), respectively.There was significant statistical differences between the two groups( P  = 0.009). This notable difference in resolution rates can greatly assist both parents and surgeons in making informed decisions regarding the preference for nonoperative treatments over surgical interventions for managing pediatric trigger thumb.

Comparisons with the existing evidence

The current study’s prevalence estimates for spontaneous resolution of pediatric trigger thumb stand at 43.5%. Notably, when the follow up time in the 24 months or longer group, this rate increases to 58.9%. These figures are significantly higher than those reported by some authors, who found no cases of spontaneous recovery during their follow-up periods [ 10 , 21 ]. The findings of this study suggest that the duration of nonoperative care can be extensive and should be a topic of discussion, allowing parents to actively participate in the decision-making process regarding the choice between nonoperative and operative treatments. One plausible explanation for this phenomenon may be attributed to the fact that some surgeons do not adhere to the recommended 24 months waiting period. Instead, they may choose to pursue alternative therapeutic approaches if spontaneous resolution is not achieved within a shorter timeframe, as indicated by previous research.

This substantial variation can be attributed to several factors including (i) There are notable variations in the characteristics of the children involved in these studies. These differences encompass the initial severity of the interphalangeal joint flexion contracture associated with trigger thumb [ 20 ], the duration of follow up time [ 18 ], as well as the age at which the condition first presented and whether it affected the right or left side [ 20 , 22 ]; (ii) Significant discrepancies exist in the definitions of spontaneous resolution of trigger thumb across various studies [ 5 , 20 ]; (iii) The clinical characteristics of participants exhibit considerable variation, encompassing factors such as metacarpophalangeal joint laxity issues [ 4 ] and the diverse ethnic and cultural backgrounds of the participants [ 20 ].

This study has unveiled significant heterogeneity among studies investigating the spontaneous resolution of pediatric trigger thumb. This observed variability can be attributed to differences in participant characteristics as well as the methodologies employed in the included studies. Concerning methodological disparities, the studies varied in several respects: sample size, the instruments utilized to measure outcomes, the sampling procedures, as well as the source of population.

Strength and limitations

The present study has several strengths. Firstly, this systematic review and meta-analysis aims to determine the prevalence of spontaneous resolution in pediatric trigger thumb cases. By consolidating existing research, it provides a foundational understanding of this medical phenomenon. Secondly, the study estimates the prevalence rates of spontaneous resolution by considering specific subgroups based on critical factors such as the age at the first visit, follow up time, and the initial severity of interphalangeal (IP) joint flexion contracture. This approach allows for a more detailed and accurate assessment of the condition across different patient demographics. Thirdly, the study incorporates subgroup and sensitivity analyses to identify and mitigate potential biases, ensuring the reliability and validity of the findings. These methodological strengths collectively enhance the study’s contribution to the field of pediatric orthopedics, offering valuable insights for clinicians and researchers alike.

Several limitations inherent in this systematic review and meta-analysis warrant careful consideration. Firstly, the majority of the included studies had relatively small sample sizes. This limitation raises concerns that the reported prevalence of spontaneous resolution among pediatric trigger thumb cases in our current analysis may not accurately reflect the true prevalence in the broader population. Secondly, our review exclusively included studies published in the English language. Consequently, there is a possibility that relevant studies conducted in other languages were overlooked, potentially introducing a language bias into our findings.

The implication of the findings

The current study bears profound implications for both research and clinical practice. To begin with, future investigations are imperative to explore the underlying reasons for the elevated prevalence rates of spontaneous resolution observed in pediatric trigger thumb cases when the follow up time in the 24 months or longer group, as compared to those with in the less than 24 months group. Additionally, it is essential that subsequent studies encompass larger sample sizes and incorporate segmentation based on gender and the affected side, thereby ensuring a more comprehensive understanding of this condition. Finally, to mitigate the need for surgical interventions and alleviate the associated suffering, early screening and public education on the spontaneous resolution of pediatric trigger thumb should be prioritized through coordinated and integrated public health strategies.

This study has demonstrated that a significant proportion of pediatric trigger thumbs resolve spontaneously. The prevalence of spontaneous resolution in pediatric trigger thumb cases is significantly higher when the follow up time in the 24 months or longer group, compared to cases with in the less than 24 months group, suggesting substantial benefits associated with an early observation approach for this condition. By opting for a nonoperative strategy initially, both parents and surgeons may be better equipped to make informed decisions about the treatment plan, potentially avoiding unnecessary surgical interventions.

The average initial flexion deformity of the interphalangeal joint, was measured with use of a goniometer, with the wrist held in neutral extension, the thumb in 20 of palmar abduction, and the metacarpophalangeal joint in neutral extension.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

We thank research office staff at Chengdu Women’s and Children’s Central Hospital.

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QingSong Tang and XinLing Miao equally to this work as co-first authors.

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Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China

QingSong Tang, Kang Zhao, Jie Hu & Xiang Ren

School of Nursing, Chengdu university, Chengdu, China

XinLing Miao

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QingSong Tang and XinLing Miao equally to this work as co-first authors. Tang QS conceptualized the study, performed the search conducted analyses, conducted the quality assessment, write-up and approval of the final manuscript. Miao XL was involved in data extraction, read and approved the final manuscript. Ren X, Zhao K, andHu J was participated in discussion and consensus and approved the final manuscript. All authors read and approved the final manuscript.

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Tang, Q., Miao, X., Zhao, K. et al. The prevalence of spontaneous resolution among pediatric trigger thumb: a systematic review and meta-analysis. J Orthop Surg Res 19 , 461 (2024). https://doi.org/10.1186/s13018-024-04960-0

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Received : 05 June 2024

Accepted : 29 July 2024

Published : 02 August 2024

DOI : https://doi.org/10.1186/s13018-024-04960-0

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Journal of Orthopaedic Surgery and Research

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• Published: 02 August 2024

The outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa: a systematic review

• Priscilla Princess Mhango   ORCID: orcid.org/0000-0003-4129-8379 1 ,
• Thokozani Linda Zungu 1 ,
• Harold Ismael Nkume 2 ,
• Alinune Musopole 3 &
• Shaffi Yusuf Mdala 1 , 2  

Systematic Reviews volume  13 , Article number:  204 ( 2024 ) Cite this article

Metrics details

Cataract is one of the leading causes of childhood blindness in Africa. The management of this condition requires timely surgical extraction of the cataractous lens with immediate optical correction and long-term follow-up to monitor visual improvement and manage complications that may arise. This review provides an opportunity to benchmark outcomes and to shed light on the reasons for those outcomes.

To review the published literature and report on the outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa.

Data source

The EMBASE, PubMed, Scopus, and Web of Science were searched for relevant articles.

Study selection

We included all published primary studies from sub-Saharan Africa on cataract surgery outcomes in children aged 0–16 years with primary intraocular lens implantation conducted between 1990 and 2020. Eligible studies were those published in English or for which an English translation was available. In addition, reviewers screened the reference lists of all studies included in the full-text review for eligible studies. During the review, studies fitting the inclusion criteria above except for having been conducted in middle and high-income countries were tagged and placed in a comparison arm.

Data extraction and synthesis

Study eligibility was determined by two independent reviewers, and data extraction was conducted by one reviewer with entries checked for accuracy by another reviewer. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data synthesis were followed. The Joanna Briggs Institute (JBI) critical appraisal checklist was used for quality appraisal of the studies. The statistical software R was used in the analysis, and data were pooled using a random-effects model. Forest plots were generated using the R package ‘metafor’.

Main outcomes and measures

The primary outcome was visual acuity (VA) after cataract surgery and the proportions of eyes that achieved good, borderline, or poor visual outcome according to the World Health Organisation (WHO) categorisation of post-operative visual acuity. The secondary outcome measures reported included lag time to surgery, rates of follow-up, and rate of complications.

Eight out of 4763 studies were eligible for inclusion in this review, and seven were included in the quantitative analysis. There was a male preponderance in the study population, and the mean age at the time of cataract surgery ranged from 3.4 to 8.4 years. Visual outcomes were available for short-term visual outcomes (1 to 6 months) as the studies had a significant loss to follow-up. The pooled proportion of eyes that achieved a good visual acuity (i.e. equal to or greater than 6/18) in the short-term period was 31% (CI, 20–42). The comparative studies from middle and high-income countries reported proportions ranging from 41 to 91%, with higher thresholds for good visual acuity of 6/12 and 6/15.

Conclusion and relevance

This review reports that there is a lower proportion of eyes with good outcomes after undergoing paediatric cataract surgery in sub-Saharan Africa than in middle- and high-income countries. Furthermore, this review states that there is a high proportion of patients lost to follow-up and suboptimal refractive correction and amblyopia treatment after paediatric cataract surgery.

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Introduction

The management of paediatric cataracts, i.e. the opacification of the crystalline lens in children, involves timely diagnosis and surgical intervention as delays can lead to permanent suboptimal functional vision due to amblyopia. Previously, corneal disease was the predominant anatomic cause of childhood blindness [ 1 ]. However, in recent years, with improved childhood immunisation coverage and vitamin A supplementation, visual impairment from cataracts has become an important cause [ 2 ].

Over the years, the technique for paediatric cataract surgery has undergone changes in order to improve visual outcomes and lower the rate of post-operative complications [ 3 ]. Substantial debate still exists among paediatric ophthalmologists regarding the best practice of intraocular lens implantation in children [ 4 ]. These include primary versus secondary implantation, intraocular lens power calculations, intraocular lens material selection, and associated safety profiles [ 4 ]. However, the general consensus is that primary intraocular lens implantation is an appropriate standard of care for children above the age of 2 years [ 5 ], with much less consensus on the implantation in infants, especially under the age of 1 year [ 6 ].

After surgical removal of the cataract, immediate correction of any refractive error is required to maximise the visual acuity and prevent amblyopia [ 7 ]. In patients with primary intraocular lens implantation, this is usually achieved using prescription spectacles. For children who are left aphakic, this can be done using aphakic glasses or more preferably contact lenses [ 8 ]. Although refractive correction alone can significantly enhance visual acuity, treatment for amblyopia is sometimes necessary. This is done by increasing visual stimulation of the amblyopic eye by intermittent occlusion of the dominant eye, either by means of patching (occlusion therapy) or atropine and optical penalisation [ 9 ].

There is a lack of comprehensive prospective studies on the outcomes of paediatric cataract surgery in sub-Saharan Africa (SSA). A few isolated reports suggest that paediatric cataract surgical outcomes in SSA are not in keeping with outcomes from other parts of the world. For example, using the World Health Organisation’s (WHO) visual acuity threshold of 6/18 for a good cataract surgical outcome, only 31.5% of eyes in a retrospective Nigerian study achieved a good visual outcome [ 10 ]. Another retrospective study conducted in Ethiopia reported an even lower proportion of 11% of the study eyes that achieved a good outcome.

Complications of paediatric cataract surgery are potentially visually significant, and they may be observed from the early post-operative period up to many years after the procedure [ 11 ]. The risk of post-operative complications is higher than in adult cataract surgery due to the more intense inflammatory response mounted by children after intraocular surgery [ 12 ]. Paediatric cataract management requires a multidisciplinary team that includes paediatric ophthalmologists, optometrists, and orthoptists to optimise outcomes [ 12 ]. Furthermore, it requires the dedication of the child’s carer to the numerous visits required to monitor for short- and long-term post-operative complications.

This review synthesised studies that reported the outcomes of paediatric cataract with a minimum follow-up of 4 weeks. The findings from this review may provide a baseline for tracking paediatric surgical outcomes in Africa. This review will be one of the first to report on the outcomes of paediatric cataract surgery in SSA. There have been some isolated reports in parts of Africa. However, there has not been a comprehensive analysis of these data to add to the body of knowledge and inform clinical practice on the surgical management of paediatric cataract in the SSA region.

This review aimed to answer the following question: what is the level of vision achieved in children who underwent cataract surgery with intraocular lens insertion in SSA?

This study protocol and review were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines [ 13 ]. The protocol was registered prospectively on PROSPERO (ID CRD42022309523).

Eligibility criteria

In 1990, the World Health Organisation (WHO) organised the inaugural meeting of experts on the prevention of blindness in children, where they estimated the global magnitude, classification, and causes of childhood blindness [ 14 ]. Following from this meeting, a new system for classifying the causes of blindness in children was developed [ 14 ]. We thus expected studies starting from 1990 onwards to be more likely to be relevant and comparable to contemporary healthcare practices in sub-Saharan Africa. We included all published primary studies on cataract surgery outcomes in children aged 0–16 years conducted in SSA between 1990 and 2020. Only studies with a minimum follow-up time of 4 weeks were included. Studies with mixed patient groups, for example, those with traumatic cataracts, were included if the data analysis regarding the visual outcomes of the aetiology was performed separately.

Articles were excluded from the analysis if the study design was a letter to the editor, a case report, or a systematic review. Studies that included children with pre-existing visually significant comorbidities such as glaucoma and retinal or corneal dystrophy were excluded. Furthermore, studies available only as conference abstracts or unpublished data and studies that were reported in languages other than English with no translation available were also excluded.

Information sources and search strategy

A search of PubMed (last searched on 21st March 2022), EMBASE (last searched on 28th March 2022), Scopus (last searched on 1st April 2022), and Web of Science (last searched on 10th April 2022) databases was done using a predefined search strategy. The full search strategy for PubMed (Additional file 1: Appendix 1 ) was modified as necessary for the other databases. The results from the four databases were uploaded to the online review management software Covidence [ 15 ]. Two independent reviewers (PPM and TLZ) performed the first and second rounds of article screening through this platform. The first round was the screening of titles and abstracts, and round two was full-text screening. The reference lists of full-text articles were also scrutinised for potentially eligible studies. All discrepancies in article selection were tagged by Covidence, and the conflicts were resolved within the software while the reviewers were blinded to each other’s conflict-resolving vote. In scenarios where both reviewers had voted to exclude an article but disagreed on the reason for exclusion, a discussion was held to reach a consensus on the reason. A third reviewer (HIN) was available as an arbitrator in case the two reviewers could not resolve any conflicts; however, the need for this did not arise. During the review, studies fitting the inclusion criteria but conducted in middle and high-income countries were tagged and placed in a comparison arm.

Data extraction

Data were extracted from studies retained from round two of screening by one reviewer (PPM) and checked by a second reviewer (HIN) for accuracy. One reviewer (PPM) conducted the data extraction for all the included studies, and a second reviewer (HIN) rechecked the results against the papers for accuracy. Discrepancies were resolved through a review of the article in question and a discussion between the two reviewers.

The primary outcome was visual acuity after cataract surgery, which was reported using the WHO categorisation of visual acuity; those with a visual acuity of 6/18 or better were categorised as ‘good outcome’, those with a visual acuity of less than 6/18 but greater than 6/60 were categorised as borderline, and those with a visual acuity less than 6/60 were categorised as poor outcome [ 16 ]. Depending on the duration after surgery, these outcomes were described as short-term outcomes (1 to 6 months), medium-term (7 to 12 months), or long-term (longer than 12 months). Data on the secondary outcome of the rate of post-operative complications such as uveitis, glaucoma, retinal detachment, and visual axis or posterior capsular opacification were also collected if reported. Where available, other data collected included publication characteristics, preoperative visual acuity, whether or not amblyopia treatment was given, and lag time. Lag time was defined as the time taken from noticing the cataract to surgery and ‘late presentation’ was defined as a delay to cataract surgery of more than 12 months.

Risk of bias and quality assessment

We applied the Joanna Briggs Institute (JBI) critical appraisal checklist [ 17 ] to the eight studies included in this review. The checklist had 11 questions with the options ‘yes’, ‘no’, and ‘unclear’. A response of ‘yes’ indicated that the study met that question’s quality criterion. Two reviewers (PPM, HIN) performed the risk of bias assessment independently, and conflicts were resolved through discussion. An arbitrator (TLZ) was on standby for conflicts that could not be resolved through dialogue. For the risk of bias and quality assessment, all the studies were classified as case series because the study population consisted of only participants who were sampled based on the presence of a specific outcome [ 18 ], i.e. visual outcomes after cataract surgery. The studies included consecutive participants who satisfied the inclusion criteria over a given period of time. Furthermore, the absence of a control group of patients that prevented the estimation of relative risk (the odds ratio) for the outcome [ 18 ] was also considered a criterion for classification as a case series.

Statistical analysis

The statistical software R was used in the analysis [ 19 ]. Forest plots were generated using the R package ‘metafor’ [ 20 ]. We used a random-effects model to evaluate pooled effects due to the high likelihood of heterogeneity among the selected studies. Heterogeneity between studies was assessed using the I 2 statistic and the chi-squared test.

Differences between protocol and review

The age of inclusion in the review was adjusted from 0–15 to 0 to less than 16 years as some studies considered this range the paediatric population. We concluded that an additional 12 months would not significantly alter or adversely affect the results.

During the review process, similar studies from middle- and high-income countries were tagged and placed in a geographical comparison group. This was done in an attempt to contextualise the results on a global scale of paediatric cataract surgical outcomes.

The search strategy extracted 6448 published articles of which 1685 were duplicates as described by the PRISMA flow chart (Additional file 1: Appendix 2). The full texts of 24 studies were evaluated, and 16 studies were excluded. A summary of excluded studies can be found in Additional file 1: Appendix 3. Eight studies were included in the quantitative analysis, seven of which were included in qualitative analysis. The study types that were included as reported by the authors were retrospective case series, retrospective chart review, prospective interventional, retrospective interventional case series, prospective longitudinal, hospital-based interventional study, prospective longitudinal hospital-based observational study, and retrospective survey. The PRISMA checklist for the review is available in Additional file 1: Appendix 4.

Clinical presentation

All the studies had a male preponderance in the patient population and the study durations ranged from 12 to 58 months. The mean age in the studies ranged from 3.4 to 8.4 years old. Only three of the studies provided the mean age along with the standard deviation. Therefore, combining the means of these studies alone, although considered, was deemed unlikely to yield meaningful results. Table 1 shows the characteristics of the included studies.

Six out of the eight studies documented the lag time of the study participants. For the studies that reported the lag time as mean, the longest mean delay was reported in Bowman et al. [ 22 ]: 44 months. Gogate et al. [ 25 ] and Mndeme et al. [ 28 ] reported similar mean delays in their study populations, 20.7 months (SD 18) and 21 months (SD 26.7), respectively. Furthermore, half of the study participants had a delay of more than 15 months in Gogate et al. [ 25 ] and more than 12 months in Mndeme et al. [ 28 ]. A larger proportion of patients with a long lag time were seen in Mboni et al. [ 26 ], with nearly two-thirds of the study population undergoing surgery after more than a 12-month delay.

Assessment and diagnosis

Six of the eight studies described the proportion of eyes that were blind prior to cataract surgery, that is, eyes with a visual acuity of less than 3/30. The remainder of the studies described the proportion of eyes that had a preoperative visual acuity of less than 6/60, and these were 98.7% and 88.4% in Mboni et al. [ 26 ] and Gogate et al. [ 25 ], respectively.

Five out of eight and six out of eight studies reported the proportion of eyes with preoperative strabismus and nystagmus, respectively. One study, Mndeme et al. [ 28 ], gave the combined proportion of patients with both findings. Six of the eight studies reported collecting data on systemic comorbidities as part of their methodology; however, only three studies reported the results of these findings (Table  2 ).

We did not specify a single surgical procedure for cataract extraction in the eligibility criteria and allowed for some variation in the surgical procedure. The reason was the consideration of the differences in the availability of resources in the various sub-Saharan countries like surgical equipment and consumables. For example, in Gogate et al. [ 25 ], the participants underwent phacoaspiration with primary posterior capsulotomy (PPC) and anterior vitrectomy (AV) performed in participants below 6 years of age. On the other hand, the cataract removal procedure performed included lens aspiration, PPC and AV in Bowman et al. [ 22 ], and extra-capsular cataract extraction (ECCE) in Onabolu and Iwuora [ 23 ] as shown in Table  1 .

Visual outcomes

All the studies except Mndeme et al. [ 28 ] reported quantifiable visual outcomes using the conventional 6 m. Although Mndeme et al. reported visual acuity in LogMar, the same WHO cut-offs for good borderline and poor categories were used. For example, the 0.48 LogMar vision for a good outcome equates to 6/18. Good short-term visual outcomes were reported for all eight studies. However, borderline and poor short-term outcomes were not available for Mndeme et al. [ 28 ] and Bowman et al. [ 22 ], and poor short-term outcomes were not available for Yorston et al. [ 21 ] (Fig.  1 ).

Short-term visual outcomes of paediatric cataract surgery

The proportion of eyes that achieved a good visual outcome after cataract surgery ranged from 16.5 to 62.0%. On the other hand, the proportion of eyes which attained poor visual outcome ranged from 0 to 51%. Only one study, Yorston et al. [ 21 ], reported medium- and long-term visual outcomes. The proportions of eyes that achieved a good visual outcome were 39.1% and 50.8% in the medium and long term, respectively. In the long term, only 6.1% of eyes in Yorston et al. [ 21 ] had maintained a poor visual outcome. The pooled proportion of eyes that achieved a good visual acuity in the short-term period is 31% (CI, 20–42), as shown in Fig.  2 .

Observational forrest plot showing the pooled proportion of eyes with short-term visual outcomes

Amblyopia treatment

Four out of the eight studies (Yorston et al. [ 21 ], Bowman et al. [ 22 ], Umar et al. [ 24 ], and Gogate) indicated that they had instituted amblyopia treatment during the post-operative period. The method of amblyopia treatment in these studies was patching of the better eye for a specified duration according to the severity of the amblyopia. A comparison of visual acuity before and after amblyopia treatment was not reported.

Post-operative complications

Five out of the eight studies reported that some eyes developed acute fibrinous uveitis. The proportion of eyes that developed this complication ranged from 1.3 to 30.5% (Fig.  3 ). Analysis yielded I 2 statistic of 96% ( p -value < 0.01). This indicated the presence of large and significant heterogeneity in the effect sizes. Pooling the data yielded a proportion of 12% (CI, 2–21) with uveitis.

Eyes that developed uveitis

Six of the eight studies reported on the development of posterior capsular or visual axis opacification within 6 months post-surgery (Fig.  4 ). Analysis for those who developed PCO yielded I 2 statistic of 93% ( p -value < 0.01). This indicated the presence of large and significant heterogeneity in the effect sizes. Pooling the proportions yielded a proportion of 13% (CI, 5–22). Only one study, Onabolu and Iwuora [ 23 ], reported the complication of post-operative retinal detachment. No study observed the development of post-operative endophthalmitis in the participants' eyes. The rest of the post-operative complications are depicted in Additional file 1: Appendix 5.

Eyes that developed posterior capsular or visual axis opacification

Post-operative follow-up

Only three of the eight studies reported a statistically quantifiable follow-up time for the study eyes. Asferaw et al. [ 27 ] reported a median follow-up time of 2.8 months (range, 1–33). Bowman et al. [ 22 ] reported a mean follow-up time of 6 months (SD 9 months), with only 54% of participants seen after 3 months. On the other hand, Yorston et al. [ 21 ] reported both mean and median follow-up times of 15 and 17 months, respectively.

Quality of the evidence and subgroup analysis

The results of the quality assessment are presented in Additional file 1: Appendix 6. Analysis output for good visual acuity reveals that Q-statistic is 22.3225 with p -value equal to 0.002, and I 2 statistic is 67.74% (CI, 23.0–91.5). This suggests the presence of heterogeneity in the effect sizes. The heterogeneity is between low to large. The heterogeneity in the effect sizes is uncertain.

An in-depth analysis of visual outcomes based on age was not possible due to the lack of homogeneity of age categories in the studies (Fig.  5 ). For example, Bowman et al. [ 22 ] did not report visual outcomes disaggregated by age, Yorston et al. [ 21 ] grouped the eyes in the categories 0–1, 2–5, and 6–10 years, and Umar grouped them 0–1, > 1–3, and > 8.

Subgroup analysis based on age

However, after stratifying the studies based on the average age of the participants, large and significant heterogeneity in the effect sizes was observed among the studies with mean age of participants of less than 6 (I 2 statistic was 94% and p -value < 0.01), while among the studies that had a mean age of participants of greater than 6, heterogeneity was medium and not significant (I 2 statistic was 57% and p -value = 0.10). Although the outcomes for those under the average age of 6 shown better visual outcomes, analysis did not yield a significant difference between the proportions (for good visual acuity) of those that were under the age of six (CI, 16–55) and those whose age was more than six (CI, 12–37).

Subgroup analysis based on whether biometry was done or not yielded an I 2 statistic of 40% ( p -value = 0.15) for the studies in which biometry was done indicating that heterogeneity in the effect sizes was low and not significant (Fig.  6 ). For studies in which biometry was done, the analysis yielded a proportion of good visual acuity of 24% (CI, 18–30). There was one study, Onabolu and Iwuora [ 23 ], which indicated that biometry was not done, and the proportion of good visual acuity was 22%(CI, 6–48).

Subgroup analysis based on biometry done or not done

Subgroup analysis was also performed based on whether single IOL or multiple IOLs types were used (Fig.  7 ). For studies that used single IOL, heterogeneity might be due to sampling error (I 2 statistic was 0% with p -value = 0.5), while among studies that used multiple IOL, it was large and significant (I 2 statistic was 81% with p -value < 0.01). The analysis yielded a proportion of 22% (CI, 18–27) for good visual acuity for studies that used single IOL, and a proportion of 46% (CI, 28–64) for those that used multiple IOLs. The proportion of good visual acuity for those who used multiple IOLs was significantly higher than that of those who used single IOL.

Subgroup analysis based on single or multiple IOL types used

In this review, we synthesised the available primary studies on the outcomes of paediatric cataract surgery with intraocular lens implantation in SSA.

Patient characteristics and presentation

All the studies in this review had a male preponderance of participants even though there is no biological evidence to support a sex-specific male predisposition in the prevalence of congenital or non-traumatic developmental cataracts [ 29 ]. Some studies [ 21 , 24 ] reported one reason is that in a lot of African communities, boys are awarded a higher societal value than girls. Other studies on paediatric cataract surgery from Africa have reported the similar findings of gender discrepancy with similar explanations [ 30 , 31 ]. These findings suggest a need to improve equitable access to paediatric cataract surgery in SSA.

The majority of the participants in the studies experienced a long preoperative delay which is not uncommon in SSA [ 25 ]. African studies that investigated the reasons for lag time and its association with visual outcomes defined delay as ‘more than 12 months’ before receiving a cataract operation [ 25 , 26 , 32 ]. This is likely due to pragmatic reasons, as it is a routine occurrence to have children with cataracts present late to the hospitals. In principle, for congenital and infantile cataracts, by the time the children are delayed for 12 months, the optimum time for surgery has passed [ 33 , 34 ].

Mwende et al. [ 32 ] reported on the causes of delayed presentation for non-traumatic cataracts in Tanzania. They found that a longer distance from the eye care facility significantly increased the delay in presentation. Furthermore, there was a positive correlation between rising maternal socio-educational status and a reduction in delay in presentation. This is because these mothers are more likely to have some knowledge of the problem and the treatment that exists. They are also more likely to have the financial means to access eye care services and accept the surgical services offered.

The lag time from the studies in this review was not qualified; it is unclear the extent of delay that resulted from late recognition of the cataract by the children’s caregivers, delay in accessing eye care services, and the delay that resulted from waiting for surgery after presentation to an eye care facility. This information would be crucial in formulating an approach to dealing with the primary barriers that exist at the community level. One study from Southwest Nigeria that investigated the factors associated with early versus late presentation to tertiary eye care facility found that children whose cataract was detected by their mothers were more likely to present to the eye care facility within 3 months of detection [ 35 ]. In addition, these children were also more likely to present at a younger age than cataracts detected by other caregivers [ 35 ]. This suggests that educating and empowering mothers about cataract in children may be a tool in the arsenal of tackling blindness from childhood cataracts.

Preoperative assessment

This review found that the proportion of blind eyes preoperatively in all the studies ranged from 50 to 100%. Preoperative findings are essential in prognosticating the outcome of surgery. The presence of strabismus and/or nystagmus can adversely affect outcomes, and their prevalence varies widely among studies [ 36 ]. Strabismus prevents the development of binocular vision, and the amblyopia it causes can have adverse aesthetic and psychological effects on the child [ 36 ]. Moreover, the presence of nystagmus and strabismus are indications that substantial visual deprivation has occurred [ 24 ]. Other studies have reported an association between poor preoperative vision and limited improvement in post-operative visual acuity [ 22 , 25 , 28 , 37 ].

During our literature review, we did not find standardised benchmark indicators for outcomes of paediatric cataract surgery comparable to the WHO guidelines established for adult cataract outcomes. Similarly, in their work on outcome indicators in paediatric cataract surgery, Nihalani et al. [ 38 ] did not identify any publication focused on benchmark indicators in paediatric cataract surgery. As such, the WHO categorisation was used in this review. The pooled proportion of eyes that achieved a good visual acuity in the short-term period was 31% (CI, 20–42). Although we did not find studies from high-income countries that defined the cut-off for ‘good visual outcomes’ as 6/18 like in the studies in our review to offer a direct comparison, there were several studies that used the cut-offs of 6/12 and 6/15 (Additional file 1: Appendix 7) The American studies Peterseim et al. [ 39 ], Wilson et al. [ 40 ], and Struck et al. [ 41 ] reported that 27 (91%) (CI, 80–97), 48 (72%) (CI, 59–82), and 13 (85.7%) (CI, 66–100) of eyes achieved a visual acuity of 6/12 or better good visual outcome at the last follow-up visit, respectively. In the UK, a study by Cassidy et al. [ 42 ], 25 (73.5%) (CI, 51–80) children achieved a visual acuity of 6/12 or better. Furthermore, the European study Ambroz et al. reported that 34 (54.0%) (CI, 41–67) of eyes achieved a post-operative acuity equivalent to 6/15 of better. Although these studies are not a direct comparison, the cut-offs of 6/15 and 6/12 are a higher standard of visual acuity. It thus suggests that outcomes that are achieved in middle- and high-income countries are superior to those from SSA.

It has been proposed that during visual development, there is a short, well-defined period in early life where the neuronal pathways are robustly restructured in response to sensory input [ 43 , 44 ]. Years after this ‘critical period’ the same stimuli have less influence on visual development. What follows from these findings is that the occlusion of one eye during this critical period in early life results in the development of a suboptimal visual acuity in the deprived eye that persists into adulthood if left uncorrected [ 45 ]. Our expectation would be that children with developmental cataract would obtain better visual outcome because during the critical period, there was no sensory deprivation, and thus, they attained optimum vision prior to the cataract.

It should be noted that the visual outcomes in SSA may be better than those reported in this review. This is because of the lack of long-term follow-up for visual rehabilitation and maturation [ 25 ], especially in younger children. Moreover, the visual function is not limited to visual acuity and other factors such as contrast sensitivity and stereopsis need to be considered. However, no study in this review reported on post-operative contrast sensitivity testing, and only one study, Gogate et al. [ 25 ], measured stereopsis preoperatively and on follow-up visits. The majority of eyes had poor stereopsis, with only 9 (18%) children achieving better than or equal to 400 s of arc.

A comparison of the follow-up times from the studies in this review to those from studies in high-income countries revealed that the latter have longer follow-up times for patients. For example, in the American study Ledoux et al. [ 46 ], the median follow-up time was 3.65 years. Similarly, Repka et al. [ 47 ], in their multicentre study of 994 children, retained 88.4 and 66% of participants at 1 and 5 years. Follow-up in Africa is usually challenging for various reasons, such as the long distance from the tertiary eye care facility, which is coupled with poor road infrastructure, financial constraints, and lack of awareness of the importance of long-term follow-up [ 48 ]. Unfortunately, without appropriate post-operative follow-up, paediatric cataract surgery alone produces limited results [ 49 ]. The value of long-term follow-up visits can be evident if the child receives the appropriate care at each visit. In many parts of SSA, post-operative services from allied personnel such as orthoptists, refractionists, and low visual aid service providers are lacking [ 50 ]; thus, the care received is likely to be suboptimal.

Acute uveitis is more common in children as they mount a greater inflammatory reaction following intraocular surgery due to an immature blood-aqueous barrier [ 51 ]. Patients are typically prescribed topical steroid eye drops and cycloplegics post-operatively [ 51 ]. These were prescribed in all the studies included in this review. Literature shows a variable incidence of uveitis after paediatric cataract surgery. The proportion of eyes with acute uveitis in this review varied from zero in Gogate et al. [ 25 ] to 30.5% in Yorston et al. [ 21 ]. This is comparable to isolated studies from the west. In the American study by Ledoux et al. [ 46 ], no eyes in their series of 139 children had post-operative uveitis, whereas in the UK study by Cassidy et al. [ 42 ], uveitis occurred in 28.2% of eyes. However, the pooled proportion of uveitis in our study was found as 12% (CI, 2–21).

Glaucoma is a significant risk in paediatric cataract surgery. Recent multicentre prospective studies in high-income countries reported the incidence of glaucoma after paediatric cataract surgery to be 10% in the first year of follow-up, with the condition occurring in both aphakic and pseudophakic eyes [ 52 , 53 ]. The highest proportion of eyes with elevated intraocular pressure was 2.9% in Mndeme et al. [ 28 ]. Glaucoma after paediatric cataract surgery is typically late-onset open-angle glaucoma [ 11 ], although it can be observed within the first few months following surgery. Most early-onset glaucoma is due to vitreous pupillary block or inflammation. But with advances in technology, changes in surgical techniques and the appropriate use of anti-inflammatory medication post-operatively, early-onset glaucoma is much more uncommon [ 54 ]. The low number of eyes that developed glaucoma in our review can be explained by the short follow-up time. Therefore, it can be anticipated that if there were a longer follow-up, there would be a larger proportion of eyes seen with glaucoma.

Eyes that have undergone cataract extraction are at an increased risk of retinal detachment. Like aphakic or pseudophakic glaucoma, retinal detachment is also a long-term complication. In Denmark, a study of 1043 eyes of children aged 0 to 17 years by Haargaard et al. [ 55 ] reported that 25 eyes developed retinal detachment after a mean duration of 9.1 years after surgery. They further reported an overall 20-year risk of retinal detachment of 7%. This highlights the need for lifelong monitoring in these patients. Our review has low numbers of eyes that developed retinal detachment for the same reason as the low number of glaucoma, which is the short follow-up time.

Heterogeneity in the effect sizes

Analysis output for good visual acuity revealed that Q-statistic was 55.83 with p -value less than 0.0001, and I 2 statistic was 87% (CI, 78–93). This indicated the presence of large heterogeneity in the effect sizes. This may result from the clinical and methodological differences across studies in this review. As previously outlined, there were variations in how the surgical procedures were conducted. Furthermore, in some studies, there was one surgeon who performed paediatric cataract surgeries, whereas some studies had multiple surgeons. In addition, the small number of studies included in the review may be the reason heterogeneity in the effect sizes is uncertain. Subgroup analysis based on whether biometry was done or not, and whether single IOL or multiple IOL types were used revealed small heterogeneity which was not significant in any of the strata. This indicates that in addition to the small number of studies considered, heterogeneity in the effect sizes was largely due to variations in the methodological designs of the studies.

Challenges that result in inferior outcomes in sub-Saharan Africa

Early surgical intervention is recommended for bilateral congenital cataracts to improve visual outcomes [ 33 ], and for unilateral cataracts, this intervention is recommended even earlier [ 34 ]. As seen from this review, the majority of patients had a lag time of more than 12 months and, in some cases, more than 36 months. In high-income countries, there are surveillance programs for routine screening of neonates for early recognition of any lens opacity and thus provide timely surgical intervention [ 56 ]. On the other hand, in low-income countries, research suggests that long lag times are multifactorial, ranging from sociocultural barriers at the community level to logistical and organisational barriers within the health care system [ 57 ]. In some cases, the late presentation is due to poor health-seeking habits of the child’s guardians, as illustrated in Gogate et al. [ 25 ], where a quarter of guardians stated the reason for the delay in seeking help as ‘did not see the need to come to hospital.’ In situations where the symptoms are painless and not considered life-threatening, there may be a delay in presentation to tertiary eye facility for treatment [ 58 ].

Another reason for poor outcomes is the shortage of specialised paediatric ophthalmologists in SSA to cater to the immense burden of paediatric cataracts. Accessing sub-specialty training for paediatric ophthalmology is difficult, especially in Francophone Africa; thus, there is a continued lack of skilled eye care providers needed in tertiary hospitals [ 59 ]. In addition, there is a lack of visual rehabilitation facilities in SSA, especially for very young children. The standard of practice for managing these children is to prescribe contact lenses in lieu of intraocular lens implantation due to the increased risk of post-operative complications and higher reoperation rates in this patient group [ 60 , 61 , 62 ]. However, their use in SSA is impractical [ 21 ]. The majority reside in rural areas where clean running water is scarce, making personal and ocular hygiene a challenge [ 63 ]. This is further compounded by the high cost of the lenses and lens cleaning solutions. Other associated problems such as the risk of microbial keratitis and lens loss also limit the use of these methods [ 8 ]. There is a paucity of research on the safety and effectiveness of these interventions in the African context. With all the problems surrounding contact lens usage and the rise of published case series reporting promising results with intraocular lens implantation in younger children [ 39 , 64 , 65 , 66 ], some paediatric surgeons are now moving to primary intraocular lens implantation in younger children.

Whether children are left aphakic or have intraocular lens implantation, they still require optical correction to maximise visual outcomes [ 67 ]. Although glasses are more appropriate for the African setting, there are few children who get the glasses even after being refracted. For instance, the Madagascan study Randrianotahina et al. [ 68 ], in their series of 86 children, found that despite three-quarters of patients having refraction performed, only 3.5% received glasses. Furthermore, the glasses may break or get lost [ 21 ], after which they may not be replaced. Other challenges in prescribing glasses to children include difficulties obtaining accurate refraction and the availability of suitable frames for very young children [ 21 ].

Strengths and limitations

This review has scope for novelty in adding to the knowledge gap regarding paediatric cataract surgery. To our knowledge, this is the first review focusing on collating outcomes of visual outcomes of paediatric cataract surgery across sub-Saharan Africa. The inclusion of primary research studies combined with rigorous article screening and quality assessment provides a comprehensive evaluation of the available evidence.

A limitation of this review is the presence of significant heterogeneity within the included studies. Given the context of the SSA setting, the nature of the study population, and intervention under investigation, identifying controlled trials for more accurate and reliable estimates proved challenging. Nevertheless, it is important to note that this review emphasised narrative synthesis of the results over quantitative analysis, aiming to highlight the underlying reasons behind the observed findings.

Caution is advised when interpreting our pooled estimate of good outcomes, as not all factors influencing post-operative visual acuity were systematically analysed. For example, the primary studies lacked information on the measures employed for visual rehabilitation in patients. Moreover, for those implementing amblyopia treatment, details on treatment compliance and the ultimate visual outcomes post-treatment were not reported. There was also no information provided on optical correction compliance for those who received glasses. Lastly, the follow-up period for most of the studies was very short; thus, visual acuity conducted on the young infants may not be reliable. A longer follow-up of patients is needed to further discuss the surgical outcomes of cataracts in SSA.

This review showed that paediatric cataract surgery outcomes in sub-Saharan Africa are lower compared to reports from high-income countries. We reported that the proportion of eyes that achieve a vision of 6/18 or better within 6 months of cataract surgery is 31%. All comparative studies from middle- and high-income countries reported proportions ranging from 41 to 91%, with a higher visual acuity cut-offs of 6/12 and 6/15. Furthermore, there are low rates of follow-up and suboptimal refractive correction and amblyopia treatment after surgery within the studies. 

Recommendations

In order to improve outcomes, there is a need to focus on visual rehabilitation after paediatric cataract surgery. Therefore, we recommend cost-effectiveness studies to establish the best models that could be adopted for a sustainable provision of refractive services to children after undergoing cataract surgery in sub-Saharan Africa.

Furthermore, we propose that stakeholders and policymakers in international eye health should come up with guidelines and recommendations for the outcomes of paediatric cataract surgeries for benchmarking, ensuring quality, consistency, and continuous improvement in patient care.

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This project was carried out in partial fulfilment of the degree of ChM in Clinical Ophthalmology at the University of Edinburgh.

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Additional file 1: Appendix 1. Search strategy. Appendix 2. PRISMA flow chart. Appendix 3. Summary of excluded studies [ 69 , 70 , 71 , 72 , 73 , 74 ]. Appendix 4. PRISMA checklists. Appendix 5. Post-operative complications. Appendix 6. Risk of bias assessment. Appendix 7. Summary of characteristics for comparative studies.

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Mhango, P.P., Zungu, T.L., Nkume, H.I. et al. The outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa: a systematic review. Syst Rev 13 , 204 (2024). https://doi.org/10.1186/s13643-024-02607-z

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At Circus Smirkus, coming to Maine on Aug. 5-6, kids entertain kids

The Vermont-based family circus will stage shows in Cumberland, Kennebunkport and Fryeburg.

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Sayad Moudachirou brought his daughters to see Circus Smirkus last year, figuring it would be a fun family thing to do.

It was. But he also left the show with a couple aspiring circus performers on his hands.

CIRCUS SMIRKUS

WHEN : 1 and 6 p.m. Aug. 5 and 6

WHERE : Cumberland Fairgrounds, Cumberland

HOW MUCH : $25 to $40

INFO : portlandovations.org

WHAT ELSE : Circus Smirkus will also be performing Aug. 8-9 in Kennebunkport and Aug. 11-13 in Fryeburg. For more info, go to smirkus.org.

“As soon as the show ended, they wanted to enroll in circus camp. They appreciated that all the performers are still kids, and that makes it so relatable,” said Moudachirou of Scarborough.

Circus Smirkus will be back in Maine for more than a dozen shows under the big top this summer. The Maine tour begins with four shows at Cumberland Fairgrounds on Aug. 5 and 6.  There will also be four shows at Rockin’ Horse Stables in in Kennebunkport on Aug. 8-9 and five shows at Fryeburg Fairgrounds on Aug. 11-13.

Moudachirou will be there with his daughters, Maya, 9 and Shoshana, 7. Both are interested in taking classes at their local neighborhood circus school, The Gym Dandies Circus School of Maine. Last year, when Moudachirou and his family saw Circus Smirkus, the show was at Payson Park in Portland. But this year, the presenter of the Portland-area shows, Portland Ovations, picked the Cumberland Fairgrounds to provide more parking and a better site for the giant tent, which holds 750 people.

Circus Smirkus features performers between 10 and 18 years old.   Photo by Justin Miel

Circus Smirkus is a traveling advertisement for the new generation of circuses, focused on young, skilled performers who take classes and study things like juggling, acrobatics or unicycling. The days when circuses were known largely for lion tamers and elephant riders are gone. Advertisement

Circus Smirkus was founded in 1987, as an arts and education organization, training performers, offering camps and classes, and putting on family shows. It’s based in Vermont.

The performers are between 10 and 18 years old, and this year’s tour theme is “The Imaginarium,” a magical toy shop that comes to life with performers taking the roles of tumbling teddy bears, high-flying marionettes or a jumpy Jack-in-the-Box.

One of the performers coming to Maine is Cora Williams, 18, of Ithaca, New York, in her third summer season with the circus. She took lessons at a circus school near her home, then studied at a circus school in Montreal.

Circus Smirkus, based in Vermont, is a circus for kids by kids. Photo by Justin Miel

She remembers seeing traditional circuses as a kid, including Ringling Bros. and Big Apple Circus. But when she first saw Circus Smirkus, she realized entertaining people under the big top was something she could do sooner, rather than later.

Williams said she loves the fact that when she does a show, she could be inspiring the next generation of circus performers.

“The nice thing is this is a show for kids by kids, but we don’t dumb it down. I love it when the kids (in the audience) come and talk to us,” said Williams. “We have lots of little kids who come up to us. That’s how I got into it. We teach them some tricks, and we get lots of hugs.” Advertisement

Williams says it took her three or four months to learn unicycle tricks. She can do spins and pirouettes and “wheel walking,” where it seems as if the cycle’s one wheel is walking, one step at a time. She’s also an acrobat, standing on others’ shoulders and being flipped and tossed through the air.

Because she’s 18, Williams is “graduating” from Smirkus. She’s excited to be part of a “new generation reimagining what circus is” without animals and without limits. She says that young performers go on to careers using their circus skills in a variety of places and fields, including with touring circuses, as part of cruise ship shows, or in companies that put on shows for businesses.

Circus Smirkus is coming to Maine this month. Photo by Justin Miel

Moudachirou said his is one of about five Scarborough families he knows that are going to the show this year. Some went last year, and some heard from others about how engaging the performances are for kids.

He said that, as a parent, he’s glad to see groups like Circus Smirkus and The Gym Dandies offering a fun activity and a chance to learn a skill, besides the traditional offerings of sports or music lessons for kids. He also thinks that from what he’s seen so far at Circus Smirkus, the performers learn more than just juggling or acrobatics.

“For me, as a parent, it was great to see the performers taking ownership of what they were doing. It goes beyond performing; it’s almost about leadership,” Moudachirou said of the show he saw last year. “They were going into the crowd and talking to people, sharing their excitement.”

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Members of Talking Heads, Styx and Foreigner all perform in Maine this week

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My Perfect Day: Baked goods and lobster rolls are must-haves for Portland Chamber Music Festival director

Woman killed, 3 injured in Portland shooting. Police scant on details.

Yard south developer files for rezoning of south portland waterfront property, why do police keep information close to the chest after shootings, town of mechanic falls mourns, seeks answers after 3 found dead over weekend, julia gagnon’s birth mother, who helped inspire her ‘american idol’ journey, has died, member log in.

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